FOR HEALTHCARE PROVIDERS

INFORMATION BY TOPIC

Igor van Laere, MD
Municipal Public Health Service (GGD)
PO BOX 2200,
1000 CE Amsterdam,
The Netherlands
ivlaere@ggd.amsterdam.nl

Introduction
Multiple social and medical problems leading to homeless people accessing multiple services hardly prevents homeless people escape from excessive morbidity and early mortality. Despite investments, research and a multitude of projects to address the most underserved, the epidemic of homelessness does not seem to decrease.1-3

With my own father as my medical teacher and with my own experience, providing full-time outreach social medical care to homeless people in Amsterdam during the last ten years, I will demonstrate that homeless people are in need of Hippocrates. I will describe my family biography and lessons learned.

Family biography
My father Roger van Laere was brought up by his caring parents in a rural Dutch village close to the Belgian border. As a child he was inspired by the professionalism of the local family doctor. My father knew he ought to become a family doctor himself. He was a curious and smart child who understood the need for books. At school he enjoyed history and biology. Outside school he enjoyed sports and dancing.

In the 1950s my father met my mother on the dance floor. From that day a caring and hospitable couple were formed. My father went to medical school at the University of Nijmegen and mom followed him as a nurse. They made good friends. Friends with whom they still are in close contact, friends who all have reached an influential position in the community. Most have been admirably successful.

After University my father went to the army, as a young family doctor. A captain, (from the rural village Liempde in a caring and hospitable province called Noord-Brabant and the place where my parents still live today), introduced him to the local family doctor who asked for my fathers substitution during his leave. Infected by the appearance and performance of the rural people, my parents found their destiny and took over the pharmacy holding family practice.

Three boys and a daughter were born. New friends were made. Patients were cared for without a single complaint or judgment, even after several assisted births during several nights and new patients waiting early in the morning. In the meantime, my father wrote fifteen books on rural people and their peculiarities coping with life and health. He lectured on birth, marriage and death. His material came from local people who were born around the 1900s. Forty years passed by. My brother Olof van Laere took over the family practice. My parents retired to enjoy their grandchildren.

After my father graduated from medical school my two brothers and me were born in the city of Nijmegen. My good sister was born in a hospital in a neighboring village of Liempde. Parents who showed care and hospitality brought us up. They stimulated school, curiosity and adventure. At school I enjoyed history and biology. Outside school I enjoyed sports and dancing. I was better at curiosity and adventure than at doing books.

Without pushing from my parents, and without guilt of choosing my own direction, initially I thought of following sports and dancing. However I made the decision to go to medical school at the University of Amsterdam. During lectures I observed teachers and my own notes. I hardly opened books. I outlived my curiosity and urge for adventure by traveling and meeting people and health services in six continents.

After my medical graduation, I decided to go into internal medicine inspired by the professional role-model of internists. A lack of senior teachers in internal medicine in Amsterdam brought me to a teaching hospital in the city of Eindhoven in my province Noord-Brabant. As a resident I observed the practice of caring and hospitable senior doctors who did not complain nor judge others but worked patiently during long-hour weeks.

Driven by my curiosity and adventure I decided to go back to Amsterdam, to become a family doctor. Due to a time consuming procedure for a biannual entrance ticket into the school for family doctors, I became a resident in internal medicine in a teaching hospital instead. I had left my caring and hospitable province life and re-entered an individual and hostile city life. Again I observed the practice of my senior doctors. This time it was different.

In the 1990s in Amsterdam I observed doctors complaining and judging others above providing care to patients. I felt less care and less hospitality. I became restless and rebellious. It took a little over a year to leave the hospital and a friend of mine guided me into community care. I felt welcomed as I entered the world of public health.

During the years that followed I missed my patients and hospital rounds. To keep in touch with hospital care as such, I freelanced as an accident and emergency doctor at the Academic Medical Centre. I love the academic smell. On the work floor I was confronted by the infectious presence of a nurse. Since than we have been trying to be a caring and hospitable couple. We made good friends with whom we are still in close contact. Friends who have reached an influential position in the community, most of whom are admirably successful.

Lessons learned
During my outreach care activities in the community I observe the appearance and behavior of homeless patients. With growing curiosity, (this time with books), I started to write on subjects reflecting highly prevalent health problems of my patients: tramps’ feet, pulmonary infections and dental problems. I wrote about my wrestling with extremely serious morbidity and providing assertive treatment: I presented a biography of life, health and amount of care invested in the homeless alcoholic. I started to collect demographics and data on health problems to look at the homeless population. 4

Due to lack of experience in epidemiology, research and building community care networks, I went to the Netherlands School of Public Health. I enjoyed my group of fellow doctors, they came from all over the country and had a wide variety of stories to tell. I enjoyed working with my teachers, immersing myself in books, visiting organizations, studying subjects on management and policy making, and writing my thesis on homelessness and health. On the last school day I graduated. In the meantime I had four papers published in Dutch medical journals.

