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The hidden truth about the health of homeless people

As many as 4 million Europeans and 3.5 million Americans experience homelessness every year, and the numbers are rising. Homeless people 'are the sickest in our society,' but just treating ill health might not be enough to help get people off the streets, according to a new two-part series on homelessness in high-income countries, published in The Lancet.

The Series highlights that being homeless is not only bad for your physical and mental health but also has dramatic effects on life expectancy [Paper 1]. Rates of tuberculosis infection, for example, are at least 20 times higher in the homeless population than the general population [page 5, table 2], while rates of depression are up to seven times higher in the homeless population and similar to levels of psychosis [page 7, table 4].

Homeless people are also two to five times more likely to die prematurely than the general population, especially from suicide and unintentional injuries. However, despite an expansion of services, this increased risk of death has remained similar over the past 20 years.

"Homeless people are the sickest in our society. The evidence on disease rates is very concerning not only for drug and alcohol abuse but also for a range of infectious diseases, heart disease and other age-related chronic conditions, and mental health disorders. The evidence shows that homeless people are old decades before the rest of the population because of their poor health"*, says Seena Fazel, lead author of the first paper and Professor of Forensic Psychiatry at the University of Oxford in the UK.

Across the European Union 400 000 individuals, and in the USA 600 000 people, are homeless on any given night [Paper 1, page 3, panel 2]. Figures from the past 5 years suggest that the number of homeless people is continuing to rise, and the number of children and families who are homeless has increased substantially. Therefore, the importance of tackling this issue is greater than ever, say the authors.

Homeless people use the most expensive acute health-care services, such as accident and emergency care, and need longer hospital stays than people with homes. In the UK, for example, homeless people are around four times more likely to use emergency hospital services than the general population, costing the National Health Service around £85 million a year**.

So what can be done to prevent adverse health outcomes [Paper 1, page 8, panels 3 and 4]? While national and state-wide targets to improve the health of homeless people should be introduced (eg, for the identification and management of infectious diseases, mental illness, and diseases of old age), the Series also calls for health-care providers to advocate for changes to the social policies and structural factors that result in homelessness, including the lack of affordable housing and employment opportunities for low-skilled workers.

Examples of integrated services across high-income countries are already bridging the gap between homelessness and health services, showing what can be achieved [Paper 2]. In the USA, for example, "Housing First" programmes that provide housing and support services for homeless individuals with severe mental illness or substance abuse problems not only improve lives but can also reduce health-care and social service costs. Medical respite programmes for homeless patients leaving hospital reduce the risk of readmission and the number of days spent in hospital [page 3, panel 1].

However, these examples are not the norm and much more needs to be done, says lead author of the second paper Dr Stephen Hwang from St Michael's Hospital in Toronto, Canada: "It needs to be recognised that preventing homelessness, by creating more opportunities for housing, work, education, and health care during high risk periods, such as being discharged from institutional care, psychiatric hospital or prisons to the community, could effectively reduce homelessness and makes sound economic sense."

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