This cold October morning, Gypsy is resting under a shower curtain duct-taped to a tarp in a thicket of thorn trees along the Spokane River.

Two Washington State University students and a Spokane caseworker who does weekly outreach to the homeless wind along the narrow brushy trail leading to his camp. The caseworker, Martha Nelson, calls out to announce the presence of visitors.

“Knock. Knock. Anybody home?”

“Who is it?” a man asks.

“It’s Martha, from outreach. I’m here with the nurses.”

Gypsy remembers Martha, and he’s been homeless long enough to remember that the student nurses come each spring and fall. Happy to see friendly visitors, he comes out in his stocking feet to welcome them. He apologizes for the mess-garbage and rusted metal-and warns about the “mine field” of feces in the wooded area he’s designated as his bathroom. He just got back from North Dakota and hasn’t had time to fix up his camp, he explains.

Students Kate Pavlicek and Jennifer Schwarzer, both 24, ask him if he has any health needs.

“You know what I need—some blankets, a sleeping bag. Somebody stole mine in Fargo. Can you believe that?”

They chat about his family back in Colorado, and his health. He’s battling emphysema and has been short of breath lately, he says. He peels off his coat and starts unbuttoning his flannel shirt, revealing scars on his chest.

“I think maybe you better take my pulse. I had a triple heart bypass up in Montana a few months ago. They opened me up like a peanut, took five veins out of my leg. But I’m taking aspirin.”

The nurses look at each other, eyebrows raised, then take his blood pressure. One-sixty over 100.

“That’s pretty high,” says Pavlicek, unstrapping the Velcro band from his thin, white arm.

“Yea, that’s hard on your heart after a new surgery,” adds Schwarzer. “You need to go in to the clinic tomorrow and get some blood pressure medicine.”

Gypsy jokes about the jump it gave his heart to see so many pretty young faces at once. The student nurses laugh and dig into their Jansport backpacks for juice, two power bars, and some fruit leather, which he eats on the spot. A carton of a half-dozen eggs on the ground by his tarp is the only food visible. They promise to check back the following week and bring blankets if they can. He promises to go downtown to the free Community Health Association of Spokane clinic the next morning.

Gypsy’s camp is evidence of the harsh living conditions faced by a growing number of Spokane’s homeless. This day it’s also doubling as a WSU classroom for students being educated as nurses. It’s a lesson in reality that often changes the way they see the world.

“I personally want to go into public health,” says Pavlicek, of Bremerton. “This opens your eyes totally.”

For Schwarzer, it’s been a new take on her hometown.

“I didn’t know there were this many homeless people in Spokane and had no idea the places they were. You could be walking by a trail to where they sleep, and never know it. I actually recognize people now. Instead of ‘Oh there’s a homeless person over there,’ it’s like ‘hey there’s Gary.’ They have names now.”

Established in 1968, WSU’s College of Nursing—also known as the Intercollegiate College of Nursing—is the nation’s first, oldest, and most comprehensive nursing education consortium. The college offers baccalaureate, graduate, and professional development course work to nursing students enrolled through its four consortium partners, Eastern Washington University, Gonzaga University, Whitworth College, and Washington State University. Each year, the college educates more than 550 graduate and undergraduate students and prepares more entry-level nurses than any other educational institution in the state. Every student who graduates with a nursing baccalaureate is required to take a semester of community health nursing. For some in Spokane, that means a semester of working with a needy downtown population-among them the poor, homeless, mentally ill, drug- and alcohol-addicted, abused.

For nearly a dozen years, faculty have arranged for WSU nursing students to provide basic health care to the downtown population as part of their formal education. The students are assigned to work on a weekly basis with a specific organization or site for an entire semester.

Some go door-to-door weekly, visiting the elderly, ex-convicts, sex offenders, and others at the city’s low-income hotels. Others walk under the city’s bridges and along its riverbanks each Wednesday delivering socks, shots, and basic health care to the homeless. Some give foot clinics and pedicures at the women’s drop-in center.

They are the eager, smiling student angels who arrive in downtown Spokane when school’s in session.

“There’s not a lot of nursing programs across the nation that send their students under the bridges of the city,” admits WSU College of Nursing dean Dorothy Detlor. “But serving the under-served population has been part of nursing history ever since public health nursing began in New York City.”

Public health nursing in the United States began in the late 1800s through the efforts of a few wealthy women in New York, Boston, Philadelphia, and Buffalo, who hired trained nurses to go door-to-door to care for the poor in their homes.

