The street is not a healthy place to live; average life expectancy for homeless people is 41 years.
Few people choose homelessness. Unfortunate life events usher it in: the loss of a loved one, unemployment, domestic violence, divorce and family disputes, leaving prison or a hospital with nowhere to go.
Sleeping rough is estimated to double or triple the rate of physical health problems.
The Centers for Disease Control and Prevention (CDC) rate mortality for homeless people four to nine times higher than in the general population, with an average life expectancy as low as 41 years in the US.
What is homelessness?
The US Department of Health and Human Services' definition of homelessness states: "A recognition of the instability of an individual's living arrangements is critical to the definition of homelessness."
- In 2009-11, 62% of homeless people using shelters were male and 38% female
- 21.8% were aged under 18, 37% aged 31-50, and 2.8% over 62 years
- The largest percentages by race were: 41.6% white people, 37% black people
John Lozier, executive director of the National Health Care for the Homeless Council (NHCHC), based in Nashville, TN, told Medical News Today, "People experiencing homelessness may be living on the streets or in shelters, or they may be 'doubled-up' in the homes of friends or family members."
While accurate statistics are hard to collect, over 578,000 people in the US are estimated to be homeless at any one time and around 1.5 million over the course of a year.
Many couch surf or shelter in tents or cars, but between 31-44% of the US homeless have no shelter at all.
As Lozier explains, homelessness "may be more visible and concentrated in cities, [but it] also persists in rural areas due to such issues as lack of affordable housing, geographic isolation and high rates of poverty, underemployment and unemployment."
Kevin Ledgard, of Urban Street Angels in San Diego, CA, explained to MNT:
"Many homeless individuals are typically unnoticed in the community. This 'under the radar' effect is explained by many factors: the hectic lives led by 21st century citizens sometimes enable us to miss people right before our eyes; the desire of many homeless individuals to live anonymously, or to avoid being harassed by others or members of law enforcement; the legal issues of some homeless people, resulting in distrust of strangers."
The better we understand the issues, the more we can help. In this spotlight, we will look at some of the health problems affecting those experiencing homelessness.
Factors leading to poor health
The environmental stresses of climate and violence; poor nutrition and hygiene facilities; low personal safety; lack of privacy, warmth and space; lack of access to warm clothing, money, mobility, stability and supportive relationships are just a few of the health risks.
Even with soup kitchens and shelters, maintaining a healthy diet is difficult, as meals are usually high in salt, sugars and starch: cheap and filling but lacking nutritional content.
Lozier sees the main problem as the "lack of housing, which results in very high rates of mortality and morbidities of all sorts."
Barriers to health care
Accessing the health system can be difficult. Thirty US states and the District of Columbia have recently expanded Medicaid eligibility to include many socially disadvantaged people, including former prisoners, as reported by MNT. But Medicare is not accessible for all due to geographical location or the lack of a fixed address or ID card. Clinics cannot always handle the complexities of homelessness.
Even those newly eligible for Medicaid may lack the confidence or administrative skills to register.
As one Medicaid report points out, "eligibility is one thing; actually getting newly eligible people enrolled in Medicaid and helping them remain enrolled is another."
Previous negative experiences can lead to mistrust, low self-esteem and an unwillingness to engage with services. Literacy and communication problems can make administration difficult; lack of transportation makes appointments impossible to keep. People "fall through the cracks." They give up.
According to Lozier, the US Health Resources and Services Administration (HRSA) provide funding to over 270 health centers nationwide, known as Health Care for the Homeless clinics, and specifically designed to meet the needs of homeless patients.
Other HRSA-funded health centers also serve people experiencing homelessness, as do hospital emergency rooms, free and faith-based clinics and public health departments.
However, provider capacity issues mean many people without homes still lack essential health services. And as days turn into weeks and months, the quest for shelter, food and warmth push health concerns to the back burner.
As one homeless man says:
"You can't plan anything 'cause you don't know where you're gonna be sleeping."
This spotlight will look briefly at some of the issues.
Common health conditions
Common conditions such as high blood pressure, diabetes, asthma, hypertension, cardiovascular disease and cancers are frequent, made worse by stressful living conditions. Rest and recuperation are impossible, medications cannot be stored and health supplies get lost through theft.
Mental health and substance abuse
Mental health issues affect some 25-30% of people who are chronically homeless. Urban Street Angels list mental health as the main issue faced by those experiencing homelessness in the US.
Depression is common among people experiencing homelessness.
A Substance Abuse and Mental Health Services Administration (SAMHSA) survey finds that 12% of homelessness is caused by mental illness. In turn, homelessness leads to depression and anxiety.
Alcohol and drug dependence affect a significant minority. SAMHSA estimate that 35-50% of homeless people have substance usage issues, either caused by or resulting from homelessness. MNT has previously reported on the high number of deaths from drug overdose in this population.
Self-harm and suicidal tendencies are common. The Homeless Hub in Canada note that 22-46% of homeless people have attempted suicide, and up to 61% have had suicidal thoughts.
Women and children fleeing abuse at home are at risk of depression and post-traumatic stress disorder. SAMHSA estimate that over 92% of homeless mothers have experienced severe physical or sexual abuse.
Sexual identity issues contribute. In 2007, the National Alliance to End Homelessness estimated that 20% of youth who are homeless identify as lesbian, gay, bisexual or transexual (LGBT); rejection by families can lead to young people with LGBT status leaving home with nowhere to go.
Infectious and respiratory diseases
Hepatitis A, B and C, tuberculosis (TB) and HIV/AIDS spread easily due to compromised immune systems, poor nutrition and hygiene, overcrowding at shelters, intravenous drug use and lack of access to treatment.