After learning the key social and medical problems of my homeless patients, the functioning of organizations to address the underserved has become my main interest. I was able to study the process and problems of people at risk to become evicted from their homes and of those already evicted. With the help of an intelligent epidemiologist, we studied the process of eviction, the annual reports of organizations involved and local policy. Additionally, we collected data of individual cases who were close to losing their home which was rented from social housing agencies. We studied the process of eviction, demographics, social and health problems and help offered by organizations. To meet the already evicted we interviewed persons who had recently become homeless and had been living on the streets for less than two years.

The results of the study homeless after eviction 5 depressed me, though they do not surprise me. Those in highest need, housed or rough, do find little social and even less medical assistance. The longer the homeless are on the streets the less help (but the more substances) they find. And if homeless people find a desk for help then often they are confronted with a problem. Organizations, their procedures, complaints and judgments prevent delivery of adequate help for those who were never able to express or address problems of their own adequately.

As a result of an increasing epidemic of homeless people and their public appearance and performance, new policy and projects, (mostly based on emotion and budget rather than on knowledge and experience), are introduced to alleviate symptoms rather than etiologic agents. While studies on effectiveness of interventions are hardly available 1-3, we are predominantly faced with ongoing symptomatic policy and fragmented research. Interventions that take place further down the road of homelessness, to bring the homeless back to society, hardly succeed without chronic intensive, expensive and coercive care.

Without a social diagnosis no medical therapy. Confronted with homeless patients I consciously make the diagnosis “homelessness” for the consequences of treatment of problems in six areas simultaneously: housing, income, activities, substance use, mental and physical disorders. If such multiple morbidity is not addressed simultaneously all efforts to support a single disease (e.g. opiate dependence, psychosis or pneumonia) will be negated as soon as the homeless person is back on the street. A valuable tool in the chain of care for the homeless, to prevent recurrent or further social and or medical damage after admission in clinics or prisons, is a shelter infirmary facility with care provided by an integrated outreach team of social and medical workers addressing the six problem areas. 4-6

Since I love to explore the borders of public health, I am currently working on a social medical care model to meet the underserved, those in social and medical exclusion. The model will be based on specific problems in the six areas (individual demands) and specific skills, tasks and individual responsibilities of social ánd medical workers simultaneously to effectively meeting up with the needs of homeless people (population supply). With ongoing curiosity and adventure I enjoy to write and lecture on homelessness, health and care.

To me, the art of social medicine is to observe man, health and community in order to discover patterns in their interactions. One has to describe carefully what one observes rather than doing expensive tests to look for what one did not observe. A diagnosis of a population’s social and medical needs can be made after curious and adventurous observation, with neither complaining nor judging the population observed. This is the essence of Hippocrates. 7

As it is harder to treat a patient than a disease, doctors can have a tendency to focus on disease and the organizational flow that follows the disease. As a consequence doctors are in danger of treating forms and procedures more than they do patients. Human beings with ill-health need social and medical care simultaneously, especially those in highest need. No matter what the diagnosis of a single disease is.

Conclusion
Healthy conclusions can be drawn if based on knowledge and experience taught by caring and hospitable doctors. I try to bring my art to homeless patients by presenting the diagnosis of homelessness and the therapeutic consequences. The six problem areas, potentially present among all underserved populations, have to be addressed simultaneously. Social and medical care have to be united in a model of outreaching 1-6, (as life in a rural village), to narrow the gap between the poor and rich, the ill and healthy.

Focus on early signs of behavior causing social and medical damage to both the individual and the community (monitor) enables us to build care networks for social ánd medical interventions to prevent unnecessary and costly disease and hazardous roads towards premature death.
Following my family biography and lessons learned, homeless people are in need of Hippocrates. According to the Greek Asclepiad tradition Hippocrates thought his sons the art of medicine. 7

So did my good father.

References

1. Morrison D. Extent, Nature, and Causes of Homelessness in Glasgow. A needs assessment. Homelessness and Partnership, NHS Greater Glasgow, March 2003.

2. MacKinnon D et al. Delivering Health Care to Homeless People: an effectiveness review. NHS Health Scotland, 2004. www.healthscotland.com

3. Ng AT, McQuistion HL. Outreach to the homeless: craft, science and future implications. J Psychiatr Pract 2004; 10(2):95-105.

4. Laere IRAL van, Buster MCA. [Health problems of homeless people attending outreach primary care surgeries in Amsterdam]. Ned Tijdschr Geneeskd 2001; 145:1156-60. [Dutch]

5. Laere IRAL van, Wit MAS de. [Homeless after eviction]. Amsterdam: GG&GD Municipal Public Health Service, February 2005. [Dutch]

6. Laere IRAL van. [Homeless and a chain of care: diagnostics and care in four problem areas simultaneously]. Medisch Contact 2004; 59(20): 830-1. [Dutch]

7. Jouanna J. Hippocrates. London: The John Hopkins Press Ltd, 1999.