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Anonymous demise: Mortality in the homeless
The Journal of Emergency Medicine, Vol 15, No 3, pp 373-374, 1997 Copyright 0 1997 Elsevier Science Inc. Printed in the USA. All rights reserved 0736s4679/97 $17.00 + .OO
ELSEVIER
PlItJm36479(~3
Emerylency Forum ANONYMOUS
DEMISE: MORTALITY Robin Cuddy,
IN THE HOMELESS
MD, MPH
Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland Reprint Address: Robin Cuddy, MD, MPH, Department of Emergency Medicine, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287
Among the homelesswho died in Baltimore in 1988 was the son of the Antarctic explorer, Admiral Richard Byrd. On September 13, the 6%yr-old Richard Byrd, Jr., Beacon Hill resident and Harvard graduate, had boarded an Amtrak train in Boston and was bound for Washington, DC to attend a National Geographic reception honoring his father. He never reached his destination. His body, clothed in a green workman’s uniform and one shoe,was found 3 wk later in a vacant warehousein Baltimore (1). The custodian who found him recalls having run him off the property a few days earlier (2). The state medical examiner determined that Richard Byrd, Jr., died of malnutrition and dehydration. He also confirmed that Byrd suffered from Alxheimer’s disease. “In his confused state, he could have appearedto be intoxicated,” said John Smialek, chief medical examiner, to an Evening Sun qmter (3). “He wasn’t able to seekhelp.” Byrd apparently got off the tram in Baltimore and wandered 1.5 miles down the tracks to the empty industrial buildings, where he spent the last days of his life. Hibbs et al. (4) recently determined the mortality rate of a cohort of homeless adults in Philadelphia. They found that the age-adjustedmortality rate for the homeless cohort was nearly four times that of Philadelphia’s general population. Injury was the leading cause of death. They pointed out that the opportunities for preventive care in this population are limited. What are the mot causesof homelessness?A report issued by the Institute of Medicine concluded that the primary factors causing the recent increase in the numbers of homeless persons are “the low-income housing
shortage, changing economic trends, inadequateincome supports and the deinstitutionalization of mentally ill patients” (5). What can an emergencyphysician do in the face of poverty, substance abuse, mental illness, and joblessness? At the very least, we can be role models to our staff and stndems and treat the homeless with care and respect. In most cases,we cannot provide shelter for the night, but we can be aware of the resources in our communities that might offer needed services-detox centers, respite units, shelters, and primary and psychiatric care. Referral cards that list social agencies,community mental health centers, detox centers,and shelters could be kept in the emergency department (ED) and given out to homelesspersonswho may not be aware of community resources. Multidisciplinary hospital task forces with representatives from emergency medicine, internal medicine, surgery, psychiatry, hospital administration, and social work could work with community groups and provide specific recommendationsto coordinate and improve the care of homelesspersonsthroughout the hospital. What else can be done to assist the indigent and homeless?We have all encounteredthe homelessin our EDs. I also have worked with patients at Health Care for the Homelessin Baltimore and Boston. I am not entirely certain of the reason that I came upon this work, but I know that it has enabled me to meet some extraordinary people whom I cannot quite forget. So I would suggestto the emergencyphysician that he or she bear witness. We can write about our experienceswith the homeless and
RFKENEX3 March 1995; PENAL SUBMISSION xncmvno: 29 August 19%; ACCIFIXD:1 October 1996 373
the indigent-in the journals, the newspapers,short stories, or to our local congressman.In the words of William Faulkner, it is our “privilege to help man endure by lifting his heart, by reminding him of the courage and honor and hope and pride and compassion and pity and sacrifice which have been the glory of his past.” The voice of the writer “need not merely be the record of man, it can be one of his props, the pillars to help him endure and prevail” (6). The homelesswoman lying on a stretcher in your ED and the man curled up on the sidewalk as you try to get to your car cast somereflection on who we are as individuals and as a nation. Write about them. Richard Byrd is probably not representative of the homeless who live and die in Baltimore and elsewhere. News of his death captured national headlines. The deaths of most homelesspersons are recorded only in a thin file in the medical examiner’s office. In some fun-
damental ways, however, perhaps Byrd is not unlike many of the homeless who wander the streets, sleep in doorways and ED waiting rooms, and line up outside grimy soup kitchens. On that Septemberday in Baltimore, Richard Byrd became tragically and irrevocably cut off from his family and society because a mental disability had rendered him vulnerable and invisible. A young journalist in Victorian London wrote: The hospitalis a refuge andresting-placefor hundreds, who but for suchinstitutionsmust die in the streets and doorways (7). The sketcheslimned by Dickens more than 150 yr ago have scarcely changed. The ED remains a refuge and resting place for the indigent and homeless,but perhaps it can also be an avenue to a life of dignity for some portion of this fragile population.
REFERENCES 1. Irwin R. The Evening Sun. 8 October 1988. 2. Bamsky S, Alvarez R. The Baltimore Sun. 8 October 1988. 3. The Evening Sun. 28 October 1988. 4. Hibbs JR, Benner L, Klugman L, SpencerR, Macchia I, Mellinger AK, Fife D. Mortality in a cohort of homelessadults in Philadelphia. N Engl J Med. 1994;331:304-9.
5. Vladeck BC, Altman D, Bassuk EL, Breakey WR, Fischer AA, Halpem CR, Lave JR, Meyer JA, Smith G , Stark L, Stark N, Turck M, Wolfe P. Homelessness,health and human needs.Washington, DC: National Academy Press; 1988. 6. Faulkner W. Nobel address.Stockholm; 10 December 1950. 7. Dickens C. Sketchesby Boz. Oxford: Oxford University Press;1836.
