Beyond the Streets: Rethinking Health Care for the Homeless Population

Housing instability's impact on health cannot be ignored by physicians. I wholeheartedly support the recommendations of the policy paper by the American College of Physicians (ACP) on safe housing as a fundamental human right. This policy paper recognizes that this public health crisis coincided with the "economic uncertainty and instability after the COVID-19 pandemic" (1). During my internal medicine intern year, I witnessed how the homeless could not escape the harsh weather due to the spread of this deadly infection in the overcrowded shelters. Using hotels did not solve the issue, and I spent many days on the wards taking care of these critically ill patients with COVID-19. The pandemic showed the fragility of our health care system and highlighted the public health role of having home.

For many of our patients, securing housing is an unattainable luxury. I witnessed this "cyclical relationship with health" (1) described in the paper in one of my continuity clinics patients. His arrival at the clinic often caused distress among the nurses due to his previous encounters with "bed bugs," as noted in his medical records. These insect bites on his arms were a testament to his dire situation. He told me he had to sleep in the backyard of his family friend since he could not afford housing. His recurring visits to the emergency department for issues such as leg pain, swollen legs, and headaches were cries for assistance for housing. The lack of stable housing severely disrupted the continuity of his care and led to his reliance on the emergency department as a place of refuge. Despite receiving a disability check, he lacked the means to secure a safe place to sleep. I am even more alarmed at how this housing crisis affects our older adults, who now represent "more than one third" (1) of the homeless population. These individuals will face "accelerated aging and premature mortality" (1) in their golden years. I recently treated an older adult with leukocytoclastic vasculitis and terrible peripheral artery disease. He had an endarterectomy with vascular surgery and received steroids from dermatology for the painful wounds on his feet. Despite the drastic improvement of his wounds, my patient was fixated on where he would live after the hospital. Homelessness could easily undo all of the efforts and improvements achieved during his hospitalization. ACP advocates education about "structural issues related to homelessness and housing-based health equities" during all medical training. Medical schools and residencies lack formal curricula on treating the homeless. Avenues for this education could include case-based learning, outreach clinics, and interprofessional projects with social work. I want to incorporate housing screening in my social history and initial visit with patients. Patients with insecure housing seek out the health care system for help. We cannot avoid these questions with our patients and need to understand how their housing will affect their care.

Furthermore, the health care system needs help from policymakers. I agree with the call for action by the ACP for public policy efforts. Models for public policy efforts exist, such as the Rapid Rehousing Program in Salt Lake City and a Tiny Village in Canada (2). We need to be able to support our patients when they leave the hospital, so they do not feel the need to return immediately where they feel safe and secure. I believe physicians experience compassion fatigue for these unhoused individuals due to a feeling of hopelessness. We need help from outside the health care field to address the needs of this population.

References

1. Serchen J, Hilden DR, Beachy MW; Health and Public Policy Committee of the American College of Physicians. Meeting the health and social needs of America's unhoused and housing-unstable populations. A position paper from the American College of Physicians. Ann Intern Med. 2024;177:514-517. [PMID: 38408358] doi:10.7326/M23-2795
2. Sleet DA, Francescutti LH. Homelessness and public health: a focus on strategies and solutions [Editorial]. Int J Environ Res Public Health. 2021;18. [PMID: 34770173] doi:10.3390/ijerph182111660

Kathleen Herring, MD

I am currently a chief of internal medicine at Wake Forest with an interest in caring for vulnerable populations, including the homeless. I am returning to my medical school in Athens, Georgia, as a primary care doctor and want to inspire trainees to treat all of their patients with compassionate care.