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Summary and
Re~on~n~endations
ORIGIN OF THIS STUDY
Among congressional actions taken in recent years to address both the
broader aspects of homelessness and the more narrow issues relating to
the health of homeless people was the Health Professions Training Act
of 1985 (P.L. 99-129~. This mandated that the secretary of the Department
of Health and Human Services ask the Institute of Medicine of the
National Academy of Sciences to study the delivery of health care
services to homeless people. This report is the result of that study.
The study committee was composed of experts in fields such as
medicine, nursing, and social sciences; two public officials who administer
statewide health and human services programs also served on the
committee.
The charge to the committee and its staff was stated in P.L. 99-129:
1. evaluate whether existing eligibility requirements for health care
services actually prevent homeless people from receiving those services;
2. evaluate the efficiency of health care services to homeless people;
and
3. make recommendations as to what should be done by the federal,
state, and local governments as well as private organizations to improve
the availability and delivery of health care services to homeless people.
The members of the study committee endorse the analyses and conclusions of the report
but unanimously wish to express their strong feeling that the recommendations are too
limited in addressing the broader issues of homelessness—especially the supply of low-
income housing, income maintenance, the availability of support services, and access to
health care for the poor and uninsured.
136
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SUMMARY AND RECOMMENDATIONS 137
At the request of the study's funding agency in the Department of
Health and Human Services, the Health Resources and Services Admin-
istration, the committee took a broad view of health care and of needs
for health care-related services, including matters such as nutrition,
mental health, alcohol and drug abuse problems, and dental care.
STUDY PROCESS
The study committee met five times during a 10-month period (December
1986 to September 19871; individual committee members participated in
site visits to 11 cities and to rural areas of four states to observe the
problems of the homeless firsthand. The committee also commissioned
10 papers on specific areas of concern, such as the legal aspects of access
to health care and the problems of providing health care for homeless
people in the rural areas of America. Committee members, assisted by a
study staff of two professionals, reviewed what is known about the health
of homeless people, as evidenced in the scholarly literature, reports of
public and private organizations, and in particular- the ongoing evalu-
ation of work of the 19 Health Care for the Homeless projects funded by
the Robert Wood Johnson Foundation and the Pew Memorial Trust.
In the course of this study, the committee encountered several major
methodological problems. For example, the lack of a uniform definition
of homelessness results in substantial disagreement about the size of the
homeless population. Some people define the homeless as only those
who are on the streets or in shelters; others include those who are
temporarily living with family or friends because they cannot afford
housing. For its working definition, the committee adopted the one
contained in the Stewart B. McKinney Homeless Assistance Act of 1987
(P.L. 100-77), which defines a homeless person as one who lacks a fixed,
permanent nighttime residence or whose nighttime residence is a tem-
porary shelter, welfare hotel, transitional housing for the mentally ill, or
any public or private place not designed as sleeping accommodations for
human beings (U. S. Congress, House, 19874.
The committee commissioned a study of the methodology of counting
the homeless, which is included as Appendix B to this report, but refrained
from providing its own quantitative estimate of the number of homeless
people. One recent estimate of the number of homeless people in the
United States, published in June 1988 by the National Alliance to End
Homelessness (Alliance Housing Council, 1988), calculates that currently,
on any given night, there are 735,000 homeless people in the United
States; that during the course of 1988, 1.3 million to 2.0 million people
will be homeless for one night or more; and that these people are among
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138 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
the approximately 6 million Americans who, because of their dispropor-
tionately high expenditures for housing costs, are at extreme risk of
becoming homeless.
WHAT WAS LEARNED
Who Are the Homeless?
Contrary to the traditional stereotypes of homeless people, the homeless
of the 1980s are not all single, middle-aged, male alcoholics. Neither are
they all mentally ill people made homeless as a by-product of the policy
of deinstitutionalization of mental health care.
The homeless are younger, more ethnically diverse, and increasingly
are more likely to be members of families than is generally believed by
the public. In most cities around the country, minorities especially
blacks and Hispanics are represented disproportionately among the
homeless as compared with their percentage of the overall population of
those cities. Children under the age of 18, usually as part of a family
headed by a mother, are the fastest growing group among the many
subpopulations of the homeless. On the other hand, the elderly are
underrepresented among the homeless in comparison with their percentage
in the general population. There are a substantial number of veterans
among the homeless, especially from the Vietnam era.
Homeless people tend to be long-term residents of the city in which
they live. The homeless in rural areas, as well as homeless urban families,
usually have gone through several stages of doubling up with family and
friends before becoming visibly homeless.
Although the old stereotype of the public inebriate does not reflect the
diversity of homelessness in the 1980s, alcohol abuse and alcoholism are
still the most frequently diagnosed medical problems among homeless
men (more than 40 percent). Substance abuse with drugs other than
alcohol also appears to be more prevalent among homeless adults than
among the general population, as is "comorbidity" that is, multiple
problems in the same individual such as alcoholism and mental illness.
The homeless have also been stereotyped as uniformly mentally ill, in
part because severe disorders such as schizophrenia are conspicuously
overrepresented among homeless individuals on the street. Most studies
of mental illness among the homeless reveal that 30 to 40 percent of the
adults show evidence of some type of major mental disorder; 15 to 25
percent acknowledge having been hospitalized for psychiatric care in the
past. These rates are several times higher than those' of the general
population (Chapter 31.
