On a Thursday morning, I squeeze into a tiny examination room at Massachusetts General Hospital in downtown Boston alongside Dr. James O’Connell ’70, a specialist in treating the chronically homeless. O’Connell is 68 years old, with silver-white hair, blue eyes and a disarmingly amiable manner. Already in the room are two psychiatrists, two nurses, a nurse practitioner and a case worker, all full-time staff of the Boston Health Care for the Homeless Program’s street team. The BHCHP is the nation’s largest freestanding health care nonprofit for the homeless, and O’Connell is the agency’s president, as well its street team director. He has a longstanding relationship with the hospital, where he maintains admitting privileges, and every week he and his team run an all-day “street clinic” out of two exam rooms on the second floor of its ambulatory care center.

photo: Christian Kozowyk

The arrangement is unique. None of the many other clinics for the homeless across the country operates from within a renowned academic medical center like Mass General, as the hospital is known locally. This inside perch gives O’Connell and his team seamless access to a full range of testing, surgery and specialty care, services that are challenging and time-consuming to arrange from off-site. The weekly clinic is popular among Boston’s street population, and, by a quarter past nine, several dozen homeless men and women are gathered on the ground floor in a special waiting area that is almost always a bit unruly and occasionally drifts into minor-league anarchy.

Before the clinic gets under way, O’Connell and the team chat about their more challenging cases. They have an easy rapport, and the talk is dense with medical shorthand. Carolyn Matheson, the nurse practitioner, is concerned about a man named Hannibal, who is back on the street after losing half a foot to frostbite. “He’s another smart person with schizophrenia,” O’Connell says to me. Matheson has a picture of Hannibal’s truncated foot on her iPhone, which she passes around. An ugly wound gapes where the amputation failed to heal. “He’s walking on that,” she says. “It’s not massively infected, but it just keeps getting bigger.” She wants him in for surgery, and O’Connell agrees. After 25 minutes of similar discussion, Melissa Kaeli, a young nurse who helps manage the waiting area, chimes in. “It’s probably chaos downstairs,” she observes. “You’re right,” O’Connell says energetically. “Let’s go.”

Health care for the homeless is a tricky business, not least because homelessness itself can be a nebulous phenomenon. A single mother who spends a few weeks in a shelter with her kids after an eviction is homeless; so, too, is the heroin-addicted Vietnam veteran who sleeps under a bridge for 20 years. They share few commonalities except extreme poverty and lack of a fixed address. Simply charting the dimensions of the problem is a challenge. Most homelessness is the temporary kind, ranging from a few days to several months. These newly homeless drift, doubling up with friends and family, cramming into motel rooms, sleeping in cars or camping out. Public shelters, where they might be easily counted, often serve as a refuge of last resort. For the very poor, this brush with homelessness is not especially uncommon. Around 7 percent of the U.S. population experiences something like it at one point in their lives, according to a 2004 study. Almost all of them eventually return to conventional housing.

photo: John Baynard

It is an unlucky few who do not. These are the chronically homeless, unable to pull themselves out of their situation and with nowhere further to fall. Mired in extreme poverty, they are hobbled by other heavy burdens: mental illness, crippling addictions, physical and intellectual disabilities, histories of abuse and trauma. If homelessness were a progressive disease, they would be in its final stages; many will die before escaping the streets or the shelters.

Their numbers are not enormous, perhaps 100,000 nationwide, according to federal estimates. Yet their impact on the health care system is fairly incredible. In early 2000, O’Connell’s staff launched a statistical study of 119 “rough sleepers,” a rugged class of Boston’s chronically homeless who live outside and strenuously avoid the shelters. Within five years, the group had logged 18,384 emergency room visits, and a third had died. The median age of those studied was 45. The findings affirmed a reality O’Connell knew from observation. Hospitals spent a fortune on emergency treatment for the chronically homeless, yet it seemed to do them little lasting good. The message seemed clear enough: The health care system was failing them. But the medical establishment took long in hearing it. “This population has been screaming at us for a long time,” O’Connell says.

