Homelessness & Health: What’s the Connection?

Homelessness can take many forms, with people living on the streets, in encampments or shelters, in transitional housing programs, or doubled up with family and friends. While the federal government reports 1.5 million people a year experience homelessness, other estimates find up to twice this number of people are actually without housing in any given year. The connection between housing and homelessness is generally intuitive, but the strong link between health and homelessness is often overlooked. This fact sheet outlines how health and homelessness are intertwined—and why housing is health care. People who are homeless have higher rates of illness and die on average 12 years sooner than the general U.S. population

Poor heath is a major cause of homelessness

An injury or illness can start out as a health condition, but quickly lead to an employment problem due to missing too much time from work; exhausting sick leave; and/or not being able to maintain a regular schedule or perform work functions. This is especially true for physically demanding jobs such as construction, manufacturing, and other labor-intensive industries. The loss of employment due to poor health then becomes a vicious cycle: without funds to pay for health care (treatment, medications, surgery, etc.), one cannot heal to work again, and if one remains ill, it is difficult to regain employment. Without income from work, an injury or illness quickly becomes a housing problem. In these situations, any available savings are quickly exhausted, and relying on friends and family for assistance to help maintain rent/mortgage payments, food, medical care, and other basic needs can be short-lived. Once these personal safety nets are exhausted, there are usually very few options available to help with health care or housing. Ultimately, poor health can lead to unemployment, poverty, and homelessness.

Homelessness creates new health problems and exacerbates existing ones

Living on the street or in crowded homeless shelters is extremely stressful and made worse by being exposed to communicable disease (e.g. TB, respiratory illnesses, flu, hepatitis, etc.), violence, malnutrition, and harmful weather exposure. Chronic health conditions such as high blood pressure, diabetes, and asthma become worse because there is no safe place to store medications properly. Maintaining a healthy diet is difficult in soup kitchens and shelters as the meals are usually high in salt, sugars, and starch (making for cheap, filling meals but lacking nutritional content). Behavioral health issues such as depression, alcoholism, or other substance use disorders can develop and/or are made worse in such difficult situations, especially if there is no solution in sight. Injuries that result from violence or accidents do not heal properly because bathing, keeping bandages clean, and getting proper rest and recuperation isn’t possible on the street or in shelters. Minor issues such as cuts or common colds easily develop into larger problems such as infections or pneumonia. Numerous health conditions among people who are homeless are frequently a complex mix of serious physical, mental health, substance use, and social problems. Poor health, high stress, unhealthy and dangerous environments, and an inability to control food intake often result in frequent visits to emergency rooms and hospitalizations. 

Recovery and healing are more difficult without housing

Stable housing not only provides privacy and safety, it is also a place to rest and recuperate from surgery, illness, and other ailments without worry about where to sleep and find a meal, or how to balance these needs with obtaining health care and social services. The best, most coordinated medical services are not very effective if the patient’s health is continually compromised by street and shelter conditions. Even inpatient hospitalization or residential drug treatment and mental health care do not have lasting impacts if a client has to return to the streets or shelters upon discharge. Source

Let's create a solution; Housing and health care work best together and are essential to preventing and ending homelessness. Health care services are more effective when a patient is stably housed, and in turn, maintaining housing is more likely if proper health care services are delivered. While there are many factors that influence health, stable housing is a key “social determinant of health” that directly impacts health outcomes. While some need only short-term assistance to regain health and reconnect to employment and housing on their own, others may be so seriously ill and/or disabled they will need longer-term support services in order to maintain housing. Either way, housing is necessary to realize a healthier society. Communities that invest in affordable housing incur lower public costs, achieve better health outcomes, and work to prevent and end homelessness.

The Role of Sanitation and Waste Management in Local Responses to Homelessness

Unsheltered homelessness is highly visible, and presents social, political, health, and safety challenges. This reality creates a conundrum: housing — access to stable, affordable housing and necessary social and medical services — is the only successful way to end homelessness. Yet, in the face of rising unsheltered homelessness, local leaders often experience pressure to respond to health and safety concerns related to unsheltered homelessness through alternative city agencies, like sanitation departments. 

They may deploy more enforcement strategies such as:

• encampment clearance without adequate notice or housing being available
• property confiscation
• relocation of unhoused people
• and waste removal. 

