The Health of the Homeless - Living In Public: Increasedhealth Problems
people care homelessness death
Health problems are recognized as both causes and effects of homelessness. For example, a health problem that prevents an impoverished person from working can result in a loss of income that leads to homelessness. For those living on the streets, lack of adequate shelter and proper facilities for maintaining personal hygiene can exacerbate illness. Alcoholism, mental illnesses, diabetes, and depression become visible and more pronounced in homeless people. Other serious illnesses (tuberculosis [TB], for example) are almost exclusively associated with the unhealthy living conditions brought on by poverty. In general, experts agree that homeless people suffer from more types of illnesses, for longer periods of time, and with more harmful consequences than housed people. In addition, according to "Homelessness and Health," a 2004 policy statement by the National Health Care for the Homeless Council (NHCHC), health care delivery is complicated by the patient's homeless status, making management of such chronic diseases as diabetes, HIV, and hypertension more difficult. Virtually all Americans suffer illness and disease at some time in their lives, but for people experiencing homelessness and poverty, illness often leads to serious health concerns or premature death.
The Homeless/Morbidity Connection
One way of measuring the health of a population is to measure its morbidity rate—the rate of incidence of a disease or a mental or substance abuse disorder. The homeless often exhibit two or more conditions simultaneously, a phenomenon known as comorbidity or co-occurring disorders. Researcher Mary Ann Burg, in "Health Problems of Sheltered Homeless Women and Their Dependent Children" (Health and Social Work, 1994), explored the relationship between ill health and poverty and categorized the health problems of homeless women and their dependent children living in shelters. Burg's study revealed three general classifications of illnesses related to homelessness:
Illnesses resulting from homelessness
Illnesses intensified by the limited health care access of the homeless
Illnesses associated with the psychosocial burdens of homelessness
Poor health has also been reported as a cause of homelessness. In a frequently cited national survey of homeless patients (James D. Wright and Eleanor Weber, Homelessness and Health, Washington, DC: McGraw-Hill, 1987), 13% of the patients said that poor physical health was a factor in becoming homeless. Of people responding in the affirmative, half said health was a "major factor" and 15% said that it was the "single most important" factor. Wright and Weber also found that up to 40% of the homeless suffered from a major mental illness. In the case of the mentally ill and the alcoholic and drug-addicted homeless, the authors asserted that the failure of America's health care system must bear a major share of the blame for their homelessness.
David P. Folsom et al. found that 15% of patients treated for serious mental illness were homeless at some point during a one-year period ("Prevalence and Risk Factors for Homelessness and Utilization of Mental Health Services among 10,340 Patients with Serious Mental Illness in a Large Public Mental Health System," American Journal of Psychiatry, vol. 162, February 2005). The authors emphasized that homelessness among the mentally ill was associated with two other factors: substance use disorders and a lack of Medicaid insurance. The authors wrote,
Although it would be naïve to assume that treatment for substance abuse disorders and provision of Medicaid insurance could solve the problem of homelessness
among persons with serious mental illness, further research is warranted to test the effect of interventions designed to treat patients with dual diagnoses and to assist homeless persons with serious mental illness in obtaining and maintaining entitlement benefits.
The Homeless/Mortality Connection
Mortality refers to the proportion of deaths to population. San Francisco, estimated to have one of the largest homeless populations in the country (6,248 in January 2005, down 28% from a high of 8,640 in October 2002), has been tracking homeless mortality data since 1985. Since 1988 the annual number of homeless deaths has exceeded 100 and reached 169 in the one-year period ending June 30, 2003 (a rate of one death every other day). The following year, homeless deaths decreased to 101. In an analysis of deaths among San Francisco's homeless (Ricardo Bermúdez et al., San Francisco Homeless Deaths Identified from Medical Examiner Records: December 1996–November 1997), the authors noted that it was obvious from this and previous reports that the homeless had a higher mortality rate than the housed population. The homeless die at younger ages; in 1997 the average age of death among the homeless was 43.3 years, compared with 72.6 years for the general population. The leading cause of death was substance abuse (50% of all deaths); 31% of deaths were caused by illicit drug use and 19% by alcohol use.
