"I define homelessness in a medical way," Heyding said during a workshop on the homeless held earlier this year. "I saw a woman who had an unusual rash on her foot. I didn't know what it was. I knew that she worked as a prostitute and one of the tests that seemed reasonable was for syphilis. It came back 5 days later, positive. But I couldn't find her. So my definition of homelessness is somebody that I can't find within 4 or 5 days because they are so transient."
Heyding recounted some of his experiences treating homeless women. "Staff at 416 [a drop-in centre for women] or Street Haven [a women's shelter] may have a patient they want me to see and that patient doesn't want to be seen. She might be afraid of doctors, afraid that I'm going to make her undress, that I'll take away her bags, that I'll stick a needle in her. One of my patients has three major medical problems: a psychotic disorder, diabetes and hypothyroidism. Her diabetes and hypothyroidism were out of control, but I couldn't treat her because her psychotic condition kept her from requesting treatment. She finally found a place to live at Street City [a women's shelter], and she is doing much better. She takes medication for her psychotic illness and we are able to treat her other medical problems because she is willing. Once you find permanent housing for these people you can start to do something medically."
Another barrier is that many homeless people don't have a health-insurance card or use the wrong number. "If I send the wrong number out, a few weeks later I get a note back saying Ôno match,' " said Heyding. "This means I don't get paid, my lab doesn't get paid and the specialists that I refer my patients to don't get paid. That's a big barrier. [But it also] limits me in terms of referral, it limits me in terms of some tests that I want to do. Getting valid cards for homeless people is a real chore."
Finding specialists who will see homeless people is a sizable hurdle. "You have to find ones who don't mind having people come into their waiting room and disrupting it. I have a stable of specialists who see my patients, and I finally found a dentist who is just wonderful. The women I send to him don't mind seeing him and he sees them quickly and treats them compassionately."
Incarceration is another barrier. "At least 33 of the 187 homeless women in my little sample have been in jail at some point during the past 2 years. Homelessness goes along with violence, prostitution and drugs. People get charged and put in jail. I might be treating somebody for something and she disappears. Turns out she's in jail, but they don't know that I've been treating her. Or if she comes out of jail, I don't know what treatment or tests she received there. The communication between medical facilities and detention centres is not that great."
There were 13 pregnancies among his sample of 187 homeless women; none got normal, comprehensive antenatal care. Of the 13, 2 had therapeutic abortions and 9 gave birth. Eight of those babies were apprehended by the Children's Aid Society. One woman still has her baby because she is in an institutional setting, but if released into the community she will probably lose custody.
Preventive medicine is very difficult to promote among the homeless, Heyding commented. "We try to get flu vaccine for everyone. We do TB tests on as many people as we can. But we are not able to do other kinds of preventive care that women should have. We can't do mammograms. If they have very high blood pressure, we may be able to do something about it, but if they are borderline they won't comply with treatment."
Another formidable barrier is mental illness. "Of the 187 women in my sample, I can't think of one who does not have a mental-health problem of some sort, if you include drug use. I know that 51 of those 187 women use crack cocaine, and at least 14 are heavy users of alcohol.
"Alcohol and drug addiction are major problems and interfere with my ability to take care of the physical problems, over and above the medical problems caused by the addictions themselves. We had one woman die of cardiomyopathy from cocaine, and another one die in an accident while intoxicated. And if I try to set up treatment for something else, like asthma or chronic bronchitis or TB, these addictions get in the way."
Even though drop-in medical clinics are available, most of the homeless use hospital emergency rooms for routine care. One recent study in Toronto found that 54% of that city's homeless population had used an emergency room in the last year, and 25% had been admitted to hospital Ä which may reflect an effort on the part of medical personnel to shelter the homeless while they are even more vulnerable due to illness. The high proportion of hospital admissions may also result from the large number of homeless people requiring psychiatric care.