CHAPTER 7
THE HEALTH OF THE HOMELESS

LIVING IN PUBLIC: INCREASED
HEALTH PROBLEMS

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 Causes

The following socioeconomic conditions contribute to the greater prevalence of illness and early death among the poor and homeless population:

• Poor diet
• Inadequate sleeping locations
• Contagion from overcrowded shelters
• Limited facilities for daily hygiene
• Exposure to the elements
• Exposure to violence
• Social isolation
• 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 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,

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:

1. The loss of convenient health care in centers or shelters
2. The habit of enduring untreated ailments, and/or
3. 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 study also suggested that clinical treatment of the homeless be accompanied by efforts to help them find permanent housing.

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.)

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,

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

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.

AIDS

The CDC reported that in 2003, between 850,000 and 950,000 Americans were living with HIV, the virus that causes AIDS, and 405,926 of those had full-blown AIDS (HIV/AIDS Surveillance Report 2003, vol. 15, March 2005). AIDS diagnoses increased in 2002 for the first time in ten years and increased another 1% between 2002 and 2003. In November 2002 the Food and Drug Administration approved a rapid test for HIV infection that can provide results in twenty minutes. U.S. Health and Human Services Secretary Tommy G. Thompson explained the significance of the test: "Each year, 8,000 HIV-infected people who come to public clinics for HIV testing do not return a week later to receive their test results.… With this new test, in lessthan a half an hour they can learn preliminary information about their HIV status, allowing them to get the care they need to slow the progression of their disease and to take precautionary measures to help prevent the spread of this deadly virus."

The CDC estimates that up to one-fourth of people infected with HIV are not aware of their condition. The CDC is working with health officials to make the rapid test widely available, particularly in places where likely victims reside, such as homeless shelters, drug treatment centers, and jails.

A study of AIDS patients in San Francisco found that poor people die sooner from AIDS ("Study: Disparity between Rich and Poor Mortality: Poor, Disadvantaged People Develop AIDS Faster," AIDS Alert, August 2003). Within five years of diagnosis, fewer than 70% of people living in the city's poorest neighborhoods were still alive, compared with more than 85% of people who lived in the richest neighborhoods. Poor people with HIV usually have a number of co-occurring disorders, such as drug dependence, mental illness, and unstable housing arrangements. The lack of affordable and appropriate housing can be an acute crisis for these individuals, who need a safe shelter that provides protection and comfort, as well as a base from which to receive services, care, and support.

The University of California at San Francisco, in HIV Prevention: Looking Back, Looking Ahead (1995), stated that almost half the homeless are estimated to have two or more of the risk factors associated with HIV—unprotected sex with multiple partners, injection drug use, sex with an injection drug user (IDU), or the exchange of unprotected sex for money or drugs. One-fourth report three or more risk factors. Having multiple sex partners is a risk for HIV, but it is extremely difficult for homeless people to form safe or stable intimate relationships due to drug use, mental illness, violence, or transient living conditions. Many homeless women are victims of rape or battery, and many women and children engage in "survival sex" or the exchange of sex for money, drugs, food, or housing.

THE MENTAL HEALTH OF HOMELESS PEOPLE

Before the 1960s people with chronic mental illness were often committed involuntarily to state psychiatric hospitals. The development of medications that could control the symptoms of mental illness coincided with a growing belief that involuntary hospitalization was warranted only when a mentally ill person posed a threat to him- or herself or to others. Gradually, large numbers of mentally ill people were discharged from hospitals and other treatment facilities. Because the community-based treatment centers that were supposed to take the place of state hospitals were often either inadequate or nonexistent, many of these people ended up living on the streets.

According to Folsom and his colleagues, 15% of patients treated for serious mental illness in California's mental health system were homeless at some point during a one-year period (American Journal of Psychiatry, vol. 162, February 2005). Twenty percent of patients with schizophrenia, 17% of patients with bipolar disorder, and 9% of patients with depression were homeless. The authors found that mentally ill people are at a much higher risk of homelessness than the general population.

