Homelessness: Care, Prevention, and Public Policy

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causes and a potential for tragic consequences, is a public health and societal problem in cities, towns, and rural areas across the United States. Homeless men ...

Homelessness: Care, Prevention, and Public Policy James David Plumb, MD

Homeless men, women, and children make up a growing population that is vulnerable to preventable disease, progressive morbidity, and premature death. Homelessness and poverty are inextricably linked, and subgroups of persons who live in poverty have a particularly high risk for becoming homeless. Providing effective primary care for homeless persons is a formidable task because of many internal and external barriers to care. Targeted care strategies and new approaches to primary care are required to lower these barriers. Effective disease prevention in the homeless requires effective programs and policies to prevent homelessness. It is imperative that health professionals, the societies to which they belong, and academic health systems reaffirm their social responsibility, commit to changing public policies that perpetuate homelessness, and assist in the development and provision of primary health care services for persons who are homeless or on the brink of homelessness. Ann Intern Med. 1997;127:973-975. From Thomas Jefferson University, Philadelphia, Pennsylvania. For the current author address, see end of text.

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omelessness, a phenomenon with complex causes and a potential for tragic consequences, is a public health and societal problem in cities, towns, and rural areas across the United States. Homeless men, women, and children make up a growing vulnerable population that has an unacceptably high risk for preventable disease, progressive morbidity, and premature death. Serious questions have been raised about the causes of homelessness and the responsiveness of U.S. society to homelessness. Is homelessness a product of "malign neglect" (1)? Is it an "acceptable price of affluence" (2)? Has there been a "social construction of homelessness" (3) in the United States? It is estimated that 7.4% (13.5 million) of persons living in the United States have been homeless at some point in their lives (that is, sleeping in shelters, the street, abandoned buildings, cars, or bus and train stations) and that 3.1% (5.7 million) were homeless between 1985 and 1990 (4). Cities across the United States are now preparing for the consequences of the welfare reform bill, officially called the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. This bill creates block grants known as Temporary Assistance to Needy Families and gives states a lump sum equivalent to their 1994 spending on welfare each year

for 5 years. As a result of welfare reform, millions of Americans will soon be expected to find adequate jobs in the face of eroding labor markets in many cities. In addition, government officials and providers of care for homeless persons are facing crises caused by cuts in many aid programs, such as the Department of Housing and Urban Development's Homeless Housing program, Aid to Families with Dependent Children, and Mental Health funding for homeless care, as well as the discontinuation of Funding for the Family Self-Sufficiency program. These cuts have left holes in the safety net (5). Because of Temporary Assistance to Needy Families and these other policy changes, the number of homeless persons in the United States is expected to increase significantly in the coming years. Homelessness and poverty are inextricably linked (6): The working poor live on a precipice that can tumble them into homelessness any time. An illness, or an unexpected layoff, brings missed paychecks, which leads to skipped utility or rent payments, which snowballs into penalties, which ends in shutoffs or eviction. That leaves a Hobson's choice between no place at all or city-run homeless shelters, which often are dirty, noisy and unsafe.

According to the U.S. Bureau of the Census, 36.4 million Americans lived in poverty in 1995 (7). This growing number can be attributed to eroding labor markets and the declining value and availability of public benefits, such as welfare payments and food stamps (5). Subgroups of persons who live in poverty run a particularly high risk for becoming homeless. These subgroups include persons with mental disability or post-traumatic stress syndrome associated with war service, persons who have been victimized (especially through domestic violence), persons with drug and alcohol addiction or health problems, and persons who lack sufficient social support to tide them over during potentially long periods of crisis. Other persons at risk are those who are least able to obtain jobs that pay enough to allow them to purchase or rent housing (such as single women with young children and unskilled workers) or those who do not qualify for welfare (1). According to Wolch and Dear (1), © 1997 American College of Physicians

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the crisis of homelessness that surfaced in American cities is the 1980s shows little sign of resolution. Indeed, most socioeconomic indicators point to a continuing deterioration . . . continuing high levels of unemployment and under employment; a deepening erosion of the welfare state; the disappearance of the federal government's affordable-housing initiatives; and the socioeconomic polarization that further separates the haves from the have-nots.