ELSEVIER
PlItJm36479(~3
Emerylency Forum ANONYMOUS
DEMISE: MORTALITY Robin Cuddy,
IN THE HOMELESS
MD, MPH
Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland Reprint Address: Robin Cuddy, MD, MPH, Department of Emergency Medicine, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287
Among the homelesswho died in Baltimore in 1988 was the son of the Antarctic explorer, Admiral Richard Byrd. On September 13, the 6%yr-old Richard Byrd, Jr., Beacon Hill resident and Harvard graduate, had boarded an Amtrak train in Boston and was bound for Washington, DC to attend a National Geographic reception honoring his father. He never reached his destination. His body, clothed in a green workman’s uniform and one shoe,was found 3 wk later in a vacant warehousein Baltimore (1). The custodian who found him recalls having run him off the property a few days earlier (2). The state medical examiner determined that Richard Byrd, Jr., died of malnutrition and dehydration. He also confirmed that Byrd suffered from Alxheimer’s disease. “In his confused state, he could have appearedto be intoxicated,” said John Smialek, chief medical examiner, to an Evening Sun qmter (3). “He wasn’t able to seekhelp.” Byrd apparently got off the tram in Baltimore and wandered 1.5 miles down the tracks to the empty industrial buildings, where he spent the last days of his life. Hibbs et al. (4) recently determined the mortality rate of a cohort of homeless adults in Philadelphia. They found that the age-adjustedmortality rate for the homeless cohort was nearly four times that of Philadelphia’s general population. Injury was the leading cause of death. They pointed out that the opportunities for preventive care in this population are limited. What are the mot causesof homelessness?A report issued by the Institute of Medicine concluded that the primary factors causing the recent increase in the numbers of homeless persons are “the low-income housing
shortage, changing economic trends, inadequateincome supports and the deinstitutionalization of mentally ill patients” (5). What can an emergencyphysician do in the face of poverty, substance abuse, mental illness, and joblessness? At the very least, we can be role models to our staff and stndems and treat the homeless with care and respect. In most cases,we cannot provide shelter for the night, but we can be aware of the resources in our communities that might offer needed services-detox centers, respite units, shelters, and primary and psychiatric care. Referral cards that list social agencies,community mental health centers, detox centers,and shelters could be kept in the emergency department (ED) and given out to homelesspersonswho may not be aware of community resources. Multidisciplinary hospital task forces with representatives from emergency medicine, internal medicine, surgery, psychiatry, hospital administration, and social work could work with community groups and provide specific recommendationsto coordinate and improve the care of homelesspersonsthroughout the hospital. What else can be done to assist the indigent and homeless?We have all encounteredthe homelessin our EDs. I also have worked with patients at Health Care for the Homelessin Baltimore and Boston. I am not entirely certain of the reason that I came upon this work, but I know that it has enabled me to meet some extraordinary people whom I cannot quite forget. So I would suggestto the emergencyphysician that he or she bear witness. We can write about our experienceswith the homeless and
RFKENEX3 March 1995; PENAL SUBMISSION xncmvno: 29 August 19%; ACCIFIXD:1 October 1996 373
the indigent-in the journals, the newspapers,short stories, or to our local congressman.In the words of William Faulkner, it is our “privilege to help man endure by lifting his heart, by reminding him of the courage and honor and hope and pride and compassion and pity and sacrifice which have been the glory of his past.” The voice of the writer “need not merely be the record of man, it can be one of his props, the pillars to help him endure and prevail” (6). The homelesswoman lying on a stretcher in your ED and the man curled up on the sidewalk as you try to get to your car cast somereflection on who we are as individuals and as a nation. Write about them. Richard Byrd is probably not representative of the homeless who live and die in Baltimore and elsewhere. News of his death captured national headlines. The deaths of most homelesspersons are recorded only in a thin file in the medical examiner’s office. In some fun-
damental ways, however, perhaps Byrd is not unlike many of the homeless who wander the streets, sleep in doorways and ED waiting rooms, and line up outside grimy soup kitchens. On that Septemberday in Baltimore, Richard Byrd became tragically and irrevocably cut off from his family and society because a mental disability had rendered him vulnerable and invisible. A young journalist in Victorian London wrote: The hospitalis a refuge andresting-placefor hundreds, who but for suchinstitutionsmust die in the streets and doorways (7). The sketcheslimned by Dickens more than 150 yr ago have scarcely changed. The ED remains a refuge and resting place for the indigent and homeless,but perhaps it can also be an avenue to a life of dignity for some portion of this fragile population.
REFERENCES 1. Irwin R. The Evening Sun. 8 October 1988. 2. Bamsky S, Alvarez R. The Baltimore Sun. 8 October 1988. 3. The Evening Sun. 28 October 1988. 4. Hibbs JR, Benner L, Klugman L, SpencerR, Macchia I, Mellinger AK, Fife D. Mortality in a cohort of homelessadults in Philadelphia. N Engl J Med. 1994;331:304-9.
5. Vladeck BC, Altman D, Bassuk EL, Breakey WR, Fischer AA, Halpem CR, Lave JR, Meyer JA, Smith G , Stark L, Stark N, Turck M, Wolfe P. Homelessness,health and human needs.Washington, DC: National Academy Press; 1988. 6. Faulkner W. Nobel address.Stockholm; 10 December 1950. 7. Dickens C. Sketchesby Boz. Oxford: Oxford University Press;1836.