Monday, January 14, 2013

The History of Homelessness and its Public Health Ramifications

Homelessness is an ongoing and disturbing aspect of modern American life.  As we have seen in previous analyses of this problem, it an issue that effects every geographicregion of the country - within rural and suburban areas as well as the major cities.  In addition to the purely moral aspect of our obligation to those bearing such a burden, there are also strictly legal obligations.  It needs to be kept in mind that The United States is a signatory to the Universal Declaration of Human Rights. Article 25 of this document clearly states that, "Everyone has the right to ... food, clothing, housing and medical care and necessary social services In addition, the Housing Act of 1949, clearly enunciates the  long term goal regarding the, "realization as soon as feasible of the goal of a decent home ... for every American family."  And again, The Fair Housing Act of 1968 made discrimination on the basis of race in the housing market illegal. To date, none of these issues have been satisfactorily addressed.  It seems that decisions made consistently by the real estate industry and its developers have been driven purely by the marketplace and by the making of profit leading to the pitiful lack of affordable housing and the continuation of practices that include racial profiling and discrimination.

There are many reasons for the development and growth of homelessness In the United States over the recent past.   A connection that is avoidable relates to the wholesale decision in terms of public policy to remove the mentally ill from the institutions that housed them in the late 1970s.  Part of the rationale for this horrific decision was based on the promise, never kept, of providing sufficient outpatient medical and social services to accommodate those who no longer had the protection provided by institutionalization.  This new reality led to a large increase in the homeless mentally ill population.

In addition there was also an apparent sea-change in public policy beginning with the administration of President Ronald Reagan in the 1980s.  This change was motivated by a political philosophy that embodied the idea that government was not only incapable of solving societal issues but was also part of the problem.  Quote here. As a direct result of this political philosophy, social services were severely curtailed leading to the growth in the number of homeless due to the precipitous drop in government subsidies previously allocated to help provide housing for those in need. These issues were further exacerbated by a huge transfer of public monies to defense-based industries and in the concomitant increase in federal budget deficits.  This was also the era in which the inequity between the vast wealth of the few in relation to the rest of the population began to rise – to eventually reach its present proportions.

Currently, homelessness is largely ignored by the mainstream media and, therefore, not a topic of conversation or concern among the general public. The following data indicate the real enormity of the problem:

·                Over 7% of persons living in the United States have been homeless (defined as sleeping in shelters, the street, abandoned buildings, cars, or bus and train stations) at some point in their lives.  

·         Homelessness rates have increased over each of the past 2 decades. An estimated 2.5 to 3.5 million people now experience homelessness each year- this represent approximately 1% of the entire population.  

·           Approximately half are families with children, the fastest-growing segment of the homeless population. In one study, youth had a 1-year rate of homelessness of at least 1 night of 7.6%.

Not only do the homeless face the agonizing challenges of attempting to live without shelter, but there is also the problem of the medical issues that they face often as a direct consequence of the emotional and physical toll of living without the warmth and protection that reliable housing provides.  There are many myths associated with the homeless that are not supported by the data.  One of these is that simply getting employment would quickly resolve the issue for those affected.  The fact is, however, that 20% of homeless persons maintain either full- or part-time jobs.


Even given this fact regarding the state of employment among the homeless, only 5% are privately insured, often through COBRA.  In addition, the majority of homeless adults is not eligible for Medicaid in most States, and is also not eligible for Medicare due to the age requirement for eligibility.  Homelessness is particularly prevalent among US military veterans.  Although 23% of homeless persons are veterans of the armed services, yet only 57% have received healthcare services through the VA system that offers services inadequate to meet the extent of the demand.

