With nearly 3 million homeless people living on the streets of European cities, street social workers struggle to find adequate answers to help the most excluded change their situation. Through a revolutionary process that bridges life on the streets with the traditional health care system, Emilie Meessen is supporting homeless people’s dignity and self-esteem while facilitating their social and professional rehabilitation. Emilie has successfully created a network of “watchdogs” that act as an early warning system. Using hygiene as a stepping-stone, they are empowering the long-term homeless by helping them to take charge of their own bodies and lives.
The New Idea
Emilie has invented a dynamic, incremental process to empower the homeless to care for their own hygiene and progressively reclaim responsibility over their lives. Aware that careless hygiene is a starting point and catalyst for the exclusion of already marginalized people, Emilie has designed an approach that reconnects homeless people with their bodies. By using this method in street work and targeting the long-term homeless, she is building a holistic pathway to self-awareness and physical, mental, and environmental health. Infirmiers de Rue follows hundreds of homeless people every year with promising results: The intensive follow-up process led nearly 70 percent of the most excluded homeless people to proper hygiene and social reintegration. As an example of the potential of her method, over a three-month period Emilie succeeded in reintegrating a person that all other organizations failed to help over the past 15 years.
In order to catalyze the impact of her approach and allow for more targeted, effective street work, Emilie is training, organizing, and strengthening a network of watchdogs to support the homeless people’s empowerment process. Citizens, shop holders, security staff, park rangers, and street social workers are all taught to use the same barometer to assess a homeless person’s degree of risk, and as a result, are together able to track and monitor the progress of the most excluded people.
Emilie is also creating an enabling environment to make the system of street-workers more efficient, by reinforcing existing infrastructures and improving their accessibility. She is shedding light on what knowledge already exists for street-workers to use (i.e. street maps and lists of places where it is possible to take a shower, drink water, or use toilets). In doing so, Emilie constructively engages local authorities to fill infrastructure gaps. Already Emilie’s approach is being adopted in three other cities in Belgium and is receiving attention from other European countries, particularly Finland and Switzerland.
There are 17,000 homeless people in Belgium and 3 million in Europe, and these numbers continue to rise. In spite of the existence of numerous street work citizen organizations (COs) and intervention programs, their health remains a pressing issue. For example, in Flanders, 75 percent of homeless people report adverse health conditions and 58 percent suffer from mental disorders. The poor monitoring of the health of homeless populations is one of the first causes of street mortality.
The deterioration of hygiene is often the starting point of a vicious cycle of exclusion. A person living day after day on the streets will progressively neglect hygiene and appearance, which often leads to the loss of self-esteem. Dirt and body odors generate rejection and marginalization from society, which accelerates the degradation of a homeless person’s physical and mental health. This gradual social exclusion further reduces their chance of finding a job, a place to live and an outlet from life on the streets.
Advocates in the traditional street work system do not address the issue of hygiene for two reasons: Hygiene problems are taboo because they are considered intimate and personal and most professionals consider hygiene as outside their scope of intervention. Just as the role of physicians is to make a diagnosis and provide a medical response, social workers are meant to help the homeless find employment, housing, and fill administrative duties.
A further challenge in addressing hygiene issues among homeless people is the siloed nature of the field. Daytime shelters, night emergency shelters, and street workers, do not coordinate their efforts. Consequently, there is no real tracking of changes in a homeless person’s situation, which prevents any comprehensive health management.
There are many untapped resources that could be leveraged to better manage the hygiene of homeless people. For instance, those in contact with the homeless on a daily basis, such as park wardens, shopkeepers, and security officers, are overlooked in the role of sentry they could play to help with the social integration of the homeless. Furthermore, public infrastructures (i.e. public toilets, water fountains, showers, and so on) and services offered by the city and other COs are unknown, sometimes misused, and often inadequate.
When Emilie began working as a nurse with homeless people, she identified a clear gap: most of the health-related social street work was conducted when a situation had reached a level of emergency, and most often occurred at night. The reason for this was that most homeless resisted stepping into existing health care centers which were open and accessible during the day. Emilie created Infirmiers de Rue (IDR) to build the missing link between reality on the streets and existing health care centers.
