Overlooked: When health care is unreachable for those who need it most

I am about to enter a pharmacy when I see her. She's sitting on the cold pavement.

Do I make eye contact? I don't think she recognises me.

"Can you spare some change?"

Her hair is cut shorter. Her clothes are baggier. She is fading into her jacket. Her nose appears bruised. She glances away and asks the next person.

I worry when I see her. I worry when I don't see her. Sometimes she looks like she's doing OK, but I never really know.

She is not one specific patient, but she could be any one of my patients who go unseen. Passed by all of us.

Offering them help sets in motion a complex process, like opening a wooden nesting doll. Removing one doll leads to another and another, until you reach the innermost doll — the baby.

That final doll can represent a lot of things, from trauma and lack of safe shelter to substance use and mental illness, coupled with the systemic failures that can shape most of our lives.

I work as a general adult psychiatrist with the Flexible Assertive Community Treatment teams in St. John's, helping people living with severe mental illness.

I cannot praise my co-workers enough for what they do each day: home visits, administering medications and sourcing clean clothes, hygiene products and food hampers to people in our community who don't have anywhere else to turn.

They work tirelessly assisting the most vulnerable people, and yet there is always more that can be done. Their needs are complex, and they may have a combination of medical and substance use issues.

The system itself, though, has many frustrating challenges.

Chronically unseen

I check patient medical charts.

Visits to the emergency department are frequent because many of them don't have a primary care provider, and the ER is their only source of health care.

They may show up for any number of reasons, but I won't know the outcome because on their chart someone has written LWBS.

Left without being seen.

They were most likely triaged but did not, or could not, wait to see the emergency physician. They carry their medical conditions with them, from tooth infections to respiratory illnesses, high blood pressure and chronic pain.

If a society is a reflection of how we treat and care for the most vulnerable, then I know we can be doing much better.- Dr. Angelique Myles

The ER represents a costly and resource-intensive environment that is inefficient at providing support for people battling both chronic health conditions and poor social circumstances.

The ongoing need for more preventative action in the community is critical.

I am going out for supper to an upscale restaurant. As I cross the street he walks past me.

"Can you spare some change?"

This time I look him in the eyes. I tell him that I would like to see him in clinic, and we are worried about him. He smiles and says "I'll try, I know."

We part ways. I head into the restaurant.

I feel upset with myself. The contrast could not be more evident. I will be eating food plated with tweezers and tongs and garnishing brushes, while he is wandering the cold streets.

We are the privileged treating the underprivileged.

She has no phone. She has broken three phones. She has no more phones to break. 

Our most difficult-to-treat patients are the hardest to find. They live in the most expensive for-profit shelter systems that don't represent a long-term solution to homelessness. We may need to contact them through a family member who has a phone.

They don't show up for appointments because they can't show up. If they do show up, we can provide support, give them their medications and help with food hampers, housing issues, social isolation and filling out the many forms often needed to apply for more financial aid or updated health cards, which they need to continue receiving medication and housing coverage.

How can I counsel patients about lifestyle changes such as eating a healthy diet, getting adequate sleep and exercising when these are far from their main issues? 

We need to address the social determinants of health. In other words, the non-medical factors such as safe housing, food security, transportation and literacy skills that influence our daily lives.

This would allow us to progress toward health equity, where everyone has the same opportunities to be healthy regardless of their social or economic circumstances.

If a society is a reflection of how we treat and care for the most vulnerable, then I know we can be doing much better.

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