Nikhil Bamarajpet and his mom had become homeless, living on Long Island among others in the same position. One night, a man in their group doubled over with excruciating pain.
EMTs eventually came, but “it took them longer to arrive than they stayed,” said Bamarajpet. They dismissed the man’s pain and said there was no room in the hospital, anyway, and then left. A few days later, the man died.
Bamarajpet was only 12, but he knew something about the encounter wasn’t right. At the same time, what could people living on the streets do about it?
That’s how Bamarajpet learned that medical care is a matter of life and death—and it’s when he decided he wanted to be a part of it. Later, when he began applying to medical schools, he wanted to find one that had an outreach program for people experiencing homelessness.
He researched the Street Outreach Program at the University of Rochester School of Medicine and Dentistry and was impressed. Today he’s a second-year medical student at Rochester, where he co-leads Street Outreach with Haley Chesbro—and has plans to expand it.
Bamarajpet’s story—from homelessness to medical school—is testament to the value of the kind of program that helped attract him to Rochester. He himself was helped along the way, including financially at Rochester as recipient of the Dr. Frank Fowler Dow and Harriet Brown Dow Scholarship and the Dr. Jean D. Watkeys Medical Student Scholarship.
The larger story is what the Street Outreach Program teaches medical students. Bamarajpet called it “one of the best learning experiences that I think you can get in medical school.” The founder of what would become Rochester Street Outreach, Emma Lo (MD ’15), came to her career in Psychiatry in large part due to her experience with the program. She’s now assistant professor of Psychiatry at Yale School of Medicine.
She’s also medical director for the Street Psychiatry Team at the Connecticut Mental Health Center, furthering the kind of outreach she began in Rochester.
Both Bamarajpet and Lo talk about the invaluable things they learned as they tried to help people living day to day, in encampments or on the streets.
Classes teach medicine, but Street Outreach helps teach how to connect with patients in ways that most students would never expect. It asks student volunteers to have hope for people who have sometimes lost all hope themselves, mirroring how society tends to view them. At times, these volunteers are trying to support people who have nobody else left who believes in them.
If the future of medicine depends on more equitable health care, participants in this program would say that learning on the streets of Rochester is helping to prepare them for that future.
What They Need, What They Learn
Rochester Street Outreach began in 2011 as UR Street Medicine, to help Rochester’s unsheltered population living under bridges, in alleyways, or in public parks.
Lo, the founder, had been an art major at Haverford College, where she built her senior thesis around portraits and sculptures of people who were experiencing homelessness.
“My goal with the project was to show the faces of homelessness and show these are the real stories that people have,” said Lo.
That same year, she met Jim Withers, MD, one of the founders of street medicine. He allowed her to shadow him in his work with Operation Safety Net in Pittsburgh. That experience and a year with Americorps set her direction: She would pursue medicine, specifically to serve people who are often isolated from the medical community and society in general.
“I really couldn’t imagine going into medicine for any other purpose,” she explained. “And so, when I came to Rochester, I had this dream in mind that this is what I want to be doing.”
But she wasn’t the type to wait. In her first year, Lo would hop on her bike to explore her new city, looking for people who were unsheltered. She knew the school wouldn’t have liked her exploring alone, but she wanted to see if a need for outreach even existed.
She was uncertain—until she met a man named Hubert, who had been living on the streets but had turned his life around and found housing.
“Hubert knew everybody who was unhoused in Rochester and knew where they were and could bring me there,” Lo said. “A lot of my initial work was just going with Hubert to places where people were staying—in the parking garage, in town spaces.”
Jared Lunkenheimer (MD ’14) was an early volunteer with the program. Others joined them along the way. Tuesdays and Thursdays, around 7 p.m., a handful of students would carpool downtown. They made rounds on the streets and parking garages, carrying a backpack of simple medical supplies and any other items they could gather: socks, fruit, granola bars.
At the insistence of the Rochester Police Department, they also carried a two-way radio that could summon officers even where cell phone service might not reach.
Sometimes the students would struggle to find people. Other times, the people they approached made it clear they didn’t want their help.