Emilie has developed a strategy that progressively builds trust and step-by-step brings the homeless closer to the mainstream health system. Pairs of nurses meet the homeless on the street with a non-intimidating approach (i.e. by foot, not in uniform, and only if the person accepts a conversation). Nurses are informed of a situation by neighbors, shopkeepers, COs, or by meeting the homeless on their regular patrols. The first encounter is a way to get to know each other and conduct a first diagnosis of the homeless person’s state of hygiene and health. During the process, the nurses respect a homeless person’s autonomy and openly discuss the situation with him/her.
The patient usually falls into one of two categories depending on their health situation. For the less serious cases, IDR is reorienting the homeless with the most relevant players. For the most critical cases, IDR develops “intensive monitoring,” a file for the individual is opened and each week the nurses will assess progress, set goals, and organize cooperation with other institutions. IDR calls upon all stakeholders that are in contact with the patient (i.e. hospitals, social services, and street-workers) to exchange information and coordinate the various steps.
In Brussels, IDR has proven the importance of placing the person at the center of a collaborative network, to establish prevention mechanisms and improve the impact of each respective intervention. To strengthen, integrate and equip this network, Emilie has created tools and common assessment standards. The evaluation and selection of priority target populations are based on a “BCB score” (body, clothing, and behavior), measured by personal hygiene, cleanliness of clothing, and behavior on the margins of society (i.e. mental disorder, social misfit, and so on). Each criterion is rated between 0 and 3 and each person is graded from a maximum of 9 points. Anyone with a score below 6 is considered a patient at-risk and therefore, a priority. The BCB scoring tool was presented at the National Institute of Health Insurance Disability, which wants to use it as a national standard.
To deepen and strengthen the watchdog networks and improve their impact on each territory, IDR is leveraging its expertise to develop and implement training programs for professions that interact with the homeless, including medical and social professionals, security guards, maintenance staff, and shopkeepers. Based on the experience acquired in identifying symptoms related to levels of hygiene and adapting treatments for street patients, these trainings aim to:
• Teach the causes and consequences of poor hygiene, and explain respective possible roles to play• Train participants on how to deal with questions of hygiene• Raise awareness on the importance of a concerted management of health issues and using coordination tools
For example, IDR trains medical professionals (i.e. doctors and nurses from local hospitals, clinics, Samu Social, and Médecins du Monde) to adapt their treatment requirements to living conditions on the streets. For security guards, IDR teaches how to maintain order and cleanliness in a station or a park with people who have little access to water, toilets, and showers, and how to manage possible confrontations between the homeless and passengers. As an illustration of the high satisfaction and enthusiasm generated by the trainings, the Belgian National Railway Company decided to increase more than tenfold the number of employees that will attend IDR trainings in 2011.
These training programs are a key accelerator for IDR’s impact. Already conducted in three Belgian cities in addition to Brussels (Charleroi, Namur, and Liège), these trainings empower stakeholders to work together and equip a broad range of professionals to work toward the rehabilitation of homeless people.
From a very young age, Emilie was attracted to street work and humanitarian work. During her studies as a nurse, she chose to volunteer in a homeless center in Brussels. She spent her free time and holidays in close contact with the homeless and soon after, decided to specialize in community health. Emilie wanted to break the cycle that trapped at-risk populations and she had the intuition that hygiene was a key part of the solution.
First pursuing her dream of doing humanitarian work in Africa, Emilie traveled extensively and wrote her dissertation in Burkina Faso on “Raising Awareness Around Hygiene and Wound Care”. Seeing firsthand the challenges of humanitarian work, she returned to Brussels to focus on hygiene work in a place she was more familiar. While finishing her specialization in tropical medicine, Emilie pragmatically conducted a field study on the needs of homeless people in Brussels and identified the missing link between people on the streets and existing institutions. When none of the organizations she identified seemed able to fill that gap, Emilie founded the Association Infirmiers de Rue in 2006.
While developing IDR, Emilie continued working part-time as a community health nurse in homeless centers. This allowed her to deepen her knowledge of the field and get to know all the key actors in Belgium. In just two years, Emilie quickly grew the organization to the point where it was necessary for her to work full-time.
Determined to bring her idea from a national to the European level, Emilie is guided by the conviction that everyone can be an agent of change around the situation of the homeless. Emilie states, “What I am truly passionate about is connecting people with themselves and increasing their autonomy.” This desire is what leads her to give every citizen a chance to act and participate in empowering the homeless they see everyday on the street.