By Larry Kravitz, MD
Why write about courage in medicine now? Simply because we are witnessing an erosion of ethics, truth, science, and altruism in our society. Not that the world has become a vast Sodom and Gomorrah, but we are seeing more amplified abandonment of idealism in front of us daily, and I have found myself more and more challenged to find public leaders embracing selflessness. It is more tempting to abandon ideals when society doesn’t seem to value them anymore. So let us look back on an era where Washington, D.C. was once referred to as “Camelot” and idealism was the dream of the entire American realm, and let us decide together to still be courageous.
The idea for John Kennedy’s 1955 Pulitzer Prize winning collection of essays, “Profiles in Courage,” was perfect. The young Senator Kennedy prepares for a future of statesmanship and service by delving back to find beacons that could light his way forward in government.
Maybe we don’t want to laud too many accolades on President Kennedy. “Profiles in Courage” may well have been ghostwritten by others. And Kennedy himself was clearly quite imperfect. It is generally agreed that the man misused steroids, amphetamines, and antibiotics while in the White House.
Though we may distance ourselves from the man himself, I would still embrace the concept of Kennedy’s proposal: that we remind ourselves of examples of selfless commitment in hopes of finding the same within us. And so I offer this profile in courage, which involves facing the impossible monster of caring for the homeless. It is a case of bringing courage to a task where there is often little hope for success, and little vision that anything will ever change.
NANCY IN THE ICU
On weekends, I work in an indigent psychiatric hospital; four floors full of depression, psychosis, substance abuse, anxiety, and despair. Behind an unbreakable Plexiglas barrier, we sit at a table in the nursing station of the third floor psychiatric ICU. There’s always a swaying body staring at us, mumbling or chanting, sometimes banging, sometimes pleading, sometimes singing, sometimes crying, and all psychotic. Here we handle all those people at the periphery of our lives. The guy standing on the street corner screaming obscenities as the cars go by. The drunk who got hit in the middle of an expressway. The woman who jumped off a bridge. The guy who called in a threat to kill the president.
Most of them drift through a revolving door of homelessness and hospitalization. When they are wandering aimlessly behind the window across from the nursing station, they are not evil, racist, ungrateful, criminal, irresponsible, stupid, or abusive. Pathetically, they’re just psychotic. And if they end up here, the system simply failed.
When I first met Nancy Miller, she was just another nurse at the table. Shift on. Shift off. She would not see herself as any different than anyone else there in scrubs. She treats patients as they are. She doesn’t project good or bad or say they are trying to manipulate us. They are broke, and we care for them as best as we are able. We fix what we can, without judging. We take care of their burden on society. We are managers of this particular human community chaos. It is our assignment. It should be done with humanity and practicality. Dispassionate and compassionate at the same time.
Medical care for the homeless. The problem haunts us. It’s hard to get our heads around it. It gnaws at the edges of a doctor’s grand perspective of health care. Save $5 on a generic med here and avoid an unnecessary lab test there; and yet the next day the homeless show up in the ER and spend $30,000 on pancreatitis from drinking alcohol. Why do we even try?
Because it turns out there are answers. Nancy Miller, RN, is part of an answer.
I’m going to talk about Austin, Texas, and you can think about your own city. In 2016, Austin had a little over 2,000 homeless people at any given moment; 1,300 in shelters; 800 on the street. Twenty-two percent are chronically homeless. Twenty percent are children. Fourteen percent are veterans. Forty-five percent have a current mental health problem. In the last six months, 63 percent have been to the ER (average $1,400), 20 percent have been taken to a mental health hospital ($1,500/day), 40 percent have used an ambulance ($880), and 33 percent have been hospitalized ($4,800/day). The health care expense staggeringly decreases once a homeless person is housed.
COMMUNITY FIRST VILLAGE
Two years ago, Nancy Miller and her husband became one of 17 missional families. She picked up from her comfortable, large suburban Westlake home, and moved into a tiny trailer at Community First Village, becoming a resident in a 27-acre community in East Austin with affordable, permanent housing for the chronically homeless.
Alan Graham is one of the founders of Mobile Loaves and Fishes, the organization that built this community. He described the idea in a December 2017 Austin Monthly article: “My model simply came from looking back at spiritual leaders over 2,000 years and what they do. Mother Teresa chose to go live in the bowels of Calcutta, India. Francis of Assisi gave up extraordinary wealth in order to go live and be amongst the lepers. And the population we’re dealing with are the most despised outcasts of our community — the chronically homeless. The men and women who are stereotyped as drug addicts, alcoholics, crack addicts, glue sniffers, prostitutes, gamers, hustlers.”