- In 2011, 1% of the homeless population were estimated to have TB
- 5% of people with TB were homeless in the 12 months prior to diagnosis
- Prevalence fell from around 1,400 people in 1994 to under 600 in 2011.
The New England Journal of Medicine states that most substantial TB outbreaks in the US have originated in homeless shelters in major cities in the last 20 years.
However, surveillance and intervention efforts have reduced the prevalence, according to the CDC.
Common respiratory problems such as chronic obstructive pulmonary disease (COPD), emphysema, bronchitis and pneumonia affect homeless people disproportionately, exacerbated by cold, wet weather, overcrowding, malnutrition, lack of hygiene facilities and the high rate of tobacco smoking (80%).
Sexually transmitted diseases are common, as youth who are homeless tend to have more sexual partners and at younger ages, increasing the risk, as well as engaging in survival sex.
Harsh climate and violence make physical health a challenge on the streets.
Average daily temperatures for 15 US cities are typically at or below freezing, or 32° Fahrenheit in winter; in summer, some cities have temperatures over 100° F for more than 100 days a year.
The extremes can be deadly.
In the US, hypothermia is a leading cause of injury and death for those without shelter; 700 homeless people die each year from hypothermia.
For people living on the street, extreme weather can be lethal.
From populated cities to remote rural areas, 1999-2002 saw 4,607 fatalities across the US, according to the National Coalition for the Homeless.
Hypothermia occurs when the core body temperature falls below 95° F, as a result of cold, wind and rain.
Symptoms include exhaustion, numbness, cold, shivering, decreased hand coordination, slurred speech, confusion and impaired judgment. The heart, brain and kidneys can malfunction, potentially fatally.
Inadequate clothing and bedding, malnutrition and underlying infection increase the risk. Wet clothing can increase heat loss 20-fold.
John Lozier told MNT:
"Hypothermia can set in when temperatures drop below 50° F, and some winter shelters only open when temperatures reach much lower. In some areas, the designated temperature for opening these shelters is 32°, 25°, 20° or even 13° F."
In the winter, more people move into shelters, but there are insufficient facilities for everyone, and most operate only at night. Come morning, people are back out in the cold.
Frostbite occurs when body tissue freezes, usually the hands and feet; ears, nose, cheeks and even the penis can be frozen.
Severity varies from superficial, impacting skin and nearby tissues, to deep, affecting bones, joints and tendons. Long-term sensory loss and sensitivity to cold, arthritis, chronic pain and even autoamputation can result.
From 2006-14, 691 people were killed by heat in Phoenix, AZ, alone; over 20% of them were homeless.
Hyperthermia occurs when the core body temperature rises excessively. Sweating and evaporation normally cool the body, but in extreme heat, perspiration fails, and the internal body temperature rises dangerously, causing brain and organ damage, and ultimately death.
Shadows, sprinklers or an all-day transport ticket can save a life.
Violence and trauma
The New York Times recently described homeless people as "considerably imperiled," citing 1,437 documented acts of violence perpetrated against homeless people by those who were not homeless in 47 states from 1999-2013.
Surveys in Toronto, Canada indicate that 40% of homeless people were assaulted within 1 year, 21% of women had been raped and homeless men were nine times more likely to be murdered than housed men.
Urban Street Angels estimate that approximately 5,000 young people die every year because of assault, illness or suicide while on the street.
Minor cuts sustained in an assault can develop into major infections.
Feet, skin and teeth
Foot disorders such as fungal infections, corns, callouses and immersion foot easily result from inadequate footwear, prolonged exposure to moisture, long periods of walking and standing, and repetitive minor trauma.
Foot disorders are common among the homeless population.
Body lice and scabies are common skin disorders stemming from the inability to maintain good hygiene.
The CDC suggest that scabies affects up to 56.5% of homeless persons, and body lice from 7-22%, depending on circumstances.
Both are transmitted through physical contact or by contaminated items such as clothes and bedding. Inability to wash or change clothes can cause body lice infestations.
Both conditions can cause severe pruritus and scratching, resulting in bacterial infections.
Dental problems such as tooth decay also result from poor hygiene.
What can be done?
Richard Gere's photo went viral recently while playing a homeless man for the movie Time Out of Mind.
While filming, he was struck by most people's "decision not to engage." After several days, he was "touched" by one woman's decision to engage, as she approached, handed him a bag of food, then left.
Engaging with a stranger who is homeless can be awkward, but a kind word goes a long way.
According to the CDC, homelessness in the US has declined by 2% since 2013 and 11% since 2007. They attribute this to "the collective and concerted work of volunteers, advocates, organizations, and government agencies."
But more, they say, is needed.
Drop-in centers help meet people's most basic needs by offering a secure location, food, showers, washing machines, clean clothes and some access to health care, without judgment. Case management, skills training and counseling may also be offered.
Simple services such as dental check-ups, foot care treatment and sock donations are important. Trim toenails, clean feet and fresh socks can make a big difference.
People who escape from homelessness often say that the turning point was "when somebody listened," often in a drop-in center.
A kind word is always welcome.
Government initiatives are extending health access to more people and helping to contain and prevent outbreaks of TB and HIV, and looking at ways of providing more housing.
Kevin Ledgard told MNT: "Everyone can help. Providing basic human services (food, water, new or gently used clothing and footwear, first aid supplies, survival gear, etc.) always helps."
John Lozier suggests donating money or items to local shelters or nonprofit organizations, including winter coats, T shirts and sweatshirts, long underwear, travel-sized toiletries (including chapstick, sunscreen and feminine hygiene items), new underwear and socks, gift cards for grocery stores, backpacks and over-the-counter medicines.
Lozier also suggests volunteering at local shelters or becoming an advocate.
"Kind treatment also helps a great deal, as most homeless individuals don't want to be living on the streets and many have felt alienated from society for some time."
There are healthier places to live than the very margins of society.