Notes from a Lecture: Homelessness and Health
I have notes from at at least three lectures I need to write up here; this is the first, on homelessness and health. Upcoming posts when I get a chance to process my notes will cover a talks by Bishop Gene Robinson, on adolescent hormone therapy for trans youth, and on taking a sexual history. The post below is from a talk I attended on February 2, 2011.
As part of the larger workplace’s Health Disparities Week 2011, I attended a lecture by Robertson Nash, MBA, MSN, ACNP, BC entitled “Homelessness and Poverty: Suffering in Nashville.” Nash is a nurse practitioner and has worked with homeless populations in Nashville in various capacities; his talk emphasized the causes and cycle of homelessness, and focused somewhat on breaking down people’s assumptions on what causes homelessness and what homeless people need from clinical care providers and others.
Nash began with this powerful statement: “Social marginalization produces measurable harm to human health.” That was our first clue that Nash was not going to let us off easy for our contributions to homelessness through our participation in larger social choices and biases.
He presented photos of makeshift shelters set up by homeless people within a mile or two of our comparably very wealthy and privileged campus population, and noted that you do not have to travel the globe to find people suffering. He introduced attendees to concepts of absolute and relative poverty, the living wage, problems with how local homeless population counts are done, and types of homelessness (transitional, episodic, and chronic).
I haven’t found the study yet, but Nash noted that the Peabody school did a study in the past few years and found that about $10K was being spent each year per chronically homeless while that person was still on the streets, and that these expenditures were more than what it would cost to house somebody. He also explained his belief, however, that simply providing housing is not an easy fix for homelessness, because it ignores the complexity of the problem, and can take people out of their cultures (including the “culture of homelessness”) and communities and dump them into isolation without the skills to succeed and thrive.
Nash then offered a fishbowl analogy to critique our society and our current approach to homelessness. He said that in the homeostatic approach, you get healthy fish by focusing on the health of the fish in the tank, but in an allostatic approach, you get healthy fish by looking at the fishbowl and how the environment and stress in that environment affects health. He then introduced the concept of the allostatic load, chronic stress and what it does to people over time.
Nash explained that our society is currently homeostatically oriented, that we are currently more interested in making sure myth of equal opportunity is upheld rather than focusing on equal outcomes for people, that we’re focused on getting people to the starting line, and then they’re on their own – we perpetuate a belief that if a person succeeds they did it on their own, and if they didn’t, then there is something wrong with the individual (not with society or the environment – the fishbowl).
As he explained, you have to take care of the aquarium, because the fish will die if you don’t. If you have a toxic environment, toxic responses are all you can expect.
In homelessness, these toxic responses can include persistent mental illness, substance abuse, lack of access to income, and the giving up of hope. Nash stated that people can become lost, and become “unmotivated by the rewards of normative behavior.” These responses can perpetuate the problem, such as when substance abuse leads to destruction of family bonds and bridges to institutional resources. Nash described these issues as parts of a cycle of chronic homelessness, including:
b) the experience of social isolation, trauma, and abuse,
c) depression, substance abuse, crime, and prostitution
Nash explained that a person can enter the cycle at any of those three points, and that once you get in it is self-reinforcing.
Nash also took a minute to speak about incarceration as a gateway to homelessness, including the “war on drugs” and racially driven aspects of our criminal “justice”/incarceration system in this country. He noted the serious racial disparities in who gets arrested for, charged with, and incarcerated for crimes in America, and the miserable job we do at reintegrating people into society post-incarceration.
Transitioning more to physical health issues, Nash talked about human beings as highly social animals with a highly developed need to belong in groups, and bodies that respond in predictable ways to social isolation with direct negative effects on our health. He argued, compellingly, that we have to move beyond biomedical model into a biopsychosocial model that recognizes the fishbowl. In other words, we can’t just look at individuals and their current health needs that we can treat with a pill or procedure – we have to look at the social structure and environment they inhabit and effect structural changes. He also spoke of specific physiologic effects of the types of stressers experienced by homeless people, including increases in glucose and cortisol, risks for hypertension, high cholesterol, and higher levels of clotting factors. Nash explained that homeless individuals may get some of these problems treated on a short term basis when they enter the healthcare system due to an emergency, but basically made the point that this ends up being short-term help for long-term, bigger problems. Or, as he put it -“if you’re homeless and are lucky enough to get by a bus you might get thirty days of lisinopril and no more treatment until you get hit by the bus again.” Shelter diets were described as “miserable,” with Nash having no love for people who – in donating substandard food to shelters – “give food they won’t eat to other people and then pat themselves on the back for it.”
As a bigger picture concern, Nash hammered home the problem of having no safe space within which to understand life as having a purpose greater than daily survival. To make this understandable to the largely privileged audience, he explained that when your next sandwich is an all-consuming thought, you can’t make a five year plan, read great books, think great thoughts, and make plans. In other words, privileges that those in the audience take for granted every day are completely inaccessible.
Finally, Nash outlined many of the barriers the medical system itself creates for homeless people seeking care. He asked us to think through a model clinic visit, in which the patient makes an appointment, shows up at clinic, understands the diagnosis and instructions, takes a prescription to a pharmacy, takes the medication, and then gets better or maintains/improves chronic illness, and the provider gets paid. Beyond the simplistic “affording it,” he noted the following problems a homeless individual may experience:
-lack of access to a phone to make an appointment, or a social worker may have made the appointment;
-lack of shared goals for care – there is no compelling reason to focus on common medical goals like improving glucose by ten points; people trying to get their next sandwich could not care less about their BMI;
-no transportation to get to the doctor or to a pharmacy, and no money for copays for medicine (Nash noted that while, for example, Publix gives away free antibiotics, they’re a suburban chain so their free antibiotics is mitigated by the fact that people in urban areas can’t get there);
-medication is easily lost or stolen in a shelter.
Nash emphasized that what we take for granted as straightforward can actually be very complicated.
The following advice was offered to future medical providers:
-know youself..authentic empathy is important but you cannot get lost in the suffering of other individuals if you want to take care of them;
-do not infantilize or enable patients;
-understand that each persons disease is their own and they are free to make both tragic or heroic decisions, and to face the consequences of those decisions (presumably within the confines of their ability to freely choose);
-move slowly and intentionally toward goals..don’t over promise and underdeliver as your failure reinforces the lack of trust
-empower patients with small goals;
-clearly accept blame for mistakes – doing so deflects cynicism;
-model with intention the kinds of socially normative behaviors you wish patients to use in their own lives – be honest, caring, and open;
-understand that just because you wrte the prescription does not mean the patient can afford it, aquire it, keep it, and understand why to take it and key side effects to look for.
Healthcare issues for homeless people – or the issues of homeless people in general – are not something I currently know much about, but I was glad to be able to attend Nash’s talk, and to share some of the ideas he presented here.