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SUPPORTING A NATIONAL PRIORITY TO ELIMINATE HOMELESSNESS

Policy Date: 1/1/1997
Policy Number: 9718(PP)

I. Statement of the Problem
Homelessness continues to be a major fact of daily existence for hundreds of thousands of Americans and presents major social service demands, health care burdens and policy dilemmas for large and small cities and the nation as a whole. Estimating the numbers of homeless people is notoriously difficult,1-3 but a recent estimate suggests that as many as 7.4% of Americans (13.5 million people) may have experienced homelessness at some time in their lives.4 Many more have lived in over-crowded, near-homeless conditions
A decade ago, Congress enacted the Stewart B. McKinney Homeless Assistance Act (PL 100-77). Under the provisions of the McKinney Act, federal agencies have funded services for homeless people, including health care, mental health care, food assistance, emergency shelter, transitional housing and facility construction. The Act also established the Interagency Council on the Homeless to coordinate the activities of federal agencies and, in subsequent reauthorizations, additional programs were designed to help persons with AIDS (acquired immunodeficiency syndrome); women in domestic violence shelters and children in homeless families. A series of research demonstration projects have been funded to develop better models of serving the needs of homeless people.
The McKinney Act was intended only as a first step towards addressing the problems of homelessness in America: more far-reaching responses were to follow, but have yet to be developed. Therefore, although immense and praiseworthy effort has gone into providing services for homeless people in almost every state, there is no evidence that the extent of homelessness in America is less than it was a decade ago. There have been considerable achievements in terms of providing services to homeless people, but little or no progress in preventing homelessness.
Research conducted in the 1980s and early 1990s has documented the characteristics of homeless people, including their health status.5-7 The focus of more recent research has shifted to special subgroups of homeless people, the dynamics of homelessness, risk factors, effective strategies for intervention, and prevention.8-11 Research has demonstrated the complexity of the homelessness problem. There is seldom a single reason that a person, or a family, becomes homeless. An array of structural problems within the society creates the conditions which place people at risk: housing shortages, deinstitutionalization policies, changes in the industrial economy, failed educational systems, racism, inadequate income supports, erosion of family and social support systems, among others.12 Another array of individual factors increases vulnerability: illness, disability, substance abuse, domestic violence, disaffiliation, or job loss.12-15 For any homeless person, external factors and individual vulnerability have contributed to their losing a permanent place to live.
The relationship between homelessness and health has been clearly demonstrated.16,17 Homelessness is injurious to people's health and the conditions under which homeless people are often compelled to live also impose health hazards. Exposure to inclement weather, limited opportunity for maintaining personal hygiene, poor nutrition, exposure to street violence including police harassment and brutality,18 sleep deprivation, heavy tobacco use, exposure to alcohol and other drugs, all pose health hazards as do the overcrowded conditions of many shelters with increased risk of exposure to parasitic or infectious diseases. Limited access to health services may mean that conditions which would in normal circumstances be easily resolved may persist, worsen, or become chronic. Homeless people are at demonstrably increased risk for tuberculosis and other respiratory diseases,19-21 trauma,22-24 major mental illnesses,25 alcoholism and its sequelae,27-29 drug abuse and dependence,26-30 HIV (human immunodeficiency virus) infection and sexually transmitted diseases.31-32 In addition, the sick and disabled are often those at greatest risk of homelessness because their disability causes them to have greater needs, because in some cases they have greater difficulty managing their resources, and because public support provided by Social Security or other funding agencies is often inadequate.33
Homeless families have been of particular concern and are believed to be the fastest growing segment of the homeless population in the 1990s.13,34 The consequences of homelessness for children are grave. Residential instability in childhood has been associated with delays in cognitive development, interruption of education and health deficits, including frequent infections, anxiety and depression, and failure to obtain necessary immunizations.35,36 Homeless adolescents are in great danger of becoming involved in high-risk behaviors, including substance abuse and prostitution.
There needs to be a greater emphasis on prevention. Providing more facilities and services for homeless people is vitally important to meet their wide variety of needs, but does not prevent other individuals from becoming homeless. Individual risk factors for homelessness are being elucidated. Events and circumstances as far back as childhood, such as physical and sexual abuse, residential instability, low educational achievement, parental absence, or foster-care placement have been shown to predict homelessness in adult life.14,37,38 Factors in adult life which are linked with homelessness include poor employment history, low income, domestic violence, mental illness, substance abuse and poor physical health. A way of preventing homelessness, or even reducing it, has still to be found.
The persisting numbers of homeless people in America are an indictment of our collective failure to make the basic ingredients of civilized society accessible to all citizens. Whatever individual vulnerabilities may exist, research continues to show that homelessness is rooted in deficiencies in these basic ingredients: the availability of adequate housing for all citizens, the opportunity to earn an adequate income, education to prepare people to be productive in the modern economy, safe communities, a supportive and stable childhood environment, and health care accessible to everyone according to their need.39,40 The complexity of the issues and the need for cross-cutting solutions present daunting challenges to the nation.

