Krystal Koop lifted her shirt slightly and touched her right hip, as if reliving the burning blisters that were there decades ago.
Thirteen-year olds don’t usually get shingles.
But as a preteen in Alaska, a tumultuous home life had, by age 12, led her to couches on the best nights and streets on the worst. What was supposed to be a one-night stay in an emergency shelter lasted for a year when no one followed through to place her in a home.
Koop relied on school and earning consistent good grades for the stability she couldn’t find elsewhere. All the while, she kept her situation hidden. By the time a classmate’s mom caught on, Koop had suffered with the painful condition — usually only found in adults with weakened immune systems — for two weeks.
When Koop finally opened up, her classmate’s mom asked, “Why didn’t you say anything?”
“That question is burned into my brain,” Koop said. “Because when she asked me that, my first answer was ‘There are so many reasons why I didn’t say anything. More than I can count.’”
Today, as a 33-year-old pursuing her master’s degree in social work at the University of Washington (UW), she manages to name a few: shame, confusion, fear that comes with living in survival mode and discouraging experiences in a difficult-to-navigate system where those there to help never did.
Her experience, coupled with 10 years of social service work, gives her rare insight as she directs a program called University District Street Medicine (UDSM). Comprising student volunteers from an array of UW health science schools, the team works to address disparities in quality health care for the area’s homeless population.
“That informs my work because I’ve dealt with the good, the bad and the otherwise,” Koop said, “and I understand how important it is not to have a cookie-cutter approach to working with people, because there are just so many layers.”
With energetic support from the community, students are developing partnerships with local service providers, conducting weekly street outreach and slowly but surely gaining ground toward the goal of establishing a free student-run clinic and connecting homeless individuals to primary care.
Homelessness brings substantial barriers to accessing health care and managing chronic diseases, injuries and infections.
Even small problems, such as a cut or a bug bite, can become unmanageable without consistent access to clean water and soap. During a survey conducted by UDSM in 2013, medical problems were the second most frequently mentioned challenge behind housing, though the two are inextricably linked.
Living on the street increases risk of violence, communicable diseases, mental health issues, substance abuse and conditions such as pneumonia, while making it difficult to get to appointments or store medication. For instance, doctors often prescribe medications that require refrigeration, but rarely ask whether a patient has a refrigerator. “I’ve never seen that on an intake form,” Koop said.
In the lobby of the UW School of Social Work, on a balmy Friday evening in August, Koop sat at a table with a handful of student volunteers and pulled supplies out of a green backpack: lists of local resources, water bottles, first-aid and hygiene kits and socks.
“Ask if they need anything,” she told the students, “but feel like it’s OK to just have a conversation and not necessarily an agenda-driven one.”
Koop was prepping the students for a weekly outreach session, in which small groups hit the streets of the University District or conduct site visits at the Elizabeth Gregory Home and the Blessed Sacrament Parish during meals provided by the St. Vincent de Paul Conference.
UDSM was born out of the monthly University District Conversations on Homelessness, after participants learned about a similar program called Detroit Street Medicine. Students conducted assessment surveys, asking homeless individuals about health care barriers, needs and experiences.
Respondents called for more adult resources in what is largely a youth-centric area, citing finances and availability as their most common obstacles to health care with respect to tooth and gum disease, mental health disorders, chronic pain, addiction, and foot and vision problems. That led to an interdisciplinary approach of exceptional breadth: The program currently pulls together UW schools of medicine, social work, nursing, physical therapy, pharmacy and dentistry, and is looking at adding the public health and law schools.
“We realized that the need in the community was much more than just what medical students could supply,” said Meghan Moorhead, a fourth-year medical student who helped launch the program.
Intertwining disciplines is meant to get students out of their silos, and, eventually, allow them to offer a wide range of services — from a social worker helping a patient navigate complex systems to a medical student providing direct care — that directly address the needs of U-District’s homeless population.
But with the first outreach in May, UDSM is in its early stages, and much remains to be done both legally and logistically.
For now, with a licensed clinician present — called a preceptor — students can guide those they meet through basic first aid, and begin offering vital sign checks during site visits at the end of August.
“Right now, it’s baby steps,” said Kelsen Caldwell, UW School of Medicine program manager. “We aren’t ready to roll out a full force of services, and part of that is really getting to know people and making sure we are accountable to the community that would be accessing it.”
But there’s plenty they can do in the meantime, and every conversation brings more knowledge about how to best meet the community’s needs.
By about 6:20 p.m., Koop, Moorhead, pharmacy student Czarina Franco and medical student Andrew Lawson were strolling down 15th Avenue past chattering groups awaiting buses. Guided by Koop’s map of “hotspots” where people often camp, they made their way toward and along Boat Street, eventually stopping under the Ship Canal Bridge.
