by Zoe Gollogly
Published 11/21/01; © Medscape 2001
Dr. Roseanna Means is driven by what she calls her “faith journey.” In 1988, this calling led Means to found WOM (Women of Means) [now known as Health Care Without Walls] as a way to help the thousands of homeless women often overlooked by the healthcare system. Based in Boston, WOM is a nonprofit organization whose mission is to enable safe and respectful healthcare — free of charge — to women who are homeless or living in marginal housing. WOM consists primarily of a network of female physicians who visit homeless women around the city in regular, safe places. The program creates an environment where trust can be developed over a period of time, thereby allowing women to feel safe engaging in an ongoing healthcare situation. “It’s an incredible network of women helping women,” says Means.
Scope of the Problem
Homelessness continues to be a growing problem in America. On any given night in the United States, anywhere from 700,000 to 2 million people are homeless, according to estimates of the National Law Center on Homelessness and Poverty. In 1996, an estimated 637,000 adults were homeless in a given week. In the same year, an estimated 2.1 million adults were homeless over the course of a year. These numbers increase dramatically when children are included, to 842,000 and 3.5 million, respectively.[1]
Homelessness is generally defined as “the precariously housed or unhoused population.”[2] This “official” definition often excludes battered women because they technically have a home to go to even if they don’t use it. But concrete numbers are almost impossible to ascribe to the homeless, because for many it is a temporary circumstance rather than a permanent condition, and methodologies for counting are often unreliable, riddled with flaws and inaccuracies. According to the U.S. Council of Mayors’ overnight census in December 2000, there are approximately 6000 homeless adults in the Boston metropolitan area, of whom one third are estimated to be women (the official count is most likely an underrepresentation). WOM researched the number of shelter beds available to women in Boston in June 2001. There were 600. This leaves the majority of homeless women, and their children, without a guaranteed bed for the night.
Medicaid is the currently available option for healthcare for the homeless, yet bureaucratic obstacles can prevent many people from getting this benefit. In order to qualify, one has to prove certain medical conditions — and poverty is not always a sufficient reason. In addition, a licensed clinician must complete a form and provide objective substantiation of the diagnosis. For someone who is struggling to meet her basic needs, undergoing the questions, exams, or tests necessary to qualify for Medicaid is a strong enough deterrent to justify avoiding medical care in the first place.[3]
A Defining Moment and “Coming Home”
Dr. Means has always felt drawn to marginalized populations. During her residency, she had an opportunity to help run a pediatrics ward and emergency room for the refugees on the Thai/Cambodian border as part of the International Rescue Committee. This experience was a defining moment in Dr. Means’s life; she was exposed to the horrors of war and a kind of medicine where the concept of the white-coat doctor didn’t exist. “What mattered was just being gentle and kind with people,” she says. Impressed by a culture that, in the face of destruction, maintained a positive and fresh outlook, Dr. Means came back to the United States with a new perspective. In 1989, her career path took her to Massachusetts General Hospital (MGH).
On her way to work each morning, Means used to walk by homeless people who had passed out on the sidewalk. Being faced daily with such an obvious problem gave her a distinct impulse to do something about it. At the time, MGH had a program for the homeless that Dr. Means became involved with. Describing her initial experience working with the homeless, she says the “feeling of coming home” made it clear that this was what she wanted to dedicate her life to.
It didn’t take long before she noticed a significant difference in the care given to homeless men vs homeless women — homeless women faced issues that needed attention they simply weren’t getting. Homeless women and men share many of the same medical issues: hypertension, diabetes, sexually transmitted diseases (STDs) and other pelvic infections, HIV disease, gastrointestinal disorders, complications of alcohol and drug abuse, urinary tract infections, peripheral vascular disease, foot and joint disorders, tuberculosis, skin disorders, dental disease, and mental illness. However, homeless women are also confronted with issues specific to them, such as prenatal care, postmenopausal hormone replacement therapy, and the risk of physical and sexual assault on the street.
Filling a Gap: Bringing the Clinic to the Women
Three years ago, Dr. Means left the Health Care for the Homeless Program and created WOM in response to the severe lack of healthcare available to homeless women. While there are specialized shelters for certain types of women — ie, battered women, independent travelers — a very small percentage are willing to go to a clinic that advertises itself for the homeless. A major reason for this is that women don’t want to be associated with the stigma of “homelessness.” Over 95% of women who are homeless have been battered physically or sexually, and Means reports that all of her patients have been physically abused. They need a place where their pride and safety aren’t being threatened.