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SUMMARY AND RECOMMENDATIONS 139
Why Do People Become Homeless?
The answer to this seemingly simple question is quite complex. Among
the many causes of homelessness, the committee identified three major,
interrelated factors that, in the face of a relatively strong economy, have
contributed to the increased number of homeless people in this decade:
1. Housing The supply of housing units for people with low incomes
has decreased considerably, while the number of people needing such
housing has increased.
2. Income and employment There has been a tightening of the
eligibility criteria for public assistance programs (especially locally funded
general relief), as well as a decline in the purchasing power of such
benefits for those who do establish eligibility. This reduction in benefits
comes at a time when the number of people living in poverty has
increased.
3. Deinstitutionalization The policy of deinstitutionalization, which
characterizes the way state mental health systems have been administered
since the early 1960s, is clearly a contributing factor; in addition, a policy
of noninstitutionalization that is, not admitting people for psychiatric
care except for very brief periods of time has further exacerbated the
problems of mentally ill homeless adults. Both policies were based upon
the assumption that treatment, rehabilitation, and appropriate residential
placement would be provided in the community. This has not happened
anywhere near the extent originally envisioned. Similar attitudes regarding
extended confinement have come to characterize policy toward general
hospitals and correctional, rehabilitation, and mental retardation facilities.
One result of these factors is that the system for providing temporary
shelter for people who are homeless has been burdened beyond its
capacity, despite enormous expansion in the last few years; people are
staying in these emergency facilities for many months, not only a few
days or weeks.
What Are the Health Problems of the Homeless?
Homeless people experience illnesses and injuries to a much greater
extent than does the population as a whole. The committee identified
three sets of health problems that specifically relate to homelessness:
1. Some health problems can cause a person to become homeless, for
example, injury on the job resulting in the loss of employment and
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140 HOMELESSNESS, HEALTH. AND HUMAN NEEDS
income, severe mental illness, alcoholism, drug abuse, and, more recently,
AIDS (acquired immune deficiency syndrome d.
2. Other health problems result from homelessness, for example,
problems resulting from exposure, such as hypothermia; problems re-
sulting from not being able to lie down, such as vascular and skin disorders
of the legs and feet; and problems resulting from specific hazards of the
homeless life-style, such as trauma from being mugged or raped on the
streets.
3. Many health problems require treatment that is made more compli-
cated or impossible by the fact that the patient is homeless. Almost all
illnesses and injuries fall within this category, and the difficulty encoun-
tered in attempting to treat even minor ailments when the patient is
homeless is one of the major issues facing health care providers. One
example would be the dietary limitations and the medication regimen
that are part of the routine care of hypertension, a problem of particular
significance among those past middle age and among blacks. Medication
can rarely be taken as prescribed, and the sodium content of food derived
from soup kitchens cannot be controlled. A simpler example would be
the frequent order to "rest in bed"; this is virtually impossible if one
does not have a bed, and very difficult at best if one must give up one's
bed in a shelter every morning and wait until evening to be reassigned a
bed.
What Other Problems Do Homeless People Have
with Health Care?
The primary problem that homeless people have with health care is
access, both financial and physical. With regard to financial access,
homeless people generally face the same problems as do other poor and
near-poor people: eligibility requirements for financial assistance, benefit
levels well below the current market price for health care, and a reluctance
of health care providers to supply low-cost treatment (especially in
specialties like obstetrics, for which malpractice premiums are extremely
high). Recent legislation has begun to eliminate one of the most serious
obstacles to financial access for homeless people, that is, the requirement
for a fixed address as a prerequisite for determining eligibility for public
health care benefits. Depending on the state and the city, however, many
homeless people especially single, nondisabled adult individuals are
simply not eligible for such benefits.
With regard to physical access, those obstacles that often prevent the
domiciled poor from obtaining health care prove to be still more difficult
for the homeless. Hospitals, clinics, and mental health centers often are
located far from the districts of cities where homeless people congregate.
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SUMMARY AND RECOMMENDATIONS 141
The primary means of getting to health care programs is public transpor-
tation, which homeless people often cannot afford. In addition, if they
do get to such programs, the long wait for services may mean that they
miss the deadline when they must be back at the shelter to sign up for a
bed for the night. Given a forced choice between treatment and a shelter
for the night, shelter invariably becomes a first priority.
Responding to the health care needs of the homeless is more difficult
than serving the medically indigent population generally. Personnel need
special training and support for working with people who often are very
distrustful, lack a network of social supports, and have a multiplicity of
medical and social needs.
What Is Being Done About the Health Problems of
Homeless People?
During the course of the study, members of the committee and the
staff observed many commendable, well-utilized (and often overextended)
health care and health care-related programs for homeless people through-
out the country. Meetings were held with local officials, service providers,
volunteers, and advocates for the homeless; numerous reports of other
programs were evaluated. Of particular interest were the efforts of the
19 Robert Wood Johnson Foundation-Pew Memorial Trust Health Care
for the Homeless projects, because they represented a particular targeted
approach to providing health care services to homeless people. Moreover,
while this study was in progress, Congress passed and the President
signed into law the Stewart B. McKinney Homeless Assistance Act (P.L.
