Homeless people in America are disproportionately vulnerable to disease compared to other population groups in society. With the exception of cancer, obesity and stroke, the homeless are more likely to suffer from all the other diseases compared to the rest of the population [NCH, 2007]. Homeless people have a mortality rate that is four times higher than that of the general population [Barrow, 1989]; clearly, there’s a problem.
Additionally, their state of homelessness exposes them to factors that do not generally affect other members of the society; that increase their chances of contracting and suffering from diseases.
A debilitating or disabling condition can also be a cause of homelessness; for example through the loss of a job or neglect by the family.
The Homeless in Perspective
Demographics
A homeless person is defined as one who is not able to maintain a regular shelter; this includes all the persons living in temporary shelters in an institution and those temporarily living with their relatives commonly known as ‘couch surfing’. It also encompasses persons in institutions such as hospitals who have no home to go to after their discharge.
The accurate enumeration of all the homeless people is technically impossible stemming from the nature of their existence since they have no permanent homes. However, it is estimated that there are half a million homeless Americans [AMSA, 2009].
Factors predisposing to disease
Homeless people are exposed to factors that are unique to their situation. First of all, they have constantly been exposed to the elements; issues of frostbite, sunburn and moisture. The homeless spend a disproportionately long time on their feet; this, coupled with poor footwear, renders them more prone to foot disorders such as ulcers [Didier et al, 2001]. They also live with the constant risk of violent encounters with street gangs and other homeless people; thus are predisposed to violent injuries [AMSA, 2009].
The population that is living in homeless shelters is prone to conditions that are predisposed by living in such close proximity; the problem of primary tuberculosis has thus been recognized as a major problem among the homeless people; other respiratory diseases spread via aerosol are also highly prevalent among the homeless[Didier et al, 2001]. Additionally, due to poor hygiene practices, the homeless are prone to skin diseases and ectoparasite infestations; the spread of these diseases is augmented by the close proximity of the shelters.
The use of intravenous drugs is disproportionately high among homeless people; this ultimately leads to drug dependency with its effects on health [Didier et al, 2001]. Additionally, the sharing of drug-use paraphernalia such as needles fuels the spread of blood-borne diseases such as AIDS and hepatitis.
The homeless also weaken their immune systems and damage their metabolism through the heavy use of alcohol and tobacco [Didier et al, 2001].
The problem of mental illness among the homeless is also a predisposing factor to the occurrence and severity of infectious diseases; it is estimated that 23% of all homeless people have some form of mental illness, most commonly schizophrenia [AMSA, 2009]; stemming from this, the person may not be able to appreciate the need for medical care due to the state of mind; additionally, the condition may lead to self neglect in issues such as hygiene and nutrition further making them vulnerable to infection [Didier et al, 2001].
The oral health of homeless people is usually very poor primarily due to a lack of basic oral hygiene practice; this is complicated by the lack of dental service due to access or cost.
Challenges to health care
The homeless offers a unique challenge to health care providers due to their way of life. They are mostly unable to pay for health services due to their situation. The homeless are usually not covered by medical insurance and thus can not depend on this factor when they visit health facilities [O’Connell, 2004]. Additionally, they may not be able to access free facilities due to overcrowding of such or due to lack of transport. Some may not be able to appreciate their condition from mental illness [AMSA, 2009]; while others may have a fear of institutions thus opt to keep away from hospitals.
Homeless people suffering from chronic diseases that require a strict medical regime, such as tuberculosis and AIDS, are very difficult to treat as compliance to the medical regime is not reliable [Didier et al, 2001]. Additionally, a follow up of such cases is made difficult by the nomadic nature of homeless persons. Additionally, in a condition such as insulin dependent diabetes, the issuance of the patient with a stock of needles for hygienic injections may precipitate violent attacks from intravenous drug users in the belief that the person is carrying and using narcotics. In addition to this, the person may not have the facilities to refrigerate the insulin stock [AMSA, 2009].
Apart from infectious diseases, the patient also presents with drug and alcohol dependency, thus requiring more vigorous treatment and possible hospitalization [O’Connell, 2004]; the major setback however is that after the recovery, the patient is released to go back to the conditions that caused the dependency in the first place.