II. Purpose of the Position Paper
Homelessness has been identified as a public health concern for specific groups in prior policy statements of the American Public Health Association: No. 8413 addressed the needs of people with mental illnesses, No. 8932 focused on homeless alcoholics and drug abusers, and No. 9003 addressed the needs of homeless pregnant adolescents. This paper is presented by the Caucus on Homelessness:
1. to reaffirm the central importance of housing for healthy living. Satisfactory housing should be identified as an important public health priority.
2. to assert the need for increased energy and resources to be directed by public health professionals and agencies towards addressing the problem of homelessness in the United States, according to housing the same degree of importance as other fundamental requirements for healthy lives, such as clean water, adequate nutrition or control of epidemics.
3. to remind public health agencies and professionals that they can be powerful advocates for change and that concerted public health advocacy on this issue will be of great value in shaping public opinion and public policy. Public health advocates are hereby urged to take a lead, along with other advocacy organizations, in pressing for a national movement, involving both governmental and non-governmental sectors of society, to eliminate homelessness in America, not only because it is an affront to human dignity, but because it poses significant health risks.
4. to urge scientists within public health to investigate the impact of housing and homelessness on health, methods for increasing access to affordable and adequate housing for everyone, and methods of assisting people to retain housing. Methods must be developed to identify individuals at special risk of homelessness and implement preventive interventions.
5. to call for incorporation of a consideration of the impact of housing and homelessness into public health educational curricula so that future generations of public health professionals will be equipped to represent the public health agenda in the ongoing debate about homelessness and the housing needs of communities.
6. to focus preventive health services on the specific needs of homeless individuals.

III. Recommended APHA Actions
1. APHA government relations staff and affiliate organizations should advocate at federal, state and local levels on behalf of any measure which will increase the availability of affordable housing for all Americans, especially those with low incomes and disabilities. Specific policy recommendations would include:
(a) That federal, state and local governments should, along with the provision of housing, make provision for adequate support systems to enable chronically homeless or disabled persons to resettle in housing once it is available, specifically that the Department of Housing and Urban Development expand its Shelter Plus care and Supported Housing programs.
(b) That federal, state and local regulations should require service system linkage for health services (primary care, mental health and substance abuse) with providers of housing services for homeless people.
(c) That states be required to ensure that new housing is available to replace beds in mental institutions that are being phased out under policies for deinstitutionalization.
(d) That public authorities address zoning and land use legislation or regulations that are unduly restrictive regarding housing options or program placement for low-income individuals and homeless persons with psychiatric and/or substance use disorders.
2. The APHA should collaborate with other scientific and advocacy agencies to support research on:
(a) methods for providing low-cost housing,
(b) the structuring of housing subsidies.
(c) policies and procedures for evictions and similar issues, emphasizing their importance as public health issues.
3. APHA should press public agencies, such as the Centers for Disease Control and Prevention, to monitor data on the morbidity and mortality associated with homelessness, including infectious diseases, nutritional deficiencies, mental illness, substance abuse, trauma, and exposure to environmental hazards.
4. The APHA should encourage federal research institutes to support research on those factors which influence residential stability, as risk/protective factors for disease.
5. The APHA should press for federal government attention to related social issues which have impact on individuals' ability to maintain stable housing. Such issues include a minimum wage level that will adequately support individuals and families, violence reduction and safety in communities, and welfare reform legislation that adequately addresses the needs of poor families and persons with disabilities.
6. Public health educators should incorporate into the curricula of schools of public health, courses which examine the impact of housing and homelessness on health and the public policies which influence the availability and accessibility of housing.

