Taking public health to the street

During the COVID-19 pandemic, North Carolina experienced an unusually high increase in hepatitis A outbreaks.

A viral illness that causes liver inflammation, hepatitis A is typically transmitted person-to-person or through food contamination. The infection is not long-lasting, but it can become severe enough to cause hospitalization or death. While a vaccine exists, most adults in the United States have never received it, given that it only became part of pediatric immunization requirements in the late 1990s.

Outbreaks of this disease have fluctuated over time, but a large spike in cases is cause for major public health concern, especially when the disease transmits in communities that don’t have easy access to health care. This was the case in 2021 in Burke County, N.C., which saw the highest rates of hepatitis A in the state due to an outbreak among the county’s unhoused population.

Even small changes in policy make critical impacts in the people we’re trying to serve. And it’s going to make work like this more important than ever.

N.C.’s public health system is largely decentralized, meaning while the N.C. Department of Health and Human Services oversees many policies and programs, the health care services and day-to-day decision-making are left to individual counties. For a small, rural county like Burke, handling a spike in hepatitis A cases during the middle of a coronavirus pandemic strained the health department’s resources. Assistant Health Director Ashley Jarrett, DNP, RN, CPH, who at the time was working as a communicable disease nurse at the health department, knew they would need to lean on community organizations and resources to address the outbreaks.

“We worked with the State of N.C. to find out who was being impacted the most,” said Jarrett. “People who were injecting drugs, people experiencing homelessness and men who had sex with men. I was able to identify organizations in Burke County that could take care of two of those communities, but no one was taking care of the homeless population.”

“We knew there were people out there who needed our help,” said Health Director Danny Scalise, MPH, MBA. “It started with health department employees, police officers, volunteers and folks at the UNC hospital here collecting donations and then going out into encampments. Street medicine.”

Street medicine can take many forms — mental health services, mobile clinics, temporary shelters, distribution of food or sleeping bags — but it all has one goal: bringing care directly to people experiencing homelessness. Not only does it improve health for vulnerable people and their community; it also builds trust and creates opportunities for non-judgmental, respectful health care relationships

“It was just as much about giving out hygiene and health checks to as it was about the things people would consider traditional health care,” Scalise explained.

Together, Burke County Public Health worked with the community to deliver necessary vaccines and medical supplies to the county’s unhoused population. It gave the team at the health department a glimpse of what a broader and more intentional effort to bring real-time health care to the homeless — street medicine — might look like beyond treating hepatitis A. This level of outreach had strong support from the community but was difficult to sustain long term without the material and technical resources necessary to build an efficient system that could deliver other facets of health, like primary care, maternal health or mental health services.

Jarrett and Scalise, through their network, connected with Oscar Fleming, DrPH, assistant professor in public health leadership and practice at the UNC Gillings School of Global Public Health. Fleming’s expertise in improving methods to expand the capacity of the public health workforce was a natural fit for Burke County’s goals in creating a formal street medicine program. As part of its mission to strengthen local public health agencies in the state, the Gillings School has a strong history of building partnerships with county health departments — most recently through its Partnership Hubs initiative in Cumberland, Durham, Halifax and Jackson counties. These partnerships provide tools, expertise and personnel support that can help health departments improve well-being in their counties.

After one phone call with Jarrett, Fleming was eager to assist in developing a street medicine outreach program that could last beyond a single disease outbreak. Most models for street medicine in other parts of the country are designed for urban areas, where density and resources facilitate the delivery of health care services. Burke County, by contrast, is small and rural, with only one major population center: Morganton.

Fleming saw a need and an opportunity to design a unique model that could address a rural county’s needs.

“Country roads medicine,” as Scalise called it.

The street medicine partnership between the Gillings School and Burke County has evolved over two years to become much more formalized thanks to the design thinking and evaluation methods from the Gillings School team combined with dedication of the health department staff, paramedics, Morganton Public Safety, and community organizations like Burke United Christian Ministries and Grace Episcopal Church. At its core, the Burke Street Medicine Team provides high-quality care to unhoused people in parks and encampments, establishes shelters during extreme weather (“Code Purple” shelters), and leverages community volunteers and donations for things like hygiene supplies. The Gillings School also supports the county through practicum opportunities, giving public health students the chance to put their classroom learning into practice as they help the health department design and deliver care in evolving ways.

The partnership has flourished despite limited financial resources, thanks to the dedication and passion of all parties involved. Jarrett says she’s grateful for the sweat equity that Fleming has put into the project, incorporating it into his coursework and finding new sources of funding, such as the Translating Innovative Ideas for the Public Good awards from Innovate Carolina, that allow for flexibility and ideation.

“When it comes to people experiencing homelessness, it’s never just about the people experiencing the homelessness,” she said. “It’s about every single body and every single system involved. So, the beauty of this is that while we don’t have much funding, we’re doing so much more systems change through reducing stigma, building networks and improving leadership in this area at the local government level.”

As the project has evolved, Fleming and Minzhi Xing, MD, MPH, assistant professor in public health leadership and practice, have worked with Burke County to launch a mobile women’s health clinic that brings services to those in need — whether they’re unhoused, living with a friend or simply lack transportation. Xing has also received funding from the N.C. Collaboratory to undertake community-engaged mapping, evaluation, and strengthening of mental and behavioral health programs and systems in Burke County. Together with Kristen Hassmiller Lich, PhD, professor in health policy and management, the systems-strengthening effort emphasizes shared leadership alongside the health department and community partners.

“At the heart of this mutually beneficial partnership is our profound respect for one another’s expertise,” said Xing. “The local health department serves as the county’s chief health strategist and convenor, while communities hold invaluable insight into their own assets, living experiences and conditions that shape effective public health solutions.”

The ultimate goal for Scalise and Fleming is to create a formal academic health department relationship, similar to the Partnership Hubs, which can help local government public health workers evaluate both the street medicine program and other work in which the county can lead.

“When you go into a teaching hospital, the clinical faculty is the attending physician and the teacher; I want to see that same type of thing here,” said Scalise, “where the faculty is the person doing the work in practice, and they’re also teaching. They could be teaching students or enriching our employees through things like program evaluation that could make them better at their jobs.”

Jarrett said that recent policy changes criminalizing homelessness have made their work more difficult, and that, more broadly, the defunding of public health services will have impacts for years to come. Policies that erode public trust in institutions and stigmatize important benefits, like housing vouchers and Medicaid, make it harder for people without resources to gain access to health care.

“Even small changes in policy make critical impacts in the people we’re trying to serve,” she said. “And it’s going to make work like this more important than ever.”