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Homeless in America

  • Joseph S. Alpert
    Correspondence
    Requests for reprints should be addressed to Joseph S. Alpert, MD, 1501 N. Campbell Avenue, Tucson, AZ, 85724-5037.
    Affiliations
    Professor of Medicine, Department of Medicine, University of Arizona, Tucson

    Editor in Chief, The American Journal of Medicine
    Search for articles by this author
Published:October 12, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.10.002
      On a recent trip to California, my spouse and I were shocked by the number of homeless that we saw on the street. Of course, we have a fair number of homeless in Tucson as well but, clearly not as many as in California. We suspected that this was the result of the uniformly pleasant weather in the Golden State. This idea is supported by the large number of homeless living in Florida. Homelessness is a huge social and medical problem here in the United States. Seventeen of every 10,000 persons living here experiences homelessness.

      National Alliance to End Homelessness. State of homelessness: 2020 edition. Available at:https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2020/. Accessed October 3, 2020.

      In 2019, there were more than 500,000 homeless individuals living in the United States. The West Coast, the Southwest, Florida, and New York are the regions with the highest numbers of homeless. The situation in Los Angeles is reaching critical proportions: “Today, Los Angeles hosts an estimated homeless population of nearly 40,000 people (the entire states of Texas and Florida have between 25,000 and 28,000 respectively). Affluent sections of the city have become dangerous with open-air drug use, human feces, medieval diseases, and, sadly, homeless encampments.”

      Andrzejewski A. Mapping Los Angeles’ homeless encampment challenge—nearly 100,000 cases reported since 2019. Forbes. Available at:https://www.forbes.com/sites/adamandrzejewski/2020/09/30/mapping-los-angeles-homeless-encampment-challenge–nearly-100000-cases-reported-since-2019/#5f986d534dee. Accessed October 3, 2020.

      On our inpatient services for medicine or cardiology, a substantial number of homeless or near-homeless individuals are admitted suffering from a variety of conditions exacerbated by their unfortunate situation: mental illness, cellulitis, addiction, respiratory illnesses, and many additional chronic conditions. There need not be a double-blind controlled trial to demonstrate that living on the street with any illness often leads to a bad outcome. Indeed, it is challenging for homeless individuals to follow any medical regimen, and often, psychiatric comorbid conditions make it almost impossible to treat usually curable or controllable maladies such as cellulitis, pneumonia, and diabetes mellitus. Many of the patients that I see also suffer from malnutrition documented in the initial set of blood tests obtained: anemia and low serum albumin values. Dental caries and severe gum disease are also rampant in these patients placing them at substantial risk for various systemic infections and atherosclerosis. Despite our best efforts, many homeless patients with serious medical conditions sign out of the hospital against medical advice, often leading to further complications and subsequent prolonged, complex, and expensive hospitalizations.
      What are the characteristics of the homeless population in the United States?

      National Alliance to End Homelessness. State of homelessness: 2020 edition. Available at:https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2020/. Accessed October 3, 2020.

      ,

      Wikipedia. Homelessness in the United States. Available at:https://en.wikipedia.org/wiki/Homelessness_in_the_United_States. Accessed October 3, 2020.

      Nearly 400,000 are single and more than 150,000 are families. A total of 37,000 are veterans, 60% percent are men, and minority individuals represent more than half of the homeless population. Chronically homeless individuals are often disabled, including a not insignificant number of veterans. Nearly half of the homeless population are older than age 50, and their situation ages them more rapidly than people who have a roof over their head.

      National Alliance to End Homelessness. State of homelessness: 2020 edition. Available at:https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2020/. Accessed October 3, 2020.

      Homelessness increased during the last 3 years and by 3% in 2019 compared with the previous year. I expect that the numbers are considerably worse in 2020 given the pandemic and its effect on the national economy. One hopeful sign is that homelessness has decreased by 12% since 2007, the first year that these statistics were compiled.

      National Alliance to End Homelessness. State of homelessness: 2020 edition. Available at:https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2020/. Accessed October 3, 2020.

      Unfortunately, it has been estimated that homelessness will triple over the next decade.

      Santos F. Elderly and homeless: America's next housing crisis. New York Times Magazine. Available at:https://www.nytimes.com/2020/09/30/magazine/homeless-seniors-elderly.html?auth=link-dismiss-google1tap. Accessed October 3, 2020.

      Homelessness has almost certainly been with us since the beginning of historical time. There are many references to hermits and vagabonds in medieval songs and literature, and undoubtedly, this state traces considerably further back in time. In the United States, homelessness became an issue in 1870 during the Progressive Era.

      Wikipedia. Homelessness in the United States. Available at:https://en.wikipedia.org/wiki/Homelessness_in_the_United_States. Accessed October 3, 2020.

      During the great economic depression following the collapse of the stock market in 1929, the country saw an explosion of homeless men known as “hoboes” who were often found near railroad yards where they could grab a free ride in an empty freight car. These individuals have often been depicted in folk songs, stories, and novels describing life at that time when approximately 2 million people wandered the country looking for food and shelter.