James O'Connell, a physician with the Boston Health Care for the Homeless program, concluded in "Death on the Streets" (Harvard Medical Alumni Bulletin, Winter 1997) that while the causes of the higher morbidity and mortality rates among Boston's homeless people were complex, there were elements of the homeless life that encourage early death. Some of these were: exposure to extremes of weather and temperature; crowded shelter living, which increases the spread of communicable diseases such as TB and pneumonia; violence; the high frequency of medical and psychiatric illnesses; substance abuse; and inadequate nutrition. A 2001 study of 558 deaths among the homeless population in Boston found that within one year prior to death, 27% of homeless people had no outpatient visits, emergency department visits, or hospitalizations (S. W. Hwang et al., "Health Care Utilization among Homeless Adults Prior to Death," Journal of Health Care for the Poor and Underserved, vol. 21, 2001). The authors concluded that even homeless people at high risk of death were underutilizing health care services.
A 2003 study of homeless deaths in King County, Washington, identified seventy-seven people who had died while homeless in the county that year (King County 2003: Homeless Death Review, Seattle: Health Care for the Homeless Network, 2004). Major causes of death included acute intoxication (26%), cardiovascular disease (17%), and homicide (9%). Most of the homeless deaths involved several illnesses prior to death; on average, those who died had three health conditions prior to death.
In a study of deaths among homeless women in Toronto, Angela M. Cheung and Stephen W. Hwang found that homeless women aged eighteen to forty-four were ten times more likely to die than women in the general population of Toronto ("The Risk of Death among Homeless Women: A Cohort Study and Review of the Literature," Canadian Medical Association Journal, vol. 170, 2004). Another key finding of the study was that the risk of death among young homeless women was nearly the same as the risk of death among men of the same age.
The following socioeconomic conditions contribute to the greater prevalence of illness and early death among the poor and homeless population:
Inadequate sleeping locations
Contagion from overcrowded shelters
Limited facilities for daily hygiene
Exposure to the elements
Exposure to violence
Lack of health insurance
The Severity of the Problem
There is a growing belief in the health care field that homelessness needs to be considered in epidemic terms—that massive increases in homelessness may result in a hastened spread of illness and disease, overwhelming the health care system. John Lozier, in The Health Care of Homeless Persons (Boston Health Care for the Homeless Program, 2004) wrote that "Primary care clinics for indigent people generally operate beyond their capacity, are not well-located to serve people staying in shelters, and are not prepared to deal with the complex conditions often presented by homeless people." He conveyed the sense of many public health officials that the health care system was facing a crisis due to homelessness when he wrote, "The public health system, which made great strides in the twentieth century by eliminating unhealthy living conditions, seems ill-equipped to contend with the teeming shelters that are a throwback to the nineteenth century."
Researcher W. R. Breakey recognized the morbidity rates among the homeless as a major public health concern. In a 1997 article in the American Journal of Public Health ("It's Time for the Public Health Community to
FIGURE 7.1 Number of people without health insurance and uninsured rate, 1987-2003 [Numbers in millions, rates in percent] SOURCE: Carmen DeNavas-Walt, Bernadette D. Proctor, and Robert J. Mills, "Figure 6. Number Uninsured and Uninsured Rate: 1987 to 2003," in Income, Poverty, and Health Insurance Coverage in the U.S.: 2003, U.S. Census Bureau, Current Population Reports, P60-226, August 2004, http://www.census.gov/prod/2004pubs/p60-226.pdf(accessed February 18, 2005)
Declare War on Homelessness"), Breakey proposed that homelessness be responded to with the same urgency as an epidemic of an infectious disease. He urged public health officials to address larger issues—socioeconomic elements such as housing availability and wages—in order to effectively treat afflicted individuals.
The scope of health issues regarding the impoverished and homeless in the United States is related in part to the number of uninsured Americans. Figure 7.1 shows that in 2003, the number of uninsured people was higher than it had been in decades. At that time, forty-five million people were uninsured. Table 7.1 shows the percentage of people who were without health insurance coverage in 2002, by state. Texas (25.8%) and New Mexico (21.1%) had the highest percentages of uninsured people, while Minnesota (7.9%) had the lowest. (See Table 7.1.) In twenty states, the proportion of people without health insurance coverage rose between 2001 and 2003; in only two states, did the proportion drop. (See Figure 7.2.)
