The Health of the Homeless - Physical Ailments Of Homeless People

A March 2000 survey of the homeless in Hartford, Connecticut, performed by the Institute of Outcomes Research for the Hartford Community Health Partnership (E. B. O'Keefe et al., Hartford Homeless Health Survey), counted 1,365 homeless persons on the evening of December 13, 1999. The vast majority (87%) of survey respondents reported a prior diagnosis of at least one of seventeen chronic conditions. The most prevalent of these chronic conditions were drug and alcohol abuse, depression and other mental illnesses, hypertension, chronic bronchitis and emphysema, HIV/AIDS, asthma, and arthritis. Comparing the responses from the homeless survey against the rates for the general Hartford population revealed that homeless people suffered twice the rate of depression (41%) as the general population (23%) and three times the rate of chronic bronchitis and emphysema (22.7%). While these chronic diseases exist throughout the general population, difficulty in providing treatment to the homeless makes them worse, as do hunger and malnutrition.

Gillian Silver of the Johns Hopkins Bloomberg School of Public Health and Rea Pañares summarized one study's findings regarding the health problems faced by homeless women, who comprised about one-third (32%) of the homeless population. This group was prone to the same physical ailments reported by the general homeless population in Hartford but also reported high rates of gastrointestinal problems, neurological disorders, chronic obstructive pulmonary disease, and peripheral vascular disease. (See Table 7.2.)

FIGURE 7.3
Percentage of uninsured persons by income range, 2003
SOURCE: Adapted from Carmen DeNavas-Walt, Bernadette D. Proctor, and Robert J. Mills, "Table 5. People With or Without Health Insurance Coverage by Selected Characteristics: 2002 and 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)

Tuberculosis

Several kinds of acute, nonspecific respiratory diseases are common among homeless people. These diseases are easily spread through group living in overcrowded shelters without adequate nutrition. Tuberculosis (TB), a disease at one time almost eliminated from the general American population, has become a major health problem among the homeless. This disease is associated with exposure, poor diet, alcoholism, HIV, injection drug use, and other illnesses that lower the body's resistance to infection. TB is spread by lengthy personal contact, making it a potential hazard not only to shelter residents but also to the general public.

From 1953 to 1984 the United States experienced a decrease of 73.6% in the number of reported TB cases (from 84,304 cases to 22,255 cases). However, in 1984 the number of TB cases began to rise, reaching 25,701 cases in 1990. According to the Centers for Disease Control and Prevention (CDC), rising homelessness and poverty account, in part, for the resurgence of TB. Poor ventilating systems and the inability to quarantine victims allowed it to become prevalent. In 2003 the CDC found that 6.3% of the homeless population were infected with TB. (See Table 7.3.) State-by-state breakdowns gave some indication of the contagious nature of the disease. In 2003, for example, Montana reported that 28.6% of its homeless population tested positive for TB, while New Hampshire, North Dakota, Rhode Island, Vermont, and Wyoming had no cases of TB among the homeless.

Clinical data from the federally funded Health Care for the Homeless program (HCH), part of the Bureau of Primary Health Care, found prevalence rates for TB to be 100 to 300 times higher among the homeless than among the overall population. An additional contributing factor was the emergence of drug-resistant strains of TB. Experts reported that to control the spread of TB, the homeless must receive frequent screenings for TB, and the infected must get long-term care and rest. A campaign for increased public awareness, particularly among members of the medical community, was launched in 1990 to identify and screen those at the greatest risk for TB. Some researchers tested pilot programs to better identify and treat homeless persons infected with TB (P. M. Kong et al., "Skin-Test Screening and Tuberculosis Transmission among the Homeless," Emerging Infectious Diseases, vol. 8, 2002). Other studies investigated how best to help homeless adults adhere to treatment for latent TB infection (J. P. Tulsky et al., "Can the Poor Adhere? Incentives for Adherence to TB Prevention in Homeless Adults," International Journal of Tuberculosis and Lung Disease, vol. 8, 2004). The number of reported TB cases in the United States declined to 14,511 in 2004.