Chronic disease is seen more frequently in homeless persons, 40% of whom report at least one chronic health problem (8). These chronic illnesses may be silent until late in their course and, because of limited medical attention, often go unrecognized and untreated. Even if the condition is detected and treated, lack of compliance and consistent follow-up often results in disease progression, disability, morbidity, and premature death (9). Premature death is the ultimate consequence of the increased vulnerability of homeless persons. Researchers in Atlanta (10) found that the median age at death among homeless persons in their study was 44 years; in a study in San Francisco, the average age at death was 41 years (11). Hwang and coworkers (12) recently reported an average age at death of 47 years in homeless persons in Boston. This study found that homicide, injuries, and poisoning (most often caused by an overdose of opiates) were the leading causes of death among persons 18 to 24 years of age; the acquired immunodeficiency syndrome (AIDS) was the leading cause of death among persons 25 to 44 years of age; and heart disease and cancer were the leading causes of death among persons 45 to 64 years of age. Other common conditions that are preventable or treatable, such as pneumonia and influenza, were frequently found to cause death in homeless persons in the Boston cohort (12). Providing effective primary care for homeless persons, who are under the safety net (13), is a formidable task. This is largely because of various internal and external barriers to care (14). Internal barriers include the denial of health problems by many homeless persons and the pressure to fulfill competing nonfinancial needs, such as those for food, clothing, and shelter. External barriers include unavailable, fragmented, and costly health care services and misconceptions, prejudices, and frustrations on the part of health professionals who care for homeless persons. In addition, according to Gelberg and colleagues (15), as health policy continues to encourage the transfer of the medical care of the poor (including the homeless) into managed care systems . . . gatekeeping mechanisms designed to ration care may lead homeless adults to further avoid seeking care in the early stages of illness if the care-seeking process becomes more arduous or time-consuming. 974

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As Hwang and colleagues point out (12), their review of the causes of death in the homeless has significant implications for clinicians and policymakers, particularly with respect to illness and death due to injuries, poisoning, opiate overdose, cancer, heart disease, and human immunodeficiency virus (HIV) infection and AIDS. High-risk sexual behavior and drug use are prevalent in homeless adults (16) and street youth (17). Preventing HIV infection in homeless persons is difficult, but not impossible, and requires specific targeted programs (16, 17). Susser and colleagues (18) reported on a program that was used to reduce HIV risk behaviors among homeless, mentally ill men in a New York shelter. The incidence of HIV infection and AIDS in intravenous drug users and prostitutes, who make up an unknown proportion of the homeless, continues to increase. Needle exchange programs that emphasize harm reduction strategies have been shown to be effective in preventing HIV infection in these groups (19); this service should be made available in locations where homeless persons congregate. Guidelines and protocols for early treatment and management of HIV infection and AIDS are well established (20), but effective use of these services requires access to knowledgeable health care providers, consistent care, and an extensive network of services. These challenges are formidable for homeless persons, who have other priorities (15). However, when services are provided in a respectful, flexible, and culturally sensitive manner, ongoing primary care for homeless persons with HIV infection is possible (21, 22). A major problem facing care providers and homeless persons is the cost of, access to, and monitoring of the intensive drug regimens now recommended in the early stages of HIV infection (20). The feasibility of creating health care services, particularly services focused on treating hypertension and tuberculosis, in places where the homeless congregate is well established (23). The progressive morbidity and mortality from infection, cancer, and heart disease in homeless persons could be reduced by developing primary care systems that include a common medical record across shelter sites and that offer targeted case management that focuses on influenza and pneumococcal immunization, cancer detection, and reduction of risk factors for premature heart disease. Increasing the availability of adequate low-income housing and violence prevention programs and improving alcohol and drug treatment programs could potentially reduce the risk for death from homicide and the morbidity and mortality associated with cirrhosis, injuries, and drug overdose. Effective disease prevention in homeless persons, however, requires effective prevention of homelessness. With 10% of single adults accounting for half

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of each year's shelter dollars in cities across the United States (6), new approaches that involve shifts in funding from shelters to innovative neighborhood programs have been developed in pilot projects in Philadelphia and New York City. These projects combine stopgap loans with long-term counseling at neighborhood sites. Efforts to decrease morbidity and mortality resulting from preventable disease should focus on identifying individual persons and families at risk and neighborhoods from which a disproportionate number of homeless persons come and on targeting primary care programs to these individual persons, families, and neighborhoods. Whatever the approach to care or prevention, it is imperative that health professionals, the societies to which they belong, and academic health systems now reaffirm their social responsibility, commit themselves to changing public policies that perpetuate homelessness, and help develop and provide health care services for persons who are homeless or on the brink of homelessness. Physicians can accomplish these goals by 1) recognizing and fighting the prejudice, discrimination, and apathy that contribute to poverty and homelessness; 2) advocating public policies that control rent, increase the number of subsidized housing units, provide job training and transitional support for those entering the job market, increase the number and quality of substance abuse treatment programs and community mental health services, improve domestic violence prevention and service programs, and provide basic health care regardless of the patient's ability to pay; 3) volunteering professional and personal time to participate in the extensive network of emergency food, shelter, and health services for homeless persons; and 4) serving as preceptors and consultants at the many successful primary care shelter clinic projects run by students and residents in health professions (24-26). In 1989, Hilfiker (2) asked, "Are we comfortable with homelessness?" Eight years later, are we still comfortable? We cannot afford to be. For the men, women, and children who are now without shelter, the toll is much too high. Requests for Reprints: James David Plumb, MD, Clinical Associate Professor, Department of Family Medicine, Thomas Jefferson

University, 1015 Walnut Street, Suite 402, Philadelphia, PA 19107.

