The Health of the Homeless - Special Population Concerns

Children

While a quarter of all homeless people may suffer from mental illness, and many more have past or current drug or alcohol addictions, these common stereotypes of the homeless do not fit the homeless population of children under eighteen years of age, who make up from 8% to 12% of the homeless.

One research team (E. R. Danseco and E. W. Holden, "Are There Different Types of Homeless Families? A Typology of Homeless Families Based on Cluster Analysis," Family Relations, 1998) sought to identify different types of homeless families and to examine children from these families. The researchers studied 180 families, with a total of 348 children, participating in a comprehensive health care program for children of homeless families. The results showed that homeless children consistently exhibited greater behavior problems and showed a trend of poorer cognitive, academic, and adaptive behaviors than children in the general population.

Similar results were found in a 1999 Urban Institute study. Its findings demonstrated that poor children were less involved in school than their wealthier peers—41% of children above 200% of the poverty level had a high engagement in school, versus 34% of children below that level. Lower-income children had 4% more behavioral and emotional problems, skipped school 7% more often, were expelled or suspended more than twice as often, and reported fair or poor health more than three times as frequently as higher-income children.

According to "Child and Youth Health and Homelessness," a 2004 policy statement of the National Health Care for the Homeless Council, homeless children experience a variety of behavioral and/or health disorders, including depression, developmental delay, asthma, respiratory infections, and gastrointestinal problems. Homeless children may also lack preventive care, such as immunizations, which leaves them vulnerable to preventable diseases. Failure to treat certain childhood conditions early (ear infections, for example) can lead to a lifetime of health problems. They also frequently suffer from malnutrition. In addition, the NHCHC policy statement noted that the condition of homelessness in childhood is a risk factor for adult homelessness.

Unaccompanied Youth

Unaccompanied youth is the term used to describe children under the age of eighteen who are either runaways (away without permission), thrownaways (told or forced to leave or abandoned), or street youth (long-term runaways or thrownaways). The 2004 Conference of Mayors report estimated that 5% of homeless people are unaccompanied youth. The National Runaway Switchboard estimates that between 1.3 and 2.8 million runaway and homeless youth live on America's streets and that one out of every seven children will run away before the age of eighteen. Many of these children are escaping physical and sexual abuse, strained family relationships, addiction of a family member, and/or parental neglect.

Access to health care at traditional health care centers is complicated for this segment of the homeless population by parental permission requirements, lack of insurance, and a reluctance to trust health care professionals. They often do not receive preventive health care or seek treatment for illnesses or injuries.

Veterans

According to the Veterans Health Administration, in 1990 veterans were present in shelters at a rate of 149 per 100,000 compared with 126 per 100,000 of other males (Data on the Socioeconomic Status of Veterans and on VA Program Usage, Washington, DC, May 2001). The National Coalition for Homeless Veterans, citing Department of Veterans Affairs (VA) sources, stated on its Web site in 2005 that of homeless veterans 2% were female, 45% suffered from mental illness, and half abused drugs or alcohol. An estimated 299,321 veterans were homeless on any single night; over the course of a year, more than 500,000 were homeless at least one night. The majority were single. Almost half (47%) of homeless veterans served in Vietnam. The 2004 Conference of Mayors report stated that 10% of homeless people in the twenty-seven surveyed cities were veterans.

To some, the homelessness of veterans is hard to understand. Since World War II, U.S. veterans have been offered a broad range of benefits, including educational assistance, home loan guarantees, pension and disability payments, and free health care. In fact, veterans consistently have higher median incomes, lower rates of poverty and unemployment, and better education than U.S. males in similar age groups. Veterans, those observers claim, should be less vulnerable to homelessness than other Americans. The belief that combat-related stress leads some veterans to become homeless has received much attention. Health care professionals believe that there may be a link between the persistence of post-traumatic stress disorder in veterans and the stresses of street living, though research on this topic is as yet inconclusive.

