Dr. Catherine Crosland is an internist with years of experience in street medicine. Currently, she is the Medical Director of Emergency Response Sites for Unity Health Care in Washington, D.C., and works on the Clinicians Network Steering Committee for the National Healthcare for the Homeless Council.
What brought you to pursue a career in medicine?
When I graduated from college, my father asked me “what do you want to do with your life?” and when I told him I wanted to address poverty, he said “That’s great. It’s not a job.” So, I spent a long time trying to figure out how I could make a meaningful contribution. My dad was a civil rights lawyer and one of my role models, but I realized that law was not for me. I looked at a bunch of different career options and found new role models in Paul Farmer and Jim Kim, physicians at Partners in Health. I went with them twice to Peru to work with their multi-drug resistant tuberculosis (MDR-TB) project. The first time, as a pre-medical student with no medical skills to offer, I went down with my camera and basically documented their work. It was an incredibly life changing and wonderful exposure to physicians who used their medical training not only to treat patients, but also to address social issues, advocating for change, equity, racial justice, and economic justice. They took Gustavo Gutierrez’s concept of providing a ‘preferential option for the poor’ and applied it to medicine. They were even able to change the World Health Organization’s policy on the treatment of MDR-TB from one of “it’s untreatable, not worth it”—essentially a death sentence for millions of people—to “it is treatable, and we should absolutely test for and treat MDR-TB.” Witnessing their work was a really formative experience.
Then before starting medical school, I volunteered as the social services assistant at an organization called Christ House. I saw all the social issues that the unhoused patients were confronting. Simple things like establishing their identity to access services were burdensome if they lost a wallet or had it stolen or didn’t have a driver’s license. When I did my social services intakes, I was also struck by how many people had spent time incarcerated. It made me reflect on the revolving door between incarceration and homelessness, and what that does to somebody’s health. It harms both medical health and mental health and creates many social challenges, like not being able secure housing or jobs because of a criminal record.
What lead you to your current work in homeless healthcare?
My first job out of residency I went to the University of San Francisco (UCSF). I was supposed to do two months of research, but two weeks before my start date UCSF asked if I would work at San Quentin prison as a primary care provider instead. At the time, medical care in the California prison system was so poor that it was put into federal receivership. The Feds were overhauling the medical system and UCSF was brought in to make sure they implemented best practices. At San Quentin, they fired every single primary care provider because none of them were board certified! This led to a desperate push to bring competent, board-certified people into the prison, which radically shifted my plans. My job was to do chart reviews, visit the prisons, and make sure their medical policies were up to par. They put me in the “gym clinic,” which was not named for General Internal Medicine (GIM), but because it was in an actual gymnasium due to incredible overcrowding. They had 300 people living in the gymnasium. My office was a converted bathroom—fully tiled, with little indented places for bars of soap, and a toilet in the corner. I had no internet access and wasn’t allowed to bring a cell phone into the prison. Not that you could make a call through the 4-foot-thick stone walls. For resources, I had two medical reference books and a landline to call the UCSF folks for backup, but usually no one was available. I was on my own. I learned a lot about treating hypertension because so many people had it, I think in large part because of stress and the amount of ramen noodles that people ate to supplement their food.
After a year at San Quentin, I worked in New York as a clinician and educator at Columbia, then in 2009, I took a job at Unity Healthcare as the medical director for Homeless Outreach Services in DC. The mission at Unity is to serve everyone, regardless of their ability to pay or their immigration status or insurance status. It feels great to be part of a community of providers where the whole goal is providing trauma-informed care for the most vulnerable residents of DC. At Unity, we believe in meeting our patients where they are, so our clinics have always been set up where our patients are already receiving services. That may be in a shelter or a day center where the patient is meeting with a housing case manager, or getting a shower, or doing laundry, or working on getting identification, or getting a meal. We’ve also had a mobile outreach van since 1987 and teams reaching out to folks who were unsheltered. Sometimes people come to us, sometimes we go to them.
