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OCR for page 183
Clike Rural Homeless
Larry T. Patton
Homelessness is a reality for a growing number of rural Americans.
This situation has received little notice, as media and research attention
has focused on the highly visible problem of the urban homeless. This
lack of public recognition is hardly surprising. Rural residents have a
long tradition of preferring self-help and reliance on relatives, friends,
and neighbors to taxpayer-supported programs, which has effectively
disguised the magnitude of the problem of rural homelessness. Some
would even argue that while private, voluntary action was meeting the
need, the policy implications of ignoring the rural homeless were minimal.
The situation appears to be changing, however. There are growing
indications that some rural communities can no longer shoulder the
burden alone. Informal community support networks are being over-
whelmed by the severity and duration of the rural economic crisis. Farm
communities, in particular, are experiencing an erosion of the old rural
ethic that "we take care of our own," a development that appears to be
independent of the rural economic crisis.
At this point, there are no answers to many questions central to the
public policy debate: issues of definition, the prevalence of rural home-
lessness, changes in its incidence, and similarities and differences between
rural and urban homeless populations. Unfortunately, this appendix
cannot authoritatively resolve these questions; that will require substantial
additional field research. The discussion presented here relies instead on
a review of the meager available research, a special survey conducted
Larry T. Patton is a Washington, D.C.-based consultant specializing in health and welfare
policy and rural issues.
183
OCR for page 184
184 APPENDIX C
by the U.S. Department of Health and Human Services (HHS) of its
community health center grantees, and two site visits to the Black Belt
counties of Alabama and Mississippi and the farm regions of Minnesota
and North Dakota- that were supported by HHS. While broad general-
izations cannot be drawn from the site visits, they proved particularly
useful in providing sharply contrasting views of homelessness.
This appendix first examines the nature and causes of homelessness in
rural areas. The structural transformation now under way in the rural
economy, the nature of the rural environment, and rural social service
networks are briefly reviewed, as is the available evidence regarding the
characteristics of the rural homeless.
The remainder of the appendix examines the scanty data on medical
care utilization by the homeless. The primary sources of data include a
study supported by the National Institute of Mental Health of the homeless
in Ohio and the community health center survey and site visits mentioned
above.
This appendix offers a number of observations:
· Rural homelessness is essentially an economic problem. The failure
of policymakers to appreciate the extent of the rural economic crisis, and
the degree to which a majority of rural counties are especially vulnerable,
has contributed to the tendency to perceive homelessness exclusively as
an urban problem.
· The nature of rural communities obscures the problem of homeless-
ness as well. With the exception of larger, more urbanized cities, rural
communities seldom have in place a formal social service network that
would permit the transient homeless to gather or be counted. In fact,
they are often met with hostility and suspicion by community residents.
· The willingness of neighbors to "take care of their own," shuttling
the economically distressed family from neighbor to neighbor, has been
a major factor leading to underestimates of the rural homeless. The site
visits also highlighted the significant private efforts being made by
philanthropic and religious organizations to assist the homeless.
· The duration and the pervasiveness of the economic crisis may
increase the public burden of rural homelessness. An important finding
in farming communities is the growing evidence that those in economic
distress can no longer rely on their neighbors for help.
· The rural homeless appear to be slightly younger than their urban
counterparts and more likely to be living in intact, two-parent families in
which both parents were recently employed before being forced into
poverty and homelessness.
~ The ability to access medical care in times of emergency appears
adequate, but this finding is tentative at best. There are few data on the
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APPENDIX C 185
homeless living in the sparsely populated areas where provider shortages
would be more common.
· Routine or preventive care is used little, if at all, which is similar to
the case for the urban homeless. The high prevalence of chronic disease
in the rural population and the high rates of malnutrition, dental disease,
and environmental hazards (poor sanitation, inadequate and dangerous
housing, and contaminated water supplies) suggest the importance of
access to such care.
· There is a great need to better utilize the existing delivery systems,
such as community, rural, and migrant health care centers, to address
the medical care needs of the rural homeless.
A final point deserves to be mentioned: the issue of relative burden.
Compared to urban America, there are great differences in the scale,
density, and resource base of rural communities that severely limit the
ability of these communities to assist individuals in economic distress.
That perspective is essential to keep in mind as we develop better
estimates of the relative distribution of the homeless in rural and urban
communities. Even relatively low numbers of homeless individuals and
families can easily overwhelm a rural community's resources.
THE RURAL ECONOMIC CRISIS
Parts of rural America are facing their worst economic crisis since the
Great Depression. In the last few years, the rural economy has been
dealt a series of economic setbacks.
· Farm foreclosures have been taking place at a staggering rate: 650,000
foreclosures have occurred since 1981 and another 2,000 farmers give up
farming each week.
· Low-wage, labor-intensive rural manufacturing has lost over half a
million jobs since 1981 as a result of foreign competition.
· Timber, mining, petroleum, and other energy industries experienced
severe downturns as energy prices tumbled (Sinclair, 1987; Brown and
Deavers, no date).
