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Wednesday, June 5, 2019

Around the Net - Disease Causing Homelessness Causing Disease

The following is an excerpt from an article by the "Institute of Medicine (US) Committee on Health Care for Homeless People. " You may see the citation at the end of this article and read more by following the links in the citation.

Grace Wins Haven and all those who join us in our mission are helping deal with some of the issues described in the article by offering a safe, dry place to be out of the weather and space to perform important self care. We also offer help in finding resources, filling out paper work, used eye glasses for those who could not otherwise see and many other ways to help that pop up everyday. As Grace Wins Haven grows we hope to offer more services and more effective services. Together we can make a difference.

Health Problems of Homeless People

Homeless people are at relatively high risk for a broad range of acute and chronic illnesses. Precise data on the prevalence of specific illnesses among homeless people compared with those among nonhomeless people are difficult to obtain, but there is a body of information indicating that homelessness is associated with a number of physical and mental problems. This is evident not only in recent data from the Social and Demographic Research Institute but also in individual published reports in the medical literature. It also was apparent to the committee in its site visits across the country.

Types of Interactions Between Health and Homelessness

In examining the relationship between homelessness and health, the committee observed that there are three different types of interactions: (1) Some health problems precede and causally contribute to homelessness, (2) others are consequences of homelessness, and (3) homelessness complicates the treatment of many illnesses. Of course, certain diseases and treatments cut across these patterns and may occur in all three categories.

Health Problems That Cause Homelessness

Certain illnesses and health problems are frequent antecedents of homelessness. The most common of these are the major mental illnesses, especially chronic schizophrenia. As mentally ill people's disabilities worsen, their ability to cope with their surroundings—or the ability of those around them to cope with their behavior—becomes severely strained. In the absence of appropriate therapeutic interventions and supportive alternative housing arrangements, many wind up on the streets. Another contemporary example of illness leading to homelessness is AIDS. As the disease progresses and leads to repeated and more serious bouts with opportunistic infections, the individual becomes unable to work and may be unable to afford to continue paying rent. Other health problems contributing to homelessness include alcoholism and drug dependence, disabling conditions that cause a person to become unemployed, or any major illness that results in massive health care expenses.
One type of health problem in this category—about which the committee heard much during several site visits—is accidental injury, especially job related accidents. Although such programs as Workers' Compensation were designed to prevent economic devastation as a result of workplace casualties, they often fall far short of what is optimal for many reasons, including lack of knowledge of the program by the employee, low levels of benefits under the program, and lack of benefits for "off the books" work and migrant farm labor. A case study illustrates the point:
Samuel Anderson arrived in New York City in 1985 from his native Oklahoma. He is 24 years old, educated through the 11th grade, and says he left his rural surroundings because there was no opportunity to work, ". . . there was no job with something ahead of it." He feels that his chances will be best in the "biggest town I know of." In New York, he is studying for a graduate equivalency diploma and supports himself as an evening security guard. His wages are enough to pay for a rented room in the borough of Queens. Five months after starting work, he scuffles with intruders and suffers gunshot wounds in his right leg and hand (he is right-handed). Mr. Anderson spends 2 weeks in the hospital after losing four pints of blood through his wounds. A vascular surgeon and a neurosurgeon repair his shattered hand during a 4-hour microsurgical procedure. In the meantime, his room in Queens (he is in a hospital in the borough of Manhattan, some distance away) is rented to someone else because of his absence and the concurrent lack of rent payment. After discharge from the hospital, he spends a few nights in a hotel. When his money runs out, he sleeps in a city park, finally coming to a shelter.
In addition to accidents, various common illnesses such as the degenerative diseases that accompany old age can also lead to homelessness:
James Barnam, now 62 years old, has worked regularly since age 17, but has never found a job with secure employee benefits. He has lived a marginal existence: adequate funds for food and a room in a single room occupancy hotel, but certainly not enough for savings. He is fired from his long-held kitchen job because he cannot see the food stains on the dishes; after working 2 days as a messenger, he is let go because items were delivered to incorrect addresses. Mr. Barnam has eye cataracts, a frequent accompaniment of older age and treatable with ambulatory surgery for those patients with health insurance. Mr. Barnam's marginal income entitles him to Medicaid benefits, but he is unable to negotiate the public welfare system and has no one to guide him through forms, appointments, and examinations. Upon losing his hotel room, Mr. Barnam goes to a shelter for homeless men after he is discovered at a bus station by outreach workers. However, even there, his health problem remains troublesome: he almost loses his bed because he fails to sign a daily bed roster he cannot see.
In each of these cases, employment was not secure, and the man lacked a network of family or friends. The fact that health problems precipitated homelessness underscores the relationships among health status, employment, social supports, and access to affordable housing.

