“So many people have lost their jobs, and then they lose their health insurance. If they get sick with any other medical condition, this can be the perfect storm that makes living on the streets favorable” said master’s thesis recipient, Jessica Bielenberg, from the UW School of Public Health.

Amongst first-world countries, nowhere is the issue of homelessness more striking than in the US. Within this marginalized community, healthcare isn’t a given; it’s something that has to be fought for. As public health analyst Martha Sandoval writes, Western Europe, Japan, and Canada are ahead of the US in housing stock. As homeless people have to constantly fight for human needs like food, shelter, and water, these battles leave a long legacy of after-effects.

Sustaining sufficient health and self-welfare becomes dissolved in one of the hundreds of daily struggles that are faced by this underserved population. Whereas in countries like Germany, the highest rate of lifetime homelessness is merely 2.4%, within the United States, it’s as high as 7%. This data further highlights the underlying problems that are present within systems in America that either keep people from being able to afford housing or prevent individuals from overcoming homelessness. These notions are further pointed out by a study conducted by Sandoval, which looked at countries where low-income residents have to devote almost a majority of their paychecks to solely mortgage or rent.

With the United States falling into fourth place, behind Colombia, Costa Rica, and Chile, it is the highest first-world country to have such a high population of people devote that much money towards their housing. These findings indicate simply one of the many struggles that people in the US face on a day-to-day basis. Something as little as the ZIP code you were born in indicates how much money you can allocate towards resources that get you situated out of issues like being low-income; however, when it comes to homelessness, there is little to no way out. The Department of Housing and Urban Development (HUD) further proves this claim when a study conducted eventually found that over 582,000 Americans were experiencing homelessness in 2022 alone, which saw an increase of over 4.000 from three years prior. Thus, this issue is unique in the sense that normal approaches and standard cognitive solutions aren’t working for this population under the current status quo. In this paper, we will examine the role social determinants of health have on the United States’ homeless populations, and how associated healthcare disparities limit them from accessing primary and preventive health services. I will do this by first contextualizing the housing crisis in the US. Then I will further examine the ways in which homeless populations have been neglected by their environment. And finally, analyze how the social determinants of health exacerbate explicit harms to this population.

Homelessness is a complex problem, and alleviating the many disparities of it requires complex solutions. In order to further humanize this issue, rather than looking at it through only statistics and hard data, for contextualization, explaining the historical context, demographics that encompass homeless people, and the systems that prevent them from getting access to the resources will provide for more effective reasoning. As an intern at the Center for Behavioral Health Statistics and Quality for Substance Abuse and Mental Health Services Administration (SAMHSA), Mark Saldua, reports that a large portion of homeless people consist of people of color. In truth, roughly 37% of the identified homeless population identifies as Black, and another 24% identify as Hispanic. With this contextualization of historically oppressed populations, the intersectionality between this demographic and homelessness makes it more comprehensible. The intersectionality doesn’t just end there. Roughly 21% of homeless people suffer through a mental illness, and about 16 percent have faced chronic homelessness between the years of 2020 and 2022 alone. This further corroborates how factors such as cognitive disorders, historical oppression, or systemic forces all play a similar role in the health care scene: they limit specific demographics from accessing health-welfare. In considering race as well, a report by the Annual Homeless Report found that of all races, Native Hawaiians were reported to have the highest rate of homelessness by a landslide.

These findings are detrimental since it proves that race plays a big factor in accessibility when taking into consideration historical trauma and oppression. As the scope of homelessness expands from mentally ill, minority races, and many more, addressing what factors specifically

The idea of impoverished peoples being limited from social mobility and welfare isn’t new. For centuries, these populations have been punished simply for being born in a zip code that wasn’t favorable. As researchers for the United States Department of Health and Human Services (USDHH) report in 2021, residents of impoverished communities are expected to face hardships that include higher rates of mental illnesses, chronic disease, higher mortality, and lower life expectancies. Furthermore, it was reported that people residing in the top 1% of income earners were expected to live over 20 years longer than those who composed the bottom 1% of income earners. While this data is only to be expected, current literature shows a vast knowledge of how those residing in impoverished communities and socioeconomic gaps are affected. In reality, little is known about specifically homeless individuals in the unique ways that barriers are presented to them. In fact, it is reported by the US Office of Disease Prevention and Health Promotion (OASH) that those who have experienced poverty are more likely to develop, “…toxic stress, chronic illness, and developmental delays into adulthood,” which further enables a vicious generational cycle of poverty and trauma. Should the problems persist with more and more people, the legacies of the issues at hand will only plague future generations until it is directly dealt with. In comparison with an even more pulverizing socioeconomic status, like homelessness, these individuals’ struggles only polarize to a higher degree than those who are going through poverty. According to data synthesized by urban welfare researcher and analyst Vineeth Shekharan, homeless populations in particular face even more dramatic effects than those who are in the bottom 1% of poverty.

The results of this study are imperative, since it sheds light on a demographic that is even lower than the bottom 1% of income earners: those who don’t earn an income at all. With the vast majority of homeless people needing both physical and mental accommodations, the intersectional social determinants debilitate any potential of accessing regular and stable treatments needed.

