Revolving Door

Lily aka “Brandon” is a 40 year-old transsexual who presented to our shelter-based clinic for a multitude of problems including diabetes management, substance abuse, and housing assistance.

Having always felt like she was trapped in the body of a boy, Lily’s childhood was spent in and out of psychiatric facilities and “special” schools.  The first time she tried on make-up at age 12, her father beat her so bad she was hospitalized.  After that, she was in and out of foster homes, and began living off the streets in her late teens.

In years past, Lily had frequented this shelter, but stopped after finding housing and a stable job in a nearby suburb.  A month ago, Lily got into fight with her boyfriend who beat her into a coma.  When she awoke in the hospital, she had lost her job and her house, and was forced back into living on the streets and selling her body for money. 

Yesterday, feeling helpless and wanting to numb the pain, Lily took several extra doses of her medication.  When I saw her this morning in the shelter, she was coherent but slightly sedated.  More than anything, she wanted someone to talk to, someone on her side.  So, for over an hour before even entering the exam room, we talked about her family and friends, her past, and her hopes and dreams. 

It seemed as if Lily had hit rock bottom, so I tried to give her a little help back onto her feet.  Given her diabetes and other medical problems, I checked her blood sugar and scheduled a follow-up appointment with her PCP for the next day.  Next, we connected her with a member of the shelter’s advocacy team to get her started back with the housing process.   

Lily’s story is an example of the revolving door that exists between being homeless and being marginally-housed.  A single unfortunate event and one can end up on the wrong side again.  It is an honor to take care of these women through the ups and downs of their lives - we hope our work gets them closer and closer to the right side of the revolving door, and in the meanwhile, feel safe and supported when they are still on the wrong side.

Lessons Learned at Women's Lunch Place

Even though I was volunteering at Women of Means for only a brief time over the summer, I learned a lot about the challenges about providing health care to homeless women. I came to realize that the instinct to walk away from a homeless women begging for money on the street isn’t due to their appearance. It’s due to the fact that you do not want to acknowledge that in some way or another, they've fallen through almost every crack in society. 

The emotional, mental, physical, challenges that homeless women face seemed overwhelming to me. However, I was impressed by how effective the organization was in providing primary health care to these women and keeping people out of the ER. This experience, in combination with studying public health in Chile, solidified the importance of primary health care for all sectors of society for me. The organization’s attempt to minimize bureaucracy is another secret to what makes Women of Means such a success. The lack of bureaucracy allows homeless women can more readily access the health care system and in a more informal manner. It also allows the interns to practice interacting with patients in ways that they wouldn't be able to do at a hospital. I was also surprised- and delighted- to see the positive effects that the informal acupuncture had on many of these women. 

The challenges I faced working for Women of Means were mostly due to time constraints. First of all, due to the lack of time, I couldn't get to know the women at Women's lunch place as well as other volunteers. Also, in order to effectively provide medicine to homeless women, health care providers need to know what other organizations exist and what services each organization in the Boston area can provide. This is an overwhelming task and impossible to do in such a short amount of time. However, in many cases Women of Means is an effective gateway to other aspects of the medical system for these women. 

Arguably the most important skill I learned from working with Women of Means is learning how effectively communicate with patients as a health care provider. I imagine that there are many instances in which these women are ignored or discriminated against in and in more formal settings and in other sectors of the health care system. The enthusiasm, compassion, and respect Women of Means doctor's have for their patients is what makes Women of Means such a successful and unique organization.  

-Nellie Triedman, Summer 2012

Rosie's Place, A Reflection 6/21/12

Tired. She looked tired. Sitting by the door my patient was wrapped in a white shawl and almost her entire body except for her face was completely covered—and it was 101 degrees outside. She had come to Rosie’s Place for medical care; tooth pain specifically. A tooth had been removed and she was in agony. I spoke slowly and not very often, trying more to understand what we could do to help her. Any language barrier between us was quickly surmounted. “The pain”, she said. “Help the pain”.

Back I forth I went to the supply room, always returning with something she had requested. It was as if she remembered each time there was something else I could help her with. First, I brought some Tylenol. Then, some throat lozenges, and finally, she remembered the small injury to her finger that hadn’t healed.  She needed a Band-Aid and some ointment. As she grew more comfortable with me, her tone became more familiar. “More. More three!”, she said with a smile. “Oh” I thought, “she doesn’t have any at home.” I stayed with her until she left. With a brief “thank you” she was out the door, gone as quickly as she had come.

