How to help homeless people in a social emergency setting? This is the practical question which guides the work of the Samusocial de Paris’s outreach team (EMA). Doing relief work (feeding, housing, clothing, and caring) should not be reduced to a functionalist or market analysis (in simple terms of supply and demand).  Helping homeless people involves legitimating a provoked street encounter by night. It means to discover the right distance between caring and humiliating. It implies to win a person’s trust, who is isolated and in need of “re-socialization”. Beyond a priori criticism stances about symbolic violence imposed upon dominated from the dominated, the issue is to characterize a specific know-how and to observe how an attachment can occur, in situ. The analysis deals with the framing operations (in the meaning of E. Goffman) performed at the same time (for the homeless as for the outreach team) and generating (or not) a common focus of attention. To study this very media-related work, but not very visible or much recognized, a double method has been used: the observation in situ (during about thirty nights) and the linguistic analysis based on interaction’ recordings. Thus, a new issue, both theoretical and methodological, is underlined: the combination of linguistic discipline (pragmatism, communication ethnography, conversational analysis) and sociological ethnography.

Protocol

Report

Articles

"La maraude à la lumière du refus d’hébergement : tensions et cadrages dans l’urgence sociale", Gardella E., Le Méner E., in Berger M., Cefaï D., Gayet C. (dir.), Du civil au politique. Ethnographies du vivre ensemble, Bruxelles, P.I.E., 2010 [sous presse].

"Enquêter sur un dispositif d’urgence sociale. Les maraudes auprès de sans-abri à Paris", Cefaï D., Gardella E., Le Méner E., in Cantelli F., Roca i Escoda M., Stavo-Debauge J., Pattaroni L., (dir.), Sensibilités pragmatiques. Enquêter sur l’action publique, Bruxelles, Bern, Berlin, Francfort, New York, Oxford, Vienne, Peter Lang, 2009, p. 39-52.

Contact : A. Laporte

The aim of this study is to describe the characteristics of hypothermia diagnosed during 2004 in Paris and to identify associated risk factors.

A case control study was carried out based on forms filled by nurses during health care interventions. Demographic clinical and environmental data were recorded. During 2004, 107 cases of hypothermia were detected among 82 individuals, constituting 7% of health care interventions. Two hundred and forty-two homeless controls were matched according to the

month of hypothermia diagnosis.

Detected cases of hypothermia were mainly (90%) mild and none was severe. They were detected throughout the year, but more frequently in November and December. In multivariate analysis, the risk of hypothermia is increased by alcohol intoxication (ORa=2.5; CI 95% [1.2 - 5.6]) and reduced mobility (ORa=2.4; CI 95% [1.1 - 5.4]).

Hypothermia seems to be a significant risk in this sub-group of population and the number of detected cases is a minimal estimate of cases reported in Paris in 2004, as it is not systematically searched by other outreach services for the homeless. Educating outreach services staff to better recognize hypothermia and to familiarize themselves with initial treatments can help prevent hypothermia related morbidity and mortality.

Grants : Entreprise Lafarge.

Article :

"Characteristics of hypothermia among the homeless in Paris, France, 2004", Carpentier S., Raymond F., Arnaud A., Gaslonde O., Tartière S., Laporte A., Bulletin Epidémiologique Hebdomadaire, 1, p. 1-3

Between June and May 2000, a systematic screening implemented among homeless at Paris Samusocial identified 37 cases of tuberculosis during a 11 months period, leading to a rate of 500 per 100 000. During clinical management of these 37 patients half were lost to follow-up.

In front of difficulties of public institutions to manage care for homeless, Xavier Emmanuelli, created, in December 2000, a tuberculosis outreach team (EMLT), thanks to Aventis funding.

The main objective is to reduce mortality, morbidity and tuberculosis transmission and to prevent anti-tuberculosis drug resistance among homeless. The specific objective is to bring to complete recovery all tuberculosis homeless patients followed by the Paris Samusocial, with one ore several risk factors of breaking treatment, thanks to DOT (Delivery Observed Therapy).

The Observatory of Paris Samusocial implements, fall 2003, a software for the following of patients under anti-tuberculosis treatment (TB Info), freely distributed by the Institut de Veille Sanitaire and used by various hospitals and care centres in a network. The software was adapted to the particularities of the Paris Samusocial population, characterised by high frequency of breaking treatment. Paris Samusocial’s medical doctors completed the data in TBinfo from 2003 to 2009. Since 2010, data on tuberculosis patients are entered in the general medical data base of the Paris Samusocial.

