Sara Robinson, MD | University of Minnesota Mankato Family Medicine Residency 2022 Namey/Burnett Preventive Medicine Writing Award Submission
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
At the University of Minnesota Mankato Family Medicine Residency, we have partnered with Open Door Community Health Centers, a Federally Qualified Health Center, to open a free clinic at a local homeless shelter. The shelter houses 35 guests overnight eight months out of the year. The free clinic occurs every other week, doing our best to take care of both acute and chronic issues of the shelter guests. I was wrapping up an appointment with a guest, assuring her that we could get her needed medications and will be at the shelter again in two weeks to check on her. She responded, “I’m glad the clinic is here, but at the end of the day, I still don’t have a home. Nothing we do here can fix that.”
Housing is so much more than four walls and a roof. Housing provides protection from the elements, a place of refuge, and a place to heal. Housing is an essential and fundamental aspect of living, and it is a provision that more than half a million Americans on any given day do not have.1 In fact, the United States has more homeless families than any other developed country.2
There are many paths to homelessness. One such cause is lack of affordable housing or housing that costs less than 30% of income.2 Poor health is another common cause of homelessness. Illness can lead to wracking debt, lost jobs and subsequent incomes and an endless cycle of worsening health, increased costs and no way to pay for it all.3 Unemployment, poverty, untreated substance dependence, domestic violence, discrimination, structural racism in the housing market, and lack of mental health resources are all contributors to the homeless crisis in the United States today.
The Impact of Homelessness on Health and Health Care
Lack of stable housing has a direct correlation with poorer health outcomes. It is estimated that those without homes have an average lifespan that is 12 years less than the general population. Those without homes also experience a disproportionately higher disease burden. Not only does homelessness put individuals at risk for new diseases, but due to minimal medical care, chronic stress, exposures, and lack of other resources, homelessness also leads to the exacerbation of underlying chronic conditions.
The percentage of diabetes in those without homes is twice those with stable housing, as is the rate of heart attacks. Substance use disorders are 3.5 times more prevalent, and depression is up to six times as prevalent. Not having adequate housing also results in higher exposure to communicable diseases either in shelters or on the streets; malnutrition due to acquiring cheaper, nutrient-depleted foods; and longer healing times for wounds due to lack of appropriate supplies and regular bathing.3 The pandemic has highlighted the pervasiveness of this crisis. Studies have shown that homeless individuals who contracted COVID-19 were 30 percent more likely to die than individuals with homes.4
Those without homes also lack easy access to affordable and preventive care. Most utilize emergency room visits rather than seeking primary care due to lack of access or insurance. A study in Boston showed that this practice cost the city an additional $16 million a year for the medical care of 6,500 individuals.4 The same study found that homeless individuals utilized the emergency room almost four times more than other low-income individuals.1 Homelessness—a public health concern that is a root cause for many individual health issues—puts a financial strain on healthcare systems. It will only get worse without intervention, and family physicians have both the ability and the responsibility to intervene.
Solutions to End Homelessness
More and more, we are understanding that poor health outcomes, especially those in underrepresented communities, are not due to lack of commitment to health but rather lack of opportunity. Research is uncovering how social determinants of health play such an essential role in our overall wellbeing—how systemic racism, poverty, lack of access to transportation, clothing and shelter profoundly affect our bodies down to the cellular level.
In order to best treat our patients as family medicine physicians, it is imperative that we recognize and advocate for the betterment of these issues. Insulin cannot fix lack of access to nutritious food. Zoloft cannot fix the sleepless nights associated with not having a roof overhead. A pillar of the practice of family medicine is prevention: intervening before problems arise. Ergo, a solution to this issue lies in persevering with conviction toward the end of homelessness.
There have been different strategies utilized over the past few decades to address this concern. One method that has proven to worsen the issue instead of improving it is the criminalization of homelessness. Laws that have been passed in various cities prohibit actions like sleeping in or even sitting in public spaces and forbidding people from sharing food with homeless individuals.5 Homelessness cannot be willed away through punitive laws—it must be brought about by addressing the underlying issues to fix what is actually wrong so that this seemingly endless cycle can be broken.
One of the most successful campaigns has been the Housing First initiative, started in 1988, which prioritizes moving homeless individuals into permanent housing. This philosophy was adapted through a variety of programs in different states. A review of a Seattle-based Housing First program for 95 individuals with severe alcohol use disorder cost the city $14,000 per person a year but ultimately saved $4 million due to the decreased health care costs.1 The U.S. Department of Housing and Urban Development reported this model decreased emergency room visits and saved $31,545 per person across the country within a two-year period.6
Looking outside of the United States, Finland has also seen great success with this model. The country created discounted loans for organizations to use to obtain affordable housing for individuals in need. These organizations are often equipped with social workers to help arrange for appropriate resources. Studies have shown that 80 percent of people in this program maintain housing and economic stability, resulting in the country paying 15,000 euros less per year per individual.7 Other unique solutions have come in the forms of tiny homes, temporary supportive housing villages and the conversion of empty hotels into affordable housing—gateways that provide necessary resources toward getting those without homes back on their feet and closer to stable housing.8–10
What Can We Do Now?
Housing is health care. As family physicians, we have the privilege of seeing people at their most vulnerable and can build trusting relationships. We can regularly screen for homelessness and who is at risk. We can be aware of resources in our areas. How many shelters are in town? Are there any availabilities? Is there transportation provided? Does your patient have a case worker? We can also start to look at the statistics in our own communities from our local healthcare systems and use that information to partner with organizations to address cost-effective, long-term solutions. We can advocate at the local, state and federal levels, using our voices and expertise to serve the underserved. The list of what we can do is endless. What we cannot do is ignore it.
To make lasting change requires ongoing effort, and that is a battle worth fighting.
ACOFP is a community of current and future family physicians that champions osteopathic principles and supports its members by providing resources such as education, networking and advocacy, while putting patients first.