And such was my first ever morning at Rosie’s Place. It is an unassuming building, sitting back from the street with trees and shrubs hiding the entrance from the harsher city surrounding it. I was surprised by a locked front door, the sign clearly posted that reads No Loitering, POLICE TAKE NOTICE, and the civilian security guard that stopped me at the doorstep and assertively asked what I was doing there. I quickly computed these facts and reminded myself that Rosie’s is a women’s shelter, where victims of domestic violence and homelessness come to have a meal, find fellowship, receive some medical treatment, and find some relief from the struggle of daily life. There is a sense of sisterhood among the guests that made me feel like I was the guest in their home. I hope I can be invited back.

Chason Ziino MS III

The Holes in the Safety Net

 Lina presents to our medical office with a complex medical history. A 40-year-old Asian female, she found out a week ago that she is pregnant, even though she has been using birth control regularly for several years. This is only the latest turn in an ongoing medical saga she has been navigating. When I introduced myself as a medical student working with the Women of Means staff, she eagerly agreed to sit down and talk with me at length – “I want you to do well on your report!”, she insisted. Throughout the ensuing conversation, I was struck by her upbeat demeanor in the face of a daunting host of obstacles. Her story is a vivid snapshot of some of the successes and frustrations that arise when healthcare reform and cultural traditions meet.

Currently homeless in Boston, Lina is unemployed and receives a small income through Social Security disability benefits. Kidney disease, high blood pressure, and schizophrenia top her list of chronic medical conditions. Per the state requirement for all residents to carry health insurance coverage, she is enrolled in a program through MassHealth in which both Medicare and Medicaid fund her health care. Her prescription medications are covered under a prescription drug plan that can provide her with medications on a pre-designated list of qualifying drugs.  Depending on the prescription, she may pay as little as one dollar as a copay for covered drugs. Her numerous doctors’ office visits and most of her prescribed medications thus pose little to no financial burden to Lina; she pays no yearly premium and no copay for primary care or specialists visits, or for hospitalization.

With this background, one might expect the financial stress on Lina for her health care to be negligible. On the contrary, her medical problems still strain her budget. She is ethnically Chinese and a firm believer in alternative herbal medications. Her kidney problems, she tells me, have no effective medical treatment under the Western medical system, so she relies heavily on herbal supplements and acupuncture. Not covered by her health insurance, the herbal medicines cost her up to $250 per month, not an insignificant portion of her monthly Social Security income. Furthermore, some prescriptions she has received for topical analgesics for joint pain or recommended over-the-counter fiber supplements are not covered through her insurance and are difficult for her to afford.

The Women of Means office at Women’s Lunch Place affords her relief in a few ways. She is here today to arrange for a volunteer to accompany to her upcoming ob/gyn appointment. She also regularly attends the weekly medical acupuncture clinic held by one of the Women of Means doctors. She expresses to me her gratefulness that since discovering this program, she has been able to receive acupuncture free of charge, which she feels helps her physically and eases some of the psychological burden she bears.

Lina’s case provides a frank view of the often harsh reality of living in poverty with multiple medical conditions, even under a system considered in some ways to be a model in providing affordable health insurance for all its citizens.  Her cultural background and reliance on alternative medicine complicates her situation, simultaneously providing her some relief that she is told Western medicine cannot afford, while further straining her already limited financial resources. Compared to many, she has increased motivation to seek medical care after seeing her father die of renal failure and an unsuccessful kidney transplant back in China many years ago. As her unexpected pregnancy brings the latest chapter of her medical story, this complex encounter with the medical system will not likely be her last. 

A New World

            Marielle is a 46 year old newly homeless Haitian woman who visits the shelter clinic for the first time today.  She appears shy when I first meet her, and desires to speak privately.  As we sit down, it becomes apparent that she has several issues that she needs help addressing. 

Turns out, Marielle had just been released from jail a week ago after 17 years for what she describes as “financial charges.” Although this seems like just the beginning of the reason for why she spent nearly two decades in jail, I do not press further.  Instead, we talk about how Marielle’s only known family in the United States, her grandparents, had passed away in Miami while she was inside.  Since being released, she has been homeless but very fortunate in being able to obtain a two week bed at a local women’s overnight shelter.  There, she made friends with a woman seasoned in the shelter system who brought her here to reconnect to medical care. 