100-77), which provides new funding for a range of services, including
general health and mental health care, in an effort to help the homeless
(U.S. Congress, House, 19871.
However, even the most energetic health care worker is repeatedly
confronted with the reality that poor and homeless people have trouble
separating a specific need, such as health and mental health care, from
the other activities needed for survival, such as securing housing and
food. The committee concluded that even if the health care services that
are clearly needed by so many of the homeless were widely available
and accessible, the impact of such services would be severely restricted
as long as the patients remained on the streets or in emergency shelters.
CONCLUSIONS AND RECOMMENDATIONS
Five Critical Observations
The fundamental problem encountered by homeless people lack of a
stable residence has a direct and deleterious impact on health. Not only
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142 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
does homelessness cause health problems, it perpetuates and exacerbates
poor health by seriously impeding efforts to treat disease and reduce
disability.
Although the urgent need for focused health care and other prompt
interventions is readily recognized, the committee found that the health
problems of the homeless are inextricably intertwined with broad social
and economic problems that require multifaceted, long-term approaches
for their resolution. In spite of the limitations brought about by the
committee's charge and the limitations of the committee's resources in
its ability to formulate detailed recommendations to deal with the root
causes of homelessness, the committee believes that those who seek
solutions to the homelessness problem itself and to its attendant health-
related problems must take into consideration the five critical observations
described below.
1. More than anything else, homeless people need stable residences.
The health problems of homeless people that differ from those of other
poor people are directly related to their homeless state. Homelessness is
a risk factor that predisposes people to a variety of health problems and
complicates treatment. The committee considers that decent housing is
not only socially desirable but is necessary for the prevention of disease
and the promotion of health. Yet the number of housing units for people
with low incomes has been steadily decreasing since 1981, while the
number of people needing such housing has been increasing during that
same period.
2. People need income levels that make housing affordable, both to
reduce and to prevent homelessness.
The issue of affordable housing has two sides: On one side is the supply
of housing at a given price; on the other is the amount of money an
individual or family has with which to pay rent. The committee observed
that in many communities neither employment at the current minimum
wage nor welfare benefits for those who are eligible provide enough
-income for them to acquire adequate housing. Given the irreducible
economic cost of housing in those communities, income adequacy must
also be addressed if homelessness and its attendant health problems are
to be prevented or remedied.
3. Supportive services are necessary for some homeless people who
require assistance in establishing and maintaining a stable residence.
Although the main issue is housing, for some homeless people, such
as the chronically mentally ill, the mentally retarded, the physically
disabled, those with histories of alcohol and drug abuse, the very young,
and the very old, housing alone may not be sufficient. They need the
kind of social support systems and appropriate health care that would
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SUMMARY AND RECOMMENDATIONS 143
allow them to maintain themselves in the community. Effective discharge
planning, outreach services, and casework are necessary to identify needs
and to ensure that these needs are met. With the proper support systems,
many will outgrow their need for therapeutic milieus and specialized
housing and will eventually become self-reliant. For some, however, the
need may be lifelong.
4. Ensuring access to health care for the homeless should be part of a
broad initiative to ensure access to health care for all those who are unable
to pay.
In its deliberations, the committee examined ways to increase and to
try to ensure access to health care for the homeless as a special group.
It concluded, on both ethical and practical grounds, that a targeted
approach was inappropriate in the long run. The committee found that,
as a practical matter, those who provide health care services to homeless
people also encounter other poor, uninsured people seeking access to
health care. Moreover, as discussed in Chapter 2, the boundary between
the homeless and the nonhomeless is thin and permeable. Although there
are some chronically homeless people, many poor people slip in and out
of homelessness. Extending health care services to the homeless while
continuing to deny them to the domiciled poor is, thus, not only
administratively impractical and bureaucratically cumbersome but also
ethically difficult for those who provide or finance health care services.
The committee agrees with the President's Commission for the Study of
Ethical Problems in Medicine and Biomedical and Behavioral Research
(19833 that the federal government has an obligation regarding access to
needed health care:
When equity occurs through the operation of private forces, there is no need
for government involvement, but the ultimate responsibility for ensuring that
society's obligation is met, through a combination of public and private sector
arrangements, rests with the federal government.
5. Short-term solutions will not resolve what has clearly become a long-
term problem.
The immediate and desperate need for shelter and food has overridden
attempts to design and implement policies that might provide some long-
term solutions. In the committee's view, what is needed now is planning
and action at the federal, state, and local levels to coordinate and ensure
the continuity of appropriate services and housing for homeless people.
Although short-term, problem-specific approaches provide essential and
sometimes lifesaving services, the committee does not believe that they
will result in major enduring change.
Keeping these five observations in mind, the committee offers some
recommendations about preventing and reducing homelessness before
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144 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
turning to recommendations focused on the immediate health care and
other service needs of homeless people.
Preventing and Reducing Homelessness and Its Related
Health Problems
As expressed throughout this report, health care and other services,
including temporary shelters, can only help relieve some of the symptoms
and consequences of homelessness. Coordinated efforts to address hous-
ing, income maintenance, and discharge planning are needed to prevent
and reduce homelessness.