But one defining moment came when Hubert brought Lo to an encampment area by the train tracks where people were playing cards. Lo decided to stay and learn the game they were playing. She didn’t push health or medicine. She simply played cards.
“Looking back on it, it was a test,” said Lo. For people who had difficult associations with health care, trust had to come before anything else. Many were grappling with mental health issues and substance-use disorders, as well as the stigma that goes along with them. Some had felt judged in past visits to emergency rooms. Many felt they weren’t presentable enough even to walk into a clinic.
By spending time with them on their terms, Lo passed the test. After that, Hubert would introduce her, saying, “This is Emma. She played cards with us on the train tracks.” It was a signal she could be trusted.
But she soon learned that trust didn’t necessarily lead where she had expected.
“I think initially, I thought we were going to offer formal medical care.” But many of the people they encountered didn’t want medical help.
What they did want was someone to truly engage with them and show them respect. The key, she realized, was to “show them that you are somebody that cares about them when potentially their entire family, everyone they've ever met, has disappointed them or traumatized them and hurt them.”
She called this realization one of the most important things the team had to learn. The focus turned to listening and building relationships. Even as the program grew connections with community groups and medical clinics for referral, and even as Lo scored a major victory by recruiting Lois Van Tol, MD, as the program’s preceptor who could offer medical care, the volunteers learned that other problems had to be addressed before medical ones could be.
One man Lo tried to help on a hot July night explained he had lost 50 pounds due to his “vodka diet.”
“Why do you drink?” she asked him.
He thought for a bit. “To try and forget all this. I try and erase it from my mind. But sometimes it just doesn’t work anymore. I stepped up to the plate! I stepped up to the plate,” he said about his time serving in the Vietnam War. “They wanted me to shoot people. I didn’t want to shoot nobody, but I had to. I didn’t want to do it, but I did it. Some people went to Canada. Cowards. I stepped up to the plate.” He was crying now.
Lo had been collaborating with community groups that could offer hotel stays for those in need. She tried to convince the man to take a room in a nearby hotel, but he hesitated—Lo sensed the man didn’t feel he deserved it. Yet, he explained that sleeping outside was dangerous because of what he called “the vermins”: the people who showed up to harass the homeless through the night. He demonstrated by holding one eye open as he pretended to sleep.
Finally he agreed to the overnight stay. When they took him to the room, the bed wasn’t made up. In her notes for that night, Lo wrote: “It was unclear if the manager had done that on purpose or if it was an honest accident.”
They brought him to a different room. It was swelteringly hot inside. “I could see how he’d prefer to sleep outside,” Lo wrote. “To be honest, I would have, too.”
It was one of many teaching moments, when Lo and her fellow volunteers learned how complicated it could be to try to help this population. It wouldn’t be the last.
The Homebuilder Without a Home
On a warm evening in August, Nikhil Bamarajpet drives his Ford Bronco to Industrial Street between the highway and train tracks in downtown Rochester. He parks at Peace Village, the city encampment for people experiencing homelessness, and unloads supplies: juices, hot water for coffee, bagels, and two kinds of sandwiches.
The program brings food donated from St. Peter’s Church in Rochester and the medical center’s SNACCs volunteer group. Today, Bamarajpet also prepared almond butter sandwiches himself.
Peace Village consists of sagging tents, small hut-like structures, a metal-handled spigot for water, and not much else. Without those things, the space would blend right in with the urban emptiness of the landscape.
Bamarajpet sets up at a makeshift table—really a large, wooden cable spool turned on one end—and calls out: “We’re here from Rochester Street Outreach! We’ve got some food, we’ve got some drinks. Juices. Rochester Street Outreach.”
Two women and a man walk over, and Bamarajpet greets them. “We have coffee,” he says. “Would you like me to make you a cup?”
The man says, “Sure,” joining the others in choosing a sandwich. One woman takes two sandwiches and says, “Thank you so much.”
Another man approaches and tells his story. He was born in Miami but after his mother died, relatives in rural North Carolina took him in. That’s how he got the nickname “Country.” When needed, he says he goes to work fixing up rental properties for his brother.