Report

Article

"Tuberculose chez les sans domicile fixe à Paris : mise en oeuvre de la stratégie DOT (Directly Observed Therapy)"  Kern T., Lardoux C., Tartière S., Emmanuelli X., Laporte A., Bulletin Epidémiologique Hebdomadaire, 17 , p. 73-74.

In Paris, the emergency number "115" aims to, among other roles, enable individuals to "report" the homeless to the Paris Samusocial so that a mobile outreach team may intervene. Through a two-pronged quantitative and qualitative research approach, we sought to understand the explanations and reasons that may account for these reports.

The quantitative study shows that an individual does not report just anytime or anywhere. Media incentive, professional paces (most reports are made after work and late in the evening), and, above all, the proximity between the reporter and the reported could explain the temporal and geographic variations of these reports.

Reporting homelessness is a seasonal approach: the reports are much more numerous in winter. The media coverage, increased during this season, may be one explanation. Reporting may also be related to perceived closeness to the situation of the homeless: direct perception of the cold seems to create empathy in the literal sense of the term. The reporter more acutely feels the harsh living conditions of homeless life (the winter, a drop of 46°F, doubles the number of reports).

The reports are more numerous in the districts of eastern Paris, where the population is less wealthy than in the west and center. Presumably, these are the areas that have the most homeless people, notably because of the day and night shelters therein. The closeness could again be a factor explaining reports: here, it would be the social and spatial proximity between the reporter and the reported.

The qualitative study refines the understanding of the reports. Any report appears as the result of a moral solicitation, based on the perception of an unusual phenomenon.

This can manifest as a disturbance in a familiar environment. This person, well known, seems significantly less well than usual. Concern switches to a report.

The unusual can also reflect a disagreeing perception in the course of a programmed action. Back from a pleasant evening, anyone could meet a person in poor shape. The unexpected calls out, more in terms of the unacceptable than guilt, and leads to a report.

This abnormality may be lastly understood as the reminder of a scandal: the very presence of homeless people in a society that could afford to avoid it. The report is thus like a quasi-militant gesture of quiet indignation and effective protest.

Report

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If the "policy thermometer" is a constant in the emergency care of the homeless, the Winter Emergency Plan (Plan d’Urgence Hivernal or PUH) is innovative in officially adapting three formal levels of mobilization based on temperature indicators, real "triggers" that cause state action with respect to this population. The automatization of care for the homeless was built on the humanitarian dimension of the public issue and a shift in the tools of public policy. But the powerful political questioning by the Enfants de Don Quichotte (NGO) during the winter of 2006-2007 finally contradicts this automatization and marginalization of the political dimension it entailed.

First, the introduction of an automatic management mechanism coupled with automatic climate indicators in the care of the homeless corresponds to the importation of civil and sanitary security tools to the domain of social action. This shift is made possible by the convergence of two aspects: a concern to rationalize the management of the homeless and a desire to limit political decision-making in this domain.

Secondly, the study of the implementation of the PUH highlights the limitations of the shift: it has not led to the automatic management of homelessness. The indicators are subject to flexible interpretation, and "spectacle – triggers" in level 2 are mainly a symbolic function in the service of a political communication strategy of the government. This has two consequences for the steering of public action: the advertising of the device counteracts the automatic functioning and produces unexpected effects contrary to the logic of automatization. The PUH is a way to reaffirm the partnership with the “official” associations in charge of services for the homeless, and the coordination of their actions. Nevertheless, the rhetoric of emergency thus alienates the critical force of these associations, which moves toward associations outside of the management of the homeless, such as the Enfants de Don Quichotte association.

Finally, the social movement of the Enfants de Don Quichotte seriously calls the mechanization of care for the homeless into question: it institutionalizes what the PUH creators had tried to avoid; that is to say, the problematization of the question as an issue requiring a political solution, and the establishment of a legal framework of state responsibility. This collective mobilization initiated change in the care policy of the homeless from a humanitarian conception to a conception in terms of social justice and law.

Report

Article

"Les enfants de Don Quichotte et le Plan d'urgence hivernale", Schvartz A., Raison Présente, 170, p. 79-90.

Read more...

• Réflexions sur l’application du principe de continuité dans les structures d’hébergement d’urgence du Samusocial de Paris et ses conséquences en terme de nombre de places d’urgence à Paris, Michelot F., Laporte A., Observatoire du Samusocial de Paris, avril 2007.

