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The ongoing battle to address respiratory health in people experiencing homelessness

2022; Elsevier BV; Volume: 10; Issue: 3 Linguagem: Inglês

10.1016/s2213-2600(22)00055-8

2213-2619

Talha Burki,

Housing, Finance, and Neoliberalism

Spurred into action by the COVID-19 pandemic, the British government tried something completely new. It made a serious effort to tackle homelessness. Local authorities in England were instructed to get people experiencing homelessness off the streets, out of communal shelters and into safe, single-room accommodation. Hotel rooms, bed and breakfasts, and student halls were booked en masse. Landlords were prevented from evicting tenants and welfare payments were increased.Alistair Story is the founder and clinical lead of Find and Treat, a specialist outreach service for homeless populations, funded by the National Health Service and based out of University College London Hospital. “If you have your own place, you have somewhere to eat, wash, and sleep in private. You have your own toilet. You can get warm. You can get dry. These are the sorts of things that keep people alive”, explained Story. According to the Office of National Statistics, there was a 12% decrease in deaths among people experiencing homelessness in England and Wales in 2020, compared with the previous year. There were just 13 documented deaths from COVID-19.“We saw something that we thought we would never see”, added Story. “This problem of homelessness, which was supposed to be chronic, intractable and irresolvable, became something that could be taken off the streets. It could be fixed. Individuals who were sleeping in shop doorways suddenly had a roof over their heads.”It now looks as if the fix was only temporary. The eviction ban has ended. Welfare payments have been cut. The nation is entering a cost-of-living crisis. The charity Shelter has warned that a surge in homelessness is likely. “We're flooded with calls from families and people of all ages who are homeless or on the verge of losing their home”, stated chief executive Polly Neate, in a press release late last year.The last time the UK was confronted with the kind of debt it now faces was in the aftermath of the 2007–08 financial crisis. The Conservative-led coalition government responded with a punishing set of austerity policies. Housing benefit was frozen. There was massive disinvestment in frontline services for homeless populations. Thousands of bed spaces were lost. Rough sleeping spiked, as did the number of the number of families living in temporary accommodation.The Lancet Respiratory Medicine visited Find and Treat on an icy day in December, 2021. The mobile clinic was parked in a small alleyway half a mile from the Houses of Parliament. Apartments in a development a few yards away were being offered for £1·75 million. The same street is home to a hostel, something of a rarity in that it is willing to accept people who have been ejected from other services or are still using drugs. “It is a bit of hardcore here; we see people who are entrenched in rough sleeping”, said Joyce, a young nurse who has been working with Find and Treat for a year or so.The van was in its first week back on duty, after a major refurbishment. A small ramp takes you into the waiting area. The mobile x-ray unit stands to the left. On the right, a door leads to the consulting room, where Joyce was offering vaccines against pneumonia, influenza, and COVID-19. The clinic had dispensed more than 7000 doses of the Pfizer vaccine against COVID-19 since the previous March. The booster campaign was well underway, though there were also plenty of people who were receiving their first and second doses. Over the next few weeks, the clinic would see a lot of cases linked to the omicron variant of SARS-CoV-2, mostly mild infections.View Large Image Copyright © 2022 University College London HospitalStory stands outside the van, directing clients to Joyce and making sure no-one leaves without being offered chocolates. A few of those visiting the clinic have bruises on their face—perhaps from falls, perhaps from violence. A woman in her twenties is on the street opposite, sheltering under a blanket. She walks over. “I'll take a chest x-ray, if there is one going”, she says. She enters the van, re-emerges a few minutes later, and returns to her blanket. It starts to rain.“People know the van. They trust us, and that is really important”, said Joyce. “There are people here who have had terrible experiences with health care. They have felt judged and unwanted, even though they are trying to access services that they are fully entitled to.” Over its lifetime, Find and Treat has administered more than 100 000 screenings. “The worst situation we have experienced is a minor altercation”, said Story. “Our clients are less trouble than the general population.”Find and Treat's major focus is active case-finding for tuberculosis. The x-ray machine delivers the results on the spot. “Respiratory health is really poor among the people we see”, said Story. Most hostel residents have long histories of rough sleeping. “People here have survived outside with next to nothing, sleeping in doorways and under bridges inhaling traffic pollution. It wrecks their immune system. People get multiple pneumonias and early-onset chronic obstructive pulmonary disease [COPD]”, said Story.Users of crack-cocaine are exceptionally vulnerable. The drug is smoked, typically in short-stemmed, home-made pipes. The smoke is incredibly hot. “X-rays sometimes show up shocking damage in young people, which we are pretty sure comes down to thermal airways injury”, said Story. “Crack-cocaine takes out your first line of defence, the alveolar macrophages, and leaves you at much greater risk of any kind of respiratory infection.” High rates of tobacco use compound the problem, especially given the obstacles people experiencing homelessness encounter when trying to access stop-smoking services. “Our clients are just as likely as anyone else to want to quit smoking, but hardly any services are set up to help”, notes Story.Alan [not his real name] has been coming to the clinic for more than 3 years. He is a heavyset man, a former rugby player, in his fifties. He speaks quietly; his accent hints at an upbringing