Homelessness is an alarming social condition that affects up to 100 million people worldwide. Visions of wretched living conditions and brutalized homeless children made last season's Academy Award winning Slumdog Millionaire a compelling movie. But a happy Bollywood ending isn't the case for most of America's chronically homeless.
As well as a social condition, the Center for Disease Control and Prevention (CDC) notes in a podcast that homeless people are vulnerable to a number of infectious diseases. Homelessness is associated with an increased risk of health problems due to overcrowding in shelters, as well as factors such as substance abuse, poor nutrition and hygiene, mental illness and trauma. Respiratory infections are among the most common problems homeless individuals face. The homeless suffer high morbidity and mortality, perhaps more than any other social group.
In a May 2004 article in Chest, written by Laurie D. Snyder, MD and Mark D. Eisner, MD, MPH, FCCP, certain respiratory infections are more common among homeless individuals and may be associated with complications unique to this population. Most literature in the field focuses on tuberculosis or on specific outbreaks of respiratory infections.
In the parlance of this past week, that could very well mean that scary Swine Flu!
The CDC concludes, in part, in a September 2008 Perspective entitled, Preventing and Controlling Emerging and Reemerging Diseases in the Homeless:
Evidence suggests that appropriate public health interventions can be effective in preventing and controlling the spread of numerous transmitted diseases among homeless persons, which is a public health concern both for the homeless and the larger population. These interventions should be tailored to the targeted populations and focused on areas where the homeless are more likely to reside. The strategies reported to be efficient include tailored education; distribution of free condoms; implementation of a syringe and needles prescription program for HIV and HCV; systematic chest radiography for TB screening in shelters and DOT for TB; improvement of personal, clothing, and bedding hygiene; use of ivermectin to treat pruritus most often caused by scabies or body louse infestation; and immunizations against HBV, HAV, influenza, Streptococcus pneumonia, and diphtheria. Implementation of systematic vaccination schedules to prevent communicable diseases in the homeless is a major public health priority.
Does that mean America's homeless are vulnerable to and could ultimately contribute to a pandemic illness? Possibly, yes.
As with other respiratory infections, poverty, malnutrition and overcrowding are all risk factors for infection. Larger, more crowded shelters with increased numbers of people sharing the same breathing space increases transmission, as well as, poor ventilation or recirculation of air.
But, why should there be concern about the homeless who, kindly put, run in different circles than the general population? The answer is simply because the homeless are more integrated than imagined.
The Indiana State Department of Health bulletin recommends that, during influenza outbreaks, homeless providers discourage their clients from sleeping in shelters. Keeping people from close contact means sending them to the streets for whatever comfort they can find. Often that means parking their sick bodies in one of the cushy chairs at the local book store.
Further, homeless individuals ride the bus with the general population. They go to grocery stores, libraries, public places. Homeless people are employed. Homeless children go to school with housed children. They go to emergency rooms. They cough where people sit. Millions who are homeless do not fit the caricature of a shopping cart-pushing street bum.
Nevertheless, homeless individuals often have weakened immune systems due to living in harsh conditions, and as such, at the cusp of contracting and unwittingly spreading infectious disease.
Scattering America's homeless to the street may not be the best plan. Instead, placing supportive housing for America's homeless as a top priority not only sets a world standard for the compassionate treatment of vulnerable people, it turns out that it's the smart thing to do.