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c' Health Problen~s of Homeless People Homeless people are at relatively high risk for a broad range of acute and chronic illnesses. Precise data on the prevalence of specific illnesses among homeless people compared with those among nonhomeless people are difficult to obtain, but there is a body of information indicating that homelessness is associated with a number of physical and mental prob- lems. This is evident not only in recent data from the Social and Demographic Research Institute but also in individual published reports in the medical literature. It also was apparent to the committee in its site visits across the country. TYPES OF INTERACTIONS BETWEEN HEALTH AND HOMELESSNESS In examining the relationship between homelessness and health, the committee observed that there are three different types of interactions: (1) Some health problems precede and causally contribute to homeless- ness, (2) others are consequences of homelessness, and (3) homelessness complicates the treatment of many illnesses. Of course, certain diseases and treatments cut across these patterns and may occur in all three categories. Health Problems That Cause Homelessness Certain illnesses and health problems are frequent antecedents of homelessness. The most common of these are the major mental illnesses, especially chronic schizophrenia. As mentally ill people's disabilities 39

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40 HOMELESSNESS, HEALTH, AND HUMAN NEEDS worsen, their ability to cope with their surroundings or the ability of those around them to cope with their behavior becomes severely strained. In the absence of appropriate therapeutic interventions and supportive alternative housing arrangements, many wind up on the streets. Another contemporary example of illness leading to homelessness is AIDS. As the disease progresses and leads to repeated and more serious bouts with opportunistic infections, the individual becomes unable to work and may be unable to afford to continue paying rent. Other health problems contributing to homelessness include alcoholism and drug dependence, disabling conditions that cause a person to become unem- ployed, or any major illness that results in massive health care expenses. One type of health problem in this category about which the committee heard much during several site visitsis accidental injury, especially job- related accidents. Although such programs as Workers' Compensation were designed to prevent economic devastation as a result of workplace casualties, they often fall far short of what is optimal for many reasons, including lack of knowledge of the program by the employee, low levels of benefits under the program, and lack of benefits for "off the books" work and migrant farm labor. A case study illustrates the point:* Samuel Anderson arrived in New York City in 1985 from his native Oklahoma. He is 24 years old, educated through the 11th grade, and says he left his rural surroundings because there was no opportunity to work, it. . . there was no job with something ahead of it." He feels that his chances will be best in the `'biggest town I know of." In New York, he is studying for a graduate equivalency diploma and supports himself as an evening security guard. His wages are enough to pay for a rented room in the borough of Queens. Five months after starting work, he scuffles with intruders and suffers gunshot wounds in his right leg and hand (he is right-handed). Mr. Anderson spends 2 weeks in the hospital after losing four pints of blood through his wounds. A vascular surgeon and a neurosurgeon repair his shattered hand during a 4-hour microsurgical procedure. In the meantime, his room in Queens (he is in a hospital in the borough of Manhattan, some distance away) is rented to someone else because of his absence and the concurrent lack of rent payment. After discharge from the hospital, he spends a few nights in a hotel. When his money runs out, he sleeps in a city park, finally coming to a shelter. In addition to accidents, various common illnesses such as the degen- erative diseases that accompany old age can also lead to homelessness: *Unless otherwise noted, all case studies in this chapter are drawn from a background paper prepared for this report, "Homelessness: A Medical Viewpoint," (Vicic and Doherty, 1987) by William Vicic, M.D., and Patricia Doherty, R.N., of St. Vincent2s Hospital Medical Center, New York City. The names, of course, are fictitious; the circumstances and clinical details are real and are drawn from Dr. Vicic's and Ms. Doherty's professional experiences working with the homeless.

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HEALTH PROBLEMS OF HOMELESS PEOPLE 41 James Barr~am, now 62 years old, has worked regularly since age 17, but has never found a job with secure employee benefits. He has lived a marginal existence: adequate funds for food and a room in a single room occupancy hotel, but certainly not enough for savings. He is fired from his long-held kitchen job because he cannot see the food stains on the dishes; after working 2 days as a messenger, he is let go because items were delivered to incorrect addresses. Mr. Barnam has eye cataracts, a frequent accompaniment of older age and treatable with ambulatory surgery for those patients with health insurance. Mr. Barnam's marginal income entitles him to Medicaid benefits, but he is unable to negotiate the public welfare system and has no one to guide him through forms, appoint- ments, and examinations. Upon losing-nis hotel room, Mr. Barnam goes to a shelter for homeless men after he is discovered at a bus station by outreach workers. However, even there, his health problem remains troublesome: he almost loses his bed because he fails to sign a daily bed roster he cannot see. In each of these cases, employment was not secure, and the man lacked a network of family or friends. The fact that health problems precipitated homelessness underscores the relationships among health status, employment, social supports, and access to affordable housing. Health Problems That Result from Being Homeless Homelessness increases the risk of developing health problems such as diseases of the extremities and skin disorders; it increases the possibility of trauma, especially as a result of physical assault or rape (Kelly, 1985~.* It can also turn a relatively minor health problem into a serious illness, as can be seen by the case of Doris Foy: Doris Foy's varicose veins occasionally result in swollen ankles. When homeless, she sleeps upright, and her legs swell so severely that tissue breakdown develops into open lacerations. She covers these with cloth and stockings- enough to absorb the drainage but also to cause her to be repugnant to others because of the smell and unsightly brown stains. She is eventually brought to a clinic by an outreach worker. When the cloth and the stockings are removed from the legs, there are maggots in the wounds. She is taken to the emergency room of a hospital, where her wounds are cleaned. Other health problems that may result from or that are commonly associated with homelessness include malnutrition, parasitic infestations, dental and periodontal disease, degenerative joint diseases, venereal diseases, hepatic cirrhosis secondary to alcoholism, and infectious hep- atitis related to intravenous (IV) drug abuse. *In several site visits, committee members heard repeated reference to the high prevalence of sexual assaults against homeless women. One shelter staff member commented: "It's not a question of whether a homeless woman will be raped, but simply a question of when."