in the west of England. Alan is now in a hostel, but spent several years sleeping rough. “In the summer, we would buy some beer and play football and then I would sleep wherever I fell down”, he recalls. Over the past year, Alan's health has deteriorated. “Worst time of my life. I have just fallen apart. I ended up in hospital coughing up blood. They said I had an unprovoked embolism”, he told The Lancet Respiratory Medicine. Alan has cut down on smoking, though he still has a few cigarettes every day. “The COPD is getting worse; I do want to stop completely, but it is not so easy”, he said.Story stresses the importance of regarding people experiencing homelessness as being at continual risk of tuberculosis. “The concept of a contact does not make sense if your entire life involves being a contact”, he said. Day centres, particularly in winter, can be crowded and poorly ventilated. People sleeping rough often huddle together for warmth, the slang term for which is “skippering”. “It is not unusual for our clients to know the person they caught tuberculosis from”, said Story.Find and Treat employs peer workers to encourage take-up of screening for tuberculosis. These are individuals who have direct experience of homelessness and tuberculosis. Active case-finding means attending hostels, soup kitchens, and other places where people experiencing homelessness gather, and striking up conversations. Oz is one of the peer workers. “I have been through exactly what these people have been through”, he said. “It makes a big difference in building trust. In this line of work, you have to have empathy.”Find and Treat is commissioned on the basis of specific services. The screening for blood-borne diseases and for tuberculosis is secure, but the work on chronic respiratory and cardiovascular conditions is funded through research grants. “We have to move to a system of focusing on people, not pathogens, so that we can provide a service that genuinely reflects the needs of our clients”, said Story. “We need to be offering truly integrated care. It does not make sense to say, ‘we can help you with this one condition, but not with this other one'.”Last year, WHO warned that the COVID-19 pandemic had “reversed years of global progress in tackling tuberculosis”. In 2020, the worldwide death toll from the disease rose for the first time in over a decade. Services all over the world have been badly affected. Find and Treat is no exception. “We have not had the capacity to do things at scale for the past 14 months”, said Story. “We are seeing a lot of delayed diagnosis, which leads to extended chains of transmission, and we are getting multiple calls from public health colleagues across the country to try to respond to outbreaks.”Moreover, tuberculosis tends to rise during economic contractions. The reversed progress of the past couple of years could easily mark the beginnings of a downward trend. “Now is the time to ramp up case-finding and invest in supporting people to take their treatment”, said Story. “But I am not hopeful this is going to happen.” He added that the government's commitment to addressing homelessness seems to have waned. “There are no long-term strategies to sort out people's housing status”, said Story. “The pandemic has accelerated inequality; the next few years are going to be really tough.” Spurred into action by the COVID-19 pandemic, the British government tried something completely new. It made a serious effort to tackle homelessness. Local authorities in England were instructed to get people experiencing homelessness off the streets, out of communal shelters and into safe, single-room accommodation. Hotel rooms, bed and breakfasts, and student halls were booked en masse. Landlords were prevented from evicting tenants and welfare payments were increased. Alistair Story is the founder and clinical lead of Find and Treat, a specialist outreach service for homeless populations, funded by the National Health Service and based out of University College London Hospital. “If you have your own place, you have somewhere to eat, wash, and sleep in private. You have your own toilet. You can get warm. You can get dry. These are the sorts of things that keep people alive”, explained Story. According to the Office of National Statistics, there was a 12% decrease in deaths among people experiencing homelessness in England and Wales in 2020, compared with the previous year. There were just 13 documented deaths from COVID-19. “We saw something that we thought we would never see”, added Story. “This problem of homelessness, which was supposed to be chronic, intractable and irresolvable, became something that could be taken off the streets. It could be fixed. Individuals who were sleeping in shop doorways suddenly had a roof over their heads.” It now looks as if the fix was only temporary. The eviction ban has ended. Welfare payments have been cut. The nation is entering a cost-of-living crisis. The charity Shelter has warned that a surge in homelessness is likely. “We're flooded with calls from families and people of all ages who are homeless or on the verge of losing their home”, stated chief executive Polly Neate, in a press release late last year. The last time the UK was confronted with the kind of debt it now faces was in the aftermath of the 2007–08 financial crisis. The Conservative-led coalition government responded with a punishing set of austerity policies. Housing benefit was frozen. There was massive disinvestment in frontline services for homeless populations. Thousands of bed spaces were lost. Rough sleeping spiked, as did the number of the number of families living in temporary accommodation. The Lancet Respiratory Medicine visited Find and Treat on an icy day in December, 2021. The mobile clinic was parked in a small alleyway half a mile from the Houses of Parliament. Apartments in a development a few yards away were being offered for £1·75 million. The same street is home to a hostel, something of a rarity in that it is willing to accept people who have been ejected from other services or are still using drugs. “It is a bit of hardcore here; we see people who are entrenched in rough sleeping”, said Joyce, a young nurse who has been working with Find and Treat for a year or so. The van was in its first week back on duty, after a major