Death Among the Homeless: New Study Sheds Light on Health Issues for Those Sleeping Rough: Public Health Watch

“Sleeping rough” earns its moniker.

And now, a new long-term study comparing mortality among homeless who reside in shelters with that of those who opt to sleep on the street proves just how hazardous the latter is to health—and not just for the people directly affected by it. In the 10-year analysis of the homeless population in Boston, Massachusetts, published on July 30 by JAMA Internal Medicine, the leading cause of death among those who opt to sleep rough—street slang for staying outside, irrespective of the weather, rather than in a shelter—was not infectious diseases such as HIV or hepatitis C (which have historically been common in this population), but cancer and heart disease.

“It’s important to remember that issues related to substance abuse are common in the homeless population, and substance abuse in and of itself can be a barrier to getting screened and ultimately treated for these often-preventable conditions,” study lead author Jill Roncarati, ScD, MPH, PA-C, Postdoctoral Research Fellow, Harvard TH Chan School of Public Health, told Contagion^®. “The issue of homelessness reflects many aspects of society: our medical system, housing, and public health. It’s not just a contained problem. And many of the homeless who are in poor health end up in emergency rooms, overwhelming the health care systems in many cities. So while many people may be annoyed by the homeless, or not want to see them, it’s important for communities to address health issues within this population.”

Indeed, as a friend and former staffer with the Partnership for the Homeless, an advocacy and aid organization in New York, reminds us, the personal stories of those living on the street are as varied as the people themselves. In short: Not all of those without roofs over their heads are mentally ill or have substance abuse problems that pre-date their time on the streets. Most, for one reason or another, have faced economic hardships. Some have found themselves homeless because they were desperate to escape abusive parents, spouses, and/or partners.

And many of them have legitimate reasons for avoiding shelters. Recent reports in New York have suggested that shelters there are “dangerous,” and residents of these facilities have been the victims of violent crimes and had their personal possessions stolen—most often by other residents. This is true of shelters in most cities, not just New York.

Still, staying outside is not without its risks. Dr. Roncarati and her colleagues assessed 10-year (2000 to 2009) mortality data from a cohort of 445 unsheltered homeless adults (44 years of age, mean) in Boston. The study participants were seen during daytime street and overnight van clinical visits performed by the Boston Health Care for the Homeless Program’s Street Team during 2000, and data documenting causes of death were collected from clinical encounters, medical records, the National Death Index, and the Massachusetts Department of Public Health death occurrence files. The authors calculated age-standardized all-cause and cause-specific mortality rates and age-stratified incident rate ratios for the unsheltered adult cohort using 2 comparison groups: the non-homeless Massachusetts adult population, and an adult homeless cohort from Boston who slept primarily in shelters.

Notably, the team found that among the 134 individuals who died during the study period, the mean age at death was 53 years. The all-cause mortality rate for the unsheltered cohort was almost 10 times higher than that of the Massachusetts population and nearly 3 times higher than that of the adult homeless cohort who used shelters. The most common causes of death were: “non-communicable diseases (eg, cancer and heart disease), alcohol use disorder, and chronic liver disease,” the authors reported.

And yet, in the nearby cities of Lowell and Lawrence, Massachusetts, a Huffington Post report notes that an HIV case cluster linked with abuse of the opioid fentanyl has been identified by public health officials there, and many of these cases involve homeless adults. Although HIV ranked behind other conditions as a cause of mortality among those sleeping rough in the study by Dr. Roncarati et al, those with the disease who slept rough were 64 times more likely to die from their illness than the general adult population of Massachusetts and 3 times more likely to die than the sheltered homeless population.

Regardless of the specific mortality data, Dr. Roncarati told Contagion^® that she and her colleagues see their findings as a call to action for cities facing significant problems with homelessness.

“Boston has really good multidisciplinary medical outreach teams that are out on the streets, day and night, checking on people,” she said. “Our findings show that there are poor outcomes in this population, even with what is almost a best-case scenario in terms of the care available to them. I think what Boston is doing is a great model, and a great starting point, but even with that, there is such high mortality among the homeless here. There needs to be greater outreach by cities to change these outcomes, and a multidisciplinary approach targeting substance abuse disorders would probably be a good place to start.”

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.