O’Connell has led the effort to answer that distress call for more than 30 years. He joined the BHCHP at its inception in 1985, as the agency’s founding medical director and only doctor. With a staff of seven and a shoestring budget, he opened clinics in shelters and soup kitchens, reaching out to a population that had come to feel itself invisible to the city’s medical community.

Today the mission remains the same but the resources at hand are exponentially greater. His staff numbers more than 400, including 15 physicians, and the annual budget is around $50 million, funded largely through federal reimbursements. The agency is active all across the city, seeing more than 12,000 unique patients a year at more than 60 locations, including shelters, soup kitchens, recovery centers, day programs and other outreach sites.

His base of operations is a four-story brick building on Albany Street in the South End, across the street from Boston Medical Center, home of the busiest trauma center in New England. With 77,000 square feet of floor space, the maze-like facility accommodates 14 primary-care exam rooms, a five-chair dental practice, a behavioral-health unit and a pharmacy, as well as the agency’s business offices. On the top two floors is a 104-bed medical respite center.

Last year, to mark its 30th birthday, the BHCHP published a book by O’Connell, his first, about his long and storied career working with the city’s dispossessed. Stories from the Shadows: Reflections of a Street Doctor is a slim volume but packs a punch. It draws heavily on scenes O’Connell recorded decades ago, often in the late hours after long and hectic clinic days, in journals he stashed in a box at the top of a bedroom closet. Full of detail and the voices of his street patients, his writing has the feel of unvarnished truth: There is pathos and humor but little sentimentality. The world he depicts is one of crushing poverty and societal indifference, saturated in darkness and awash in violence. “Death lurks steadfastly on the streets and in the shelters,” he writes in an early passage.

photo: Rick Friedman

At the book’s close, O’Connell notes with pride the program’s broad improvement of health services for Boston’s street folk. Yet he ends not on a valedictory note but with a call to action. Homelessness in the city is as intractable a problem as ever, he observes, with rapid gentrification and redevelopment since the turn of the century driving housing costs to ever-more stratospheric heights. And while the city’s public spaces have become cleaner and safer, they are also increasingly hostile to the homeless. “I worry that the streets of Boston have grown meaner,” O’Connell writes in the final chapter. “Seismic upheavals in attitude have displaced rough sleepers and cast them yet further to the fringes of Boston’s urban landscape.”

His agency treats all people experiencing homelessness, however they may define it, and no one seeking care at his clinics is turned away. O’Connell and the street team, however, focus their energies on the rough sleepers, current and former, who number perhaps a few hundred but are far and away the toughest cases. This work involves time in the clinic but also on the streets; he knows from experience that to wait for a rough sleeper to come to him for help is often to wait too long. So he takes the clinic to them, scouting the familiar haunts of downtown by foot and by van, doing check-ups and first aid, and urging those in poor health to come inside and be treated.

His longstanding presence on the street makes him a trusted figure to the rough sleepers, who consider him a friend and ally and universally call him “Dr. Jim.” He in turn shares a deep affection for his street patients. This dynamic is immediately in evidence at the Thursday clinic, where O’Connell’s first patient of the day is Bryant, a sprightly, impish man with a neat gray beard, who wears an oversize camouflage jacket and enters the examination room hoisting a massive olive-drab duffel bag over one shoulder. They shake hands warmly, and O’Connell asks about his health. “My health is good,” Bryant rasps. “My health is falling to pieces. I don’t know. I’ll tell you one day.” He cackles with laughter.

Bryant is a veteran, a former medic in the Navy, and carries his VA card in a battered lanyard around his neck. For long years he was a rough sleeper, “a survivalist,” he says, but recently moved into a city-subsidized apartment. He met O’Connell well over a decade ago — the first doctor Bryant had ever seen out in the streets. “There’s no place he doesn’t go, no person he won’t see. There’s nothing he won’t do,” Bryant says, rhapsodically. “He never tells us to get lost, because he always knows where to find us.”