Marielle hands us a pile of paperwork from the penitentiary clinic.  Fortunately, she had not experienced any serious health problems requiring hospitalization during her time in jail, but had several medical issues documented during recent physicals. Specifically, she has gastro-esophageal reflux (heartburn), seasonal allergies, osteoporosis, mild iron deficiency, a breast cyst found on mammogram that requires a follow-up ultrasound, and gynecological complaints consistent with bacterial vaginosis.   

            While divulging her history, it was clear that Marielle is quite insecure about being released into society with no family, no social network, and no medical safety net.  In the clinic, we were able to address her immediate needs for antihistamines to relieve her allergies and antacids for her heartburn.  Still, the more important issue in this moment for Marielle is obtaining stable medical care to help with with her unstable life.  As such, we spend time going through her medical paperwork and write Marielle a clinical communication with all her medical needs that she can bring tomorrow to the reputable healthcare program close to her overnight shelter.  There, she can be linked to primary health care and have her preventive care addresses.

            We check that Marielle understands exactly what we are doing for her, but she appears understandably overwhelmed at the end of our visit.  As such, each member of our medical team gives her a hug as she exits the clinic in order to address her most fundamental concern – her feeling of being alone in this new world.

The Roof over your Head

  

          Jessica is a 63 year old homeless woman who presented to clinic today for complaints of lower back pain that started four days ago.  She does not remember a clear inciting event for the pain, and denies partaking in any physical activity that could have caused it (lifting heavy objects, sports, etc).  She saw a chiropractor the day after the pain started for a correction, which had little relief.  Since then, the pain has stayed the same in severity and location.  Reassuringly, she denies any tingling or shooting sensations down her leg, and bowel/bladder problems that could indicate a more serious neurologic problem of the spinal cord.  On exam, there is no pain on palpation of the vertebrae, but pain is elicited when she flexes at the waist, and there is significant muscle spasms in the bilateral lumbar paravertebral regions. 

I remember from the last time we treated Jessica a few months ago that she had been in an unstable living situation, couch hopping from one friend’s apartment to the other. Today, she acknowledges little improvement of her living situation, and complains about the cleanliness of her friends’ apartments and the discomfort of their couches. In the context of her housing situation, the most likely diagnosis is musculoskeletal low back pain from lack of back support when sleeping at night.  We provide her with some extra-strength Tylenol and ibuprofen for pain, and encourage her to increase her back support when sleeping.

The irony of the situation is that Jessica has her real estate license, and used to be in the business of high end rentals in Boston’s most prestigious neighborhoods.  I do not know how she became homeless, as she is a highly guarded person with large fluctuations in her mood.  What I do know is that so long as she remains a migrant with no power over her nighttime residence, there is little hope for improving her back pain.

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Carrie is a 76 year old woman who I also saw in clinic today.  She became homeless many years ago after her husband passed away, and is a long-time Women of Means client. On top of many chronic illnesses, Carrie is plagued with recurrent MRSA skin infections, which includes most recently, an infection of her bilateral hands superimposed on top of her chronic eczema.  MRSA, short for methicillin-resistant staphylococcus aureus, is a nasty antibiotic-resistance bacterium that can cause serious infections.  While it was previously most common in hospitals, it is now rampant in community settings such as homeless shelters and nursing homes. 

Carrie’s best bet at preventing further infections would be to transition into a stable housing situation.  In fact, our dedicated nursing staff helped her qualify for housing nearly three years ago, but Carrie has been resistant to committing to an apartment, as she has long adjusted to shelter life.  She has a daily routine moving from her overnight shelter to the day shelter, and a strong community of homeless women with whom she likes to commiserate. 

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Jessica and Carrie are two examples of how lacking a roof over one’s head can be detrimental to the daily health of homeless women.  At the same time, finding housing is not a quick fix, as women can have many psychosocial reasons for being homeless, including resistance to change.

Behind those Walls

Sylvia is a 58 year old marginally-housed woman who I became familiar with today for the first time.  She was second on the sign-up sheet for the shelter clinic, and when we sit down to talk, she appears collected, sharp, and witty.  Sylvia is knowledgeable about her extensive past medical history, which includes asthma, osteoporosis, hypertension, high cholesterol, diabetes, carpal tunnel syndrome of both hands, depression, and anxiety.  More impressive is her ability to name all of her daily medications: albuterol and Advair inhalers for her asthma, metformin for her diabetes, lisinopril for her hypertension, sinvastatin for her hyprelipidemia, Zoloft for her depression, Klonapin for her anxiety, gabapentin for her chronic pain.  She sought care today because she is feeling short of breath increased from her baseline that is not responding to her daily inhalers.  She also describes some low back pain for which she would like some ibuprofen.

