ALLENTOWN, Pa. - Nurse Laura LaCroix was meeting with one of her many homeless patients in a downtown Dunkin' Donuts when he mentioned that a buddy was lying in agony in the nearby woods.
"You should check on him," said Pappy, as the older man is known. "But don't worry, I put him on a tarp, so if he dies, you can just roll him into a hole."
LaCroix called her boss, Brett Feldman, a physician assistant who heads the "street medicine" program at Lehigh Valley Health Network. He rushed out of a meeting, and together the two hiked into the woods. They found Jeff Gibson in a fetal position, vomiting green bile and crying out in pain from being punched in the stomach by another man days earlier.
Feldman told him he had to go to the hospital.
"Maybe tomorrow," Gibson replied.
"Tomorrow you'll be dead," Feldman responded.
Months later, the 43-year-old Gibson is still in the woods, but this time showing off the six-inch scar - for a perforated intestine and peritonitis - that is evidence of the past intervention. He greets Feldman warmly. "You're the only person who could have gotten me to the hospital," he says. "You're the only person I trust."
Pappy and Gibson are "rough sleepers," part of a small army of homeless people across the country who can't or won't stay in shelters and instead live outside. And LaCroix and Feldman are part of a burgeoning effort to locate and take care of them no matter where they are - whether under bridges, in alleyways or on door stoops.
"We believe that everybody matters," Feldman says, "and that it's our duty to go out and find them."
Most of the time, members of his team provide basic primary care to people who live in dozens of encampments throughout eastern Pennsylvania's Lehigh Valley. During their street rounds, they apply antibiotic ointment to cuts, wrap up sprains and treat chronic conditions such as blood pressure and diabetes.
But they also help people sign up for Medicaid, apply for Social Security disability benefits and find housing. Three or four times a month, they deal with individuals threatening to commit suicide. After heavy rains, they bail out "the Homeless Hilton," a campsite under an old railroad tunnel that frequently floods - and where two rough sleepers once drowned. Many days, they simply listen to their patients, trying to relieve emotional as well as physical pain.
Street medicine was pioneered in this country in the 1980s and 1990s by homeless advocates Jim O'Connell in Boston and Jim Withers in Pittsburgh. Yet only in the past five years has it caught fire, with a few dozen programs becoming more than 60 nationwide. A recent conference on the topic in Allentown drew 500 doctors, nurses, medical students and others from 85 cities, including London, Prague and Delhi, India. Most programs are started by nonprofit organizations or medical students.
Even as it comes of age, street medicine faces new challenges. A younger set of leaders is less interested in cultivating a bleeding-heart image than in establishing the approach as a legitimate way to deliver health care not only to the homeless - whose average life expectancy is about 50 - but also to other underserved people. Backers say street medicine should be considered a subspecialty, much like palliative care is, because of the unique circumstances of treating its target population.
Proponents also are pressing for much more financial support from hospitals, which can benefit greatly when homeless individuals receive care that helps keep them out of emergency rooms. Feldman's program - which includes the street team, medical clinics in eight shelters and soup kitchens, and a hospital consult service - has slashed unnecessary E.R. visits and admissions among its clientele. The result, to the surprise of Lehigh Valley Health Network officials, was a $3.7 million boost to the bottom line in fiscal 2017.
Perhaps the biggest issue facing street medicine, however, is figuring out how to provide more mental-health services. About one-third of homeless people are severely mentally ill, and two-thirds have substance-use disorders. Long waiting times for psychiatric evaluations delay needed medications and, in some cases, opportunities to get housing.
Psychiatrist Sheryl Fleisch is working on that problem. In 2014, she founded Vanderbilt University Medical Center's street psychiatry program, one of a few such initiatives in the country. Every Wednesday morning, Fleisch and several medical residents visit camps in Nashville, handing out shirts, blankets - anything that can build trust.
Then they split up to talk one-on-one with people waiting on park benches, at bus stops and in fast-food restaurants, providing a week's worth of prescriptions as needed. Fleisch says these homeless patients almost never miss an appointment.
