Dying in the shadows: the challenge of providing health care for homeless people.

Commentary Commentaire T he study of mortality among homeless women reported in this issue by Cheung and Hwang 1 (see page 1243) is a clarion call to our society and our health care community. The stunning 10-fold disparity in mortality rates between Toronto's homeless and housed women aged 18–44 is complemented by data from 7 other cities, which show that the risk of death among younger homeless women is 5–30 times higher than the risk among their housed counterparts. Previous studies by Hwang and others of homeless people in Boston and Toronto have reported overall mortality rates 3–5 times higher than those among the general public. 2,3 This smouldering public health crisis can no longer be ignored. Homelessness is a prism that refracts the failures of soci-ety's key sectors, especially housing, welfare, education, health care and corrections. This complex social phenomenon thwarts simple definitions and resists easy solutions. The often-romanticized hobos and skid-row denizens of past lore have been joined by families with children, runaway and " throwaway " adolescents, struggling minimum-wage workers and fragile elderly people. Only the economics seem straightforward. Housing is a scarce but highly valued commodity. Those least able to compete are doomed to fail; among them are people whose opportunity and choice are limited not only by abject poverty but also by chronic mental illness, substance abuse, physical and sexual violence, illiteracy, complex medical problems and advancing years. The complexity of need, the rich diversity and the growing numbers of homeless people have baffled researchers, bewildered policy-makers and exhausted the compassion of our society. Homelessness magnifies poor health and exposes those huddled in crowded shelters to communicable diseases such as tuberculosis and influenza. It complicates the management of chronic illnesses such as diabetes and asthma, makes health care harder to access and presents vexing obstacles that exasperate health care providers and confound delivery systems. The burdens of mental illness and substance abuse are well documented in homeless populations. Chronic illness is also common: many homeless people have hypertension, diabetes, peripheral vascular disease, respiratory problems, and liver and renal disease. Skin diseases are extraordinarily common and can lead to costly hospital admissions because of cellulitis. Hypothermia and frostbite are dreaded hazards of life on the streets and have been shown to be risk factors for early death. Some conditions, such as diphtheria, pellagra and lice infestations resulting in endo-carditis from Bartonella quintana, 4–6 hearken to earlier …