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  • Writer's pictureJorge Petit

The Intersection of Homelessness and Health Equity: A Deeper Dive


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Homelessness is a very complex and pervasive issue that affects thousands of people across the United States—cutting across demographic, geographic, and socio-economic boundaries. It represents a critical challenge to individuals, families, communities, and society as a whole. Housing is the pillar of stability and security for an individual or family and needs to be seen as a basic right and not a commodity (OHCHR). The growing rate of homelessness in the U.S. is a harsh indictment of our societal values and the continuation of the many factors that lead to and/or exacerbate housing instability and homelessness. These factors include poverty and economic hardship, unemployment, housing affordability issues, mental health and substance use challenges, family breakdown, in addition to the overarching systemic inequities faced by marginalized populations.

There are many conceptualizations, definitions and types of homelessness that go beyond the typical image the public has of homelessness, often as an individual panhandling or sleeping on the streets. Individuals or families can be considered homeless, at risk for homelessness or experiencing housing instability, they can be sheltered or unsheltered, they can be fleeing or attempting to flee from domestic violence as well as homelessness can be considered transitional, episodic, chronic or hidden. But at its core, homelessness is when individuals or families lack a stable, safe, and consistent place to live, often leading to inadequate or insecure housing arrangements, ranging from sleeping on the streets, in shelters, in temporary accommodations, or in inadequate and overcrowded settings. See definitions section at end.

The prevalence rates of homelessness varies by region and is often challenging to quantify accurately due to its transient, episodic and hidden nature. In the United States, it is estimated that there were over 580,000 people experienced homelessness on a single night in January 2022 (HUD PIT Data). Data shows that approximately 60% of those are in some type of sheltered setting while the remaining 40% are in unsheltered settings. The overall numbers continue to grow especially among unsheltered families with children, unaccompanied youth (under 25 years old), chronic homeless, and African Americans and indigenous peoples being overrepresented. As an example, in August 2023, in NYC shelters while there were over 86,000 people, 29,000 were children, according to the Coalition for the Homeless.

Health equity is fundamental to understanding and addressing disparities in healthcare and health outcomes; health equity refers to the principle that all individuals should have the opportunity to attain their highest level of health and wellbeing. Specifically, this means that everyone, regardless of their background, should have a fair and just opportunity to access the resources and services necessary for overall good health.

Health equity is a fundamental social justice principle that underpins the delivery of behavioral health services, and eradicating homelessness is a key component of this endeavor. In my estimation the intersection of health equity and homelessness highlights the urgent need for healthcare professionals and policymakers to adopt a holistic approach to the systemic disparities that perpetuate the challenges so many Americans face.

Analyzed from a health equity lens, homelessness is a systemic and multidimensional issue that is not just a result of individual choices but is deeply rooted in structural factors, including poverty, discrimination, lack of affordable housing, mental illness and substance use, and inadequate social safety nets. It must be understood as a condition where individuals lacking stable and secure housing are more vulnerable to a range of physical and behavioral health problems and face significant barriers in accessing quality health and behavioral health supports, services and treatment. In order to eradicate these health inequities, we must shift our focus from solely providing healthcare services in the traditional medical model to addressing the social determinants of health, such as lack of affordable housing, accessibility and transportation challenges, linguistic and cultural barriers, food insecurity, limited employment opportunities, income inequality, and lack of or limited access to educational/vocational options—to ensure that everyone has an equal opportunity to attain their highest level of health and wellbeing.

Achieving health equity for individuals experiencing homelessness requires tailoring interventions to address the unique challenges they face, including stigma, access to care, and social determinants of health. By working collaboratively with and across other sectors, such as housing and social services, we can all play a pivotal role in ensuring that individuals without stable housing receive the support and services they need, ultimately promoting a more equitable and compassionate healthcare system.


HEALTH DISPARITIES

The impact of homelessness on overall health is profound and multifaceted, as individuals experiencing homelessness face a range of physical, behavioral, and social challenges that significantly affect their health and wellbeing. Homelessness exacerbates existing health disparities and creates new ones, making it a tremendously complex public health issue.