Housing
The problem of homelessness will persist and grow in the United States
until the diminution and deterioration of housing units for people with
low-incomes are reversed and affordable housing is made more widely
available. Because of recent media attention to the refusal of certain
homeless people to reside in institutional domiciles, there may be a
misconception that homeless people will reject offers of decent and
appropriate housing. There are no known studies that prove that if
affordable housing were provided to homeless people they would use it,
but several reports of the U.S. Conference of Mayors (1986a,b; 1987)
regarding shelter utilization in excess of capacity support the belief that
if such housing were available, the great majority of homeless people
would surely accept it.
This is not a report on housing, nor was this committee made up of
housing experts.* However, in light of the frequency with which the
subject of housing arose during the course of this study, the committee
makes the following observations:
1. For nearly five decades, beginning with the National Housing Act
of 1938, the federal government has acknowledged, as a matter of explicit
policy, its obligation to help ensure that every American family has access
to decent housing. Because of the retreat from that commitment over the
last several years, there has been a dramatic increase in the number of
homeless people. The committee believes that if the health problems
caused by homelessness are to be prevented, this commitment to housing
should be reaffirmed.
2. Increasing the number of housing units for low-income people
* For a thoughtful analysis of this very complicated set of issues, see Alliance Housing
Council (1988).
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SUMMARY AND RECOMMENDATIONS 145
obviously requires major budgetary commitments. The lack of funds,
however, is only one of several impediments to augmenting the housing
supply. Among the nonfiscal issues that must be addressed are the impact
of zoning regulations, real estate tax exemptions as incentives or dis-
incentives to construct low-cost housing, local building construction
standards, and the need for greater communication and coordination
between the public agencies responsible for the disposition of abandoned
housing and the public and private agencies that seek to help the homeless
and ensure an adequate supply of affordable housing.
3. Many individuals and families only require a stable place to live,
but some, especially the mentally ill, alcohol and drug abusers, the
physically handicapped, and those with chronic and debilitating diseases,
need housing and an array of professionally supervised supportive services
in order to remain in the community—and, in many cases, to enable a
transition to independent living. The committee believes that supportive
housing programs for homeless people with disabilities are likely to be
cost-effective and may lead to a reduction in future public expenditures;
eventually, they may also enable these individuals to become economically
productive citizens. Although there has long been a commitment to
provide specialized housing (in the Community Mental Health Centers
Act of 1962 EP.L. 88-1641, for example, and implicitly in state governments'
deinstitutionalization policies), the federal and state governments have
not lived up to this commitment.
4. The Emergency Assistance program plays an important role in the
provision of housing, especially as it relates to homeless families. In the
committee's opinion, major aspects of this program that need to be
reassessed include voluntary versus mandatory participation by the states,
the use of Emergency Assistance funds to prevent rather than simply
to alleviate homelessness, and the period of time and type of facilities
(hotel rooms versus apartments) for which Emergency Assistance funds
can be used. This reassessment is especially urgent in light of the present
high prevalence of homelessness and the widespread expectation that the
problem will get worse before it gets better.
Income and Benefits
Throughout its deliberations, the committee was impressed by the fact
that improvements in income maintenance and other benefit programs
for people in poverty would help appreciably in preventing and reducing
homelessness and its related health problems. In this section the committee
offers some observations and conclusions, urges the implementation of
existing legislation, and recommends that some new legislation be con-
sidered.
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146 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
The committee observes that a growing number of people with full-
time jobs are becoming homeless. During its site visits around the country,
the committee heard numerous references to people who are working but
who cannot afford the most basic form of housing, not even a single
room (see Chapters 1 and 21. This suggests that the relation of the
minimum wage level to housing costs should be reexamined.
The committee also observed that many homeless people do not qualify
for federally supported entitlement programs such as Medicaid and food
stamps. Moreover, for those who do qualify, the benefit levels are so
low as to make it impossible for them to obtain adequate housing or
services. The committee did not find that there is any substantial
justification for major geographic variations in eligibility standards. There
may be a basis for some differences in benefit levels because of regional
variations in the cost of living, but the dramatic differences in benefit
levels from state to state identified in Chapter 4 do not appear to be
justified.
Therefore, we recommend that the federal government should review
all federally funded entitlement programs in order to create rational
eligibility standards and establish benefit levels based upon the actual cost
of living in a specific region. The committee commends state courts, such
as those in Massachusetts and New York, for their recent decisions
holding that entitlement benefits should be great enough to enable the
recipients to afford that for which the benefits are intended, whether it
be housing, food, or health care (see Chapter 5), and recommends that
this approach be adopted by other states and the federal government in
establishing benefit levels.
In terms of eligibility for benefits, the committee found that the 1986
federal legislation requiring the development of procedures to ensure that
the absence of a permanent address does not constitute a barrier to
receipt of cash assistance, food stamps, Medicaid, and other benefits has
yet to be fully implemented. The committee urges prompt, uniform
implementation of these procedures. Furthermore, the committee recom-
mends that state and local governments reexamine their documentation
requirements for public benefit programs to ensure that they, too, do not
impose unrealistic requirements on homeless people (Chapter 21.
The committee observed that some homeless people who are eligible
for income and other benefits are unaware of their eligibility or are unable
to secure them. Augmented outreach efforts to identify and assist the
homeless and those at risk of becoming homeless (especially those about
to be discharged from institutions) could reduce and prevent homelessness
(see the section Health Care and Related Services in this chapter for a
more complete discussion of outreach). The committee recommends the
following:
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152 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
services for homeless people who are mentally ill, irrespective of their
location.
