Hemorrhages and Homelessness


My instructor in inpatient medicine seemed to be obsessed with anemia. Whenever a patient in the hospital had a low red blood cell count, he would write in his notes, “w/u anemia” (for “work-up anemia”) It was such a common occurrence that one year the residents bought him a rubber stamp with “w/u anemia” on it so he wouldn’t have to write it anymore!

Anemia does require a medical work-up. The single abnormality of a low red blood cell count can have many different causes, each with a different treatment. Sometimes anemia is due to a single episode of blood loss and a transfusion is all that is needed. Other times, such as with bleeding ulcers, the bleeding must be stopped so the anemia can be treated, repeated transfusions make no sense. Other times anemia is a sign of another disease that needs to be treated. Alcoholism, vitamin deficiencies, kidney disease, cancers and infections can all suppress blood cell production in the bone marrow and lead to anemia. Fixing the blood count requires the physician to address the underlying cause.

Given the long list of possible causes, the word “anemia” used in isolation, is near meaningless. More information is needed to understand the word and devise treatment. There is no single solution to the problem. A doctor who orders iron tablets for every anemia is a very bad doctor.

Homelessness and anemia have this in common. All homelessness involves people living on the streets, but not all homelessness is the same. There are many different causes of homelessness, and treating the problem will require varied approaches

Some homeless people want to participate in society and have the ability to work, but need some help rejoining the workforce. Others are so damaged mentally and emotionally that participation in society is impossible. They lack the personal and mental skills needed to hold a job, handle money and relate to others. Many, perhaps the majority, could participate in society if they wanted to, but don’t want to. The causes are varied, and the solutions must vary as well.

The “capable homeless”, those who want to work and provide for themselves are perhaps the easiest to help. These unfortunate souls often find themselves on the street due to a combination of poor planning and bad luck and on occasion, burned bridges. They may be hardworking people who were barely getting by, living paycheck to paycheck until a health crisis, loss of transportation, or lost job left them with no place to go. Whether due to pride or social isolation, they have no friends or family to turn to. For these people a homeless shelter, some free meals and some financial assistance (perhaps affordable housing) could turn their lives around. When it comes to the problem of homelessness, these people seem to be in the minority.

The mentally ill pose a unique problem. People who suffer from psychotic disorders may never be able to participate in society. Delusional thinking, hallucinations, lack of interpersonal skills and inability to handle complex tasks may render them incapable of holding down a job or managing their finances. Mental illness can also make it impossible for them to comply with medication regimens, trapping them in a cycle of isolation. Our society decades ago decided it was immoral to force these individuals into institutions, is so doing ignoring the reality that a life on the streets trapped in delusions is an even crueler existence. Temporary shelters may provide a brief respite for those suffering from severe mental illness, but like blood transfusions for a bleeding man they do nothing to solve the underlying problem.

The most numerous and most troubling segment of the homeless population are those who have (or had) the ability to work and participate in society but choose not to. The stress of normal life, of waking up on time, going to a boring job, answering to a boss, and paying bills is more than they care to handle. Some escape from the stresses of life via needle or bottle, living from one high to the next. There are others who are simply antisocial. They do not care at all about other people or how their actions impact others. They want what they want, when they want, how they want, refusing to answer to anyone. Paradoxically, these people act as if the world owes them everything and that they owe the world nothing.

This last category may be the largest. They know help is available, know there is a way they could rejoin society, but have no interest in such help. They prefer a life on the streets to a life of responsibility. They will take food and financial assistance when offered but will intentionally avoid such help if it requires them to change their behavior. It is difficult for others to understand, but to these people a life of “freedom” on the streets is superior to a life of responsibility.

Just as the treatment of anemia is dependent on the underlying cause, the treatment of homelessness must also take root causes into consideration. There is no single response to the homeless problem that will work for all. If the problem of homelessness is to be addressed multiple solutions will need to be pursued. As obvious as this truth is, it seems to not be understood by the judges who hand down rulings demanding more shelters or the politicians who make our laws. Our government leaders seem to think the solution is to provide everyone with a place to live and food to eat. While this may work for the small subset of unfortunate individuals who want to work and rejoin society, it will do nothing to address the root causes for the majority of those living on the street.