Malnutrition

Homeless people face a daily challenge to fulfill their basic need for food. They often go hungry. This was borne out in an analysis of the findings of the 1996 National Survey of Homeless Assistance Providers and Clients by Martha R. Burt et al. (Homelessness: Programs and the People They Serve, Urban Institute, August 1999). Clients of homeless assistance programs were found to have higher levels of food problems than poor people in general; 28% reported not getting enough to eat sometimes or often, compared with 12% of poor American adults. More than one-third of the homeless clients had been hungry in the past thirty days but did not eat because they had no money for food (39%), and 40% reported going at least one whole day without eating. Undernourishment and vitamin deficiency can cause or aggravate other physical conditions.

Meg Wilson found in a study published in 2005 that despite being homeless, many homeless women practiced "health-promoting behaviors" ("Health-Promoting Behaviors of Sheltered Homeless Women," Family and Community Health, vol. 28, January-March 2005). However, because of their homelessness, they had difficulty getting adequate nutrition.

The diet of the homeless is generally not balanced or of good quality, even among those who live in shelters or cheap motels. Homeless people often rely on ready-cooked meals,

TABLE 7.2
Health problems faced by homeless women, 2000
SOURCE: Gillian Silver and Rea Panares, "Table 2. Summary of Study Findings Related to Health Problems Faced by Homeless Women," in The Health of Homeless Women: Information for State Mental and Child Health Programs, Women's and Children's Health Policy Center, Johns Hopkins Bloomberg School for Public Health, 2000,http://www.jhsph.edu/WCHPC_/Publications/homeless.PDF (accessed March 31, 2005)

Health Issue	Key findings
Chronic disease	The most common chronic physical conditions (excluding substance abuse) are hypertension, gastrointestinal problems, neurological disorders, arthritis and other musculoskeletal disorders, chronic obstructive pulmonary disease, and peripheral vascular disease.
Infectious disease	The most common infectious diseases reported were chest infection, cold, cough, and bronchitis; reporting was the same for those formerly homeless, currently homeless, and other service users. Homeless patients with tuberculosis were more likely to present with a more progressed form than nonhomeless. Widespread screening for TB in shelters may miss most homeless persons because many do not live in the shelter, and instead present in emergency departments.
STDs/HIV/AIDS	A mobile women's health unit in Chicago reported that of 104 female homeless clients, 30 percent had abnormal Pap smears—14 percent with atypia and 10 percent with inflammation; the incidence of chlamydia was 3 percent, gonorrhea 6 percent, and trichomoniasis 26 percent. HIV infection was found to be 2.35 times more prevelant in homeless, drug-abusing women than homeless, drug-abusing men.
Stress	Homeless mothers reported higher levels of stress, depression, and avoidance and anti-cognitive copying strategies than low-income, housed mothers.
Nutrition	Currently and formerly homeless clients are more likely to report not getting enough to eat (28 and 25 percent reprectively) than among all U.S. households (4 percent) and among poor households (12 percent). Contrary to their opinions, homeless women and their dependents were consuming less than 50 percent of the 1989 recommended daily allowance for iron, magnesium, zinc, folic acid, and calcium. Subjects of all ages consumed higher than desirable quantities of fats. The health risk factors of iron deficiency anemia, obesity, and hypercholesterolemia were prevelant.
Smoking	More than half of both homeless mothers and low-income housed mothers were current smokers, compared with 22.6 percent of female adults 18 years and over.
Violence	Poor women are at higher risk for violence than women overall; poverty increases stress and lowers the ability to cope with the environment and live safely. In a study of 436 sheltered homeless and poor housed women: 84 percent of these women had been severely assaulted at some point in their lives; 63 percent had been severely assaulted by parental caretakers while growing up; 40 percent had been sexually molested at least once before reaching adulthood; 60 percent had experienced severe physical attacks by a male intimate partner, and 33 percent had been assaulted by their current or most recent partner. A study of 53 women homeless for at least three months in the past year demonstrated that this group is at a very high risk of battery and rape, with 91 percent exposed to battery and 56 percent exposed to rape.
Substance abuse	Homeless women comprise a subpopulation at high risk for substance abuse; rates of substance use disorder range from 16 percent to 67 percent. There exists an imbalance between treatment need and treatment access. Some homeless people with mental disorders may use drugs or alcohol to self-medicate.
Mental health/depression	A case-control study of 100 homeless women with schizophrenia and 100 nonhomeless women with schizophrenia found that homeless women had higher rates of a concurrent diagnosis of alcohol abuse, drug abuse, antisocial personality disorder, and also had less adequate family support. Many homeless women with serious mental illness are not receiving care; this is due to lack of perception of a mental health problem and lack of services designed to meet the needs of homeless women.

