The Public's Health: Homelessness | The Public Health Post

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Homelessness is a brutal, demoralizing experience. Every day brings the difficult search for shelter, food, clothing, a place to wash, a place to go to the bathroom for more than 550,00 Americans, and those who find their way to shelters have three times the age-adjusted risk of dying compared to the general population. Those who go unsheltered, the so-called “rough sleepers,” have 10 times the mortality.

Homelessness has the power to move us to action like few other failings in a modern world. Unfortunately, our efforts to tackle homelessness have long fallen short. Historically, making housing contingent on sobriety and employment—forcing those who did not meet these marks to fall away and become chronically homeless—has imperiled millions. Housing First—a program that provides housing and support services without requiring employment or pretreatment for mental health conditions and substance use disorders—has gained traction. Compared to treatment first, Housing First leads to improvements in housing stability, reduced hospitalizations and use of emergency departments, and better quality of life.

Making housing more permanent and affordable is an essential first step, if dual-edged. Moving the urban homeless from their current situation offers protection, but also isolation from the little help and friendship known to these individuals, especially those with mental illness or disability. Still, rapid re-housing availability for those in need is critical.

Adding to the challenge, over eight million more Americans are one step away from homelessness. And unlike the homeless, they are often invisible. The number of renters with very low income, who use half of it for housing and receive no government assistance, has grown 25% in the past decade. Many become homeless through temporary personal or financial crises, and 40% of people experiencing homelessness are families with children. Preventing homelessness in these lower-income households requires the creation of a living wage (impossible at $7.25 an hour, the Federal figure). But prevention is also about identifying risk, and providing supportive services when an individual or family is on the brink.

About one in 10 homeless persons is a veteran, up from one in three only a decade ago. What the Department of Veterans Affairs has recognized is that homelessness is finite and its disappearance requires two ingredients: individual planning and available housing stock. Even if homelessness cannot be fully prevented, it can be responded to with immediacy, resources, and an attitude that no one should stay on the street or in a shelter for long. A community with the support of state and federal government funding—and health plans like Kaiser—that offer collaborative programming and care, can do what is needed.

Doing everything within our power to minimize homelessness is a matter of health equity. Efforts to address homelessness have made slow progress, but we should resist mission fatigue. We cannot allow the next recession, which will make matters worse for the homeless when it arrives, to add to our national disgrace.

Michael Stein & Sandro Galea 

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