One of the most characteristic and consistent human behaviors over thousands of years is that humans build shelters. Homes offer protection from the elements and from a variety of health hazards and provide basic amenities such as a secure place to eat and sleep, to keep one's possessions, to raise a family, and be part of a community. Housing is a basic human need, yet the 1997 Human Development Report notes that more than 1 billion people—one-quarter of the world's population—live without shelter or in unhealthy and unacceptable conditions. Over 100 million people around the world have no shelter whatsoever. The health consequences of this level of homelessness are profound.
HOMELESSNESS IN NORTH AMERICA
Homelessness is a matter of concern anywhere in the world, but it is a particular cause for concern—and shame—when it occurs in the richest nations in the world. Sadly, homelessness is a significant problem in both the United States and Canada. Accurate statistics on the level of homelessness are hard to come by. In part, this is because definitions of homelessness vary. It includes not only those who are living on the streets or in shelters and hostels but also those who are living in temporary accommodation or in housing that is unfit for human habitation. Estimates of the number of people without homes in the United States vary from 230,000 to 3 million, including between 50,000 and 500,000 children. The U.S. Department of Housing and Urban Development estimated in 1999 that "there are at least 600,000 homeless men, women, and children in the United States on any given night," adding that roughly one-third of this population is composed of families with children. In its 1997 position paper on eliminating homelessness, the American Public Health Association (APHA) noted that "as many as 7.4 percent of Americans (13.5 million people) may have experienced homelessness at some time in their lives." Homelessness increased in the 1990s, and the fastest growing segment of the homeless population was homeless families.
In Canada, it was estimated in 1986 that 130,000 to 250,000 Canadians were homeless or living in substandard housing, while a one-night census by the Canadian Council for Social Development in 1987 found 10,672 people in emergency shelters—undoubtedly an undercounting of the true homeless. Up to half of the homeless in Canada now are believed to be families with children.
A wide array of factors contribute to homelessness, but they can be thought of as falling into one of two categories: structural problems and individual factors that increase vulnerability. Structural problems include a lack of affordable housing, changes in the industrial economy leading to unemployment, inadequate income supports, the deinstitutionalization of patients with mental health problems, and the erosion of family and social support. Added to this are factors that increase an individual's vulnerability, such as physical or mental illness, disability, substance abuse, domestic violence, or job loss. Reducing homelessness will mean addressing issues such as these.
THE HEALTH EFFECTS OF HOMELESSNESS
The health effects of homelessness include higher rates of infectious diseases, mental health problems, physical disorders, disability, and premature death. A United Kingdom report noted that those sleeping on the street on average lived only to their mid-to-late forties. Higher rates of infectious disease result from overcrowding, damp and cold living conditions, poor nutrition, lack of immunization, and inadequate access to health care services. There has been a particular concern with increased rates of tuberculosis (TB), particularly multiple drug-resistant TB. It has been reported, for example, that 48 percent of the homeless in Toronto test positive for TB. Another factor leading to increases in TB and other infectious diseases is the higher prevalence of AIDS (acquired immunodeficiency syndrome) in those segments of the homeless population involved in drug abuse and prostitution.
The conditions in which homeless people live also make them more prone to trauma. A study of street people in Toronto found that 40 percent had been the victims of assault in the previous year, while 43 percent of the women reported sexual harassment and 21 percent reported they had been raped in the previous year. These street people were also more than five times more likely to have been involved (as pedestrians) in a motor vehicle accident than the general population, and one in twelve of them had suffered frostbite in the previous year.
Homeless people are also more likely to suffer from cardiovascular, respiratory, arthritic, gastrointestinal, and skin disorders. The Toronto study found that arthritis and rheumatism were twice as frequent, emphysema and bronchitis five times as frequent, asthma two and one-half times as frequent, gastrointestinal problems twice as frequent, and epilepsy six times as frequent as in the general population.
Mental health problems contribute to and result from homelessness. The United Kingdom report noted that 9 to 26 percent of those living on the street have serious mental health problems (compared to 0.5 to 2% in the general population), while Canadian estimates are that 20 to 40 percent of those using shelters have substance abuse or psychiatric problems. Alcohol abuse and dependency is also very common in this population. But while such substance abuse and mental health problems contribute to homelessness, homelessness also contributes to these problems. The Toronto study, for example, found that one-third of the street people interviewed had feelings of worthlessness, that more than one in four (and almost two-thirds of the women) had contemplated suicide in the past year, and that one in twelve (and almost one in three of the women) had attempted suicide in that same period.
The increase in homelessness among families in recent years has focused increasing attention on the serious health problems faced by children living in hostels and temporary accommodation. These problems include disturbed sleep, mood swings, depression, and developmental delays, as well as increased rates of obesity, anemia, infections, injuries, and other health problems.
HEALTH SERVICES FOR THE HOMELESS
Not surprisingly, given all their health problems, homeless people make significant demands on the health care system. The Toronto study found that in the previous year, two-thirds of street people had seen a physician, more than half had used emergency rooms, and one-quarter of them had been admitted to hospital. But at the same time, homeless people—both those living on the street and those living in hostels and temporary shelters— experience significant barriers in accessing care. These barriers include procedural barriers such as the need to have a home address or a health card, economic barriers in terms of purchasing necessary medications, medical supplies, or appropriate foods, and—perhaps worst of all—prejudice and rude treatment on the part of health care providers. It is particularly unfortunate that a group that is so vulnerable and has such high needs should suffer further indignity and prejudice from what are supposed to be the caring professions.
Homelessness is a significant public health and health care issue. But more than that, as the APHA position paper concludes, "The persisting numbers of homeless people in America are an indictment of our collective failure to make basic ingredients of civilized society accessible to all citizens."
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