Vol. 13 •Issue 9 • Page 32
Helping the Homeless
A Host of Respiratory Problems Plagues This Underserved Population
Mop-haired Gabriel Micah Toala-Bungy toddles and waddles around the floor. He enjoys handfuls of noodles and gleefully gobbles up milk in a sippy cup. And he offers wide smiles when his belly gets tickled or when his picture is taken.
Gabriel has adorable qualities similar to most other 17-month-olds. But, being homeless, he also falls into a category that many children in his tiny shoes share: having asthma.
Recent research in the Archives of Pediatric and Adolescent Medicine shows that homeless children have asthma at a rate six times the national average.1 Asthma is only one of the myriad respiratory diseases that afflict the homeless.
Between 600,000 and 800,000 people are homeless in the United States on any given night, according to the Urban Institute. Over a year, that translates into approximately 3.5 million people — about the total population of the state of Oregon.
Yet, like passersby who hurry past panhandlers, the medical community often turns a blind eye to this growing population’s health care needs.
“There’s a great lack of awareness of how much co-morbidity exists in the homeless,” said Jacqueline Peterson Tulsky, MD, associate professor of medicine, University of California, San Francisco. “There’s a lot that’s misunderstood, misrepresented or just not talked about.”
Few researchers have tackled the subject of health care and the homeless. Many times, people may be apprehensive to fully engage the homeless because of their appearance or other negative impressions of them.
“You have to get past this image of someone in front of you who hasn’t showered in a few days or isn’t wearing the same sort of clothing that you would walk out of the house in,” Dr. Tulsky said.
Beth Shilkret, RN, infection control coordinator of the Philadelphia Health Management Corp.’s Health Care for the Homeless program, has worked with homeless patients for more than a decade. “We have to recognize their humanity,” she said. “That’s the challenge for a lot of people.”
BARRIERS TO CARE
Not only do homeless people face social stigmas, they also encounter many systemic obstacles such as lack of health insurance and difficulty finding a provider who understands their situation and can give care in a timely and sensitive fashion. Also, they may have personal issues that become barriers to accessing care.
“Survival needs such as food, shelter and just getting by are going to be more important than health care,” said Stephen W. Hwang, MD, MPH, a research scientist at the Inner City Health Research Unit, St. Michael’s Hospital, Toronto, who has conducted 20 studies on health issues in the homeless. “They may delay seeking care even when they know it’s needed. In some cases, they may not appreciate the need for health care due to problems such as mental illness or substance abuse and addiction.”
Mental illness may make the homeless reluctant to interact with other people, added Jean Hochron, director of the Office of Minority and Special Populations, Bureau of Primary Health Care, Health Resources and Services Administration — the government agency that runs 165 federally funded Health Care for the Homeless programs across the country.
“Many have had very negative experiences by being institutionalized and are not comfortable with and don’t trust health care providers,” she said.
For those more mentally sound, Dr. Tulsky has found in her own research that many have solid motivation to get healthy. “It’s not like the homeless want to be sick and die,” she said. “It takes so much organizational skill, with or without insurance, to identify a clinic or physician, get the appointment, and keep the appointment.”
Most seek care in the emergency room or the clinics in the shelters when they have medical problems. Both locations generally emphasize acute care issues, Dr. Tulsky said. It’s a luxury to think about preventive health care.
“With COPD, if you’re having an exacerbation, then it gets addressed,” she said. “But stepping back and documenting it as a chronic disease and saying, ‘What can we do to stabilize this disease?’ is lower down on the priority list both for the person and his providers.”
CAN YOU SPARE A CIGARETTE?
Homeless people have a high prevalence of chronic obstructive pulmonary disease. Not surprisingly, the main culprit comes from cigarettes.
Thumbtacked to the wall of the medical clinic in a North Philadelphia homeless shelter hangs one poster that’s particularly blunt.
“Lady Killer,” reads the time-stained piece of paper from the American Cancer Society. Above the headline, an ashtray sits with a lit cigarette, lipstick marks wrapped around the end.
The message may be simple, but getting homeless people to follow it often proves difficult.
“There’s so much going on in there,” Shilkret said, pointing to her head. “You don’t want to take away every crutch. But smoking cessation is something you work toward. It’s always on the burner.”
Seventy percent of homeless adults smoke cigarettes, Dr. Hwang said. In the general U.S. population, it’s 23 percent.2
Dr. Tulsky came across similar findings. The smoking rate of homeless women hovers at 72 percent, with a medium smoking history of 25 years.
“Can you imagine?” said Dr. Tulsky, concerned by the results.
With the exception of psychiatric patients, you would have a tough time finding a population that has a higher smoking rate than homeless adults.
In fact, because many homeless people suffer from mental illness, that could be a significant contributing factor to their addiction, Dr. Tulsky said. Nicotine tends to be a stress reducer for a group who deals with extreme trauma on a daily basis.
Also, smoking appears to be a way to bond with other homeless people, said Laurie Snyder, MD, pulmonary/critical care fellow at Duke University, Durham, N.C. “If you’re in a shelter or develop a network of people, smoking is a social outlet. It’s almost part of the culture.”
Shelters have moved slowly to outlaw smoking — even in states on the forefront of indoor smoking bans like California. “Many larger shelters are uncomfortable doing it because it’s one of the only rewards you can offer people that would influence behavior,” Dr. Tulsky said.
Regardless, for the protection of smokers and those inhaling the secondhand toxins, she urges facilities to implement a full smoking ban and offer more help to quit.
“But it should be done in the most sympathetic and supportive way,” Dr. Tulsky said. “If you can’t do nicotine replacement programs, at least do group support sessions that allow people, on a drop-in basis, to talk about their struggles with smoking.”
