Homeless women see hope in street medicine

Five days after giving birth, Melissa Crespo was already back on the streets, recovering in a moist, litter-strewn water tunnel, when she got the decision from the hospital.

Her baby, Kyle, who had been born three months prematurely, was in respiratory failure within the neonatal intensive care unit and fighting for his life.

The chances had been against Kyle long before he was born last summer. Crespo, who was abused as a baby, was hooked on fentanyl and meth — a day by day habit she found inconceivable to kick while living homeless.

Crespo got a ride to the hospital and cradled her baby in her arms as he died.

“I do know this happened due to my addiction,” Crespo said recently, just after a nurse injected her on the streets of downtown Redding with a robust antipsychotic medication. “I’m attempting to get clean, but that is an illness, and it is so hard when you’re out here.”

Crespo, 39, is amongst a growing variety of homeless pregnant women in California whose lives have been overrun by hard drug use, a deadly coping mechanism many use to endure trauma and mental illness. They’re a largely unseen population who, in battling addiction, have lost children — whether to death or local child welfare authorities.

She and other women at the moment are receiving care from specialized street medicine teams fanning across California to treat homeless people wherever they’re — whether in squalid encampments, makeshift shantytowns clustered along rivers, or vehicles they stealthily maneuver from one neighborhood to a different in quest of a secure place to park.

“It is a really impoverished community and the massive thing immediately is maternity care and prenatal care,” said Kyle Patton, a family doctor who leads the road medicine team for the Shasta Community Health Center in Redding, about 160 miles north of Sacramento in a largely rural and conservative a part of the state.

Patton, who dons his mountaineering boots and jeans to make his rounds, has managed about 20 pregnancies on the streets since early 2022, and even totes a conveyable ultrasound in his backpack to learn the way far along women are. He’s also helping homeless moms who’ve lost custody of their children attempt to get sober in order that they can reunite with them.

“I didn’t expect this to be an enormous a part of my practice once I got into street medicine,” Patton said on a hot June day as he packed his medical van with contraception implants, tests to diagnose syphilis and HIV, antibiotics, and other supplies.

“The system is broken and folks lack access to health care and housing, so managing pregnancies and providing prenatal care has turn out to be a extremely big a part of my job.”

Street medicine is not recent, nevertheless it’s getting a jolt in California, which is leading the charge nationally to deliver full-service medical care and behavioral health treatment to homeless people wherever they’re.

The practice is exploding under Democratic Gov. Gavin Newsom, whose administration has plowed tens of billions of dollars into health and social services for homeless people. It has also standardized payment for street medicine providers through the state’s Medicaid program, called Medi-Cal, allowing them to be paid more consistently. The federal government expanded reimbursement for street medicine this month, making it easier for doctors and nurses across the country to receives a commission for delivering care to homeless patients outside of hospitals and clinics.

State health officials and advocates of street medicine argue it fills a critical gap in health care — and will even help solve homelessness. Not only are homeless people receiving specialized treatment for addiction, mental illness, chronic diseases, and pregnancy; they’re also getting help enrolling in Medi-Cal and food assistance, and applying for state ID cards and federal disability payments.

In rare cases, street medicine teams have gotten a few of the state’s sickest and most vulnerable people healthy and into housing, which supporters point to as incremental but meaningful progress. Yet they acknowledge that it’s no quick fix, that the expansion of street medicine signals an acceptance that homelessness is not going away anytime soon — and that there may never be enough housing, homeless shelters, and treatment beds for everybody living outside.

“Even when there’s all the cash and space to construct it, local communities are going to fight these projects,” said Barbara DiPietro, senior director of policy for the Tennessee-based National Health Take care of the Homeless Council. “So street medicine is shifting the concept to say, ‘If not housing, how can we manage folks and supply one of the best possible care on the streets?'”

The expansion of street medicine and other services doesn’t at all times play well in communities overwhelmed by growing homeless populations — and the rise in local drug use, crime, and garbage that accompany encampments. In Redding and elsewhere, many residents, leaders, and business owners argue that expanding street medicine merely enables homelessness and perpetuates drug use.

Patton acknowledges the means of getting people off drugs is long and messy. As a rule, they relapse, he said, and most expectant moms lose their babies.