The secondary effects have been just as severe. It is estimated that
one business fails for each six to seven farms lost to foreclosure (Ranney,
19861; in fact, in 1985, 130 banks closed, the highest number in any year
since the Great Depression (U.S. Congress, Senate, Committee on
Governmental Affairs, 1986~. The rural unemployment rate now consis-
tently exceeds the urban unemployment rate, a reversal of the historical
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186 APPENDIX
C
trend. In addition, the rural poverty rate approached the 20 percent mark,
the highest level in two decades (Brown and Deavers, no date).
Yet the impact of these economic changes on rural counties has been
uneven: Some rural counties have experienced few repercussions from
the worsening economic climate; others have been devastated. Two
aspects of the rural economy are useful in identifying those rural counties
most at risk.
First, most rural counties have never successfully diversified their
economic base. As a result, the economies of two out of every three
nonmetropolitan counties are dominated by a single industry. In 1985, of
the 2,443 nonmetropolitan counties, 29 percent (702 counties) were
primarily dependent on agriculture, 28 percent (678 counties) were
manufacturing dependent, and 8 percent (200 counties) were mining
dependent (Brown and Deavers, no date).* All of these industries are in
financial distress.
Second, while poverty has left few rural counties untouched, rural
poverty has always been extremely concentrated. Two-thirds of the rural
poor reside in the southeastern states, as do 93 percent of rural blacks
(Ghelfi, 1986; National Association of Community Health Centers, 19871.
Of the 231 counties that have ranked in the bottom fifth of income for
the past 30 years, all but 18 are located in the southeastern United States.
In fact, four states (Georgia, Kentucky, Mississippi, and Tennessee) each
had more than 20 such counties. The 18 persistently poor counties outside
the South were all minority dominated (Hoppe, 19851.
Counties whose economies are dominated by a single industry in
distress—particularly those plagued by persistent poverty—offer dis-
placed workers few job alternatives. Unfortunately, there is little basis
on which to predict whether rural displaced workers will migrate to
metropolitan areas, where some may contribute to the urban homeless
problem, or remain in rural areas. While there is now under way a net
migration away from rural areas (Sinclair, 1987), migration clearly works
in both directions. Migrant laborers; those alienated from urban life;
unsuccessful job seekers in urban areas returning to their families; and
even those accidentally stranded in their job searches due to emotional,
financial, or physical collapse all contribute to migration into rural areas
(Frank and Streeter, 1987~. In addition, the rapid rise in the poverty and
unemployment rates in rural areas demonstrates that many rural residents
have chosen to remain, despite the low probability of finding alternative
employment above the minimum wage.
*A county is viewed as being dependent on a specific industry when the weighted average
annual income of the industry accounts for 20 percent or more of weighted annual total
labor and proprietor income, according to Brown and Deavers (no date).
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APPENDIX C 187
DEFINING RURAL HOMELESSNESS
The impediments to establishing a clear-cut definition of homelessness
in urban areas are only exacerbated in rural America. Clearly, all displaced
workers or farmers do not always join the ranks of the homeless; many
do not even make it into the official unemployment count.
How then do we define those who are homeless in rural areas? Do we
include those in substandard housing? How do we treat those living with
friends and relatives? Do we exclude those who pay nominal rents? At
what point does a temporary housing arrangement become permanent?
The following case highlights this dilemma:
Family of three (elderly woman, adult daughter, infant grandchild) living in
two-room shack (family home for over 20 years on relatives' property in rural
area); approximate dimensions, 12 by 20 feet. No electricity, water, or septic
tank. Shack is located in area of water runoff and floor is wet most of the year.
(Household) head receives disability (Supplemental Security Income), adult
woman works minimum-wage job. Rent is $40/month. Water is carried one-half
mile from church spigot; has privy. Has been on waiting list 2 years for Section
8 (housing); list is 4 years long. House cannot be winterized due to size and
placement of wood stoves, it is felt that making the house weathertight would
increase danger of fire. No available affordable housing for this family at this
time.
This example was volunteered by a Community Action Agency director
as a portrait of their "typical" homelessness case, and it is very
compelling.* But elements of this profile are unsettling: Is this family
truly homeless? The literature review and the site visits did not provide
an operational definition of rural homelessness, but they did provide a
general framework for approaching the question.
First, there is little disagreement that those without any form of shelter
are homeless; the critical question is the extent to which any definition
includes those who are temporarily housed as well. In urban areas,
researchers have the option of including selective groups of people with
temporary housing, such as the portion of the homeless served by
shelters. In truly rural areas, such an option is unavailable because formal
services such as shelters are virtually nonexistent; residents who become
homeless must rely on friends, neighbors, and relatives for temporary
housing.
A relative or friend will often bear the burden alone, initially; later,
sharing responsibility by "shuttling the person (or family) along from
*This was one Community Action Agency director's response to a survey being conducted
by the Housing Assistance Council (1984) of Washington, D.C. The survey was not complete
when this report was drafted.