fast-food restaurants, garbage cans, and the sometimes-infrequent meal schedules of free food sources, such as shelters, soup kitchens, and drop-in centers. Many soup kitchens serve only one meal a day, and many shelters that serve meals—and not all of them do—serve only two meals a day.

BARRIERS TO ADEQUATE NUTRITION.

People who live below the poverty level, including the homeless, are eligible for food stamps, but many people are not aware that they are eligible. In her speech before the New York City Coalition against Hunger on June 16, 2003, public advocate Betsy Gotbaum described an investigation into the reasons why New Yorkers' participation in the food stamp program was declining even though the city had endured high unemployment as a result of the national recession that began in March 2001, combined with the further blow to the city's economy caused by the terrorist attacks of September 11, 2001. The investigation revealed that welfare participants who had left the welfare rolls following the 1996 welfare reform legislation were not aware that they could still receive food stamps. Even if people were aware of their eligibility, they were required to fill out a seventeen-page form to receive benefits. This is the type of barrier that prevents the poor and homeless from accessing or effectively using federal assistance programs.

In 2004 the U.S. Conference of Mayors reported that nearly all (96%) of the twenty-seven cities they surveyed reported an increase in requests for emergency food assistance over the course of the year by an average of 14%. Over half (56%) of those requesting food assistance were children or their parents. Fewer than half (44%) of the cities reported that their facilities were able to provide an adequate amount of food. Officials cited unemployment or underemployment, low-paying jobs, high housing, utility, and transportation costs, medical or health costs, reduced public benefits, and high child-care costs as causes of hunger in their cities.

Alcoholism, drug use, mental illness (especially severe depression), and physical illness contribute to nutritional deficiencies or lack of appetite. Some soup kitchens TABLE 7.3
Tuberculosis cases by homeless status,^a 2003
SOURCE: "Table 30. Tuberculosis Cases and Percentages by Homeless Status: 59 Reporting Areas, 2003," in Reported Tuberculosis in the United States, 2003 Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, 2003, http://www.cdc.gov/nchstp/tb/surv/surv2003/PDF/Table30.pdf (accessed March 31, 2005)

