REV SUSAN BRANDT
Homelessness inevitably causes serious health problems. Illnesses that are closely associated with poverty — tuberculosis, AIDS, malnutrition, severe dental problems — devastate the homeless population. Health problems that exist quietly at other income levels — alcoholism, mental illnesses, diabetes, hypertension, physical disabilities — are prominent on the streets. Human beings without shelter fall prey to parasites, frostbite, infections and violence.
Each year, millions of people in North america are homelessness and are in desperate need of health care services. Most do not have health insurance of any sort, and none have cash to pay for medical care. Homeless people are concentrated in the nation’s urban centers and are dispersed throughout rural America, frequently not near the health care facilities that they need. They don’t have transportation or real control over their daily lives, since they depend on the routines of shelters, soup kitchens and marginal jobs to meet their most basic survival needs.
Finding health care is tough or impossible. People who are homeless are more concerned with meeting immediate needs for shelter, food, clothing, and safety than with seeking health care. For some, the symptoms of their illnesses or bad experiences with the health care system in their past cause them to actually avoid health care.
Unacceptable costs result from poor access to health care. Because homeless people often are uninsured and lack access to low-cost preventive health care, they go without care until relatively minor problems become urgent medical emergencies. Ultimately, most homeless people do get treated, but it is treatment of the most expensive sort, delivered in hospital emergency rooms and acute care wards. Through taxpayer support of public institutions and through the cost-shifting inherent in the health insurance system, we all pay the high costs of care deferred.
Undetected and untreated communicable diseases threaten the health of other homeless people in particular and of the public in general. These infectious and communicable diseases quickly escalate from personal trials to become costly and deadly public health emergencies. In the long run, perhaps the greatest costs are the moral and social results of neglecting the needs of dispossessed, seriously ill people in our midst.
An Effective Response to the Problem
A sensible and effective response to the health needs of homeless people has developed over the past seventeen years. In locations where homeless people congregate, health and social service workers have established clinics designed to overcome the access problems they face. These sites provide comprehensive care that improves people’s health and helps them to escape the trap of homelessness. These clinics are in shelters, soup kitchens, and skid-row store fronts. Medical vans visit parks, underpasses and encampments. Contact with the homeless population is extended by outreach workers who aggressively seek out and patiently engage the most isolated of homeless people.
Multidisciplinary teams work to remedy the variety of problems that affect their clients’ health. Going beyond traditional medical care, these effective teams work with their clients to address issues of safe shelter and permanent housing, jobs and income, family relationships and substance abuse. This comprehensive approach helps people get well and move out of homelessness.
Health Care for the Homeless Projects are successful because they are designed and controlled by local communities to fill significant gaps in existing health care delivery systems. Each project has well-established relationships with providers of shelter, mental health, substance abuse and hospital services in its community, and has developed considerable experience in managing the care of homeless people. Careful attention is paid to delivering high quality care in a cost-effective manner.
This model of care was developed through a 19-city demonstration program established in 1985 by The Robert Wood Johnson Foundation and the Pew Memorial Trust. In 1987, the Stewart B. McKinney Homeless Assistance Act replicated the foundations’ program and now 143 Health Care for the Homeless Projects are funded in part by the United States Public Health Service. The federal Health Care for the Homeless Program is widely recognized as one of the most effective McKinney Act programs, and is an indispensable, front-line component of our country’s struggle with homelessness.
Some Facts about Homelessness and Health Care
Many factors put people at risk of homelessness. Systemic issues of unemployment, low wages, expensive housing, lack of health insurance and racial discrimination combine with common personal issues such as domestic violence, abuse of alcohol and other drugs, and serious mental and physical illnesses to create this persistent social problem.
In the late 1990s between 2.3 to 3.5 million people were homeless at some point during an average year. 13.5 million of us have experienced “literal homelessness” at least once in our lifetimes.
1.2 million American families on waiting lists for subsidized housing are at particular risk of homelessness today. Any crisis could cause them to lose their precarious housing and wind up on the streets.
Like 40 million other Americans, homeless people typically do not have health insurance. The federal Medicaid program has provided coverage for many homeless women and children and some disabled men, but Medicaid policy changes are causing loss of health coverage for many people without homes.
Homeless people are particular victims of certain diseases. Approximately one-third have mental illnesses. Perhaps one-half have a current or past drug or alcohol addiction. Communicable diseases, including HIV/AIDS and tuberculosis, ravage the homeless population. Infections of every sort are prominent among homeless people. Trauma resulting from violence and conditions caused by exposure to the elements are common among homeless people.
Homeless people also have all the same health problems as people with homes, but at elevated rates. Without a home, there is no place to recuperate from an illness or to treat an injury, and health problems tend to get far worse before they get better.
A large segment of the homeless population is families with children, in a survey of 25 cities, accounting for 36% of the homeless population.
Each year, more than 1.35 million children and youth experience life without a home – living in shelters, vehicles, and parks.
One out of seven of those treated by homeless health care projects is a child under age 15.
Two out of five Health Care for the Homeless patients are females.
31% of homeless persons are over the age of 45.
Forty percent of homeless men are veterans, although veterans comprise only 34% of the adult male population.
More than 60 percent of Health Care for the Homeless clients are from racial or ethnic minority populations.
QUICK FACT SHEET on HOMELESS HEALTH CONCERNS
-Most chronic health problem is Hypertension
-Alcohol and smoking are direct causes of hypertension
-High sodium content of shelter food makes low salt diet unrealistic
-Cocaine can bring on coronary artery vasoconstriction
-90% of shelter users smoke
-Respiratory infections are common among homeless
-Pneumonia is prevalent
-Recuperation is more difficult given their poor living conditions, high incidence of substance abuse and poor nutritional status
-TB is seen in shelters testing ought to be done yearly but its not
-In Toronto .5% of shelter population have TB
-AIDS is the strongest risk factor for death
-Many argue the homeless ought not to be given antiviral because the med regime must be strictly followed
-Antiviral are not given to alcoholics actively using
-Liver disease occurs in those sleeping outside more than those sheltered because of increased liver enzymes
-This disease increases your risk of death by 6x
-Cirrhosis; end stage liver disease; due to alcoholism
-Hepatitis produces cirrhosis
-Hepatitis A; fecal oral transmission
-Hepatitis B; sexual, blood
-From sharing IV drugs
-Hepatitis C;IV transmission
-Pancreatitis; inflammation of pancreas
-Due to alcohol complications can be fatal
–Peptic ulcer; 5x more common amongst homeless
-Cirrhosis is associated with ulcers
-Cellulitis; bacteria infection of skin
-Foot problems; trench foot [soggy foot] -Frostbite; frozen tissue exposure
-Impegato; honey colored oozing
-Leg ulcers; lower leg venous dysfunction because of not being able to stretch out when sleeping
-Lymphedema; cause infection
-Onychomycosis; nail fungus
-Warts at least 60 types