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42 HOMELESSNESS, HEALTH, AND HUMAN NEEDS Homelessness as a Complicating Factor in Health Care For even the most routine medical treatment, the state of being homeless makes the provision of care extraordinarily difficult. Even the need for bed rest is complicated, if not impossible, when the patient does not have a bed or, as is the case in many shelters for the homeless, must leave the shelter in the early morning. Diabetes, for example, usually is not difficult to treat in a domiciled person. For most people, daily insulin injections and control of diet are adequate. In a homeless person, however, treatment is virtually impossible: Some types of insulin need to be refrigerated; syringes may be stolen (in cities where IV drug abuse is common, syringes have a high street value) or, sometimes, the homeless diabetic may be mistaken for an IV drug abuser; and diet cannot be controlled because soup kitchens serve whatever they can get? which rules out special therapeutic diets. The following case illustrates the various problems involved in treating a homeless man with another common chronic medical problem, hypertension: Tyrone Harrison is black, 26 years old, and homeless because he cannot find a job. He wants to work in the shelter kitchen and waits 3 hours for a preemployment physical examination. He is friendly and describes himself as "very healthy." His blood pressure is 180/120. His smile disappears and he feels "cut down." Because he is homeless, he must deal with his illness, private and asymptomatic, in the public spaces of the shelter. He refuses to talk about high blood pressure with the fellows in the dormitory it diminishes his macho image. He tells the nurse that his blood pressure reading must be a mistake. Three weeks later, after six contacts with the medical outreach worker, he confides that his cousin had been a dialysis patient because of hypertensive kidney disease. Weeks later, after several more visits to the medical team, Tyrone consents to medication for his persistently elevated blood pressure. His 2-week supply of pills are stolen 4 days later. An argument erupts in the dormitory and, in accord with routine regulations, Tyrone is put out of the shelter for 2 weeks. On his return to the shelter, his blood pressure is uncontrolled because he had no medication. The cases described above exemplify not only how homelessness complicates treatment but how burdens are placed on various parts of the social system and on the homeless persons themselves. Because he lacked any form of health insurance, Samuel Anderson did not receive rehabilitation therapy for his right hand, and as a result developed stiffness and had significant loss of fine and gross motor skills; he had to apply for permanent disability benefits. Doris Foy was admitted to the hospital, because the treatment for her leg ulcers, which consisted of elevating her leg and taking prescribed antibiotics, is impossible for a homeless patient. Not only does her hospital stay make a bed unavailable for someone else who might possibly be in more serious need of inpatient treatment, but

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HEALTH PROBLEMS OF HOMELESS PEOPLE 43 it also means that the hospital will not be reimbursed for her treatment because under the present system of utilization review, cellulitis with leg ulcers is judged to be treatable on an outpatient basis, and therefore, inpatient treatment for this condition may not be covered by Medicaid. GENERAL HEALTH PROBLEMS OF HOMELESS ADULTS Although homeless people are susceptible to the same range of diseases that occurs in the general population, the conditions discussed below appear to be especially prevalent among homeless people. Tables 3-1 through 3-6 delineate the prevalence of various acute, chronic, and infectious diseases among homeless people. A section providing a key to the abbreviations and some other explanatory notes follows the text (pp. 69-71~. These tables were developed by the Social and Demographic Research Institute (SADRI) of the University of Massachusetts, Amherst, and are based on the reports from 16 of the Johnson-Pew Health Care for the Homeless (HCH) projects during their first year of full operation (Wright et al., 1987b). The prevalence rates are given both for the total number of people seen and for those seen more than once (Tables 3-1, 3-3, and 3-51. This group of tables is divided further by sex, ethnic group, and age (Tables 3-2, 3-4, and 3-61. The comparable prevalence rates for the domiciled general population are available from the National Ambu- latory Medical Care Survey (NAMCS) of 1979, a study of a random sample of adult patients' visits to doctors' offices throughout the United States conducted by the U.S. Department of Health and Human Services (19791. It should be noted that the SADRI data are for homeless people who sought health care from facilities available to them; therefore, they may not be truly representative of all homeless people. Because the NAMCS figures are derived from doctors' offices not hospital emergency rooms, clinics, outpatient departments, and so on the sample is not weighted for people in the lowest socioeconomic groups. The two data sets also differ in age, gender, and ethnicity (older white women were more commonly involved in the NAMCS data, whereas nonwhite men were more prominent in the SADRI data). Although comparisons between these figures are inexact, they do provide general measures of the severity and frequency of certain medical conditions seen among the homeless as compared with those among the general patient population seen in doctors' offices. Traumatic Disorders Contusions, lacerations, sprains, bruises, and superficial burns are more commonly reported in the homeless population (TRAUMA in