• Les personnes en famille hébergées via le 115 de Paris entre 1999 et 2004, Mougel S., Observatoire du Samusocial de Paris, septembre 2005.

• "Psychiatric disorders among homeless people: evidences for improving psychiatric services and housing policies. Preliminary results”, Chan-Chee C., Douay C., Detrez M-A., Le Masson V., Le Strat Y., Chauvin P., Laporte A. and the SAMENTA research group. 15^th EPA symposium for section epidemiology and social psychiatry, Bergen, Norway, june.

• "Enquête sur la santé mentale et les addictions chez les sans logement franciliens (Samenta): une double contrainte d’enquête", Detrez M.-A., Douay C., Le Strat Y., Chauvin P., Laporte A., VIème colloque francophone sur les sondages, Tanger, Maroc, mars.

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Survey in process

The number of families (defined as at least one adult with at least one minor child) receiving care from the homeless aid system is growing. The duration of care is increasing. The limited available data suggests considerable social difficulties, and a worrying state of health, both physical and psychological. The situation of children – the majority of whom are not considered children at risk despite unsafe living conditions – seems particularly alarming.

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Epilepsy is a common chronic neurological disorder, with an estimated prevalence of 5–8 cases per 1000 persons in industrialized countries. Many people with epilepsy feel socially

stigmatized. Discriminatory behaviours still persist, notably in the workplace. Homelessness is associated with increased morbidity and mortality compared with the general population, and some medical problems are particularly prevalent such as seizures. In 2003, a study was initiated among the homeless people seeking assistance from a welfare organization (samusocial) in Paris (France), to estimate the prevalence of epilepsy and to determine its characteristics, management practices, the impact of the disease on professional career and the consequences of street life on seizure frequency.

During the study period, 592 adults attended at least one medical consultation 86 subjects reported at least one seizure over their lifetime history which amounts to 14.5% (95% CI 11.8–17.6) for the overall sample. A logistic regression among men showed an increased risk of seizures among alcoholics and persons homeless for more than 2 years; and a lower risk among persons aged more than 60 years. Among the 86 patients who reported a history of seizures, 59.3% were classified as having epilepsy and 40.7% as having alcohol related seizure (ARS). The prevalence of active epilepsy in the entire population was 8.1% (6.0–10.6). Among the 86 patients, 57.1% had anti-epileptic treatment and 77.1% took their drug daily. In 46.5% of cases the frequency of seizures increased following the onset of homelessness; the principal stated reasons were alcohol (75%), sleep privation (42.5%), anxiety (32.5%), and stress (27.5%). Seizures had an impact on the employment of 30.6% of subjects in the epilepsy group, of whom 78.6% had given up work entirely.

The prevalence of active epilepsy in the study population (8.1%) is markedly higher than that estimated in the general population (<1%). These results suggest that epilepsy is a serious health problem among the homeless and that it contributes to the social exclusion process. The proportion of subjects taking treatment for epilepsy and the compliance rate challenge certain prejudices regarding non-compliance and widespread alcoholism and call for reflection on the optimal management of epilepsy in this population.

Grants : Sanofi-Aventis

Partnerships : Ligue Française Contre l’Epilepsie, Fondation Française pour la Recherche sur l’Epilepsie.

Preliminary results

Premiers résultats de l’étude de prévalence de l’épilepsie chez les sans-domicile prises en charge par le samusocial de Paris

Article

"Epilepsy among the homeless: prevalence and characteristics", Laporte A., Rouvel-Tallec A., Grosdidier E., Carpentier S., Benoit C., Gérard D., Emmanuelli X., European Journal of Public Health, 16, 5, p. 484–486.

Consensus conference, 17 novembre 2004, Paris.

Conclusions of the consensus conference, Paris, novembre 2004.

Recommandations : Prise en charge de l'épilepsie chez les personnes en grande précarité.

Publication des recommandations dans les revues médicales suivantes :Neurologies (avril 2005 ;8 (70) : 177-180) ; La lettre du NeurologueEpilepsies (2005 ; 17 (3) : 141-3) ; Urgences pratiques (juillet 2005 ;71 : 43-45) ; La revue des SAMU (juillet 2005 ; 27 (5) : 224-26) ; JEUR(Journal Européen des URgences)(2005 ; 18 : 179-182) ; La revue Neurologique (2006 ; 162(2) : 265-267). (juin 2005 ;9 (6) :212-14) ;

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