“Plumbing, floors, roofs, drywall—I can do anything with houses,” he says.
He used to live with his brother’s family, but tensions arose, so he has been living at Peace Village for eight months. “I like my own rules. When you live with somebody, you gotta live by rules.”
Along the way, Country also learned that “the drug life goes nowhere. The problem goes away for a moment, but then it’s there afterward.”
He says they’re lucky to have Street Outreach bring things they need—shoes, socks, sleeping bags, and other items, much of it donated by medical students. He says counselors visit occasionally. But so did the river rats. “Thousands of rats. The rats were bigger than cats. Cats wouldn’t mess with them.”
Still, he says he won’t accept outside help to get him off the streets. “I put myself here. I gotta get out of here myself.”
Later Bamarajpet says, “How ironic—Country builds houses but he doesn’t live in one.”
Usually, four or five program volunteers go out on a shift—including some nursing students—twice a week.
On Thursdays, they also visit Open Door Mission homeless shelter, where Mike Hudson, MD, runs Regional Health Reach, a federally qualified health center that provides medical care to people experiencing homelessness in Rochester.
Bamarajpet calls Hudson “a great role model for medical students” because he understands that this population can be fearful and skeptical of the medical system.
Bamarajpet has seen how Hudson’s slow, patient approach with people who are experiencing homelessness helps build trust. Letting the patients lead the conversation can create a rare moment in which they feel they’re in charge and important enough to be heard.
It's vital that the outreach effort and the medical clinic take similar approaches, because it can take a lot for Street Outreach to establish a relationship and persuade people to go see Hudson. When that trust is honored in a medical setting, “they leave the clinic happy that they could get help,” Bamarajpet says.
Likewise, Hudson sees immediate and long-term benefits of the learning experience.
“At the shelters, students see mental health pathology and addiction that they only rarely would experience in the outpatient setting,” he explains. “And beyond getting to talk with residents of the shelters and understand their personal and medical histories, they get to learn about and witness firsthand the structural violence that creates a society where so many people are pushed to the margins and left to fend for themselves.”
In an important way, Bamarajpet sees this as a perfect complement to classwork: “In a course about the brain, you might learn about problems of the brain. But you never see the human behind the problem. You never see the problem behind the life. We learn about diseases in the class. When I’m out, I see how that disease affects someone’s life.”
Back at Peace Village, the sunlight is fading. Bamarajpet begins to pack up. The food is gone, to the disappointment of a man who arrives late to the table. Somehow, as if intuitively, the woman who took two sandwiches returns and gives one to the man.
As Bamarajpet walks toward his car, a man in a colorful jacket steps forward. He had been on the outskirts, observing silently. Now he walks closer.
“What are you doing here?” he asks. “Why are you here?”
“Because I care,” Bamarajpet answers.
Soon the man is talking—about his struggles, about being good at heart. “I just need some guidance,” he says. His name is Peter. Bamarajpet shakes his hand and gives him a hug.
It’s the first time Peter has come over to engage with Street Outreach. “He just needed someone to listen,” Bamarajpet says later. “A large part of what we do is just listen.”
On his way out, Bamarajpet asks Peter if he needs anything.
Peter doesn’t hesitate. He would like a chess set. “Checkers, chess. I play all that,” he says.
Bamarajpet nods. “I think we can arrange that.”
How to Be Radically Patient-Centered
Early on, Lo stated a goal of the program was “connecting homeless people with medical, social, and psychiatric resources in the community.” What she and others discovered through the years was that many in the unsheltered population didn’t share that goal.
“It’s so easy in medical care and any service field to think, ‘This is what I can offer—I should be giving that thing to this person,’” Lo says.
But that can easily turn into a “take it or leave it” approach. If someone doesn’t seek out care, it’s easy to assume they don’t need or want it. People experiencing homelessness often do need care, but they face too many barriers. So Lo turned to what she calls being radically patient-centered or radically person-centered.