      Wikipedia. Homelessness in the United States. Available at:https://en.wikipedia.org/wiki/Homelessness_in_the_United_States. Accessed October 3, 2020.

      Most of these individuals were white males older than age 45. In the late 20th century, homelessness was recognized as a major social problem in the United States, and President Reagan signed into law the McKinney-Vento Homeless Assistance Act in 1987, which funded a number of support services for the homeless such as shelters and food kitchens. However, the growing number of homeless continually stresses the ability of these and other social services to assist every homeless person. The current pandemic is making it even more difficult to care and feed the homeless who, therefore, often end up in the hospital where they can rest, sleep, and eat while receiving needed medical care. Some of these patients have Medicaid or Medicare insurance, but many are without health care resources and seek emergency Medicaid support with the help of hospital social workers and case managers. Unfortunately, emergency Medicaid funding does not extend beyond the hospitalization, and so further care for these patients depends on federally supported community health clinics. And, of course, these individuals end up back on the street following their inpatient stay.
      Given the enormity of this problem, what possible solutions are available or planned? Some help in the form of additional financial support for various programs that assist the homeless was passed into law during President Barack Obama's administration. The federal government under President Obama instituted several pieces of legislation that addressed the homelessness crisis. The American Recovery and Reinvestment Act of 2009 addressed homelessness prevention, allocating $1.5 billion to the Housing and Urban Development (HUD) arm of the federal government for the “Homelessness Prevention and Rapid Rehousing Program (HPRP).” In addition, during 2009, the federal government initiated the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act. It was part of the Helping Families Save Their Homes Act of 2009. The HEARTH act allows for the prevention of homelessness, rapid rehousing, consolidation of housing programs, and new homeless categories.

      Wikipedia. Homelessness in the United States. Available at:https://en.wikipedia.org/wiki/Homelessness_in_the_United_States. Accessed October 3, 2020.

      Unfortunately, despite this increased assistance for the homeless, their number is growing and outpacing the social considerable success.

      Wikipedia. Homelessness in the United States. Available at:https://en.wikipedia.org/wiki/Homelessness_in_the_United_States. Accessed October 3, 2020.

      ,
      • Sandel M
      • Matthew D
      Investing in housing for health improves both mission and margin.
      ,
      • Tsai J
      • Gelberg L
      • Rosenheck RA
      Changes in physical health after supported housing: results from the collaborative initiative to end chronic homelessness.
      The Housing First model has seen a number of successes since its initial implementations in 2009. The program provides housing to homeless people with addiction or mental health issues. This program enables homeless men and women to be taken into private community-based apartments without requiring treatment first. Housing allows these homeless to return to some sense of normalcy from which it is believed they are better prepared to tackle their addiction or sickness. The relapse rate through these types of programs is lower than that of other conventional homeless programs.
      • Abel D
      For the homeless, keys to a home: large-scale effort to keep many off street faces hurdles.
      In summary, homelessness is a major social issue in the United States today. It is associated with substantial expense to our society as well as threats to public health. I am personally hopeful that programs now in place, as well as others envisioned for the future, will assist in decreasing homelessness in the United States. As always, I am glad to hear from readers at [email protected] or on our blog at amjmed.org.

      References

      1. National Alliance to End Homelessness. State of homelessness: 2020 edition. Available at:https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2020/. Accessed October 3, 2020.

      2. Andrzejewski A. Mapping Los Angeles’ homeless encampment challenge—nearly 100,000 cases reported since 2019. Forbes. Available at:https://www.forbes.com/sites/adamandrzejewski/2020/09/30/mapping-los-angeles-homeless-encampment-challenge–nearly-100000-cases-reported-since-2019/#5f986d534dee. Accessed October 3, 2020.

      3. Wikipedia. Homelessness in the United States. Available at:https://en.wikipedia.org/wiki/Homelessness_in_the_United_States. Accessed October 3, 2020.

      4. Santos F. Elderly and homeless: America's next housing crisis. New York Times Magazine. Available at:https://www.nytimes.com/2020/09/30/magazine/homeless-seniors-elderly.html?auth=link-dismiss-google1tap. Accessed October 3, 2020.

        • Sandel M
        • Matthew D
        Investing in housing for health improves both mission and margin.
        JAMA. 2017; 318: 2291-2292https://doi.org/10.1001/jama.2017.15771
        • Tsai J
        • Gelberg L
        • Rosenheck RA
        Changes in physical health after supported housing: results from the collaborative initiative to end chronic homelessness.
        J Gen Intern Med. 2019; 34: 1703-1708https://doi.org/10.1007/s11606-019-05070-y
        • Abel D
        For the homeless, keys to a home: large-scale effort to keep many off street faces hurdles.
        Boston Globe. February 24, 2008; (Available at:) (Accessed October 13, 2020)