That is true especially of homeless moms like Crespo, who has been using hard drugs for nearly twenty years but is eager to get clean so she will be able to reconnect together with her 4 living children; they vary in age from 12 to 24, Crespo said, and she or he is estranged from all of them. Two other children have died, one from lymphoma at age 15 and baby Kyle, in August 2022, primarily resulting from complications from congenital syphilis.

Patton is treating Crespo for mental illness and addiction and has implanted long-acting contraception into her arm so she won’t have one other unexpected pregnancy. He has also treated her for hepatitis C and early signs of cervical cancer.

Although she’s still using meth — as is her boyfriend, Kyle’s father — she’s six months sober from fentanyl and heroin, that are more deadly and addictive. “You’d think I could just get clean, nevertheless it doesn’t work that way,” said Crespo. “It’s an ongoing fight, but I’m healing.”

Patton doesn’t see Crespo’s continued drug use as a failure. His goal is to determine trust along with his patients because overcoming addiction — which frequently is rooted in trauma or abuse — can take a lifetime, he said.

“We’re playing the long game with our patients,” he said. “They’re really motivated to hunt treatment and get off the streets. However it doesn’t at all times work out that way.”

Street medicine takes off

Patton is a young doctor. At 39, he’s on the vanguard of a movement to entrench street medicine in California, home to just about a 3rd of all homeless people in America. He has specialized in taking good care of low-income patients from the beginning, first as an outreach employee in Salt Lake City and, later, in a family medicine residency in Fort Value, Texas, focused on street medicine.

Previously two years, the variety of street medicine teams operating in California has doubled to at the very least 50, clustered primarily in Los Angeles and the San Francisco Bay Area, with 20 more within the pipeline, said Brett Feldman, director of street medicine on the University of Southern California’s Keck School of Medicine.

Teams are frequently composed of doctors, nurses, and outreach employees, and are funded largely by health insurers, hospitals, and community clinics that serve homeless individuals who have trouble showing as much as appointments. That could be because they do not have transportation, don’t need to go away pets or belongings unattended in camps, or are too sick to make the trip.

Feldman, who helped persuade Newsom’s administration to expand street medicine, notched a critical success in late 2021 when the state revamped its medical billing system to permit health care providers to charge the state for street medicine services. Medi-Cal had been denying claims because providers had treated patients in the sector, not in hospitals or clinics.

“We didn’t even realize our system was denying those claims, so we updated 1000’s of codes to say street medicine providers can treat people in a homeless shelter, in a mobile unit, in temporary lodging, or on the streets,” said Jacey Cooper, the state Medicaid director, who this month leaves for the Centers for Medicare & Medicaid Services to work on federal Medicaid policy. “We wish to transition these women into housing and treatment to offer them more hope of keeping their kids.”

The state is not pumping recent money into street medicine, but primarily redirecting Medicaid funds that will have paid for services in brick-and-mortar facilities.

Cooper has also pushed insurance firms that cover Medi-Cal patients to contract directly with street medicine teams, and a few have done so.

Health Net, with about 2.5 million Medi-Cal enrollees across 28 counties, has contracted with 13 street medicine organizations across the state, including in Los Angeles, and is funding training.

“It’s a greater use of taxpayer funding to pay for street medicine relatively than the emergency room or consistently calling an ambulance,” said Katherine Barresi, senior director of health services for Partnership HealthPlan of California, which serves 800 homeless patients in Shasta County and contracts with Shasta Community Health Center.

‘There is no accountability’

Redding is the county seat of Shasta County, which has experienced a serious political upheaval in recent times, driven partially by the anti-vaccine, anti-mask fervor that ignited in the course of the covid-19 pandemic and the Trump presidency.

Yet residents of all political stripes are growing frustrated by the surge in homelessness and open-air drug use — and the spillover effects on neighborhoods — and are pressuring officials to clear encampments and force people into treatment.

“I do not care for those who’re left, right, middle — what’s happening here is uncontrolled,” said Jason Miller, who owns a neighborhood sandwich shop called Lucky Miller’s Deli & Market. Miller said he’s had his windows smashed thrice — costing $4,500 in repairs — and has caught homeless people defecating and performing lewd acts in his doorway.

Miller moved to Redding 15 years ago from Portland, Oregon, after losing patience with the homeless crisis there, and tries to assist, handing out shoes and food.

He said he also understands that many homeless people need more services — comparable to street medicine.

“I get what they’re attempting to do,” he said of street medicine providers. “But there’s loads of questioning in the neighborhood around what they do. There is no accountability.”

