Homelessness: reducing health disparities.

Commentary Commentaire H omelessness, a phenomenon with complex causes and potential for tragic consequences, is a public health and societal problem in cities, towns and rural areas worldwide. Men, women and children — be they refugees in Eastern Europe, street children in Uganda or what the developed world thinks of as " the homeless " — make up a growing vulnerable population that is at an unacceptably high risk for preventable disease, progressive morbidity and premature death. In the developed world homelessness and poverty are inextricably linked: The working poor live on a precipice that can tumble them into homelessness any time. An illness, or an unexpected layoff, brings missed paychecks, which leads to skipped utility or rent payments, which snowballs into penalties, which ends in shutoffs or eviction. That leaves a Hobson's choice between no place at all or city-run homeless shelters, which often are dirty, noisy and unsafe. 1 Subgroups of people who live in poverty are at particularly high risk for becoming homeless. They include people with mental disability or post-traumatic stress syndrome, people who have been victimized, especially through domestic violence, people with drug and alcohol addiction and people who lack sufficient social support to tide them over during potentially long, or repeated, periods of crisis. Into the mix of poverty and these other " comorbidities, " homeless people are also plagued by multiple internal and external barriers to obtaining effective primary care. 2 Internal barriers include the denial of health problems and the intense pressure to fulfill competing needs, such as obtaining food, clothing and shelter and maintaining safety. External barriers include unavailable or fragmented health care services, and misconceptions, prejudices and frustrations on the part of health care professionals who care for homeless people. With poverty, complex comorbidities and multiple barriers to care, it is no wonder that homeless people have excessively high mortality rates. In Philadelphia homeless people had an age-adjusted mortality rate 3.5 times higher than that of the general population, 3 and in New York City they had a rate 2 to 3 times higher. 4 A recent study of mortality rates among men using shelters in Toronto showed that the rates were higher than those in the general population of Toronto but much lower than those reported in the homeless populations of New York City, Boston and Philadelphia. 5 Contributing factors leading to the differences in mortality rates in Canada …