References 1. Wolch J, Dear M. Malign Neglect: Homelessness in an American City. San Francisco: Jossey-Bass; 1993. 2. Hilfiker D. Are we comfortable with homelessness? JAMA. 1989;262:1375-6. 3. Robertson MJ, Greenblatt M. Preface. In: Robertson MJ, Greenblatt MJ, eds. Homelessness: A National Perspective. New York: Plenum; 1992:xi. 4. Link BG, Susser E, Stueve A, Phelan J, Moore RE, Struening E. Lifetime and five-year prevalence of homelessness in the United States. Am J Public Health. 1994;84:1907-12. 5. NCH Fact Sheet # 1. Washington, DC: National Coalition for the Homeless; 1997. 6. Take-Charge Program [Editorial]. The Philadelphia Inquirer. 29 March 1997. 7. Poverty in the United States: 1995. Consumer Income. Washington, DC: U.S. Bureau of the Census; 1996. 8. Ropers R, Boyer R. Homelessness as a health risk. Alcohol, Health and Research World. 1987:38-41. 9. Fleischman S, Farnham T. Chronic disease in the homeless. In: Wood D, ed. Delivering Health Care to Homeless Persons: The Diagnosis and Management of Medical and Mental Health Conditions. New York: Springer; 1992:81. 10. Death among the homeless—Atlanta, Georgia. MMWR Morb Mortal Wkly Rep. 1987;36:297-9. 11. Deaths among homeless persons—San Francisco, 1985-1990. MMWR Morb Mortal Wkly Rep. 1991;40:877-80. 12. Hwang SW, Orav EJ, O'Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med. 1997;126:625-8. 13. Brickner PW, Scharer LK, Conanan BA, Savarese M, Scanlan B. Under the Safety Net: The Health and Social Welfare of the Homeless in the United States. New York: WW Norton; 1990. 14. Stark L. Barriers to health care for the homeless. In: Jahiel Rl, ed. Homelessness: A Prevention-Oriented Approach. Baltimore: Johns Hopkins Univ Pr, 1992. 15. Gelberg L, Gallagher TC, Anderson RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87:217-21. 16. St. Lawrence JS, Brasfield TL HIV risk behavior among homeless adults. AIDS Educ Prev. 1995;7:22-31. 17. Sweeney P, Lindegren ML, Buehler JW, Onorato IM, Janssen RS. Teenagers at risk of human immunodeficiency virus type 1 infection. Results from seroprevalance surveys in the United States. Arch Pediatr Adolesc Med. 1995;149:521-8. 18. Susser E, Valencia E, Torres J. Sex, games and videotapes: a HIV prevention intervention for men who are homeless and mentally ill. Psychosocial Rehabilitation Journal. 1994;47:33-40. 19? Vlahov D, Brookmeyer RS. The evaluation of needle exchange programs. Am J Pub Health 1994;84:1889-91. 20. Carpenter CC, Fischl MA, Hammer SM, Hirsch MS, Jacobsen DM, Katzenstein DA, et al. Antiretroviral therapy for HIV infection in 1996. Recommendations of an international panel. International AIDS Society— USA. JAMA 1996;276:146-54. 21. Levine RN, Dzuber V, Sparks V, Lane SR, Ruiz K, Freeman M. The San Francisco AIDS Outreach Program to the homeless [Abstract]. Int Conf AIDS. 1991;7:394. 22. Swislow L, Epstein P, Forstein M, Haley J, Givelber F. The Multidisciplinary AIDS Program: a model of effective care [Abstract]. Int Conf AIDS. 1992;8:D522. 23. Brickner P, Mc Adam J, Vivic WJ, Doherty P. Strategies for the Delivery of Medical Care—Focus on Tuberculosis and Hypertension. In: Robertson MJ, Greenblatt M, eds. Homelessness: A National Perspective. New York: Plenum; 1992. 24. Haq CL, Cleeland L, Gjerde CL, Goedken J, Poi E. Student and faculty collaboration in a clinic for the medically underserved. Fam Med. 1996;28: 570-4. 25. Fournier A M , Perez-Stable A, Greer PJ Jr. Lessons from a clinic for the homeless. The Camilus Health Concern. JAMA. 1993;270:2721-4. 26. Plumb JD, McManus P, Carson L. A collaborative community approach to homeless care. In: Perkel RL, Wender RC, eds. Models of Ambulatory Care. Philadelphia: WB Saunders; 1996:17-30.

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