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188 APPENDIX C
family to family as their 'welcome' is exhausted" (Ohio Department of
Mental Health, 19851. Data on rural households suggest that the demands
placed on friends and families have escalated rapidly in the 1980s. The
Housing Assistance Council, tracking rural household size from 1979 to
1983, found that:
. . . the increase in rural working poverty over that period was strongly
associated with an increase in household size, not by one or two persons, but by
three or more persons. Such large increases, we believe, can Drily be explained
by wide-scale doubling up among working poor families. Wilson, 1983)
While the inclusion of those with temporary housing in rural areas
presents serious methodological problems for researchers, the evidence
suggests that there are few alternatives to their inclusion; otherwise,
similarly situated urban and rural homeless people would be classified
differently.
Second, in some cases the homeless pay nominal rents. One source of
housing for the homeless is substandard, seemingly abandoned housing
stock. In urban areas, much of this property appears to be commercial
or owned by absentee landlords, often enabling the homeless to make
use of it virtually unnoticed. The site visits conducted by committee
members and the author suggested that these types of dwellings are often
located on private property that is either occupied by the owner or
adjacent to the owner's property. Because of the increased visibility of
transients in rural communities, and the proximity of the property's
owner, it was not unusual to see nominal rents imposed on those taking
refuge in such dwellings.
Finally, for an individual or family to be considered homeless, the
housing arrangement must be temporary or unstable; there must be a
need to search constantly for more permanent quarters because of the
fear of imminent eviction or displacement. The case outlined above lacks
this element of instability; it has served as a family dwelling for more
than 20 years.
This appendix thus considers individuals or families as homeless if
their housing situation is both unstable and temporary (whether it is in a
formal shelter, in a makeshift dwelling, or with friends, without regard
for the payment of nominal rent) and they lack the resources to secure
adequate housing. It is important to reemphasize that the essential criterion
is the instability of the housing arrangement; otherwise, we would simply
be redefining the nearly 2 million rural poor who live in substandard
housing as homeless, which would not be accurate (Housing Assistance
Council, 19841. At the same time, individuals or families awaiting certain
eviction in the very near future would be categorized as homeless under
this definition.
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APPENDIX C 189
WHO ARE THE RURAL HOMELESS?
It is predictably difficult to answer this question. The rural homeless
are more geographically dispersed and the shelter facilities available in
rural areas tend to be small, making it difficult for even shelter operators
to categorize the population definitively. We will use two approaches to
answer this question: The first Is a conceptual framework for classifying
the rural homeless; next, we will review the Ohio Mental Health study,
which, while limited as a single-state case study, provides the only
comprehensive statistical comparison of the rural and urban homeless
that has been completed to date.
A useful framework developed by Frank and Streeter (1987) suggests
that the rural homeless can be categorized into five distinct groups: (1)
the traditional homeless, (2) the new poor, (3) the mentally ill, (4)
displaced farmers and farm-related workers, and (5) the new hermits.*
This grouping can be examined from two perspectives. In comparison
with the urban homeless, the latter two groups (displaced farmers and
farm-related workers and new hermits) are unique to rural areas. Another
perspective is the extent to which these groups reflect the "new"
homeless, whose descent into homelessness is of relatively recent origin.
That grouping would primarily include the new poor and displaced farmers
and farm-related workers.
The Traditional Homeless
These are the street people similar to many of those seen in urban
areas, suffering from substance abuse, personal tragedy, or mental or
physical disabilities. They have had little recent attachment to the labor
force and have trouble maintaining a permanent address or securing
employment. They are predominantly single men.
The New Poor
Driven by financial catastrophe, this category has made the largest
contribution to the number of rural homeless in recent years. For the
most part, they are the working poor or near poor and are two-parent
families with children; in most cases, both parents hold part- or full-time
jobs. The combination of the recent recessions and the structural trans-
formation of the rural economy often leaves them with few local em-
ployment opportunities. As their meager savings are quickly eroded, they
42).
*This section is drawn directly from the typology of Frank and Streeter (1987, pp. 39-
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19O APPENDIX C
are faced with two equally unpalatable alternatives: move in with friends
or travel in search of employment.
Those choosing to move on often find free shelter unavailable and are
forced to rely on abandoned dwellings, sleeping with the entire family in
their vehicles, or, in warmer climates, camping out. A recent study
suggests that the homeless are making use of state and federal campground
areas (Mariani, 19871. For example, in one Maricopa County, Arizona,
campground, over half of the campers were homeless people in search
of jobs. For those choosing to move in temporarily with friends, neighbors,
or relatives, the hazards are different: Stress often builds quickly in
overcrowded quarters and may result in both psychological and physical
abuse (Redburn and Buss, 19871.
The Mentally Ill
The number of chronically mentally ill patients in specific rural com-
munities varies significantly. For the most part, they appear to gravitate
toward the larger rural communities or towns within close proximity to
state mental hospitals. For example, there appeared to be a substantial
chronically mentally ill homeless population in the Minnesota-North
Dakota shelters, all of which were within close proximity to state mental
hospitals. By contrast, the Alabama and Mississippi site visit identified
few chronically mentally ill patients.