Physical Health Disparities:

  • Homeless individuals are at greater risk of experiencing a wide range of acute and chronic health conditions, including infectious diseases, malnutrition, and injuries due to exposure and violence.

  • Access to clean water, nutritious food, and sanitation facilities is limited for those living on the streets, leading to health issues such as dehydration, foodborne illnesses, and inadequate hygiene.

  • Lack of safe and stable shelter often results in poor sleep quality, which can contribute to a range of health problems, including cardiovascular issues, weakened immune system, and cognitive impairments.

  • Homeless individuals are more vulnerable to infectious diseases, including HIV, tuberculosis, and hepatitis, due to overcrowded shelters and poor hygiene conditions.

  • Barriers to healthcare access often result in lower vaccination rates among homeless populations.

Behavioral Health Challenges:

  • Homelessness is often both a cause and consequence of behavioral health issues, and a significant proportion of homeless individuals suffer from conditions like depression, anxiety, bipolar disorder, and schizophrenia.

  • Some individuals experiencing homelessness turn to substance use as a way to cope with their living conditions and health challenges, leading to addiction and worsening overall health.

  • The harsh conditions and instability of homelessness can exacerbate stress and trauma.

  • Homeless individuals often have limited access to behavioral health supports, services and treatment programs, making it difficult to address their underlying issues.

Access to Care Barriers:

  • Homeless individuals face numerous barriers to accessing healthcare, including lack of transportation, limited financial resources, loss of entitlements or benefits, and geographic challenges.

  • Stigma related to homelessness can lead to discrimination within the healthcare system, causing many to avoid seeking care until their conditions become severe.

  • Frequent mobility and lack of stable housing can disrupt the continuity of healthcare, making it difficult to manage chronic conditions and adherence to treatment plans.


 

A CALL TO ACTION FOR INDIVIDUALS, COMMUNITIES, AND POLICYMAKERS

Addressing homelessness and health equity is a collective responsibility that involves individuals, communities, and policymakers. Over the last 30 years of working in the public sector as a psychiatrist on the front lines providing direct services or overseeing behavioral healthcare services—through city government, as a managed care executive, or as a leader of social service agencies—I am announcing here a call to action for those that are passionate about eradicating homelessness in our lifetime.


INDIVIDUALS

We can all play an important role in eradicating homelessness and promoting health equity.

Educate yourself about homelessness and its causes. The more you know about homelessness, the better equipped you will be to advocate for the right solutions in your community.

Challenge negative stereotypes about homeless people—everyone deserves to be treated with dignity, respect and compassion.

Support organizations that are working to end homelessness. There are many non-profit organizations that are providing essential services to people experiencing homelessness. You can donate your time, money, or goods to help support these organizations.

Volunteer at a local homeless shelter, food banks, soup kitchen and/or organizations working on homelessness. This is a great way to meet people who are experiencing homelessness and to learn more about their needs.

Donate to organizations that provide housing, healthcare, and support services to those in need and that are working to end homelessness; even a small donation can make a big difference.

Contact your elected officials and urge them to support legislative policies that address the root causes of homelessness, including policies that promote supportive and affordable housing, increase access to healthcare, and economic security for all people.


COMMUNITIES

Communities can play a vital role in eradicating homelessness and promoting health equity. Local communities must develop a holistic plan to end homelessness, including periodic needs assessments and strategies for addressing those. A comprehensive plan should involve all stakeholders, including people who have experienced homelessness, so that services are designed to meet the needs of the community and that they are located in areas where they are accessible to homeless people.

Invest in supportive and affordable housing, a critical intervention for ending homelessness. Communities can invest in supportive and affordable housing by building new housing units, providing rental assistance to low-income households, and preserving existing affordable housing.

Educate the public about homelessness through community forums, presentations, and educational materials.

Expand access to quality healthcare by providing on-site healthcare services at homeless shelters, enhancing community-based health and behavioral health centers (FQHCs or CCBHCs), and expanding Medicaid eligibility.