I meet more admirers downstairs, in the street team waiting area, which consists of a windowless alcove and a short hallway just off a busy, light-filled atrium. The small space fairly overflows with humanity. A few patients sit in wheelchairs, while dozens more stand in bunches, mill around or park themselves in a long bank of chairs along the hallway wall. They are an older group — no one looks younger than 40 — and mostly male and white. Many sit or stand beside huge bags or backpacks, and they have the look of weary migrants in the midst of a forced trek by foot through an unrelenting landscape.

Nick, a mellow-looking man with a bushy goatee and iron-gray hair tied in a ponytail, tells me he first met O’Connell about 10 years ago, during a long period he spent living rough on the street. Struggling with mental illness at the time, he spent many nights in city emergency rooms. “With those doctors, you’re in and you’re out. They treat you like a number,” he says. O’Connell offered a different approach. “He’s like the old country doctor. He’s got the bedside manner. You don’t get that anymore, from anyone. He takes the time to listen to people, to find out what’s going on in their lives. He persuades us what we need to do to deal with our problems.”

O’Connell came of age in the 1960s, and his path into medicine was like a long and winding road. The second-oldest of eight children in a steadfastly Irish Catholic family, he grew up in Newport, Rhode Island, where his father worked at the naval shipyard and his mother taught grade school. When he graduated from Notre Dame in 1970 with a philosophy degree, the war in Vietnam was at its peak and President Nixon had just instituted the draft lottery. O’Connell opposed the war and was caught up in the spirit of the times. “It looked like there could be a much better world,” he tells me.

O’Connell was lucky, drawing a high draft number that kept him out of the war. So after graduation he traveled, studying philosophy and theology at England’s University of Cambridge, then teaching high school in Honolulu for a few years. From Hawaii he bounced to Manhattan, where he briefly pursued a doctorate at The New School under the social philosopher Hannah Arendt, famed for her studies of Nazi atrocities and her concept of the “banality of evil.” When Arendt died shortly after his first semester, he drifted back to Newport and tended bar down on the waterfront. Soon restless again, he saved his tips, pooled the money with some friends and bought an old dairy barn in remote north Vermont, which they converted into a commune of sorts. Up in the woods, he lived sparsely, read a lot, skied all winter, rode motorcycles and talked late into the night with his housemates.

As his 20s drew to an end, he felt pulled toward a more conventional life, and after witnessing a serious motorcycle accident finally set his mind on a medical career. He would practice in rural Vermont, traversing the countryside, doing house calls like a figure in a Robert Frost poem. Returning to Rhode Island, he earned the science and math credits he needed for medical school, then mailed out some applications. He was 30 years old. “I held out from going into the traditional world,” he says. “Many of us from that time tried to do alternative things. We drifted back into the mainstream.”

He entered Harvard Medical School in the fall of 1978, and his vision of a solo practice in the woods began to yield to the fast pace and high stakes of big-city medicine. And in his third and final year of residency in internal medicine at Mass General, he won a prestigious oncology fellowship at New York’s Memorial Sloan Kettering Cancer Center, to begin in the fall of 1985.

Late that summer, however, Dr. John Potts called O’Connell into his office. His Mass General boss and mentor had a proposition. A pilot health care project for the homeless was in the works, and it needed a full-time doctor. Was he interested? It would be like an urban Peace Corps, Potts suggested, something good to do for a year. O’Connell liked the idea; he hadn’t lost the spark of his late-’60s idealism and social consciousness. So he committed to the project — but for just a year and on the condition that his Sloan-Kettering fellowship still be available when he finished. Potts made the arrangements, and O’Connell left Mass General that August to lead the embryonic Boston Health Care for the Homeless Program.

He knew little about the homeless or their health problems. Yet he was hardly alone in this respect; for much of America, homelessness was a new and frightening thing. In the span of about a decade the urban street population had exploded, and no one knew exactly why — nothing like it had been seen since the Great Depression. Municipal health systems reeled, with unprecedented numbers of homeless people dying on the streets or flooding emergency rooms in medical crisis.