Displaced Farmers and Farm-Related Workers
The pace of farm foreclosures has resulted in the displacement of large
numbers of farmers and farm-related workers. Social workers dealing
with farm families argue strongly that farmers face unique stresses as a
result of foreclosure. Foreclosure represents the loss of the family home,
the farmer's job and primary social network, and the children~s inherit-
ance; if the farm has been in the family for several generations, the guilt
and self-recrimination are magnified.
When foreclosures are especially numerous in an area, banks and
lending institutions often have trouble reselling the farms quickly. As a
result, farm families are often permitted to remain as caretakers on a
day-to-day basis with eviction quickly following the final sale of the
property. From the point of foreclosure, farmers in this unstable and
transient position are essentially homeless under our definition.
The site visits confirmed earlier work (Frank and Streeter, 1987) that
farmers seldom make use of the available shelters in the larger rural
communities; anecdotal evidence suggests that they rely on friends or
relatives in other parts of the county or neighboring counties for temporary
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APPENDIX C 191
housing. Service providers consistently agreed that this population is
greatly in need: marriages dissolve; generations are divided; family abuse
rates are up; and alcoholism, stress, depression, and suicide attempts are
on the rise (Wall, 1985; Heffernen and Heffernen, 1986~.
This group also includes migrant and seasonal farm workers whose
housing, health care, and social service needs have never been adequately
met by the existing delivery systems, even in the best of times.
The New Hermits
There is a new group of homeless that is small in number. They have
sought refuge in the mountains of Arkansas, Oregon, Washington, and
West Virginia. Some are "survivalists," Vietnam veterans, "back-to-
the-landers," and others who are isolated from mainstream American
society.
There are few data about these individuals and little understanding of
whether their homelessness is by choice or economic necessity.
THE OHIO STUDY
Statistical data on the rural homeless have not been collected on the
national level. The most exhaustive and authoritative effort to date was
the 1985 Ohio Mental Health Study (Ohio Department of Mental Health,
19851.* Because the researchers conducted extensive interviews with 790
urban and 189 nonurban homeless people, their survey provides the most
extensive data base available on the demographics of the rural homeless
and the ways in which they are both similar and different from their
urban counterparts.
These data cannot be generalized to the nation. It is, after all, a case
study of one state. Despite that limitation, the Ohio study data provide
a rich source of information for developing a preliminary sense of the
rural homeless.
In categorizing their data, the Ohio researchers looked at three types
of counties: urban, rural, and mixed (rural counties adjacent to urban
areas). In preparing their summary tables, some of which are reproduced
here, most of the data are consolidated into two categories: urban and
nonurban (which includes both the rural and mixed counties). When this
combination distorts the analysis, the data will be disaggregated. All of
the tables in this section have been reproduced from the Ohio study's
final reports, although evidence from other studies and the interviews
conducted for this paper will also be cited.
*The tables and analysis are drawn directly from the chapter on urban/nonurban
comparisons, Ohio Department of Mental Health (1985, p. 53).
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192 APPENDIX C
Demographics
Table C-1 provides a summary comparison of the demographics of the
urban and nonurban populations interviewed by the Ohio research team.
A few highlights are given below.
Sex and Marital Status
Women constitute a much higher proportion of the rural homeless
population (32.3 versus 15.8 percent of the urban homeless), a fact that
is partly explained by the much higher percentage of rural homeless who
are married (18.5 percent of the rural homeless versus 6.7 percent of the
urban homeless).
Ethnicity
Ethnicity reflects the demographics of the state and is representative
of many Midwestern states, which do not have significant minority
populations other than blacks (e.g., Hispanics or Indians).
