Homeless people are invisible. At least, many people wish they were, like those who look away if they see someone who appears to be homeless. Many local governments have criminalized it, sending people to jail because they lack a home. At the very least law enforcement will drive them away from places where they are visible to others, especially tourists.
America’s medical care system tends to deliver treatment to the homeless with the same blind eye. Whether a person is housed or homeless, rich or poor, care givers plan treatment regimens based on the health condition. Yet, wouldn’t treatment plans be more complete if they factored in the patient’s total circumstances?
Homeless people have a lifestyle. To some, the word lifestyle may imply it is a choice. In truth, the homeless lifestyle chooses them. Consider the root causes, the most basic of which is poverty. Long term poverty is a symptom, if you will, of an underlying condition. Severe mental illness, alcoholism, drug abuse, traumatic brain injury and criminal histories undermine a person’s ability to gain employment that pays a living wage. Homeless persons’ work histories are often littered with attempts to work that resulted in repeated failure.
The homeless lifestyle, by its nature, impedes successful adherence to outpatient treatment. Homelessness is a nomadic existence in which the most immediate needs dominate daily activity. Food instability is an oblique reference to the plain fact that they cannot count on having food every day. Finding a safe place to sleep can supersede protection from bad weather. Homeless people must be hypervigilant. They are attractive prey for bullies just because of who they are – the homeless. Even if they don’t have money, thieves know decent shoes, food or medication have “street value”, which some homeless people have in their possession. Restful, healing sleep is out of the question.
Sadly, this lifestyle of survival limits their success in improving their lives. “Janet” might sleep in a crack house because it’s 12 degrees outside. She may start out sober but then leaves as a new user on the road to addiction. In some cities a homeless person like “Michael” will get arrested for being homeless. This blemish on his record will make employment even harder to get. “Joe” may run away from an abusive home, but he has to hide from those who could help him. Fear of authority is natural when facing a choice between getting shipped back to the family abuse or going into foster care. Not all foster parents create a more stable environment.
Countless studies have chronicled the higher rates of disease and shortened lifespans of homeless people. Obvious factors include exposure to all types of weather. The risk of heat stroke is as dangerous as the risk of frostbite. Rain seeps into the homeless’s shoes and without a place to dry their feet, they suffer from trench foot and its complications. Adequate food is sporadic, and adequate nutrition is even more unpredictable. Minor wounds may not get cleaned and bandaged before infection sets in. Some level of traumatic brain injury (TBI) is extremely common. According to one study by The Disability Trust, 48% of homeless people surveyed had a TBI, and over 60% of those individuals had experienced it more than once.
This data should not be surprising, given the prevalence of violence, mental illness, addictions and learned fears of authority among long-term homeless people.
In this context, it’s easy to understand why homeless people fail to adhere to a treatment regimen. Our system of care for the homeless is essentially emergency room treatment. They may get the best of care while there, but they leave with a set of written instructions and a handful of samples with the assumption they can get their prescription filled. These assumptions don’t reflect the reality of their harsh lifestyles.
Homeless people don’t have a safe, reliable space to keep their medicines. The medicines fall out of their pockets or are stolen. They get wet. There is no refrigerator to store them. A homeless person who has “food instability” cannot take medication in sync with meals. Clean water sources to wash down pills may not be available either. Patients who need multiple medicines have a more complicated job to follow directions about how much to take and when to take it.
Medications with strong side effects can make the life of a homeless person more miserable. Dizziness, drowsiness and disorientation will lead to more falls. Diarrhea and nausea are disruptive to people with a home and a bathroom. Homeless patients don’t even have that luxury.
While we’re on the topic of cleanliness, access to bathing depends on the availability of showers and clean clothes depend on money for laundromats. Cleaning wounds and putting on fresh dressings are hard to do without regular access to hot water, soap and clean towels.
My agency, ICAN Housing Solutions in Canton, Ohio, provides housing for homeless people with mental illness. Drugs to reduce mental illness symptoms commonly cause the same discomforts described above, and more. Anti-psychotics and anti-depressants result in debilitating fatigue, confusion, headaches and dizziness. If a person has Medicaid, it won’t pay for newer medicines with fewer side effects. It is no wonder our clients stop taking the drugs when the side effects are worse than their symptoms. Life is hard enough for them.
Conventional medical care is not designed for the lifestyle of homeless people. As Einstein said, we should look for the simple solution. Safe, stable and affordable housing increases patients’ adherence to treatment regimens. Housing leads to better medical outcomes and reduces expensive medical services. The simplicity of housing for the homeless is not only medically prudent, it is cost-effective and humane.
When health care providers understand the homeless lifestyle, they may be able to find ways to compensate for it. This works for all; they achieve the outcomes they want for their patients, and the patients’ well-being improves.
See http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/The-Homeless-in-America-Adapting-Your-Practice.pdf for more information that care providers can use to serve homeless persons more successfully.