Facts and Myths about Tuberculosis and Homeless People

While I was homeless, in 1995, 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 community room that our homeless men and women 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 homeless people. You won't catch TB from a rug that a homeless man slept on the night before. In case you were worried.

Shortly after that, I was invited into an online discussion about "homeless people spreading drug-resistant TB." These are notes from that discussion; reposted now because lately, I've been hearing some of the same comments.

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?

While I was in a homeless shelter, I shared the space with several men and women who were working, full-time -- 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 month's 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. "I am in pain, not incompetent."

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 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 insisted, "A large percentage of TB inflicted people in the US are homeless, this vector has a hard time taking its meds, as a generalism." My response:

I heard a public health nurse speak about tuberculosis and homeless people: 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

http://www.ama-assn.org/special/hiv/library/jama95/oc4703.htm

"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
http://www.doh.wa.gov/topics/TB.html

"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."

A public health nurse told me that 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

• Spread education, yourself. Get public health pamphlets for your church, school, and office; have a speaker come in to your community group, or school, or office, to present the facts on TB, AIDS, and local health issues; provide links from your webpage to accurate health info pages; if you hear someone using inaccurate facts, correct them.
  
  
• Notice what's going on around you. If someone you know shows signs of a medical problem, get them to see a doctor.
  
  
• Don't withdraw from friends -- or family, co-workers, church members -- who are ill or in pain. People do, not just from fear of contagion, but from awkwardness and the pain of helplessness. Being emotionally and socially isolated is one of the things that makes people get sicker, or fail to get well.
  
  
• If you get sick, take your meds as the doctor orders -- but FIRST get the doctor to explain the medication she's prescribing, also read up on it yourself and talk it over with your pharmacist. People who take responsibility for their own health live longer. People who blindly do whatever their doctor tells them to statistically have a shorter life expectancy than people who don't go to doctors at all.
  
  
• Support spending money for public health. (Take it out of the corporate wealthfare funds.) Tuberculosis was almost wiped out in this country, then we cut back on public health and it resurged, complete with antibiotic-resistant strains -- as if the Unite States was a patient who stopped taking his meds because he started feeling better.
  
  
• Support local hygiene centers -- places where homeless people and others in need can shower and wash their clothes. And tourists, and tired shoppers, and everyone else stuck downtown without a bathroom.
  
  
• Campaign to cut out corporate wealthfare entirely and use it to provide adequate housing for all. We should have zero homeless people. (Okay, it doesn't relate directly to TB. I just thought I'd throw it in.)
  

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