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44 HOMELESSNESS, HEALTH, AND HUMAN NEEDS TABLE 3-1 Rates of Occurrence (in percent) of Acute Physical Disorders in the Johnson-Pew HCH Client Population Adults Seen More Than Once All Not Adults Total Men Women White White (N= (N= (N= (N= (N= (N= Diagnosis 23,745) 11,886) 8,329) 3,468) 5,659) 5,928) INF 3.3 4.9 4.8 4.8 6.3 3.5 NUTDEF 1.2 1.9 1.7 2.4 2.2 1.6 OBESE 1.5 2.3 1.4 4.5 2.7 2.1 MINURI 23.6 33.2 33.4 32.8 36.0 30.8 SERRI 2.2 3.4 3.9 2.5 3.7 3.3 MINSKIN 9.8 13.9 14.1 13.5 15.7 12.4 SERSKIN 2.7 4.2 4.6 3.4 5.1 3.5 TRAUMA ANY NA 23.4 26.3 16.7 2J.2 22.1 FX 3.1 4.5 5.4 2.5 5.2 4.0 SPR 5.1 7.1 7.6 5.9 8.1 6.2 BRU 4.0 5.6 5.7 5.3 6.1 5.2 LAC 6.3 8.6 10.5 4.3 8.9 8.5 ABR 1.5 2.2 2.6 1.3 2.5 1.9 BURN 0.8 1.1 1.2 0.8 1.1 1.0 NOTE: See "Key to Abbreviations and Explanatory Notes," pp. 69-71. SOURCE: Wright et al. (1987b). Tables 3-1 and 3-2). Results of a 1983 study indicated that approximately 30 percent of 524 homeless people treated in San Francisco over a 6- month period presented because of trauma-related injuries (Kelly, 19854. Homeless people are at high risk for traumatic injuries for a number of reasons. They are frequently victims of violent crimes such as rape, assault, and attempted robbery. In addition, primitive living conditions result in unusual risks; for example, the use of open fires for warmth predisposes them to potential burns. Most of the findings in the literature, including those from the national HCH program, describe inner city homeless people. It is not known whether these observations can be extrapolated to the homeless people in rural areas. For example, during visits to rural areas of Alabama and Mississippi, committee members commented on the relative infrequency of traumatic disorders.

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HEALTH PROBLEMS OF HOMELESS PEOPLE 45 Disorders of Skin and Blood Vessels Pustular skin lesions secondary to insect bites and other infestations are common among homeless people (SERSKIN in Tables 3-1 and 3-21. In addition, venous stasis of the lower extremities (i.e., poor circulation because of varicose veins) caused by prolonged periods of sitting or sleeping with the legs down predisposes homeless people to dependent edema (swelling of the feet and legs), cellulitis, and skin ulcerations. Although there is reason to speculate that venous valve incompetence would develop more frequently in homeless patients and lead to chronic phlebitis, data are meager. The term "peripheral vascular disease" (PVD in Tables 3-3 and 3-4) is frequently used to connote venous stasis; there is no clear evidence that arterial vascular disease is more prevalent in this population than in a nonhomeless population. Recurrent dermatitis (MINSKIN in Tables 3-1 and 3-2), which is possibly related to inadequate opportunities to bathe or shower and which is associated with infestations TABLE 3-2 Rates of Occurrence (in percent) of Acute Physical Disorders, by Age, in the Johnson-Pew HCH Client Population Adults in the Following Age Groups Seen more than Once I II III IV NAMCS (N= (N= (N= (N= (N= Diagnosis 3,766) 5,783) 1,892) 445) 28,878) INF 5.0 4.8 4.2 7.0 0.1 NUTDEF 1.7 1.8 2.2 3.1 0.1 OBESE 2.0 2.5 2.6 1.3 2.7 MINURI 34.5 33.5 32.7 19.3 6.7 SERRI 2.8 3.8 3.9 2.5 1.0 MINSKIN 14.8 13.7 13.2 11.2 5.0 SERSKIN 4.4 4.5 3.3 2.7 0.9 TRAUMA ANY 23.8 24.4 21.8 15.7 NA FX 3.9 4.8 5.2 3.4 2.2 SPR 7.3 7.4 6.5 4.0 3.1 BRU 6.1 5.5 5.2 3.6 1.0 LAC 9.0 9.2 7.3 4.0 1.2 ABR 2.3 2.2 1.8 2.5 0.4 BURN 1.2 0.9 1.3 0.9 0.2 NOTE: See `'Key to Abbreviations and Explanatory Notes," pp. 69-71. SOURCE: Wright et al. (1987b).

