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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

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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 distressparticularly those plagued by persistent povertyoffer 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 REFERENCES Brown, D. L., and K. L. Deavers. No date. The Changing of the Rural and Economic Demographic Situation in the Eighties. Washington, D.C.: U.S. Department of Agriculture Economic Research Service. (Unpublished draft.) California Department of Economic Opportunity. 1986. The Status of Poverty in California, 1984-1985: A Report by the Advisory Commission. Sacramento: California Department of Economic Opportunity. Congressional Research Service. 1986. Rural hospitals and Medicare's Prospective Payment System. A background paper prepared for use by the members of the Senate Committee on Finance. Washington, D.C.: Congressional Research Service. Elison, G. No date. Frontier areas: Problem for delivery of health care services. Rural Health Care: The Newsletter of the National Rural Health Association 8(5):1. Food Research and Action Council. 1987. Miles to Go: Barriers to Participation by the Rural Poor in the Federal Food Assistance Programs. Washington, D.C.: The Food Research and Action Council. Frank, R., and C. L. Streeter. 1987. The bitter harvest: The question of homelessness in rural America. Pp. 36-45 in Social Work in Rural Areas: Proceedings of the Tenth National Institute on Social Work in Rural Areas, A. Summers, J. M. Schriver, P. Sundet, and R. Meinert, eds. Batesville: Arkansas College of Social Work Program. Ghelfi, L. 1986. Poverty Among Black Families in the Nonmetro South. Rural Development Research Report no. 62. Washington, D.C.: Economic Research Service, U.S. De- partment of Agriculture. Heffernen, J. B., and W. D. Heffernen. 1986. When farming families have to give up farming. Rural Development Perspectives 2(June):18. Hoppe, R. A. 1985. Economic Structure and Change in Persistently Low-Income Nonmetro Counties. Rural Development Research Report no. 50. Washington, D.C.: Economic Research Service, U.S. Department of Agriculture. Housing Assistance Council. 1984. Taking Stock: Rural People and Poverty from 1970 to 1983. Washington, D.C.: Housing Assistance Council. Kindig, D., and H. Movassaghi. 1987. Physician supply: Small rural areas falling behind. Rural Health Care: The Newsletter of the National Rural Health Association 9(5): 10. Mariani, D. 1987. First Water Campground: Demographic Analysis. Flagstaff: Northern Arizona University. (Unpublished.) Maryland Department of Human Resources. 1986. Where Do You Go from Nowhere: Homelessness in Maryland. Annapolis: Maryland Department of Human Resources. McCormick, B. 1987. Economics, lack of services, thwart rural psychiatric care delivery. AMA News, May 4: 6. National Association of Community Health Centers. 1987. Rural Health Policy Statement. Washington, D.C.: National Association of Community Mental Health Centers. Ohio Department of Mental Health. 1985. Homelessness in Ohio: A Study of People in Need. Columbus: Ohio Department of Mental Health. Ranney, R. J. 1986. Rural health crisis: The effects of the rural economy on primary health care. Pp. 53-64 in Children and Families in the Midwest: Employment, Family Services and the Rural Economy. Select Committee on Children, Youth and Families, U.S. Congress, House of Representatives. Washington, D.C.: U.S. Government Printing Office. Redburn, F. S., and T. F. Buss. 1987. Responding to America's Homeless: Public Policy Alternatives. New York: Praeger. Sinclair, W. 1987. Grief is growing on farm land. The Washington Post, May 24: A3.

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APPENDIX C 217 Southern Minnesota Family Farm Fund. 1986. Questionnaire. Albert Lea, Minnesota: Southern Minnesota Family Farm Fund. U.S. Congress, Senate, Committee on Finance. 1986. P. 77 in Hearing of the U.S. Senate Committee on Finance: Examination of Rural Hospitals Under the Medicare Program. Washington, D.C.: U.S. Government Printing Office. U.S. Congress, Senate, Committee on Governmental Affairs. 1986. P. 1 in Governing the Heartland: Can Rural Communities Survive the Farm Crisis? Washington, D.C.: U.S. Government Printing Office. Vermont Department of Human Services. 1985. Homelessness in Vermont. Montpelier: Vermont Department of Human Services. Wall, W. 1985. Growing up afraid: Farm crisis is taking subtle toll on children. The Wall Street Journal, November 7: 1. Wilson, H. 1983. Housing Assistance Council Testimony: The Rural Homeless. Washington, D.C.: Housing Assistance Council.