		Cases with information on homeless statusa		Cases among homeless persons
Reporting area	Total cases	Number	(%)	Number	(%)
United States	14,874	14,555	(97.9)	913	(6.3)
Alabama	258	258	(100.0)	12	(4.7)
Alaska	57	57	(100.0)	9	(15.8)
Arizona	295	281	(95.3)	35	(12.5)
Arkansas	127	122	(96.1)	3	(2.5)
California	3,227	3,198	(99.1)	226	(7.1)
Colorado	111	111	(100.0)	6	(5.4)
Connecticut	111	98	(88.3)	2	(2.0)
Delaware	33	33	(100.0)	2	(6.1)
District of Columbia	79	79	(100.0)	14	(17.7)
Florida	1,046	1,045	(99.9)	76	(7.3)
Georgia	526	511	(97.1)	27	(5.3)
Hawaii	117	117	(100.0)	1	(0.9)
Idaho	13	9	(69.2)	—	—
Illinois	633	623	(98.4)	21	(3.4)
Indiana	143	143	(100.0)	4	(2.8)
Iowa	40	40	(100.0)	1	(2.5)
Kansas	75	74	(98.7)	8	(10.8)
Kentucky	138	138	(100.0)	7	(5.1)
Louisiana	260	255	(98.1)	26	(10.2)
Maine	25	25	(100.0)	6	(24.0)
Maryland	268	268	(100.0)	4	(1.5)
Massachusetts	261	260	(99.6)	15	(5.8)
Michigan	243	239	(98.4)	7	(2.9)
Minnesota	214	214	(100.0)	8	(3.7)
Mississippi	128	124	(96.9)	6	(4.8)
Missouri	131	128	(97.7)	7	(5.5)
Montana	7	7	(100.0)	2	(28.6)
Nebraska	28	28	(100.0)	2	(7.1)
Nevada	107	106	(99.1)	13	(12.3)
New Hampshire	15	15	(100.0)	0	(0.0)
New Jersey	495	494	(99.8)	17	(3.4)
New Mexico	49	48	(98.0)	5	(10.4)
New York stateb	340	338	(99.4)	12	(3.6)
New York City	1,140	973	(85.4)	60	(6.2)
North Carolina	374	374	(100.0)	37	(9.9)
North Dakota	6	6	(100.0)	0	(0.0)
Ohio	229	227	(99.1)	15	(6.6)
Oklahoma	163	161	(98.8)	7	(4.3)
Oregon	106	106	(100.0)	8	(7.5)
Pennsylvania	336	331	(98.5)	8	(2.4)
Rhode Island	46	46	(100.0)	0	(0.0)
South Carolina	254	252	(99.2)	12	(4.8)
South Dakota	20	20	(100.0)	1	(5.0)
Tennessee	285	277	(97.2)	27	(9.7)
Texas	1,594	1,589	(99.7)	104	(6.5)
Utah	39	39	(100.0)	1	(2.6)
Vermont	9	9	(100.0)	0	(0.0)
Virginia	332	322	(97.0)	9	(2.8)
Washington	250	248	(99.2)	38	(15.3)
West Virginia	21	20	(95.2)	1	(5.0)
Wisconsin	66	65	(98.5)	1	(1.5)
Wyoming	4	4	(100.0)	0	(0.0)
American Samoac	…	…	…	…	…
Fed. States of Micronesiac	…	…	…	…	…
Guamc	61	59	96.7	0	(0.0)
N. Mariana Islandsc	45	45	100.0	0	(0.0)
Puerto Ricoc	115	115	100.0	5	(4.3)
Republic of Palauc	9	9	100.0	0	(0.0)
U.S. Virgin Islandsc	…	…	…	…	…
aHomeless within past 12 months. Percentage based on 52 reporting areas (50 states, New York City, and the District of Columbia). Counts and percentages shown only for reporting areas with information reported for ≥ 75% of cases.
bExcludes New York City.
cNot included in U.S. totals.

and shelters exclude persons under the influence of drugs or alcohol from partaking of meals at their facilities. Intoxicated persons may not be interested in food and can lose a substantial amount of weight as a result. Some advocates for the homeless suggest providing vitamin and mineral supplements to homeless substance abusers.

Skin and Blood Vessel Disorders

Frequent exposure to severe weather, insect bites, and other infestations make skin lesions fairly common among the homeless. Being forced to sit or stand for extended periods results in many homeless people being plagued with edema (swelling of the feet and legs), varicose veins, and skin ulcerations. This population is more prone to conditions that can lead to chronic phlebitis (inflammation of the veins). A homeless person with circulatory problems who sleeps sitting up in a doorway or a bus station can develop open lacerations that may become infected or maggot-infested if left untreated.

Regular baths and showers are luxuries to most homeless people, so many suffer from various forms of dermatitis (inflammation of the skin), often due to infestations of lice or scabies (a contagious skin disease caused by a parasitic mite that burrows under the skin to deposit eggs, causing intense itching). The lack of bathing increases the opportunity for infection to develop in cuts and other lacerations.