            Despite Sylvia’s initial composure, she seems surprised when I deviate from the traditional medical interview and ask her, “How have you been doing recently?” It is almost as if this additional expression of personal concern tore down Sylvia’s wall, and she reveals to me that she has actually been under a lot of personal distress.  Her best friend who is also battling depression recently gave birth to a baby boy, to whom Sylvia was the godmother.  Just four days ago, her best friend locked herself and her baby in the car and attempted suicide by taking “a bottle of pills.”  Worried family members called the police, who were able to reach the mother, but unfortunately not the baby, on time.  Sylvia spent all weekend in the hospital with her friend and mourning the loss of her godson.  Today was the first time she was able to take a little break to take care of her own health.

            To address her immediate issue of Sylvia’s difficulty breathing, I examine her and find that she does not have significant wheezing.  However, she does have has reduced peak flows (150-200 on three attempts) consistent with her an asthma exacerbation, so we give her a nebulizer treatment.  She is provided ibuprofen for her back pain, and given that it is an unusually cold day, we also offered her a hat.  She feels better and one of our staff members escorts her to the elevator.

An hour or so later, I run into Sylvia in the dining room where I notice that she has changed into a bathrobe.  I comment that she looks comfortable and cute, but Sylvia nearly bursts into tears while telling me that she “wet” herself in the elevator because it was taking too long.  Turns out, Sylvia suffers from urinary incontinence, a condition quite common among women but understandably embarrassing.  Seeing her shame, I quietly offer to grab her some Depends adult diapers.  I return with them concealed in a plain brown bag, and Sylvia gives me a small smile full of immense gratitude.

            Sylvia exemplifies the great efforts that many homeless/marginally-housed women take to maintain facades of control and strength.  Behind her strong exterior was significant personal loss and embarrassment about her common female condition (urinary incontinence).  In a world of constant uncertainty, most women in unstable housing situations find that keeping their guards up is the best way to survive, both physically and emotionally.  However, behind those walls is often immense insecurity and heartbreaking stories that want to be shared…

A Piece of the Puzzle

Stephanie is a 64 year-old homeless woman who approached me today as I entered the shelter.  She says in a hurry, “Doctor, I have high blood pressure, but I ran out of my medicine on Friday (4 days ago).  Can you give me a refill? My head started pounding yesterday, and now my fingers are tingling.”

Given Stephanie’s active symptoms, I take her into the clinic.  She is alert and oriented while I measure her blood pressure to be 180/95.  She denies any chest pain, palpitations, shortness of breath, blurred vision, and abdominal discomfort.  On exam, her lungs are clear and her heart sounds are normal with a regular rate and rhythm.  Together, this reassures me that her blood pressure is not high enough to require immediate, urgent medical treatment for which we would either transport her to an emergency room or prescribe antihypertensive medications.

            Turns out, Stephanie, like many women who frequent the shelter, is a victim of domestic violence.  Up until a year ago, she worked as a sous chef at one of Boston’s upscale hotel restaurants.  However, her boyfriend with whom she shared an apartment became a drug addict, and the more injection drugs he used, the more he beat her.  It took her over two years to leave him, and by the time she finally did, she had lost her job, had no money, and was forced to live on the streets.  Around that same time, Stephanie’s primary care physician of seven years retired, so in addition to losing her job, she also lost her regular source of medical care.  When she ran out of her blood pressure medications 5 months ago, she was able to get her most recent refill at a local emergency room.

            As I put Stephanie’s story together, I realize that this specific incident of running out of medication is just one hurdle in her large attempt at piecing her life back together.  Instead of providing Stephanie a quick-fix by renewing her prescription, I thought it would be better to reconnect her to the medical system.  After multiple phone calls, I find the young, enthusiastic physician who had taken over her previous PCP’s practice. When I speak to him, he is eager to see her after hearing her situation and together we arrange for Stephanie to visit his office in two hours.  Although Stephanie is initially stressed that this visit will get in the way her job search, I am able to convince her that reestablishing a regular source of care will save her a lot of time in the future.

            Many homeless women live in a world of uncertainty – precarious housing and limited income on top of complex medical and psychiatric problems.  With so many moving parts, it is no wonder that some things fall to the wayside, as did Stephanie’s medical care in this case.  By providing stable health care to these women, we hope to place some pieces of the puzzle in the right place.

