Facts and Myths on Tuberculosis and the Homeless

Some groundwork:

  1. Anyone can become homeless, for any reason. 1/3 of the American population is under the poverty line right now; another 1/3 are sliding down toward it. In spite of the stereotype of the homeless as mentally ill and/or alcohol/drug addicted, the major cause of homelessness is poverty, combined with the lack of affordable housing.

  2. Well-educated and mentally healthy people from middle-class backgrounds can, and have, become homeless. A car accident and no insurance, a bad divorce, a layoff when you were living on no margin -- sh*t happens.

  3. "I am in pain, not incompetent" -- a quote from a "mentally ill" person. Myself. Many "mentally illnesses" are distressing, and at times disabling -- but do not make the intelligent, mature sufferers incapable of managing their own affairs. I am manic-depressive, stable on Lithium -- and I take my Lithium. Even on Lithium I have some depressive and manic episodes -- I know the warning signs, and I take precautions -- like not driving or making major decisions, notifying friends to let me know when I'm acting inappropriately. I would challenge most health-care professionals to demonstrate as much self-awareness as my fellow BP sufferers and I do.

  4. Not following through on medication is common behavior among the homeful (people in housing). I am not sure what the comparative statistics are on that. But I know that the comparative statistics -- which you can check on in a book called Merchants of Misery, for one source -- the record of paying mortgages and other loans faithfully is higher in low-income brackets than in upper-income brackets, and the turnover in low-income housing (including permanent housing for the formerly homeless) is lower than in upper-income housing (even when alternative low-income housing is available). I feel justified in extrapolating from this kind of dependablity and stability to theorize that homeless and low-income patients may take their medications more faithfully than higher-income patients.

  5. During my own homeless period, a homeless group I worked with opened a new shelter with the aid of a neighborhood church. We held several community meetings in the process. One of the objections some neighborhood residents brought up was that "homeless people have TB" -- the Boy Scouts used the same communtiy room that our homeless would sleep in, and the children could catch TB. A district nurse came to a meeting and testified, among other things, that TB is still HIGHER among non-homeless populations than among homeless populations. What makes it a critical issue among the homeless is not the high incidence, but that the circumstances of their lives make the disease a greater threat to them -- as well as more contagious, when thirty of you are sleeping on the floor in one room. But the contagion rate in schools and offices is still higher than among the homeless.
        Oh -- and you won't catch TB from a rug that a homeless man slept on the night before. In case you were worried.

"Think twice before you speak about the homeless --
the dignity you save may be your own."

A correspondent equated homelessness with "poverty, illness, and insanity." My response:

Poverty, yes -- you can definitely be allowed to be categorical on that. No one with the money to escape it *chooses* to sleep on pavement, or on a mat with two army blankets on the floor of a church basement.

I acknowledge the correlation between poverty and homelessness. I still don't see that it proves anything. Or are we going to bring in Calvinism? To be poor is to be morally inferior, to be homeless is to be poor, therefore to be homeless is to be morally inferior, therefore of course they don't take their meds?

Illness AND insanity, though -- good grief, we not only HAVE to have one of them, we HAVE to have both? We are homeless AND poor AND sick AND insane? <g>

While I was in a homeless shelter, I shared the space with several men and women who were working, fulltime -- at blue-collar, minimum-wage jobs, or at seasonal jobs, or they had just gone back to work after illness or injury. It would take them several months, at least, to save up enough to move back into housing -- first and last months rent, furniture and all the things required for living in a house, from dishes to toilet paper.

None of them were, at the time, physically or mentally ill.

Our shelter was one of the self-managed shelters organized by homeless people themselves. Everyone participated in cleaning and administering the shelter. Therefore the portion of the population we served was more active, motivated and responsible than in, for instance, the city-run emergency shelter. Several of the people in the shelter were, however, in the category of "mentally ill", "disabled by reason of mental illness." I was one of them. My illness had made it impossible for me to do my former work of computer programming. But I could take my medication. I could take a large portion of responsibility in the shelter, and it increased as I recovered.

