Vulnerable Populations in Disaster: Caring for the Homeless

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Vulnerable Populations in Disaster Caring for
the Homeless

• CDR Al-Karim Dhanji M.D. USPHS
• Ready Responder, HRSA

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Disclaimer

• The contents of this presentation are solely the
  views of the author and do not necessarily
  represent the official view of HRSA, DHHS or
  Boston Health Care for the Homeless.

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Overview

• The Homeless
• Health Implications
• The Challenges
• Considerations for Care
• Summary

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The Homeless
Homeless people are the sum total of our dreams,
policies, intentions, errors, omissions,
cruelties, and kindnesses as a society.
Peter Marin Sociologist
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The US Homeless

• Estimated 2.3 to 3.5 million people1
• - 1 US population per year
• Men (77) gt Women (23)2
• More than 760,000 people sleep on the streets or
  in shelters every night.3
• 49 AA, 35 White, 13 Hispanic, 2 NA, 1 Asian
• 40 served in armed forces
• 1 Urban Institute, 2000
• 2US Conference of Mayors, 2003
• 3 Urban Institute, 2001

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The US Homeless

• The Shelter Population
• - 80 stay in shelter 1-2 nights
• - 10 Episodic Users 3 weeks at a time Young
  and Heavy Drug Users
• - 10 Chronically Homeless for years Mentally
  Ill. Physically Disabled. The Stereotype

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Health Implications
First respite facility in Boston, Shattuck
Hospital (picture from J. OConnell)
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Health Implications

• Mortality is 3.5 times higher (NEJM, 1994)
• Why
• Many problems present in advanced stages
• Very little preventive care
• Patient priorities are on food, shelter,
  clothing, safety, self-medication
• Homelessness precludes good nutrition, good
  personal hygiene, basic first aid

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Health Implications

• Lifetime History1
• - 62 Alcohol Problems
• - 58 Drug Problems
• - 57 Mental Health Issues care
• Increase Risk Compared to Domiciled Populations2
• - Asthma and COPD
• - DM, HTN, PVD
• - Chronic Renal and Liver Disease
• 1 Urban Institute 2003
• 2 Fleischman, et al.1992Wright, 1990

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Health Implications

• Hospitalization rate is 5 times higher (Hwang,
  CMAJ, 2001)
• Average Age of Death in Boston 47 (Annals, 1997)
  vs Average National Mortality for white Male 74.5
  (CDC/NCHS)

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Health Challenges

• Homeless people may resist treatment or have
  difficulty with adherence particularly those with
  substance abuse and mental health disorders
• Medications are lost, stolen, diverted or abused
  multi-dose regimens are especially challenging
• Many conditions very difficult to treat without
  adequate housing
• - TB, HIV, DM, HTN, addiction, mental illness

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Health Challenges

• Problems secondary to exposure to the streets or
  outdoors frostbite, immersion foot, hypo- and
  hyperthermia
• Problems secondary to exposure to the shelters
  infestations, respiratory infections, TB,
• hepatitis A
• Greater risk of trauma resulting from muggings,
  rapes, beatings

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Institutional Challenges Disaster Paradigms1

• Traditional Mass Care
• Top Down Command
• - Injuries and Infections
• Survival of the Fittest
• Compliance Dependent
• Externally Supported
• 1 Jones, U. Albany, Grand Rounds 2006
• 2 Mokdad et al,Prev Chronic Disease

• Special Needs Care
• Community Based
• Internally Supported
• Chronic Diseases2
• Flexible
• Support the Weakest Link
• Longer Term Commitment

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Institutional Challenges The Provider

• Our Unrealistic ExpectationsTheir Non Adherence
  Understand their Issues 1
• Personal vs Societal Responsibility
• Practicing In Vertical Silos 2
• 1 National Health Care for the Homeless
• 2 Soskin, MPP Thesis JFK School- Harvard

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Institutional Challenges The Provider

• Our Values and Judgements the Issue of
  Compassion 1
• Canadian Study Looking at Stable Homeless
  comparing usual care with usual care plus
  personal contact
• Cut the rate of average return visits per month
  by about a third
• If we tell them to, they will do it 2
• Does informationInspiration? Action? Results?
• 1 Redelmer, the Lancet, 1995
• 2 Jones, U. Albany, Grand Rounds 2006

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The team approach to care
The care of homeless people is so complex, that
to put that burden on one person would be
impossible. What is impossible in a traditional
system is a joy in a system where the care is
shared by the team. I cant imagine practicing as
a physician without the whole team. I dont think
I could do it, nor could I deliver good care. Jim
OConnell, MD President, Boston Health Care for
the Homeless Program
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Organizational Considerations

• Balancing traditional with special care
• Community based approach
• Build on pre-established local networks for care
  delivery
• Greater understanding of the needs of vulnerable
  clients
• Promote Cultural Competency
• Better access to Local Communities outreach to
  sites