The mentally ill are often unable to access help on their own and thus will need hospitalization, institutionalization, or ongoing supervised care. They need to be in settings where there are people to make sure they take their medications appropriately, counselors to help them understand the world, and structure to keep them safe from their bad judgment and destructive behaviors. Our society needs to let go of the belief that such arrangements violate the rights of the insane. If we do not change our approach, there plight will not change. They will remain on the streets.

The anti-social, drug addicted and alcoholic homeless present a different problem. As long as they are given the option of living outside of the rules of society, most will choose it. They will refuse shelter and services when offered. Those that accept shelter will not typically stay long, leaving when they realize they cannot use drugs or drink. Getting these people off of the streets will require a firm and decisive response from society. Instead of building shelters with swinging doors and no obligations, we will need to develop a path to reenter society. We will need programs, camps or facilities to provide these people with opportunities to get sober, receive psychiatric care, life counseling and job training. These able bodied homeless will need to be given a clear choice, enroll in a reentry program and become someone who contributes to society, or go to jail and contribute to society via a supervised work problem. Returning to the streets cannot be an option. If it is, they will choose it.

I have little hope that these approaches will ever be implemented, for they will require us to accept hard truths about human nature and to change our way of thinking. Simple solutions, though destined to fail, are more politically and socially palatable.


Trans Before Trans Was Cool


He was not what I expected. I had met his wife his wife that morning, an attractive woman in her 40’s and when she told me that I would be seeing her husband in the afternoon I pictured a man who would look manly, masculinity to match her femininity.

He looked to be in his early 50’s, and was quite effeminate. He was darkly tanned, almost bronze. His perfectly coiffed blond hair was long enough to cover his collar and parted on the side, with a layered cut that was popular in the 70’s. His clothes, a khaki shirt, khaki pants, khaki belt and khaki shoes, matched perfectly, so perfectly as to merit the term “ensemble”. His speech and mannerisms were distinctively feminine.

I shrugged off his appearance and greeted him in my usual fashion. His wife had told me he was in to have a mole checked so I asked him to remove his shirt. Without a word he unbuttoned it and set it over the chair. As he did I was suddenly aware of the reasons for his feminine appearance. He had breasts.

They were not the “man boobs” of an obese man, nor were they gynecomastia, the slightly prominent breast tissue sometimes seen as a side effect of medications. He had female breasts. Any doubts I may have entertained as to the nature of his bosoms, any thought that he was not striving to be a women disappeared when I saw the tan lines outlining his pale breasts. He had been tanning in a bikini top!

Wondering what to say, I quickly took a look in his chart. The medication list told the story. He was taking estrogen pills. He was in the process of a sex change.

The first thought that passed through my mind was, “Why didn’t his wife warn me about this?” Some form of heads-up would have been appropriate, something along the lines of “My husband is coming in to see you this afternoon for a mole on his chest, and by the way, he has boobs,” would have been nice. I struggled to come up with an appropriate response. (“Nice boobs, are they new?” did not seem appropriate…)

It was one of the rare times in my life that I had no idea what to say. I decided to say nothing at all. I examined the mole as if there was nothing at all out of the ordinary. I diagnosed the skin lesion, recommended a course of action and sent him on his way.

I never saw either one of them again. I have no idea if they stayed married or if he completed his transition. I do know that I will never forget him, and that I never know what I will find behind each exam room door!

At that when in doubt, the best response is to simply do my job.


Broken Windows Parenting


“It was an accident!”

My son’s explanation was the same as millions of others little boys throughout history who found themselves in trouble. On this day and in my son’s case the explanation was true.

He was playing across the street in the neighbor’s yard. His friend had a new boomerang which he had eagerly shown to our 6-year-old son. Like any self-respecting little boy, he threw it, hard. He and his friend watched as it flew in a graceful arc, spinning majestically through the air until it came to a sudden stop against the window of the neighbor’s garage. The boomerang remained in one piece, the window did not.

“It was an accident!” my son repeated his defense, obviously fearful of my paternal wrath. To his surprise, I was not angry.

“I know it was an accident, and you are not in trouble,” I said. I saw the fear begin to leave his eyes, slowly being replaced by hope. “You are not in trouble, but the window is still your responsibility. You are going to have to pay for the window.” The hope faded.