Age
On average, the rural homeless are a slightly younger population, with
72 percent being under age 40 (versus 60 percent of the urban homeless
that are under age 401. These results are parallel to those of a study in
Vermont, in which it was found that most homeless are in their early 30s
TABLE C-1 Demographic Comparison of Urban and Nonurban
Counties (Ohio Data)
Urban Nonurban Total
Characteristic No. Percent No. Percent No. Percent
Sex
Male 665 84.2 128 67.7 793 81.0
Female 125 15.8 61 32.3 186 19.0
Total 790 100.0 189 100.0 979 100.0
Ethnicity
White 466 59.0 173 91.5 639 65.3
Black 281 35.6 11 5.8 292 29.8
Hispanic 30 3.8 3 1.6 . 33 3.4
Other 6 0.8 0 0.0 6 0.6
No answer 7 0.9 2 1.0 9 0.9
Total 790 100.1 189 99.9 979 100.0
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APPENDIX C 193
TABLE C-1 Continued
Urban
Nonurban Total
Characteristic No. Percent No. Percent No. Percent
Age (years)
18-29 250 31.6 90 47.6 340 34.7
3~39 224 28.4 46 24.3 270 27.6
40-49 139 17.6 25 13.2 164 16.8
50-59 115 14.6 15 7.9 130 13.3
~60 53 6.7 10 5.3 63 6.4
No answer 9 1.1 3 1.6 12 1.2
Total 790 100.0 139 99.9 979 100.0
Education
No formal schooling 7 0.9 1 0.5 8 0.8
1-8 graces 129 16.3 32 16.9 161 16.4
9-11 grades 291 36.8 73 38.6 364 37.2
High school graduate 241 30.5 57 30.2 298 30.4
Some college 97 12.3 22 11.6 119 12.2
College graduate 19 2.4 3 1.6 22 2.3
No answer 6 0.8 1 0.5 7 0.7
Total 790 100.0 199 99.9 979 100.0
Marital Status
Married 53 6.7 35 18.5 88 9.0
Separated 114 14.4 21 11.1 135 13.8
Widowed 39 4.9 4 2.1 43 4.4
Divorced 199 25.2 48 25.4 247 25.2
Never been married 366 46.3 72 38.1 438 44.7
Living together 12 1.5 9 4.8 21 2.1
No answer 7 0.9 0 0.0 7 0.7
Total 790 99.9 189 100.0 979 99.9
Veteran status
Yes 264 33.4 46 24.3 310 31.7
(Vietnam veteran) (73) (9.2) (10) (5.3) (83) (8.5)
No 523 66.2 142 75.1 665 67.9
No answer 3 0.4 1 0.5 4 0.4
Total 790 100.0 189 99.9 979 100.0
Ever been in jail/prison
Yes 470 59.5 103 54.5 573 58.5
No 313 39.5 85 45.0 398 40.7
No answer 7 0.9 1 0.5 8 0.8
Total 790 100.0 189 100.0 979 100.0
SOURCE: Ohio Department of Mental Health (1985).
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APPENDIX C 207
TABLE C-8 Major Health Problems of the Rural Homeless (Chicago
HHS Region V Data)
Problem
Frequency in:
Ill. Ind. Mich. Minn. Ohio Wis.
Total
Acute/episodic illnessa
Malnutrition
Alcoholism/drug abuse
Emergency
Dental
Mental health
Chronic illnessb
Hypothermia/overexposure
Maternity/obstetrics/gynecology 2 2
Hygiene/sanitation
Seek pain medication
OtherC
2
6 1 9 1 3
4
4
2 1 2
22
22
1 3 1 3 1 10
4 1 2 1 10
8
7
6
s
J
2
aIncludes upper respiratory, gastrointestinal, dermatological, and similar disturbances.
bIncludes diabetes, cardiovascular, hypertensive, arthritic, and similar disturbances.
CIncludes general malaise, neglected medical attention, and similar conditions.
SOURCE: C. Tavani, Office of Planning, Evaluation, and Legislation, Health Resources
and Services Administration, U.S. Department of Health and Human Services, Washington,
D.C. Personal communication.
supplemental food program for Women, Infants, and Children (WIC),
and similar services. The frequency of nutritional counseling attests to
the importance of nutrition as a health risk factor in this population.
THE OHIO MENTAL HEALTH STUDY
Unfortunately, the data presented above do not permit a comparison
with the urban homeless population; for such a comparison, the only
source of statistical data, once again, is the Ohio Mental Health Study.
Health Status
The Ohio Mental Health Study asked the homeless to identify their
physical health problems; the answers are presented in Table C-10.
Overall, 30.7 percent of respondents reported a current medical problem;
no striking differences emerged from the data for the urban and nonurban
homeless. The differences between this list and the one presented by the
Chicago Region V office in Table C-8 may reflect reporting bias; these
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208 APPENDIX C
TABLE C-9 Services Provided to Rural Homeless (Chicago HHS
Region V Data)
Frequency of Response
-
Type of Service Ill. Ind. Mich. Minn. Ohio Wis. Total
Primary care 5 1 11 2 6 2 27
Social services 3 1 6 1 5 2 18
Nutntion 5 1 5 1 2 14
Dental 1 4 1 1 7
Health education 1 1 2 2 6
Transportation 1 2 1 2 6
Pharmacy 2 2 1 1 6
Specialized medical care 1 1 1 1 4
Mental health 1 2 1 4
Translation 1 1 1 3
Substance abuse 1 1
SOURCE: C. Tavani, Office of Planning, Evaluation, and Legislation, Health Resources
and Services Administration, U.S. Department of Health and Human Services, Washington,
D.C. Personal communication.
data are based on self-reports; the Midwest data are based on provider
recall. There were no data available on the rural homeless based on chart
review or actual patient exams. The limitations of self-reporting are best
demonstrated by the limited recognition by the rural homeless that they
face dental problems. Health care providers and the site visits substan-
tiated that dental problems are among the most significant of the unmet
health care needs of the rural homeless.
An interesting finding resulted when the data for the nonurban group
were disaggregated into a rural county category and a mixed (urbanized
rural) county category. Significant differences emerged in the overall rate
of reported illness: In comparison with 31 percent of the urban homeless
who reported a health problem, the mixed (urbanized rural) county rate
was 20.4 percent while the rate for rural homeless was 41 percent.
