Dr. Seth Ammerman listens intently to his new, 21-year-old patient. Ernesto, who does not want his last name disclosed, is homeless. He is earning a high school degree and working part time, but at night, he and his brother share a tent that they set up on the streets of San Jose, Calif. The daily stress of being homeless is wearing Ernesto out, and making him light up too many cigarettes.
"I just want to cut down on my smoking," says Ernesto, in a tentative, soft voice. "I've been on the streets all the time, you know? I just want to make sure I'm OK."
That's why Ernesto walked into this mobile clinic, parked just a few steps from his classroom at a continuation high school. Inside the shiny blue tour bus, the exam room where Ernesto sits is equipped with Wi-Fi and the ability to get HIV test results in 20 minutes.
Ammerman, medical director of the van clinic and a clinical professor of adolescent medicine at Stanford University, nods sympathetically as he listens. In his 20 years of working with the program, he says, he has treated thousands of uninsured and homeless young people ages 24 and under.
Twice a week, Ammerman and two nurses park the clinic at continuation high schools and other places frequented by at-risk adolescents in Santa Clara, San Mateo and San Francisco counties. The van is a community project of the Lucile Packard Children's Hospital Stanford and the Children's Health Fund, with support from Samsung.
The team provides free medical, nutrition and mental health services, including reproductive health care and treatment for chronic illnesses, substance abuse and depression. All medications are free and provided at the time of consultation. A social worker available for counseling sometimes connects patients to outside resources. And a registered dietitian works with teens who are malnourished, which is a frequent health issue for this population.
Some of the 400 patients annually who visit the teen health van have never before seen a doctor, Ammerman says.
"Going to the patients makes all the difference," he says, "and it's not just a matter of convenience. It really is that these kids, because of all these access barriers — lack of insurance, lack of transportation — they're not going to get this kind of care unless we go to them."
For many patients, the teen health van becomes a trustworthy and reliable place in an otherwise unstable world.
Grace Kim first set foot in the van 10 years ago, when she was 17. She admits she was skeptical.
"Because it was a van, and I wasn't really sure what they could really provide for me," Kim says. She doesn't initially trust people very easily, she says. "That probably comes from the territory that I grew up in."
Kim says she grew up with abusive relatives in a house "full of conflict." By the time she was 14, she had already attempted suicide. With the help of a high school counselor, Kim moved out of her parents' home into a transitional living program, which initially required her to get medical checkups at the van. For the next four years, Kim was a regular patient.
Ammerman and other staff at the van treated Kim's malnutrition, substance abuse and other health issues. They also connected her with free visits to see a psychiatrist at Stanford Medical Center who treated her depression. Kim thrived.
"If I didn't get that help, I would probably be in a very bad place," says Kim, who is now working on her master's degree in counseling psychology at Santa Clara University. "The whole mental health aspect of it was probably the most beneficial, probably the most powerful."
Today, Kim facilitates a support group for suicide survivors at Santa Clara Valley Medical Center and says her passion for her work comes from those dark days in her past. She still keeps in touch with Ammerman, calling him once in a while with health-related questions.
"I trust him absolutely with everything because he's seen me at my worst, and he still, to this day, has the most faith in me," says Kim, adding that Ammerman motivated her to take care of herself and do better. "To have someone care for you and tell you that you can get better and do anything that you put your heart into. ... I mean, there are no words for that."
Kim recognizes she was lucky to have access to housing, medical and mental health resources — that isn't always true for others, she says.
Health Van's Patients Often Face Precarious Housing
More than 40 percent of the patients treated at Stanford's health van are homeless, says Ammerman. They are under the age of 25 and live on the streets, in cars and, most commonly, in overcrowded apartments. While doubling up with relatives or friends may sound like housing, Ammerman explains, it's not stable because people can be asked to leave at any time.
Ammerman says he's seen a significant increase in the number of teens and young adults living in overcrowded conditions since 2008. Working families unable to make rent are more likely to end up in these challenging conditions.
"We are seeing, unfortunately, more homeless kids," he says. "And that's really due to the housing crisis that we are all aware of, here in the Bay Area."
Numbers Of Homeless Youth Growing In California
California as a whole has seen a greater number of homeless kids in recent years, according to figures collected by the California Department of Education and crunched by Kidsdata.org. The education department designates students as "homeless" if their primary residence at any point in the school year was a shelter; a hotel or motel; shared housing with others due to loss of housing or economic hardship, or if they had no shelter at all.
Statewide, the rate of homeless public school students in kindergarten through 12th grade jumped in just three years from 3.6 percent in 2011 to 4.8 percent in 2014. More than 86 percent of the nearly 300,000 homeless public school students statewide are living "doubled up with friends or relatives," according to the Kidsdata.org report.
"So it's a very unstable housing situation, and that is always problematic for your health," says Ammerman.
Studies show that children and youth facing homelessness or housing insecurity are more likely than their peers to face chronic illness and mental health problems, as well as traumas and safety risks.
Resources For Homeless Youth Are Not Keeping Up
Shahera Hyatt directs the California Homeless Youth Project at the California Research Bureau in Sacramento. She supports Ammerman's assessment of why the state is seeing a lot more homelessness among children, youth and families.
"We know that housing affordability is in crisis proportions," says Hyatt. "In many communities across the state there's rapid gentrification happening, and a very low housing stock."
Homeless youth — particularly those constantly on the streets or without any access to shelters — risk sexual abuse, police harassment and substance addiction, she says. Yet the state is still lacking in services and resources for this population.
For example, Hyatt says, Sacramento has a single six-bed transitional housing center for young adults — and a nine-month waiting list of about 100 people. Two-thirds of the state's counties lack shelters and other basic services for homeless youth, she says.
"There's a lot of mythology about why young people become homeless ... that they are unruly or want to live outside. But that's not true," says Hyatt.
According to a spokesman for the California Department of Finance, the state spends $1.1 million annually on programs that serve homeless youth, including the Homeless Youth and Exploitation Program and the California Youth Crisis Line.
A bill recently introduced by Assemblywoman Young Kim, AB1699, would provide $25 million in funding for homeless youth emergency service projects. The bill's first hearing should take place within the next couple of months, according to her office.
Popularity Of Mobile Clinics Increases
Meanwhile, mobile health clinics like Ammerman's in San Jose continue to fill a gap in access to care for young people who lack health insurance. The model of delivering care directly to underserved populations has been gaining popularity nationwide.
In the last two decades, the number of mobile clinics has grown to about 2,000 throughout the country, according to the Mobile Health Clinics Association.
"What we are seeing is greater acceptance that mobile care can be really high-quality care," says Dr. Delaney Gracy, chief medical officer with the Children's Health Fund. "More people are realizing that mobile health is an important part of safety net care."
Inside the teen health van's exam room, Ammerman ends his consultation with Ernesto by handing him packages of nicotine gum — the medication Ernesto chose from several options to help him quit smoking. Before Ernesto leaves, Ammerman has one last question for the first-time patient.
"We literally ask each kid, 'What are you good at, what are your strengths?' And they're shocked at this question because no one's ever asked that before," says Ammerman.
Ernesto thinks for a while before responding.
"Um ... I like to work and stay busy," Ernesto says. "And I motivate my brothers a lot, as much as I can."
"Cool! That's a really cool thing," Ammerman tells him.
As patients successfully take steps to care for their health, Ammerman says, they also gain the confidence to tackle other goals — like getting steady housing.
"These kids have strengths," he says. "And by focusing on their strengths, it can really make a difference. Because strength builds strength. And success builds success."
This story was produced by KQED's health blog, State Of Health.