Means saw a need to create a model where women could get good medical care and still support the traditional medical model of an ongoing relationship with a single provider. Maintaining continuity in medical care is one of the greatest challenges in treating the homeless, so Means devised a way to encourage more repeat visits from women in order to build trust in the medical care system. Instead of asking women to come to the clinic, Means decided to bring the clinic to the women. WOM provides a bridge of clinical support among the various shelters that house women and children who are homeless or battered and to the clinics and hospitals that have traditionally provided healthcare to them. WOM doesn’t replace their clients’ existing primary care provider, but rather fills in the gaps that break continuity of care.
Education is central to WOM’s mission. Means has given numerous talks to medical groups to increase awareness and knowledge of how to care for the homeless. She is a member of the Massachusetts Behavioral Health Plan (MBHP) Homeless Task Force, through which she educates policy makers for Massachusetts Medicaid on the challenges faced by homeless persons. She also serves as Commissioner of the Massachusetts Commission on the Status of Women.
Training Others
As an elective offered by Harvard Medical School, third-year students have the opportunity to spend 4 consecutive Wednesday mornings at Rosie’s Place, a shelter in Boston. Means is also involved in a multidisciplinary collaborative effort with nurses from the Regis College of Nursing. Medical students and residents from the Brigham and Women’s Hospital also visit Rosie’s Place. “The aim of this collaborative program is to provide an opportunity for students in both nursing and medicine to work together for the common goal of providing improved access to medical care for indigent persons.”
Means is the physician leader for all the students. She and her students perform a variety of tasks, such as checking blood pressure levels and finger stick blood sugar values (in diabetic patients); providing wound care, foot soaks, and basic podiatry; treating colds and allergies; providing post-assault counseling; and working with patients with full-blown mental illness. Typical complaints that WOM doctors handle are acne, eczema, dry skin, and some problems that are aggravated by being homeless, such as athlete’s foot, swollen legs, and superficial skin infections.
Means and her fellow doctors travel up to 1 hour to see patients weekly or twice a month in a variety of settings, ranging from shelters to drop-in centers to soup kitchens. By frequenting the same places week after week, homeless women slowly build trust in the regularity of the doctors’ presence. Volunteer doctors are required to commit for at least a year in order to become part of WOM’s physician network. One volunteer doctor read about WOM in a newsletter of the Massachusetts Medical Society and joined, saying, “I had been looking for a volunteer activity which could use my abilities — writing a check or giving canned food didn’t lead me to feel I was making much of a difference for anyone. I feel like I’m helping just a little bit — doing it personally makes it feel more real. I also gain an appreciation for the blessings I have and a realization of how fragile the balances in our lives are.”
Since Means already had a familiarity with the homeless population, she started her work in 1988 by visiting shelters dressed in her jeans, with stethoscope and clipboard in hand. Her attitude toward the women was casual, friendly, and discreet. Means didn’t ask for any personal information — no social security numbers, no history, not even names. The objective was to get into the world of the women she was treating, to understand their problems on a practical level, and to provide care that would be useful on a daily basis.
During the early stages of WOM, the church that Means belonged to donated $7500 to get it off the ground. Such limited funding meant the program consisted of once-weekly visits by Dr. Means to the shelters to provide care. WOM currently runs on private donations and grants, and has blossomed into a group of 8 physicians following in Means’ footsteps. Its productivity has grown from 700 clinical encounters in 1999 to over 1600 encounters in 2000, and the 2001 figure is already way beyond this number.
This year marks a small triumph for WOM as Judith Perry, Assistant to the Director, will receive the organization’s first salary. Perry joined WOM 2 years ago, after attending graduate school for health services management. She says that working with WOM has shown her the meaning of “compassionate healthcare.” “Just the mention of Dr. Roseanna brings smiles to the women’s faces,” says Perry. “I never cease to be amazed at her level of commitment and the hard work done by all. Some lives have been saved and others have been turned around in a positive direction.”
