Street medicine: caring for the pets of the homeless

Jon M. Geller The Street Dog Coalition, Fort Collins, CO

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The Homeless and Their Pets

There are 580,000 homeless individuals in the US as indicated by an annual count done in 2020,1 but other estimates put the number much higher.2 According to general observations and intermittent counts, approximately 10% of people experiencing homelessness have pets.3,4 Based on this estimate, 58,000 to 140,000 pets likely exist in the US that belong to owners who have no funds for veterinary care. The exact number is hard to ascertain because pet owners constitute a hidden subpopulation of those experiencing homelessness, oftentimes due to concerns about their pets being taken from them.5 Pet ownership among the homeless widely varies among regions, often influenced by weather conditions and opportunities to live outside. In Canada, 20% of those experiencing homelessness are estimated to have pets.6

Although some people question the need for those living on the street to have pets, as well as their suitability as pet owners, there is a growing understanding that pets may provide homeless individuals with a primary purpose for living.6 Indeed, some pets living on the street with their homeless owners may live better lives than homed pets. Continual contact of pets with their owners, active lifestyles, and continual socialization support this argument, but it is also clear that many homeless pet owners prioritize their pets’ needs over their own, as sociologist Leslie Irvine points out in her book My Dog Always Eats First.5 Williams and Hogg7 have observed similar circumstances in the UK.

A Story of Despair and Hope: Homeless Veterans and Their Pets

Sadly, between 30,000 and 40,000 homeless veterans populate the streets of the US.8 Many suffer from posttraumatic stress disorder (PTSD), depression, isolation, loneliness, and a sense of lost hope.8 Although veterans make up only 7% of the US population, they comprise 16% of all suicides, numbering between 20 and 22/d.9 Recent research10 has shown that pet companionship could be effective in lowering suicide rates of homeless veterans, but these veterans face the same barriers to pet ownership as other homeless individuals, including an inability to pay for veterinary care, pet food, or pet supplies as well as loss of access to needed services. Government programs, perhaps somewhat misdirected, place service dogs with housed veterans suffering from PTSD, but little consideration has been given to those who are homeless.

The Need for a One-Health Approach

Providing veterinary care to the pets of people living on the street cannot occur in a silo. Multiple studies have shown that people experiencing homelessness face significant challenges in terms of medical conditions, mental health, and substance abuse, which result in major shortening of life expectancy, especially for those who are not staying in homeless shelters. For example, a study11 of homelessness in Boston showed that an unsheltered person was 3 times as likely to die as someone staying in a shelter and 10 times as likely to die as someone from the general population. People living on the streets of Southern California have an average life expectancy of 42 to 52 years of age, compared with 78 years for individuals with homes.12 In addition, 38% of those experiencing homelessness have 2 or more major medical illnesses, 25% have severe mental illness, and at least 30% have a current drug-use disorder.12 A 2012 study13 showed that up to 80% of the chronically homeless had a history of traumatic brain injury. This points at the need for a collaborative one-health approach to care.

Access to Care: Transportation and Shelter

Access to care in veterinary medicine has been an important topic of discussion as the rate of increase in mean income in the US dips below the mean cost of a veterinary visit.14 AlignCare, a program being launched by the University of Tennessee’s Access to Veterinary Care Coalition, is creating a subsidy program for low-income earners to receive veterinary care from a network of providers.15 However, for people without housing or transportation, there is no safety net. Those with pets are often forced to sleep outside due to the restrictions on pets at most homeless shelters. An unpublished survey conducted by the author’s group—The Street Dog Coalition—in 2019 revealed that only a small percentage (6%) of homeless shelters in larger US cities are pet-friendly, with exceptions allowed for service animals. Efforts are underway to make domestic violence shelters for women pet-friendly as well, and the benefits of having pets staying with their owners in these settings are many. Oftentimes, women who are living on the street seek out the safety of a women’s shelter, where they can escape an abusive relationship.16

In addition, due to safety and liability concerns, public transportation in the US is also not pet-friendly, and apart from service dogs, most bus and subway systems allow only pets small enough to ride in a carrier under the seat. In a survey conducted by the author, information on public transportation policies for pets in the 50 largest US cities indicated that only 3 large cities allow all pets to ride on buses and subways as long as they are leashed. Seven cities do not allow any pets, other than service animals, to ride on public transportation. Thus, the inability to be able to get to a veterinary hospital, or even a mobile street clinic, is another major obstacle the pet-owning homeless population faces.

A pilot program is being developed by veterinary students, in conjunction with The Street Dog Coalition, that will allow pet owners to ride public transportation with their pets without creating a safety threat to other riders or pets.17 This program includes veterinary checks, behavioral assessments, and green-tagged cage muzzles as part of a proposed “Ticket to Ride” program, soon to be pilot tested in several US cities.

