Editor’s Note: This is the second of three parts.

The flies were persistent. They buzzed around the open wound on Daniel Quiral’s ankle looking for a landing. He needed bandages to cover the sore and antibiotics for the infection.

Quiral sleeps at Kakaako Waterfront Park on the outskirts of Honolulu’s downtown business district and well out of view of the Waikiki tourists, whose eyes city and business officials want to shield from a growing homelessness problem they have yet to solve.

He’s one of thousands of homeless people struggling to survive on Oahu, a singular face among dozens of families that have pitched tents along the streets in his neighborhood. Like many others, he goes for long stretches without medical care. That’s why the cut on his ankle was festering.

Quiral knew he needed attention, and, more specifically, Band-Aids. On Oct. 9, he rode his bicycle to a free mobile clinic for the homeless parked outside the University of Hawaii medical school, not far from where he lives.

University of Hawaii John A. Burns Medical school student Harry Wynn-Williams takes blood pressure of a patient  (gave name as Junior) during volunteer outreach work  near Kakaako Park.  9 October 2014. photograph by Cory Lum

University of Hawaii medical school student Harry Wynn-Williams takes Daniel Quiral’s blood pressure. Quiral, who is homeless, came for treatment for a wound on his ankle.

Cory Lum/Honolulu Civil Beat

The clinic, which is run out of a modified recreational vehicle, is part of the Hawaii H.O.M.E. Project that teaches aspiring physicians how to provide medical care to the homeless.

Sometimes it’s the only health care a homeless person receives for months, even years.

It’s a major reason why the homeless on average die decades before people who are housed. A small affliction, such as a small cut, can easily turn into a crisis that requires immediate medical attention.

Not only does this contribute to higher death rates among the homeless, but it also ends up costing taxpayers in the long run.

“You learn to survive,” Quiral said. “I’m not going to the doctor unless I’m in real bad pain.”

A Deadly Lifestyle

Poor health is a part of homelessness. Mental illness and substance abuse can drive people to the streets. So too can a debilitating injury and hefty medical bills.

But once people are living outside they face a bevy of other problems.

“Doctors can’t do everything. The patients have to manage their own lives. But some of them just can’t.” — Janet Onopa, medical director of Queen Emma Clinic

The homeless suffer from the same afflictions as those living in homes, but they experience those illnesses — including influenza, cancer, HIV, diabetes — at much higher rates.

According to the National Health Care for the Homeless Council, the average age of death for someone living on the streets is 50. That’s the same life expectancy as Americans living in 1900.

While substance abuse and mental illness often increase the risk of death, health conditions caused by poor nutrition and exposure to the elements can be equally deadly.

A Civil Beat analysis of Honolulu death records found that 139 of the 417 homeless people who passed away from March 2006 to July 2014 died of natural causes, most often heart disease and pneumonia.

That’s second only to drug and alcohol-related deaths, which totaled 142 in the same period.

A Health Care Conundrum

Health care officials say homeless people in general are difficult to treat because they’re part of a transient population. Many of them also have mobility issues, whether it’s a lack of transportation or a disability that prevents them from visiting a doctor.

Other barriers include mental illness and severe forms of psychosis that can make it difficult for someone to go to an appointment or walk through the door of a clinic. There’s also the matter of trying to find food and a safe place to sleep.

“There’s a lot of chaos for homeless people,” said Janet Onopa, medical director of the Queen Emma Clinic. “Your life has just fallen apart. There are all kinds of things going on around you when you’re trying to live like that. It’s hard to take care of yourself.”

The Queen Emma Clinic is located in downtown Honolulu on Punchbowl Street. Many of its clients are uninsured and impoverished. Over the years it has treated hundreds of Honolulu’s homeless, as well as others on the verge.

Dr. Charles Sakamoto uses warm water in a syringe to irrigate patients ear canal as University of Hawaii Medical Student left, Yun Jenny Jiang fronting the Hawaii Home Project vehicle near Kakaako park. 9 October 2014. photograph by Cory Lum

Warm water in a syringe is used to irrigate a patient’s ear canal at a mobile clinic for the homeless in Kakaako. Doctors had discovered a wax build-up in the patient’s ears that made it hard for him to hear.

Cory Lum/Civil Beat

Onopa said that because so much attention is being paid to day-to-day necessities such as food and shelter, it’s easy for a homeless person to lose track of seemingly little things that can eventually lead to long-term health consequences.

Small scrapes and cuts that would normally be treated with a first aid kit, or even some Neosporin and a paper towel, can lead to an infection that infiltrates the entire body. Appointments are missed and prescriptions go unfilled. Illnesses that require ongoing treatment, such as HIV or tuberculosis, become less treatable.

Nutritious food is scarce, encouraging dependence on the dollar menus at fast-food restaurants and shelter food purchased in bulk. Drugs and alcohol are often the alternative to  painkillers when medications run out.

“Doctors can’t do everything,” Onopa said.”The patients have to manage their own lives. But some of them just can’t.”

A Costly Burden

Last year, Queen Emma Clinic saw about 150 homeless patients even though it has about 600 homeless patients listed in its electronic database. Many more receive treatment from paramedics responding to 911 calls and emergency room doctors.

In fact, Queen’s Medical Center officials say that in fiscal year 2014, the hospital received 4,000 to 5,000 emergency room visits from homeless people. It’s a figure that highlights the dearth of regular care for the homeless population.

Hospital staff and paramedics call the regulars “frequent fliers,” and they’re a well-known burden for medical providers across the islands.

In October 2012, the Honolulu Emergency Services Department launched a program to reduce the number of 911 calls it received from “frequent fliers,” more than a third of whom were homeless and suffered from mental illness.

