Empowering destitute people towards transforming communities

3.1“Outside-in” missions as the connecting of destitute people to clinical services

Destitute people often become ill, which is usually something outside of their control. Against this background, helpers should be able to connect destitute people to health services. Those who experience destituteness are subject to conditions that can result in deterioration of health or which exacerbate existing chronic or acute illnesses, leading to rates of illness and injury from two to six times higher than for people who are housed (Wright, 1990a:55).
Three premises are evident here. Firstly, no helpers can provide all the services often required to empower destitute people, because of the fact that destitution is a complex problem. Secondly, some issues associated with destitution, such as health problems or substance abuse, require intervention by specialized professionals. Therefore, helpers should be able to “map” the array of services often required that is available in their vicinity, so that they can connect people to these services. Thirdly, “connecting” does not merely mean “referring”. Connecting carries with it the meaning of reaching out and engaging destitute people, and only then (if they agree) can helpers take them by the hand and physically lead them to the necessary services. Referring is usually unsuccessful, because the destitute person still feels unsure, but if he trusts the helper, he may allow the helper to connect him.

3.1.1Problems with health care for destitute people

Destitution severely complicates the delivery of health services (Walker, 1989:20). Without access to appropriate health care, acute and chronic health problems may go untreated, creating medical complications in multiple co-occurring conditions and ultimately impeding the individual’s ability to overcome destituteness. If we fail to provide destitute people with health care of a standard that is available to other people, even when they need elaborate or expensive treatments, this constitutes a form of discrimination that should be unacceptable in a democratic society (Bangsberg et al., 1997:67).
Destitute people are part of a heterogeneous group with multiple and complex needs, so that numerous personal and societal factors outside the clinicians’ control may therefore affect the final outcomes for individual patients. Also, their mobility often makes it difficult to track destitute people for follow-up measures” (U.S. Department of Health and Human Services, 1996: ii).
A central question is to determine what qualifies as a “successful outcome”. In this respect healthcare practitioners working with destitute people are concerned with improving health status, level of functioning and quality of life.
Chronic conditions—especially substance abuse and mental illness—are subject to regressions and relapse. This result should be expected and needs to be built into planning of programmes, as well as into outcome evaluation methodologies.

3.1.2What are the health problems of destitute people?

As a consequence of the poor nutrition, lack of adequate hygiene, exposure to violence and to the elements, increased contact with communicable diseases, and fatigue that accompany the conditions of destituteness, destitute people suffer from ill health much more frequently than the non-destitute. Several studies have found that one-third to one-half of destitute adults display some form of physical illness (Bassuk & Rosenberg, 1988; Burt & Cohen, 1989; Gelberg & Linn, 1989; Morse & Calsyn, 1986; Roth & Bean, 1986). At least half of destitute children are physically ill (Wood et al., 1990:860) and they are twice as likely as other children to suffer such illnesses (Wright & Weber, 1987:24). This lack of health takes its toll by preventing many destitute people from escaping from destitution. For example, one-quarter of destitute adults reported that their poor health prevented them from working or attending school (Robertson & Cousineau, 1986:561). Even more seriously, rates of mortality are three to four times higher in the destitute population than they are in the general population (Hanzlick & Parrish, 1993:488-491; Hibbs et al., 1994:305; Wright & Weber, 1987:18).
The most common physical illnesses among destitute people include upper respiratory tract infections, trauma, female genitourinary problems, hypertension, skin and ear disorders, gastrointestinal diseases, peripheral vascular disease, musculoskeletal problems, dental conditions, and difficulties with vision (Wright & Weber, 1987:19; Reuler et al., 1986:1131-1134; Miller & Lin, 1988:668-673). Inadequate immunization, while not a physical illness, reflects the lack of preventive health care in this population (Alperstein et al., 1988:1232-1233; Miller & Lin, 1988:669). However, the two health conditions most likely to trap people in a state of chronic destituteness are those of substance abuse disorders and mental illness.
Health problems in these three domains—physical illness, mental illness and substance abuse disorders—are intimately related. For example, surveys of the health status of destitute people demonstrate repeatedly that the single most common disorder is substance abuse. This in turn contributes to a wide range of other health problems resulting from self-neglect and poor hygiene, nutritional deficiencies, trauma, exposure, accidents, victimization, toxic effects of ingested substances (e.g., hepatic cirrhosis due to alcohol) and infections (e.g., bacterial endocarditis, hepatitis and HIV infection). Studies also indicate the poor general health status of severely mentally ill destitute people. They are more prone to neglect personal hygiene and their basic health care needs, and to be poorly nourished. Seriously mentally ill destitute people have been found to be at higher risk for tuberculosis (Sakai et al., 1998:346) and HIV infections (Susser et al., 1993:568).
Another example of the way in which many of these problems overlap is evident in the area of impairment of physical function. Despite their young age (mean age in the mid 30's), half of the destitute adults surveyed state that they are limited in performing vigorous physical activities (Gelberg, Linn & Mayer-Oakes, 1990:1221).
Based on the broad scope of health problems described above, it is clear that a full array of services must be made available and accessible for people who are destitute. Otherwise, the care might easily revert into “Band-Aid medicine” and miss underlying or co-occurring conditions. Such adapting of clinical practices should cover elements of health care encounters common to medical, mental health or substance abuse services, including: intake and assessment; clinical preventive services; diagnosis; referrals for specialty and inpatient care; linkages to non-health services; and follow-up to ensure continuity of care. It is important to remember that these elements may not necessarily occur in this order, or be provided in a typical clinical setting.