Many homeless people do not realize how ill they are and how dependent they are on regular treatment. Others no longer believe the system can or will help them. This seems to have been borne out by a 1999 survey of 301 homeless adults in Buffalo, New York (O. Acosta and P. A. Toro, "Let's Ask the Homeless People Themselves: A Needs Assessment Based on a Probability Sample of Adults," American Journal of Community Psychology, vol. 28, 2000). When researchers asked homeless people what their greatest needs were, respondents listed affordable housing, safety, education, transportation, medical/dental treatment, and job training/placement. Formal mental health and substance abuse services were rated as unimportant by comparison, easy to obtain, and not very satisfactory to people who had used them.

In a 1998 study of 132 homeless adults (E. M. Reichenbach et al., "The Community Health Nursing Implications of the Self-Reported Health Status of a Local Homeless Population," Public Health Nurse, December 1998), researchers explored the personal characteristics and the health and health-related concerns of homeless health clinic clients. The study examined the significant differences in health and well being between homeless shelter residents and nonshelter residents. The homeless population studied featured a majority of males with an average age in the mid-thirties, a high rate of unemployment, and a low rate of health insurance. One-third of respondents reported their own health status as fair or poor. Joint problems and cardiovascular disease were the two most common physical ailments mentioned, while depression was the most common self-identified mental health problem. The most common fear mentioned by study participants was loneliness, but homeless people staying in shelters reported this fear much less often than those who did not stay in shelters.

Table 7.2 describes a study of 100 homeless women with schizophrenia and 100 non-homeless women with schizophrenia. The study, summarized by Silver and Pañares, found that homeless schizophrenic women had higher rates of co-occurring disorders, including alcohol and/or drug abuse and antisocial personality disorder.

Silver and Pañares noted that families with children comprise about 40% of the total homeless population, and the vast majority (about 90%) are female-headed. The authors reported on a study of 436 sheltered homeless and low-income housed mothers. The study found that 84% of all of these women had a history of having been severely assaulted at some point in their lives. Research has shown that mothers with a history of abuse are more likely to have children with mental health problems.

Perceptions of Mental Illness and the Homeless

Homeless people may be looked upon as mentally ill when their "abnormal" actions may actually be behavior caused by social and economic problems. For example, some homeless women act strangely and neglect personal hygiene as a way to protect themselves from attack. A 1988 report on homeless women in San Francisco (C. J. Cooper, "Brutal Lives of Homeless S.F. Women," San Francisco Examiner, December 18, 1988) revealed a high rate of rape and sexual assault—some of the women had been raped as many as seventeen times. The report stated that to protect themselves from attack, homeless women would wear ten pairs of panty hose at once and bundle up in layers of clothing.

Prevalence and Treatment

There is some debate over the rate of mental disorders among homeless populations, but there is general agreement that it is greater among the homeless than the general population. The 2004 U.S. Conference of Mayors study revealed that an average of 23% of the homeless in the twenty-seven surveyed cities were mentally ill. The National Resource and Training Center on Homelessness and Mental Illness reported in "Get the Facts: Why Are So Many People with Serious Mental Illnesses Homeless?" that a disproportionate percentage of the homeless population suffers from serious mental illnesses of the most "personally disruptive" kind, "including severe, chronic depression; bipolar disorder; schizophrenia; schizoaffective disorders; and severe personality disorders." An estimated 20% to 25% of the homeless population is afflicted, compared with only 4% of the general population.

Mentally ill homeless people present special problems for health care workers. They may not be as cooperative and motivated as other patients. Because of their limited resources, they may have difficulty getting transportation to treatment centers. They frequently forget to show up for appointments or take medications. They are often unkempt. The addition of drug abuse can make them unruly or unresponsive. Among people with severe mental disorders, those at greatest risk of homelessness are both the most severely ill and the most difficult to help.