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Cultural Considerations

• Realize that there is a culture to be
  understood
• Using Person-Centered Values
• Empowered and Educated to make choices
• Dignity and Respect our language
• Creating Hope to combat despair and helplessness
• Integrating into Therapeutic Relationship where
  relationship is valued as much as expertise
• Build the Trust

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Clinical Considerations
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Clinical Considerations

• Enquire about Medical Conditions
• At risk for Asthma, Anemia, DM, CVD,TB,HIV,STI
• At risk for Death Alcohol Abuse, Opiates, HIV,
  Arrhythmias, Liver Disease, Frostbite, Renal
  disease, Hypothermia, Trench Foot 1
• Normalize Discussion of Mental Health or
  Cognitive Deficits
• Feeling down, difficulty focusing, sleep issues,
  keeping track of things 1 Hwang,,
  Archives 1998

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Clinical Considerations

• Alcohol/Drug Use
• Engage the Patient What is good or not so good
  about using?
• At risk for detoxing
• Physical Examination
• Ask permission before each part of the exam
• Do you have their trust?

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Homelessness and TB

• Homeless individual are at increased risk
  malnutrition, substance abuse, living
  conditions/shelters
• In 2002, Six percent of TB cases were Homeless in
  preceding twelve months in the US
• Always have a high index of suspicion
• DOT may be beneficial for active disease

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Homelessness and Diabetes

• Most have limited control over their diet
• - shelter food tends to be high fat, salt, sugar
• Liver dysfunction is common in those living
  outside which affects med choice/regimen
• Avoid hypoglycemia Harm Reduction
• If using insulin, have a plan for how someone
  will give it to self, store it
• - consider using Lantus, once-daily dosing
• Ask about potential SE and how pt will deal with
  it (e.g. diarrhea and metformin)

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Homelessness and Dermatological Problems

• Diseases
• Venous Stasis
• Cellulitis and Ulcers
• Immersion/Trench Foot
• Infestations

• Causes
• Chronically on their feet
• Ill-fitting shoes/clothes
• Wet and cold Conditions
• Poor Hygiene
• Use of infested blankets/clothes

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Venous Stasis

• Predisposes patients to ulcers and cellulitis
• Interferes with patients ability to ambulate
  during the day
• Treatment difficulties include lack of BR if give
  diuretics

Photo from J. OConnell
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Cellulitis and Ulcers

• Can be complication of venous stasis
• Predisposing factors tinea, onychomycosis,
  calluses, immersion foot, inadequate shoes, wet
  conditions
• Ulcers common even without co-morbid conditions,
  like PVD or DM

Photo from M. Bharel
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Photo from M. Bharel
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Immersion Foot

• AKA Trench Foot b/c it was common among soldiers
  in WWI who stood in water-logged trenches for
  long periods at a time.
• Occurs when feet are subjected to cold and wet
  conditions for prolonged periods of time, without
  freezing of tissue.
• Conditions create damage to skin, nerves and
  muscle.
• Contributing factors malnutrition, PVD, improper
  clothing, wind, inactivity.

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Immersion Foot

• Symptoms
• Initially tingling, numbness, itching, pain.
  Signs edema, pale, clammy, macerated skin
• Late anesthesia to touch, walking on blocks of
  wood
• Re-warming burning or throbbing pain, swelling
• Can have symptoms of hypersensitivity, sweat
  gland dysfunction, and pain for months to
  permanently
• Can be complicated by infection

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Immersion Foot

• Treatment
• Dry feet, Dry socks, Dry Shoes
• Slow re-warming
• Avoid weight-bearing or trauma
• Prophylactic topical or oral antibiotics,
  antifungals
• Treat pain

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Immersion Foot
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Lice
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Lice

• Homeless People Suffer Infestations Three times
  general adult population 1
• Pediculus humanus head lice (corporis) and body
  lice (capitis)
• Serve as vectors for other infectious diseases
  like epidemic typhus, trench fever and relapsing
  fever
• 1 Healing Hands Newsletter, Feb 2005

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Scabies

• Pimple-like irritations, burrows or rash of the
  skin, especially in skin folds or webbing between
  the skin (i.e. fingers)
• Intense itching
• Sores on body caused by scratching
• Acquired by direct, prolonged, skin-to-skin
  contact
• Symptoms may take 4-6 wks if never had scabies
  before. If exposed in past, may take just a few
  days
• Symptoms may persist for 2-3 wks after treatment

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Scabies
Diffuse the Shame!
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In Conclusion

• Be aware of the risk homelessness itself imparts
  on a patients overall health and risk of death
• There is a cultural competency centered around
  compassion, hope and relationship
• Appreciate the challenging congruence of medical
  conditions in this vulnerable population

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