When students go door-to-door in Spokane, they are often shocked at the grim conditions in which many low-income residents live and the variety of untreated ailments they endure.

“We reach a lot of people that would not get served for a variety of reasons,” says Carol Allen, a WSU College of Nursing instructor who coordinates the students’ downtown work. “Some students are a little frightened when they start out . . . some of the people are a little hard to work with.”

In fact, they travel in pairs, carry cell phones, and leave money and valuables at home when doing their downtown rounds. But few have had bad experiences. Most of the homeless and low-income residents just want to be treated with dignity and respect, says Allen. “For the most part these people are not accepted. Others don’t see them, they look right through them.”

In order to address their needs, the students must learn how to access a patchwork of community, government, and volunteer aid organizations. They must be able to assess the people they see in a holistic way in order to help them get the diverse array of help they may need.

The work is challenging. The grimy low-income downtown hotels can be particularly demanding at the first of the month, when most residents get their checks, and when some purchase their substances of choice. One afternoon at the Red Lion students came across a 61-year-old man with severe diarrhea, incontinence, and scabs on his face and hands. He had recently had hernia surgery and hadn’t ingested anything other than beer for some time.

“He said he thought he might die, and his neighbors down the hall said we think he might too,” Allen recalls.

The nurses suspected he was severely dehydrated, bleeding internally, and in need of paramedics. He was adamant about not going to the hospital. Finally, one male student convinced him to go. Because of cost constraints and lack of transport services, Allen drove the ailing man to the hospital in her van, after warning her students not to ever do what she was doing.

The students’ real-world nursing experience wouldn’t be possible without the back-up support of faculty like Allen. Most of the College of Nursing faculty members practice what they teach by dedicating their own nursing knowledge to helping the underserved.

For starters, College of Nursing faculty staff The People’s Clinic, a grant-funded downtown health clinic that serves Spokane residents regardless of their ability to pay. Even the College of Nursing associate dean, Anne Hirsch, puts in her day a week as the on-site health care professional.

Founded in 1998, the tiny clinic tucked above the city’s
YWCA provides primary care, child exams, immunizations, mental heath counseling, breast and cervical health care, and sexually-transmitted disease screening and treatment, as well as on-site lab testing for those largely left out of the health care system.

Nurse-managed, the clinic serves approximately 250 patients per month, 10 percent of whom are homeless, and 51 percent of whom don’t have insurance and pay a fee for service based on their income. Margaret Bruya, one of the clinic’s founding faculty members, staffs the clinic once a week. This day, she’s still wearing her white coat, long after the clinic has closed, cleaning, refilling the bowls of free condoms and toiletries, finishing her charts.

“There’s such a need for primary health care in the under-served population,” says Bruya. “There’s thousands of people who don’t have insurance and have hurdles and barriers they have to overcome to get health care.”

Like Spokane’s pole dancers, strippers, and sex workers, some of whom come in battered by pimps and customers. Or the children Bruya sees with fragmented medical histories and parents who shrug their shoulders when asked what immunizations they’ve had, or when their child last saw a doctor. There are the 45-year-old women who walk into the clinic who have never had a pap, never had a mammogram. The clinic detected breast or cervical cancer in seven patients in October 2001 alone.

About 44 million Americans live without health insurance. More than 130,000 Spokane-area residents lack adequate insurance. Fourteen thousand of them are children.

In two years, the clinic has treated more than 5,000 clients, while at the same time giving nursing students hands-on clinical experience. When people can’t come to the clinic, a woman named Loly Reyes-Gonzalez takes it to them.

Reyes-Gonzalez, 49, is an energetic retired air force nurse who now works as the clinic and outreach manager. She has brought one-day health clinics to low-income communities all over Spokane for basics like mammograms, insulin shots, or blood pressure testing. She laughs when asked what vehicle functions as the mobile clinic.

“It’s my truck. I put everything in my truck. See that bag,” she says, pointing to a large black duffel bag. “That’s the mobile clinic.”

Yet despite the many nurses like Reyes-Gonzalez, who frequently stretch the conventional boundaries of the profession, College of Nursing officials lament that the public’s traditional stereotype of the nurse as a white-uniformed doctor’s assistant won’t seem to go away.

“The most difficult part about it is the idea of the nurse as the ‘assistant,'” notes Dean Detlor. “The backbone of the whole health care system across the country is the nurse.”