refurbishment. A small ramp takes you into the waiting area. The mobile x-ray unit stands to the left. On the right, a door leads to the consulting room, where Joyce was offering vaccines against pneumonia, influenza, and COVID-19. The clinic had dispensed more than 7000 doses of the Pfizer vaccine against COVID-19 since the previous March. The booster campaign was well underway, though there were also plenty of people who were receiving their first and second doses. Over the next few weeks, the clinic would see a lot of cases linked to the omicron variant of SARS-CoV-2, mostly mild infections. Story stands outside the van, directing clients to Joyce and making sure no-one leaves without being offered chocolates. A few of those visiting the clinic have bruises on their face—perhaps from falls, perhaps from violence. A woman in her twenties is on the street opposite, sheltering under a blanket. She walks over. “I'll take a chest x-ray, if there is one going”, she says. She enters the van, re-emerges a few minutes later, and returns to her blanket. It starts to rain. “People know the van. They trust us, and that is really important”, said Joyce. “There are people here who have had terrible experiences with health care. They have felt judged and unwanted, even though they are trying to access services that they are fully entitled to.” Over its lifetime, Find and Treat has administered more than 100 000 screenings. “The worst situation we have experienced is a minor altercation”, said Story. “Our clients are less trouble than the general population.” Find and Treat's major focus is active case-finding for tuberculosis. The x-ray machine delivers the results on the spot. “Respiratory health is really poor among the people we see”, said Story. Most hostel residents have long histories of rough sleeping. “People here have survived outside with next to nothing, sleeping in doorways and under bridges inhaling traffic pollution. It wrecks their immune system. People get multiple pneumonias and early-onset chronic obstructive pulmonary disease [COPD]”, said Story. Users of crack-cocaine are exceptionally vulnerable. The drug is smoked, typically in short-stemmed, home-made pipes. The smoke is incredibly hot. “X-rays sometimes show up shocking damage in young people, which we are pretty sure comes down to thermal airways injury”, said Story. “Crack-cocaine takes out your first line of defence, the alveolar macrophages, and leaves you at much greater risk of any kind of respiratory infection.” High rates of tobacco use compound the problem, especially given the obstacles people experiencing homelessness encounter when trying to access stop-smoking services. “Our clients are just as likely as anyone else to want to quit smoking, but hardly any services are set up to help”, notes Story. Alan [not his real name] has been coming to the clinic for more than 3 years. He is a heavyset man, a former rugby player, in his fifties. He speaks quietly; his accent hints at an upbringing in the west of England. Alan is now in a hostel, but spent several years sleeping rough. “In the summer, we would buy some beer and play football and then I would sleep wherever I fell down”, he recalls. Over the past year, Alan's health has deteriorated. “Worst time of my life. I have just fallen apart. I ended up in hospital coughing up blood. They said I had an unprovoked embolism”, he told The Lancet Respiratory Medicine. Alan has cut down on smoking, though he still has a few cigarettes every day. “The COPD is getting worse; I do want to stop completely, but it is not so easy”, he said. Story stresses the importance of regarding people experiencing homelessness as being at continual risk of tuberculosis. “The concept of a contact does not make sense if your entire life involves being a contact”, he said. Day centres, particularly in winter, can be crowded and poorly ventilated. People sleeping rough often huddle together for warmth, the slang term for which is “skippering”. “It is not unusual for our clients to know the person they caught tuberculosis from”, said Story. Find and Treat employs peer workers to encourage take-up of screening for tuberculosis. These are individuals who have direct experience of homelessness and tuberculosis. Active case-finding means attending hostels, soup kitchens, and other places where people experiencing homelessness gather, and striking up conversations. Oz is one of the peer workers. “I have been through exactly what these people have been through”, he said. “It makes a big difference in building trust. In this line of work, you have to have empathy.” Find and Treat is commissioned on the basis of specific services. The screening for blood-borne diseases and for tuberculosis is secure, but the work on chronic respiratory and cardiovascular conditions is funded through research grants. “We have to move to a system of focusing on people, not pathogens, so that we can provide a service that genuinely reflects the needs of our clients”, said Story. “We need to be offering truly integrated care. It does not make sense to say, ‘we can help you with this one condition, but not with this other one'.” Last year, WHO warned that the COVID-19 pandemic had “reversed years of global progress in tackling tuberculosis”. In 2020, the worldwide death toll from the disease rose for the first time in over a decade. Services all over the world have been badly affected. Find and Treat is no exception. “We have not had the capacity to do things at scale for the past 14 months”, said Story. “We are seeing a lot of delayed diagnosis, which leads to extended chains of transmission, and we are getting multiple calls from public health colleagues across the country to try to respond to outbreaks.” Moreover, tuberculosis tends to rise during economic contractions. The reversed progress of the past couple of years could easily mark the beginnings of a downward trend. “Now is the time to ramp up case-finding and invest in supporting people to take their treatment”, said Story. “But I am not hopeful this is going to happen.” He added that the government's commitment to addressing homelessness seems to have waned. “There are no long-term strategies to sort out people's housing status”, said Story. “The pandemic has accelerated inequality; the next few years are going to be really tough.”