HOMELESSNESS, HEALTH AND ADVOCACY

She sat in front of me on the examining table: bony frame, blonde hair pulled back in a ponytail, tattoos brocading her pale arms. Like so many of my patients whose lives are spiraling apart, hers seemed the stuff of tragedy. She had trouble obtaining access to medical care; the pains in her stomach knifed into her from her inadequately treated colitis, and she had lost her medications when she joined the ranks of the homeless after her landlord evicted her because she could not pay the rent. She sobbed, she raged at me and at the heavens, she often missed appointments, and she couldn't hold down a job.

For family medicine practitioners and for other doctors who take care of poor people, the presentation of this woman is not uncommon. We do what we can: sign people up for indigent drug programs and/or give them free samples, opt to work in community health centers, help patients apply for disability, hook them in to places where they can get free or discounted care, and call them occasionally to maintain contact. By doing so, we try to help them, as individuals, deal with their health.

But health is a complex tapestry, with threads that lead in all directions. At the end of one thread is employment. Without a stable job, patients may not have access to health insurance, or money for food. Another thread leads to housing. My patient, for instance, was off all her medications for two weeks between the time when she lost her apartment and when she came in to see me. Other threads lead to access to state and federal benefits such as social security and welfare, but the homeless often cannot/do not access benefits for which they are eligible.

Homeless people are exposed to a number of adverse health risk factors, including assault and victimization, illicit drug use and alcohol abuse, and exposure to heat and cold.1 They are more likely than the general population to contract tuberculosis, HIV, hepatitis B or hepatitis C.1 Homeless women use preventive screenings less than the general population.1 Poor health can, in turn, make it difficult for those who are homeless to procure stable housing.1

Rhode Island exhibits similar connections between health and homelessness to those shown in national data. One recent study revealed that 17% of homeless shelter clients had experienced medical problems in the past six months, with 17% reporting domestic violence and 14.5% reporting mental health problems within the same period.2 Nineteen percent of homeless single women stated that domestic violence was their reason for seeking shelter.2 In another recent state survey, homeless respondents were asked about services they had needed in the previous twelve months but were unable to find.3 Medical care and financial assistance for medical care were at the top of the list.3

In Rhode Island, escalating housing prices and rents have brought about steep increases in the homeless population. Since 1997, the cost of housing has grown twice as quickly as household income.4 From July 2002 through June 2003, 5,686 Rhode Islanders sought emergency shelter, a 29% increase from 2000-2001.4 One particularly disturbing statistic is the number of children who were homeless-1,450.4 Average income has not kept pace with average monthly rents: a person working at the state's minimum wage of $6.75 per hour would have to work 116 hours per week to pay for a typical two-bedroom apartment.4 To cope with the rising number of homeless people, the state has increased the number of shelter beds from 500 in 1991 to 650 beds in 2003.5

To serve as true advocates for our poor and homeless patients, we need to look beyond our examining rooms. We must continue to care, in our practices and clinics, for individual patients - to give antibiotics for pneumonia or permethrin for scabies, for instance. Still, without addressing their problems at a broader level, the number of people with no or unstable housing will only increase.

Rhode Island doctors, and doctors nationally, can become meaningfully involved. We can ask our patients about their housing status. We can learn about resources in our community to which we can direct patients who are homeless or have housing instability. For instance, the Rhode Island Coalition for the Homeless publishes "Street Sheets," a listing of resources for homeless people in various parts of the State, in both English and Spanish. In addition to treating the patients who come to us, we can go to them. Traveler's Aid's Mobile Health Van visits homeless shelters in the evenings and is always looking to increase its pool of volunteer physicians. We should also work together as a team with social workers, lawyers and other advocates on behalf of patients who are experiencing housing difficulties. We should raise our own awareness by keeping up-to-date on housing and poverty issues. We should speak informally and formally about these issues, raising others' awareness. And we should advocate for systemic reforms to ameliorate conditions that perpetuate homelessness. One method is by working with One Rhode Island, a state-wide coalition addressing health care, housing, child care, and state benefits. Together, we can make our state and nation a better place for all of us.

SOURCES

1. Gelberg L, Arangua L. Homeless persons. Chapter in press, used with author's permission.

2. Rhode Island Emergency Food and Shelter Board, Rhode Island Emergency Shelter Information Project: Annual Report, July 1, 2001-June 30, 2002.

3. Hirsch E, Classer I, Zywiak W. A view from the street: causes, consequences, and solutions for homelessness in Rhode Island, January 2004.

4. Poverty Institute. Affordable housing, One Rhode Island 2004 Fact Sheets, www.povertyinstitute.org.

5. Liberman E, No place to call home, Rhode Island Monthly, 2003; 16: 9.

JOANNA BROWN, MD

Joanna Brown is a 3rd-year resident in the Brown University/Memorial Hospital Family Medicine Residency. She was involved in an emergency homeless shelter at her synagogue that opened last winter, and coordinates resident participation in the Travelers Aid Mobile Health Van.

CORRESPONDENCE:

Joanna Brown, MD

Memorial Hospital

Brewster St.

Pawtucket, RI 02860

Fax: (401) 729-2923

e-mail: joannabrown14@yahoo.com

Copyright Rhode Island Medical Society Nov 2004
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