Vulnerable Vulnerable Populations in Populations in

Disaster: Disaster: Caring for the Caring for the

HomelessHomelessCDR Al-Karim Dhanji M.D. USPHSCDR Al-Karim Dhanji M.D. USPHS

Ready Responder, HRSAReady Responder, HRSA

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.

OverviewOverview

The HomelessThe Homeless Health Implications Health Implications The Challenges The Challenges Considerations for CareConsiderations for Care SummarySummary

The HomelessThe HomelessHomeless people are the sum total of our

dreams, policies, intentions, errors, omissions, cruelties, and kindnesses as a

society. Peter Marin Sociologist

The US HomelessThe US Homeless Estimated 2.3 to 3.5 million peopleEstimated 2.3 to 3.5 million people11

- 1% US population per year- 1% US population per year Men (77%) > Women (23%)Men (77%) > Women (23%)22

More than 760,000 people sleep on the More than 760,000 people sleep on the streets or in shelters every night.streets or in shelters every night.33

49% AA, 35% White, 13% Hispanic, 2% 49% AA, 35% White, 13% Hispanic, 2% NA, 1% AsianNA, 1% Asian

40% served in armed forces40% served in armed forces

11 Urban Institute, 2000 Urban Institute, 200022US Conference of Mayors, 2003US Conference of Mayors, 200333 Urban Institute, 2001 Urban Institute, 2001

The US HomelessThe US Homeless

The Shelter Population:The Shelter Population:- 80% stay in shelter 1-2 nights- 80% stay in shelter 1-2 nights

- 10 % Episodic Users 3 weeks at a - 10 % Episodic Users 3 weeks at a time; time; Young and Heavy Drug Young and Heavy Drug UsersUsers

- 10% Chronically Homeless for - 10% Chronically Homeless for years; years; Mentally Ill. Physically Mentally Ill. Physically Disabled. Disabled. “The Stereotype”“The Stereotype”

Health ImplicationsHealth Implications

First respite facility in Boston, Shattuck Hospital (picture from J. O’Connell)

Health ImplicationsHealth Implications

Mortality is Mortality is 3.53.5 times higher (NEJM, 1994)times higher (NEJM, 1994)

WhyWhy Many problems present in advanced Many problems present in advanced

stagesstages Very little preventive careVery little preventive care Patient priorities are on food, shelter, Patient priorities are on food, shelter,

clothing, safety, self-medicationclothing, safety, self-medication Homelessness precludes good nutrition, Homelessness precludes good nutrition,

good personal hygiene, basic first aidgood personal hygiene, basic first aid

Health ImplicationsHealth Implications Lifetime HistoryLifetime History11::

- 62 % Alcohol Problems- 62 % Alcohol Problems- 58% Drug Problems- 58% Drug Problems- 57% Mental Health Issues care- 57% Mental Health Issues care

Increase Risk Compared to Domiciled Increase Risk Compared to Domiciled PopulationsPopulations22

- Asthma and COPD- Asthma and COPD- DM, HTN, PVD- DM, HTN, PVD- Chronic Renal and Liver Disease- Chronic Renal and Liver Disease

11 Urban Institute 2003 Urban Institute 20032 2 Fleischman, et al.1992;Wright, 1990Fleischman, et al.1992;Wright, 1990

Health ImplicationsHealth Implications

Hospitalization rate is 5 times Hospitalization rate is 5 times higher (Hwang, CMAJ, 2001)higher (Hwang, CMAJ, 2001)

Average Age of Death in Boston Average Age of Death in Boston 47 (Annals, 1997) vs Average 47 (Annals, 1997) vs Average National Mortality for white Male National Mortality for white Male 74.5 (CDC/NCHS)74.5 (CDC/NCHS)

Health ChallengesHealth Challenges Homeless people may resist treatment or have Homeless people may resist treatment or have

difficulty with adherence particularly those with difficulty with adherence particularly those with substance abuse and mental health disorderssubstance abuse and mental health disorders

Medications are lost, stolen, diverted or abused; Medications are lost, stolen, diverted or abused; multi-dose regimens are especially challengingmulti-dose regimens are especially challenging

Many conditions very difficult to treat without Many conditions very difficult to treat without adequate housingadequate housing- TB, HIV, DM, HTN, addiction, mental illness- TB, HIV, DM, HTN, addiction, mental illness

Health Challenges

Problems secondary to exposure to the Problems secondary to exposure to the streets or outdoors: frostbite, immersion streets or outdoors: frostbite, immersion foot, hypo- and hyperthermiafoot, hypo- and hyperthermia

