Dying in the shadows: the challenge of providing health care for homeless people

Abstract

CommentaryCommentaire T he study of mortality among homeless women reported in this issue by Cheung and Hwang 1 (see page 1243) is a clarion call to our society and our health care community. The stunning 10-fold disparity in mortality rates between Toronto's homeless and housed women aged 18-44 is complemented by data from 7 other cities, which show that the risk of death among younger homeless women is 5-30 times higher than the risk among their housed counterparts. Previous studies by Hwang and others of homeless people in Boston and Toronto have reported overall mortality rates 3-5 times higher than those among the general public.2,3 This smouldering public health crisis can no longer be ignored.Homelessness is a prism that refracts the failures of society's key sectors, especially housing, welfare, education, health care and corrections. This complex social phenomenon thwarts simple definitions and resists easy solutions. The often-romanticized hobos and skid-row denizens of past lore have been joined by families with children, runaway and "throwaway" adolescents, struggling minimumwage workers and fragile elderly people.Only the economics seem straightforward. Housing is a scarce but highly valued commodity. Those least able to compete are doomed to fail; among them are people whose opportunity and choice are limited not only by abject poverty but also by chronic mental illness, substance abuse, physical and sexual violence, illiteracy, complex medical problems and advancing years. The complexity of need, the rich diversity and the growing numbers of homeless people have baffled researchers, bewildered policy-makers and exhausted the compassion of our society.Homelessness magnifies poor health and exposes those huddled in crowded shelters to communicable diseases such as tuberculosis and influenza. It complicates the management of chronic illnesses such as diabetes and asthma, makes health care harder to access and presents vexing obstacles that exasperate health care providers and confound delivery systems. The burdens of mental illness and substance abuse are well documented in homeless populations. Chronic illness is also common: many homeless people have hypertension, diabetes, peripheral vascular disease, respiratory problems, and liver and renal disease. Skin diseases are extraordinarily common and can lead to costly hospital admissions because of cellulitis. Hypothermia and frostbite are dreaded hazards of life on the streets and have been shown to be risk factors for early death. Some conditions, such as diphtheria, pellagra and lice infestations resulting in endocarditis from Bartonella quintana, 4-6 hearken to earlier centuries. Those caring for this population must merge medicine with public health: tuberculosis and HIV/AIDS are endemic; outbreaks of communicable diseases such as influenza and infestations are ubiquitous in shelters; trauma and violence hound homeless poor people. 7Cheung and Hwang reviewed excess mortality in 7 cities in 4 countries: England, Canada, Denmark and the United Stat...

The Mental and Physical Health of Homeless Youth: A Literature Review

“…This population often has more advanced illnesses than their housed counterparts due to the lack of prevention and early intervention, which in turn results in illnesses that are more expensive and complicated to treat [64]. These youth are at high risk for infectious diseases, such as influenza, hepatitis, and sexually transmitted infections (STIs) [59].…”

“…Diabetes and dental problems are also common in this population. Further, many homeless youth present with skin and respiratory diseases, such as asthma and pneumonia, which are typically contracted while living on the streets or in crowded emergency shelters [64].…”

Being homeless and the use and nonuse of services: a qualitative study

“…Some research emphasizes problems with the services themselves and has highlighted issues such as the lack of information among health professionals, differing views about what constitutes a housing need, and the ways in which being mobile with no permanent address is not compatible with services that are offered in specific places at specific times (Means & Smith, 1996;O'Connell, 2004). Other research focuses on the homeless person themselves and emphasizes how the homeless Correspondence to: Jane Ogden, Professor in Health Psychology, Department of Psychology, University of Surrey, Guildford, Surrey GU2 7XH, UK.…”

Homelessness in the Suburbs: Engulfment in the Grotto of Poverty

“…(Gaetz, 2008) Homelessness and poverty in urban areas are well researched, particularly their impacts on health, (Bryant, 2004;Cheung & Hwang, 2004;Frankish, Hwang, & Quantz, 2005;Hwang, 2001;Layton, 2000;Levy & O'Connell, 2004;O'Connell, 2004;The Street Health Report, 2007;Woolf, 2007). We know that morbidity and mortality rates are significantly increased for those lacking stable housing and other associated social determinants of health, such as secure access to food and healthcare (Hwang, 2001;Hwang, Martin, Tolomiczenko, & Hulchanski, 2003;Mikkonen & Raphael, 2010;O'Connell, 2004;Raphael, 2003). Some literature also describes the lived experiences from the perspectives of those who are homeless (Acosto & Toro, 2000;Daiski, 2008;Lafuente, 2003;Davis Halifax, 2010, Davis Halifax, Meeks, Yurichuk, & Khandor, 2008Davis Halifax & Yurichuk, 2007).…”