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By Susan M. Lankford

Photography: Susan M. Lankford and Polly L. Smith

Volume 2, Issue 1, Summer 2013, Cancer InCytes Magazine

The homeless population of America has changed over the years.  And with it, the healthcare needs of these people.  Yet, the municipal response to homelessness has not changed, costing tax-payers hundreds of millions of dollars each year to cover treatments for cancer, drug addictions, and mental health problems for the homeless.  The root cause needs to be addressed.  The approach needs to change.

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Homeless styles and behaviors have changed. Health conditions of the homeless today have evolved, as a third generation of drug and alcohol victims has arrived with mental health complications. A medical professional finds himself asking, “Was this person on drugs before he presented with severe depression, hypertension or diabetes, or did he take drugs to numb his depression, thereby worsening other health issues?”


Homeless people today are easily brushed off as victims of the economy, post-war vets with PTSD or those with addictions and health conditions taxing their capabilities to hold a job—lost souls living off the streets.


Do we have a clear understanding of the issues that plague the homeless today? They are not the same wily, creative panhandlers rushing about on crack as the homeless of 20 years ago. Today’s homeless people are chronically ill individuals costing society millions each year, with multiple expensive emergency room (ER) visits, yet no connection to follow-up care.


James Dunford, MD, the Emergency Medical Services director in San Diego, describes a female in her early 50s with many trips to the ER for alcohol intoxication treatment, released repeatedly on her own recognizance. It turns out she had been beaten so badly over the years that the frontal lobe of her brain was missing. “She was in the ER 131 times over 11 months costing $180,000,” Dunford reports, “but the ER did not reveal this outrageous condition.” It took a CT scan during a neuropsychiatric exam to determine why she had the markings of a craniotomy. CT scans are not regular tools of detection for intoxication. After years of ER trips for drunkeness, trips in and out of jails and sleeping inside restaurants, collapsed over table tops, costing literally millions of dollars, she had not previously been tested for cognitive impairment.


The article FALLING OFF THE EDGE, in the Feb. 20, 2013 issue of the Journal of the American Medical Association, reports that there is a clear cognitive decline among the homeless today. “It’s a condition that is hard to diagnose, particularly when intoxication is involved,” Dunford says. “Neuropsych testing is not regularly offered in ERs for homeless presenting with head injuries, alcohol intoxication, unattended sores on legs or confusion. We sober up the individual, give three days of antibiotics and trust this individual will access another follow-up route toward health. No one can detect cognitive decline.”


The health conditions of the homeless in America are vastly different from those of the homeless in the 1990s. Crack and meth drove the addiction/prostitution cycle for many women along with hardcore recycling for many homeless men. Today it is apparent that mental health issues are present, complicated by alcohol and/or drug abuse, regardless of which came before the other. Addictions and mental illness are not a recipe for success. Building more shelters will not answer the problem either. It is commonplace that particular groups of homeless will not live in a shelter. They choose the outdoor life over the rules and regulations of a provider.


Jeffrey Brenner, MD, founder of Camden Coalition of Healthcare Providers, grew discouraged with the growing healthcare costs, which have become unsustainable for businesses and residents. He tracked Camden’s most vulnerable homeless and other marginal populations to evaluate the crisis—one that seemed to have no answers.


“When an uninsured patient gets cancer that we could have prevented, we all pay the bill,” he observes. “When an uninsured child is hospitalized for asthma, we all pay the price.”


He began to study the proximities of the most vulnerable homeless, the number of 9-1-1 calls and the trips to local hospitals. He discovered that 1% of the individuals in one multi-story nursing home necessitated 30% of the total 9-1-1 calls and were therefore targeted for multiple ER visits.


“Asthma and diabetes visits in the ER are not the greatest opportunity to treat chronic mentally ill,” Brenner adds. “The most expensive people are getting terrible care. How would the medical establishment react if suddenly the most expensive and lucrative patients started costing half of what they do now? Beds and floors of hospitals would close down.”


So who are these people today? With smart phone cameras and recorders, I set out to interview many of the homeless along the San Diego harbor, where the USS Midway has been permanently positioned as a museum.


Chris is a homeless female in her late 40s who lives by the ship. “That was my home for seven years, she says, pointing to the ship. “I was a cook.” Asked why she isn’t working inside the museum/ship, Chris explained that she is on disability and can’t hold down a job. She collects SSI every month. Taking a swig from her Coca Cola bottle at 10 a.m., she admits, “Yeah, I got some vodka in here. Need a little bit throughout the day.”


Chris also tells me that two of the guys I had spoken to in the group the week before were gone. “Joe’s in jail and Pete’s in the hospital. Yeah, he was picked up here on the ground… heart? Stoned. He can’t hold his booze.”


Scott, a 36-year-old schizophrenic shares, “I was four when my baby brother died. My mother was bisexual at the time, so my father wasn’t there. I was taken away by Children and Family Services because they thought it was my mother’s fault. They were wrong. From there it was a rollercoaster. I’m 34; I can deal with the medicines.” He said he lives in the Metro low-income housing, but he can’t sleep inside at night. “Just can’t do that.”


Deborah says, “I just got out of federal prison; did a year. I been arrested 80 times in my life for almost anything: drugs, alcohol, stealing. Never in jails have I been offered any help until the last judge asked for my history and only gave me a year.”


How did you get that big scar on your arm?


“I got a ride with someone and was attacked. I got away from the guy when he tried to rape me.”


You got in a car with someone you didn’t know? (Nods.)


You mentioned not being close to your family. Is there a reason? (Nods.)


Were you molested as a child? (Nods.)


A family member?


She says it was her mother’s twin brother. “Later on, my stepbrother, my grandfather and my uncle. Trouble is, my mother knew about it. I was the youngest, and they did the same thing with my sister. My grandfather abused my mother when she was young. Now I just want to stay alone, because I’m not good to anybody.”


One-third of the homeless today are over the age of 50, compared with only 11% in 1990. Associated with aging are the rising rates of cognitive impairment and dementia.


Several years back, San Diego started the Serial Inebriate Program (SIP) [1] in which 10 chronic alcoholics were tracked back and forth to the ER. It was discovered that those 10 individuals cost the county $1.5 million for six months of ER visits.


With SIP designed to detect the most vulnerable homeless alcoholics, costing millions annually, Project 25 [2] has now been added to track the most vulnerable chronically ill homeless who are not alcoholics. This is a three-year pilot program that provides permanent housing, support services and discharge to 25 or more chronic homeless people who frequently use city of San Diego resources.


Permanent housing for the most chronic homeless population is being proposed in many cities. Without immediate health interventions and follow-up, this may be an expensive route to “just getting them off the streets.” In San Diego, Connections Housing [3] has recently opened a new collaborative operation for permanent and transitional housing under the same roof. Family Health Center is located within the structure. Counseling and job training skills are incorporated into the individual profiles, thus creating a networking platform for the 225 homeless members in Connections Housing.


Susan Madden Lankford is a photojournalist, author and documentary film producer. She serves on the editorial board of Cancer InCytes Magazine. 




1. San Diego Serial Inebriate Program website:


2. Project 25:


3. Connections Housing.


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