Indeed, nurses fill a broad range of positions across the health care spectrum, both blue- and white-collar. They work in hospitals, health departments, private law practices, insurance and pharmaceutical companies, for starters. They are often key figures in clinical trials and medical research. Increasingly, nurses are moving into leadership positions-as in Tacoma, where the CEO of the multi-care health system is a nurse. And at the WSU College of Nursing, many dedicate their energy toward helping Spokane’s poor.

Associate professor Merry Armstrong recently landed a $99,800 Helene Fuld Health Trust grant to provide health expertise to addicted women who are also chronically homeless. The money will help develop an addiction course and provide clinical and research opportunities for students to work with homeless women in Spokane. Three graduate students will be assigned to the downtown women’s shelter to talk with residents and assess how best to reach the population with necessary health information.

“I want to invite graduate students to work with this population,” says Armstrong. “They are so needy, and yet the women are very welcoming. You get a lot of bang for your buck.”

According to Armstrong, the city had no idea there were so many homeless women before the downtown women’s shelter opened in 1999 in response to fears about Spokane’s serial killer.

Homeless women are a largely invisible population because they spend so much time on the move, trying to find safe places to rest where they won’t be assaulted or raped. “Their safety is to always be mobile,” says Armstrong. “But clearly there’s a lot more homeless women here than anyone thought.”

And for those addicted to drugs and alcohol, there is a glaring gap in health care services in Spokane, primarily as a result of a chronic disjoint between the city’s mental health and addiction counseling communities.

Armstrong, who wrote her doctoral dissertation on women who use drugs and alcohol during their pregnancies, is hoping her grant will help establish a way to deliver important, basic health information to homeless women trying to get clean and improve their health long term.

“It’s a thousand-step process, it’s the rest of your life.”

Diana Boyd knows that firsthand. The Bellingham woman was a heroin addict for 35 years, until she kicked the habit a year and a half ago after moving to Spokane for detox. She now suffers from chronic depression and a myriad of other health problems from her many years of homelessness and addiction.

“I had hepatitis C. My teeth were falling out. All my time, energy, and money went into my addiction,” recalls Boyd, 51. “When you’re in that situation, you have no resources. You’re out stealing, turning tricks, whatever. You’re at the mercy of the medical community, and it can be so degrading.”

To show how far she’s come, she displays her driver’s license picture, taken more than a year and a half ago, when she was still hooked. In the photo her face is sallow, her eyes sunken, her mouth toothless. She looks like a different woman now, tall and confident, unafraid to smile since intensive dental work gave her back “a full set.” Armstrong’s grant would provide hope for other women like Boyd, who after living in transitional housing for a year, is about to move out on her own and take a part-time job. She is a regular at the Women’s Drop-In Center, a safe harbor for women in the heart of downtown.

The center, on Howard, is a safe and welcoming place for women to go in the daytime for support, advice, and friendship, not to mention the basics like a snack, a shower, or something to wear. Pastries and coffee are on the table, artwork about and by women covers the walls, a phone in the corner is available for local calls.

With an annual budget of $200,000, plus five staff and 20 volunteers, the center serves close to 100 women a day. Some of them are homeless women who stay in shelters at night but have no place to go during the day. Some of them arrive bruised and battered, ready to leave an abusive spouse. Some, like Boyd, stop by for support or to ask health questions to the nursing students, who come every Wednesday.

“I just started taking hormones for menopause,” Boyd explains. “I had some questions about it and the nurses were here one day, so I asked them. We looked it up together. It was empowering for me, it was like I was in on it.”

“It takes awhile for women to get to know them and trust them,” says center director Mary Rathert. “But it fills an important service. Often they feel comfortable asking questions to the student nurses because they sometimes don’t feel comfortable with the whole medical system.”

The City of Spokane’s Human Services conference room looks out over the bridge under which two nursing students found Betty, a homeless Native American woman in her 50s, her “old man” asleep next to her under the blankets and tarps that served as their only shelter.

Between September 2000 and August 2001, 9,352 people like Betty lived homeless in Spokane. And those were just the documented ones.

“For a city our size we have a very high percentage of homeless,” says Spokane Human Services director June Shapiro.

For six years, Shapiro’s office has tracked information about Spokane’s homeless population
. The top five reasons for homelessness in Spokane? Poverty is the main one. After that, the biggest percentage are dually diagnosed—they are mentally ill and have substance abuse problems. Often, the latter is a result of the former, as people attempt to medicate themselves. Then come domestic violence, eviction, and relocation, in that order.