Dr. Snyder knew this high prevalence of cigarette smoking, coupled with the poor nutrition and adverse environmental exposures they frequently face, makes these urban nomads susceptible to obstructive lung disease (OLD).
To find out the exact rate using objective data, Dr. Snyder and a colleague recruited 68 adults living in a San Francisco homeless shelter.3 They used a multifaceted approach to assess OLD, including respiratory symptoms, self-reported physician diagnosis of asthma, chronic bronchitis, emphysema or COPD, and spirometry.
The results showed a sky-scraping rate of cigarette smoking (75 percent ever-smokers, 68 percent current smokers) and a high prevalence of symptoms suggestive of OLD, including cough (29 percent), wheezing (40 percent), chronic bronchitis symptoms (21 percent), and dyspnea on exertion (29 percent).
A substantial proportion of participants indicated a prior diagnosis of asthma (24 percent), chronic bronchitis (19 percent), and COPD (4 percent).
Based on spirometry, they had a 15-percent prevalence of OLD, which more than doubles the rate in the general U.S. population.
“We need to wake up and realize we need to address this as a problem,” Dr. Snyder said. “Obstructive lung disease might land you in the ER for an acute problem episode, but it’s really a disease process that can be controlled as an outpatient.”
They did some brainstorming and considered three theories for the connection between homelessness and OLD.3 First, if the OLD is severe and debilitating, and a person couldn’t work, then the OLD may have led directly to homelessness. “I think that would be the minority,” she said.
Second, some aspect of homelessness caused OLD or increased the rate of OLD in those predisposed to it. This relationship may be due to the high prevalence of smoking or higher rates of respiratory infections among the homeless. Respiratory infections may play a role in the development of OLD, as well as other environmental exposures, malnutrition and smoking.
Lastly, homelessness may exacerbate pre-existing OLD. This could be due to smoking, infections, general health, nutrition, environmental stress, drug and alcohol abuse, or poor access to care.
Because they used objective data, she said their study has the advantage over others that looked at respiratory problems in the homeless. Those researchers had relied just on symptoms such as shortness of breath and wheezing, Dr. Snyder noted, which also could signal cardiac problems.
“With a pulmonary function test, it’s hard to deny it’s a much higher rate than it should be,” she said.
However, she admitted the study had some limitations. Because the study took place in a shelter, the people interviewed were more likely to be homeless for a shorter period of time and have a greater chance to have an established way to get health care. Homeless people who must fend for themselves on the streets, she suspected, probably have even worse respiratory troubles.
Dr. Snyder also was disappointed with low participation rates. Many of the shelter’s residents distrusted this “outsider,” at first. One wondered, “Are you going to give me an infection with this breathing machine?” But after several days and nights of visiting the shelter, she gained the trust of some.
It takes a special kind of person to work with the homeless, and it’s a job that can’t be taught in any training program. “It’s one that you learn through practice,” Dr. Hwang said.
He suggests anyone unaccustomed to providing care for the homeless to link up with experienced providers in order to take advantage of that expertise.
Almost all medical professions can contribute, Dr. Hwang added. Helping the homeless requires integrated care that involves primary care physicians, nurses, social workers, addiction counselors, pulmonologists and respiratory therapists.
Another way health care practitioners can help is with the written word. Dr. Tulsky said people have this sense that monitoring the homeless and conducting studies on them can be difficult, but as shown by Dr. Snyder’s study, it can be done — and it can provide revealing results.
Research on the homeless, though, must be paired with support or intervention programs. “They just can’t go out, document ‘this is a big problem,’ and walk away,” Dr. Tulsky said.
Mike Bederka is associate editor of ADVANCE. He can be reached at [email protected].
For references and more on health care in the homeless, visit www.advanceweb.com/respmanager.
Add another disease to the already long list of serious medical problems the homeless face — tuberculosis. Research shows 25 percent to 30 percent of homeless people have positive skin tests for TB.1 Rates of active TB among the homeless soar to what’s found in sub-Saharan Africa — more than 250 people per every 100,000.2
These kinds of astronomical TB rates come from the fact that homeless people live in group settings and often don’t have ready access to health care early on, said Beth Shilkret, RN, infection control coordinator at the Philadelphia Health Management Corp.’s Health Care for the Homeless program.
“They can’t discover in a timely way they’re sick,” she said. “That whole delay in care is an opportunity to infect their circle.”
Philadelphia’s Health Care for the Homeless program hopes to prevent any future outbreaks, and to do this, the staff provides symptom screenings to all adults entering the city’s shelter system. The TB nurse follows all positive screens until TB is ruled out or directly observed therapy is instituted.
When a screening reveals positive symptoms, the nurse formulates a plan for the homeless person, the case worker and herself. When indicated, the plan includes medical evaluation, obtaining medical records, consultation with TB control, and follow-up. “The client doesn’t come to the shelter,” Shilkret said. “The client is directed to the hospital and then goes inpatient, so he’s removed from the congregate setting where he can no longer infect somebody.”
The Health Care for the Homeless program works hand in hand with the TB control unit of the Philadelphia Department of Health. Shilkret monitors the patients’ attendance at the Directly Observed Therapy Center, and the Department of Health provides the medication and medical monitoring with a TB specialist. “The goal is that with cooperation between our two organizations, clients with symptoms are identified and triaged; active cases stay in therapy, preventing development of drug-resistant TB; and patients with active disease who stop attending DOT are found,” she said.
For a list of references, please call Mike Bederka at (610) 278-1400, ext. 1128, or visit www.advanceweb.com/respmanager.