Homelessness Should Be Treated As A Major Health Issue

It is incongruous that in an era of great economic strength, with low unemployment, low inflation, a booming stock market, and high consumer optimism, a walk down the streets of any of our metropolises will reveal homeless people who are bedraggled, poor, and in many cases disabled by illness. It is all the more perturbing when one considers that these visibly destitute individuals, the sight of whom often offends the sensibilities of passersby, represent the mere tip of an iceberg of poverty and dislocation, most of which is invisible to the casual observer: Many homeless people are able to maintain a relatively normal appearance while living on the streets and are not particularly noticeable. In addition to street people, many other homeless people live in temporary or emergency shelters or seedy motels, and large numbers live in substandard housing or shanties. Yet others move in with relatives or friends because they cannot find, or afford, a place of their own. Estimating the numbers of homeless people is notoriously difficult, but clearly the scale of the problem is much greater in America than many people realize. A recent estimate by Bruce Link and colleagues at Columbia University, using a sophisticated sampling procedure, suggests that as many as 7 percent of Americans (13.5 million people) may have experienced homelessness at some time in their lives. As fall progresses toward winter, there inevitably will be a resurgence of public sympathy for homeless people. However, temperature extremes are by no means the worst aspect of being homeless. It is the lack of shelter, the loss of privacy, the exposure to infectious disease, the risk of intimidation and physical attack, the impermanence, and the social isolation that are its most injurious aspects. Journalists, activists, and advocates have vividly portrayed the plight of homeless people and the miserable conditions in which they live in America, but still not much happens, in terms of major public policy initiatives, to rectify the situation. That hundreds of thousands of people are homeless is a major indictment of our current political economy. It is also a major health issue. The relationship between homelessness and disease has been clearly demonstrated. Exposure to inclement weather, limited opportunity for maintaining personal hygiene, poor nutrition, exposure to street violence, sleep deprivation, heavy tobacco use, and exposure to alcohol and other drugs all pose health hazards, as do the overcrowded conditions of many shelters, with increased risk of exposure to parasitic or infectious diseases. Limited access to medical, psychiatric, dental, and podiatric care means that conditions that would in normal circumstances be easily resolved may persist, worsen, or become chronic. Homeless people have been shown to be at increased risk for tuberculosis and other respiratory diseases, trauma, schizophrenia, depression, alcoholism and its sequelae, drug abuse and dependence, HIV infection, and sexually transmitted diseases. In addition, those who are already sick and disabled are often at greatest risk of homelessness because of loss of income, because of their greater needs, because they have greater difficulty managing their resources, and because support provided by Social Security is often inadequate. Homeless families, most often consisting of mothers and children, have been of particular concern and are believed to be the fastest growing segment of the homeless population. The consequences of homelessness for children are grave. Residential instability in childhood has been associated with delays in cognitive development, interruption of education, frequent infections, anxiety and depression, and failure to obtain necessary immunizations. Homeless adolescents are in great danger of becoming involved in high-risk behaviors, including substance abuse and prostitution. The view from my office window includes rows of boarded-up city houses, condemned but not repaired to make them habitable, while hundreds, perhaps thousands, of people in the city are homeless today. But this is not generally thought of as a health concern: Policies governing housing and homelessness are considered to be economic or social policies, in spite of the fact that a home is as essential for health as are clean water, pure air, and uncontaminated food and that lack of a home endangers the health of individuals and families and that, on occasion, it endangers life itself. When a cluster of cases of coliform enteritis occurs owing to contaminated hamburgers, it becomes a public health emergency, and health agencies mobilize. Public agencies, in order to protect the public health, also are authorized to control the lead content of paints and gasoline, to control cigarette advertising, and to close beaches if the water is contaminated. In contrast, when a homeless man dies in a fire in an abandoned building where he has sought shelter from the cold, it is seen as a law-enforcement matter-he has committed crimes of breaking and entering and arson. When an epidemic of HIV infection or tuberculosis occurs among homeless people, health authorities question whether the shelters should be closed rather than insist that decent housing be provided as a public health measure. It would be unfair and inaccurate to imply that there has been no governmental response to homelessness. A decade ago, Congress enacted the Stewart B. McKinney Homeless Assistance Act (PL 100-77). Under the provisions of the McKinney