“It’s really about truly, truly listening to what the person wants for themselves,” Lo explains. Often, she found that formal medical care wasn’t what would lead to a meaningful intervention—it was hearing out people’s stories of injustice and trauma that began to help. Her instinct might have been to get someone into rehab or housing, but what that person wanted first for a better life was, say, to reconnect with an estranged son.
One person the team met would drink every day and lash out at people. He had a lot of medical problems but was difficult to approach because of his behavior. The outreach team worked with him for more than two years, starting with simply saying hello and tolerating him.
They stayed respectful—for months. “Eventually he would invite us over and say, ‘These are my sisters. These are the people that care about me.’ And because of that relationship, we were able to advocate for him getting housing.”
His behavior had led him to be banned from housing in the past. “We kind of felt like we were the only people left to believe in him.”
Once he was housed, “he almost completely stopped drinking on his own, without any kind of medications,” Lo says. “He was so grateful. I think he didn't see us as much as providers as his extended family.”
In this case, “radically patient-centered” meant being radically patient. It also meant addressing a root cause of this person’s medical issues, not the issues themselves.
What made the outreach team not give up?
Lo says, “I think partly because we, in our hearts, knew that there was no one else out there for him.”
The Future and Legacy of Outreach
Program participants say what they learn through outreach can have a career-long effect. Lo says the hope is that volunteers, even if they do this kind of outreach for only a few sessions, will see their future patients in a different light.
Even a health care provider in a highly specialized realm, she says, will inevitably treat an unhoused patient or one who presents challenges to care. The provider might be in an office setting, but ideally they would remember the people they encountered on the street, and that will help them better understand the person in front of them.
In her career, Lo says, she has seen how the system can lead to certain patients being "dehumanized and judged and labeled, and they don't get proper care because of that.” Street Outreach, she says, helps answer the question, “How can we humanize that group and be able to build practitioners who are empathic?”
Once students become physicians, they’re in a position to do more. As a resident in the Yale School of Medicine, Lo shadowed a street-medicine program in New Haven and learned there was no psychiatric component to it. She created an elective to start doing street psychiatry, then was promptly called into an overdose emergency in New Haven that made national news.
The pilot work she was doing was seen as a potential solution. In just a few months, her team was able to get funding to start a full outreach program and hire a clinical social worker, program manager, recovery coach, and Lo herself once she graduated from residency.
“We go out four days a week to different areas of New Haven, doing outreach. And still, most of what we do is engagement and trust building and relationship building,” she says.
Haleh Van Vliet (MD ’12), who first learned about street medicine while at Rochester, now practices it as an emergency medicine physician with Tower Health Medical Group in Pennsylvania. She wrote about her experience for the American Association of Women Emergency Physicians, saying: “The settings and circumstances of street medicine may be difficult to navigate, but the work is beyond rewarding.”
Van Vliet is part of a group of emergency medicine physicians who work with homelessness agencies to visit encampments and other spots so they can administer care. At a time when the business of medicine can sap precious time and energy, she describes an encounter with someone she helped as “the unadulterated, pure practice of medicine that first fueled my interest in becoming a physician. In that moment, it was just me, another human being, and care. That’s it.”
She says that "street medicine is an opportunity to move beyond the conventional modern-day practice of health care and feed our souls, and a soul that is well fed is a soul that has more to give to ill patients stuck in the hospital."
And there's no telling when this kind of work can change lives. After all, Bamarajpet was on the other side of this as a child. He and his mother became homeless when his father, a lawyer, got lung cancer and died. They had spent all of their money on medical bills, and family members urged them to return to India. But his mother didn’t believe in “running away from your problems,” Bamarajpet said. “And she believed in the American education system.”
She looked for work, but it was difficult for her. They slipped into homelessness and only recovered when an old family friend found her a job. Bamarajpet saw a lot of suffering along the way, and it made him want to be in a position to help someday.
Now, Bamarajpet would like to bolster the medical side of Street Outreach with more funding and donations. In the meantime, he and his fellow students continue to make connections and help however they can. After the conversation with Peter at Peace Village, he used some of the program’s funds to buy him a chess set.
But the next few times the group visited, Peter was nowhere to be found. The chess set stayed in the backpack, ready when Peter is.