Unfortunately, a table disaggregating the specific health problems was
not available. One possible explanation for the higher rural rate would
be the very high accident rate in farming that might leave former farm
laborers with residual chronic problems.
Emergency Room Utilization
The overall rate of emergency room utilization by the homeless was
only slightly higher than that for the general population (Table C-11~. In
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APPENDIX C 209
1984 Redburn and Buss (1987) reported that 23 percent of the adult
population in Ohio reported that they had been to an emergency room
in the previous year, compared with 25 percent of the homeless overall.
Table C-11 shows that the nonurban homeless use emergency rooms
at a slightly higher rate (29.6 percent); the urban homeless use emergency
rooms at a level closer to that for the general population (23 percent).
Despite the lack of alternative primary care providers, the voluntary
use of emergency rooms may actually be far lower than these numbers
suggest. Very often emergency room visits are instigated by local
TABLE C-10 Physical Health Problems Identified by Homeless People
(Ohio Data)
Urban Nonurban Total
Problem
No. Percent No. Percent No. Percent
Reported no physical problems 536 67.8 133 70.4 669 68.3
Reported physical problems 245 31.0 56 29.6 301 30.7
Ill-defined conditions 70 8.9 19 10.0 89 9.1
Arthritis, rheumatism, and other 38 4.8 11 5.8 49 5.0
diseases of the musculoskeletal system
Injury and poisoning
Diseases of the heart and circulatory
system
Diseases of the nervous system and
38 4.8 4 2.1 42 4.3
33 4.2 5 2.6 38 3.9
27 3.4
7
34 3.5
sense organs
Diseases of the respiratory system 24 3.0 6 3.2 30 3.1
Diseases of the digestive system 21 2.7 7 3.7 28 2.9
Eye problems 18 2.3 4 2.1 22 2.2
Endocrine and nutritional disorders 14 1.8 4 2.1 18 1.8
Dental problems 14 1.8 2 1.0 16 1.6
Infections and parasitic disorders 8 1.0 3 1.6 11 1.1
Neoplasms (cancer and benign tumors) 7 0.9 3 1.6 10 1.0
Diseases of the genitourinary system 6 0.7 4 2.1 10 1.0
Pregnancy 6 0.7 3 1.6 9 0.9
Diseases of the blood 6 0.7 2 1.0 8 0.8
Alcoholism 6 0.7 0 0.0 6 0.6
Diseases of the skin 4 0.5 0 0.0 4 0.4
No answer 2 0.2 2 1.0 4 0.4
No answer 9 1.1 0 0.0 9 0.9
Total 790 100.0 189 100.0 979 99.9
NOTE: Subtotals for types of problems do not add to the values for "Reported physical
problems" because 127 respondents indicated they had two problems.
SOURCE: Ohio Department of Mental Health (1985).
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210 APPENDIX C
TABLE C-11 Social Service Usage by Homeless People (Ohio Data)
Urban Nonurban Total
Social Service No. Percent No. Percent No. Percent
Community kitchens 531 67.2 64 33.8 595 60.8
Shelters 506 64.0 46 24.3 552 56.4
Welfare/general relief 319 40.4 116 61.4 435 44.4
Hospital emergency rooms 184 23.3 56 29.6 240 24.5
Shelters for battered women 21 18.6 2 4.0 23 12.4
Community mental health centers 91 11.5 28 14.8 119 12.2
SOURCE: Ohio Department of Mental Health (1985).
authorities if a homeless person is arrested for drunkenness, substance
abuse, or loss of emotional control (Redburn and Buss, 1987J. The
decision to take the person to the emergency room is often a pragmatic
move in an effort to limit the potential liability of the authorities in these
cases if anything should go wrong.
More often than not, the homeless only use the health care system at
times of mental or physical health crisis.
Psychiatric Hospitalization
The number of homeless people in Ohio that have been deinstitution-
alized does not reflect the previous high estimates of the Reinstitutionalized
identified in earlier studies. For both the urban and rural homeless, 3 out
of 10 were hospitalized for emotional or mental health problems at some
point in their lives (Table C-121.
The Ohio study concluded that the urban homeless "exhibit rates of
psychiatric symptoms similar to the rural homeless but show higher rates
of behavioral disturbance" (Redburn and Buss, 1987~.
Alcohol Abuse
As much as one-third of the total homeless population has problems
with alcohol or drugs. The available data (Tables C-13 and C-14) suggest
that alcoholism poses a larger problem for the urban homeless. Twice as
many urban homeless reported that they drank a lot during the previous
month (21.3 percent for the urban homeless versus 10.6 percent for the
nonurban homeless). In addition, nearly 3 out of 10 urban homeless
reported that they had sought help for their alcoholism, compared with
20.1 percent of the nonurban homeless population.