References


  1. Breakey WR, Fischer PJ. "Homelessness: The Extent of the Problem." Journal of Social Issues, 1990;46(4):31-47.

  2. Appelbaum RP. Counting the Homeless. Chicago, IL: University of Chicago, Center for Urban Research and Policy Study, 1987.

  3. Burt M. Practical Methods for Counting Homeless People. Washington, DC: The Urban Institute, 1996.

  4. Link BG, Susser E, Steuve A, Phelan J, Moore RE, Struening E. Lifetime and Five-Year Prevalence of Homeless in the United States. Am J Public Health 1994;82(12):1907-1912.

  5. Gelberg L, Linn LS. Assessing the Physical Health Status of Homeless Adults. JAMA, 1989;262(14):1973-1979.

  6. Breakey WR, Fischer PJ, Kramer M, Nestadt G, Romanoski AJ, Ross A, Royal RM, Stine OC. Health and Mental Health Problems of Homeless Men and Women in Baltimore. JAMA, 1989;262(10):1352-1357.

  7. Susser E, Struening EL, Conover S. Psychiatric Problems in Homeless Men. Archives of General Psychiatry, 1989;46:845-850.

  8. Susser E, Lin SP, Conover SA, Struening EL. "Childhood Antecedents of Homelessness in Psychiatric Patients." American Journal of Psychiatry, 1991;148(8):1026-1030.

  9. Weitzman BC. Pregnancy and Childbirth: Risk Factors for Homelessness? Family Planning Perspectives, 1989; 21(4):175-178.

  10. Lezak AD, Edgar E. Preventing Homelessness among People with Serious Mental Illnesses. Rockville, MD: Center for Mental Health Services, 1996.

  11. Shern D, Felton C, Hough R, Lehman A, Goldfinger S, et al. Housing Outcomes for Homeless Adults With Mental Illness: Results From the Second-Round McKinney Program. Psychiatric Services, 1997;48(2):239-241.

  12. Koegel P, Burnam A. Getting Nowhere: Homeless People, Aimless Policies. In JB Steinberg, DW Lyon & ME Vaiana (eds.) Urban America: Policy Choices for Los Angeles and the Nation. Los Angeles, CA: Rand; 1992.

  13. Bassuk EL, Buckner JC, Weinreb LF, et al. Childhood and Adult Risk and Protective Factors for Homelessness in Female-Headed Families. Am J Public Health, 1997;87(2):241-247.

  14. Herman DB, Susser ES, Struening EL, Link BL. Adverse Childhood Experiences are Risk Factors for Adult Homelessness. Am J Public Health, 1997;87(2):248-254.

  15. Drake RE, Osher FC, Wallach MA. Homelessness and Dual Diagnosis. American Psychologist, 1991;46(11): 1149-1158.

  16. Scharer LK, Berson A, Brickner PW. Lack of Housing and Its Impact on Human Health: A Service Perspective. Bulletin of the New York Academy of Medicine, 1990;66(5):515-525.

