At any given night in the United States, approximately 600,000 people are without shelter while more than 2 million may have been homeless in any given year. Estimates put the number in the United States who have experienced homelessness and its health consequences at least once at about 12 million people. Most counts and studies define homelessness as being without stable housing and include those staying in shelters and sleeping overnight in their cars and doubled up with others in a temporary arrangement as well as those living on the streets.
An increase in the rate of homelessness beginning in the 1980s has been attributed to increases in the rate of poverty, decreases in cash and other public benefits, and decreases in the availability of affordable housing. Personal factors related to homelessness include mental and physical problems, a history of domestic abuse, substance abuse, and a lack of resources including social support. In fact, one extensive survey of a clinic population noted that health issues are at least a partial contributing factor to homelessness among the vast majority of those surveyed.
As well as being a reason for homelessness, mental and physical health problems may also be the result of homelessness. Overall, the total rates of illness and injury among the homeless are 2-6 times those of the general population. Homeless people lack the simple essentials for health including a good diet, daily hygiene, sleep, rest, and safety. The homeless are frequently forced to live in overcrowded, unsafe, or unsanitary conditions that expose them to communicable diseases, violence, and the outdoor elements as well as increase their stress. Some engage in risky behaviors such as substance abuse and unprotected sex, which increase the likelihood of disease.
Common health problems among the homeless include upper respiratory infection (about six times the rate as those who are housed); lacerations, fractures, and other outcomes of trauma (about three times the rate); skin ailments (including scabies, lice, and skin infections); chronic gastrointestinal problems; and peripheral vascular disease including cellulitis, leg ulcers, and phlebitis (the latter two found at rates 2-5 times higher). The most common reason for hospitalization is trauma and cellulitis. The rate of tuberculosis is anywhere from 25 to 300 times the rate of those who have regular housing, the rate of HIV infection is 3-4 times higher, the rate of other sexually transmitted diseases 2 times higher, and the rate of violence is 4 times higher than that of the general population. Over 50% of the homeless adult population have gross dental decay. Given these data, it is not surprising that long-term homelessness may result in about a 20-year reduction in life expectancy.
Studies tend to overstate the rate of mental illness because some mental health symptoms are also common reactions to a homeless situation and do not necessarily indicate a long-term diagnosable disorder. However, it is estimated that about 20-25% of the homeless have had a severe mental disorder at some time in their life. The most common disorders are schizophrenia, depression, personality disorders, and posttraumatic stress disorders. An analysis of ten studies showed that the rate of schizophrenia is about 4-16% with a mean of 11%.
Substance abuse also has a high prevalence among the homeless. Some studies estimate that half of those who are homeless had a substance abuse problem sometime in their lives. Those who are homeless may abuse drugs and alcohol in order to self-medicate for a mental illness or the stress of life on the streets. Substance abuse increases the risk of trauma, neurological problems, liver disease, and tuberculosis.
The serious health problems of the homeless are aggravated by poor access to health care. The homeless often lack the essentials needed to access care, such as health insurance or the money to pay for care, transportation to get to care, and documentation that is required by many facilities. Many in this population have language and cultural barriers and may fear and distrust the people and facilities that provide care or have little sense of time, which is needed to keep appointments. Even those who can get services can find it difficult to follow treatment since they cannot keep or store medications or get bed rest and must spend time on more critical survival needs. For example, in a study of over 1,000 people who had been prescribed medications, almost a third were unable to comply. The availability of treatment for women with children and those who are dually diagnosed (those with a mental and substance abuse disorder) is particularly limited.
Families are the fastest growing segment of the homeless population. Women are found in equal proportions to men in the under-20 population of homeless and comprise 25% of those who are homeless. Many have had a history of abuse in their past (reported rates of 31-60%) and continue to be vulnerable to abuse on the streets. Homeless women in one study had been robbed an average of 3 times, assaulted 14 times, raped 5 times, and shot once in their lives. One analysis found that 53% of the homeless women suffered from posttraumatic stress disorder and 60% from clinical depression. The related rate of substance abuse in homeless women has been reported from 16% to 67%. Homeless women have an unusually high pregnancy rate and their infants are more likely to die or be born with a low birthweight.
To address the health problems of the homeless, the Health Resources and Services Administration of the federal government administers the Healthcare for the Homeless Program under the Health Centers Consolidation Act of 1996. This program provides basic and preventive health services, street outreach, and critical case management services to over 500,000 people each year but cannot meet the huge demand for necessary and accessible medical care. Effective treatment programs require services that are comprehensive, accessible, and nonthreatening and address the other essential needs of the population, especially food and housing.
SEE ALSO: Access to health care, Domestic violence, Mental illness, Prostitution, Rape, Sexual abuse, Substance use, Violence
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