Diabetes is an emerging national crisis. It is the leading cause of heart disease and stroke and the 7th leading cause of death in the United States. According to recent data from the Centers for Disease Control and Prevention (CDC), an estimated 25.8 million people are affected with diabetes with a staggering 79 million more living at high risk for the disease, a stage known as pre-diabetes. Unfortunately, about a third of those affected with diabetes are unaware that they have the disease.
These statistics raise special concerns in our homeless communities, in which access to diabetic management may not be readily available. Diabetes requires one to not only adhere to a strict insulin regimen with regular physician visits and a ready source of medical supplies, but also modify one’s lifestyle and eating habits, requirements that many living on the streets find difficult, if not impossible, to fulfill.
At the very center of this issue are competing priorities and financial barriers. Is it possible for one to be homeless and not worry about one’s immediate needs such as food, shelter, and clothing let alone other needs? Thus, diseases such as diabetes are often overlooked. And once detected, those living on the streets often do not know where to go for continued care, confronted with eminent financial burdens. A study reports that seven percent of the homeless population was denied health care because they did not have a health card. Furthermore, the long waiting times at various free clinics and emergency rooms have deterred many from obtaining the care they needed.
In San Francisco, more than 40% of the homeless reported that they could not afford public transportation to and from clinic visits. These barriers would eventually lead to lower outpatient care and more frequent hospitalizations. The sad reality is that many would often be too sick to seek care by the time they truly needed it.
Among other barriers leading to poor diabetes management are lack of provider sensitivity, poor adherence to treatment plans, and psychological ailments associated with substance abuse, as reported by a quarter of the homeless. More often than not, the homeless reported that physicians showed a lack of overall concern for their needs and having to see different doctors eventually led to a sense of confusion about how to adequately manage their diabetes.
Scheduling conflicts and a lack of ready source of medical supplies also pose grave concerns. A crucial component of reducing diabetic complications is planning medications to coincide with each mealtime, a necessity that 18% of those in the recent study said were not met. Two participants in the study reported, “I must revolve around the shelter schedule, so nothing is consistent…I can’t time my insulin with my food; I’m supposed to take insulin half an hour before my meals and usually I can only get it 10 minutes before.” If medications are not taken at the appropriate time, those with diabetes often face the immediate concerns of shock and seizures.
Moreover, even if medications were readily available, there are the inherent problems of storage (the insulin used to treat diabetes must be refrigerated) and fear of being caught and stigmatized by shelter staff. It is also not uncommon for those with drug addictions in these shelters to steal needles from diabetics to get another all-time high. These concerns were strongly voiced by one participant in a recent study: “I give myself insulin in the bathroom most mornings, but if I ever got caught, they’d give me a hard time…I hope that no one takes my insulin or my needles. I’m dealing with junkies and crack heads and they want the needles.”
Yet the most important concern among the homeless with diabetes is one of dietary intake. Fast foods on the streets and those provided at shelters are often high in fat and starch and low in fibers. These conditions are simply not favorable for those living with diabetes, who must adhere to a well-balanced diet that is low in simple sugars (sodas and processed foods) and high in complex sugars (fruits and vegetables). Since diabetics are already at higher risk than the general population to develop cardiovascular disease, excessive salt and fat consumption would drastically exacerbate that risk to fatal numbers.
Having looked at the overwhelming problems that confront the homeless living with diabetes, one would assume that being diabetic and living on the streets are impossible combinations.
However, these problems are far from impossible with proper strategic planning. The resources around us are bountiful. Fortunately in most US cities, there are many homeless empowerment projects that network with local homeless advocacy sites which ensure that actions are taken to better conditions for those living with diabetes on the streets. What is needed, however, is a strong sense of activism—a desire to reach out and do something.
Among the crucial things that could be done is enhancing collaborative efforts between health-care providers and homeless service providers. Stronger collaboration would translate into more accessibility to medications, storage space for these medications, and more timely access to care in times of crisis. Shelter staff, for instance, could be trained to routinely monitor blood sugars of diabetic patients and inform physicians about any unusual highs or lows. Moreover, since transportation often limits many from receiving care, medical professionals could volunteer their time to make regular visits to shelters to educate the homeless on proper diabetes management. These efforts would hopefully lead to monthly multidisciplinary diabetes clinics specifically aimed at reducing and preventing complications associated with the disease.
Proper nutrition should also be at the forefront of this strategic planning. It is imperative that shelters and free clinics continue to network with licensed nutritionists to educate the homeless on meals that meet the ADA guidelines. Shelters should employ the help of social workers and psychologists to provide valuable insights and strategies on overcoming psychosocial barriers of homeless health, thereby, promoting a healthier way of living for our homeless populations.
At the heart of it all, what is important to address is that diabetes is only one among a long list of health problems that confront the homeless. What is strategically sound for diabetes management, thus, could also be applied to other emerging diseases. It is therefore essential that we maintain strong community efforts to learn more about the needs of homeless individuals and work collectively to help them overcome health-care barriers that would otherwise limit them from rights to a full life that every human being deserves.
Duc Chung is a resident physician and chair, public health committee, resident and fellow section, American Medical Association.