To be poor is bad enough; to be ill as well is a nightmare.

For any poor person in India, to fall ill is a monumental calamity, because whatever public health services exist are beyond their reach. In cities, health facilities are available in private clinics and large public hospitals. But it is hard for poor city residents to enter their doors. The obstacles are highest for homeless persons, stigmatised by public authorities as illegal, illegitimate, unsanitary burdens on the city and its infrastructure, including hospitals.

Public health scholar and paediatrician Vandana Prasad undertook a study to understand the barriers faced by adult street dwellers in Delhi in accessing health care. The study focused on this most marginalised and socially invisible urban population living on city streets, including able-bodied casual workers, rag-pickers, women who escape or are expelled from violent and abusive homes, and people suffering from a variety of disabilities (including mental illness).

Almost all homeless people typically suffer major health problems, not surprisingly because they are forced to sleep rough, exposed to extremes of the seasons, and with virtually no access to clean drinking water, sanitation and home-cooked food. Their health burdens were reported by the Health Initiative Group for the Homeless based on a survey of 2,955 homeless respondents: “A high proportion of homeless people were suffering from serious respiratory ailments including tuberculosis, acute and chronic infections, skin diseases and diarrhoeal diseases”. Our earlier research by the Centre for Equity Studies found that health issues may be also the reason for homelessness in the first place, including mental illness, mental retardation and stigmatising illnesses that precipitate homelessness. Prasad's study clearly documents the occurrence of catastrophic illnesses as a factor that has tipped poor people into homelessness

The study finds that upper-most among the many barriers faced by the homeless in attempting to access public health care services is simply the lack of money. They lack BPL cards which would otherwise make them eligible for free medicines, and are forced to buy medicines and pay for tests. Many give up because they cannot afford the services even of public hospitals, with devastating outcomes on their health, livelihoods, and their survival with dignity. The researchers encountered from a very small sample three able-bodied, working, homeless men who suffered injuries which could have been treated. But they could not afford the cure in government hospitals. As a result today they are permanently disabled, and forced to beg life-long.

Bureaucratic maze

Another prominent barrier to accessing health care was the delays and “shunting” experienced by the participants in busy public hospitals, which led many participants to give up before their health problem could be addressed. A young homeless woman spent two years begging doctors in four tertiary care public hospitals in Delhi to treat her young baby. They kept insisting that there was nothing wrong with her baby. It was only her persistence — she describes it as haath pair jodna or begging the doctors — that led them to recognise at the end of two years a congenital intestinal blockage, and agree to operate on her child, thereby saving her life.

These problems are compounded by low literacy, isolation, unfamiliarity and stigma. A few homeless people reported insulting behaviour by attending doctors as one of the reasons they hesitate to approach public health facilities: some doctors refuse to touch them because they are unclean; others heap humiliating taunts about their producing too many babies. (But the majority of homeless people said government doctors were courteous.) Other barriers commonly mentioned included difficulties in safely storing their records.

Not a single homeless respondent possessed a BPL card or any other automatic proof of their status as “poor”. The study confirmed a near absence of social security entitlements that are meant for the poor amongst the homeless participants, such as pension or the BPL ration card, which has great practical significance not only for cheap food but as a prerequisite for getting free treatment.

Other barriers included the lack of address, and no attendant. There is a cultural expectation in India that every patient would be accompanied by family members or friends, who would stay with the patient throughout hospitalisation and assist with various tasks such as buying drugs and other consumables, fetching reports, accompanying the patient for various procedures and even, on occasion, nursing and dressing. They take the patient to the toilet, and call for the doctor or nurse when required.

At a disadvantage

Elderly or disabled persons need attendants to negotiate even out-patient services since there are long queues and services are time-bound. People who do not have the ability to read signs and fill in forms, or the social confidence to approach designated help-desks which are also overcrowded, also need assistance. But most homeless persons do not have a family living with them, and even if they do, other members have to work to eat food each day. A woman said that while she was sick and making her endless rounds of hospitals, her husband had to pull his rickshaw and take care of their children on the streets.

It is often said that the greatest crime in India is to be poor. Vandana Prasad's rigorous and compassionate study documents in painful detail how hard it is to be homeless and require health care. She concludes that it is only a comprehensive universally free public system of health care, one that does not require any cash transactions between the service providers and the users, which could enable the homeless to surmount the barrier of prohibitive costs of care.

They would require, in addition, comprehensive social protection, homeless shelters, recovery shelters, and support for their peculiar needs as homeless persons such as nutritional support and paid attendants for the periods when they need to be hospitalised. But in a country where even existing public health services are being down-sized and privatised, there can be little optimism that the homeless will secure the dignity of health care if they have the misfortune to be houseless, alone, and unwell.