Nutrition
Nutrition is of particular concern to the health and well-being of the
homeless, who are usually too poor to purchase adequate food and who
have no place to prepare it. For those who receive food in soup kitchens
and shelters, they get what is available without regard for special dietary
needs. Homeless infants, children, and chronically ill adults are especially
vulnerable to nutritional problems. Therefore, the committee recommends
the following:
· Providers of food to the homeless, such as operators of shelters, soup
kitchens, and food pantries, should be educated in and encouraged to follow
principles of sound nutrition and the special nutritional needs of the
homeless (Chapter 3~.
· The recently established practice of permitting food stamps to be used
at soup kitchens and other feeding sites should be extended to permit the
use of food stamps to purchase prepared foods from restaurants and
elsewhere (Chapters 1, 2, and 44.
· Because even the most prudent and imaginative parents in homeless
families cannot provide adequate nutrition for young children at existing
levels of food stamp benefits, such benefits should be recalculated to reflect
realistic expenses to meet nutritional requirements.
· The Special Supplemental Food Program for Women, Infants, and
Children (WIC) provides food assistance and nutritional screening to
women and children below 185 percent of the poverty level; however,
funding for this program is not adequate to provide such benefits to all
those who are eligible (U.S. Congress, House, Committee on Ways and
Means, 19871. Because many homeless women are pregnant and a growing
number of homeless people are children, it is especially important that
the WIC Program be strengthened in order to address comprehensively the
nutritional needs of pregnant women and young children.
Mental Health, Alcoholism, and Drug Abuse
Alcohol-related problems and mental disorders are the two most
prevalent health problems among homeless adult individuals, and drug
abuse appears to be on the increase. Since the early 1980s the National
Institute of Mental Health, the National Institute on Alcohol Abuse and
Alcoholism, and the National Institute on Drug Abuse have each funded
programmatic and basic research in these areas as they relate to home-
lessness. More recent programs, such as the community mental health
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SUMMARY AND RECOMMENDATIONS 153
services demonstration projects for homeless individuals who are chron-
ically mentally ill and the community demonstration projects for the
treatment of homeless individuals who abuse alcohol and drugs (as
mandated by Sections 612 and 613 of the Stewart B. McKinney Homeless
Assistance Act), have significant potential for combating the major
problems of these populations. Increased efforts to aid other homeless
people, whether they are individuals or families, should not be at the
expense of these existing programs.
In recent years, the trend has been to separate programs that serve
the mentally ill, alcoholics, and drug abusers. However, because there
is growing evidence of dual and multiple diagnoses among these popu-
lations (see Chapters 1 and 3) and because there are certain basic
similarities in efforts to provide treatment, those recommendations that
address elements common to programs that treat individuals with all
three diagnoses are identified before those recommendations relating to
individuals with a specific diagnosis. In seeking to resolve the very
complicated interrelationships among homelessness and mental illness,
alcoholism, and drug abuse, the following services should be included:
· targeted outreach services directed at homeless individuals suffering
from mental illness, alcoholism, or drug abuse;
~ supportive living environments encompassing programs ranging from
the most structured to the least structured; this is necessary so that as
the individual improves, progress can be made through several stages of
decreasing support and on to independent living, when possible (some
will need various support services throughout their lifetimes);
· treatment and rehabilitation services appropriate to the individual's
diagnosis and functional level; this must be a range of such services so
that, again, the individual who improves can become less dependent on
such programs while moving to self-sufficiency; and
· specialized case management provided by professionals who not only
understand the complexities of these illnesses as they relate to home-
lessness but who also understand the complexities of systems that seek
to provide mental health, alcoholism, and drug abuse services.
In addressing the issues of the mentally ill, alcoholic, or drug-abusing
homeless, the committee saw repeated reference in the literature and
heard from those actively engaged with these populations that greater
communication, consultation, and continuing liaison between providers of
services are needed. This is especially true for homeless adult individuals
who suffer from more than one of these diagnoses, who suffer from one
such diagnosis along with some other disabling condition (e.g., a physical
disability), or who suffer from one form of substance abuse while using
other substances as "enhancers." It is critical that people suffering from
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154 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
dual or multiple diagnoses (physical illnesses, mental disorders, and addic-
tions) not be left unserved or underserved because of the overspecialization
of treatment programs. It is far more cost-effective to coordinate existing
services than it would be to create new treatment programs directed at
each possible combination of diagnoses.
With regard to specific problem areas, the committee offers the following
conclusions and recommendations.
Mental health. The institutional mental health system appears to be
an inappropriate place to focus policymakers' attention in trying to resolve
the broad problems of homelessness. Proposals purporting to resolve the
problem of homelessness by changing commitment laws or by substantially
relaxing standards for admission to mental hospitals are misguided and
lead to an erroneous belief that the mental health system alone can correct
a problem for which all systems bear a responsibility. The central issue
in mental health care is the lack of an adequate supply of appropriate
and high-quality services throughout the mental health care system,
including state psychiatric centers and psychiatric units in acute-care
hospitals and in the community. The committee recommends that the first
priority in addressing the problems of the mentally ill homeless must be to
ensure the adequate availability of clinical services (including professionally
supervised supportive housing arrangements) at all levels. Of these, the
most serious deficiency between supply and demand—and that which is
most directly linked to homelessness- is at the community level.