Skin Deep

Jen is a pleasant 68 year-old homeless woman who frequents the day shelter and shelter clinic.  She is familiar face to the Women of Means staff and has regular follow-up with one of our nurses for supplies.  Two weeks ago, as I was talking with another shelter guest, I noticed that Jen had a large 3inch x 3inch piece of gauze covering the left posterior-lateral region of her neck.  Concerned, I asked her if there was anything wrong and she informed me that she yet another methicillin-resistance Staph. aureus (MRSA) abscess for which she was being treated with the oral antibiotic Bactrim (trimethoprim-sulfamethoxazole).  Today, she approaches me to tell me that her neck infection has cleared up, but expresses extreme concern that “this just keeps happening over and over again” and asks me why and how she can make it stop.

MRSA is a strain of bacteria that is highly resistant to antibiotics, and therefore, very difficult to treat.  Jen has had multiple infections with this nasty bug over the 9 months, which include cellulitis (an infection of the superficial layers of the skin) of her left lower leg and a right groin abscess that have each taken over a month to resolve.  Last winter, she had multiple bouts of bronchitis, and one episode of pneumonia for which she had to be hospitalized. On top of this, Jen has a complex medical history that includes poorly-controlled hypertension currently being treated with clonidine (a antihypertensive drug), hypothyroidism on levothyroxine (thyroid replacement hormone), and eczema currently being treated with topical steroids. 

Jen is embarrassed by her continued MRSA infections, as she considers herself a clean person despite living in a shelter.  She describes to me her nightly routine of using hand sanitizer to wipe down her mattress – however, she has been unable to do so over the last 2-3 weeks due to the outbreaks of Norovirus in her shelter.  To compensate, she has been washing her hands more frequently, but this in turn, exacerbates her eczema and dry skin, now with multiple cracks in them.

Jen’s situation is an example of the web of medical complexities that many homeless women live in. While homeless individuals tend to have similar chronic medical problems as the general population, they are also plagued with additional dermatiologic disorders due to their living conditions.  This ranges from infestations by lice, bed bugs, and scabies to dermatitis from cold or chemical exposure.  Not only does Jen’s prior skin infectious predispose her to further skin infectious, her eczema and dry skin provide the small sites for bacteria innoculate an infection.  Jen’s question is a good one – with her living situation and skin condition, preventing further infections is a difficult task.  The best thing I can offer her today is my support and empathy, and together we agree to start with some baby steps – education and some lotion/hand sanitizer – to improve her health.

Everyone Has a Story

            Paola is an 81 year old Ecuadorian woman who I met for the first time 6 months ago.  Today, I noticed her enter the shelter and eye the clinic sign-in sheet from a distance before proceeding to the breakfast line.  Wondering if Paola had a medical issue but was too reticent to sign up, a common situation among some of the homeless women, I approached her in line and asked her how she was doing.  She gave me a big smile, and exclaimed, “Doctor, you remember me? That is so nice!” 

Turns out, Paola did had a reason to come see us.  She reported itching of her both feet that started 2 months ago with burning when she takes a shower.  In the clinic, her foot examination revealed bilateral clearly-demarcated, erythematous, plaques with central clearing on the soles of both feet extending up the medial aspect of the feet.  She had associated thickening and cracking of her toenails characteristics onychomycosis, a fungal infection of the toenails.  The diagnosis was tinea pedis, more commonly known as Athlete’s foot, which is a fungal infection of the feet readily-treatable with antifungal cream and hygiene.

            While applying Paola’s cream and helping her put on a new pair of socks, I took the chance to get to know her better. I found out that Paola came to Boston close to 20 years ago with her husband for tourism.  They did not speak the language, nor did they have families in the country, which made it extra devastating when her husband became ill and required a long hospital stay that they could not afford.  By the time Paola’s husband had recovered, they had used up all their travel money and were without means of returning home.  As such, this brave elderly couple remained in the Boston, in and out of homelessness, until they were able to learn English, apply for a Green Card, rent an apartment in their ethnic neighborhood, and establish medical care at a prestigious hospital. 

            Beyond being an inspiring story of overcoming adversity, Paola and her husband are an example of the cycle of homelessness.  Traditional teaching delineates personal versus economic reasons for homelessness.  Personal factors include mental illness, substance abuse, domestic violence, and illness itself while economic factors include extreme poverty that makes rent and health insurance out of reach.  However, I think the most important thing to understand is that all these factors are interlinked.  Paola and her husband lack most factors leading to homeless, but an acute illness resulted in enough financial destitution to render these two people helpless and homeless.  Six months ago, I had no idea where Paola came from, but I am so grateful to have been able to hear her story.