HERE ARE some symptoms of scabies: night itching, rashes between the fingers, pencil-mark lines. Here is a diagnostic finding: trails under the skin where mites lay their eggs. These are called burrows, which sounds altogether too homey. Here is a treatment: permethrin 5 percent topical cream, after washing clothes and bedsheets in very hot water. Here is the problem: Most shelters have no public washing machine, and a load in the local laundromat runs $6 to $7.
We had seen him in the shelter for a few weeks. Before voices drove him into the clinic — their intrusiveness was almost an act of compassion — he lived and drank for years on the street. He was still drinking, but accepted antipsychotic medication, and a referral for primary care, since he hadn’t been to a doctor in decades. He didn’t mention the scabies.
We noticed it on a copy of the primary care examination, below his weight and blood pressure, partway down the problem list. Of the problems that can be diagnosed in a doctorless man during a first visit, this was among the less dire. Infestation is painful and unpalatable, but it’s also curable.
MassHealth covered the cost of the cream. But it did not cover the cost of a load of laundry. Here, assistance broke down. He didn’t have $7. He had no funding at all. Until he came to the shelter, his existence had hardly been registered in any formal way. Applying for disability would take weeks.
Meanwhile, he was using the new cream and wearing the old clothes. It was only a matter of time before he became a homey burrow again. Sleeping hip-to-hip with his neighbors, it was only a matter of time before they did, too.
It was only a matter of time before the scabies would reoccur, but the homeless man had no money for the laundromat.
We gave him the money, and a little more. Obviously we did, even though giving clients money is against shelter policy (“preferential treatment”). We chalked it up as a public health intervention.
We hope he went to the laundromat. Of course, he might have gone to the package store instead. We knew there was this possibility when we gave him the money. He knew there was this possibility when he took it.
Elissa Ely is a psychiatrist.