3.1.3Ways to overcome “access barriers” to health services

Compounding the increased risk for illness or injury, there is evidence that destitute people encounter major obstacles to obtaining needed medical and psychiatric services. The majority of destitute adults state that they did not obtain necessary medical care in the previous year (Gelberg, Linn & Rosenberg, 1988:168; Robertson and Cousineau, 1986:562). Even among those with a chronic medical condition, half had not seen a doctor within the previous year (Robertson, Ropers and Boyer, 1985:14). Organizations providing services to destitute people have described numerous difficulties in accessing substance abuse treatment for their clients (Williams, 1992:122).
Some of the barriers to access to health services are related to external factors such as lack of transportation (Robertson & Cousineau, 1986:563). Others are internal, for example, denial of existence of a health problem, lack of awareness of available services, or active avoidance due to fear or distrust of large institutions. Because an exhibition of toughness is necessary in order to survive on the streets, destitute people may at times deny that they suffer from health difficulties in an attempt to maintain a sense of their own endurance. People with substance abuse disorders or mental illness may deny experiencing a problem or be unaware of its severity.
Even when aware of their problem and of available services, many destitute people are distrustful of any offers of help, owing to previous negative experiences with the health care and social services systems. They may be too embarrassed to allow medical professionals to see them in a condition of poor personal hygiene. Or they may avoid seeking health care because of the fear of having their meagre financial resources taken away to pay for the services they receive, or fear of authority figures (Stark, 1992:44), including immigration authorities, child protective service workers (amongst runaway teenagers and destitute women with children), and police (amongst drug abusers or ex-convicts) (Jahiel, 1992:231).
Against this background helpers should advocate and work for health services that are easier to access. This can be brought about in a number of ways:

3.1.3.1By making it easier to reach service delivery locations

Either by using mobile services that go out on the street, or by making sure that service locations are close by (Cousineau et al., 1995:87).

3.1.3.2By scheduling services at times that would be most convenient for destitute people

They often experience trouble in keeping appointments owing to competing priorities for survival, such as finding day labour, a free meal or a shelter bed for the night (Gelberg, Gallagher, Andersen & Koegel, 1997:218), and they do not enjoy access to telephones so as to change appointments. Scheduling services in the early morning or evening, while people are still at the shelter, would make a difference.

3.1.3.3By helping with financial barriers to services

Either by providing free services or heavily subsidizing these in a way that would also allow those with no money or means to obtain them (Cohen, Teresi & Holmes, 1988:127).

3.1.3.4By improving “cultural competence”

This denotes a positive, open attitude of being culturally sensitive, firstly by respecting the “culture” of being destitute, and secondly by respecting other cultural differences such as race or language.

3.1.3.5By dealing positively with “disruptive behaviour”

This refers to destitute people with histories of disruptive behaviour who are often barred from services. Helpers should continually assess the nature of such behaviour: is the person acting out because of a mental illness beyond his or her control, or are the actions intentional and meant to do harm? Against this background a delicate balance must be maintained.

3.1.3.6By using “multi-disciplinary” teams

Health services must not be “singly focussed” (for instance only providing dental care), but should be integrated with other services. In other words, a number of different kinds of services are needed, which calls for multi-disciplinary teams (Burness et al., 1990:131).

3.1.3.7Conclusion

Providers of health care need to be aware of all of these potential barriers, making adaptations as necessary and paying special attention to the characteristics of the population they are serving.
Nine general principles have emerged as lessons for practitioners involved in providing care for destitute people:

1. 
   The importance of outreach in order to engage clients in treatment.
   
2. 
   Respect for the individuality of each person.
   
3. 
   Cultivation of trust and rapport between service provider and client.
   
4. 
   Flexibility in service provision, including location and hours of service, as well as flexibility in treatment approaches.
   
5. 
   The need to attend to the basic survival needs of destitute people and to recognize that until those needs are met, health care may not be an individual’s priority.
   
6. 
   The importance of integrated service provision and case management to coordinate the needed services.
   
7. 
   Clinical expertise to address complex clinical problems, including access to specialized care.
   
8. 
   Need for a range of housing options, including programmes combining housing with services.
   
9. 
   A longitudinal perspective that ensures continuing care until the person’s life situation is stabilized.
   

Despite the knowledge and experience that has been gained from the past in adapting clinical practice to the needs of destitute people, there is still much to be learned; numerous threats also challenge the successful practice of health care for the destitute. I am not a medical practitioner; however, literature study, as well as personal experiences and discussions with relevant health care practitioners, have led me to the above insights.