Alcoholism and alcohol abuse. In addition to an inadequate supply
of those services cited earlier (outreach, supportive living, treatment,
and case management) as they relate to homeless individuals suffering
from alcoholism, the committee notes a serious shortage of services
directed toward the specific relationship between alcoholism and home-
lessness. In light of the fact that studies have shown that homeless
alcoholics are at significantly greater risk of certain health problems (e.g.
tuberculosis and hypothermia) than nonalcoholic homeless individuals
and that alcoholism may become an integral part of the life-style of
homelessness, the treatment of alcoholism among the homeless in the
same manner and at the same locations as those for the domiciled
alcoholic may not be the most effective. The committee recommends that
both public and private agencies and organizations treating alcoholism
develop programs specifically for the homeless and those alcoholics at high
risk of becoming homeless. The committee notes that recent developments
such as alcohol-free living environments (e.g., "sober hotels") and
programs that combine both medical and social approaches to the
treatment of alcoholism appear to be especially promising.
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SUMMARY AND RECOMMENDATIONS 155
Drug abuse. While not yet as prevalent as mental illness or alcoholism
among the homeless single adult population, drug abuse, especially among
younger adult men, is increasing. In particular, because of its close
correlation with AIDS, the issue of intravenous drug abuse has come to
greater public awareness, as has the inability of the existing drug abuse
treatment system to respond to the increased demand for treatment
services. The committee joins with others in recommending that treatment
services for intravenous drug abusers be increased to the extent that anyone
desiring such services can be accommodated. The cost of such services is
relatively minor when compared with the costs of treatment and care for
those physical diseases associated with intravenous drug abuse, such as
AIDS and hepatitis.
The prevalence rates for mental illness, alcoholism, and drug abuse
are much lower among adults who are members of homeless families
than among homeless adults who are not, but the fact remains that such
health problems are more prevalent among homeless parents than among
the general population. Furthermore, the long-term impact on treatment
programs and social service systems resulting from the effect of the
parents' problems on the children could become very costly in the future.
Both in terms of their value as a preventive measure and as the more
cost-effective approach to contain the need for such services years from
now, the committee recommends that the relevant federal, state, and local
agencies, as well as the relevant private not-for-profit agencies, should
begin to examine alternate ways to treat mental illness, alcoholism, and
drug abuse among homeless parents, giving due consideration to the
limitations of time and mobility inherent in a parent's role. In addition,
Congress should consider extending the provisions of the Stewart B.
McKinney Homeless Assistance Act of 1987 that currently deal with mental
illness and the treatment of alcoholism and drug abuse in individual adults
to cover homeless parents, children, and adolescents as well.
Convalescent Services
The committee recommends that Federal Emergency Management
Administration funds and other funds be made available, in every com-
munity, to support the development and operation of facilities in which
homeless people can safely convalesce from subacute illnesses or transient
exacerbations of chronic illnesses, or to which they can safely and appro-
priately be discharged from acute-care facilities. As described in Chapter
3, adequate health care for homeless people is often made impossible by
the simple absence of a secure place for them to convalesce. There is a
clear need for facilities that provide appropriate rest and nutrition as well
as limited personal care for periods generally not in excess of 30 days.
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156 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
Other Services
The Stewart B. McKinney Homeless Assistance Act of 1987 (P.L. 100-
77) creates a federal Interagency Council on the Homeless and charges
it to "review all federal activities and programs to assist homeless
individuals." This study committee, in the course of its many site visits,
observed several programs that are partially federally funded. For ex-
ample, the Cardinal Medeiros Center in Boston receives some of its
funding under the Older Americans Act (P.L. 89-73), and the Larkin
Street Youth Center in San Francisco receives some of its support under
the Runaway and Homeless Youth Act (P.L. 98-4734. Often, these
programs are not targeted directly toward, or identified with, the homeless.
In some cases, such funding is due to expire along with the enabling
legislation.
The committee recommends that the interagency council mandated by
P.L. 100-77 give high priority to its review of all programs that might be
of assistance in helping subpopulations among the homeless, irrespective of
whether such programs are specifically directed toward helping homeless
people. The council should:
· conduct an extensive review of such support programs, primarily to
identify programs that are providing or that could provide help to
subpopulations among the homeless;
· review joint federal-state efforts, such as state veterans homes with
partial federal funding, that, although not targeted directly to the homeless,
might help many homeless people;
· publicize successful efforts to help the homeless as a means of
encouraging other groups to develop similar programs in their commu-
nities; and
· consider ways and means of extending or enhancing the funding for
programs that are deemed effective in relieving or preventing homeless-
ness until the current prevalence of homelessness is substantially reduced.
Special Needs of Homeless Children and Their Parents
The committee feels strongly that the growing phenomenon of homeless
children is nothing short of a national disgrace that must be treated with
the urgency that such a situation demands. The committee has chosen
to offer a number of recommendations relating to services for homeless
children, only because it believes that the fundamental reforms to income
maintenance programs, the child welfare system, and foster care programs
will take a number of years to implement and that, in the interim, the
tens of thousands of homeless children are in urgent need of a broad
~ .
range of services.