Pet owners who are unsheltered have few opportunities to participate in activities that will help them find jobs and housing or even find adequate health care. Job interviews, doctor visits, free meals, and housing applications become problematic when owners must bring their pets with them because they have nowhere else to temporarily keep them. Programs that will partially subsidize the cost of doggie day care for homeless pet owners are being developed, including one in Fort Collins, Colorado, that allows 2 free vouchers for daycare/wk. For longer-term solutions, such as when an unsheltered pet owner is hospitalized, admitted to an addiction treatment center, or jailed, foster programs can be developed to provide pet care when these facilities are not pet-friendly, which, in the author’s experience, constitutes the majority.

Access to Information: Hotline for Unsheltered Pet Owners

Many unsheltered pet owners do not have good access to information, especially regarding shelters that might be pet friendly, or veterinary clinics or outreach organizations that provide veterinary care or pet food and supplies. Although many people experiencing homelessness have cell phones, they may not have smart phones or the technical knowledge and ability to locate information online.18 Challenges keeping a phone charged when living on the street are another indirect barrier to information and communication.

Most states have a United Way–sponsored 211 hotline that provides resources for individuals living in poverty and without the resources for a successful life.19 In Colorado, a Homeless Pet Owner Resource Guide has been developed with support from a grant from PetSmart Charities and is being provided to 211 staff so they can provide the appropriate information to callers. Similar resource lists need to be developed and provided for 211 staff in all US cities.

Street Medicine: Taking the Medicine to the People

Look up, not down

In his book, Stories from the Shadows,20 physician James O’Connell writes about establishing trust on the street by reversing the typical doctor-patient relationship. Approaching his patients with an attitude of nonjudgmental respect and unconditional kindness, he sheds his white coat and gets down on the sidewalk or park grass with his patients, and listens. Dr. O’Connell, and the many physicians he has trained in street medicine, initially focus on the condition of their patients’ feet, since those patients typically walk many miles, often starting treatment with a foot bath and treatment of any wounds or diabetic ulcers. Establishing trust with pet owners, and their pets, is a required first step in providing care and is more likely accomplished by looking up rather than down.

Doing more with less

History and physical examination become the key diagnostic tests in street medicine. Not unlike emergency medicine, street medicine often relies on owners’ observations of how their pet seems to be doing in determining the seriousness of a condition and whether to treat or refer. Basic diagnostic tools such as glucometers, BUN reagent strips, urine dip sticks, and refractometers for assessment of urine specific gravity are helpful in ruling out diabetes mellitus, renal failure, and urinary tract infection in dogs and cats. When pale gums or lethargy suggest anemia, small, patient-side hematology analyzers (eg, the Hb 201 from HemoCue America) can provide an accurate hemoglobin measurement. Other methods of estimating blood hemoglobin concentration in the field are also being explored by examining the color of a drop of blood using the World Health Organization hemoglobin color scale.21 The use of an ophthalmoscope-otoscope, proparacaine, Schirmer tear test strips, and fluorescein stain, along with otic or ophthalmic medications (eg, otic solution containing florfenicol, terbinafine, and mometasone furoate), can effectively be used to treat common ear and eye conditions. Use of newer medications for atopy and allergic skin disease (eg, oclacitinib) make treatment for these conditions more successful, in part by reducing the need for a multimodal approach and challenges with compliance when more traditional treatments are used. When a source of electricity is available, a microscope can be used to examine cytology samples, ear swabs, and skin scrapings. Higher-technology diagnostic equipment such as an FDA-approved (for human use) ECG application (eg, KardiaMobile from Alivecor Inc) and a wireless ultrasound probe (eg, the CH3 HD multipurpose scanner from Santa Cruz Animal Health) linked to a phone or tablet can be effective screening devices and effective ways to assess for pregnancy or diagnose a heart condition. Electronic medical records can be considered when feasible, although scanning written records after the fact is generally more practical, especially when working in inclement weather without internet access, such as under a bridge in the rain.

Ultimately, diagnosis on the street is more based on a best-guess approach, rather than a rule-out approach, so clinical experience helps. Conditions that could affect owner compliance must be considered when prescribing medications, particularly in locations where theft and loss are common, and underlying conditions of the pet owner such as alcoholism or drug addiction can undermine medication schedules. Controlled drugs, or those with potential for abuse, should not be prescribed because of the high incidence of substance abuse among homeless populations,12 but can be used to sedate the animals during a procedure. An emergency kit with appropriate drugs for treating adverse effects of vaccinations or anaphylaxis should also be available and include IV and SC fluid capabilities along with a portable miniature-oxygen-cannister system with a flow-metered mask (eg, Pawprint Oxygen Cannisters from Aeronics Inc). In the author’s experience, the oxygen cannisters provide approximately 15 minutes of oxygen at a flow of 1 L/min, making short-term sedation with dexmedetomidine safer for the patient.

Preventive care, including core vaccines and gastrointestinal parasite, ectoparasite, and heartworm testing and prevention, is similar to in-clinic care, but with nuances related to the challenges of pet owners living on the streets and unpredictable follow-up opportunities. High-compliance products are important, especially for long-term flea and tick control (eg, fluralaner) and, when appropriate, longer-term heartworm prevention with an injectable product (eg, moxidectin). Booster vaccinations are a challenge on the street and often fail to happen, even with a follow-up street clinic scheduled for that purpose. Recommended vaccination and other treatment schedules sometimes need to be modified since some pet owners living on the street may only be seen once, adding a risk-to-benefit ratio that must be considered.