Health Problems That Result from Being Homeless

Homelessness increases the risk of developing health problems such as diseases of the extremities and skin disorders; it increases the possibility of trauma, especially as a result of physical assault or rape (Kelly, 1985). It can also turn a relatively minor health problem into a serious illness, as can be seen by the case of Doris Foy:
Doris Foy's varicose veins occasionally result in swollen ankles. When homeless, she sleeps upright, and her legs swell so severely that tissue breakdown develops into open lacerations. She covers these with cloth and stockings—enough to absorb the drainage but also to cause her to be repugnant to others because of the smell and unsightly brown stains. She is eventually brought to a clinic by an outreach worker. When the cloth and the stockings are removed from the legs, there are maggots in the wounds. She is taken to the emergency room of a hospital, where her wounds are cleaned.
Other health problems that may result from or that are commonly associated with homelessness include malnutrition, parasitic infestations, dental and periodontal disease, degenerative joint diseases, venereal diseases, hepatic cirrhosis secondary to alcoholism, and infectious hepatitis related to intravenous (IV) drug abuse.

Homelessness as a Complicating Factor in Health Care

For even the most routine medical treatment, the state of being homeless makes the provision of care extraordinarily difficult. Even the need for bed rest is complicated, if not impossible, when the patient does not have a bed or, as is the case in many shelters for the homeless, must leave the shelter in the early morning. Diabetes, for example, usually is not difficult to treat in a domiciled person. For most people, daily insulin injections and control of diet are adequate. In a homeless person, however, treatment is virtually impossible: Some types of insulin need to be refrigerated; syringes may be stolen (in cities where IV drug abuse is common, syringes have a high street value) or, sometimes, the homeless diabetic may be mistaken for an IV drug abuser; and diet cannot be controlled because soup kitchens serve whatever they can get, which rules out special therapeutic diets. The following case illustrates the various problems involved in treating a homeless man with another common chronic medical problem, hypertension:
Tyrone Harrison is black, 26 years old, and homeless because he cannot find a job. He wants to work in the shelter kitchen and waits 3 hours for a preemployment physical examination. He is friendly and describes himself as "very healthy." His blood pressure is 180/120. His smile disappears and he feels "cut down." Because he is homeless, he must deal with his illness, private and asymptomatic, in the public spaces of the shelter. He refuses to talk about high blood pressure with the fellows in the dormitory—it diminishes his macho image. He tells the nurse that his blood pressure reading must be a mistake. Three weeks later, after six contacts with the medical outreach worker, he confides that his cousin had been a dialysis patient because of hypertensive kidney disease. Weeks later, after several more visits to the medical team, Tyrone consents to medication for his persistently elevated blood pressure. His 2-week supply of pills are stolen 4 days later. An argument erupts in the dormitory and, in accord with routine regulations, Tyrone is put out of the shelter for 2 weeks. On his return to the shelter, his blood pressure is uncontrolled because he had no medication.
The cases described above exemplify not only how homelessness complicates treatment but how burdens are placed on various parts of the social system and on the homeless persons themselves. Because he lacked any form of health insurance, Samuel Anderson did not receive rehabilitation therapy for his right hand, and as a result developed stiffness and had significant loss of fine and gross motor skills; he had to apply for permanent disability benefits. Doris Foy was admitted to the hospital, because the treatment for her leg ulcers, which consisted of elevating her leg and taking prescribed antibiotics, is impossible for a homeless patient. Not only does her hospital stay make a bed unavailable for someone else who might possibly be in more serious need of inpatient treatment, but it also means that the hospital will not be reimbursed for her treatment because under the present system of utilization review, cellulitis with leg ulcers is judged to be treatable on an outpatient basis, and therefore, inpatient treatment for this condition may not be covered by Medicaid.
Institute of Medicine (US) Committee on Health Care for Homeless People. Homelessness, Health, and Human Needs. Washington (DC): National Academies Press (US); 1988. 3, Health Problems of Homeless People. Available from: https://www.ncbi.nlm.nih.gov/books/NBK218236/

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