As I said in an earlier post, mental illness does not always equal incompetence.

My correspondent said (as most people believe) that "the homeless are more *likely* on an individual basis to forget or neglect prescribed medications, especially ones taken after they are pushed back on the streets."

My response:

The University of Washington, in Seattle, offers optional courses for social workers or health professionals who want to gain more understanding of the homeless population, and working with the homeless poplulation. If you would like to learn more about the realities of homelessness, and health treatment of the homeless, you might check with your local college or university, or I could put together a reading list for you.

I have been a nurses aide and an inhalation therapist, I like to read about medical stuff a lot and I've had friends who were doctors or nurses. That's the source of my statement. Well, that and my Grandfather's history.

The incidence among the homeful of not finishing medication and not taking it as prescribed is HUGE. It is a continual problem doctors and pharmacists wrestle with. This is with educated, stable, working adults living in their own homes. They either decide that taking one pill a day for twenty days is too slow, they'll take four a day for five days; or they take the pills for three days and forget for a week; or they take them for ten days and feel better and save the rest for the next time they get sick; have a talk with your doctor the next time you see him, he'll give you lots more variations.

I can find no evidence anywhere that homeless people are any worse about taking medication than people in housing are.

Because any statistic -- or hint of a supposition of a statistic -- can be used to justify blame and horrid measures, it is very important to be responsible about using them, or letting them be used. I reply to any stereotypes about the homeless wherever they show up. Being kind to poor helpless weak-minded sick homeless people or being cruel to stinking useless crazy criminal addict homeless people are both abusive -- abusive to a different extent, in different ways, but the kind pity makes it easier for the cruel oppression. What is really needed is to realize that there are people who have homes, there are people who do not have homes; there is an equally wide spread of intelligence, education, physical fitness and mental health in both categories.

And all those varieties of human should be regarded with as much dignity as you demand for yourself.

End of sermon. Smile, I don't pass a collection plate!

Still another correspondent still insists, "A large percentage of TB inflicted people in the US are homeless, this vector has a hard time taking it's meds, as a generalism."

My response:

I heard a public health nurse speak about tuberculosis and the homeless, just last year, and as I remember it she said that most of the people who have TB are not homeless. This is what I put together from a quick check on the Web:
Eleven Years of Community-Based Directly Observed Therapy for Tuberculosis September 27, 1995. (c) AMA 1996
C. Patrick Chaulk, MD, MPH; Kristina Moore-Rice, RN; Rosetta Rizzo, RN, MHS; Richard E. Chaisson, MD

"Conclusions.--In contrast to the national TB upswing during the 1980s, Baltimore experienced a substantial decline in TB following implementation of community-based DOT, despite highly prevalent medicosocial risk factors. Directly observed therapy facilitated high treatment completion rates and bacteriologic evidence of cure. Directly observed therapy could help reduce TB incidence in the United States, particularly in cities with high case rates."

Directly monitoring patients improves their compliance with meds; this was independent of all other socioeconomic factors. Middle-class homeful folk did better on the direct observation treatment program, just as poor immigrants did.

"Factors contributing to increased TB morbidity and drug resistance include physician mismanagement of cases, patient nonadherence with therapy, human immunodeficiency virus (HIV) infection, and a substantial decline in funding for public TB control programs."

The rise in homelessness is not cited as a factor.

Department of Health Public Health Fact Sheet * Tuberculosis fact sheet Copyright =A9 1996 Washington State Department of Health
"Prolonged exposure is normally necessary for infection to occur."

(Just in case the conversation makes you concerned about catching TB from a homeless person you pass on the street.)

To put some perspective on "people not being compliant with their meds" --

"People with active TB must complete a course of curative therapy. Initial treatment includes at least four anti-TB drugs for a minimum of six months."

According to the public health nurse I talked with today, treatment can mean up to twelve pills a day. For months. The nurse said that compliancy is NOT a problem restricted to the homeless. "People are not compliant, period. *I* am not always compliant about my meds."

Things That You Can Do to Stop the Spread of TB

Homeless Columns ed. by Anitra L. Freeman