When I started at Unity, we started our very first formally defined street medicine model that didn’t use the van. Sometimes a large, 20-foot vehicle gets in the way; you can’t always get close enough to the patients because of parking constraints and traffic. So, we go out with a backpack, and partner with existing outreach programs, like shelters and day centers, meal programs, and even needle exchange. Those programs have designated, neighborhood-based ‘partner spots’ and existing relationships with unsheltered residents, so they can make introductions for us like, “Hey Mr. Jones, we have a doctor coming here Tuesday. We’d love for them to look at your feet that you’ve been having trouble with.” Then we go to the designated partner spots to take the next step and start building a relationship with patients over time. We have twelve or thirteen of these sites and, as Medical Director, I rotated through all of them. We are constantly assessing: Where are the gaps? Where do we need to be that we aren’t? We go to new neighborhoods and find partner organizations to do a trial to see how many patients we may see in that area, and then create new sites. This idea of providing care in a place that our clients already know is a safe space has been really successful.
Can you describe your experience treating homeless DC residents during the peak of the Covid-19 pandemic?
During the pandemic, people were advised to quarantine to protect themselves from Covid, or isolate if they had symptoms. Unfortunately, those recommendations don’t work for people experiencing homelessness who are living in large congregate shelters. So, colleagues at the US Department of Health and Human Services and DC Department of Health asked me to help write guidelines for shelters and looked to Unity Healthcare for guidance, as the largest provider of medical care to people experiencing homelessness in the city. Together we developed non-congregate shelter spaces focused on two primary strategies. The first strategy was reactive: create isolation and quarantine hotels for anybody who had diagnosed Covid, who had symptoms of Covid but was awaiting test results or needed testing, or who was exposed to Covid. In the early days, we admitted upwards of 60 people per day, and we had people cycling in and out throughout the entire pandemic.
The second strategy, which I advocated for early, was proactive: create protective hotels to shelter people experiencing homelessness who are most likely to develop complications or die from Covid. At the time, everybody talked about flattening the curve to not overwhelm the medical system. Our first protective hotel opened just a week after the first isolation and quarantine one; it was for anyone over 80 years of age, anyone over 70 with lung disease, and anyone under 70 on dialysis or who had cancer or any medical vulnerability. Over time we relaxed the criteria as the pandemic progressed. Currently, we have just three of these protective hotels and one isolation/quarantine hotel still running. Over three years, we served close to 2000 people and helped transition over 800 into housing. It’s a remarkable model of a unit-based setting where people who are experiencing homelessness and who are older and highly medically vulnerable, can have a private and dignified space. There’s a sense of community having their peers and medical care teams and home health aides onsite. Some folks have transitioned from these spaces into housing, with their home health aide following them. But honestly, some people will need this care for the rest of their lives, and that’s the population we’re trying to figure out. How do we maintain this model moving forward, for what we know is an increasingly older and more medically complex population of people experiencing homelessness? This is a pressing issue nationwide, not just in DC.
Are there policies you think should be prioritized to help patients experiencing homelessness?
I’d like to see medical respite care prioritized. Medical respite is very specific to homeless medicine—it’s a place for people to recuperate who are too sick to be on the street or in a shelter, but not sick enough to be in the hospital. Whether it’s getting the flu, or needing to prep for a colonoscopy, or undergoing chemotherapy, people need a place where they can access a bathroom or get wound care from a nurse or things like that. It’s usually only needed for a limited time. After medical respite, hopefully people can be moved to a better place like housing, but unfortunately, sometimes they go back to where they had been previously. Another big priority is getting rid of the X waiver* for prescribing Suboxone and decreasing that barrier for providers to be able to help unhoused patients with opioid use disorder.
*An X waiver is a certification that healthcare providers must obtain in order to prescribe medications to treat substance use disorders, and it requires numerous hours of training. Notably, providers do not need to complete this training or obtain an X waiver to prescribe the same medications for pain control.
