It’s easy to forget about the feet. High blood pressure, a cough, a rash, an infected cut, asthma, diabetes-things you’d expect a doctor to notice when treating a homeless patient. But it’s easy to forget about the feet.

Roseanna Means ‘76, SM ‘77, remembers. On a chilly October morning, she greets a thin, elderly woman named Roberta shuffling into the conference-room-turned-exam-room at the Wellness Center at Rosie’s Place, a sanctuary for poor and homeless women in Boston’s South End. Means listens as Roberta describes her symptoms: she can’t swallow, and she gags when she tries to eat or drink anything, even water. Means and a medical resident begin their examination, taking vitals and gently quizzing their patient. When did you eat last? Has anyone ever told you that you have an irregular heartbeat? Can I examine your feet? That question gives Roberta pause, and she raises her eyebrows with an expression that seems to ask, Why would you want to do that? Feet take a beating when they are your only means of transportation, the doctor explains, eyeing Roberta’s thin socks and ragged shoes.

Means slips Roberta’s worn loafers off and removes her socks. The doctors aren’t sure why swallowing is painful for Roberta, and the abnormal rhythm of her heart worries them. Her feet, however, are in good shape. Means massages the arches, notes the discoloration on the toenails. Sugar diabetes, she thinks. She gently clips Roberta’s toenails and slips new socks over her feet. Roberta seems relieved by the doctors’ soft touch and assurances that they won’t do anything without her consent.

“For homeless people, one of the most powerful things they can do is say No,’” says Means. For doctors who treat homeless patients, she says, the most powerful thing they can do is respect that answer.

Means learned that lesson after she joined the paid clinical staff at Boston Health Care for the Homeless. She also learned why male patients outnumbered women three to one: Women who had become homeless through “economic demise” felt humiliated, and they thought that using a homeless clinic sent the message to the world that they were failures. Others had fled violent homes and didn’t want to be discovered. And a few had come for treatment following physical or sexual assault on the streets, only to find their abusers among the patients in the waiting room. So in 1999, Means launched Women of Means, a nonprofit organization that places doctors and nurses in women-only homeless shelters in the Boston area, such as Rosie’s Place. Means’s goals at the outset were simple but ambitious: she wanted to offer homeless women medical care in places they would feel safe. She wanted to staff the program with unpaid volunteer doctors (doctors with Boston Health Care for the Homeless are paid), and she wanted to create a medical rotation for medical and nursing students, to expose them to a population they might not otherwise see.

The care Means can offer homeless women like Roberta is limited to exams, over-the-counter medication, written prescriptions, and the recommendation to go to a hospital-today. Roberta, however, offers little assurance that she will seek the recommended follow-up care once she arrives at her final destination in Maine.

“We’ve increased the chances that she’ll get help, but there’s no guarantee,” Means says. Nonetheless, providing limited care in a safe environment can make a great difference.

Responding to a Growing Need

From the first time she began working with homeless patients, Means has had an innate sense of how their experiences influence their overall well-being. Those who know her often wonder how a woman with an upper-middle-class upbringing can identify so closely with those without homes. But showing compassion for others is a lesson Means recalls learning at an early age from her parents in her hometown of Milton, MA. Means now lives with her husband and three sons in Wellesley, MA. She has a private practice there, and her patients come from backgrounds much like her own.

She started Women of Means with one volunteer-herself-and a $7,500 grant from the Wellesley Congregational Village Church. Today, Women of Means has 15 volunteer doctors (including a podiatrist and a pediatrician), two paid part-time nurses, some 20 medical and nursing students who do rotations each year, and an annual operating budget of around $250,000. The doctors visit nine women-only homeless shelters in Boston, including Rosie’s Place and Women’s Lunch Place, the two largest in the city. Each volunteer is assigned to one center and must commit to at least one visit a month for a year. Because the centers aren’t licensed clinics, their services are limited. But doctors can do routine exams, check blood pressure, test for strep throat and pregnancy, measure blood glucose levels, and provide nonprescription medicine, such as cough syrup and ibuprofen.

Some patients are shelter residents, and others are poor women who come to the shelters just to see the doctor. The women aren’t required to provide any personal information they don’t want to-including their names. It makes tracking the number of patients served difficult. So Means tracks “clinical encounters”-the number of patient visits, not patients. From January through November 2003, Women of Means processed 4,637 clinical encounters-almost double the number in all of 2002 and nearly six times higher than in 1999, when the program began.

That increase mirrors a rise in homelessness around the country, Means notes, adding that women and children are the fastest-growing subset of the homeless population in the United States. According to an annual homeless census by the U.S. Conference of Mayors, the number of homeless women in Boston alone jumped 10 percent in 2002. Nationally, the number of single women and families without homes has increased in most large cities, and the numbers are even higher in rural America. The U.S. Conference of Mayors reports that in a 2003 survey of 27 cities around the country, 40 percent of the homeless population was families, and another report found that the majority of homeless people in rural areas are single mothers, families, and children.

Working Overtime

Means is founder, medical executive director, president of the board of directors, and chief fund-raiser for Women of Means. In addition to working 20 hours a week in her own private practice, Means volunteers eight to 10 hours a week at Rosie’s Place and Women’s Lunch Place and spends another 40 hours a week on administrative tasks. Although she earns a yearly administrative salary of $50,000 from Women of Means, Means estimates that she donates as much as $200,000 of her time each year to the program. She makes sure nurses and doctors have what they need to provide care to patients, writes grant applications, processes the obligatory paperwork that goes along with running a large health-care program, and tracks schedules for all the nurse and physician volunteers and medical students. Her aim is to run the program in such a way that the only thing the volunteer doctors need to do is treat patients.

“She provides structure for someone like myself who has good intentions but none of those other skills,” says Virginia Byrnes, a volunteer physician in the program since 2001. Byrnes was attracted to the program because of its focus on homeless women. It targets a specific population that she says is often overlooked by the medical community.

Third-year Harvard Medical School student Kiwita Phillips had never worked with homeless patients before November, when she began a one-month rotation with Women of Means.

“I learned that we make assumptions about patients, but a homeless person is not always identifiable as such,” Phillips says. “We must be mindful of our interactions with people and attempt to understand that inadequate health care is not the only issue and may not even be the most important issue for our patients.”

Ateev Mehrotra ‘94 completed a rotation as a resident in internal medicine and pediatrics with Women of Means in August 2003. Mehrotra notes that while many of the health problems he treated during his rotation are no different than what he might see in other populations, treatment options are more limited. Keeping follow-up appointments can be a challenge for a person who moves from shelter to shelter, he says, and there’s little guarantee that the patient will follow doctors’ orders.

“The fact that we have limited treatment optionsis frustrating,” Mehrotra says, “and makes you feel you are placing a temporary and small Band-Aid on a much bigger problem.”

Means has felt that frustration, too. But she’s learned to look at each patient as a small victory, and many small victories could one day lead to success on a greater scale.

“I can’t cure homelessness,” she says. “I can’t cure poverty.”

But she can look her patients in the eye, offer health care in a safe place, and attend to their medical needs, right down to their feet.