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46 HOMELESSNESS, HEALTH, AND HUMAN NEEDS TABLE 3-3 Rates of Occurrence (in percent) of Chronic Physical Disorders in the Johnson-Pew HCH Client Population Adults Seen more than Once All Not Adults Total Men Women White White (N= (N= (N= (N= (N= (N= Diagnosis 23,745) 11,886) 8,329) 3,468) 5,659) 5,928) ANYCHRO 31.0 41.0 42.8 36.8 39.4 43.2 CANC 0.4 0.7 0.7 0.7 1.1 0.3 ENDO 1.4 2.2 1.5 3.8 2.6 1.9 DIAB 1.8 2.4 2.2 2.8 2.3 2.6 ANEMIA 1.3 2.2 1.7 3.5 2.0 2.4 NEURO 5.6 8.3 7.7 9.9 8.8 8.1 SEIZ 2.8 3.6 3.9 2.9 3.4 3.8 EYE 5.0 7.5 7.7 7.2 7.0 8.2 EAR 3.4 5.1 4.7 6.0 6.6 3.7 CARDIAC 4.4 6.6 6.9 5.7 7.4 6.0 HTN 10.4 14.2 15.7 10.8 10.9 17.7 CVA 0.1 0.3 0.3 0.1 0.3 0.2 COPD 3.2 4.7 4.8 4.4 5.9 3.6 GI 9.2 13.9 13.2 15.5 15.9 12.2 TEETH 7.0 9.3 9.7 8.6 9.4 9.5 LIVER 0.9 1.3 1.5 1.0 1.4 1.4 GENURI 4.1 6.6 4.2 12.4 7.2 6.2 MALEGU 1.3 1.9 1.9 0 1.2 1.4 FEMGU 11.3 15.8 0 15.8 13.0 9.2 PREG 9.9 11.4 0 11.4 9.2 10.0 PVD 9.1 13.1 14.0 11.1 14.6 11.8 ARTHR 2.7 4.2 4.1 4.3 4.2 4.3 OTHMS 3.9 6.0 6.3 5.3 6.8 5.4 NOTE: See "Key to Abbreviations and Explanatory Notes," pp. 69-71. SOURCE: Wright et al. (1987b). with lice and scabies, is prevalent among the homeless population. This form of dermatitis is frequently confused with bacterial cellulitis, since they both present with red, warm, tender skin lesions. This confusion may lead to inappropriate management. Moreover, homeless people do have an increased frequency of bacterial cellulitis and other pustular skin lesions. Finally, homeless people are at high risk of developing subcu-

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HEALTH PROBLEMS OF HOMELESS PEOPLE 47 taneous abscesses, but this may be related in part to an increased prevalence of needle-stick infections from drug abuse. Respiratory Illnesses Acute nonspecific respiratory diseases (MINURI and SERRI in Tables 3-1 and 3-2) are commonly reported in populations of homeless people in shelters. Living in groups, crowding, environmental stresses, and poor TABLE 3-4 Rates of Occurrence (in percent) of Chronic Physical Disorders, by Age, in the Johnson-Pew HCH Client Population Adults in the Following Age Groups Seen more than Once I II III IV NAMCS (N= (N= (N= (N= (N= Diagnosis 3,766) 5,783) 1,892) 445) 28,878) ANYCHRO 25.5 42.6 63.1 57.3 24.9 CANC 0.3 0.7 1.4 1.6 3.5 ENDO 1.9 2.1 2.8 3.4 1.6 DIAB 0.9 2.4 5.1 4.3 2.7 ANEMIA 2.3 2.0 2.5 2.5 0.9 NEURO 7.4 9.1 7.8 8.5 1.8 SEIZ 2.5 4.3 3.9 1.3 0.1 EYE 6.6 7.2 9.8 10.6 5.5 EAR 6.0 4.8 3.9 5.6 1.6 CARDIAC 3.6 6.1 11.6 16.2 6.2 HTN 4.5 15.6 27.6 20.9 8.0 CVA 0 0.2 0.6 0.9 0.7 COPD 2.5 4.2 9.3 9.2 3.2 GI 14.1 13.4 15.3 12.1 5.6 TEETH 10.4 10.3 5.8 2.9 0.3 LIVER 0.9 1.6 1.7 0.4 0.3 GENURI 8.9 5.4 5.5 8.3 2.9 MALEGU 1.6 1.0 1.3 1.5 3.2 FEMGU 13.3 11.3 4.5 1.4 7.3 PREG 18.1 4.8 0 0 0.5 PVD 9.8 13.4 17.4 18.2 0.9 ARTHR 1.4 3.4 10.9 9.7 3.7 OTHMS 5.2 5.9 8.0 6.1 5.8 NOTE: See "Key to Abbreviations and Explanatory Notes," pp. 69-71. SOURCE: Wright et al. (1987b).

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48 HOMELESSNESS, HEALTH, AND HUMAN NEEDS TABLE 3-5 Rates of Occurrence (in percent) of Infectious and Communicable Disorders in the Johnson-Pew Health Care for the Homeless Client Population cults Seen more than Once All Not Adults Total Men Women White White (N= (N= (N= (N= (N= (N= Diagnosis 23,745) 11,886) 8,329) 3,468) 5,659) 5,928) AIDS/ARC 0.1 0.2 0.2 0.1 0.2 0.2 Tuberculosis TB 0.3 0.5 0.6 0.2 0.5 0.5 PROTB 2.5 4.5 5.4 2.5 3.5 5.6 ANYTB 2.7 4.9 5.8 2.7 3.9 5.9 Sexually transmitted diseases VDUNS 0.4 0.7 0.7 0.7 0.7 0.7 SYPH 0.1 0.2 0.2 0.2 0.1 0.3 GONN 0.5 0.8 0.6 1.3 0.7 0.9 ANYSTD NA 1.6 1.4 2.0 1.3 1.8 Other INFPAR 0.2 0.3 0.4 0.3 0.2 0.5 ANYPH NA 17.4 18.7 14.3 18.5 16.6 NOTE: See "Key to Abbreviations and Explanatory Notes," pp. 69-71. SOURCE: Wright et al. (1987b). nutrition may predispose homeless people to infections of the upper respiratory tract and lungs. Tuberculosis has become a major health problem among homeless people (TB in Tables 3-5 and 3-61. Characteristically, this has been a disease associated with exposure, poor diet, alcoholism, and other illnesses that can lead to decreased resistance in the host. Substance abusers and the elderly are at high risk for developing tuberculosis. Immigrants from Third World countries also have art increased risk of infection (U.S. Department of Health and Human Services, 1980; Brickner et al., 19851. In a study of tuberculosis among homeless people in New York City in 1980 (Sherman, 1980), based on tuberculin skin test reactivity and subsequent case findings, 191 people were initially screened. Of these, 98 had positive skin tests and 13 had positive sputum cultures for Mycobacterium tuberculosis. Forty-four required either prophylaxis or treatment according to recommendations of the American Thoracic Society. Compared with nonhomeless populations, these homeless indi- viduals had a very high frequency of skin test reactivity and positive cultures. Whether homelessness alone led to the high prevalence of