“But I don’t have hardly any money!” he replied.

“How much do you have?” I asked

“Seven dollars”

“Okay, you can give me the seven dollars and I will pay for the rest.”

“But it was an accident!”

“I know it was an accident. But the window is broken and it has to be fixed, and that costs money. Someone has to pay for it, and because you broke it, you have to pay for it. Even though it was an accident, you are still responsible.”

My son was unconvinced but obedient. We went home and gathered all of his change and took it back across the street. The neighbor reluctantly accepted our payment. He felt badly for my son and quietly told me that we did not need to pay. I told him that we had to, because my son needed to learn the meaning of responsibility.

I thought of this story this last week when my dog was attacked by another dog. The dog’s owner offered the same defense as my 6-year old had proclaiming, “It was an accident!” It was obvious that to him the lack of intention absolved him of any obligation to remedy the situation. Because it was “an accident” he owed me nothing.

It was clear to me that his father had not taught him the meaning of responsibility (or the he had had failed to learn the lesson when his father tried to teach it). He truly believed in his "accident defense.”

He is not alone in this belief. It is clearly shared by the person who did not leave a note when he dented by car 6 months ago and by the vast majority of people who bounce checks in my office. Most people do not think of the consequences of their actions or the impact on others. Their primary goal is to avoid responsibility.

What can be done? How do we get people to accept responsibility for their actions?

I do not know how I can get other adults to take responsibility for what they do, but I do now how to get future adults to take responsibility for their actions.

One window at a time.

  • Bart

Attacked By a Bum


“You mother &$%#! Don’t you ever come back here again! This is my park. If you come back here again my bros and I will mess you up! Mother…”

The profanities and threats continued as the man, a vagrant, strode toward us across the parking lot, clenching his fists, his face contorted in rage. Lisa and I, each with one of our dogs on a leash, backed away as he approached. We were frightened, our fear only partially assuaged by the presence of our dogs and other park visitors. His anger was intense.

I had incited his rage by my actions a few days earlier during another walk in the park. It was a Sunday, and there were several child’s parties going on in the picnic area. Bounce houses, barbecues, balloons and balls abounded, and the joyous laughter of children filled the air.

I noticed the man about 50 feet from one of the bounce houses. He sat shirtless on the ground with a syringe in his right hand as he considered where in between the fingers on his left hand he wanted to inject himself. He was clearly in the process of getting high. (I assumed it was heroin but was sure it was not insulin!) Without even thinking I heard myself exclaim loudly, “Seriously? There are children 50 feet away!”

Appalled that he would so brazenly use drugs around children I grabbed my cell phone and quickly took a picture. Certain I was observing a crime in process I called the police, convinced they would share my concern and respond to my call. I was mistaken. I waited, at a distance, for over 15 minutes for the police to come. I never saw them arrive.

They must have arrived sometime later, as intermingled with the profane threats hurled our way a few days later were declarations that I had wronged him. “You liar, tell the police I was shooting up when I wasn’t!” was one of the refrains.

As he yelled his threats from across the parking lot I pondered what to do. I was not confident that the police would respond to a call but felt compelled to call anyway. I did not want to yield dominion of the park to such a man. This time they responded. A policeman came to my home a short while later. He seemed genuinely bothered by my story but offered little reassurance. “You can file a report,” he said, “but nothing will happen to the guy.”

He went on to explain that recent changes in California law had rendered the man’s blatant drug use and subsequent threats on my person mild offenses on the level of a parking ticket. All he could do was issue a citation, which would almost certainly be ignored. This, he told me, was the way things worked now. He then shared with me the uncomfortable truth that almost all of his fellow officers were planning to leave the state as soon as they qualified for retirement. For them, the war was lost and the bad guys had won.

In spite of his discouraging words I encouraged him to file my complaint and confront the man. “He needs to know that this is not acceptable,” I said, “If there are enough complaints maybe someone will do something.”

I do not know what followed, but I have not seen the man in the park since.