  17. Wright JD, Weber E. Homelessness and Health. Washington, DC: McGraw-Hill's Healthcare Information Center, 1987.

  18. Amnesty International. Police Brutality and Excessive Force in New York City Police Department. June 26, 1996.

  19. Layton MC, Cantwell MF, Dorsinville GJ, et al. Tuberculosis Screening among Homeless Persons with AIDS Living in Single-Room-Occupancy Hotels. Am J Public Health, 1995;85(11):1556-1559.

  20. Nettleman MD. Use of BCG Vaccine in Shelters for the Homeless. Chest, 1993;103(4):1087-1090.

  21. Saez H, Valencia E, Conover S, Susser E. Tuberculosis and HIV among Mentally Ill Men in a New York City Shelter. Am J Public Health, 1996;86(9): 1318-1319.

  22. Harris M. Modifications in Service Delivery and Clinical Treatment for Women Diagnosed with Severe Mental Illness Who Are Also the Survivors of Sexual Abuse Trauma. Washington, DC: Community Connections, 1994.

  23. Schutt RK, Mescede T, Rierdan J. Distress, Suicidal Thoughts and Social Support among Homeless Adults. Journal of Health and Social Behavior, 1994;35(2):134-142.

  24. Hurlburt MS, Hough RL, Davies-Netzley S. Childhood Abuse as a Precursor to Homeless Women with Severe Mental Illness. Violence and Victims, 1996;11(2).

  25. Federal Task Force on Homelessness and Severe Mental Illness. Outcasts on Main Street. Report of the Federal Task Force on Homelessness and Severe Mental Illness. Washington, DC: Interagency Council on the Homeless, 1992.

  26. Dennis DL, Buckner JC, Lipton FR, Levine IS. A Decade of Research and Services for Homeless Mentally Ill Persons: Where Do We Stand? American Psychologist, 1991;46(11):1129-1138.

  27. Baumoh J, Huebner RB. Alcohol and Other Drug Problems Among the Homeless: Research, Practice, and Future Directions. Housing Policy Debate, 1991;2(3):837-866.

  28. Fiscller PJ, Breakey WR. The Epidemiology of Alcohol, Drug, and Mental Disorders among Homeless Persons. American Psychologist, 1991;46(11): 1115-1128.

  29. Robertson MJ. Homeless Women With Children: The Role of Alcohol and Other Drug Abuse. American Psychologist, 1991;46(11):1198-1204.

  30. Wenzel S, Ebener P, Koegel P, Gelberg L. Drug-Abusing Homeless Clients in California's Substance Abuse Treatment System. Journal of Psychoactive Drugs, 1996;28(2):147-159.

  31. Empfield M, Cournos F, Meyer I, et al. HIV Seroprevalence among Homeless Patients Admitted to a Psychiatric Inpatient Unit. American Journal of Psychiatry, 1993;150(1):47-52.

  32. St. Lawrence J, Brasfield T. HIV Risk Behavior among Homeless Adults. AIDS Education and Prevention, 1995; 7(1):22-31.

  33. Institute of Medicine. Homelessness, Health and Human Needs. Washington, DC: National Academy Press, 1988.

  34. McChesney KY. Family Homelessness: A Systemic Problem. Journal of Social Issues, 1990;46(4):191-205.

  35. Bassuk EL, Gallagher, EM. The Impact of Homelessness on Children. Journal of Children and Youth Services, 1990;14:19-35.

  36. Rafferty Y, Shinn M. The Impact of Homelessness on Children. American Psychologist, 1991;46(11):1170-1179.

  37. Calsyn RJ, Roades LA. Predictors of Past and Current Homelessness. Journal of Community Psychology, 1994; 22:272-278.

  38. Koegel P, Melamid E, Burnam MA. Childhood Risk Factors for Homelessness among Homeless Adults. Am J Public Health, 1995;85(12):1642-1649.

  39. Baumohl J. (ed). Homelessness in America. Phoenix, AZ: The Oryx Press, 1996.

  40. lnteragency Council on the Homeless. Priority: Home! The Federal Plan to Break the Cycle of Homelessness. Washington, DC: US Department of Housing and Urban Development, 1994.


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