Health Care Must Be a Priority in Solving the Problem of Homelessness
The recent police sweeps of homeless people from the streets of Skid Row in Los Angeles, and the opening of a downtown campground, made us aware again that not all of us have a place to call home. Upwards of 30,000 men, women and children--no one really knows how many--fall into that category in Los Angeles County, one of the largest concentrations of homeless in the United States.
The city’s campground idea at best is a Band-Aid on a festering sore that will do little to alleviate homelessness. Indeed, the campground, while perhaps safer than the streets, is an unhealthy alternative to more sheltered environments where food, medical care, showers and social services could be provided more effectively. But the campground serves to remind those of us lucky enough to be well-fed and well- housed of the harsh and dangerous conditions faced each day by the homeless.
A lack of low-cost housing and job opportunities lie at the heart of the homeless problem in Los Angeles as well as the rest of the country. For people without homes, things aren’t likely to get better soon. The limited number of emergency shelter beds in Los Angeles leave thousands without protection from the elements. Without shelter, the kind of ordinary daily hygiene most of us practice without a second thought is impossible. Some shelters themselves, and downtown Skid Row hotels, can be crowded, violent and dirty.
Such conditions put the homeless at risk for serious disease and injury. Our clinics for the homeless commonly treat people for hypothermia, traumatic injuries, infestations of lice and scabies, peripheral vascular disease, skin disorders and leg ulcers. Not surprisingly, upper respiratory infections such as colds, bronchitis and pneumonia are common among the homeless. Alcoholism, a common affliction of the homeless, leads to cirrhosis, hepatitis, anemia and ulcers. Homelessness is particularly harmful to the health of children, whose rate of chronic physical disorders is twice that observed among children in general.
Homeless health problems post a serious threat to public health at large. There is an alarmingly high rate of tuberculosis: In 1986, 191 TB cases--14% of all cases in the county--occurred in the Central Health District, which includes Skid Row. The TB rate there is more than four times the rate for the county in general. Substance abuse also puts the homeless at high risk for AIDS.
Another problem inadequately addressed by our current programs--a problem readily apparent to anyone working in or passing through the Skid Row area--is mental illness, both a contributor to and consequence of homelessness. At least a third of the homeless suffer from schizophrenia, manic depression, substance abuse or other chronic mental illness. But most homeless people are on the streets not because they are mentally ill, but because they have lost a job or are unable to find a place to live. For them, the stress of homeless life leads to depression, alcoholism and suicide.
Providing health and mental-health care to the homeless should be part of any effort to get people off the street and into a sheltered and less-dependent environment. Men and women who are ill cannot work; often they can’t even manage to apply for programs that could help them find shelter or a job.
Because the homeless are the poorest of the poor, they experience extreme difficulty in getting medical care. And of course, few have such middle-class amenities as health insurance. The overcrowded county health system makes it necessary for patients to wait up to seven hours to see a physician; for specialty care or prenatal appointments, the delay is more likely to be four months.
Helping homeless people to obtain public assistance, particularly Supplemental Security Income and Aid to Families With Dependent Children, can effectively increase their access to health care; as welfare recipients they would usually be eligible for Medi-Cal or Medicare. But keeping those benefits, if you are homeless, is not easy. For example, many shelters limit stays to 30 days or less. When people leave, they risk losing eligibility, since recipients are required to have an address, and social workers are often unable to track them as they move onto the street or into other shelters.
Many of the homeless are single adults and thus ineligible for Medi-Cal, no matter how poor. County General Relief automatically entitles a person for free care at county health facilities; but again, keeping on the rolls can be difficult when you have no place to call home. The Department of Social Services penalizes people for infractions of eligibility rules by terminating General Relief benefits for 60 days; without such a stipend, a person will again become homeless.
Since it seems obvious that an adequately funded county health system is at the core of any effort to increase health services to the homeless, why has the state cut back on such funding? Gov. George Deukmejian recently vetoed $110 million earmarked for county indigent health programs. In Los Angeles, these cuts have forced a $4-million reduction in adult services at the County Medical Center, services desperately needed by the homeless.
Solving health problems of the homeless awaits a solution to the root causes of homelessness itself: a lack of affordable housing and employment. But adequate health services are a necessary concomitant. An illness or injury can deplete the resources of an impoverished family or individual and push them over the edge, down the steep and slippery slide of unemployment, poverty, eviction and homelessness.
But any one approach won’t bring an end to the sad spectacle of thousands of Americans forced to live mean lives on city streets, fallouts from one of history’s most affluent societies. Los Angeles--and the United States--needs a comprehensive policy for the homeless that provides for transitional and emergency housing, employment and health care for all. Only then will we be on the way to solving one of our most pressing social problems.