The following is taken from a exceedingly well-documented report entitled, Homelessness in the United States: History, Epidemiology, Health Issues, Women and Public Policy authored by Dr. Martin Donohoe (July 7, 2004) and appearing in

"Because they usually lack health insurance, homeless persons tend not to get adequate preventive care and appropriate routine management of such chronic illnesses as hypertension, heart disease, diabetes, and emphysema. They tend to visit emergency rooms for acute illnesses.  Besides lack of health insurance, other barriers to care include denial of health problems; the pressure to fulfill competing nonfinancial needs, such as those for food, clothing, and temporary shelter; and misconceptions, prejudices, and frustrations on the part of health professionals.  When hospitalized, the average length of stay of a homeless individual, in 1 study, was 4.1 days, or 36% longer than that of low-income, non-homeless individuals, even after adjustment for differences in the rates of substance abuse and mental illness and other clinical and demographic characteristics. The cost of the additional hospital days per discharge ranged from $2414 to $4094 (1992-1993 dollars).

Homeless adults have an age-adjusted mortality rate nearly 4 times that of the general population; their average life span is shorter than 45 years. Homeless women 18 to 44 years of age are between 5 and 31 times more likely to die than women in the general population. Homeless women older than age 44 are only 1 to 2 times as likely to die, and are healthier than their male counterparts. However, homeless women in their mid-fifties are as physiologically aged as housed women in their seventies and are afflicted to a similar degree with chronic diseases, yet they do not qualify for elderly housing assistance.

Homeless women are more likely than homeless men to have experienced childhood sexual abuse and/or foster care and adult partner abuse. More than 50% of all homeless women and children become homeless as a direct result of fleeing domestic violence. The availability of domestic violence shelter beds in the United States is poor; up to 70% to 80% of women, and 80% of children, are turned away on any given night in major cities. Shelters are woefully underfunded; some do not allow children. Average length of stay at a US shelter is 14 days; most allow a 30-day maximum stay.  Ironically, women fleeing domestic violence are often not counted in studies of homelessness, since they are considered to have a home (albeit unlivable) or are staying temporarily in shelters.

On average, homeless adults have 8 to 9 concurrent medical illnesses.  The homeless commonly suffer from dermatologic conditions (e.g., skin lice, scabies, eczema, and allergic rashes), respiratory infections, tooth decay, foot problems (e.g., trench foot, tinea pedis), vision disturbances, sexually transmitted infections (STIs), and trauma. Functional limitations, substance abuse, and mental illness (particularly depression, schizophrenia, posttraumatic stress disorder, and personality disorders) are very common. Mental illness is reported in 30% of homeless persons, and in 50% to 60% of homeless women.  The usual chronic diseases, such as hypertension, diabetes, and asthma, are quite prevalent and difficult to manage. Preventive tests are underutilized because of time and funding constraints and because patients tend to present with acute care needs that require immediate attention. Homeless children frequently suffer from respiratory, ear, and skin infections, failure to thrive, developmental delay, and face neglect and abuse.


STIs are common among homeless girls and women, a function of limited access to reproductive health services, prostitution, and survival sex (i.e., sex in exchange for food, drugs, or temporary shelter). Twenty-six percent of female street youths (28% of male street youths and 10% of shelter youths) report having participated in survival sex, which is associated with older age, more days away from home, victimization, criminal behaviors, substance use, suicide attempts, STIs, and pregnancy.  Homeless women have a pregnancy rate about twice the national rate.  HIV rates are higher than in the general population, which has been attributed to higher prevalence of intravenous drug use, STIs, prostitution, survival sex, and limited access to condoms.


Unique aspects of homelessness that contribute to hard-to-manage medical and psychiatric illness include enhanced vulnerability to crime and violence; prolonged standing; excessive outdoor exposure; infectious disease transmission due to overcrowding; high risk of being robbed of medication; limited access to water for showers, dental care, and personal hygiene; inability to follow complex treatment and home care regimens; lack of privacy; and social isolation.  Those with language barriers -- particularly those who lack citizenship and work long hours under dangerous conditions -- such as homeless migrant and seasonal farm workers, face particular challenges and are often afraid to access even emergency care."

These data shed a disturbing light on the enormity of the problem of homelessness.  It is unconscionable that a prosperous nation that often prides itself on its adherence to so-called "family values" and repeatedly claims the moral high ground within the community of nations would permit such an issue to go unaddressed within its own borders.  

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