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HEALTH PROBLEMS OF HOMELESS PEOPLE 49 tuberculosis or whether multiple other predisposing factors were equally important is not obvious from the results of this single study. However, other studies performed in New York City and Boston between IS-82 and 1986 confirm earlier observations and support the findings that homeless people have a greater prevalence of tuberculosis (Glickman, 1984; Centers for Disease Control, 1985; Barry et al., 1986; Bricl~ner et al., 1986; Narde et al., 19861. Because tuberculosis is spread by personal contact, these infections pose a potential public health problem to occupants of shelters and to the general population. Chronic Diseases ~ The proportion of adults seen more than once in the HCH clinics who suffer from various chronic illnesses (e.g., hypertension, diabetes, and chronic obstructive pulmonary disease) is high 41 percent compared with 25 percent in domiciled outpatients described in the NAMCS data (Tables 3-3 and 3-4J. The high prevalence of hypertension can be explained partially by age, race, and alcohol consumption; but homelessness makes TABLE 3-6 Rates of Occurrence (in percent) of Infectious and Communicable Disorders, by Age, in the Johnson-Pew Health Care for the Homeless Client Population Adults in the Following Age Groups Seen more than Once: I II III IV NAMCS (N= (N= (I= (N= (N= Diagnosis 3,766) 5,783) 1,892) 445) 28,878) AIDS/ARC 0.3 0.2 0.2 0 NA Tuberculosis TB 0.2 0.6 1.0 0.9 0.1 PROTB 3.0 4.5 6.9 7.4 NA ANYTB 3.1 4.9 7.6 8.3 NA Sexually transmitted diseases VDUNS 1.4 0.4 0.1 0.2 0.6 SYPH 0.2 0.3 0.1 0.4 0.1 GONN 1.7 0.4 0.1 0 0.1 ANYSTD 3.1 1.1 0.3 0.4 NA Other INFPAR 0.6 0.3 0.2 0 0.7 ANYPH 16.8 17.7 17.6 18.7 NA NOTE: See "Key to Abbreviations and Explanatory Notes," pp. 69-71. SOURCE: Wright et al. (1987b).

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HEALTH PROBLEMS OF HOMELESS PEOPLE 65 bitts, bacterial endocarditis, and tuberculosis. Other, more exotic infec- tions that are not frequent in the United States are more common among drug abusers, such as malaria, which can be transmitted among patients who share needles. SADRI specially analyzed its main data base, which consisted of all clients with two or more visits who abused drugs, and found that some disorders were more common among drug abusers than among non-drug abusers. To some extent, however, the differences could be ascribed to various demographic characteristics, specifically, age and the presence of other disorders such as alcohol abuse or mental illness. Using this series of multivariant analyses, which controlled statistically for age, sex, ethnicity, and family status and for alcohol abuse and mental illness, the following disorders were found more commonly among homeless people who were drug abusers: AIDS, liver disease, cardiac disease, peripheral venous stasis disease, and chronic disorders such as diabetes and diseases of the liver and genitourinary tract. Although the exact relationship between homelessness and drug abuse and these illnesses is unclear, most of the findings are not surprising. AIDS and liver disease, for example, are associated with an increased frequency of hepatitis exposure among drug abusers. Comorbidity Finally, a point must be made about the comorbidity caused by mental illness, alcoholism and alcohol abuse, and illicit drug abuse. There is a growing concern among those who work with homeless people about clients with dual and multiple diagnoses (further exacerbated by a higher prevalence of many acute and chronic physical illnesses). For example, the HCH data point to correlations among drug abuse, alcohol abuse, and mental illness. Among drug abusers, 42 percent of the men and 41 percent of the women who visited HCH projects and gave evidence of that diagnosis could also be classified as mentally ill; 59 percent of the male clients and 46 percent of the female clients who abused drugs also evidenced a problem with alcohol (Wright, 19871. In another recent study drawn from a broad geographic base, the Veterans Administration Homeless Chronically Mentally Ill program reported that of the homeless for whom evaluations were performed, 32 percent had combined diagnoses of alcohol and drug abuse. Sixty-four percent had been hospitalized for any treatment for mental illness, alcoholism, or drug abuse. Because this latter figure is less than the sum of the prevalence rates for homeless veterans seen for each diagnosis (33 percent reported being hospitalized for psychiatric illness, 44 percent for alcoholism, and 14 percent for drug abuse), it appears that many of these hospitalizations were for dual or multiple diagnoses (Rosenheck et al., 1987~.