Euthanasia, when the best choice, should not be performed in the street setting due to the distress it might cause to observers as well as the possibility of technical difficulties. Ideally, a referral arrangement would be set up with a local 24-hour hospital for potential euthanasia and aftercare. In addition, less urgent conditions may exist that require referral, necessitating the need for street medicine organizations to have funding set aside for additional care.

Spay-neuter resistance

In the author’s experience, significant resistance to sterilization surgery exists among the indigent pet owner population, even when the surgeries are offered at no cost. Various reasons expressed for turning down vouchers for free pet sterilization procedures include prospects for selling puppies and kittens, a desire for a female to “be a mother,” concerns about surgical risk, and undesirable changes in behavior. A lack of access to information about the benefits of sterilization for pets is likely a factor in this resistance to sterilization. In conversations with these pet owners, it can be helpful to point out that sterilization, on average, will increase a pet’s lifespan by about 18%, or 2 to 3 years, based on a large study of approximately 40,000 dogs.22

Not dissimilar to incentives offered to people to encourage vaccination, such as those for COVID-19 during the pandemic, incentives such as grocery store vouchers may be effective for encouraging indigent pet owners to agree to sterilize their pets. Although homeless people may prefer cash incentives, these are not recommended owing to the challenges related to handling money securely and safely, especially within the inner-city environment. The cost of a cash-like incentive, even as much as $50 or more, will offset the future costs of managing the offspring of unsterilized pets. Incentive vouchers must be offered to all pet owners in a given homeless community to avoid unrest and dissatisfaction from those who initially agreed to sterilize their pet without such an incentive. Additionally, to solidify trust among these communities, any incentives should be paid promptly at a recheck examination following sterilization.

Street Activism and Veterinary Outreach

The need to consider the needs of the person on the other end of the leash is undeniable when working with pet owners who are homeless or at risk of becoming homeless. Exciting collaborations are forming among health professionals providing street outreach. Case workers, medical students, physicians, nurses, and mental health professionals are joining veterinarians, nurse-technicians, and veterinary students to provide one-health services to these populations.6 In particular, based on the author’s observations, veterinary students are passionate about getting more involved with issues such as social injustice and poverty, which intertwine with veterinary street clinics and one-health outreach to provide hands-on opportunities to help people and pets in need. Multiple programs involving collaborative street medicine have been developed,23,24,25 and more are on the way.

The Street Medicine Institute,26 an international one-health organization devoted to providing care to rough sleepers (a term denoting the unsheltered homeless population) is recognizing the importance of the bond between those living on the streets and their pets and embracing a veterinary component to their efforts.

Creating a bridge of trust

With the appeal of providing veterinary care for pets of people experiencing homelessness, and the trust that is quickly established between veterinary providers and pet owners through such initiatives, a bridge is theoretically created whereby pet owners become more willing to accept medical or other health care for themselves since they are “here anyway” so “why not?” In the author’s experience, often this initial care is limited to history collection and physical examination, but such care opens the door for more extended care and potential referral, which are ongoing challenges on the streets. This one-health approach is being modeled at Colorado State University, where medical and social work students have joined veterinary students in weekly free clinics at a local homeless facility.27 Case workers and mental health professionals are vital components of the outreach team because of the preponderance of mental health and addiction disorders among those living on the streets. Should a homeless person express thoughts about suicide, veterinarians speaking with these individuals can make an instant referral.

Veterinary case managers, a proposed new designation, are being trained by The Street Dog Coalition as part of a pilot program in multiple cities to follow up with homeless pet owners to address ongoing needs, both veterinary and nonveterinary, and provide reminders on upcoming preventive care.

For the first time, veterinary services are being offered by veterinary teams at Veterans Stand Downs, which are 1- to 2-day events put on by the US Department of Veterans Affairs providing free services, clothing, and gear for homeless veterans.28 The Street Dog Coalition is working on a program called A New Found Life to place well-behaved shelter dogs with homeless veterans. Although service dogs have been placed with housed veterans through Zoetis’s K-9 Courage Program,29 placing a shelter dog with an unhoused person would represent a major paradigm shift for animal shelters since there are usually rigorous requirements for potential adopters, especially in regard to their housing situation.

Ultimately, we are all in this together; stress, financial hardship, depression, suicide ideation, drug and alcohol abuse, and social dysfunction are not unique to people living on the street. Working toward an atmosphere of trust and nonjudgmental acceptance, the veterinary profession can lead the way for other health-care providers to create a safety net for those struggling to survive, and contribute to a sense of purpose for themselves and others, in a spirit of collaboration, passion, and promise.

Acknowledgments

No third-party funding or support was received in connection with the writing of this manuscript. The author declares that there were no conflicts of interest.

The author thanks Isabella Mazariegos, Fred Palmer, and Katrina Weschler for their assistance with this project.

References

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