Many "have been thrown out of other programs or are too anxious to go to regular office sessions," she said. "We have some patients who will get up and sit down 15 times during our appointments. We don't give up on them."
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On a muggy fall morning, Feldman's team makes its way from the Hamilton Street Bridge in downtown Allentown to a swath of mosquito-infested woods between the railroad tracks and the Lehigh River. A few blocks away, an extensive redevelopment project, complete with a luxury hotel and arena for the minor-league Phantoms hockey team, is revitalizing parts of the long-depressed area.
Bob Rapp Jr., who has worked extensively with homeless veterans and knows the location of many campsites, is the advance man. "Good morning! Street medicine!" he calls out.
Feldman carries a backpack full of drugs. LaCroix uses her "Mary Poppins bag" to try to coax people out of their tents: "We've got supplies - socks, toilet paper, tampons!"
A thin woman with striking blue eyes pops out of a tiny tent, pulling at her wildly askew blonde hair as she glances in a mirror propped up against a tree. Her toenails are painted gold. A Phillies cap and a Dean Koontz book, "Innocence," sit on one of her two chairs.
"Tampons!" exclaims the woman, who identifies herself only as Duckie. "I just turned 60. I don't think I need tampons!" She hugs LaCroix, with whom she bonded after the nurse helped her get new clothes and emergency treatment for a virulent, highly contagious skin infestation called Norwegian scabies.
Feldman kneels in front of Duckie with his stethoscope to check her lungs; the last time he saw her, the longtime smoker had bronchitis. No breathing problems this time, but Feldman tells her he wants a psychiatric evaluation. If the doctor confirms that she has bipolar disorder, depression or post-traumatic stress disorder - all diagnoses Duckie says she has heard over the years - she will be able to get the drugs she needs and perhaps transitional housing.
"I self-medicate," she shrugs. But she likes the idea of moving inside with winter coming.
"It stinks out here," she says. "It's cold. I have to watch out for rats and raccoons and people." She agrees to see a psychiatrist - a volunteer who comes out once a month - at her tent the following week.
Later in the day, the team goes to see a favorite patient. When the group approaches his plastic-covered hut in the woods, Mark Mathews frantically orders them to stop. "I don't want to be caught with my pants down!" he yells from within.
Moments later, khakis on, the 57-year-old emerges. The son of a successful Allentown actor, the grey-bearded Mathews spent years playing Santa Claus in malls. He also worked for a high school theater department and in the 1980s was part of a local-cable comedy show "Sturdy Beggars."
He became homeless after having a falling out with his sister four years ago. "The money ran out, and I couldn't get another job," he says.
LaCroix takes his blood pressure. The reading is high, something Mathews blames on not having taken his blood-pressure medicine that morning. The team will be back in two days to do a recheck, which is fine with him. "I enjoy their company," he says.
Once, LaCroix carried a mattress across an old railroad trestle and up a steep hill to deliver it to his hut. Like other patients out here, Mathews has the team's cellphone numbers. He frequently texts LaCroix to tell her jokes or alert her to someone's possible health problem.
Mathews is sure his life has purpose. "I try to help other people," he says. "I lend people phones if they don't have them. I help them get to their appointments. I should be nominated for sainthood."
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About 550,000 people in the United States were homeless in 2016 on a given night - according to the most recent estimate by the Department of Housing and Urban Development - and about a third of them were sleeping outside, in abandoned houses or in other "unsheltered" places not meant for human habitation. In Santa Barbara, California, so many people live in their cars that the local street medicine team provides care in automobiles.
Federal and regional estimates for the number of homeless people in the Lehigh Valley - which includes the cities of Allentown, Bethlehem and Easton - range from more than 700 to almost twice that number. But that's likely a big undercount.
A research study of people who came to three area emergency rooms during the summer of 2015 and the following winter identified 7 percent as homeless. Feldman, who led the study, said the finding suggested that more than 9,200 of the health system's E.R. patients were homeless sometime during the year - in communities with no permanent emergency beds for couples and fewer than two dozen for women.