According to EMS data from that time, 50 people made 1,200 calls to 911 in the first nine months of 2012. The year before, one man called every other day. Officials estimated that the callers cost the taxpayer-funded health care system at least $3 million a year for ambulance response and trips to the ER.

To cut down on these costs, then-Emergency Services Director Jim Ireland started sending paramedics directly to the most frequent callers for home visits before they had the chance to pick up the phone.

The idea was that going to them would reduce the burden not only on ambulance crews, but also on the ERs because patients could be treated in the field instead of the hospital.

“We basically did it for a few weeks to see about the feasibility,” Ireland said. “What we found was that it was very, very difficult to find the person in the same place we found them the last time because they were so mobile.”

It probably would have been more effective, he said, if the paramedics were stationed outside an ER entrance.

But the program, which was started under former Mayor Peter Carlisle, barely got off the ground. It was shelved after Mayor Kirk Caldwell took office, with EMS officials citing staffing concerns.

“Community paramedics are a great idea,” said Shayne Enright, a spokeswoman for Honolulu EMS. “We just don’t have the manpower to put into it.”

Still, there are others trying to deliver health care to the homeless who have seen success. Much of this work is happening in the nonprofit sector, where there’s a higher level of expertise in delivering services tailored to the city’s homeless.

‘Sometimes it’s Life-changing’

Jason Espero runs the Care-A-Van clinic, part of Waikiki Health, a nonprofit that provides affordable medical, dental and mental health services. It also operates the Next Step Shelter for the homeless in Kakaako.

The Care-A-Van is essentially a medical office on wheels that travels around much of Oahu searching for homeless people who might be in need of health care. It also has a permanent office in Kaimuki for walk-in patients who are homeless or at risk of becoming homeless.

Espero said outreach is a critical component of the program because many of his clients suffer from debilitating injuries, some of which prevent them from walking to a bus stop or hailing a cab.

While Care-A-Van workers will scour the urban landscape searching for homeless clients — such as underneath the H-1 airport viaduct — he said they also seek out more remote populations. They’ve even trudged through the pineapple fields of Wahiawa.

“Out here it’s tough. Healthwise you got to be good.” — Daniel Quiral, a homeless man living in Kakaako

“Wherever there are homeless people we get out of the vehicles and we go to them,” Espero said. “We’re always exploring new territories and new areas to find clients.”

On one occasion, Espero found a patient near a bus stop in Kailua with a cut on his leg that had become badly infected. The man, who suffered from severe mental illness, had been hit by a car about two months before but never sought treatment.

Hundreds of maggots had taken up residence inside his leg, eating the dead and infected flesh. Espero said he could smell the rot from 10 feet away. A nurse practitioner used tweezers to pull out the maggots and clean the wound as best she could until an ambulance arrived to transport the man to the hospital. Not only did he survive, but he kept his leg.

“If we didn’t encounter that person that ambulance would not show up,” Espero said. “We come and we intervene and we make that call for them. Sometimes it’s life-changing.”

Staying Alive

The sore on Daniel Quiral’s ankle probably would not have killed him. He had cut it several weeks before while swimming in the ocean and had already gone to the emergency room to get a first round of antibiotics.

But as the aspiring physicians at the H.O.M.E. Project prepared to treat his wound, they also checked his blood pressure.

It was high, which surprised Quiral. He pounded his chest and said he’s never had a problem with high-blood pressure in the past. He blamed it on the methamphetamine he smoked earlier in the day.

Quiral is 51, meaning he’s reached the average life expectancy of a homeless person living in Honolulu. He’s also part Hawaiian, which studies have shown does not bode well for his health.

University of Hawaii John A. Burns third year medical student Princeton Ly examines Junior's infected left ankle during volunteer outreach work with the Hawaii Home Project at Kakaako Park.  9 October 2014. photograph by Cory Lum

Princeton Ly, a third-year medical student at UH, examines Daniel Quiral’s infected left ankle at a mobile outreach clinic for the homeless in Kakaako.

Cory Lum/Civil Beat

Not only do Hawaiians make up a disproportionate number of the state’s homeless population — nearly 30 percent — but they also tend to die at a younger age than other residents in the Aloha State.

Poor health is pervasive among Native Hawaiians, as they tend to suffer from higher rates of cardiovascular disease, hypertension, obesity, diabetes and asthma, studies have shown.

They also have higher rates of tobacco, alcohol and methamphetamine use which, when combined with poor nutrition from a high-fat, low-fruit-and-vegetable diet, can lead to greater risk of chronic disease.

“Wherever there are homeless people we get out of the vehicles and we go to them. We’re always exploring new territories and new areas to find clients.” — Jason Espero, director of Care-A-Van

And while homeless populations tend to suffer from poor health in general, a study published in the Hawaii Medical Journal found that homeless Hawaiians have an even higher prevalence of hypertension and asthma than their peers.

The study found they also had a greater frequency of prior drug use, particularly with marijuana and methamphetamine.

Quiral said he’s seen plenty of dead bodies in his years on the streets. He described them as the casualties of drugs, violence and drownings.

It’s best not to think about them, he said. “You got to live day to day.”

No one expected Quiral would return for a follow-up exam, not even him. The wound on his ankle, although ugly and weeping, was on the mend. His infection had subsided, and he had another dose of medication.

As he looked at the growing number of tents on the sidewalks around the park — many of them belonging to families with young children — he talked as if they’d just arrived on a prison cellblock.

They haven’t lived like he has, he said. At least not yet.

“Out here it’s tough,” Quiral said, his legs bouncing and eyes darting side to side. “Health-wise you got to be good.”

In a matter of minutes he was back on his bicycle, riding into the cityscape.

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