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SUMMARY AND RECOMMENDATIONS 157
Recent studies have documented that the majority of homeless children
of various ages manifest delayed development, serious symptoms of
depression and anxiety, or learning problems (Bassuk and Rubin, 1987;
Bassuk and Rosenberg, 19884. These are early signs that vulnerability is
turning into disability for these youngsters; efforts by human service
professionals may be able to reverse these liabilities and to prevent
further damage. There is now a considerable body of evidence demon-
strating the benefits to disadvantaged and disorganized families of inten-
sive family-oriented services; such approaches are characterized by
flexibility in meeting families' multiple needs and by specific aids such
as developmental day care, infant stimulation programs, parental coun-
seling, and Head Start. Such intensive intervention efforts—even if
expensive to begin with have proved to be cost-effective in the long
run (Schorr, 19881. Because the homeless are an especially vulnerable
subpopulation of poor people, the committee believes that such programs
would be of similar benefit to this group. It recognizes that because the
population of homeless families includes some of the most hopeless and
alienated among the poor—and because they are more likely to move
from place to place there may be obstacles to participation in such
programs; therefore, the committee recommends the following:
· Federal support for enriched day care and Head Start programs should
be expanded and coupled with the development of outreach efforts to
encourage homeless parents to take advantage of enrichment programs for
themselves, their infants, and their young children.
· Local and state agencies that receive federal Head Start funds should
be mandated to develop plans to identify and evaluate homeless children
of preschool age and to provide them with appropriate services.
· Federal support for local and state education agencies should be
conditional on the adoption of plans for identifying, evaluating, and serving
homeless children of school age, including needed transportation services.
These plans should include specific mechanisms for liaison and service
coordination among educational, shelter, and social service agencies (Chap-
ters 1 and 3~.
· Apart from any mandates that may accompany federal support,
community agencies—acting in concert with school boards, local philan-
thropies, and other organizations—should be encouraged to develop pro-
grams of family-oriented services for homeless children and their parents.
Such services need to be both intensive and comprehensive.
Shelters
In the committee's view, shelters should not become a permanent
network of new institutions or substandard human service organizations.
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158 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
As desirable housing is developed, the shelter system should be substan-
tially reduced in size and returned to its original intent to provide short-
term crisis intervention. In the interim, the committee recommends that
action be taken to reduce the hazards to the health of homeless people
that may be created or exacerbated by shelters.
· The federal government should convene a panel of appropriate experts
to develop model standards for life and fire safety, sanitation, and disease
prevention in shelters and other facilities in which 10 or more homeless
people are domiciled. This code should be predicated on the recognition
that shelters, welfare hotels, and the like should provide short-term,
emergency housing and are not satisfactory longer term substitutes for
housing and other services (Chapters 2 and 31.
· Once a model code is developed and after a reasonable amount of
time has passed for compliance to be obtained, the federal government
should adopt the standards as a condition for receipt of Emergency Assistance
payments or other federal assistance, including Federal Emergency Man-
agement Agency funds. However, Federal Emergency Management Agency
funds should be made available to assist existing shelters to achieve
compliance with the standards.
· The federal government should disseminate the model code to encourage
voluntary compliance. State and local governments should be encouraged
to adopt it on a mandatory basis for shelters that do not receive federal
funds but that do receive funds from state and local governments.
· Adequate provision must be made to shelter families as a unit. The
consequences of homelessness are serious enough without being worsened
by family disruption.
· In light of the increasing prevalence of sexually transmitted diseases,
including AIDS, and unplanned pregnancies among the homeless, the
committee recommends that shelters, particularly those used by younger
single men, women, and adolescents, provide birth control counseling and
services, including free condoms, to reduce the risks of these conditions
(Chapters 1 and 31. It is recognized that data on the effectiveness of these
recommendations in shelter populations do not exist and that many
individuals, including some providers of services, may have ethical or
philosophical objections, but it is the consensus of the committee that
this recommendation represents sound public health practice.
Volunteer Efforts
The provision of services to homeless people depends heavily on the
efforts of volunteers. Even with the recommended expansion of federal,
state, and local government support, volunteers will be needed. The
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SUMMARY AND RECOMMENDATIONS 159
committee believes that the extraordinary contributions of services to
homeless people by volunteer professionals and laymen must be better
recognized, encouraged, and rewarded. Federal, state, and local govern-
ments and local United Way and other charitable agencies should work
with service-providing organizations to improve their capacity to recruit,
train, use, and recognize volunteers. Universities should play a major role
in providing support by using programs for the homeless as part of their
training curricula, especially in social work, law, medicine, dentistry,
nursing, optometry, and the allied health professions. Not only would
this improve the quantity and quality of volunteer efforts, but it would
also provide students with extraordinary learning experiences and make
them more sympathetic to those whom they will serve during their
careers. Hospitals and other health care facilities should be encouraged
to provide in-kind support (including clinic space and medications) for
volunteers in their communities who help the homeless. Health profes-
sionals and lawyers should be encouraged to provide pro bono services,
and professional organizations on the national, state, and local levels
should establish formal programs in support of such efforts and provide
recognition of those who provide such services.