Overcoming Obstacles
For a homeless person, there are many unseen obstacles that prevent getting appropriate medical treatment. These include lack of affordable housing, inadequate welfare-to-work programs, domestic violence, transience, and the medical community’s lack of education about how to treat homeless populations.[4] One of the most basic problems is that many homeless women — particularly those who are mentally ill — have no place to go. This means that the streets are the only option, and shelters are left to deal with overflow. But it’s not uncommon for shelters to be filled, and even when beds are available, the stay is limited. A typical schedule for someone living in shelters is to line up at 3 PM, wait for the doors to open at 5 PM, have something to eat, clean up, and lights out at 9 PM. The morning alarm goes off at 5:30 AM, a modest breakfast of coffee and starch is doled out, and the women are back on the street by 7 or 8 AM. Not only is explaining this schedule to a prospective employer obviously difficult, but so is going to a doctor’s office, where you may have to wait past 2:30 PM and risk losing your bed for the night.
Homeless shelters are not equipped to offer medical care because they’re designed to provide shelter, not medicine. Government agencies have many categories for assigning who qualifies for what type of aid, and the accompanying paperwork and other bureaucratic requirements are often experienced as overwhelming. It is such challenges — and lifestyle issues such as lining up for beds at 3 PM — that form an important part of what it means to be homeless, and that make the homeless population vulnerable, unable to voice their needs, and hard to provide continued healthcare for. The medical community is often unaware of the more subtle challenges of daily living that a homeless woman faces and is uneducated about the most effective strategies for improving health outcomes. All of this explains why an organized program such as WOM is essential — it allows the shelters to focus on their service, it saves the medical system money by thwarting emergency room visits, it allows homeless women to get care without having to go through the humiliation so often experienced in a regular hospital setting, and it provides doctors with an opportunity to give back to the community.
According to Means, one of the biggest issues for the homeless is the disconnect between public policy and what it actually takes to survive in modern times — wages don’t match the basic standard of living. In 1996, the welfare reform bill put a 2-year time limit on the ability to claim welfare, as well as requiring female heads of households to work 20 hours per week. “But if you can’t read or write well, or you have children, this is very difficult,” she points out. “Women are being asked to do things that are against the laws of physics. Women are particularly vulnerable because most applicable jobs often don’t offer benefits, or are only part-time, and if children are in the picture, the situation becomes even more difficult. When you’re on the street, everyone’s attitude changes and it’s hard to get out. There needs to be more of a safety net between poverty and homelessness. Another problem we have is callousness in our society, partly because we have information overload with worldwide problems, so it’s hard to feel sorry for the woman on the corner because you don’t know how to deal with it.”
Serving Homeless Women
Means believes strongly in the power of listening, exercising patience, and building trust with patients. One of her techniques for breaking down initial barriers with her patients is to use a podiatry kit to shave calluses, cut toenails, and scrub feet. Nonthreatening bodily contact allows the women to feel at ease, and they tell her more during a pedicure than during almost any medical procedure. Means gives a lot of positive feedback so that her patients will internalize the positive messages. This often means praising small accomplishments such as showing up to an appointment, or eating 1 hamburger instead of 2.
Means works with 2 female-centered homeless services in Boston: Rosie’s Place and the Women’s Lunch Place. The Women’s Lunch Place is open every day from breakfast to lunch. There is a homey atmosphere with fresh flowers, a nap room, a library, laundry facilities, and free clothing and home-cooked food. Sylvia Reevay, an advocate for The Women’s Lunch Place, explains the unique perspective that Dr. Means brings to the women: “The other day we had our annual fundraiser, and instead of coming and being guests, Roseanna and her family came and actually served the meal to the women, waiting tables for the evening. The women are so comfortable with her. For a lot of the women here, they don’t get treated with much respect on the street. Roseanna gives them such respect and they love her for her compassion and for treating them as equals. Because at the end of the day, we are. We’re women helping women. She makes them feel safe and she really works hard to get their needs met.”
Means spends 2 1/2 days in private practice, and the rest of the time working on WOM. She has taken a significant income cut in order to devote her energy to WOM. “It’s sort of painful if I think about it, but it’s a calling… my faith journey, so I just don’t go there. I’m hoping to be a role model for other people, to try to influence them outside of the box. You can have a career in medicine that doesn’t have to be this set career. You can be true to yourself as to why you want to be a doctor.”
Related Links
- Health Care Without Walls
- International Rescue Committee
- Rosie’s Place Women’s Shelter
- Women’s Lunch Place
References
- National Resource Center on Homelessness and Mental Illness. Get the Facts.
- Burt M, Aron LY, Lee E, eds. Helping America’s Homeless: Emergency Shelter or Affordable Housing. Urban Institute Press; 2001.
- Means R. A primary care approach to treating women without homes.
- National Health Care for the Homeless Council, Inc. Relational care: clinicians’ imperative. Healing Hands. 2000; 4:3.