Recently I had a discussion regarding health care and its role in outreach to people who are on the street, are prostituted, or other similar population groups. This person told me that her organization had “tried” a health care outreach once but it didn’t seem go over very well. A group of foreigners in Thailand, including some health care professionals, were visiting on a short term trip. They went out to visit bars and invite them to a free clinic. They expected quite a few people – free health care from Americans! However, the group was disappointed because the only people who came were the five people that they already know and normally see. Why?

Sounds strange, doesn’t it? You’ve heard of short term trips that go into villages and they are inundated with patients who come from all over to take advantage of the opportunity to see a western doctor. Yeah, I’ve been there. I’m not a big fan of these kinds of clinics either, but that’s not what I’m discussing today.

Random and one-off clinics like that don’t work well in the “street” population unless there is a foundation of relationship – a bit of trust built up. Caring people doing outreach in the streets may not know each individual, but if a group has had a solid and consistent presence in an area, frequent visits, some relationship with the mama-sans or bosses, then the turn-out is usually better. If the health care professional has also been a consistent presence on the street then the success can be even greater.

outdoor clinic during an outreach to prostituted women and their children

I have been involved in larger clinics targeted to prostituted women providing care and I have seen them work pretty well. This is because the partner organization had already been present in that community for years and had developed sound relational capital. The partner organization also did quite a bit of work in preparation and getting the women and their children to the location of the clinic. Teams also visit this organization every six months, so there is some follow up of care. Of course it is ideal to have a more regular and more local source of care, but this kind of clinic outreach can work in certain situations. It also provides an opportunity to introduce the women to the work of the organization and the other services available to them.

There are, in many places, all kinds of health care options available in a city, even low-cost clinics. There are clinics specializing in STI treatment. Just because there are clinics available, even at low cost, street kids and prostituted women still don’t attend them. They typically don’t like going to doctors – they have had bad experiences due to discrimination (perceived or real).  Clinics often open during times that don’t fit with their work hours or “lifestyle”. Therefore I prefer to take my care to them.

Hey, this doctor already knows where I come from… I don’t have to explain as much… I have less to fear… less shame to face.

Many people on the street or in the bars are afraid to go to the doctor and want to avoid further discrimination. Health care professionals don’t want to take any time with them or explain anything regarding their problems. I know as a doctor that trying to help people who live on the street has its challenges, but it is worth trying. If it were only a matter of testing blood or urine, then it would be easy, but that doesn’t constitute holistic health care.

I find that many people in this situation are actually afraid of the diagnosis – even if most don’t come right out and say so. This may be cultural. This may also be because they lack support from friends and families and there is nobody to lean on or help care for them should they get some difficult news. Generally, they have very low view of themselves. Why should they care about themselves when nobody else seems to?

A lot of people working in bars don’t want to pay for health care. They may already strapped with debt or family obligations and expectations and are already sacrificing so much – to pay for their health care can seem too much and too indulgent. Furthermore, if they have a very low view of themselves – if they believe they are as worthless as everyone else treats them – why should they pay to take care of themselves?

Some people who are exploited or trafficked have truly limited access to health care. Their pimp or trafficker won’t allow them to see physicians, or will charge them extra for time off work. The controllers simply don’t care about their workers, and there is no impetus for health maintenance or preventive medical care. There are, however, times when trafficked people are allowed access to health care and through careful identification and relationship-building, health professionals are able to help, and perhaps even work to get the patient to freedom.

Patients who come from the streets or bars often have a lot of chronic, non-specific, and seemingly random physical complaints – problems that frustrate clinicians. These problems don’t seem “very important” and are difficult to “treat and street”. But they are important to the person suffering them. They will not come to you (unless you have a really good relationship) initially about their HIV, their drug misuse, suicidal tendencies or other things that the clinician thinks would be important and worth his/her time. The patients are difficult. They don’t know their history very well and they wait a long time before presenting. They also tend to play down physical findings they know are related to something “bad” such as abuse burns, cut marks, or needle tracks. Trying to find a way to keep them healthy in their current living situation is often very frustrating. Yet we try to continue to build the bridge, to show we care, even if we can’t “do” much. The fact that we even ask about what ails them can heal their soul, if not their body.

examining a kid in the bed of a truck

The diseases and disabilities found in the bodies of exploited and trafficked people don’t account for the entirety of their health care problems. Many of their health care problems stem from the barriers to accessing health care, the discrimination, and the social injustice of the health care system. Health care is really much more than providing medicines to cure a disease, it is helping someone towards a more holistic well-being.

The onus is on health care professionals to start to build the bridge towards these people who need love, care, and understanding. They are at risk of abuse, exploitation and being trafficked. We can’t continue to wait for them to come to us – let’s not wait until they are a “survivor”. I will be one of those breaking barriers to go meet them where they are.