State insurance commissioners should take measures to prevent carriers
of medical, professional, or institutional liability insurance from charging
additional, excessive, or discriminatory premiums or refusing to provide
coverage for health care providers who serve the homeless without adequate
documented actuarial experience to justify such action. This is especially
critical in regard to malpractice and liability insurance because it is
already difficult to recruit volunteers and to create university affiliations
for training in the settings in which homeless people are served; these
programs can ill afford to bear the additional burden of excessive insurance
premiums or the potential loss of coverage.
Research
Many questions about the health of the homeless remain unanswered.
Research is needed to elucidate the health and mental health disorders
of the homeless, the methods of providing health care, and the factors
that affect accessibility.
The Johnson-Pew Health Care for the Homeless projects provide the
only extensive data base on the general health condition of homeless
people (Wright and Weber, 19871. The shortcomings of these data are
that they document health problems in individuals seeking help at clinics
and are based on presenting complaints rather than systematic health
evaluations; therefore, hidden health problems are not included.
There are no longitudinal data that document the fate of homeless
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160 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
people. For example, it is a frequent observation that there are relatively
few homeless people over the age of 50, but the reasons for this are
unknown. Though there have been calls from many quarters for additional
resources to meet the needs of homeless people, there is still a paucity
of information as to the ways in which resources should be allocated.
Various subgroups of the homeless have different health service needs;
to consider the homeless as a homogeneous population is to be mistaken.
Research is needed to identify the various subgroups of homeless people
and their particular problems and health service requirements. Regional
variations are also important; the problems of displaced workers in rural
areas or small towns of the South or Midwest can be very different from
those of displaced factory workers in the eastern industrial cities, which
have more diversified economies.
Specific disorders deserve particular attention by researchers in epi-
demiology and health care services. These include tuberculosis and AIDS.
Alcoholism has traditionally been and continues to be the most prevalent
single medical condition of homeless people; improved methods of
outreach, detoxification, rehabilitation, and long-term maintenance should
be developed and evaluated. Abuse of other drugs also needs further
research. The National Institute of Mental Health and the Robert Wood
Johnson Foundation are to be especially commended for the initiatives
that they have taken in encouraging and supporting research in the
financing, organization, and delivery of services to the severely mentally
ill.
Public and private research funding organizations should encourage
research into the dynamics of homelessness, the health problems of homeless
people, and effective service provision strategies. Specifically, the following
research is most critically needed:
· longitudinal studies of the natural history of homelessness;
· studies of the prevalence of acute and chronic diseases in homeless
populations;
· the role of illness as a precipitant of homelessness and the ability of
health care and social service systems to prevent this outcome;
· studies of the homeless population and the prevalence of infectious
diseases (e.g., tuberculosis, hepatitis, and AIDS) and chronic disorders
or disabilities (e.g., mental retardation and epilepsy);
· studies of effective treatment programs for homeless alcoholics;
· development and evaluation of programs for homeless people who
are mentally ill; and
· studies of the effects of homelessness on the health and development
of children and evaluation of strategies to prevent homelessness in
families and to give additional support to homeless families.
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SUMMARY AND RECOMMENDATIONS 161
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Alliance to End Homelessness.
Bassuk, E. L., and L. Rosenberg. 1988. Why does family homelessness occur? A case-
control study. American Journal of Public Health 78(7):783-788.
Bassuk, E. L., and L. Rubin. 1987. Homeless children: A neglected population. American
Journal of Orthopsychiatry 5(2):1-9.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and
Behavioral Research. 1983. Securing Access to Health Care: The Ethical Implications
of Differences in the Availability of Health Services, Volume 1. Washington, D.C.:
U.S. Government Printing Office.
Rosenheck, R., P. Gallup, C. Leda, P. Leaf, R. Milstein, I. Voynick, P. Errera, L. Lehman,
G. Koerber, and R. Murphy. 1987. Progress Report on the Veterans Administration
Program for Homeless Chronically Mentally Ill Veterans. Washington, D.C.: Veterans
Administration.
Schorr, L. B. 1988. Within Our Reach: Breaking the Cycle of Disadvantage. New York:
Doubleday.
U.S. Conference of Mayors. 1986a. The Growth of Hunger, Homelessness, and Poverty
in America's Cities in 1985: A 25-City Survey. Washington, D.C.: U.S. Conference of
Mayors.
U.S. Conference of Mayors. 1986b. The Continued Growth of Hunger, Homelessness, and
Poverty in America's Cities: 1986. A 25-City Survey. Washington, D.C.: U.S.
Conference of Mayors.
U.S. Conference of Mayors. 1987. Status Report on Homeless Families in America's Cities:
A 29-City Survey. Washington, D.C.: U.S. Conference of Mayors.
U.S. Congress, House. 1987. Stewart B. McKinney Homeless Assistance Act, Conference
Report to accompany H.R. 558. Report 100-174. 100th Cong., 1st sess.
U.S. Congress, House, Committee on Ways and Means. 1987. Background material and
data on programs within the jurisdiction of the Committee on Ways and Means. 100th
Cong., 1 st sess. March 6, 1987.
Wright, J. D., and E. Weber. 1987. Homelessness and Health. New York: McGraw-Hill.
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Representative terms from entire chapter:
mentally ill