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66 HOMELESSNESS, HEALTH, AND HUMAN NEEDS There are two major problems that relate specifically to homeless people with multiple diagnoses. During the site visits, it was repeatedly emphasized to the committee members by those who work with the homeless that homeless people with dual and multiple diagnoses are among the most difficult to entice into treatment. Second, when outreach efforts are successful, there often are no appropriate programs into which such homeless people can be enrolled. Each separate diagnosis correlates to a specific treatment modality and treatment system. These programs frequently exclude those with secondary and tertiary diagnoses of other illnesses. It is rare to find programs that will address a combination of diagnoses on other than the most episodic of terms. HEALTH PROBLEMS OF HOMELESS FAMILIES, CHILDREN, AND YOUTHS Perhaps the most distressing and dramatic health problems caused by homelessness are those experienced by homeless families with children. Although the adult members of homeless families appear to be in better health than homeless single adults, they are still in poorer health than the general population. Using data from the HCH projects in 16 cities, Wright and Weber (1987) described 1,417 adult family members who were seeking health care; they represented 15 percent of the total adult population of the 16 programs. The authors concluded that in comparison with the NAMCS population, "homeless adult family members are . . . much more ill on virtually all indicators than the general ambu- latory population." With regard to a specific subpopulation of homeless adults in families, the Coalition for the Homeless (1985) has identified the following problems among homeless pregnant women: lack of prenatal care, poor nutrition, and low birth weight of the infants. In a study comparing homeless women living in New York City welfare hotels with women living in low-income housing projects, Chavkin et al. (1987), using data drawn from birth certificates for single births, determined that pregnant homeless women were more likely not to receive prenatal care, were more likely to have babies of low birth weight, and had higher infant mortality rates. With regard to mental illness, although many homeless mothers have emotional problems, most do not suffer from a major mental illness (e.g., schizophrenia). Furthermore, in contrast to adult homeless individuals, a relatively small percentage of homeless mothers had ever been hospitalized for psychiatric reasons (Bassuk et al., 19861. Wright and Weber (1987) found that various chronic physical disorders are nearly twice as common among homeless children as among ambu- latory children in the general population. Illnesses such as anemia,

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HEALTH PROBLEMS OF HOMELESS PEOPLE 67 malnutrition, and refractory asthma were many times more common among homeless children. Acker et al. (1987) concluded that more than 50 percent of homeless children had immunization delays. Although there is no precise information indicating that homeless children are more vulnerable to contracting such illnesses as diphtheria, tetanus, measles, or polio, existing epidemiologic data suggest that they are a high-risk group. Using data from the HCH projects, Wright and Weber (1987) reported that the rate of chronic physical disorders is nearly twice that observed among the children in the NAMCS population in general. Whether geographic mobility and residential instability will make these children a greater health risk to the general population is unknown, but it is a potential public health problem of concern. While access to food or, more appropriately, adequate and appropriate nutrition is a problem for homeless people of all ages, it is an especially critical issue for children and youths. Many welfare hotels where homeless families reside do not provide cooking facilities or refrigerators: For a hot meal, families must either violate safety codes by "smuggling" a hot plate into their room or use the little money they have to eat in a restaurant. This means that families usually rely on canned goods, dry cereals and other non-per~shable items for nourishment. Lack of refrigeration is particularly prob- lematic for mothers with infants who must devise other methods for keeping milk or formula cold, such as using toilet tanks as coolers. (Gallagher, 1986) Acker et al. (1987) compared 98 children up to 12 years old who were living in New York City welfare hotels with 253 domiciled poor children who presented at the Bellevue Hospital pediatric outpatient clinics. Homeless children between the ages of 6 months and 2 years were at higher risk for iron deficiency, leading the authors to conclude that "this may indicate the presence of other nutritional deficiencies and should be the subject of further investigation." In addition to physical health problems, homeless children appear to suffer greater emotional and developmental problems. Kronenfeld and colleagues (1980), in their report on children living at the Urban Family Center, a residential facility for homeless families on public assistance in New York City, found that homeless children were having serious problems in school. Children living in this facility were usually 2 or more years behind their age-appropriate grade level in reading and mathematics, often had discipline problems, and were frequently truant. Bassuk and colleagues (1986, 1987, 1988) described serious develop- mental, emotional, and learning problems in a population of homeless children residing in family shelters in Massachusetts. They reported that of the preschoolers tested on the Denver Developmental Screening Test, 47 percent manifested serious developmental delays in at least one of the

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68 HOMELESSNESS, HEALTH, AND HUMAN NEEDS four areas tested (language skills, gross motor skills, fine motor coordi- nation, and personal/social development). One-third of the children manifested more than two developmental lags. In this study, the school- age children were depressed and anxious; half of them required further psychiatric evaluation. Many had severe learning difficulties: 43 percent had already failed to complete a grade and 25 percent were in special classes. It is difficult to determine the extent to which homelessness per se was the principal variable accounting for each of these findings, but a comparison to poor, domiciled children documented that homelessness makes a major contribution (Bassuk and Rosenberg, 19881. With regard to homeless youths and adolescents, Wright and Weber (1987) reported that substance abuse, sexually transmitted diseases, and pregnancy were more prevalent among the homeless adolescents seen in the HCH projects than among the same age group in the domiciled population reported in the NAMCS study. The three studies on runaway and throwaway youths discussed in Chapter 1 (Shaffer and Caton, 1984; Greater Boston Adolescent Emergency Network, 1985; Janus et al., 1987), while not specifically examining the general health of this popu- lation, reported that the youths that they interviewed were not in poorer health than adolescents in general. However, as with the HCH project population, the major exceptions were pregnancy and sexually transmitted diseases. Both sets of findings might be attributed to the fact that these teenagers tend to be more sexually active at a younger age, even prior to becoming homeless. Given that AIDS is a disease that can be transmitted through sexual contact, the staff of the Larkin Street Youth Center in San Francisco expressed serious concern to the committee members during the site visit to that facility that AIDS may spread among runaway youths. SUMMARY Homeless people experience a wide range of illnesses and injuries to an extent that is much greater than that experienced by the population as a whole. First of all, health problems themselves, directly or indirectly, may cause or contribute to a person's becoming or remaining homeless. The leading example is major mental illness, especially schizophrenia, in the absence of treatment facilities and supportive housing arrangements. Second, the condition of homelessness and the exigencies of life of a homeless person may cause and exacerbate a wide range of health problems. Just as ill health can cause homelessness, so can homelessness cause ill health. Examples of this include skin disorders and the sequelae of a traumatic injury. Finally, the state of teeing homeless makes the