Problems secondary to exposure to the Problems secondary to exposure to the shelters: infestations, respiratory shelters: infestations, respiratory infections, TB, infections, TB,

hepatitis Ahepatitis A Greater risk of trauma resulting from Greater risk of trauma resulting from

muggings, rapes, beatingsmuggings, rapes, beatings

Institutional Challenges: Disaster Paradigms11

Traditional Mass Care– Top Down Command- Injuries and Infections– “Survival of the

Fittest”– Compliance Dependent– Externally Supported

11 Jones, U. Albany, Grand Jones, U. Albany, Grand Rounds 2006Rounds 2006

22 Mokdad et al,Prev Chronic Mokdad et al,Prev Chronic DiseaseDisease

Special Needs Care– Community Based – Internally Supported– Chronic Diseases22

– Flexible– Support the

Weakest Link– Longer Term

Commitment

Institutional Challenges: The Provider

Our Unrealistic Expectations=Their Non Adherence: “Understand their Issues” 11

Personal vs Societal Responsibility

Practicing In Vertical Silos 22

11 National Health Care for the Homeless National Health Care for the Homeless2 2 Soskin, MPP Thesis JFK School- Harvard Soskin, MPP Thesis JFK School- Harvard

Institutional Challenges: The Provider

Our Values and Judgements “ the Issue of Compassion” 11

– Canadian Study Looking at “Stable” Homeless Canadian Study Looking at “Stable” Homeless comparing usual care with usual care plus comparing usual care with usual care plus “personal contact”“personal contact”

– Cut the rate of average return visits per month Cut the rate of average return visits per month by about a thirdby about a third

If “we” tell “them” to, “they” will do “it” 22

– Does information=Inspiration? Action? Results?Inspiration? Action? Results?

11 Redelmer, the Lancet, 1995 Redelmer, the Lancet, 1995 22 Jones, U. Albany, Grand Rounds 2006 Jones, U. Albany, Grand Rounds 2006

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 can’t imagine practicing as a physician without the whole team. I don’t think I

could do it, nor could I deliver good care.Jim O’Connell, MD

President, Boston Health Care for the Homeless Program

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”

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

Clinical ConsiderationsClinical Considerations

Clinical Considerations Enquire about Medical Conditions:

– At risk for: Asthma, Anemia, DM, CVD,TB,HIV,STI

– At risk for Death: Alcohol Abuse, Opiates, HIV, Alcohol Abuse, Opiates, HIV, Arrhythmias, Liver Disease, Frostbite, Renal Arrhythmias, Liver Disease, Frostbite, Renal disease, Hypothermia, Trench Foot disease, Hypothermia, Trench Foot 11

Normalize Discussion of Mental Health or Cognitive Deficits– Feeling down, difficulty focusing, sleep issues,

keeping track of things11 Hwang,, Archives 1998 Hwang,, Archives 1998

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?

Homelessness and TBHomelessness and TB Homeless individual are at increased risk: Homeless individual are at increased risk:

malnutrition, substance abuse, living malnutrition, substance abuse, living conditions/sheltersconditions/shelters

In 2002, Six percent of TB cases were In 2002, Six percent of TB cases were Homeless in preceding twelve months in Homeless in preceding twelve months in the USthe US

Always have a high index of suspicionAlways have a high index of suspicion DOT may be beneficial for active diseaseDOT may be beneficial for active disease

Homelessness and DiabetesHomelessness and Diabetes

Most have limited control over their dietMost have limited control over their diet- shelter food tends to be high fat, salt, sugar- shelter food tends to be high fat, salt, sugar

Liver dysfunction is common in those living Liver dysfunction is common in those living outside which affects med choice/regimenoutside which affects med choice/regimen

Avoid hypoglycemia “Harm Reduction”Avoid hypoglycemia “Harm Reduction” If using insulin, have a plan for how someone If using insulin, have a plan for how someone

will give it to self, store itwill give it to self, store it- consider using Lantus, once-daily dosing- consider using Lantus, once-daily dosing

Ask about potential SE and how pt will deal with Ask about potential SE and how pt will deal with it (e.g. diarrhea and metformin)it (e.g. diarrhea and metformin)

Homelessness and Homelessness and Dermatological ProblemsDermatological Problems

Diseases:Diseases: Venous StasisVenous Stasis Cellulitis and Cellulitis and

UlcersUlcers Immersion/Trench Immersion/Trench

FootFoot InfestationsInfestations

Causes:Causes: Chronically on their Chronically on their

feetfeet Ill-fitting Ill-fitting

shoes/clothesshoes/clothes Wet and cold Wet and cold

ConditionsConditions Poor HygienePoor Hygiene Use of infested Use of infested

blankets/clothesblankets/clothes

Venous Venous StasisStasis

-Predisposes patients to ulcers and cellulitis

-Interferes with patient’s ability to ambulate during the day

-Treatment difficulties include lack of BR if give diuretics Photo from J. O’Connell