Policy makers and public health advocates eventually took notice, and in 1984 the Robert Wood Johnson Foundation, the nation’s largest health-oriented philanthropy, launched a national pilot project on health care for the homeless. The initiative provided 19 big-city mayors across the country with $1.4 million grants distributed over four years. There was to be little central planning; cities were to experiment and innovate, then report back on successes and failures. O’Connell’s new job was to kick off the project’s Boston effort. He saw the posting as no more than a feel-good detour on the road to a serious career in oncology. “I was only going to do this for a year,” he says.

Two days after finishing his residency, at the age of 37, he walked into the Pine Street Inn, the oldest and largest shelter in New England, for his first day of work. The shelter, located in the old Central Fire Station, an iconic brick building with an Italianate tower, had 700 beds and was ground zero for the homelessness crisis. Since 1969, it had hosted the city’s only dedicated clinic for the homeless, run largely by volunteer nurses from nearby Boston City Hospital. Barbara McInnis, a nurse with the Massachusetts Department of Public Health, had been assigned to the clinic since 1972 and was the resident expert on the homeless and their health care needs.

In his book, O’Connell depicts McInnis as a skeptical, brassy Virgil to his naively confident Dante. “You’ll have to forget much of what you were taught in residency,” she informed him at their first meeting. Mass General interns were trained to be fast and efficient, not to waste time in chitchat with patients. But that approach didn’t wash in the shelters, McInnis warned him. He soon found she was right. Street people tended to be wary of strange doctors, and before he could treat them, they needed to trust him. “You’ve got to listen. Have a coffee. Share something about yourself,” O’Connell says. “Which is all completely against what we were taught to do.”

He had little time to get his bearings before a double-barreled crisis — a simultaneous outbreak of AIDS and drug-resistant tuberculosis — hit the street population. Isolated cases of both diseases surfaced at the Pine Street Inn within weeks of his arrival and spread rapidly from there. Tuberculosis was deadly but at least a known quantity, having long stalked the homeless. Yet AIDS had never been seen before in the shelters. There was no cure and no treatment, not even a test for the virus. Diagnosis had to wait for the emergence of rare cancers and opportunistic infections that flourished as the body’s immune system withered. The afflicted wasted away, went blind and lost their minds to dementia.

“It was the most frustrating thing I’ve ever seen. You could treat the infection, but you couldn’t treat the underlying virus,” O’Connell says. “Some people got better, but they only got better to get sick again.”

The experience was haunting. “It hit the community hard,” he says. “It was really the worst. We watched a lot of people die.” The outbreak also exposed what he considered the medical system’s fatal indifference to the unique needs of the homeless. Even without treatment, AIDS takes time to kill, yet the sick and dying among the street population had nowhere to go for even rudimentary long-term care. They landed in city hospitals, only to be quickly discharged back to the streets or into shelters with no capacity to care for them. “We just started getting creamed with people who were really sick, who had no place to go except a shelter or the streets, but the hospitals were saying they were done with them,” O’Connell says. “It became a screamingly clear indictment of a system that doesn’t have the right tools. The continuum of care for a homeless person had a big gap in it.”

To fill that gap, he and his team created the country’s first medical respite unit, where homeless people who were too ill or weak for the streets but not sick enough for hospitalization could rest and heal. The unit began with 25 beds in a corner of a state-run shelter, but demand for beds far outstripped the supply. Eight years later, O’Connell and the BHCHP managed to buy an old nursing home in Boston’s Jamaica Plain neighborhood, and the unit soon tripled in size. “It was the first time we had our own place,” says O’Connell, who named the building Barbara McInnis House.

The outbreak of tuberculosis precipitated another set of innovations. To halt its spread, the sick needed prompt and aggressive treatment, something easier said than done. The full medication course then required four pills a day over 18 months, a high bar for the itinerant street population. Making matters worse, many of those who contracted the disease in the shelters had fled to the streets, fearful of returning to the place where they’d been infected.

To find their patients, O’Connell and his staff fanned out across the city, combing alleys and parks, lonely stretches of riverbank, train stations and dive bars. They did check-ups and distributed pills, occasionally in unorthodox ways. “If we knew you drank at J.J. Foley’s every afternoon, we could leave the medicine with the bartender,” O’Connell says. The program worked. Almost everyone finished the treatment, no one died, and the outbreak burned itself out.