People without insurance are less likely to seek medical care. In "Out of Pocket Medical Spending for Care of Chronic Conditions" (Health Affairs, November–December 2001), S.W. Hwang et al. noted that "among chronically ill persons the uninsured had the highest out-of-pocket spending and were five times less likely to see a medical provider in a given year."
The Health Costs of Street Living
The rates of both chronic and acute health problems are disproportionately high among the homeless population. With the exception of obesity, strokes, and cancer, homeless people are far more likely than the housed to suffer from every category of chronic health problems. Conditions that require regular, uninterrupted treatment, such as TB, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), diabetes, hypertension, malnutrition, severe dental problems, addictive disorders, and mental disorders, are extremely difficult to treat or control among those without adequate housing.
Street living comes with a set of health conditions that living in a home does not. Human beings without shelter tend to fall prey to parasites, frostbite, leg ulcers, and infections. Homeless people are also at greater risk of physical and psychological trauma resulting from muggings,
TABLE 7.1 Percentage of people without health insurance coverage, 2002 [242,360 represents 242,360,000. Based on the Current Population Survey (CPS) and subject to sampling error] SOURCE: "Table 140. Persons With and Without Health Insurance Coverage by State: 2002," in Statistical Abstract of the United States: 2004-2005, U.S.Census Bureau, http://www.census.gov/statab/www/sa04api.pdf (accessed March 31, 2005)
Total persons covered (1,000)
Total persons not covered
Children not covered
Percent of total
Percent of total
beatings, and rape. With no safe place to store belongings, proper storage or administration of medications becomes difficult. In addition, some homeless people with mental disorders may use drugs or alcohol to self-medicate, and those with addictive disorders are more susceptible to HIV and other communicable diseases.
Homeless people may also lack the ability to access some of the fundamental rituals of self-care: bed rest, good nutrition, and good personal hygiene. The luxury of "taking it easy for a day or two," for example, is almost impossible for homeless people; they must often keep walking or remain standing all day in order to avoid criminal charges.
Unwell homeless people also remain untreated longer than their sheltered counterparts because obtaining food and shelter takes priority over health care. As a result, relatively minor illnesses go untreated until they develop into major emergencies, requiring expensive acute care treatment and long-term recovery.
The Urban Institute analyzed the results of the 1996 National Survey of Homeless Assistance Providers and Clients, the only survey of its kind (studies of the homeless tend to focus on local populations). The analysis showed that in the year preceding the survey, 25% of the clients studied had needed medical attention but were not able to see a doctor or a nurse. The study also revealed that newly housed people were even less likely to receive medical help when needed (26%) (Homelessness: Programs and the People They Serve—Findings of the National Survey of Homeless Assistance Providers and Clients, Urban Institute, December 1999).
The authors attributed the higher rate of health problems among newly housed people to several factors, including:
The loss of convenient health care in centers or shelters
The habit of enduring untreated ailments, and/or
a lack of health care benefits (common among people below the poverty level)
Figure 7.3 shows that the lower the income range of a household, the greater possibility the household would be uninsured. Among households with an annual income of less than $25,000 in 2003, almost a quarter (24.2%) were uninsured. Moreover, between 2002 and 2003, the percentage of uninsured people rose in every income bracket except the highest one.
The results of a study published in February 2000 (L. Gelberg et al., "The Behavioral Model for Vulnerable Populations: Application to Medical Care Use and Outcomes for Homeless People," Health Services Research) on the prevalence of certain disease conditions among homeless adults revealed that 37% suffered from functional vision impairment, 36% from skin/leg/foot problems, and 31% tested positive for TB. The authors of the study indicated that homeless people who had a community clinic or private physician as a regular source of care exhibited better health outcomes. The research
FIGURE 7.2 Differences in uninsured rates by state, 2001-02 to 2002-03 SOURCE: Carmen DeNavas-Walt, Bernadette D. Proctor, and Robert J. Mills, "Figure 10. Differences in 2-Year Average Uninsured Rates by State: 2002-2003 Less 2001-2002," in Income, Poverty, and Health Insurance Coverage in the U.S.: 2003, U.S. Census Bureau, Current Population Reports, P60-226, August 2004, http://www.census.gov/prod/2004pubs/p60-226.pdf (accessed February 18, 2005)
study also suggested that clinical treatment of the homeless be accompanied by efforts to help them find permanent housing.
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