Ashish Mahajan
4th year medical student, University of Alberta, Edmonton, Alberta, Canada.

In 1946 the constitution of WHO officially recognised that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”¹. This was further defined as the right of “access to medical care and social services” by the 1948 Universal Declaration of Human Rights.²

The dogma of universally accessible health care has since been ratified in numerous international treaties and has been a source of pride for many developed nations. While these industrialised nations generally boast a high standard of living and good access to healthcare services, there exists a subset of citizens who have poor healthcare access. The homeless population is hard to define due to its transient nature. However, its size can be estimated by extrapolating information from census data for poverty and the use of emergency shelters. US homeless shelters housed 170 706 people in 2000³ while the UK had 384 036 applications to authorities under homelessness legislation in 2004.⁴ These and other statistics estimate that there are approximately 2 million homeless in the USA and more than a million in the UK. Homeless individuals as a group do not have unique medical problems, however, the increased rate of psychiatric illness, substance abuse, tuberculosis and other infectious disease in the population requires extensive intervention. These problems are compounded by negative attitudes from healthcare providers, poor access to healthcare and lack of follow-up.

The negative attitudes of healthcare providers towards homeless people can have a deterrent effect on access to medical care. In one survey of people using emergency shelters, homeless individuals cited the attitudes of healthcare and shelter providers as one of the most difficult aspects of being homeless.⁵ Such attitudes often stem from unfamiliarity. Western medical training has traditionally been very scientific and is generally geared towards treating the middleclass, moderately educated patient. There is some evidence to suggest that trainee attitudes towards the disenfranchised are negatively affected as they progress through medical school.⁶ Gradual changes in medical education are addressing this problem. Mandatory rotations in inner-city medicine and the increased emphasis of humanism in medical training have been shown to positively change attitudes.⁷

Homeless individuals often encounter difficulty in accessing healthcare services. In countries with publicly funded health care systems such as the UK, homeless people have difficulty accessing services as they don’t have a fixed address. In private systems, lack of insurance often precludes homeless people from receiving extensive diagnostic workups and specialist attention. In both systems it is difficult to receive sustained treatment for co-morbid substance abuse and mental illness. Inner city clinics specializing in homeless issues have popped up in metropolitan cities throughout the developed world. For example, in Edinburgh The Access Point is a full primary-care clinic offering GP, nurse, mental health and addictions services. Unfortunately, the number of such services decreases outside the metro areas so smaller urban and rural areas may have little to no facilities specialising in the health of homeless people.

Addictions, infectious disease and mental health problems pervade all segments of society but the approach to their treatment must be modified for homeless people. As environment (including housing) is a key determinant of health, physicians have a responsibility to address the lifestyle of their homeless patients. Specifically physicians used to treating socially stable patients must alter the way they arrange treatment and follow-up, ensuring that patients are able to afford treatments and have transportation to follow-up appointments. The physician should be able to refer willing patients to appropriate organisations where they may receive social support. Lower thresholds for inpatient admissions are often required with homeless people. Specialised discharge-planning teams are available in some hospitals, whose function is to liaise with various community and government social agencies to ensure that the homeless patient has access to social services, financial aide and medical follow-up in the community. Cooperation between hospitals and social organisations has been shown to improve outcomes in treating homeless patients.⁸

Negative attitudes, lack of access and poor follow-up are some of the barriers that homeless people face when trying to access healthcare. These obstacles are not concrete and are gradually being dismantled with increasing education and innovative solutions pioneered at major centres across the globe. While homelessness has its roots in economic and social factors, healthcare professionals have the responsibility of dealing with it, and catering for the specific needs of homeless people, until such a time that homelessness can be globally eradicated

References

1. United Nations. Constitution of the World Health Organization. Basic Documents. 2006; 45 1-18. Accessed online at: http://www.who.int/governance/eb/who_constitution_en.pdf on 20/03/07

2. United Nations. Universal Declaration of Human Rights. Accessed online at: http://www.unhchr.ch/udhr/lang/eng.pdf on 20/03/07

3. Smith, Annetta C, Smith, Denise I. Emergency and Transitional Shelter Population: 2000. October 2001

4. Thomson, Stephen. European Observatory on Homelessness: Statistics Update 2005. December 2005. FEANTSA. Accessed Online at: http://www.feantsa.org/files/national_reports/uk/UK%20STATS%20REPORT_2005.pdf on 20/03/07

5. Attitudes of Medical Trainees Towards Homeless Persons Presenting for Care in the Emergency Department. Clinical Trial In Progress. Accessed online at: http://clinicaltrials.gov/ct/show/NCT00281398… on 20/03/07

6. Masson, Neil, Lester Helen. The attitudes of medical students towards homeless people: does medical school make a difference? Medical Education 2003; 37(10): 869

7. Buchanan, David, Rohr Louis et. al. Changing Attitudes Toward Homeless People A Curriculum Evaluation. J Gen Inern Med. 2004; 19: 566-568

8. Quilgars, Deborah, Pleace Nicholas. Delivering Health Care to Homeless People: An Effectiveness Review. May 2003. Centre for Housing Policy, University of York

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