by Tracy Kidder, 2023

Cover image of the book Rough Sleepers

Tracy Kidder, a literary journalist who won the Pulitzer Prize for The Soul of a New Machine in 1981, has written a compassionate and personal account of the homeless community in Boston, Massachusetts, and the medical doctor who is determined to treat them wherever they are—under a pile of dirty blankets, inside a tent, in the doorway of a church, or on top of a filthy mattress.

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Dr. Jim O’Connell’s ministry to Boston’s homeless population and the mobile clinic he built to treat and serve them is the subject of Kidder’s book, Rough Sleepers. The phrase refers to those who choose (or have it chosen for them) to sleep in the rough: out on the streets, in parks and alleyways, on cardboard, in tents, “unhoused.”

In Jim O’Connell’s final days of medical residency at Massachusetts General Hospital, he’d just won a fellowship in oncology at Sloan Kettering in New York when he was called into the office of Mass General’s chief of medicine. He was asked to put his career plans on hold for a year. Boston needed a doctor to commit to a one-year program that had grant money attached to it: help create a medical program that would integrate the city’s homeless into their mainstream medical care. Boston wouldn’t get the grant money without the doctor. Jim agreed for one year. This was in 1985. In 1986, he deferred his oncology fellowship for one more year. By 1987, now fully committed to serving the homeless, he gave up on his fellowship altogether.

In 1985, on Day 1 when Dr. Jim showed up for work at the Pine Street Inn Homeless Shelter, the group of nurses who’d been working there for years, several of whom were volunteers, were less than enthusiastic about his arrival. The last thing they needed or wanted was a doctor around, “practicing” on their patients, only to pull up stakes after a year and leave. If that was his plan, they pointed toward the door. He was taken aback; this was not the welcoming committee he’d expected.

The head nurse, Barbara McInnis (a lay Franciscan), took him outside and had a private talk with him. She explained that yes, we do need a doctor here, but he’d been trained all wrong. If he was willing to let the nurses retrain him to deal with this specific homeless community, they would welcome the help. And she instructed him to put his stethoscope away, in a drawer.

They started him on, of all things, soaking feet. For the first month he did nothing else but soak feet. Homeless men spent their days standing in line on concrete for hours—waiting for food, waiting for housing vouchers, waiting to get into clinics, into shelters and out of the cold, waiting for…anything and everything. By the time they arrived at the shelters they were exhausted and their feet were in terrible shape: swollen, painful cracked skin, toenails that hadn’t been cut for years and were curled back on themselves, with athlete’s foot and trench foot. They would let him look at their feet before they would let him look at any other part of them. This first month taught him to listen to his patients. Before long, they were asking him for medicine to help them sleep, to get rid of this pain or that itch, to look at this sore that wouldn’t heal. He slowly gained their trust by being willing to soak their feet.

Kidder focuses on a few key homeless men and women that Dr. Jim got particularly close to and follows their personal odysseys in and out of Boston’s shelters, hospitals, drug treatment centers, court systems, and housing. One dominant character in the book is Tony Columbo (a pseudonym), someone who spent 18 years in prison on an assault and attempted rape charge and became homeless upon his release. On his good days, Tony acts as a mediator who breaks up fights between warring factions, protector to vulnerable females in the neighborhood and the shelter, and caretaker to a fellow homeless man who lost his legs to frostbite. As such, Jim comes to depend on him for these critical services of social director. On his bad days, Tony disappears for weeks on end and falls down the rabbit hole of drug and alcohol dependency. Jim suspects Tony is bipolar and has ADHD, but he can’t get him to stay on his meds when he’s not staying at the shelter.

One thing that becomes very clear as Kidder tells these stories of the chronically homeless: nearly all of them were subjected to some sort of severe childhood trauma. They were all failed by deeply flawed parents or foster parents, and a deeply flawed society who used and abused them. The need for understanding, empathy, and compassion when dealing with the homeless is paramount. None would choose the difficult life they are living; it has been thrust upon them.