Promote economic opportunity by increasing minimum wage, providing job training and placement services, and investing in small businesses.

Reduce stigma and discrimination by launching community education campaigns and further educating the public about homelessness.

Defeat NIMBYism. NIMBY, an acronym for "Not In My Backyard," is a phenomenon in which residents of a community oppose the development of certain types of facilities, such as homeless shelters, affordable housing, or mental health clinics, in their neighborhood. NIMBYism can be a major barrier to addressing homelessness and promoting health equity. Whether it is borne out of fear or stigma, NIMBYism can have a significant impact on the health of homeless people, such as inability to access basic services (housing, food, and healthcare), increased social isolation and discrimination, perpetuating negative stereotypes about homeless people and people with mental illness.


POLICYMAKERS

Policymakers and other stakeholders have a critical role to play in eradicating homelessness and promoting health equity for all people. Policymakers need to embrace strategies that are proven effective and evidence-based approaches that can make an impact in eradicating homelessness. These initiatives must also go beyond those that target homelessness per se and must address the root causes of homelessness, for example: eradicating poverty, removing barriers to healthcare enrollment, expand Medicaid to all low-income adults, implement anti-discrimination laws and policies that protect LGBTQ+ individuals and minority communities from housing and healthcare discrimination, increasing the minimum wage, expanding access to education and job training.

Here are a few proven strategies and evidence-based interventions that address homelessness:

1. Housing First: This approach prioritizes providing individuals or families experiencing homelessness with permanent housing without requiring them to meet any preconditions, such as sobriety or employment. Housing First has been shown to be the most effective way to end homelessness for individuals and families with complex needs, such as chronic mental illness or substance use disorders.

2. Rapid Re-Housing: This program provides individuals and families experiencing homelessness with short-term financial assistance and support services to help them move into and maintain affordable housing.

3. Coordinated Entry: Ensures that individuals and families experiencing homelessness are seamlessly connected to the most appropriate housing and services for their needs with a low barrier, housing first approach, as well as being fair, equitable and person centered. Coordinated entry helps to reduce duplication of services and ensure that individuals and families are not waiting long periods of time to get the help they need.

4. Assertive Community Treatment (ACT): ACT is a team-based approach to providing mental health services to people in their communities. ACT teams work with people to develop and implement individualized treatment plans, and they provide ongoing support and monitoring and has been shown to be effective in reducing homelessness for people with chronic mental illness.

5. Supported Employment: Supported employment programs help people with mental illness or disabilities find and keep jobs by providing job training and placement services, as well as ongoing support and supervision. Supported employment has been shown to be effective in reducing homelessness and improving quality of life for people with disabilities.

6. Trauma-Informed Care: Trauma-informed care is an approach to service delivery that recognizes that many people have experienced trauma in their lives and that this trauma can have a significant impact on their health and wellbeing. Trauma-informed training improved understanding of the effects of trauma and creates safe and supportive environments for people who have experienced it.


Addressing homelessness and health equity as a social justice action is not just a moral imperative but a practical necessity for building healthier, more inclusive, and more equitable communities. It requires the collective efforts of individuals, communities, and policymakers to create a world where everyone has the opportunity to attain their highest level of health, wellbeing and happiness.


 

Resources

National Alliance to End Homelessness Racial Equity Resources

 

DEFINITIONS

Homeless: An individual or family who lacks a fixed, regular, and adequate nighttime residence, such as those living in emergency shelters, transitional housing, or places not meant for habitation, or

An individual or family who will imminently lose their primary nighttime residence (within 14 days), provided that no subsequent housing has been identified and the individual/family lacks support networks or resources needed to obtain housing, or

Unaccompanied youth under 25 years of age, or families with children and youth who qualify under other Federal statutes, such as the Runaway and Homeless Youth Act, have not had a lease or ownership interest in a housing unit in the last 60 or more days, have had two or more moves in the last 60 days, and who are likely to continue to be unstably housed because of disability or multiple barriers to employment, or

An individual or family who is fleeing or attempting to flee domestic violence, has no other residence, and lacks the resources or support networks to obtain other permanent housing.


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