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OCR for page 39
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 visits—is 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
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Representative terms from entire chapter:
mentally ill
