Health workers take to streets to reduce impact of homelessness
CMAJ 2000;163(2):202
A few years ago, the steep increase in the HIV infection rate among injection drug users prompted Vancouver's Lookout Emergency Aid Society to begin admitting some of the epidemic's sickest victims. "We admitted people we thought were going to die soon," says society worker David Richardson. The society began setting aside 5 of its 39 tenancy beds for homeless and HIV-positive drug users. Today, 2 of the first 5 tenants are dead, but the other 3 have moved on to more independent living. "Miracles can happen with stable housing, proper medication, decent meals and some people around who care," explains Richardson (see page 161).
The society's successes are noteworthy, but for too many sick, homeless people in cities like Vancouver and Toronto the things that can turn their lives around — stable housing, people who care — can prove elusive.
 | Photo courtesy of Canapress |
"Getting access to a doctor, to medical care, is one piece [of caring for the homeless sick], but it's actually the easiest piece," says Kathy Hardill, a street nurse with Toronto's Regent Park Community Health Centre. She spends much of her time helping homeless people gain access to the drug benefit cards they need to fill prescriptions. In Ontario, welfare recipients are entitled to prescription drugs with only a small copayment. However, getting on the welfare rolls can be a major hurdle for the homeless, and drug coverage isn't always automatic. "The process is not what you'd call streamlined," says Hardill.
Hardill met with one homeless woman who, unable to fill a prescription for antibiotics for a urinary tract infection, was hospitalized with pyelonephritis. "From a purely economic point of view it makes more sense to improve accessibility to the drugs," Hardill says. Ontario's community health centres, many of which are located in marginalized communities, can pay for some drugs in emergencies, but their resources are being stretched thin as the ranks of the most needy swell.
"Patients should never be discharged from hospital with prescriptions they can't fill," says Hardill. "We want medical staff to routinely ask if they can fill their prescriptions, or if they can afford the [recommended] over-the-counter drugs."
In downtown Vancouver, access to prescription drugs by homeless people is a bit easier than in Ontario. Welfare payments are a formal precondition for access to the provincial drug plan, Pharmacare, but the rules are eased a little for needy clients of the Downtown Community Health Clinic and the BC Centre for Disease Control's Street Nurse Program. The downtown clinic operates a community pharmacy that provides prescription and over-the-counter drugs to patients who have seen clinic doctors and are waiting to receive welfare or disability payments.
"We operate on the premise that some people are caught between a rock and a hard place," says pharmacist Cathy Cormier. Clinic staff help clients navigate through the application maze, and most people are covered by a drug plan within 3 months. The pharmacy fills between 150 and 200 prescriptions a day, she said, and up to 25% of the people receiving them are not covered by Pharmacare.
Hardill says Toronto's street nurses have argued without success for a community pharmacy that provides medication for people waiting for drug cards. Even if they do get their drugs, chaotic circumstances can make it hard for the homeless to take them properly. One of her clients, an elderly homeless man with multiple chronic ailments, has coverage for his prescription drugs, but diarrhea is a troubling side effect of his medication. His usual shelter has beds for 100 people but only 2 bathrooms; he doesn't bother to take his drugs when he stays there.
Meanwhile, emergency housing is hardest to find for the sickest people, says Hardill. "If someone is chronically ill or disabled — say they are blind or incontinent — I call a shelter to find them a bed. I describe their condition. I'm told, 'No, we just can't deal with someone who is not self-managing.' The shelter staff are stretched to the max."
Another homeless client has a serious mental illness and a significant physical disability. He can be difficult and combative, and hence is unwelcome at emergency shelters. "We just don't have enough appropriately staffed emergency beds to respond to the crisis — 3 staff to 100 people is pretty typical." In the space of a few weeks, her client was hit by a car, causing a neck fracture. Shortly after his release, he was beaten so badly that he spent 3 days in hospital as a surgical patient. "It is very stressful looking after [people like] him," says Hardill, a nurse practitioner with 12 years' experience as a street nurse. "Community health has become about the basics of survival." — Ann Silversides, Toronto
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