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In her work with the Boston Health Care for the Homeless Program (BHCHP), Massachusetts General Hospital dermatologist Jennifer Tan, MD, sees patients hit with the double whammy of homelessness and a pandemic.
The recommendation to stay at home is meaningless to a person who has no home. Same for some other coronavirus disease 2019 (COVID-19) mitigation measures, such as frequent handwashing—difficult when even many “public” restrooms are for customers’ use only—and social distancing, which is tricky to maintain on the streets or in homeless shelters.
On top of that, exposure to harsh weather and the inability to maintain good hygiene mean people experiencing homelessness develop skin problems more frequently than people with stable housing. One out of every 5 visits by a person who is homeless to an emergency department or community clinic is due to dermatological conditions, according to the American Academy of Dermatology.
Before the pandemic, Tan spearheaded an effort to collect donations of dandruff shampoos, moisturizing creams, and other over-the-counter remedies for skin problems and assemble them into kits to distribute to Boston’s homeless population. This year, one of the medical students she mentors suggested adding COVID-19–related products, such as hand sanitizer and masks, to the kits.
Tan, recently named a “Patient Care Hero” by the American Academy of Dermatology for helping to create and distribute more than 1000 COVID-19 care kits in Boston, Massachusetts, and Portland, Maine, spoke with JAMA about the challenges of treating skin conditions in people experiencing homelessness, especially during the pandemic. The following is an edited version of that conversation.
JAMA:Why did you become interested in caring for people experiencing homelessness?
Dr Tan:Taking care of patients, both at Mass General and at BHCHP, is a privilege. It's truly the best part of my job. But taking care of a particularly vulnerable patient population, members of society who are sometimes ignored or stigmatized, is especially meaningful to me because it feels like I'm helping to address a health care disparity that needs fixing. I really love contributing to a mission that is so much greater than myself.There's a lot of stigma around homelessness and assumptions that patients who are experiencing homelessness have mental illness or substance use disorder. While certainly a portion of our population has these comorbidities, many people are homeless because they lost their job in a very expensive city or were diagnosed with a devastating illness and couldn't pay their hospital bills, or are refugees or immigrants or single moms.Some of our dermatology residents are able to rotate through our clinic at BHCHP. I really hope to show our future generation of physicians that there are many faces of homelessness, and we need to look beyond the appearances and not make assumptions based on what we see.
JAMA:What dermatological conditions are common among homeless individuals?
Dr Tan:Skin disorders are very common. They account for about 6% of visits to all physicians and up to 25% of visits to primary care physicians. The homeless population is really no exception and may even have a higher proportion of skin disorders. When there are competing priorities such as the need to find food and shelter every day, health concerns are sometimes neglected. With the skin being the body’s largest organ and widely visible to patients, sometimes it will be their skin disorder that prompts a visit to their primary care provider.
JAMA:Where do you care for individuals who are homeless? What are some of the challenges of caring for them?
Dr Tan:We care for patients in the places where they typically seek care. That's been very important in working with this population—meeting these patients at a familiar place where they’re less likely to be stigmatized. We deliver care wherever our patients are. Boston Health Care for the Homeless involves more than 60 clinical sites. Often, these are small clinics run in conjunction with a shelter or a soup kitchen or even on the streets. We have a street team that's led by Dr Jim O'Connell, who founded Boston Health Care for the Homeless back in 1985. For dermatology specifically, our primary site is the main outpatient facility at BHCHP.We also see patients in the inpatient medical respite center, which is like a step-down medical facility that provides care for patients who are too sick to live on the streets or in shelters. I also go out to a few of the family-based shelters to see women and children. These are usually small clinical sites that are predominantly staffed by primary care physicians, nurse practitioners, physician assistants. There's usually psychiatric care there as well. Once a month we'll provide dermatologic care in some of these family shelters. And I have on occasion also seen patients on the streets. We've provided care out of a van, which enables us to go directly to the areas on the streets where patients spend most of their day.And over the past few years, with the support of a generous grant through Massachusetts General Hospital, we've been able to develop a teledermatology program where providers at Boston Health Care for the Homeless Program are able to upload photos, send them to one of our dermatologists at Mass General, and get guidance and feedback.Dermatology outreach by Boston Health Care for the Homeless was started informally back in 1998 by Dr Ernesto Gonzalez, who is a professor of dermatology at Massachusetts General Hospital and has been one of my mentors. Dr Gonzalez worked with Dr O'Connell to get the program going. He started by monthly providing informal services. Now we have a clinic that runs on a weekly basis, which is incredibly exciting, and teledermatology.
JAMA:What are some of the challenges of caring for individuals experiencing homelessness? Do you sometimes have difficulty providing follow-up care?