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HEALTH PROBLEMS OF HOMELESS PEOPLE 69 treatment and management of most illnesses more difficult even if services are available. Examples of this can be found for alcoholism and nearly any chronic illness, such as diabetes or hypertension. As with all other aspects of the problems of homeless people, data on their health problems and health care needs are partial, fragmentary, and incomplete. Still, enough is known about the health problems of homeless people to provide basic descriptive information and draw inferences for the purposes of programmatic intervention. KEY TO ABBREVIATIONS AND EXPLANATORY NOTES FOR TABLES 3-1 TO 3-6 The data in the tables indicate the percentage of the various subgroups within the client population who have been diagnosed with the various disorders listed. Thus, in Table 3-1, 23.6 percent of all adult clients ever seen (in 16 cities through the end of June 1986; N = 23,745 adult clients) have had a minor upper respiratory infection. Among clients (same cities and time frame) seen more than once (N = 11,886), the percentage with a minor upper respiratory infection is 33.2 percent, and so on through the tables. The rates of occurrence are given for adult clients only in 16 cities and are for the total number of people seen and for those seen more than once. This latter group is then divided further by sex, ethnic group, and age. In all tables, "NA" indicates that the data are not available at this time. In Tables 3-2, 3-4, and 3-6, age groups are as follows: I = 16-29; II = 30-49; III = 50-64; IV = 64+. The last (rightmost) columns of numbers in Tables 3-2, 3-4, and 3-6 show the data for adult respondents in urban areas from the National Ambulatory Medical Care Survey (NAMCS) done in 1979 (U.S. Department of Health and Human Services, 1979). Explanations or the abbreviations and terms used in Tables 3-1 to 3-6 are as follows: Acute Disorders (Tables 3-1 and 3-2J INF Infestational ailments (e.g., pediculosis, scabies, worms) NUTDEF Nutritional deficiencies (e.g., malnutrition, vitamin defi- . . clencles) OBESE Obesity MINURI Minor upper respiratory infections (common colds and related symptoms)

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70 HOMELESSNESS, HEALTH, AND HUMAN NEEDS SERRI Serious respiratory infections not classified elsewhere (e.g., pneumonia, influenza, pleurisy) MINSKIN Minor skin ailments (e.g., sunburn, contact dermatitis, psoriasis, corns, calluses) SERSKIN Serious skin disorders (e.g., carbuncles, cellulitis, impe- tigo, abscesses) Injuries Any trauma Fractures Sprains and strains Bruises, contusions Lacerations, wounds Superficial abrasions Burns of all severity TRAUMA ANY FX SPR BRU LAC ABR BURN Chronic Disorders (Tables 3-3 and 34) ANYCHRO Any chronic physical disorder CANC Cancer, any site ENDO Endocrinological disorders (e.g., goiter, thyroid, pancreas disease) DIAB ANEMIA NEURO SEIZ EYE EAR HTN CVA GI TEETH LIVER GENURI Diabetes mellitus Anemia and related disorders of the blood Neurological disorders, not including seizures (e.g., Par- kinson's disease, multiple sclerosis, migraine headaches, neuritis, neuropathies) Seizure disorders (including epilepsy) Disorders of the eyes (e.g., cataracts, glaucoma, de- creased vision) Disorders of the ears (e.g., otitis, deafness, cerumen im- paction) CARDIAC Heart and circulatory disorders, not including hyperten- sion and cerebrovascular accidents Hypertension Cerebrovascular accidents/stroke Chronic obstructive pulmonary disease Gastrointestinal disorders (e.g., ulcers, gastritis, hernias) Dentition problems (predominantly caries) Liver diseases (e.g., cirrhosis, hepatitis, ascites, enlarged liver or spleen) General genitourinary problems common to either sex (e.g., kidney, bladder problems, incontinence)

