Some street lessons from the

International Street Medicine Symposium Dublin 10 October 2014

Igor van Laere MD PhD, Wendy Broeren RN, Marcel Slockers MD, Fifi Groenendijk MD

What?

• Pathways into the International Street Medicine Community

• Street Medicine Group the Netherlands

• Some street medicine lessons to share

Becoming a doctor for the homeless starts at home

3 Poverty and Health

April 1969

Amsterdam Care for the Poor

• 1901 Municipal Health Service (GGD) • doctors for the poor

• 1930-1960 Mental Hygiene • social psychiatry (prof.dr.Querido)

• 1970-2002 Drug department • social addiction care

• 2002- community mental health dept • social medical care GGD Valckenierstraat

9 GGD Ambulant Medical Team Amsterdam 1997-2010

10

Chair project

Salvation Army Shelter

Soup Bus Emergency Shelter Feantsa Homelessness & Health Workshop Warsaw Poland March 2006 Doctors for Homeless Workshop Amsterdam October 2006 Doctors for Homeless workshop Amsterdam 27 October 2006

Angela Jones, Jill Roncarati, Igor van Laere, Jim Withers www.icuh2006.com 2nd International Street Medicine Symposium Santa Barbara USA, 15 November 2006 European Network Homeless Health Workers (ENHW) initative FEANTSA Brussels January 2007

Igor van Laere Freek Spinnenwijn

Dearbhal Murphy

Dr.Angela Jones Dr. Maria Luisa Marin i Puig Associacio Rauxa Barcelona February 2007 European Network of Homeless Health Workers launch Oxford University 24 September 2007 3rd International Street Medicine Symposium Houston USA, November 2007

Night round with dr Jim Withers Operation Safety Net, Pittsburgh November 2007 People and dwellings Netherlands 2013

• 16.8 m inhabitants • 7.5 m households • 7.3 m dwellings (42% social rent) • 1.3 m single male households • 0.2 m stay in residential facilities • 1.6 m receive social welfare

financial debts and evictions

• 961,000 households at risk of financial problems • 359,000 problematic and no financial support • 172,000 problematic and financial support • 22,000 court orders for eviction • 7,000 households evicted

• 66,000 Shelter users 2013 (50,000 in 2009) • 27,000 Homeless people 2013 (23,000 in 2010)

Social rent evictions in the Netherlands

25000

20000

15000

court order eviction 10000

5000

0 2006 2007 2008 2009 2010 2011 2012 2013 Pathways into homelessness

• Homeless after eviction study Amsterdam 2002 – Outreach interviews recently homeless people in the streets, drop in centers and emergency shelters (van Laere & de Wit, 2005; van Laere et al. BMC Public Health 2009)

• Urban social exclusion research Amsterdam, , , 2012 – Outreach interviews shelter users during winter cold emergency response 2011/2012 (Buster et al. G-4 USER study, 2012)

Demografics

2002 2012 Demografics N=120 N=567 male 88% 90% age 38 y 41 y Dutch 48% 27% Surinam/Antiles 20% 12% EU/non-EU 31% 53% Last housing

2002 2012 2012 A'dam A'dam 4 Big cities last housing N=120 N=96 N=291 rent house 65% 52% 49% with others 23% 32% 36% residential 9% 11% 11% other 3% 4% 4% How homeless?

2002 2012 2012

A'dam A'dam 4 Big cities how homeless N=109 N=97 n=286 eviction 38% 53% 47% conflict 35% 29% 30% residential 6% 8% 8% from abroad 2% 10% 8% other 20% 0 7% Evictions Amsterdam 1600

1400

1200

1000

800 Evictions Amsterdam

600

400

200

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Intellectual disability (ID) in homeless people in the Netherlands N=387 in the 4 big cities • 29.5% suspected ID • higher mean age, more likely to be male and in the lowest category of education Suspected ID related to • general psychological distress (OR = 1.56, p<0.05) • somatization (OR = 1.84, p<0.01) • depression (OR = 1.58, p<0.05) • substance dependence (OR = 1.88, p<0.05).

Van Straaten B et al. PLoS ONE 2014 9th International Street Medicine Symposium Boston USA 23 October 2013 10th International street medicine symposium Dublin Ireland, October 2014 Street Medicine Group the Netherlands

• Meetings in Amsterdam, , Rotterdam, Utrecht

• June 2014 formal group established

• Sponsor

• Promote and strengthen street medicine lessons: practice, education, research and policy making

• Find and meet street medicine workers (inter)nationally Recent actions Street Medicine Group

• Quarterly meetings • Reach out and find peers in other cities • Collect data on national homeless health care workers, practice and clients • Organize first national street medicine symposium (4 November 2014)

Questionnaire

Questions • Who are the street medicine workers? • How is their practice organized and financed? • Who are their clients?

Methods • Share online questionnaire within own networks across the country

Results Dutch street medicine pilot • 122 workers emailed • 57 respondents from 18 cities – Rotterdam 13 – 6 – Utrecht 8 – Nijmegen 5 – Amsterdam 4 – 3 – Den Bosch 3 – 2 – The Hague 1

Street medicine workers

Profession (n=56) doctor 21 38% nurse 33 59% other 2 4% Organization (n=56) (outreach) GP practice 11 20% Municipal Health Service (GGD) 29 52% Mental Health Service 6 11% Addiction Health Service 1 2% Assertive outreach team 3 5% Shelter facilities 5 9% Nursing home elderly 1 2% Workers characteristics

N=57 N % male 25 44% female 32 56% year of birth 1942-1982 year of diploma 1966-2008 year start homeless health care 1961-2013 specific training 24 42% teaching others on homelessness health 17 30% conducting research homelessness health 16 28% wish involvement Street Medicine Group 47 82% wish symposium Steet Medicine 46 81% Homeless healthcare team partners

N=59 regular GP 21 33% social medicine doctor (GGD) 14 22% psychiatrist 13 21% social nurse 28 44% social mental health nurse 21 33% nurse practitionar 12 19% social workers 21 33% Access to specific healthcare for homeless people care provision occasions (n=37) N % < 1x per week 5 14% 1x per week 15 41% 2-5 x per week 15 41% 6-10x per week 2 5% hours per week (n=37) 1-9 hours 20 54% 10-16 hours 5 14% 20-60 hours 4 11% type of location (n=56) day center 21 38% emergency shelter 20 36% residential shelter 10 18% respite care facility 8 14% own GP practice 10 18% streets 6 11% Funding Healthcare for the homeless Programs city council (n=30) N 60 euro 1 5,000-10,000 euro 3 1,1 million euro 1 private sponsors (n=28) 12 euro 1 1,000-3,000 euro 2 Health Insurance company (n=37) 10 rate per consultation 9 euro 4 17-30 euro 4 50-70 euro 2 Reach of Homeless Healthcare Practices

unique homeless persons per year 2011-2013 (n=7) 15-71 persons 4 320 persons (estimation) 1 700-950 persons (estimation) 1 homeless persons reached (n=9) 2011 1209 2012 1414 2013 1500 Some Dutch Street Lessons

• Street medicine lessons are valuable for public health, housing and social welfare: practice, education, research and policies

• Prevention: focus on HOW people become homeless

• Beware of intellectual disability among (nearly) homeless people Thank you

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