The LVHN Street Medicine program, which he founded takes care of about 1,500 people a year. Since 2015, it has pressed relentlessly, taking laptops into the woods to get homeless patients insured, usually through Medicaid; today, 74 percent have coverage. Over the same period, E.R. visits by the program's patients have fallen by about three-quarters and admissions by roughly two-thirds.
It has taken Feldman years to get to this point. In high school, he began lifting weights after getting into a car accident and fracturing three vertebrae. In 2000, as a freshman at Pennsylvania State University, he won the National Physique Committee teen championship.
"It gave me laser focus, but I was the only person who was helped," he said. "It was very unfulfilling, and I decided that whatever I did after that would be different."
His close collaborator is his wife, Corinne Feldman, a physician assistant who is an assistant professor at DeSales University. When they first moved to the Lehigh Valley in 2005, the couple wanted to work with the homeless but couldn't find them - until realizing they were in campsites in the woods. These days, one encampment is even in the shadow of a defunct Bethlehem Steel facility.
The Feldmans started by setting up free clinics in shelters where they worked without pay. But a 2013 Boston conference on street medicine sharpened their focus. They would go to wherever the homeless were.
"We thought, this is all we want to do with our lives," he recounted.
By then a physician assistant at Lehigh Valley Hospital, Brett Feldman got a grant from a local philanthropy, the Dorothy Rider Pool Health Care Trust, that allowed him to do street medicine one day a week. Over time, he received more grants, as well as backing from the health system to set up a full-time street medicine program. It launched in 2014.
There have been plenty of disappointments and heartbreaks: Two patients at an encampment in Bethlehem froze to death. A man with third-degree burns from sleeping on a heating vent fled rather than have his badly infected lower leg amputated. And before the psychiatrist could come out, Duckie disappeared.
At the same time, there have been poignant victories. When a 50-year-old man, living in a drainage pipe, was diagnosed with advanced colon cancer, he declined treatment but eventually was able to move in to an apartment, where the street-medicine team provided him palliative care. When his symptoms worsened and Feldman said it was time to go to hospice, the man replied, "First, I have to clean up the apartment because the landlord was so nice."
The team helped him do the cleaning and then took him to hospice, where he died a peaceful death.
"Most of our folks think they will die alone, that their future is canceled," Feldman says. "Bringing hope is more important than any medicine."
WASHINGTON - In the eight years since Airbnb began operations in the District of Columbia, thousands of homeowners have used it to become short-term landlords, often illegally. But now, a practice welcomed as a novel way to augment income - and maybe befriend tourists - has become a flash point in the city's debate over gentrification.
Opponents of Airbnb and similar companies are backing legislation before the District Council to prohibit some short-term rentals and regulate the rest. They say that renting houses and apartments for brief stays gobbles up living space that could ease the city's shortage of affordable housing.
Many citizens also resent seeing a surge of transients disturb the residential character of their buildings or street blocks. Residents complain about noise, unfamiliar faces and loss of precious parking spaces.
But Airbnb's defenders turn the gentrification argument on its head. Given the city's high housing costs, they say, people rent out rooms in their primary residences, or in second and third homes they own, to earn enough money to remain in the District.
They also say that the housing shortage has resulted not from short-term rentals - which occupy a small fraction of the city's total housing stock - but from larger economic factors such as the desire of millennials to live in cities.
The dispute over online, short-term rental services has erupted at community meetings, on neighborhood message boards, in courtrooms and in ads on television and radio. It pits entrenched interests in the hotel industry and their union against an upstart competitor in a classic example of how a new technology can threaten an established business model.
At the core of the controversy are the same questions that grip the District over how redevelopment is transforming neighborhoods, raising housing costs, adding to congestion, and altering the city's economic and racial demographics.
"Most of the Airbnb folks don't fit into the neighborhood that well," said the Rev. H. Lionel Edmonds, pastor of Northwest D.C.'s Mount Lebanon Baptist Church, who is helping lead a grass-roots campaign in favor of tough regulations. "They don't invest in the community. . . . It increases the gentrifying component."
