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Margarita Sloan, RN, an independent nurse practitioner in Houston who has worked with indigent patients for 20 years, treats her patients without charge or questions about documentation. Here, she examines Alicia Boado, sitting alongside her mother, Dolores.

On her way to the theater in Houston one evening, Margarita Sloan, RN, MPH, FNP, was struck by the sight of a homeless woman on a street corner. Open sores, probably a side effect of diabetes, covered the woman’s legs, Sloan said. The woman was talking to herself and obviously
mentally ill.

The homeless woman’s corner was two blocks away from the Texas Medical Center, one of the best health care facilities in the United States. But the woman might as well have lived in India, said Sloan, an independent nurse practitioner who has worked with indigent patients for nearly 20 years. “She wasn’t getting medical care.”

As Sloan and other U.S. nurses who work with the poor know, even in a land of shining health care centers and medical miracles, many people on the lowest end of the economic scale are not receiving basic health services.

To serve them, these nurses have eschewed comfortable offices, state-of-the-art operating rooms, and glass-and-steel complexes in favor of homeless camps, run-down apartment buildings, and the hallways of inner-city emergency departments.

Their miracles don’t come from research breakthroughs or new technology or amazing medications. They settle for getting an asthmatic patient to stop smoking, or an illegal immigrant hooked into the health care system, or a mentally ill homeless man to let someone wash his rotting feet.

They also advocate for their patients on a broader level, working to persuade legislatures and communities to support health care programs for poor and uninsured people. Some have worked with vulnerable populations for years; others are students who realize this work may be their calling.

All are heeding the call from the International Council of Nurses to work “side-by-side with clients, service providers, community leaders, policy makers and politicians” to “reduce the plague of poverty.”

Spokane: Helping the homeless

In the common room of the House of Charity, a homeless shelter in Spokane, Wash., nursing student Sachiko Yakashiro noticed an elderly man who wore slippers instead of shoes. When she and other students tried to get him to take off the slippers so they could examine his feet, he refused, saying the smell was too awful.

Foot problems are a common condition among the homeless, said Carol Allen, RN, PhD, a senior instructor at the Intercollegiate College of Nursing/Washington State University College of Nursing in Spokane. The homeless spend a lot of time on their feet, she said. They often have terrible shoes and no places to change their socks — if they have socks to change into. Some may have fungal problems, others may have disabilities that preclude proper care for their feet.

As part of their clinical work in community and psychiatric health, WSU nursing students like Yakashiro visit homeless shelters, homeless camps, and low-income housing complexes to help bring health care to those who can’t afford it or won’t seek it.

Allen, who has worked in Micronesia and with low-income African-American communities in Southern California, accompanies the students as they offer health education, care for wounds, take blood pressures, and listen to people’s stories.

Health problems among the homeless and poor usually are complicated, Allen said. Many patients are mentally ill and won’t take medications because they don’t like the side effects or the way medications make them feel. Many are addicted to drugs or alcohol and not ready to seek treatment for their addictions, but need medical care for conditions such as abscesses caused by skin-popping methamphetamines and other drugs.

At first, Yakashiro thought the best way to help the man in the homeless shelter was simply to listen to him. She discovered he lived in a small car and slept sitting up. He spent most of his days in the library, researching his family’s genealogy. She knew he was mentally ill, but he didn’t want to talk about his illness.

“I was trying to build up his trust,” she said. Finally, he took off his slippers and showed her his feet. They were puffy, bleeding, cracked, and weeping. He had venous and arterial insufficiency, accompanied by severe edema. She soaked his feet in water and tried to massage them, but that was too painful, she said. So she kept soaking them and removed as much dead skin as she could. She also showed him how to care for his feet on his own.

Her treatments, coupled with medication, started to work.

After three weeks, the swelling subsided, the color became more normal, fluid stopped seeping out.

“I had no problem with the feet and the smell,” Yakashiro said. “It made me think that I want to go into this field later. I really like working with this population. I found no difference between the people in the shelter and me and my friends.”

Yakashiro will graduate in May. She has finished her work in the shelter and misses her patient, who told her she was the fourth person in his 71 years who had influenced his life deeply. “I’m really happy that I had the chance to meet him,” she said, “because he taught me a lot of things, too.”