SUBSTANCE ABUSE

The abuse of alcohol and other drugs has long been recognized as a major factor contributing to the problems of the homeless. According to the National Coalition for the Homeless, in No Open Door: Breaking the Lock on Addiction Recovery for Homeless People (December 1998), the number of addictive disorders per capita within the homeless population is nearly twice that of the general population, and even higher in certain localities. The 2004 Conference of Mayors report estimated that 30% of homeless people in the twenty-seven cities surveyed were substance abusers.

Being intoxicated or high in public is considered socially unacceptable. Housed substance abusers have the luxury of staying out of public scrutiny when in such a condition. Homeless people, however, may have no place else to be except outside; many homeless shelters refuse to provide shelter to intoxicated persons. Consequently, homeless substance abusers are often more visible than those in the general population. In addition, studies published in the 1970s and 1980s often used lifetime rates of substance abuse, rather than current rates, and tended to focus on single, homeless men, which led to inflated statistics. The overall effect has been to create a false impression among many people that most or all of the homeless are drunks and drug addicts.

Young homeless people are at the greatest risk for substance abuse problems. Children, either in families or on their own, are the fastest-growing segment of the homeless population. In "Substance Use among Runaway and Homeless Youth in Three National Samples" (American Journal of Public Health, 1997), researchers J. M. Greene, S. T. Ennett, and C. L. Ringwalt found that 81% of street youth (children under eighteen who have been on their own for an extended period of time) and 67% of homeless youth in shelters were using alcohol. In addition, 75% of street youth and 52% of sheltered youth were using marijuana, and 26% of street youth and 8% of sheltered youth were using crack cocaine. Among housed youth, 64% used alcohol, 25% used marijuana, and 2% used crack cocaine.

Dual Diagnosis and Substance Abuse

The National Institute of Mental Health and the National Institute on Alcohol Abuse and Alcoholism report that mental illness and substance abuse frequently occur together; clinicians call this dual diagnosis. Experts state that in the absence of appropriate treatment, persons with mental illness often resort to "self-medication," using alcohol or drugs to silence the voices or calm the fears that torment them. Homeless people with dual diagnoses are frequently excluded from mental health programs because of treatment problems created by their substance abuse and are excluded from substance abuse programs due to problems in treating their mental illness. Experts explain that the lack of an integrated system of care plays a major role in their recurrent homelessness. They stress that transitional or assisted housing initiatives for homeless substance abusers must realistically address the issue of abstinence and design measures for handling relapses that do not place people back on the streets.

Welfare Reform and Substance Abusers

Some people fear that welfare policy changes have increased homelessness among impoverished people with addiction disorders. In 1996 Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act (PL 104-193), which, among other things, denies Social Security Income and Social Security Disability Insurance benefits and, by extension, Medicaid to people whose addictions are a "contributing factor" in their disability. More than 200,000 people were affected by the cutoff. In "Welfare Reform and Housing: Assessing the Impact to Substance Abuse" (T. L. Anderson et al., Journal of Drug Issues, Winter 2002), the authors discussed their study of the effects of terminating the benefits to addicts "at a time of diminishing social services and a housing market explosion." Former benefit recipients reported increased homelessness and were found to be at increased risk of drug and alcohol use, criminal participation, and criminal victimization.

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."

PROBLEMS IN TREATING THE HOMELESS

To understand why health care may not be readily available to the homeless population, one must look at American health care in general. In "U.S. Health-Care System Faces Cost and Insurance Crises: Rising Costs, Growing Numbers of Uninsured and Quality Gaps Trouble World's Most Expensive Health-Care System" (The Lancet, August 2, 2003), Michael McCarthy described a system "lurching towards crisis." Costs continue to rise, as do the numbers of people who do not have insurance. The Census Bureau noted in 2004 that the number of Americans living below the poverty line increased by 1.3 million in 2004, and the number of uninsured Americans grew by 1.4 million.

