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.