Terrence Brown was homeless for about 14 months just over a year ago. He also has Type 2 diabetes.
It was a constant effort managing these two realities. Being diabetic meant having to adhere to a strict routine in his diet and medication. Being homeless meant that maintaining routines was sometimes impossible.
While he was homeless, Brown tried to take his insulin or Metformin dose with his morning coffee so that he wouldn’t forget, but he said the lack of routine made it difficult. Many days he would realize late in the afternoon that he’d forgotten to take his morning meds.
It was especially difficult to wait all day to eat one meal at night. While it is always possible to get access to a meal program in Seattle, he said, it doesn’t always work for the tightly controlled eating schedule most diabetics must adhere to.
Many ‘feeds’ are dinnertime, and a homeless person wandering the city with no money can’t exactly pop in to a 7-11 to grab an energy bar when their blood sugar drops.
“A lot of those places try very hard and some of them do a great job,” he said of the food programs he frequented. “But you may need to eat at another time of day, or you don’t have bus money to get to the feeds or whatever. It’s not unusual that people put the housing and food higher on their list than any medical problems.”
Managing diabetes is a complicated affair. When someone receives a diagnosis of diabetes, either type I or type II, it changes everything, from food choices to free time. Even in the context of a stable home, a steady income and good mental health, diabetes is a challenge. Pair that challenge with the complications of homelessness, and diabetics have a recipe for disaster.
Dr. Richard Waters, a family practitioner at Neighborcare Health’s Boren Clinic, one of its three homeless-focused clinics, said that the barriers to getting proper care for diabetics are often steep.
“For some it is a survival thing,” he says. “Where am I going to eat? Where am I going to sleep? Priorities that can take precedence over the understandably lower priorities of ‘did I take my medication?’”
Accessing care is challenging for homeless diabetics, Waters said. Despite programs like Neighborcare’s homeless clinics, which offer sliding-scale or free healthcare to homeless and formerly homeless populations, people often struggle to sign up for health insurance, find a clinic, keep an appointment and get transportation.
There are also substance abuse and mental health issues to deal with, which are often more prevalent among homeless populations. Treating these other issues often makes diabetes care, which requires coordinated and consistent management, much more difficult for homeless people.
“I was very impressed at how busy it is being homeless,” he said. “You don’t have a car, and you’re trying to get to a bunch of different social service appointments.”
Brown knew that housing offered the best chance at managing his diabetes.
“I kept saying, ‘All I need is housing, all I need is housing, all I need is housing,’” he said. Even though he had good access to care, as well as diabetes medicines and supplies, living on the street made managing his blood sugar extremely difficult. Housing makes all the difference, he says.
“There are tremendous barriers,” Waters said. “It doesn’t mean that they’re not surmountable. Of course, if we can get people out [of homelessness] that’s going to be better for their health.”
On the streets, diabetics have trouble accessing food, making it to their appointments, getting medication, keeping identification and hanging on to their supplies and meds despite ongoing sweeps of unauthorized encampments.
The food was a particular challenge for Brown. Without access to a kitchen, his food options were few and far between. Most of what he found to eat when he was homeless was heavy in carbs: filling but not ideal for folks with diabetes.
“Most of it isn’t good for diabetics,” he said of the food he finds at food banks and meal programs. “It’s fatty, it’s cakes, it’s candies. Breads and stuff that we’re not supposed to eat.”
Lois Van Ottingham, a nurse at Neighborcare’s Ballard Homeless Clinic, said a lot of people lose their IDs, which can create another barrier to health care. The Ballard clinic will provide care whether a homeless person has ID or not.
“We have a number of people that don’t have ID,” she said. “We would see somebody anyway. Even if they didn’t have ID, we’d take the information that they have, especially if they needed to be treated that day.”
Often, she refers people to the nearby Ballard Food Bank, which she praises as an excellent service for homeless people looking to restore lost identification. Also, Neighborcare does not deny active drug users, even if they refuse rehab, which can otherwise keep some homeless people from accessing medical services.
In addition to the struggles with food, there is the very tangible risk of losing one’s medicine. Brown says he lost his several times, twice to theft and once because he lost track of his bag for a moment — it was, of course, gone when he returned.
“Everywhere you go you’ve gotta watch your backpack,” he said, adding that even at meals he had to guard his possessions, keeping his bag clenched between his knees while he ate. “Even when you’re at a feed, they’ll steal from you there. The thievery is very abundant.”
Diabetics can also lose crucial supplies in sweeps. The city has said that any used needle is considered a biohazard, whether it is for insulin or illegal drugs, and that, during cleanups of unauthorized encampments, a tent with a used needle out in the open would be thrown out in its entirety.
“I think it’s fucking ridiculous that police and parks workers throw away people’s stuff with valuable medicine in there that they sometimes had to borrow, beg and steal to get,” said Shilo Murphy, director of the People’s Harm Reduction Alliance, a needle exchange in the University District. “It is fucking unconscionable to throw people’s medicine away because it’s in their bag. People are barely surviving and we’re going to worsen their health care because we’re angry about their poverty and their tent camping.”
He said he has heard numerous stories of cleanup workers tossing insulin needles. A massive stack of insulin needle boxes dominate Murphy’s office. They are the same ones he gives out to active heroin users.
Homeless diabetics, he said, are often painted with the same brush as active heroin users, which can make their lives more difficult in subtle ways.
“People look at you and think you’re a drug user,” Murphy says.
Brown agreed, saying that public judgment was a constant thing.
“Even today, if I don’t do it in the privacy of my own home, people are looking, like, ‘What’s he shooting up?’” Brown said. Being seen with needles, even if they are for insulin, could get a homeless person branded as a junkie, denying them access to otherwise friendly public restrooms or causing the occasional trickle of monetary goodwill to dry up.
Despite the difficulties many face, Waters says good care is possible.
“There are also success stories, individuals who have a fantastic ability — more so than many of us — being able to navigate the challenges that come with being homeless while using insulin and keeping blood sugars under control,” he said. Indeed, Brown is one of them. A lot of things went right for Brown, but the most important one, he said, was having people treat him like a human being.
“Every time I come in here,” he said of Neighborcare, “I’m in tears, man. Nobody cared about me, but they did. This place did care about me.”
Asked if that caring translated to noticeably improved blood sugar numbers, he agreed vehemently.
“Certainly!” he said, beaming widely. “I’m right at 100 nowadays.”