Most of the homeless are invisible

Last week I went on my first outreach visit to the homeless. In preparation we stocked up on water, gloves, gauze, and medications, put on our sneakers and headed out to the streets. We exited the front of the building, turned right and walked three blocks until we reached the corner with the highway on-ramp. We started crossing the street and about halfway, just past the service road and before the on-ramp, we stopped and turned right into a narrow triangle of grass over- grown with trees. We followed a lightly-worn path through the trees and came out into a small clearing with tents and makeshift cardboard lean-tos. We called out to see if anyone was around but nobody was home. We would have to come back again some other time.

The most recent census, done in 2011, shows that approximately 636,000 people experience homelessness on any given night. It’s estimated that approximately 3.5 million people, 1% of the population, experience homelessness at some point each year.

The chronically homeless are the ones who we traditionally think of as homeless. They’re the ones who are disheveled, who occupy storefronts at night, who carry all their belongings with them. And they’re the ones with higher rates of asthma, heart disease, mental health disorders and death. Yet they comprise only about 18% of the homeless population.

Most of the homeless are invisible: they dress the same as you or I do, they shop in the same supermarkets and they are either working or looking for a job. In fact, looking out over the waiting room of the homeless clinic where I work, I am struck by how utterly unremarkable the scene is, as if it was just any old doctor’s office.

Regardless of whether someone is briefly or chronically homeless, their needs are complex. As part of their health care we work on getting them housing, nutritional assistance (food stamps), and mental health services as needed. It does no good to talk about eating right and taking your medications if you don’t also care about where they’re going to sleep tonight. I may not be able to fix their homelessness today, but working towards the solution builds trust and acknowledges that their needs go beyond just health.

Complicating this effort is the fact that about 70% of the homeless don’t have health insurance despite the fact that they live in poverty. Thankfully, in 2014 when Medicaid expands its eligibility to everyone making less than 138% of the federal poverty level access to health care will greatly increase. They will be able to get the care that most of us take for granted which will in turn make it easier for them to stay employed and break out of the cycle of homelessness.

As for the folks in the clearing who were out during the day, some of them were at work, some of them were trying to get a meal, and others were just not in. We’ll have to go there again in a few days to see if they have any needs we can help them with. In the meantime, I now look around while I’m walking, alert to the world that I always looked past, alert to the invisible.

Nilesh Kalyanaraman is a physician who blogs at Progress Notes.

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