>Re:  HOMELESSNESS KILLS
>---------------------------------------------
>
>from
>
>Annals of Internal Medicine,  Volume 126(12),
>June 15, 1997, pp 973-975
>
>Homelessness: Care, Prevention, and Public Policy
>
>by  J.D. Plumb, MD
>
>================================
>
>...
>
>"Premature death is the ultimate consequence of the increased
>vulnerability of homeless persons. Researchers in Atlanta (10) found
>that the median age at death among homeless persons in their study
>was 44 years; in a study in San Francisco, the average age at death
>was 41 years (11). Hwang and coworkers (12) recently reported an
>average age at death of 47 years in homeless persons in Boston. This
>study found that homicide, injuries, and poisoning (most often caused
>by an overdose of opiates) were the leading causes of death among
>persons 18 to 24 years of age; the acquired immunodeficiency
>syndrome (AIDS) was the leading cause of death among persons 25 to 44
>years of age; and heart disease and cancer were the leading causes
>of death among persons 45 to 64 years of age. Other common conditions
>that are preventable or treatable, such as pneumonia and influenza,
>were frequently found to cause death in homeless persons in the
>Boston cohort (12).
>
>"Providing effective primary care for homeless persons, who are under
>the safety net (13), is a formidable task. This is largely because of
>various internal and external barriers to care (14). Internal
>barriers include the denial of health problems by many homeless
>persons and the pressure to fulfill competing nonfinancial needs,
>such as those for food, clothing, and shelter. External barriers
>include unavailable, fragmented, and costly health care services and
>misconceptions, prejudices, and frustrations on the part of health
>professionals who care for homeless persons. In addition, according
>to Gelberg and colleagues (15),
>
>"as health policy continues to encourage the transfer of the medical
>care of the poor (including the homeless) into managed care systems
>... gatekeeping mechanisms designed to ration care may lead homeless
>adults to further avoid seeking care in the early stages of illness
>if the care-seeking process becomes more arduous or time-consuming."
>
>"As Hwang and colleagues point out (12), their review of the causes
>of death in the homeless has significant implications for clinicians
>and policymakers, particularly with respect to illness and death due
>to injuries, poisoning, opiate overdose, cancer, heart disease, and
>human immunodeficiency virus (HIV) infection and AIDS. High-risk
>sexual behavior and drug use are prevalent in homeless adults (16)
>and street youth (17). Preventing HIV infection in homeless persons
>is difficult, but not impossible, and requires specific targeted
>programs (16,17). Susser and colleagues (18) reported on a program
>that was used to reduce HIV risk behaviors among homeless, mentally
>ill men in a New York shelter. The incidence of HIV infection and
>AIDS in intravenous drug users and prostitutes, who make up an
>unknown proportion of the homeless, continues to increase. Needle
>exchange programs that emphasize harm reduction strategies have been
>shown to be effective in preventing HIV infection in these groups
>(19); this service should be made available in locations where
>homeless persons congregate. "
>
>...
>
>"Whatever the approach to care or prevention, it is imperative that
>health professionals, the societies to which they belong, and
>academic health systems now reaffirm their social responsibility,
>commit themselves to changing public policies that perpetuate
>homelessness, and help develop and provide health care services for
>persons who are homeless or on the brink of homelessness. Physicians
>can accomplish these goals by
>
>"1) recognizing and fighting the prejudice, discrimination, and
>apathy that contribute to poverty and homelessness;
>
>"2) advocating public policies that control rent, increase the number
>of subsidized housing units, provide job training and transitional
>support for those entering the job market, increase the number and
>quality of substance abuse treatment programs and community mental
>health services, improve domestic violence prevention and service
>programs, and provide basic health care regardless of the patient's
>ability to pay;
>
>"3) volunteering professional and personal time to participate in
>the extensive network of emergency food, shelter, and health services
>for homeless persons; and
>
>"4) serving as preceptors and consultants at the many successful
>primary care shelter clinic projects run by students and residents in
>health professions (24-26).
>
>"In 1989, Hilfiker (2) asked, "Are we comfortable with homelessness?"
>Eight years later, are we still comfortable? We cannot afford to be.
>For the men, women, and children who are now without shelter, the
>toll is much too high."
>
>================
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