Street medicine’s hard choices

In January 2007, I started treating homeless patients on the streets of Santa Monica. I met Michael during the first few weeks. The first time I met him, he had all his belongings skillfully balanced on his bicycle. He seemed shy but pleasant. With a smile, he said, “No, thank you,” to my offer of medical help and avoided looking me in the eye. The next time I saw him, he asked one of the medical students who joined us in our outreach efforts for something to treat a rash.

Seeing that my previously spurned efforts were now welcome, I gave Michael (medical privacy rules don’t allow me to use his full name) an antifungal cream, which made me feel as if he had just agreed to lifesaving cancer treatment. The next week, he said the cream didn’t work, so I arranged for the care and supervision of his heavily laden bicycle and took him to the clinic for a proper examination and treatment. He was seen, treated and referred to a specialist.

Not many people know much about street medicine, in which healthcare providers go to where the homeless are, rather than waiting for them to come to our offices and emergency rooms. The practice began in the 1980s when the homeless population began to explode and primary-care physicians realized that the homeless population was extremely ill, failing to receive appropriate care, relying heavily on emergency room care and dying at an alarming rate.

The way it works is that I go in a van with other outreach workers to find homeless people under the pier, in the parks, on the Promenade, in the alleys, on the beach. I walk with my backpack filled with medications and supplies, a clipboard and a stethoscope, asking homeless people if they need medical attention. I’ve taken out sutures, removed staples, cleaned wounds, treated bronchitis, diagnosed diabetes and brought patients to the clinic or to the emergency room.

According to the most recent information provided by the Los Angeles Housing Service Assn.(current as of October), about 73,000 homeless people seek shelter or are on the streets on any given night in Los Angeles County. There are fewer than 13,000 shelter beds in the county, so more than 60,000 people live in the streets. Twenty-five percent are part of a homeless family, 15% are under the age of 18, and according to a study by the nonprofit group Shelter Partnership, there are from 3,000 to 4,000 homeless people older than 62 in L.A. County.

When considering the causes of homelessness, the following statistics may provide some insight. Seventy-four percent of L.A.’s homeless are disabled in some way; 33% suffer severe mental illness; 35% are physically disabled; 42% struggle with addiction; and 50% are clinically depressed.

As a doctor working with this community, the most troubling statistic was one I learned only recently: The mortality rate of the homeless is three to four times greater than that of the general population. The causes of death are the same as those in the general public: heart attacks, strokes and cancer. But they occur decades sooner for those living on the streets.

The Los Angeles Coalition to End Poverty and Homelessness released a document in December that presented the results of a study of homeless mortality in the county from January 2000 through May 2007. This study presented the sobering statistic that the average age of death was 48.

Among younger homeless people, AIDS, overdose and trauma are more prevalent causes of mortality.

A week after his clinic visit, Michael was still not better. So I decided to be a bit more assertive. I brought a male outreach worker with me and examined Michael’s rash in the men’s room. I diagnosed him with a severe infection known as balanitis. This type of infection is often seen in diabetics, so I measured his blood glucose, which was very high at 289. His blood pressure also was elevated, at 210/105. He appeared less excited about his diagnosis than I was. He declined treatment but humored me while listening to my fervent lessons on diabetes and diet.

After a few more visits in the park, he finally agreed to see me at the clinic for treatment of his diabetes and hypertension. I declared proudly to anyone who would listen that I had diagnosed diabetes in the field and that now the patient was visiting me in the clinic and was doing great.

But then I didn’t see Michael for months. He stopped coming to the clinic. I didn’t even see him in the park. It wasn’t until just a few weeks ago that I ran into him.

“Where have you been?” I asked. “I’ve been looking for you. Why haven’t you come to the clinic? Are you still on all your medications?”

“No,” he said, half-smiling and a little embarrassed.

“Do you want to die?” I said in exasperation. (In retrospect, this is never an effective line of questioning and rarely changes a patient’s behavior.)

“Well ... ,” he said softly, shrugging his shoulders. The tone of his voice told me that he had given up. Not just on keeping his diabetes and hypertension in control but on everything.

In a feeble attempt to scare him out of his hopelessness, again in exasperation, I threatened, “Well, you’re not actually going to die any time soon; you’re just going to get really sick, have a stroke and then not be able to walk or talk. You also might need an amputation. Maybe even dialysis. Life will only be more miserable.”

He shrugged again.

His hopelessness seeped into me. I had always believed that he was chronically depressed, and thought perhaps that was a major contributing factor to his homelessness. I also had entertained the idea that he might have slight cognitive disabilities. My goal had been to get him to the clinic, to start treating his diabetes and hypertension, to develop a relationship with him and then to try to address his depression. But maybe, I realized, I should have addressed the depression first.

As I thought about Michael’s uncontrolled diabetes and hypertension, the numbers that ran through my head were staggering. The cost of treating a stroke patient -- if it should come to that -- is about $75,000. An amputation could cost $50,000. Dialysis runs as much as $100,000 annually. Permanent housing for a year, $10,000 or so.

If a disease emerged that struck hundreds of thousands of people and killed its victims at an average age of 48, the Centers for Disease Control and Prevention would jump to attention and commit enormous resources to curing it. The National Institutes of Health would grant millions of dollars for research. Scientists who developed effective treatments would rightly be celebrated.

A disease like this does exist: homelessness. Its cure is widely available and even cost-saving. Studies show that one homeless person can cost a community hundreds of thousands of dollars a year in medical and legal expenses.

For example, the director of emergency response calls for the Santa Monica Police Department says that half of all the 911 calls in Santa Monica are related in some way to a homeless person. In a study conducted by Dr. James O’Connell, president of the Boston Health Care for the Homeless Program, 119 people living on the streets visited emergency rooms more than 18,000 times in a seven-year period.

So what is the cure? Assertive mental health programs for the homeless increase opportunities for housing and improve their quality of life. Attending especially to the high-risk homeless -- those with mental illness, substance abuse problems and certain chronic medical conditions-- will likely decrease mortality rates. Respite care also has been shown to drastically cut hospital costs. And most important, of course, the homeless need housing.

Yet homelessness still exists in epidemic proportions. Why? Because the homeless are often not hospitalized if they are uninsured; they are not being placed in psychiatric units because there are not enough beds available; and they are not being housed. Even worse, they are being demonized instead of being treated for their addictions. What we really need is to provide compassionate, respectful, quality care to this very vulnerable group.

In November, Michael told one of the outreach workers that he wanted me to check his sugar the next time I went out. We found him and checked his blood glucose, which was again very high at 321. He agreed to take a ride to the clinic that day to get refills of his medications. He accepted the outreach worker’s invitation to stay at the local shelter, where his bicycle and possessions would be safely stored.

Since then, he has shown up for all his appointments with me since then. He’s still in the shelter. One is permitted to stay at this shelter for six months.