Dr Tan:The largest barriers to general medical care include lack of a telephone, no permanent address, and expensive or unreliable transportation. A patient might not be able to make their appointment because they need to be at the shelter at a certain time to make sure they have a bed for the night. There are also social barriers to care, including severe poverty, fear of stigmatization. This is at the root of why it's so important to bring services directly to the patient, rather than trying to have them find their way to our dermatology clinics. And just the daily need to find shelter or food competes with their priorities for medical care.Dermatologic care brings up a whole set of different barriers. If you don't have a cell phone or a means of communication or transportation to a visit, it's so difficult to navigate the system, to try to not only schedule an appointment with a specialist but then figure out how to get to the specialist's office. And in some shelters, there’s no place to store medications to treat dermatologic conditions. Sometimes injectable medications have to be refrigerated. And then think about lack of access to hygienic care, the long periods of time that somebody might be walking or standing, and difficulty applying topical medications. Exposure to harsh weather conditions not only causes significant sunburns but also breakdown of skin due to prolonged periods of wetness. One of the final barriers is the cost of over-the-counter medications to treat common skin disorders. And the close quarters that these patients live in tends to promote the spread of infectious disease.
JAMA:How has the pandemic affected people experiencing homelessness, and why are they particularly vulnerable to COVID-19?
Dr Tan:Individuals experiencing homelessness find it difficult to practice some of the measures that slow transmission. Many of our patients are older adults with comorbidities that increase their risk for severe COVID disease. They're also from socially disadvantaged and minority populations that data suggest are at increased risk of mortality due to COVID-19, which has brought attention to numerous disparities in health care.
JAMA:Has the pandemic changed how BHCHP cares for patients?
Dr Tan:COVID-19 has been incredibly isolating for all members of society. At the same time, we've learned to take care of each other in really innovative ways, which is one of the silver linings to the pandemic, if there is one. The team at BHCHP, in collaboration with the City of Boston, has developed innovative ways to not only test patients but also provide treatment and isolation facilities. As a member of that team, I found dermatology could be most helpful by developing creative ways to provide virtual visits to our patients while our clinics at BHCHP were closed down and by creating the skin care kits that would enable our patients to have access to some of the supplies that were really necessary for prevention of the spread of disease.
JAMA:What’s in the kits?
Dr Tan:These kits have been an extension of a preexisting program we had to provide basic over-the-counter treatments for common skin disorders, such as acne and seborrheic dermatitis and dry skin. In recent years we’ve worked with a number of skin care companies to be able to create these specialized kits.The COVID-19 kits were really the brainchild of one of our fantastic medical students, Haya Raef, a third-year medical student at the Tufts University School of Medicine. She really did the heavy lifting for this project. She was rotating with me at BHCHP. When COVID-19 hit, she realized how difficult it was to obtain basic necessary skin care, such as soap and hand sanitizer, so she approached me about ways that we might be able to help. She began to reach out to our contacts in skin care and was able to obtain a significant amount of donations, including soaps, hand sanitizers, moisturizers, and dental care products. She reached out to Tom's of Maine, which supplied a significant amount of oral care supplies for our patients. She reached out to several local distilleries that helped with hand sanitizers. And then our partners at L’Oréal Cosmetics, the parent company to CeraVe and La Roche-Posay, shipped enough donations for over 1000 kits, which were distributed throughout Boston, mostly through the sites covered by Boston Health Care for the Homeless Program. And then also in Portland, Maine, where Haya was doing her clinical rotations.Some of the other items that we included in the kits were hand-cut bandanas, which were to be used as face shields. Now, as PPE [personal protective equipment] has become more plentiful, masks are provided by BHCHP to our patients. Haya also developed a COVID-19 informational pamphlet for the kits. We also tried to include items such as puzzles or crossword puzzles and earbuds for when patients were staying in isolation facilities and using borrowed iPads and Kindles to help pass the time.
JAMA:Are dermatologists in other cities following your lead and assembling and distributing COVID-19 kits?
Dr Tan:Just recently, we put together a brief report of the kit assembly process and were able to publish it in the Journal of the American Academy of Dermatology, so I am just starting to hear from some of my colleagues who are interested in setting up similar programs.
JAMA:What are your plans for the kits when the pandemic ends? Are you going to continue to distribute them? What will be in them that might not be in them right now?
Dr Tan:For a while, we will continue with the distribution of the COVID-19–specific kits. But at the same time, I think that our diagnosis-specific kits are very useful for patients. The ones that focus on having a week or 2 worth of treatment of either over-the-counter products for acne or eczema or dry skin care or diaper rash—the types of products that pose major barriers for our patients to acquire. Giving them 4 or 5 kits at a time is very helpful for them. In the future, we will eventually shift gears back to these diagnosis-specific kits. And Haya, who is so passionate about this project, has the idea of trying to set up an online portal that can help connect community members in need or, possibly, facilities that are taking care of patients experiencing homelessness with potential donors.
JAMA:What gives you the greatest satisfaction in caring for people experiencing homelessness?
Dr Tan:Being able to contribute to a mission greater than myself and help address a health care disparity gives me the greatest satisfaction. I think that there needs to be more awareness of the urgency of homelessness in America. Physicians from all specialties can contribute to the health of this population. With increasing housing and job instability due to COVID-19, we all really need to do our part to address this public health crisis. A lot of our success has been due to collaboration between primary care and specialty care, and that's a really special part of my job. If there could be more programs such as this, we might be able to further address the health care disparities that exist today.
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Rubin R. Helping People Who Are Homeless Stay Healthy During the Pandemic. JAMA. 2021;325(6):517–519. doi:10.1001/jama.2020.23436
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