Cellulitis and UlcersCellulitis and Ulcers

Can be complication of Can be complication of venous stasisvenous stasis

Predisposing factors: Predisposing factors: tinea, onychomycosis, tinea, onychomycosis, calluses, immersion calluses, immersion foot, inadequate shoes, foot, inadequate shoes, wet conditionswet conditions

Ulcers common even Ulcers common even without co-morbid without co-morbid conditions, like PVD or conditions, like PVD or DMDM

Photo from M. Bharel

Photo from M. Bharel

Immersion FootImmersion Foot

AKA Trench Foot b/c it was common AKA Trench Foot b/c it was common among soldiers in WWI who stood in among soldiers in WWI who stood in water-logged trenches for long periods at water-logged trenches for long periods at a time.a time.

Occurs when feet are subjected to cold Occurs when feet are subjected to cold and wet conditions for prolonged periods and wet conditions for prolonged periods of time, without freezing of tissue.of time, without freezing of tissue.

Conditions create damage to skin, nerves Conditions create damage to skin, nerves and muscle.and muscle.

Contributing factors: malnutrition, PVD, Contributing factors: malnutrition, PVD, improper clothing, wind, inactivity.improper clothing, wind, inactivity.

Immersion FootImmersion Foot Symptoms:Symptoms: Initially – tingling, numbness, itching, pain. Initially – tingling, numbness, itching, pain.

Signs: edema, pale, clammy, macerated Signs: edema, pale, clammy, macerated skinskin

Late – anesthesia to touch, “walking on Late – anesthesia to touch, “walking on blocks of wood”blocks of wood”

Re-warming – burning or throbbing pain, Re-warming – burning or throbbing pain, swellingswelling

Can have symptoms of hypersensitivity, Can have symptoms of hypersensitivity, sweat gland dysfunction, and pain for sweat gland dysfunction, and pain for months to permanentlymonths to permanently

Can be complicated by infectionCan be complicated by infection

Immersion FootImmersion Foot

Treatment: Treatment: Dry feet, Dry socks, Dry ShoesDry feet, Dry socks, Dry Shoes Slow re-warmingSlow re-warming Avoid weight-bearing or traumaAvoid weight-bearing or trauma Prophylactic topical or oral Prophylactic topical or oral

antibiotics, antifungalsantibiotics, antifungals Treat painTreat pain

Immersion FootImmersion Foot

LiceLice

LiceLice

Homeless People Suffer Infestations Homeless People Suffer Infestations Three times general adult population Three times general adult population 11

Pediculus humanusPediculus humanus – head lice – head lice ((corporiscorporis) and body lice () and body lice (capitiscapitis))

Serve as vectors for other infectious Serve as vectors for other infectious diseases like epidemic typhus, trench diseases like epidemic typhus, trench fever and relapsing feverfever and relapsing fever1 1 Healing Hands Newsletter, Feb 2005 Healing Hands Newsletter, Feb 2005

ScabiesScabies Pimple-like irritations, burrows or rash of the Pimple-like irritations, burrows or rash of the

skin, especially in skin folds or webbing skin, especially in skin folds or webbing between the skin (i.e. fingers) between the skin (i.e. fingers)

Intense itchingIntense itching Sores on body caused by scratchingSores on body caused by scratching Acquired by direct, prolonged, skin-to-skin Acquired by direct, prolonged, skin-to-skin

contactcontact Symptoms may take 4-6 wks if never had Symptoms may take 4-6 wks if never had

scabies before. If exposed in past, may take scabies before. If exposed in past, may take just a few daysjust a few days

Symptoms may persist for 2-3 wks after Symptoms may persist for 2-3 wks after treatmenttreatment

ScabiesScabies

Diffuse the Diffuse the Shame!Shame!

In ConclusionIn Conclusion

Be aware of the risk homelessness Be aware of the risk homelessness itself imparts on a patient’s overall itself imparts on a patient’s overall health and risk of deathhealth and risk of death

There is a cultural competency There is a cultural competency centered around compassion, hope centered around compassion, hope and relationshipand relationship

Appreciate the challenging Appreciate the challenging congruence of medical conditions in congruence of medical conditions in this vulnerable populationthis vulnerable population