About the Author:

As a second-year medical student, Addie Netsanet serves as the American Medical Association (AMA) student Delegate for the University of Colorado School of Medicine, and the President of the Colorado Chapter of the Student National Medical Association (SNMA). She envisioned leading advocacy work that limited identity-based advocacy and encouraged a need-based and community-based advocacy approach. Addie started the CU Anschutz SUNS Clinic (Supporting our Unhoused Neighbors through Service) along with mentors Dr. Rene Kafka and Dr. Steven Lowenstein. Addie hopes to expand her advocacy work throughout her medical career. 
 
Healthcare workers constantly juggle the responsibilities of administering allopathic treatments while still promoting the importance of preventive healthcare. Preventive care is especially challenging to promote within in marginalized and medically underserved communities, where resources for maintaining adequate health and preventing exacerbations of chronic conditions are scarce. Promoting preventive healthcare  in underserved populations requires investments at individual, local, and national levels, with emphases in community engagement and building community-wide trust in the organized healthcare system. In Stephen Covey’s book The 7 Habits of Highly Effective People, Covey describes his seventh and final habit with the analogy “sharpen the saw.” This metaphor describes the task of trying to cut an object with a dull saw without first taking the time to sharpen it. Then, he explains how it is more effective to approach this challenge by first investing the time and effort to sharpen the saw to ultimately perform this task more effectively. Sharpening the saw of our healthcare system requires us to assess structural inefficiencies that are often ignored in the interest of continuing with work as usual. It entails building trust within communities  outside of the formal clinical space, and letting communities lead the conversation by telling us what they need most. The rise of the novel COVID-19 pandemic especially highlighted the incredible and disproportionate susceptibilities to decompensated health outcomes in historically underserved communities, including communities of color, communities with limited socioeconomic resources, and people experiencing homelessness.

People experiencing homelessness have unique vulnerabilities; this population’s health outcomes can be significantly improved by community resources and local support. Approximately 5,317 of our neighbors in the Aurora/Denver area are homeless on any given night, which makes up nearly half of the estimated 10,857 persons experiencing homelessness in Colorado as a whole. In this population, the socioeconomic and environmental barriers to maintaining adequate health can seem insurmountable. ² High proportions of people in this community carry the burdens of untreated physical and mental illnesses every day. Various social factors often cause conditions that are usually considered to be “primary care-responsive”  to become medical emergencies instead. Consequently, it is not surprising that people experiencing homelessness are more frequent users of Emergency Departments compared to the housed population, a pattern that could be ameliorated with enhanced access to preventive care and local support. Up to 80% of Emergency Department visits made by people experiencing homelessness are for exacerbated presentations of illnesses that could have been addressed and maintained with preventive care.¹ People experiencing homelessness face multiple barriers to accessing medical care, including mistrust in the organized healthcare system, the high burdens on personal health resulting from a nomadic lifestyle, and having less access to clean spaces to maintain appropriate wound care or personal hygiene.⁴ Simple interventions such as foot care, wound care, access to clean needles, and protection from cold climates can prevent someone who is experiencing homelessness from presenting to emergency services in a decompensated medical state that requires an extreme, life-altering intervention, like a foot amputation.  

These emergency crises come at a high public cost. According to the US National Library of Medicine, homeless individuals visit an Emergency Department an average of 5 times per year.  With the cost of each visit averaging $3,700, this amounts to about $18,500 per homeless individual per year.⁵  At least part of this financial burden falls on the public sector. The Journal of the American Podiatric Medical Association emphasizes the danger posed by the combination of high-risk and low-resource factors in the homeless population when it comes to seeking preventative care for foot pathologies. “It is important in the realm of public health to keep lower-extremity health in mind because it plays an important role in preventing the spread of infection and lowering the social economic burden.”.³ Common ailments within the homeless population, like foot pathologies arising from various underlying conditions, can incapacitate these individuals and prevent them from accessing resources to help them improve their health and ultimately escape homelessness. Improving care for this population with special consideration for their unique medical and social needs is a vital and burgeoning topic in medicine with the potential to significantly impact our unhoused neighbors and our healthcare system.

It’s time to sharpen the saw.  The CU Anschutz SUNS Clinic (Supporting our Unhoused Neighbors through Service) at the Aurora Day Resource Center will provide preventive health interventions and resources to reduce the frequency of exacerbated pathologies and help build trust in the medical system among the homeless community in Aurora, Colorado. We hope to increase use of local free clinics and reduce the need for Emergency Department visits at UCHealth from medical conditions that were exacerbated due to hesitance in visiting a medical provider, lack of knowledge about local free clinic resources, or specifically from foot conditions that were not properly cared for before progressing to a pathologic state. Finally, we hope to foster civic engagement, empathy, optimism, and a sense of altruism among CU Anschutz students and faculty, so they feel empowered to make positive impacts within their community and uplift historically vulnerable, medically underserved populations.

Preventive interventions have the potential to improve health outcomes in communities, if we take the time to sharpen the saw. When we pause to analyze and address patterns of a sub-optimal and often ineffective healthcare  system, and when we work collaboratively with our community partners, we can improve our patients’ individual outcomes, help build a healthier and more resilient community and  enhance the reach of the healthcare system, in service to our neighbors.

1. Green Doors. The cost of homelessness facts. www.greendoors.org/facts/cost.php Accessed January 5, 2011.
2. Davies, A., & Wood, L. J. (2018). Homeless health care: meeting the challenges of providing primary care. The Medical journal of Australia, 209(5), 230–234. https://doi.org/10.5694/mja17.01264
3. Chen, Bright, et al. “‘Step Up for Foot Care” Addressing Podiatric Care Needs in a Sample Homeless Population. Journal of the American Podiatric Medical Association, Allen Press, 1 May 2014, https://meridian.allenpress.com/japma/article-abstract/104/3/269/184860/Step-Up-for-Foot-Care-Addressing-Podiatric-Care.
4. The Council of Economic Advisers. The State of Homelessness in America. Executive Summary September 2019. https://www.nhipdata.org/local/upload/file/The-State-of-Homelessness-in-America.pdf
5. Garrett DG. The business case for ending homelessness: having a home improves health, reduces healthcare utilization and costs. Am Health Drug Benefits. 2012;5(1):17-19.