This week I had a different sort of encounter with a transient, even more frightening than the first. This time it was my daughter and I walking our dogs. We had taken them to a small park in a neighborhood a short way away from our home and had rounded the corner onto a street heading towards our house.  We were walking on the sidewalk along a row of parked cars when from behind a small cabover camper came a snarling pit bull. Before I could react the dog was upon us, growling and biting at our dogs. Sadie, our shepherd mix, rose to our defense, bravely biting at the other dog as I forcefully pulled her and Kona away and out of the other dog’s reach.

I saw that the pit bull was tied to the back of the camper and briefly thought I had backed away far enough and that we were safe. I looked for the owner and sawvhim across the street talking to another man. The owner turned at the sound of the dogfight and ran towards us from across the street, yelling at his dog as he came.

His dog ignored his commands. With a powerful lunge the pit bull broke free from its chain and attacked again. I vainly tried to pull my dogs away, spinning and tugging as Sadie again did her best to defend us all. The man finally arrived and grabbed his dog and pulled it away.

“I’m sorry,” he cried, “It was an accident!”

I was not interested in his excuses or apologies. He had foolishly and irresponsible left his violent dog unattended. I do not recall all that I said, but I remember telling him that it was dumb to leave his dog alone and that I better never see his dog unattended again. Remarkably, I did not resort to profanity.

I looked quickly at our dogs, and not seeing any blood, continued toward home. Sadie, powered by adrenaline, seemed unhurt. It was not until we were home that we discovered the extent of her injuries. She had deep puncture wounds in her chest and a tear on her back near her shoulder. It was clear that she needed medical attention. Lisa took her to the vet while I walked back to talk to the man about Sadie’s injuries.

I found him standing on the sidewalk next to his camper, talking to a friend. In as calm a voice as I could manage I said, “I realize it was an accident, but as a result of your mistake my dog has been injured and we are taking her to the vet. You are responsible for her injuries and I think you should pay for her treatment.”

“I’m homeless,” he replied, “I don’t have any money.”

And that was that. There was nothing I could do. I called animal control, but all they did was leave me a form to complete. The animal control officer told me that no action would be taken against the man or his dog.

The care of Sadie’s wounds required her to be sedated while the cuts were cleaned, dressed and sutured, at a cost of nearly $700. By the time we got Sadie home, Kona was displaying signs of injury, refusing to bear weight on her hind leg. Close examination revealed that she too had been bit. The next day saw $300 more in vet bills when she received care.

The man and his dog simply drove away. His foolishness and irresponsibility cost him nothing.

The last few days I have been ruminating about each of these encounters. I have come to the conclusion that they each reveal the root cause of the “homeless problem” facing our nation- the benefits of unaccountability. Both men did something clearly wrong, yet neither faced any consequences for their actions.

This is the reality for nearly all who choose to live on the streets (and for the vast majority of vagrants, it is a choice). They have withdrawn from civilized society, have cast aside the obligations of citizenship and any sense of responsibility for their actions or to their fellow man. They pay no taxes, utility bills or rent. They do not need to show up for work, answer to a boss, or meet any deadlines. They do not in any way contribute to society. They do what they want, when they want.

They often ignore basic hygiene and cleanliness, leaving their trash and excrement scattered around for others to collect. Many use drugs whenever they can, and often cast their used needles on the ground for others to retrieve or step on. They commit misdemeanor crimes with impunity, knowing they will be back on the streets before the officer completes his paperwork. They support themselves with gifts of food and money from strangers without shame or consequence, and many receive government aid.

While others may consider their quality of life unacceptable, many of them are content with their existence. It is the life they choose. They do not have to answer to anyone else, not to family, friends or supervisors. This freedom from accountability outweighs the discomforts of being homeless. They do not want to be a part of our world.

Their choices impact the lives of law-abiding citizens, but these citizens have little recourse. The legal system now sides with them, as the 9th Circuit Court of Appeals has declared that there is a right for people to sleep in public places unless someone else provides them with a free place to stay. According to the courts, it is up to the rest of us to support their existence.

What can be done?

The debate about what to about this problem rages in newspapers, city council chambers, courtrooms, and even churches. Good people who care about the plight of their fellow man struggle with what to do when they care more about this plight than those who endure it.