Most of Spokane’s homeless—70 percent—report having lived in Spokane prior to being homeless, and another 11 percent report living in Spokane County.

“People have the stereotype that [the homeless] are transients, that they are not ours,” notes Shapiro. “But our database is telling us that’s not true. Most of our homeless are our people.”

And many of them are children. Of the nearly 9,352 homeless persons documented, 2,731 were children within households, and another 300 were independent youths under the age of 18.

Maria Ruiz traded her Wilbur home for the streets of Spokane after her only parent—her father—left when she was 15. Now 18, she lives under Spokane’s bridges, though you wouldn’t guess it from her meticulously applied makeup and well-kept hair. She has a huge winter coat, a backpack with all her things, and stays wherever she can with her boyfriend, and occasionally with an uncle.

Few shelters allow men and women together. As a result, couples and families often choose to stay homeless rather than be split up for shelter. But when Ruiz’s boyfriend runs errands, she’s left to fend for herself.

“It’s hard being alone, like sometimes when he has to go out and get food or whatever,” says Ruiz while waiting with her boyfriend at the House of Charity as lunch is being prepared. Women on the street not only face more violence, but they also have unique health needs. Shyly, Ruiz admits “the monthly things” are hard.

“Sometimes you have to walk a couple of miles to a restroom. It can be really uncomfortable.”

New state Medicare and Medicaid regulations and the serious budget cuts threatening state and local coffers will likely leave Ruiz and others in even worse circumstances.

More affordable housing and better substance abuse treatment and mental health care are among Spokane’s biggest human services needs.

“The concern is that people with mental disabilities are falling through the cracks,” Shapiro says. “Too many of them are being forced into homelessness.”

Most of Spokane’s $3 million human services budget consists of federal and state dollars. The amount of money Spokane budgets for human services agencies from its own general fund is embarrassingly low, given the magnitude of the problem. The City of Seattle spent 45 human services dollars per capita in recent years, compared to $12 in Tacoma, $4.28 in Bellingham, and just $2.27 in Spokane. Although the mayor and city council recently increased the amount Spokane allocates to these agencies from $430,000 to $747,000, that’s still less than one percent of its entire budget.

That allows a lot of the underserved population to fall through the cracks. WSU’s College of Nursing is catching a few—by educating students about community health nursing while at the same time lending a hand to Spokane’s neediest.

“Health care is the biggest gap in services, so the nurses are a very valuable asset for this community,” Shapiro says. “Everything we do for this population is positive. I think it is a great approach for a nursing program.”

The homeless whom the nursing students reach also seem grateful that someone’s looking out for them.

“Thanks for coming,” says Mark Linza, 55, one of four homeless acquaintances camping together along the Spokane River. Their small fire had alerted Kate Pavlicek and Jennifer Schwarzer to their presence among the reeds and brush. “We’re okay. We look out for each other.”

It’s not uncommon for the homeless to band together in informal support networks to avoid being beaten or harassed. They share security and moral support and sometimes help keep each other fed.

Over the fire this morning, Mark, Paul, Jeff, and Shirley are charring pastrami sandwiches that one of them had rescued from a dumpster where they know a vending machine operator throws out sandwiches past their freshness date.

These four have it better than most. They have tents, held off the ground by pallets and concrete blocks and insulated with cardboard boxes. They also have a basket of spices and food, and even a sack of cat food for a stray that also calls the riverbank home.

“I can do without,” says Shirley Royer, a slight woman with kind eyes and shoulder-length hair she says she had brushed that morning. “But I need to find a job before wintertime.”

Royer, 42, survives with what’s given her during the day while displaying a cardboard “homeless and hungry” sign. Originally from nearby Coeur d’Alene, Idaho, Royer has been homeless on and off since 1979. But with help from local shelters where she can get clothes and a shower, she still manages to laugh and keep herself “cleaned up.”

Paul came to Spokane six months ago after losing his job as a machinist in St. Paul, Minnesota. He doesn’t want his full name used or his face shown in photos, because he’s actively looking for work. He strips off his socks to show his feet, raw and blistered from walking in ill-fitting dress shoes.

“The reality is, we don’t have an address, we don’t have a phone number, and you can’t put that on an application. So you just hope they hire you on the spot . . . because they can’t call.”

Schwarzer nods understandingly, rummages through the first aid supplies in her backpack, then gingerly applies Neosporin and bandages to his sore, chafed feet.