Homeless Health: Definitions and Difficulties
Because of the great stress of not having a place to live, the phrase “homeless health” is an oxymoron for most non-housed persons. Having no shelter greatly exacerbates problems and bad health. These facts cannot be disputed, given the clear evidence from study after study on homeless, its impact on health, and the connection between homelessness and public health problems. There are even experts who feel that homelessness – itself – is a public health issue (Housing and Homelessness as a Public Health Issue (apha.org)).
There are many technical terms the reader must digest in order to be able to follow the arguments for and against the different models of intervention. Poor health continues from persons being non-housed, in some cases is caused by being non-housed, and certainly in other cases it is exacerbated by being non-housed.
Poor health and lack of secure housing go hand in hand. To understand the challenges of being ill while homeless – and to understand some of the arguments about solutions, it is essential to comprehend some of the terms used often in discussions. It is helpful to comprehend the vocabulary from fields such as social work, counseling, and psychology that refer to the various issues, solutions, interventions, and models employed.
There are a variety of illnesses, difficulties, and challenges in the realm of health and well-being when a person is non-housed. For example, without a safe place to keep medication, vitamins, and healthful foods and drinks, it is hard to recover from sickness – even from the common cold! Providing permanent housing, and quickly, to people experiencing chronic homelessness is the answer, according to the research and the experts in government agencies also (Housing and Shelter | SAMHSA).
Chronic housing, as mentioned above, is a term reserved for longer-term living outside a home or apartment. It does not mean couch-serving at a couple different friends’ homes for a week or two; it does not mean sleeping in one’s car for a few days until the lease on a new apartment begins. The US Department of Housing and Urban Development (HUD) has a very specific definition for chronic homelessness, in contrast with temporary non-housed status of an individual. “According to HUD, chronic homelessness means: (1) A homeless individual or head of household with a disability that meets the HUD definition of a disability who (a) lives in a place not meant for human habitation, a safe haven, or in an emergency shelter; AND (b) has been homeless and living in one of these places continuously for at least 12 months OR on at least 4 separate occasions in the last 3 years, as long as the combined occasions equal at least 12 months and each break in homelessness separating the occasions included at least 7 consecutive nights of not living in one of the aforementioned places” (Microsoft Word - Home Stretch Chronic Homelessness Guide (everyonehome.org)). These factors all must be met for someone to be considered an individual suffering from chronic homelessness by HUD.
Research shows very clearly that if non-housed persons are provided with a place to live their health improves dramatically and almost immediately. Advocates for the homeless share this belief with researchers and government experts. For example, it is believed by experts of the National Health Care for the Council and other advocacy groups that housing means better health (https://nhchc.org/wp-content/uploads/2019/08/homelessness-and-health.pdf).
There are a variety of illnesses, difficulties, and challenges in the realm of health and well-being when a person is non-housed. Post-Traumatic Stress Disorder (PTSD) is a common diagnosis of US veterans and the disorder is exacerbated by lack of treatment and failure to observe medication regiments and other important keys to treatment – common among the homeless (Homeless Veterans Living With PTSD (verywellmind.com)).
Regarding such illnesses as PTSD, it is first important to understand that homelessness does not cause mental illness. However, homelessness and its complications can exacerbate symptoms. For example, someone with social phobia or PTSD has fewer support systems in place often. Without reliable access to counseling or medication, some homeless individuals have a tougher time with the illnesses. PTSD can cause problems as the homeless person does not often have places to “hide out” while symptoms are presenting. For example, a homeless person may be forced to deal with anxiety while on the bus or sitting at McDonalds for several hours. In contrast, someone with a place to live can just stay home that part of the day – or the entire day – to avoid dealing with people and the stress of public transportation, crowds at a grocery store, or unhappy employees at a restaurant.
There are, in fact, various models of providing locations for the homeless to convalesce. A recent British plan involves housing the homeless and providing healthcare support in one central location – they do not need to travel around, sleep in another location, and eat in another location, while trying to recover from the illness (Homeless people discharged from hospital had nowhere to go – until now | Healthcare Network | The Guardian). As with any model, however, the question comes up: who pays for the intervention?
There are various models, from various fields and traditions. For example, “rapid rehousing” is a model whereby the invidual who is non-housed gets placed into a secure temporary living situation right away. Rapid housing helps the individual immediately, and the speed is important. This model gets the benefits to the homeless person right away, obviously, and the results are encouraging (Rapid Re-housing: What the Research Says (urban.org)).
Rapid rehousing is one of the technical terms used in helping those individuals who are currently “non-housed” and who need immediate assistance in finding stability. It is not permanent housing. The benefits of getting non-housed persons indoors and helping them with other supports have been seen in a number of studies, and advocacy groups and councils feel strongly these benefits are worth the investment. Rapid rehousing gets people indoors – without having to jump through an impossible number of hoops that are designed to keep people out of housing. Individuals do not have to pay exorbitant fees or deposits for utilities, pass credit or employment checks, or go through other locked gates. The benefits are clear, according to groups such as the National Alliance to End Homelessness. They are convinced that “Rapid rehousing is a primary solution for ending homelessness. It has been demonstrated to be effective in getting people experiencing homelessness into permanent housing and keeping them there” (Rapid Re-Housing - National Alliance to End Homelessness). They explain how the stability factor works: “By connecting people with a home, they are in a better position to address other challenges that may have led to their homelessness, such as obtaining employment or addressing substance abuse issues.” This first step, this rapid entry into a secure environment, is helpful in curbing recurring homelessness for these individuals and leads to permanent housing later.
“Housing first” is another common term used to discuss a model in which a secure location is established for the non-housed person. Rather than looking at such issues as securing employment, saving up dollars for security deposits, holding onto money for deposits on utilities, recovering from addictions – even as simple as quitting smoking – the model provides for housing before other activities, milestones, goals, or objectives. Yes, those other aspects of the non-housed person’s life are very important. However, the model has been proven to work: housing first establishes a safe and secure place for all of these other places to happen (ACKNOWLEDGEMENTS (huduser.gov))
HUD feels housing first should be used with a variety of non-housed persons, including those with mental health issues and US veterans. As with other models, housing first has different iterations, different flavors, depending on why, how, and where it is put into place. A recent HUD study showed three different projects making use of housing first principles and how the interventions were all successful (ACKNOWLEDGEMENTS (huduser.gov)).
Providing safe and secure locations (meaning in this case a place to eat, sleep, and recover) is the goal of many advocates, activists, counselors, social workers, family members, clergy, teachers, community members, supporters, and friends of non-housed persons. Having a place to keep pills, to take naps, to bathe, and to make plans is essential to human beings trying to regain their health. For non-housed persons, these goals are simply dreams. Even the most basic needs to recover from illnesses are out of the reach of the non-housed persons in our community.
Getting the most basic supplies and containers is an important step for establishing a location to convalesce from an illness – again even one as basic as the common cold. Imagine not having a secure place to keep your vitamins, aspirin, and other pills. No place to keep a bottle of orange juice. No safe cabinet to keep facial tissues in. No bed to rest on. No blanket to wrap yourself in as you shiver from drafts and you try to recover from the cold… from the flu….