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APPENDIX C 211
TABLE C-12 Psychiatric Hospitalization Reported by Homeless People
(Ohio Data)
Urban Nonurban Total
Hospitalization
No. Percent
No. Percent
No. Percent
Never been hospitalized 536 67.8 137 72.5 673 68.7
Been hospitalizeda 242 30.6 51 27.0 293 29.9
Veteran's hospital 55 7.0 5 2.6 60 6.1
General hospital 100 12.7 29 15.3 129 13.2
State hospital 155 19.6 25 13.2 180 18.4
No answer 12 1.5 1 0.5 13 1.3
Total 790 99.9 189 100.0 979 99.9
Hospitalized subtotals do not add to the percentages listed as '`Been hospitalized"
because some respondents had hospitalizations in more than one type of setting.
SOURCE: Ohio Department of Mental Health (1985).
TABLE C-13 Reported Drinking by Homeless People During the
Previous Month (Ohio Data)
Urban Nonurban Total
Amount of
Drinking No. Percent No. Percent No. Percent
Some 349 44.2 92 48.7 441 45.0
A lot 168 21.3 20 10.6 188 19.2
Not at all 268 33.9 77 40.7 345 35.2
No answer 5 0.6 0 0.0 5 0.5
Total 790 100.0 189 100.0 979 99.9
NOTE: Urban (28.1 percent) homeless people were somewhat more likely to report
seeking help for a drinking problem than were nonurban people (20.1 percent). This may
be the result of service availability in urban versus nonurban areas.
SOURCE: Ohio Department of Mental Health (1985).
TABLE C-14 Reported Seeking Help for Drinking by
Homeless People (Ohio Data)
Behavior No. Percent of Total
Have ever sought help 260 26.6
Have not sought help 693 70.8
No answer 26 2.7
Total 979 100.1
SOURCE: Ohio Department of Mental Health (1985).
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212 APPENDIX C
General Well-Being
Tables C-15 and C-16 suggest that the homeless population has a far
more optimistic self-evaluation than might be expected. A large percentage
rate their outlook positively, and nearly a third of both groups described
their lives as satisfying. There are no significant differences between the
two groups on these measures.
Overall, the available data and the site visits suggest that the health
care needs of the rural homeless are not significantly different from those
of their urban counterparts. It is important to reemphasize, however,
that the existing data base is quite meager.
The major health care problems among the adult population are
malnutrition, alcoholism and substance abuse, dental care, respiratory
illness, stress, depression, mental illness, and environmental health
problems such as those related to impure drinking water.
While there is little continuity of care, access to acute health care
services seems adequate if there is a pressing physical health problem.
Routine or preventive care services are seldom sought because of
significant barriers to access, shame, or hostility toward the health care
system.
Access to mental health professionals is different, however. Not only
are services limited but there is every indication that there is an unmet
need for such services among the chronically mentally ill and specific
homeless groups, such as farmers. The chronically mentally ill often have
trouble accessing the available resources; in general, farmers will not or
cannot utilize the available resources because of strong conservative
cultural forces (McCormick, 19871. Among teenagers, venereal disease
and pregnancy are the two major health issues; little prenatal care is
TABLE C-15 Self-Ratings by Homeless People of Their Nerves, Spirits,
Outlook, or Mental Health at Present (Ohio Data)
Urban Nonurban Total
Response No. Percent No. Percent No. Percent
Excellent 77 9.7 13 6.9 90 9.2
Good 239 30.2 66 34.9 305 31.2
Fair 274 34.7 64 33.9 338 34.5
Poor 125 15.8 27 14.3 152 15.5
Very bad 60 7.6 17 9.0 77 7.9
No answer 15 1.9 2 1.1 . 17 1.7
Total 790 99.9 189 100.1 979 99.9
SOURCE: Ohio Department of Mental Health (1985).
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APPENDIX C 213
TABLE C-16 Self-Ratings by Homeless People of Their Satisfaction
with Life (Ohio Data)
Urban Nonurban Total
Response No. Percent No. Percent No. Percent
Very satisfying 80 10.1 16 8.5 96 9.8
Somewhat satisfying 189 23.9 43 22.7 232 23.7
Mixed 282 35.7 78 41.3 360 36.8
Not very satisfying 161 20.4 35 18.5 196 20.0
Not at all satisfying 63 8.0 16 8.5 79 8.1
No answer 15 1.9 1 0.5 16 1.6
Total 790 100.0 189 100.0 979 100.0
SOURCE: Ohio Department of Mental Health (1985).
provided in the South until the final trimester. As in other areas, the
malpractice crisis has limited the number of physicians willing to handle
obstetrical cases.
Children suffer from malnutrition and failure to thrive, and are at
serious risk of accidents, particularly those living in substandard dwellings.
They also fail to receive the necessary preventive care. The consequences
of this can be devastating.
The depression, stress, and suicidal tendencies among the farm popu-
lation warrant special outreach efforts in the view of most of our key
informants. They strongly suggest that suicides in the farm community
are deliberately misreported by the families to save face, that spouse and
child abuse rates are rising in this population group, and that alcoholism
is increasing. Senator David Durenberger's report of trends in services
in southwestern Minnesota may be indicative: according to the senator,
a mental health worker in that region stated that between 1983 and 1985
her center experienced a 330 percent increase in the number of people
using the 24-hour crisis line and a 30 percent increase in the number of
outpatient mental health services (U.S. Congress, Senate, Committee on
Finance, 19861.