“People sleep here, quite a bit,” Koop said, pointing up and raising her voice above the roaring traffic. “That takes a toll. These are things to think about when working with people.”
A few minutes later, students were sitting with a group of men at a picnic table, explaining the concept of UDSM and hearing their stories, not just about health care and hospital visits, but also jobs, hobbies, even botany.
Eventually, Moorhead asked if anyone needed anything from her supply bag. Band-Aids are a common request, but on this night, the answer was resounding: socks.
“Socks are like a rare commodity,” said Austin, one of the men at the table, as the students handed over fresh pairs of white, fluffy socks. “If your socks are wet, your feet get messed up, and you can’t even walk down the street.”
Austin’s health concerns reflected what students had discovered about gaps in the U-District. At 26, Austin had just aged out of Teen Feed, and now must travel outside the neighborhood to find meals most days of the week. Tooth decay was also on the list.
“A smile is one of the first things people notice,” Austin said, “and I don’t even like smiling anymore.”
During the needs assessment, dental care was cited often enough that it received its own category.
“Because of the way dental care is structured, even if they have Medicaid or Medicare, getting in to access a dentist is really hard,” Caldwell said. “If you have tooth pain and you don’t have a place to go, that can be pretty devastating.”
Fostering the future
Even in its infancy and without the capacity to offer much medically, UDSM is able to take on what organizers see as fundamental flaws in the health care system. During the most recent needs assessment in August, a majority of homeless individuals who responded said the No.1 thing they wanted their doctor to do was “Just listen to me.”
“Seattle is a medical hub in a way, and we have such innovative research and practices,” Koop said, “yet we’re hearing a good majority of this population say we don’t even have the basics down.”
Koop took students down the alley behind Cafe Allegro, pointing out the big blue doors that mark the entrance to Urban Rest Stop. She explained how social services are often understaffed and underfunded and discussed public health issues while standing over orange needle caps on the ground. Koop is doing more than educating. She is fostering providers who are not detached from the reality of what it means to be homeless and try to access health care, who are informed about resources available, who know how to build relationships and trust, and who might even become advocates for changing the system. Providers who step out of their white coats and sterile labs to understand their patients’ barriers, Koop and Caldwell echoed, are doctors who will provide better care.
“People start to develop competencies that I think are really going to serve them in the future,” Caldwell said. “They are going to have a level of sensitivity. The normative understanding of who a patient is doesn’t always take into account a person’s circumstances.”
For instance, patients in traditional settings are sometimes labeled “noncompliant” when they fail to take their medication or make an appointment.
“Managing something like diabetes is complex if you live in a home and have stable income and access to health care, but you add these layers on top of where you are going to sleep, where you are going to store your medication, and I think a lot of health professionals are not up to speed on what needs to be done to support people,” Caldwell said. “When you understand power structures and how they weigh down on people, you are better able to understand why things are the way they are and not engage in stigmatizing and pathologizing people, which I think is often directed and targeted toward people who are homeless.”
And a lot can be done with a conversation. There was the man with Crohn’s disease who hadn’t eaten in nearly a day and falsely believed his insurance wouldn’t cover a trip to the emergency room. Or the woman whose feet were swollen, bare and at risk of ulcers, who strategized with Moorhead about how to get to a clinic.
“I’m imagining patients I’ve seen in hospitals who are having amputations and dying of infections,” Moorhead said. “And I’m going, ‘We could start with some socks.’”
Exchanges such as this represent a higher level of care — whether on the street or in a clinic — where providers invest in a successful referral, and Koop believes students will carry that with them.
“Those moments are really important,” she said. “We want to focus on not just handing someone a piece of paper and saying, ‘These are the hours of the 45th Street clinic. Good luck.’”
It’s already starting — one student switched paths to public and community health after volunteering; formerly homeless students have said UDSM is the first program they’ve felt passionate about; and pharmacy student Franco plans on applying for a grant for UDSM through the Association of Colleges of Pharmacy. The program does not currently have a consistent funding source and has relied on some donated seed money and supply contributions from the community.
“In order to provide help in the best possible way, we need to know what the struggles are and not just assume we know that this is this and that is that,” Franco said. “This is a way to bridge gaps between these populations and dispel myths on both sides.”
After the outreach session, students sat on the rocks outside the School of Social Work and debriefed, discussing their experiences and planning for the future. Though the goal is to open a clinic — Koop said they will present a proposal to partner with UW's Roosevelt medical center at the end of September — outreach will always be the anchor and heart of the program.
“We get a lot of feedback, literally and figuratively, of ‘Meet us where we’re at,’” she said.
When asked what changes Austin would want to see in health care, his words echoed UDSM's model of providers who see the person behind the condition.
“A lot of people don’t take the chance to turn the page,” he said. “They just look at the cover.”