Patton is not deterred by the community’s skepticism or the cycle of addiction, even amongst his pregnant patients. The way in which he sees it, his job is to offer one of the best health care he can, irrespective of the condition his patients are in.

“It’s loads of wasted energy, judging people and labeling them as noncompliant,” he said. “My job is not to find out if a patient is deserving of health care. If a patient is sick or has a disease, I actually have the talents to assist, so I will do it.”

‘I actually have the willpower’

Shasta County, like much of California, is seeing its homeless population explode — and get sicker. An on-the-ground count this yr identified 1,013 homeless people within the county, up 27% from 2022. Most are men, but women account for a growing share of Patton’s patients because “an increasing number of are getting pregnant,” he said.

County welfare agencies have little alternative but to separate babies from their moms when substance use or homelessness presents a risk to the kids, said Amber Middleton, who oversees homelessness initiatives on the Shasta Community Health Center.

“We’re off the charts with maternal substance abuse,” said Middleton, who previously worked for Shasta County’s child welfare agency. “A number of these women are attempting to get clean in order that they can get their children back, but they’re also trying to offer themselves the childhood that they never had.”

Crespo turned to alcohol and medicines to take care of deep emotional pain from her youth, when she was passed amongst members of the family and, she said, beaten repeatedly by certainly one of them.

“He would give me black eyes and I’d run away,” she recalled in tears, admitting she has perpetuated that cycle of violence by punching her former husband when she felt provoked.

She has overdosed “more times than I can remember,” she said, and credits naloxone, an opioid overdose reversal drug, for saving her life repeatedly.

Patton routinely tests Crespo and other patients for sexually transmitted infections, gets them on prenatal vitamins, and treats underlying conditions like hypertension that may result in a high-risk pregnancy. And he’s helping women get sober, often using a drug called Suboxone, which is a mix of two medications used to treat opioid addiction. Its forms include a strip that providers snip to make the needed dose.

“A number of these women have already had children removed, and plenty of are pregnant again,” he said. “If I can get them on Suboxone, they are going to have a greater probability of being successful as a family once they deliver.”

On that sweltering June day, he met Tara Darby, who was on fentanyl and meth and living in a tent along a creek that feeds into the Sacramento River. Patton began her on a course of Suboxone and got her right into a hotel together with her boyfriend to assist her take care of the initial detox.

He also administered a pregnancy test and discovered she was already a number of months along. “It’s rough out here. There is no bathroom or water. You are nauseous on a regular basis,” Darby, 40, said. “I need to get out of this example, but I’m terrified about getting clean, the detox, having my baby.”

When Patton offered her support from a drug and alcohol treatment counselor, Darby promised to try. “I need to do it. I actually have the willpower,” she said.

Across town, Kristen St. Clair was nearly 7 months pregnant and living in a hotel paid for by Shasta Community Health Center. Patton was helping her and her boyfriend, Brandt Clifford, get off fentanyl.

“I need to have a healthy, completely happy life with my baby,” said St. Clair, 42, who already had one baby taken from her due largely to her drug use. “I’m frightened it’s too late now.”

However the prospect of getting clean felt daunting. Clifford, the daddy of her child, and an Iraq War veteran with a traumatic brain injury, had overdosed the day gone by and needed five doses of naloxone to return back. “We saved your life, man,” Patton told Clifford.

Patton snipped a strip of Suboxone, explaining that addiction is complicated. “Science is showing that, for whatever reason, certain people were born with the proper mixture of genetic predisposition after which have had various things occur to them of their lives, that are unfair,” he said.

“After which once you tried opioids for the primary time, your brain said to you, ‘That is the best way I’m imagined to feel.’ It takes little or no to get hooked.”

Despite their desperation to kick their drug habit, St. Clair and Clifford have since relapsed, Patton reported. St. Clair delivered in early September, and her little boy was taken into custody to “withdraw in a neonatal abstinence program,” Patton said. Darby, who was evicted from her hotel room after relapsing, was in residential treatment to get sober as of early October.

Crespo is making headway, Patton said. She and her boyfriend, Andy Gothan, 43, are staying at a hotel while Patton’s team helps her hunt for a landlord who will accept a low-income housing voucher.

“I’m so close. They’ve helped me a lot,” Crespo said. Meth is “at all times around, at all times available. If I can get inside, it’ll help me take care of the stress of getting clean without all those triggers.”

This text was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

This text was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is certainly one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.