Getting to the streets proved eye-opening. O’Connell found a whole strata of homeless people — a group he dubbed the “rough sleepers” — existing almost totally beyond the reach of the city’s safety net. Disdainful of the crowds and rules of the shelters, they lived outside in all but the harshest weather, sleeping under bridges and in tunnels, in doorways and abandoned cars, alone and in small encampments.

The rough sleepers were in terrible shape. Many had avoided doctors for decades, even as their health declined precipitously. Their worst problems often were easily treatable conditions that had spiraled out of control. “They had diabetes that they hadn’t ever talked to anybody about. Bad emphysema and no one had ever treated them,” O’Connell says. Even in medical crisis, some refused to be hospitalized or even visit a shelter clinic. So O’Connell and his team treated them on the street as best as they could. “Disaster-drill type of care,” he says.

Between the streets and the shelters loomed a lifetime of intense and challenging medical work, with problems of health entwined with conundrums of psychology, economics and public policy. It had the feel of a calling, not a brief sideline. When his first year on the job came to an end, he decided to stick it out a bit longer. “I barely understood what I was working on,” he says. “I needed at least another year.”

It was not an especially difficult choice. O’Connell found that work among the homeless suited him. He was intrigued by his patients’ medical quandaries but also fascinated by their stories, where they had come from, the strange and meandering paths of their lives. The truth, when he could ferret it out, was rarely what he imagined. “Things are seldom what they seem on the streets or in the shelters,” he writes in Stories from the Shadows.

He developed a special sympathy for the rough sleepers. Fiercely independent and self-reliant, they seemed to him like nomads lost in time, the fading echoes of an older, wilder America. A few raved like Old Testament prophets, railing apocalyptically against decadence and corruption. Others had the vague air of outlaws, their backgrounds deliberately murky and their identities cloaked by street names: Bear, Indian Jimmy, John Hennessey. All seemed to drag long trains of grief and tragedy, misdeeds and misfortune. Many kept their secrets even in death, their bodies unclaimed at the morgue and finally laid in anonymous graves.

Thirty years down the road, the rough sleepers are out there still, and so, too, is O’Connell. Every week, he hits the streets, checking the old haunts, asking questions, seeing who’s around. He calls these walkabouts “street rounds,” and the day after that Thursday clinic in January, invites me to tag along. We meet in the morning in the Mass General lobby and head out from there. The work can be a cold slog in winter, but today it’s mild for the season, with the sun shining and the temperature hovering in the low 40s. O’Connell wears blue jeans, a wool sweater and a faded Notre Dame baseball cap, and carries a small knapsack over one shoulder that holds a stethoscope, a blood pressure sleeve, a first aid kit and some other medical essentials.

We go west, up the wide, red brick sidewalks of Cambridge Street. Fit and trim, his face ruddy in the brisk air, O’Connell moves at a steady clip, chatting enthusiastically. If working with the homeless is wearying to body and soul, he shows no signs of it; after decades on the job, he appears remarkably positive and betrays no trace of burnout. He seems to have achieved an equilibrium, one weighted decisively toward altruism without tipping over into zealotry.

A few blocks up the street, we stop at a sort of alcove tucked between a Bank of America and a small library branch. It’s a stealthy little spot, public yet private, enclosed on three sides and shaded by trees. This morning a small group of street people, four men and a woman, gather there in the shadows, passing around a plastic half-gallon of cheap vodka. O’Connell strolls up casually, smiling and greeting everyone. His arrival has a scattering effect; the drinking circle breaks up and the vodka disappears into a duffel bag. O’Connell quickly zeroes in on an older man slumped in a wheelchair. He’s missing a leg, and his haggard face is mostly obscured by a low-slung knit cap and the bunched folds of a grimy parka.

“Good morning, Mike. How’s it going?” O’Connell says to him mildly. “I’m doing alright, Dr. Jim,” Mike replies, all evidence to the contrary. He’s slurring badly, almost unintelligible, and his sweatpants appear to be soaked with urine. O’Connell kneels down and listens as Mike unreels a hard-to-follow story involving some lost money. “We need to get you back in the hospital,” O’Connell says finally. “Is that okay?” Mike blinks hard and something like regret passes over his face. “Yeah, I’ll go,” he says after a long beat. “Great,” O’Connell says. “Let me work on it.”

