Poor health is a primary outcome of being without a home, house or shelter and, as with so much else, COVID-19 has made the problem worse.
Homelessness—particularly unsheltered homelessness—was on the rise even before the pandemic, according to Shad Yasin, a first-year student at Rutgers New Jersey Medical School. He noted that out of the 580,500 people estimated to be houseless in January 2020, 18.3% were children.
For panelist Robert Fullilove, EdD, it is the condition of homelessness that contributes to a number of the medical problems that physicians must treat.
“A more rational society” would address the underlying issue of shortage of affordable housing, said Fullilove, associate dean for community and minority affairs and a professor of clinical sociomedical sciences at Columbia University Mailman School of Public Health.
In the meantime, doctors and other health professionals struggle to address the sequelae of homelessness in their patients.
Panelist Kelly Doran, MD, MHS, an assistant professor of emergency medicine and population health at the New York University School of Medicine and Bellevue Hospital Center, described the conditions that frequently bring homeless patients to the emergency department.
These include infections in the legs and feet that are so severe they may require amputation, injuries from violent trauma and sexual assault, and COVID-19.
Drug overdoses and HIV are also common, panelists said.
“HIV is a disease of marginalized communities,” Fullilove said. “Who is more marginalized in our society than folks who can’t maintain their presence in a house?”
Panelist Alaina Boyer, PhD, the National Health Care for the Homeless Council’s director of research, noted those who are homeless often feel unsafe and barely get any sleep. This sleep deprivation can lead to confusion that causes problems when confronted by police.
Boyer advocated harm-reduction strategies such as needle exchanges for patients who are homeless, and she described the benefits of “respite care,” a growing option for patients no longer sick enough to stay in a hospital and who are discharged without a place to go.
There are about 100 such programs in the U.S., with some making use of old hotels where they provide short-term housing and linkages to services that help improve self-management and transitions to outpatient coordinated care, Boyer said.
Dr. Doran noted that research suggests respite care can cut future hospital admissions, inpatient hospital days and hospital readmissions.
The AMA adopted policy in 2018 to support permitting Medigap and Medicare Advantage plans to offer a respite care benefit as an option.
Yasin asked the panelists to offer advice to the medical students and future policymakers.
Dr. Doran told students to “try not to get too jaded,” as research shows that people’s attitude toward patients who are homeless gets worse as they progress through medical training.
“Just listen to people and ask about their housing without making assumptions,” she said. “People going through homelessness are often among the kindest, most giving people around and will help you to learn if you’re nonjudgmental.”
Fullilove noted that his grandfather started practicing medicine in 1907 and his father became a physician in 1934. He offered advice from the perspective of a family dedicated to practicing medicine in underserved Black communities for a century.
He said that there is too much labelling in society and to not approach patients’ health care according to labels they have been given.
“They are not their labels,” Fullilove said. “You will be a better physician by really understanding who the patient is—not what the patient is.”
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