Usually, it is not possible to employ some of standard principles of medicine used on regular patients on homeless people [Wright, 2006]; for example, it may not be practical to give a homeless person an appointment for a review since the circumstances may not allow the person to be present in the area at the time of the appointment. Additionally, prescribing lifestyle changes as a remedy for a condition may not be effective as such practices may be an integral part of the person’s survival on the streets [O’Connell, 2004].
Discussion
The healthcare system as it is today is not friendly for the homeless people in America. The dominance of health insurance as the mode of payment for healthcare services effectively locks out the majority of these people [O’Connell, 2004]. The other alternative is the free clinics and county hospitals; however, the resources of these institutions are spread thinly over insatiable health needs [Wright, 2006].
The available health institutions also lack a strong framework and communication with other government agencies that would facilitate the transition of a homeless person back into the society once cure has been achieved rather than just releasing them back into the streets [O’Connell, 2004]; this has resulted in having no concrete progress in improving the health of this portion of the society since they go back to the same environment that predisposed their condition in the first place.
There has also been a failure in the healthcare system in recognizing the homeless people as a unique epidemiological group with predispositions that are not remotely similar to those of other regular patients; this has resulted in the blanket application of medical practice across the board with expectedly unsatisfactory results among the homeless.
The viewing of homeless patients with a stereotypical attitude by medical providers as drug users or irresponsible has also contributed to the mediocre provision of health services to them and also to the fear of institutions by some of the homeless people.
Recommendations
The problem of homelessness is a major and growing one in the United States; the recently volatile economic outlook and the accompanying economic recession will no doubt create more homeless people through foreclosures of their homes.
Therefore it is important to come up with health provision policies and structures that will cover the unique health needs of homeless people [O’Connell, 2004]. The issue of reducing homelessness is in the jurisdiction of the economic policy-makers and implementers. However, the modalities of reducing the occurrence of homelessness should be a concerted effort between various government agencies with the participation of the health providing agencies. A program to provide adequate healthcare should maximize on accessibility; mobile clinics that regularly visit the areas where homeless people congregate for example homeless shelters and soup kitchens would go a long way in improving the accessibility of healthcare to homeless people; it would also improve on albeit moderately medical follow-up to ascertain regime compliance. Alternatively, these people may be offered transportation to the health facilities [O’Connell, 2004].
Such a program should be based on a mode of practice that is specifically designed for the homeless so as to be more effective in diagnosis and treatment of the cases to avoid relapse into the disease status after the treatment [Wright, 2006].
The affordability of health services for the homeless is also a major impediment for the provision of this essential service; thus a system should be formulated to offer free pharmaceuticals to these people; this may not be sustainable for providers, therefore, means of securing government support should be designed. The model should also be designed to give a comprehensive service to the homeless patient; the scope should cover chronic infectious diseases, hygiene, nutrition, drug and alcohol dependency; and mental health [Wright, 2006]. The approach to the homeless patient by the health practitioner is also very essential for the success of such a program [O’Connell, 2004]; a stereotype-tinted view of the patient will lead to a feeling of rejection by the patient and may discourage future visits to the health facility.
Conclusion
The problems ailing the homeless people span more than the provision of healthcare to them, consequently, it is not prudent to assume that effective healthcare to this segment of the society will solve all of their problems. As much as it would alleviate the suffering of the person by giving emergency care, the predisposing factors to this ill-health will still be there when the patient leaves the hospital; therefore improvement of the health of this person is not progressive. A much wider approach is thus required to improve the social and economic status of the person so as s/he can stop being homeless.
References
- American Medical Student Association (2009): Health Care for the Homeless.
- Barrow, S. M. (1989): Mortality among homeless shelter residents in New York City: American Journal of Public Health. 1999; 89(4):529-34.
- Didier Raoult, Cédric Foucault, and Philippe Brouqui (2001): Infections in the homeless: Lancet Infectious Diseases 2001; 1: 77–84
- National Coalition for the Homeless (2007): Health Care and Homelessness
- O’Connell, James (2004): The Health Care of Homeless Persons: a Manual of Communicable Diseases & Common Problems in Shelters & On the Streets. Boston Health Care for the Homeless Program
- Wright N.M. Tompkins C. N. (2006): How can services effectively meet the needs of homeless people?’ British Journal of General Practice 2006; 56(525):286-93