If this problem is going to be solved it will require hard truths to be faced. For me, I am going to start by changing the words I use to describe people who choose to live on the streets. I am not going to call them “homeless” any longer. That term implies a desire to find a home and the responsibilities that come with it.  (consider- no one calls a retired person or stay-at-home mom “jobless”). Only those down on their luck individuals who are truly trying to get back on their feet deserve to be called “homeless”.

For the majority of street people who do not want to participate in society, I now choose to describe them with terms that reflect their choice. Language should communicate the truth of things, and as a society we have not been truthful about the nature of the problem. We need to use terms that reflect reality. Many of these people are not “homeless”. They are vagrants, transients, and bums, on the streets by choice.

If these vagrants are to ever rejoin society, they will have to learn to follow the rules of civilized society, to accept the responsibilities the rest of us fulfill every day. When we give them money, food, and other support we keep them from having to accept these responsibilities.

 If we are going to solve this problem, we must first begin by acknowledging the truth of it. If we don’t the problem will only get worse.


When Doctors Overrule Parents

Do parents always know best?


On the evening news tonight was a story about the parents of a 3 year-old boy with acute lymphocytic leukemia, an aggressive cancer with a fatality rate of 100% if untreated. As deadly as the cancer is, 98% of children achieve remission within a few weeks of starting chemotherapy, and 90% of those who complete chemotherapy are ultimately cured of the disease.

Perhaps because so many of its victims are children, ALL is one of the most studied and best understood cancers. Treatment protocols are well established and widely accepted. There is no debate regarding the role of chemotherapy in treatment.

No debate between physicians that is. The parents of little Noah decided they knew better than his doctors about how to cure his cancer. They rejected medical advice, believing that a mixture of herbs and supplements were the answer for their son. To them, chemotherapy is toxic and harmful and too risky for their child. They took their son and ran to another state in order to avoid treatment.

The doctors notified the state child protection agency which issued an urgent order that Noah be found and returned to Florida to complete his medical treatment. He was located in Kentucky, taken from his parents and placed in the custody of his grandparents. His chemotherapy was restarted and his parents have filed suit to stop it.

It seems to me that parental distrust of the medical profession is on the rise, associated with an increased trust in alternative therapies unsupported by scientific study. I see this most commonly with vaccines, where hardly a month goes by that I do not have standard immunization recommendations challenged by a parent who “knows better.” Parental belief in the harm of vaccines can be incredibly strong. A former patient of mine recently moved her family to Colorado in order to avoid California’s mandatory vaccine law! She is now a militant anti-vaccine voice on social media.

As foolish and as deserving of public shaming these parents may be, there is one area in which they have  arguments that are valid. They argue that allowing physicians to overrule parental choice is a slippery slope that may lead to harm. Recent cases suggest their fears are not unwarranted.

There are some medical conditions where expert opinion is not as united or where treatment choices are not as clear. In some cases, such as in children with gender dysphoria, medical opinion appears to be driven more by political correctness than by science. (For example, although studies have shown that 75% of children who identify as transgender will ultimately identify as their biological gender, the American Academy of Pediatrics now recommends that all such children be supported in their transgender feelings.)

In spite of medical data calling into question the validity of transgender identity, doctors are forcing parents to yield to “expert” opinion. In British Columbia a father has been threatened with prison time if he refers to his biological daughter by her birth name. A father in Ohio lost custody of his child for refusing to consent to hormone therapy intended to change his 14 year-old daughter into a boy. He has been ordered to consent to counseling for his younger children so they can accept there sister’s transition.

Things are not always crystal clear with immunizations either. While the public health argument for mandatory immunizations for highly contagious diseases is compelling, there are a number of vaccines for diseases that can be avoided by other means. Hepatitis B and HPV for example, are typically sexually transmitted. While the vaccines are not harmful, should we force parents of young children to consent to their administration? Or punish them if they don’t?

While there are times when parents do not act in the best interest of their children, this does not mean that parents should be overruled in every such instance. If we wish to maintain trust in the medical profession, we should respect parents whenever possible, only overruling them when the risks to their child or to public health are extremely compelling.

If we fail to do so, we risk losing the trust of parents everywhere, and should not be surprised when some parents do not accept even our most clear and most emphatic recommendations