He takes out his cell phone and makes a call that lasts for a few minutes. When he’s done he has good news: There’s a bed for Mike at McInnis House, the BHCHP medical respite unit. Minutes later, a white van pulls to the curb and its side doors pop open. It’s the agency’s own medical transport van, which by chance was around the corner. The driver helps O’Connell load Mike and his wheelchair on board, then shuts the doors and pulls back into traffic. As the van disappears, O’Connell jots some notes in a small spiral notepad. Soon we’re walking again. “Let’s see who else is out here,” he says.

His street practice has evolved over the years, O’Connell says later that afternoon as we sit in his cozy office on the first floor of his South End headquarters. Most importantly, the homeless are no longer uncharted territory to him and his staff. “Most of these people we’ve seen many times, and we’ve got them in a system,” he says. “It’s not like you’re starting at square one anymore.” And there is much less demand for the urgent, first-aid style treatment that predominated in the past. "I can go out some days and not pull the stethoscope out of the bag.”

Yet here his work can grow thornier than ever. If the surface debris of acute and chronic ailments is swept away, what lies underneath may be more complex and deep-rooted. These core ills, the devastating addictions and furies of profound mental illness, can resist even heroic interventions; the trajectory into chronic homelessness tends to parallel a long road of failed treatment. His severely alcoholic patients, for instance, have typically tried everything to quit: multiple rounds of detox and rehab, Alcoholics Anonymous, behavioral therapy, inhibiting medications like Antabuse and naltrexone. Yet nothing takes; they relapse and go back to drink, even unto death. At this late stage, O’Connell says, medicine should be seen as the art of the possible, and progress measured by degrees.

“There’s an outcome issue that we often deal with,” he says. “Does success mean that they’re not going to be homeless anymore? Can you do enough care that somebody will get a hopeful, productive life happening again?” It can be tempting, particularly for his newest doctors, to strive for such transformations. It falls to O’Connell to keep expectations in check. While these outcomes do occur, they are not the norm. “If that’s what you’re looking for, you’re going to burn out tomorrow,” he says.

Instead, he urges his staff to focus on the here and now. “Whatever is bothering you today, let’s try to fix that and give you at least enough hope so we can start again tomorrow,” he says.

At the end of the day, I follow O’Connell on a final swing through the respite unit on the third and fourth floors. Like the rest of the building, it is clean and modern and quietly bustles with activity. The unit serves many purposes: detox, pre- and post-operative care, rest and recuperation for cancer patients on radiation. “We do an awful lot of end-of-life care,” he says. A few rooms are singles but most house four to six people, and all have private showers and lockers and televisions with headphones. Hospitals throughout the city, and even outside Boston, routinely refer patients here, and beds are in high demand. “We save the hospitals a ton of money,” O’Connell says. Every day, they turn people away for reasons of space.

We stop outside a partially darkened room with the door slightly ajar. Lying on a bed by the window is Mike, the man in the wheelchair from the morning, fast asleep, a blanket pulled up to his chest. A beam of blue light from under the shade falls across the white stubble on his chin. He looks peaceful. Mike is a tough case. In an earlier life, he captained a lobster boat somewhere up the coast. He’s been on the street for many years now, to the point that he’s considered an “anchor,” one of the old-timers. A rough sleeper, his missing leg was lost to frostbite. “He’s a really substantial person when he gets sober,” O’Connell tells me later. “His problem is drinking and the call of the streets.”

As his doctor, O’Connell’s first challenge is always to get Mike to accept help, to come inside, to take another chance on recovery. It requires a light touch and just the right amount of pressure. “He’s his own person. When I see him, I ask if he is ready to go. I don’t push him any further, because he won’t be moved,” he says. “When Mike says he’s ready, you can’t wait.”

John Rudolf is a freelance writer based in Portland, Maine.

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