Tony’s situation is a particular case in point. Because he was convicted of a crime, and specifically he was classified as a sexual predator, in Boston he must register with the police once a month. If he fails to do so, an arrest warrant goes out for him. Being classified as a sexual predator never disappears from your record, so it automatically disqualifies you for any kind of housing, even government-assisted housing. He was also automatically disqualified for any kind of job; no one would hire him with a rape conviction. Being unemployable and disqualified for housing meant he was doomed to a life on the streets from the minute he was released from prison—there was essentially no avenue in Boston under which he could obtain housing. There were no second chances for him or for people like him.

In 2005, Boston started their own version of “Housing First,” a program that is currently underway in Houston. The idea is that once a homeless person is provided with housing, dealing with their other issues will be that much easier. But for the next 15 years that this program was in effect, their actual results were disappointing. The finely tuned skills for surviving in the outdoors didn’t translate well to living indoors. Jim knew of one person who actually pitched a tent inside his apartment, to make it feel like “home.” Others never used the TV because they didn’t know how to turn it on. One person made a tape recording of street sounds so he could fall asleep at night. And they were just downright lonely—they were used to being around their buddies, night and day, and now they were alone, often halfway across the city in a neighborhood they did not know and nowhere near a bus or rail stop. For those who had been chronically homeless for years or even decades, they’d simply forgotten how to live indoors, and to just deposit them into an apartment without followup support or training usually meant certain failure.

In addition to telling their stories and putting real faces on Boston’s homeless population, Kidder also traces the causes of homelessness in America. He states that America’s modern era of homelessness started in the 1980s, when the problem began to rise dramatically. He attributes this to many factors, but chief among them are the demolition of affordable housing for luxury units (gentrification of neighborhoods) and the consequent turning out of the poor, elderly, and Vietnam veterans who had once lived in those neighborhoods. These people flooded the homeless shelters like Pine Street Inn. He states that,

“A severe recession in 1980 had inaugurated the era of rising homelessness. But the problem was driven and sustained by many long-brewing problems: the shabby treatment of Vietnam veterans; the grossly inadequate provisions that had been made for mentally ill people since the nation began to close its psychiatric hospitals; the decline in jobs and wages for unskilled workers; the continuation of racist housing policies such as redlining and racially disproportionate evictions; the AIDS epidemic and the drug epidemics that fed it. Also the arcana of applying for Social Security disability—a process so complex that anyone who could figure out how to get assistance probably didn’t need it.”

Kidder traces the dramatic rise in homelessness to Reagan-era policies, but he also emphasizes that homelessness continued to grow with every presidency that followed, regardless of the political party in office. In addition to the nationwide issues that America was facing, problems unique to each city, such as the child abuse crisis in the Catholic Church, were particularly rampant in predominantly Catholic cities such as Boston and were the common background fabric of childhood trauma that Jim heard time and again from his patients.

Dr. Jim O’Connell is now in his 70s and with health problems of his own, is facing retirement. He has spent his entire career—more than 40 years—serving and advocating for the Boston homeless community. He has built such close relationships with some of his patients that when he was in the hospital being treated for his ailments, they visited him, concerned about his well-being.

I was so touched by this book and also educated by it, gaining a much fuller appreciation of the issues surrounding homelessness and the gargantuan task that our cities and government face. You cannot read a book like this and have the same rush to judgment when you see a panhandler or a tent city that you might have had before you read it. This book will change your attitudes.

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2 Responses

  1. Wow, you made remember what a phenomenon “House” was back in the day. I didn’t realize the author was still alive and productive, but COVID put a pause in the lives of most of us.

    1. Yes – the subject of the book, the doctor, is also still at it. In my opinion he should be nominated for a Nobel Prize; he’s a modern-day Mother Theresa as far as I’m concerned.

      The book does touch on how COVID affected this population as well and I almost included that in my review, but it already had gotten so long I decided not to. But it’s in there, if you’re interested to find out.

      This was my first Tracy Kidder book to read, but it won’t be my last. Thanks for commenting!

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