Teenagers who live on farms appear to be having a particularly rough
time. In some cases, their entire lives are preordained: First, they become
members of 4-H and Future Farmers of America, and subsequently, they
take over the family farm. Now their inheritance and their future are
gone, often resulting in resentment and the blaming of their parents for
mismanagement. In a small town in North Dakota there were 14 suicides
of people living on farms in 14 months, and teenage alcoholism is rising
rapidly. In Nebraska one minister reported a tripling in the number of
suicide calls he had received over the previous year. In Iowa, Youth and
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214 APPENDIX C
Shelter Services reported a sharp jump in rural teenage runaways (Wall,
1985).
Another group, while small in number, appears to need additional
attention: rural veterans. While most veterans gravitate toward urban
areas where Veterans Administration services are more plentiful, veterans
remain visible in rural areas and in great need of additional support and
counseling. A study of the homeless in Vermont found "homeless veterans
who seem to be making rounds from V.A. hospital to V.A. hospital
around New England" (Vermont Department of Human Services, 19854.
CONCLUSION
The continuing rural economic crisis ensures that homelessness will
remain a problem in rural America. For the most part, it is the working
poor and farm families who are the newest rural homeless. Compared
with their urban counterparts, they are younger; live in intact, two-
parent, two-worker families; and have strong ties to their local community
but few economic prospects. They disproportionately live in states that
discriminate against intact families in their assistance programs and in
communities dominated by a single industry in distress, where their only
alternative is a minimum wage, service sector job.
They often face two equally unpleasant options: moving in with friends
or relatives or moving in search of employment. In either case, in the
long term, they are plagued by the lack of low-cost, affordable housing.
Even when subsidized public housing is available, it is generally in the
larger rural towns and seldom in the smaller communities that many rural
homeless would prefer. Regardless of location, waiting lists for subsidized
housing can stretch for years.
The health status of the rural homeless and their utilization of services
do not appear to be significantly different from those for the urban
homeless. Malnutrition, alcoholism and substance abuse, dental problems,
stress, depression, and mental illness are pervasive. Many infants and
children suffer from a failure to thrive, malnutrition, and accidents, while
teenagers also face high rates of venereal disease and pregnancy, often
without the benefit of prenatal care.
In times of emergency, access to physical health care appears adequate.
By contrast, routine or preventive care services are seldom sought
because of significant barriers to access, shame, or hostility toward the
health care system.
Because of the importance of overcoming barriers to routine and
preventive care, outreach efforts by community health centers would
appear to be critical. As one HHS regional administrator noted, com-
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APPENDIX C 215
munity health centers are the "backbone" of the health care delivery
system in the poorest counties. Yet, the centers are being pushed in what
appears to be incompatible directions. The long-term strategy of increasing
their income from paying patients appears to be difficult to reconcile with
the centers' original mission of meeting the needs of the poor and
underserved.
The dramatic changes now taking place in farming communities,
particularly within the families of financially distressed farmers, are
reminiscent of the self-blame, depression, and suicidal tendencies seen
in the 1930s. Farm communities seem to be splintering, providing little
sympathy or support for neighbors in economic distress. These farm
families then tend to turn inward, using few support services such as
shelters or mental health networks. Enhanced outreach efforts such as
those provided by the Agriculture Extension Service, child protection,
workers, or innovative programs such as the peer counseling program
cited earlier appear warranted in an effort to break this unhealthy, self-
imposed isolation.
State mental health institutions in rural areas have recently begun to
cooperate more extensively with community shelters that accept the
chronically mentally ill. Simple efforts at coordinating discharge planning
can be of great importance, as demonstrated by the Fargo, North Dakota,
shelter.
In the course of site visits, a number of homeless farm families
communicated their belief that income support programs in particular,
food stamps used eligibility criteria that systematically disqualified
farmers from receiving timely assistance that might have forestalled their
descent into homelessness. Several social workers affirmed this claim.
This suggests that there is a need for a systematic assessment of food
stamp and other income support programs to determine whether better
targeting of these existing programs could serve as an important preventive
measure.
Finally, there is a need for additional research on the rural homeless
and their health care needs. Two reports that are now under way may
be helpful. The Housing Assistance Council is conducting a survey of
community action agencies that have been active in working with the
rural homeless. The National Coalition for the Homeless is also at work
on a report on rural homelessness in the South and is conducting more
extensive site visits than those used to prepare this appendix. Both
studies should be available in the fall of 1988.
A more systematic assessment of the health care needs of the rural
homeless in areas served by the federally funded community and migrant
health centers would appear to be a logical starting point for future data
collection.
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216 APPENDIX C
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APPENDIX C 217
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Representative terms from entire chapter:
urban homeless
