Health beyond the headlines
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Neglecting the Homeless

Healing public health policies for a vulnerable population

By Kathleen Bachynski

Published January 14, 2014

The extra volunteers who lent a helping hand at shelters over the holiday season have now departed. The special holiday parties for homeless children have ended. The tax-deductible donations for 2013 have already been made.

Yet long, cold winter months stretch out ahead, remaining a major threat to the health and lives of homeless Americans. Hundreds of homeless people die of hypothermia each year, even in the wealthiest parts of the country. And as communities make public spaces, such as train station waiting areas increasingly off-limits to homeless people, options for refuge become even scarcer. In Prince Edward Island, a homeless man with psychiatric problems was jailed to keep him from freezing on a bitterly cold evening, because no bed was available for him at the hospital.

In December, national Homeless Persons’ Memorial Day commemorates the many homeless people who have died in the past year. As Kurt Runge, director of advocacy at Miriam’s Kitchen told the Washington Post, “Homeless people are dying young, and they’re dying from preventable and manageable diseases.”

Current work to end homelessness has yielded mixed results, with both positive and negative trends documented. Since 2007, homelessness has declined by 9% nationally. But major cities with large homeless populations have seen significant increases. Notably, over this same time period, New York has seen a 13% increase in homelessness.

Unfortunately, compounding these many challenges, some public health policies neglect to account for the unique health needs of homeless people. One problem has been a narrow focus on just one segment of a larger homeless population. This group, chronically homeless persons, has been defined as “unaccompanied individuals who had a disabling condition and who had been homeless for a year or had three episodes of homelessness in the past four years.”

Three federal agencies—The Department of Housing and Urban Development, the Department of Health and Human Services, and the Department of Veterans Affairs—collaborated to fund projects to end chronic homelessness as defined above. But, as noted by researcher Cheryl Zlotnick and colleagues, this policy approach systematically excludes other groups of homeless people, including families, couples, and children. Dasani, a young girl profiled in a recent New York Times series on homelessness, is just one member of one of these groups that public policies too often ignore.

Additionally, preparedness plans for public health emergencies do not always adequately account for the needs of homeless people. For example, in its Q&A recommending actions to take in the event of pandemic influenza, the Indiana State Department of Public Health states that “homeless people should not be encouraged to come to shelters.” Instead, the department advises that health care providers should “check on people in the streets” and may need to increase distribution of supplies “to keep people away from the shelters.”

Yet cold temperatures often coincide with the flu season.

In a commentary for the Canadian Journal of Public Health, Diego Silva and his co-authors observe, “it seems untenable that persons who use shelters will be able to, or ought to be able to, stay away from them without placing themselves in danger of other perils, such as freezing to death.” Pandemic preparedness plans that do not make alternative provisions for sheltering homeless people may put them at greater risk for disease or death.

Despite these policy failures, many public health professionals, advocates, and public officials have sought to creatively address the unique circumstances of homeless people. To prevent the transmission of flu, some community organizations have arranged impromptu clinics in unconventional locations to reach homeless populations. For instance, in Edmonton, registered nurses have set up mini flu clinics at bars and pubs, where they have immunized over 170 homeless people.

In New York City, Bill de Blasio’s new mayoral administration has already altered policies that previously threatened the well-being of the city’s homeless population. Deputy Mayor for Health and Human Services Lilliam Barrios-Pauli directed that any homeless family seeking shelter on a cold night would be granted it, even if they had been previously turned away.

In December 2013, the American Journal of Public Health published a special supplemental issue highlighting the latest research on homelessness and public health. Interventions examined included a nutrition education program for homeless children, intensive housing placement and community transition services, and tailored primary care programs.

Public policies should address the needs of homeless people in their full range of circumstances, from chronically homeless individuals to temporarily homeless families. They should encourage the adoption of interventions shown to improve this population’s well-being. And, taking into account the unique needs of homeless people, they must guard against polices that “perpetuate disadvantage among those already disadvantaged.” The health of some of our most vulnerable neighbors depends on it.

Note: In this cold winter weather, if you see a homeless person who needs help and shelter, you can call one of these hotline numbers based on your location to request professional assistance.                                                                                                                                   

Edited by Joshua Brooks.

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The views and opinions expressed on this website are solely those of the authors and do not represent those of the Department of Epidemiology, the Mailman School of Public Health, or Columbia University.