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The short-term rental market has exploded in the District since Airbnb got its start with homeowners renting space to visitors for President Barack Obama's first inauguration in 2009. Last year, the number of Airbnb guest arrivals jumped almost 80 percent, from 160,000 to 287,000. The number of people who hosted at least one trip jumped from 3,900 to 4,900.
Although Airbnb is the largest and best-known short-term rental service in the city, other companies such as HomeAway and VRBO are active, as well.
The rapid growth has stirred concerns. Brenda Shields, an advisory neighborhood commissioner in the low-income Congress Heights neighborhood in Southeast Washington, says Airbnbs victimize the needy citizens she sees when she volunteers at her church food pantry or delivers clothing and toiletries to the homeless. She's willing to let people rent rooms in their homes but wants a ban on Airbnbs in multiunit buildings.
"You're taking away an apartment that somebody could live in, who's living in the streets," Shields said. "You're taking away from those people and giving to people who are here for a weekend or a week."
Airbnb was a hot topic at a summer meeting of the Congress Heights Community Association, which was unable to reach a consensus.
Mary Cuthbert, vice president of the association and an advisory neighborhood commissioner, warned that short-term rentals bring in transients who dilute a neighborhood's residential character and pose safety risks.
"You see all sorts of strange people coming and going" at Airbnbs, Cuthbert said. "Somebody may want to rent a room who is a psycho killer."
She said short-term rentals were also contributing to a change in the racial makeup of the community.
"You have people coming in, and rents being pushed up, and minorities moving out to Maryland," Cuthbert said.
But a short drive away, in River Terrace in Northeast, Shaun Johnson said he can afford to stay in the city only because of the extra income he makes as an Airbnb host. Johnson regularly rents out two bedrooms and the basement in his rowhouse and describes the extra $40 or $50 a night per rental as a "godsend" in meeting his mortgage payments.
Johnson, a baggage ramp employee for American Airlines at Reagan National Airport, also says he has befriended many of his guests and especially enjoys introducing Washington to foreigners.
"I feel like I'm an ambassador for the city and black Americans," he said.
Johnson resents the accusation that he is contributing to a lack of affordable housing in the city. He says the government and big developers, not little guys trying to make a buck from Airbnb, are to blame for high housing costs.
"Why should the burden of affordable housing be on me? I can barely keep a roof over my head in my own house," Johnson said.
On Capitol Hill, which has the most short-term rentals of any neighborhood in the city, Dunnzy Levin is concerned because the proposed legislation would bar her and her husband from operating a building they own that has six units for corporate furnished rentals and short-term Airbnbs.
"It's a huge deal for the income," Levin said. "It's giving us a little bit of a cushion to put some money away, because living in the city is kind of hand to mouth."
If the legislation sets a limit lower than six for the number of units that a host can rent - as council members say is practically certain - then, Levin said, she and her husband would "change our business model."
Another host concerned about the bill is Ruth Hamilton, who uses Airbnb to rent out one of two units in a rowhouse in Southwest that she and her husband own, in addition to the rowhouse where they live nearby. The Hamiltons' experience shows the financial incentive to rent through Airbnb rather than through a traditional, long-term lease.
The downstairs unit, which is rented long-term, has been fetching the couple $1,500 a month - a rate they expect to jump to between $1,700 and $1,900 a month with the next tenant.
But the upstairs unit, which they rent on Airbnb, yields an average of about $117 a night, and the unit is rented about three-quarters of the year. That works out to more than $2,500 a month.
"I do make more on that apartment than I would if I rented it out on a long-term basis," Hamilton said. The extra money has helped cover her son's college costs.
"It's really enabled us to do that without debt," she said. "I understand the concerns about big apartment buildings going Airbnb and the need for affordable units. In our circumstances . . . our real estate is our way of making ends meet in the city."
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The legislation before the District Council was the subject of a lively hearing in April. Council Chairman Phil Mendelson, D, expects the council to act on it by January.