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HEALTH PROBLEMS OF HOMELESS PEOPLE 71 FEMGU PAD ARTHR OTHMS MALEGU Genitourinary problems found among men (e.g., penile disorders, testicular dysfunction, male infertility) (Note: Data on MALEGU shown in the table are for men only in all cases.) Genitourinary problems found among women (e.g., ovar- ian dysfunction, genital prolapse, menstrual disorders) Pregnancies (Note: Data on FEMGU and PREG shown in the table are for women only in all cases.) Peripheral vascular diseases Arthritis and related problems All musculoskeletal disorders other than arthritis Infectious and Communicable Disorders (Tables 3-5 and 3-6) AIDS/ARC Acquired immune deficiency syndrome, AIDS-related complex TB Active tuberculosis infection, any site PROTB Prophylactic anti-TB therapeutic regimen ANYTB Either TB or PROTB or both VDUNS Unspecified veneral disease, herpes SYPlI Syphilis GONN Gonnorhea ANYSTD VDUNS, SYMPH, or GONN, or any combination INFPAR Infectious and parasitic diseases (e.g., septicemia, ame- biasis, diphtheria, tetanus) ANYPH AIDS, ANYTB, ANYSTD, INFPAR, SERURI, INF, or SERSKIN, or any combination of these REFERENCES Acker, P. J., A. H. Fierman, and B. P. Dreyer. 1987. An assessment of parameters of health care and nutrition in homeless children. American Journal of Diseases of Children 141(4):388. Alstrom, C. H., R. Lindelius, and L. Salum. 1975. Mortality among homeless men. British Journal of Addiction 70:245-252. Anderson, N. 1923. The Hobo, The Sociology of the Homeless Man. Chicago: University of Chicago Press. Annis, H., N. Geisbrecht, A. Ogborne, and R. B. Smart. 1976. Task Force II Report on the Operation and Effectiveness of the Ontario Detoxification System. Toronto: Addiction Research Foundation of Ontario. Arce, A.. A., and M. J. Vergare. 1984. Identifying and characterizing the mentally ill among the homeless. Pp. 75-89 in The Homeless Mentally Ill, H. R. Lamb, ed. Washington, D.C.: American Psychiatric Association. Arce, r>~. A., M. Tadlock, and M. J. Vergare. 1983. A psychiatric profile of street people admitted to an emergency shelter. Hospital and Community Psychiatry 34~9):812-817. Bachrach, L. L. 1984. The homeless mentally ill and mental health services: An analytical review of the literature. Pp. 11-53 in The Homeless Mentally Ill, H. R. Lamb, ed. ~Vashington, D.C.: American Psychiatric Association.

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HEALTH PROBLEMS OF HOMELESS PEOPLE 75 Schutt, R. K., and G. R. Garrett. In press. The homeless alcoholic: Past and present. In Homelessness: The National Perspective, M. J. Robertson and M. Greenblatt, eds. New York: Plenum Publishing. Shaffer, D., and C. L. M. Caton. 1984. Runaway and Homeless Youth in New York City: A Report to the Ittleson Foundation. New York: The Ittleson Foundation. Shandler, I. W., and T. E. Shipley. 1987. New focus for an old problem: Philadelphia's response to homelessness. Alcohol, Health, and Research World 11(3):54-57. Shaw, J. M., G. S. Kolesar, E. M. Sellers, H. L. Kaplan, and P. Sandor. 1981. Development of optimal treatment tactics for alcohol withdrawal. Journal of Clinical Psychophar- macology l(November):382-389. Sherman, M. N. 1980. Tuberculosis in single-room-occupancy hotel residents: A persisting focus of disease. New York Medical Quarterly 1:39-41. Stark, L. 1985. Strangers in a strange land: The chronically mentally ill homeless. International Journal of Mental Health 14(4):95-111. Stark, L. 1987. A century of alcohol and homelessness: Demographics and stereotypes. Alcohol, Health, and Research World 11(3):8-13. Stevens, A. O., L. Brown, P. Colson, and K. Singer. 1983. When You Don't Have Anything: A Street Survey of Homeless People in Chicago. Chicago: Chicago Coalition for the Homeless. Straus, R. 1946. Alcohol and the homeless man. Quarterly Journal of Studies on Alcohol 7:361-404. Streuning, E. L. 1986. A Study of Residents of the New York City Shelter System. New York: New York State Psychiatric Institute. U.S. Department of Health and Human Services. 1979. National Ambulatory Medical Care Survey. Washington, D.C.: U S. Department of Health and Human Services. U.S. Department of Health and Human Services. 1980. Tuberculosis Statistics: States and Cities. Publication no. (CDC)82-8249. Atlanta: Centers for Disease Control, U.S. Department of Health and Human Services. Vicic, W. J., and P. Doherty. 1987. Homelessness: A medical viewpoint. Paper prepared for the Institute of Medicine, Washington, D.C. Whiteley, J. S. 1955. Down and out in London: Mental illness in lower social groups. Lancet ii:608-610. Wiseman, J. P. 1987. Studying the problem of alcoholism in today's homeless. Paper presented at the National Institute of Alcohol Abuse and Alcoholism Conference on the Homeless Population with Alcohol Problems, Rockville, Md., March 24-25. Wright, J. D. 1987. Special Topics in the Health Status of America's Homeless. Special report prepared for the Institute of Medicine by the Social and Demographic Research Institute, University of Massachusetts, Amherst. Wright, J. D., and E. Weber. 1987. Homelessness and Health. New York: McGraw-Hill. Wright, J. D., J. W. Knight, E. Weber-Burdin, and J. Lam. 1987a. Ailments and alcohol: Health status among the drinking homeless. Alcohol, Health, and Research World 11(3):22-27. Wright, J. D., E. Weber-Burdin, J. W. Knight, and J. A. Lam. 1987b. The National Health Care for the Homeless Program: The First Year. Report prepared by the Social and Demographic Research Institute, University of Massachusetts, Amherst. Wynne, J. 1984. Homeless Women in San Diego: A New Perspective on Poverty and Despair in America's Finest City. San Diego: Alcohol Program, Department of Health Services, County of San Diego.