My flights had been delayed, and I did not arrive at the hotel in downtown San Francisco until almost 1 a.m. As I exited the Uber, struggling to shoulder my briefcase and wrangle my suitcase, I was a bit startled to hear a very loud voice coming from my left. “Hey, mister, do you have a dollar or two?” I had been in the city for less than one minute, and had already come face to face with one of the most pressing problems this California metropolis was facing: homelessness.
According to the “State of Homelessness: 2023 Edition,” homelessness has been on the rise since 2017. In 2022, counts of individuals (421,392) and chronically homeless individuals (127,768) reached record highs in the history of data collection. Data from HUD’s 2022 Point in Time Count revealed that 582,462 people were experiencing homelessness across America, amounting to roughly 18 out of every 10,000 people. The vast majority of these were adults, but 28 percent were families with children.
The Colorado Coalition for the Homeless published “Health and Homelessness, Issue Brief 2023,” which took a closer look at why homelessness is such a problem from the medical and mental health point of view. According to this report, poor health and homelessness are often shared experiences. Being homeless, as you can probably imagine, is physically taxing, emotionally draining, and mentally challenging. Due to exposure to many noxious environments and social and behavioral stressors, it can be very hard to access even rudimentary health care and treatment for conditions that may worsen over time without proper attention.
Housing is one of the key social determinants of health. As this issue brief puts it, “housing is health care.” Without a stable place to stay, it is hard to take good care of yourself, get the exams, evaluations, and treatments you need, and just exist in a safe place. Preexisting health care conditions can deteriorate, and new ones can go unnoticed, undiagnosed, and untreated. Cascading problems sometimes include the loss of financial security, employment, and eviction from current living situations, making the problems even worse. The report stated that people experiencing homelessness have a comparatively higher incidence of chronic conditions and co-occurring health problems than those with stable housing. Life expectancy is between 15 to 30 years shorter for those experiencing homelessness compared to the general population. Read that again. It hits hard.
Other things that are adversely impacted by homelessness, according to this Issue Brief, include sleep and personal safety. Sleep deprivation, simply due to poor sleeping areas, concern over safety, and intermittent interruptions, affects overall mental and physical health. Some chronically sleep-deprived individuals may even develop suicidal ideation and psychosis. People who have no safe place to stay are more vulnerable to personal violence and injury. The homeless are more often the victims of crime than the perpetrators of it, contrary to some conventional wisdom. One cited study found that about half of unhoused respondents had experienced a violent attack, and as many as 62 percent had witnessed an attack on another individual. It is commonly thought that those with mental illness are violent and attack others, but they are actually much more likely to be the victims of a violent assault or other attack themselves.
Just the act of living on the street, homeless, is physically taxing, with an increased risk of sprains, strains, contusions, burns, or other injuries. Some people who are homeless live every day with chronic pain. Lack of ongoing, timely screening and care for early, simple medical or mental health issues may then lead to much more complicated presentations and scenarios that are much harder to treat, especially if the emergency department is that person’s primary health care provider. Think of it as living in a state of low-grade emergency almost all the time. Mental health issues and substance use disorders are quite common among people who are homeless. In 2022, about 21 percent of people living in a homeless state in the United States had a severe mental illness. Adults aged 25 to 44 who are homeless are nine times more likely to die from an opioid overdose than their housed counterparts.
What is the answer to this problem? It is a multipart one. First, making access to medical, dental, and mental health care better is one way to tackle this, per the Issue Brief. This can sometimes be accomplished through Federally Qualified Health Centers that serve all patients regardless of their ability to pay. Expanded recuperative and respite care is another possibility that was discussed in this paper, as it would drastically cut down on the cost of a multi-day or week hospital admission. Supportive housing programs to break the cycle between the street and jail and facilities might also be beneficial.
We certainly do not want those who are homeless to fade away, especially thirty years before their time. Attention to these broader and more long-term solutions, whether in San Francisco or locally in South Carolina, will help to craft much better solutions than simply handing over a five-dollar bill and continuing down the street.
Greg Smith is a psychiatrist.