While unsheltered homelessness presents many distinct challenges, including threats to public and individual health and safety, encampment clearance without providing housing options for residents does not end homelessness. 

Unsheltered homelessness is highly visible, and presents social, political, health, and safety challenges. Despite this, most unhoused people do not live on the streets. They either live in temporary shelters, or in unstable housing arrangements such as couch surfing with friends or family. While these individuals and families face immense challenges and experience worse outcomes on a variety of dimensions, their day-to-day lives are largely invisible to the general public.

The brief finds that sanitation agencies are frequently involved in implementing city responses to homelessness. Additionally, such responses are most often distinct, or isolated from, primary municipal homeless policies such as homeless plans. Findings include:

• 72% of municipalities enlist sanitation institutions as a part of their response to homelessness.
• 50% of sanitation policies involve the police. In America’s 50 largest cities, 68% of sanitation responses involve police.
• Of the 100 largest cities, the majority of sanitation strategies target encampment abatement (63%), including property confiscation, and physical removal of unhoused individuals from areas. 90% of the 50 largest cities describe encampment abatement as the primary goal of sanitation responses to homelessness.
• Nearly half (41%) of sanitation strategies in the 100 largest cities include coordinating referrals to social or medical services. However, efforts where sanitation strategies link back to any type of shelter — permanent or temporary — occur in just one in 10 municipalities’ sanitation responses.

To address this issue effectively, there needs to be better coordination between sanitation agencies, homeless services, and housing departments. The federal government should incentivize cities to adopt policies that emphasize long-term housing solutions over short-term punitive measures.

Recommendations:

• Federal Financial Incentives: Provide financial incentives for encampment removal only when long-term housing solutions are available.
• Integrated Policy Design: Encourage local sanitation agencies to collaborate with homeless and housing departments when creating and implementing policies.
• Resource Strengthening: Increase resources from federal, state, and local governments to enhance the capacity of housing and homeless departments to invest in evidence-based solutions.
• By focusing on these recommendations, cities can develop more effective, humane responses to homelessness that address the root causes rather than merely the symptoms. Source

Domestic Violence and Homelessness

There is a lot to understand in making the connection between domestic violence and homelessness. A domestic violence experience is common among youth, single adults, and families who become homeless. For many, it is the immediate cause of their homelessness. Survivors of domestic violence may turn to homeless service programs seeking a safe temporary place to stay after fleeing an abusive relationship. Others may turn to homeless service programs primarily because they lack the economic resources to secure or maintain housing after leaving an abusive relationship.

In 2023, approximately 10.4% percent of all Emergency Shelter, Transitional Housing, and Safe Haven beds in homeless service systems were targeted to survivors of domestic violence and their families. The immediate need of a survivor fleeing domestic violence is safety. Some survivors may be able to safely stay in their own home with some additional financial support through rental assistance while others may require a stay in an emergency shelter or transitional housing program before re-entering their own independent housing.

Short- or long-term rental assistance can be used to help survivors exit shelter and regain housing. Having an affordable place to call home is crucial for this population, to both reduce their risk of homelessness as well as the possibility of future violence. Research indicates that families that receive a housing subsidy after exiting homelessness are far less likely to experience interpersonal violence than those that do not.

Beyond addressing their immediate safety and housing needs, survivors of domestic violence require supportive services that can help them heal from the trauma of abuse and improve their economic security and well-being. Source

Housing Affordability and Homelessness

As the gap between increasing housing costs and stagnant incomes widens, the end result is that more people become homeless. The nation is currently facing one of the most severe affordable housing crises in history. Not surprisingly, those living in poverty are the most significantly affected.

In the 1970s, communities had plenty of affordable housing. That meant that when a family or individual experienced a crisis and lost housing, they could quickly find another place to live. But by the mid-1980s, the supply of low-cost housing had shrunk significantly. Since then, rents have continued to rise and lower-income people in particular have experienced slow or stagnant wage growth.

Today, 11 million extremely low-income households pay at least half of their income toward housing, putting them at risk of housing instability and homelessness. In many places across America, there is simply not enough available affordable housing. Without this housing stock, many homeless Americans are likely to continue to cycle in and out of homelessness. Source