I was on call in the hospital last winter when I received notification of a new admission, “30-year-old homeless woman admitted to ICU for DKA.”
“Leslie,” as I’ll call her, was admitted to the intensive care unit for diabetic ketoacidosis, a condition that occurs in diabetics when blood sugar levels are dangerously high. She was critically ill, with acid and sugar levels in her blood so high that she was in a coma.
A Muni driver had found her in the back of the bus and called 911. Her records showed that she had been admitted to emergency rooms around the city multiple times for this same problem.
It was relatively easy to stabilize her medically. Tempering the social ills that prompted her admission was a greater challenge. She had fallen upon hard times and lost her home. As a Type 1 diabetic, she needed to take regular insulin injections to stay out of the hospital. However, all her possessions kept getting stolen.
Leslie, a slight, thin woman, felt unsafe among the predominantly male homeless population, who would frequently heckle and threaten her. I asked her why she didn’t go to a shelter, and she said that it was much worse there. The moment she closed her eyes to sleep, she would get robbed, again and again. Her insulin and lifeblood would get lost each time. Through tears of hopelessness, she expressed fears that she would die the next time this happened. I could not disagree.
Social workers had tried to help, but the best they could offer was to return to a shelter. In my eyes, discharging her to the street felt complicit in her impending death. It felt morally reprehensible, and yet our social workers told me I might not have a choice.
Vulnerable groups, such as women, the disabled, chronically ill or elderly, face additional dangers, which make shelters more treacherous than sleeping on the streets. An elderly patient told me it was a relief to sleep under the stars because she had been assaulted in a shelter. On another occasion, she escaped a rape attempt in the bathroom only to be forced to sleep through the night in the same room as her perpetrator. The spaces intended to help instead became spaces where they were further victimized.
A study from San Francisco General Hospital on homeless women showed that 27 percent of the homeless were women; 60 percent of the homeless women experienced some form of physical, emotional or sexual abuse. The majority of the women had endured emotional violence while approximately a third had experienced physical violence and a similar number experienced sexual violence.
Homelessness remains one of the greatest threats to health. A study in the United Kingdom showed that the average life expectancy for a homeless person was 30 years lower than the general population, and another study showed that the risk of death was four to 31 times higher in homeless women than among women in general.
Efforts to improve homeless services in San Francisco should pay special attention to these vulnerable populations. This includes expanding women-only shelters and medical respite programs, which provide shelter and care for patients like Leslie. Medical respite programs in the city are in short supply. These are only temporary fixes to more long-term problems that require solutions such as housing policy reform, long-term drug rehab centers and supportive housing.
Funding is persistently inadequate, hampering efforts to provide homeless services. The average cost for a day in the hospital is $3,000 and significantly more for stays in the intensive care unit — a cost transferred onto taxpayers for the homeless and uninsured. Strengthening homeless services to prevent hospital admissions may not just be the right thing to do, but might also be cost saving.
Due to our social workers’ advocacy, we were able to find a place for Leslie in medical respite. This was such an unlikely outcome that our case manager called her our “Christmas miracle.” The security to take life-saving medications shouldn’t have to be a miracle.
In this case, we were able to safely discharge her, but all too often these women are not able to make it into appropriate support systems. In some of these cases, this is a matter of life or death.