Psychiatrist Leader: Action Needed Around Homeless Deaths
Katherine A. Koh, M.D., a practicing psychiatrist in the Department of Psychiatry at Massachusetts General Hospital, and a psychiatrist who helps to lead the Boston Health Care for the Homeless Program, notes in her “Perspectives” article in The New England Journal of Medicine online, published on Nov. 16, “Invisible Deaths—Mortality among People Experiencing Homelessness,” that deaths among homeless people are increasing, and argues that health system leaders can take action to recognize the increase and respond to it.
“The epidemic of premature death among people who experience homelessness in the United States is staggering and has continued to grow,” Koh writes in her op-ed. “The mean age at death in this population is 51 years — nearly 25 years younger than that in the general population and an age at which Americans commonly died in 1900. The statistics are particularly striking for certain subgroups, such as people who sleep on the street. Age-adjusted mortality in this group is nearly 10 times that in the general housed population and nearly 3 times that among people who sleep primarily in shelters.”
Significantly, Koh writes, “Various factors contribute to an increased risk of premature death among people experiencing homelessness. People who become homeless have often had exposure to health-harming factors from an early age, such as neighborhood disadvantage and discrimination, that are linked with premature death in other historically excluded populations (e.g., people with severe mental illness and marginalized racial and ethnic groups). People who experience homelessness have a substantially higher disease burden than the general population, including more advanced cardiovascular disease and higher rates of cancer. Limited access to health care, medications, and a safe place to rest contributes to this burden and complicates management of medical conditions.”
In fact, Koh writes, “Though no federal agency collects nationwide data on deaths among people experiencing homelessness, a study of data from 10 states found that all-cause mortality in this population increased 238% between 2011 and 2020. The aging of this population, the increased availability of fentanyl, and disruptions in social services during the Covid-19 pandemic have contributed to steep increases in deaths. In some cities, numbers of deaths among people experiencing homelessness have recently doubled.”
And, things can be done: “One policy change could involve requiring the recording of housing status on death certificates,” Koh writes. “Collecting standardized data related to mortality among people who experience homelessness, including sociodemographic information and place and cause of death, could enhance understanding of this pressing public health issue among clinicians and policymakers. Linking mortality data with data on the use of health care and social services could permit identification of potential points of intervention. Postmortem examinations conducted in this population could consistently test not only for the presence of drugs but also for other plausible causes of sudden death. Meanwhile, increased investments in Housing First, street-medicine, and harm-reduction programs are critical to reduce rates of disease and premature death.”