The Veterans Administration operates numerous out-reach programs designed specifically to help homeless veterans in areas of health, housing, and employment. Among those that address the health concerns of homelessness are:

• Health Care for Homeless Veterans (HCHV), which offers comprehensive health and psychiatric evaluations, treatment, and referrals at 135 locations nationwide.
• Domiciliary Care for Homeless Veterans (DCHV), a residential treatment and rehabilitation program operating at thirty-five VA medical centers in twenty-six states. Services include screening and assessment; medical and psychiatric examinations, treatment, vocational counseling, and post-discharge support.
• Drop-In Centers, providing daytime environments where homeless veterans can eat, shower, do laundry, and participate in organized activities that promote life skills.
• Stand Downs, comprising one- to three-day programs that offer safe haven for homeless veterans. According to the fact sheet "VA Programs for Homeless Veterans" (VA, March 2002), "Stand Downs give homeless veterans a temporary place of safety and security where they can obtain food, shelter, clothing and a range of community and VA assistance. In many locations VA provides health screenings, referral and access to long-term treatment, benefits counseling, ID cards and linkage with other programs to meet their immediate needs."

Victims of Violence

VIOLENCE TOWARD HOMELESS WOMEN.

Angela Browne and Shari Bassuk, in a study funded by the National Institute of Mental Health and the Maternal and Child Health Bureau, found that lifetime prevalence rates of physical and sexual assault among homeless women were particularly high. The study, "Intimate Violence in the Lives of Homeless and Poor Housed Women: Prevalence and Patterns in an Ethnically Diverse Sample" (American Journal of Orthopsychiatry, April 1999), which surveyed both homeless and very poor, housed women, found that although violence by intimate male partners was high in both groups, homeless women experienced violence at a somewhat higher rate (63.3%) than poor, housed women (58%).

Homeless women (41%) were also more likely than housed women (33%) to report a male partner threatening suicide. More than one-third (36%) of homeless women said their partner had threatened to kill them, compared to 31% of poor, housed women. Almost 27% of homeless women and 19.5% of poor, housed women needed or received medical treatment because of physical violence. Table 7.2 summarizes other studies related to violence and homeless women.

HATE CRIMES.

According to the National Coalition for the Homeless (NCH), homeless advocates have demanded that crimes against homeless people be defined as hate crimes, which may result in harsher penalties in federal courts. Determining how many of these crimes occur is difficult. Some factors that have an effect on the accuracy of the count are:

• The bodies of the victims are not always discovered.
• Bodies may be badly decomposed, preventing accurate identification of the cause of death.
• Local authorities may rule causes of death other than violence.
• Survivors do not always report crimes, and murdered victims cannot tell their own stories.

In April 2003 the NCH released the results of a four-year study of hate crimes and violence committed against homeless people (Hate, Violence, and Death on Main Street, USA: A Report on Hate Crimes and Violence against People Experiencing Homelessness from 1999-2002, Washington, DC). The NCH identified 123 deaths and eighty-nine nonlethal attacks on homeless people over the four-year period that they considered hate crimes. The crimes occurred in ninety-eight cities in thirty-four states and in Puerto Rico. According to the NCH, the five most dangerous cities for people experiencing homelessness are Denver, Las Vegas, Rapid City (South Dakota), Toledo, and New York.

In "Hate Crimes and Violence against People Experiencing Homelessness" (June 2005), the NCH recommended the following actions to address the problem of violence against homeless individuals:

• "A public statement by the U.S. Department of Justice acknowledging that hate crimes and/or violence against people experiencing homelessness is a serious national trend."
• A Department of Justice database to "track hate crimes and/or violence against people who are experiencing homelessness."
• Justice Department guidelines "for local police on how to investigate and work with people experiencing homelessness" and recommendations for improvements to state law that would "better protect against violence directed against people experiencing homelessness, including tougher penalties."
• "Inclusion of housing status in the pending state and federal hate crimes legislation."
• "Sensitivity/Awareness training at police academies and departments nationwide for trainees and police officers on how to deal effectively and humanely with people experiencing homelessness in their communities."
• "A U.S. Government Accountability Office (GAO) study into the nature and scope of hate crimes and/or violent acts and crimes that occur against people experiencing homelessness."