While programs for homeless people exist in trying to connect them to medical resources and physical inspection, getting connected to them via social workers, permanent residences, and online mobility restricts those who can feasibly utilize these resources, making research on this demographic harder to find. Thus, there is a need for more studies and research to be conducted for homeless people to synthesize solutions for alleviating the multifaceted issue of the housing crisis.

The people who compose homeless populations are stripped of vulnerability and resources due to systemic neglect. This section hopes to hone in on the little literature presented that looks into this niche intersectional issue. Everyday privileges that other demographics are able to at least somewhat have, like access to clean water, sanitation, and food, aren’t presented in the same way to people experiencing homelessness. This makes many of the issues faced by this demographic unique and a bigger problem to tackle than others.

Analyzing the social determinants of health that restrict access to higher health care and preventative measures against malnourishment provides a nuanced scope for the issue of homelessness. The medical doctor at the Royal Perth Hospital, Amanda Stafford, and principal nutritional investigator, Lisa Wood, wrote about this very phenomenon in a published paper on December 14th, 2023. After finding that out of 307 homeless people sampled, 71% had visited the emergency room in the past six months, they aspired to understand the causes for delayed treatment and later-stage diagnosis. Ultimately, they deduced that social determinants of health often start with adverse early life experiences and trauma, which are often followed by poor educational outcomes, involvement in drugs, and dysfunctional families. As was the case for a 31-year-old non-Indigenous woman who spent 18 months homeless after she became estranged from her partner and family due to heavy alcohol use and an eating disorder during her late teens. The implications of these social determinants are huge. With legacies of addiction and other cognitive disorders being inflicted onto the underserved homeless populations in the United States, these increase the number of steps that keep homeless people out of clinics and other health settings that aren’t the emergency room. Even at the clinic I volunteer at, Pacific Free Clinic–whose primary purpose is to serve only uninsured patients–during training and in the clinic, we’re instructed to not take in homeless people due to the infrequent follow-ups. Something as little as an address line keeps disadvantaged people from accessing preventative healthcare and creates an environment where only the most urgent of issues get treated.

The symbolic dynamic of keeping healthcare systems and homeless populations separated from each other until dire incidents occur is a trend that has long repeated itself as one of the byproducts of the social determinants of health faced by the housing crisis. It was found that homeless individuals were overrepresented in city hospitals by over 65-70% in emergency rooms and appeared as the most frequent patients. By applying a temporary solution to a symptom rather than curing the problem from its root, this cycle only continues. In fact, the vast majority of health problems faced by homeless populations are actually preventable and curable if dealt with early on; however, due to the infrastructure of American hospitals, this problem is only delayed until it becomes dire. This furthers how invisible systemic forces keep those who need to use hospitals the most. These systems only continue the cycles of poverty and generational trauma to further the restriction of healthcare.

Cruel and declining care and treatment go a long way in exacerbating systems of oppression against unhoused people. The homeless population represents a sizable portion of the United States in comparison to other first-world countries as well. Therefore, making clinics and access to healthcare more exclusive creates an environment where only the rich are able to stay healthy while the poor die off. As Loma University’s Institute for Health Policy and Leadership reports, the homeless population is 0.2% of the US population, and California has about 1.9 times the overall US rate. In fact, the states of California, New York, Hawaii, and Oregon collectively comprise 20% of the overall US population, but contain over 50% of the entire US homeless population. With a population becoming this size, making healthcare access more affordable and accessible is needed. With studies from the National Health Care for the Homeless Council showing that homeless people, on average, die 15 years sooner than the general US population, the need to address the disparities in the social determinants of health is more crucial than ever. Homeless populations are at greater risk since residing on the streets creates even more unique health risks like being exposed to communicable diseases, violence, and malnutrition.

Lastly, one of the many root causes is also the declining mental health and social stigmas that are applied to homeless people. The presence of a personality disorder is associated with poorer health outcomes, treatment of depression, and may lead to an increased risk of deliberate self–harm. These conditions, combined with the situation of being in shelters or the streets with other homeless people, create an unsafe environment. Social stigmas and negative perceptions of homeless people have been shown to affect their mental health by declining their trust in others and creating a survivalistic mindset. Thus, with many of these factors being exacerbated as their health is neglected, this only polarizes the symptoms that come with the condition of being homeless. While there is little research on what exactly there is for homeless populations to do in order to prevent their physical and mental health from declining, this gap in literature could be alleviated by experimenting with programs and laws that go on to alleviate this issue at its core.

Although the issue of homelessness is deeply intricate and resides in many practices that are overlooked, ultimately, the condition of being homeless comes with sacrifice and consequences. There ought to be more research done to fill the gap in the actual, feasible solutions that come with the nuanced issue of homelessness. One piece of legislation attempted to alleviate the intersection between homelessness and healthcare disparities in California’s Senate Bill 1152 in 2018, which requires hospitals to provide clothing, meals, and transportation for homeless patients on top of documentation of discharge to a safe location. Should more states adopt similar legislation and attempt to tackle the issue of homelessness by addressing health concerns to prevent the worsening of symptoms, the United States would be on track of being able to develop further solutions to the issue. However, as of the current status quo, this issue requires much more legislation, systemic reconstruction, and empathy in order to alleviate it.

Photo Credit: Ryan Garza, Detroit Free Press