McCarthy noted that while most hospitals by law must provide care for the indigent, in reality an uninsured patient is less likely to receive any care at all and, if hospitalized, is less likely to receive the same quality of care as an insured patient. He cited a 2002 study by the U.S. National Academy of Sciences Institute of Medicine (Care without Coverage: Too Little, Too Late, National Academies Press). That study found that "uninsured patients who are hospitalized for a range of conditions are more likely to die in the hospital, to receive fewer services when admitted, and to experience substandard care and resultant injury than are insured patients."

Medicaid

Medicaid is the federal health insurance program for low-income families with children, among others. In "'I Abhor the Status Quo': HHS Secretary Tommy G. Thompson's Plan to Revamp the Healthcare Industry" (Michael T. McCue, Managed Healthcare Executive, March 2003), Tommy Thompson, Secretary of Health and Human Services, described Medicaid as an outdated system that does not adequately serve the mentally or chronically ill, people with substance abuse problems, or childless adults (who make up a significant portion of the homeless population).

Medicare payments to physicians were cut in the early 2000s. Projections prepared by the Office of the Actuary for the Centers for Medicare and Medicaid Services indicated that Medicare will reduce payment rates to physicians by about 5% each year for seven years, beginning in 2006 ("Johnson Announces Hearing on Medicare Payments to Physicians," Press Release, Committee on Ways and Means, Subcommittee on Health, February 3, 2005). As a result of these cuts, some medical providers turned Medicaid patients away. A survey by the American Medical Association found that the number of physicians who said they planned to participate in the Medicare program in 2003 was down to 83%, 9% lower than the previous year (92%). Almost one-quarter of physicians had scaled back on the number of Medicare patients they would treat (American Medical Association: "Research Brief on Medicare Physician Payment Cut Survey," 2002). As a result, access to health care for many low-income people has been compromised.

HEALTH CARE FOR THE HOMELESS

In 1987 Congress passed the Stewart B. McKinney Homeless Assistance Act (PL 100-77) to provide services to the homeless, including job training, emergency shelter, education, and health care. Title VI of the Act funds Health Care for the Homeless (HCH) programs. HCH has become the national umbrella under which most homeless health-care initiatives operate. In 1994 there were 119 HCH programs in the United States; by 2005, 172 programs provided health care to about 600,000 people each year. In the year 2000 the government appropriated $88 million for HCH programs, almost double the $46 million appropriation of 1987, the first year of the program. The president's proposed FY 2006 budget included approximately $175 million for HCH programs.

Nonprofit private organizations and public entities, including state and local government agencies, may apply for grants from the program. The grants may be used to continue to provide services for up to one year to individuals who have obtained permanent housing if services were provided to them when they were homeless.

The goal of the HCH program is to improve health status for homeless individuals and families by improving access to primary health care and substance abuse services. HCH provides outreach, counseling to clients explaining available services, case management, and linkages to services such as mental health treatment, housing, benefits, and other critical supports. Access to around-the-clock emergency services is available, as well

as help in establishing eligibility for assistance and obtaining services under entitlement programs.

Table 7.4 shows characteristics of people treated in HCH centers in 2003. The majority of clients (59%) were male. Almost two-thirds (60%) of homeless clients were members of minority groups: African-Americans made up 37%; Hispanics, 19%; Asians/Pacific Islanders, 2%; and Native Americans/Alaskan natives, 2%.

Clients between the ages of twenty and forty-four represented the largest portion of people served by the HCH programs (53%), followed by individuals between the ages of forty-five and sixty-four (28%), children up to age fourteen (11%), and teenagers between the ages of fifteen and nineteen (4%). Homeless persons over sixty-five comprised 2% of clients served.

Of clients seen in HCH centers, 43% lived in shelters at some point during treatment, while 11% lived on the street. The remainder lived in transitional housing, with family or acquaintances, or in some other type of temporary living arrangement. The majority (71%) of HCH users had no medical care coverage. Of those who had some type of insurance, 22% were enrolled in Medicaid, 3% were enrolled in Medicare, 2% had private insurance, and 3% had some other type of insurance.