Act, federal agencies have funded services for homeless people, including health care, mental health care, food assistance, emergency shelter, transitional housing, and facility construction. The act also established the Interagency Council on the Homeless to coordinate the activities of federal agencies and, in subsequent reauthorizations, additional programs were designed to help persons with AIDS, women in domestic violence shelters, and children in homeless families. A series of research demonstration projects has been funded to develop better models of serving the needs of homeless people. However, the McKinney Act was intended only as a first step. More far-reaching responses were to follow but have yet to be developed. Although immense and praiseworthy public and private effort has gone into providing services for homeless people in almost every state, there is no evidence that the extent of homelessness in America is less than it was a decade ago, and strong suggestions that it may be greater. More and more people end up in shelters or on the streets: There has been little or no progress toward preventing homelessness, in spite of the fact that preventing homelessness will promote health. Prevention is central to public health practice. Preventive public health strategies include immunization, smoking cessation and anti-drug campaigns, violence prevention, occupational safety measures, food inspection, control of lead in the environment, programs to promote balanced nutrition and dental hygiene, and water purification. We should now accept that the availability of adequate housing is an important preventive public health measure to be mandated by government and implemented by public agencies. This will require a concerted effort, supported by a national consensus that homelessness is as unacceptable in our society as dirty drinking water, dangerous workplaces, or unsafe highway bridges. It will require federal-state-city partnerships and the involvement of the private sector. Existing programs, such as Section 8 and other Housing and Urban Development initiatives, will need to be expanded and creativity applied to develop new solutions. First, housing must be available for all Americans: Currently there simply are not enough housing units for all of us, and there needs to be a massive program of housing construction. Different mechanisms will need to be developed to support this effort. Along with other initiatives, nonprofit housing construction and rehabilitation groups, such as Habitat for Humanity, should be encouraged and supported with public funds. Second, housing must be also be accessible-affordable and located in places where there is employment and freedom from cultural barriers, and with access to the other necessities for community living. Even then, many homeless people will have great difficulty in settling into mainstream living, either because of mental illness or developmental disability or because they have become acculturated to a different way of life. Thus the third requirement is that social services, health care, and other support systems be available to enable such people to acquire and maintain a permanent home. Scientists have been effective in advocating for sane public policies in relation to other issues, such as nuclear disarmament and control of tobacco sales. Scientists, particularly those in the public health arena, should be equally vociferous in advocating for a national endeavor to ensure that every American has access to an adequate home as a prerequisite for healthy living. Such advocacy will bring us into the political arena in a way that may make us uncomfortable. In 1988 the Institute of Medicine published a report, Homelessness, Health and Human Needs, which described the very considerable body of scientific knowledge then available about the impact of homelessness on health. The report-methodical, objective, and comprehensive as it was-did not generate a great deal of interest outside the relatively small circle of health professionals, scientists, and policymakers who were involved with homelessness. However, a great deal of media attention was given to an unofficial statement signed by almost all of the members of the committee who authored the report, expressing outrage at what they had discovered as they conducted their research for the report about the conditions under which homeless American citizens were forced to live, and the impact on their health. The academy held that the expression of outrage had no place in a scientific document; the committee members felt that they could not keep silent. Scientists should not keep silent today. They should join their voices with public health advocates and others to impress upon policymakers and those who elect them that homelessness is not only an affront to our ideas of America as a just and prosperous society, but also a health hazard that can and should be recognized as such and eliminated, like water pollution or malnutrition. We in the United States have a good record in confronting awesome technical challenges and achieving important objectives against enormous odds when we establish a national consensus. Cleaning up the rivers, immunizing children, fighting AIDS, and exploring the solar system all come to mind. If we decide to do so, we can eliminate homelessness. William R. Breakey is a professor in the department of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine.

Homelessness Should Be Treated As A Major Health Issue

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