More about Community First Village. There are 140 residents at any given time. There is some rent. Everybody does some work. That work is nominal — maybe not what you or I call work. Twenty residents have left. Of those, eight went to their families; eight went to jail (weapons or substance abuse). Currently, two dozen are active alcoholics. Some are still on meth and crack — yes, they are. Some are chronic psychotics. All have PTSD of course, rape, assault, and other horrors, as you can imagine. Despite best efforts, the population is still preyed upon by criminal elements.
How do they handle danger? They dial 911, same as anyone else. They do have aggression reduction training for staff. Generally, the police love Community First Village, as the alternative for many of these people is constant run-ins with law enforcement.
The village now has a trailer rehab facility, and a trailer hospice, too. There is a public health clinic three days a week. An average dwelling is 180 square foot, as per the city minimum requirement, basically one room, for a cost of about $25,000. The dwellings have electricity only. Plumbing, cooking, and laundry are at communal buildings. Food is grown in the gardens. There’s an outdoor movie theater, a small store, an art studio, a machine shop, a bed and breakfast (imagine that), and social science internships with universities. Housing on 24 more acres will open soon.
BECOMING NANCY AND THE NATURE OF COURAGE
As Nancy says, “Maybe it’s built on previous steps.” Her story starts as a nurse married to a doctor with five children in an upscale suburb. She began training for nursing pastoral visits and then went for a masters in counseling. Next, she left nursing for a private practice in counseling. Then divorce happened after 30 years of marriage, along with a neck injury and spine surgery. Painful time passed. She married again to a cardiac nurse. Eventually she was back working, transitioning to psychiatric nursing. Then she and her husband moved to Community First Village. These are how the dots connect.
What do I want to say about the nature of courageous choices? Which events on that timeline required the most courage? Rank ordering them, I think the divorce took the most courage. This was the hardest time in her saga, the time that summoned the most courage and strength.
Devoting your life to the homeless may take courage. Putting yourself and your family back together after divorce, common though it may be, is a harder act of courage. But women like Nancy do that every day. Everyday family courage is more challenging than any ethical medical courage. Nothing we do in medicine matches the courage we must muster to weather family stress all the time. That’s the twist to consider.
Just for the record, there’s more to her “leap” to the homeless village. “It’s a pie chart,” she says, and faith is just one piece of the pie. For Nancy, living in the village is egosyntonic; it is in harmony with who she is. “The population is attractive to me.”
Although there is no precedent in the U.S. for what they are building at Community First Village, the prospect of being a pioneer wasn’t what enticed Nancy. She was drawn by what she calls the “creativity of maintenance,” working out how to keep things going, or as she says: “Figuring ways to keep the plate spinning on the pole.”
Nancy felt the need to pay back. I hear that a lot from volunteer faculty for medical schools as well. “Someone taught me,” they say, “and I was thankful, so I wanted to pay back.” It’s so universal. What is that emotion, the “pay-back” emotion? Why is that such a big piece of our medical motivational pie?
How does she deal with moments of doubt and adversity? What were her disappointments? “I thought I would be doing more.” The lesson of medical courage is that, in the end, you must look in the mirror and face how all the phenomenal energy that you threw to the task didn’t really do that much.
What was the scariest thing? “Immersing myself in the people. … Fear of harming them, being pointless, or being rejected.”
It’s funny to think about being scared of rejection by the homeless. But this is their community. And Nancy Miller is a suburban do-gooder. The homeless can see right through that part of her. It’s worked out. They have made peace with that.
How does she deal with boundaries between herself and the homeless? Money boundaries? Social boundaries? One goal in medicine is to practice with enough warmth that patients yearn to cross boundaries. And part of the strength and the drain of medicine is having firm but warm boundaries. It’s a challenge. “It’s new every day,” Nancy says.
John Kennedy’s book explored courage. For now, let’s not say that Nancy Miller, our muse in this endeavor, is courageous. In the end, she would never be comfortable with that. It’s just where her life ended up. But go ahead and be like Nancy anyways, in any way you can. Is this courage? You can’t always get perspective when you’re immersed in your commitments. Yet Nancy does show us a path to extraordinary acts; and that there is a journey in our everyday lives to something that is both accessible and exceptional.