Both supporters and detractors say the bill could result in a satisfactory compromise. In theory, it would permit individuals and small operators to take advantage of the "sharing economy" by renting out their primary residence, while insisting that they meet basic safety and licensing requirements.
At the same time, it would prohibit large-scale commercial operators from using short-term rental services as a way to operate as hotels while dodging strict regulatory standards required in that business.
"We definitely want to go after the bad actors," said council member Kenyan McDuffie, D, who wrote the bill. People would still be free to market their property, provided they "submit to a clear, concise regulatory framework," he said.
But there is no resolution of several major questions over how far the law would go. The outcome will affect whether large numbers of hosts can continue to rent out rooms and houses and whether it will still be profitable to do so.
It hasn't been decided how many nights each year an absentee host could rent their primary residence. The bill would set a cap of 15 nights, although McDuffie expects that will be amended to 60 or 90. The industry is pushing for at least 180 nights a year.
The biggest dispute may be over whether people can rent out a second home at all. The bill says no, and McDuffie wants to keep it that way. But Airbnb wants hosts to be able to rent at least three "entire home" units. That typically means a house, apartment or basement with its own entrance, as opposed to a single room in a residence.
Short-term rental companies are also worried that new licensing and inspections requirements will discourage too many owners from taking advantage of the service. They say the hotel industry and its allies are stirring up exaggerated arguments about housing costs to protect a monopoly at consumers' expense.
"We find the bill really onerous and overly restrictive for the vast majority of our hosts who occasionally rent out their home or room in their home," said William Burns, the public policy director for Airbnb.
One potential advantage of the bill is that it would make it easier to get a license for short-term rentals - a legal requirement that is widely ignored.
A large but unknown number of hosts are renting rooms or houses in violation of city zoning regulations, according to District officials and Council members. The city has mostly turned a blind eye to the violations, saying it doesn't have the resources to enforce the laws.
In residential zones, where many Airbnbs operate, a single-family home typically can offer short-term rentals only if it obtains a bed-and-breakfast license with a home occupation permit. Many hosts lack such licenses, or are not serving breakfast to their guests, as the permit requires.
"The estimated number of short-term rentals being offered do exceed the number of licenses that would cover that type of activity," the Department of Consumer and Regulatory Affairs said in a written statement.
The fine for operating without a license is $2,000, but the regulation is rarely enforced. In the past two years, DCRA has issued $30,000 in fines for individuals or business for operating unlicensed short-term rentals.
The DCRA said enforcement is "complaint driven," and investigations "generally require considerable time to develop." The new legislation, if approved, "would require considerable additional staffing to implement," the DCRA said.
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Much of the debate over short-term rentals has addressed the extent to which they are contributing to the city's chronic lack of affordable housing.
Airbnb issued a report in April suggesting the impact was minimal. It found that of more than 300,000 housing units in the city, fewer than 9,000 "entire home" listings have hosted a trip via Airbnb.
The results were reassuring to the Coalition for Nonprofit Housing and Economic Development, which supports low-cost housing and requested the study from Airbnb.
"We don't see alarming numbers," said Stephen Glaude, executive director of the coalition, said. Short-term rentals "do not have a major impact on the housing stock."
But opponents note the housing shortage is so severe that it's harmful to lose even a small number of apartments or homes.
For instance, in 2016, according to Airbnb, 1,242 "entire homes" were rented for 90 days or more. That is more than the approximately 1,000 affordable housing units created or preserved each year under Democratic Mayor Muriel Bowser's much-praised $100 million annual contributions to the Affordable Housing Trust Fund.
Burns, of Airbnb, said there was no guarantee that the Airbnb units would be affordable if rented long-term.
McDuffie says that even if the numbers are comparatively small, the rapid growth in short-term rentals is a threat to the city in the long run.
"They are taking homes off the long-term rental market in favor or more lucrative short-term rentals," McDuffie said. "If that phenomenon continues without sensible regulations, it's going to have an impact. We have to look to the future."