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IV.     Discussion

a.      Comparison to Other Cities
         i. New York City:
In 2005 the City of New York passed Local Law 63 (LL63) which requires the New York City Department of Health and Mental Hygiene (DOHMH) to track and report the deaths of homeless persons. In 2006, the DOHMH began releasing quarterly reports and analyses of homeless deaths in New York City. LL63 defines a “homeless person” as “a person who at the time of death did not have a known street address of a residence at which he or she was known or reasonably believed to have resided.” This definition leads to a more accurate account of homeless deaths than does the process used by Los Angeles County.

New York City’s Department of Homeless Services releases a daily census of the number of homeless people living in New York and an annual analysis of these figures which details successful strategies and new partnerships. These studies have shown that the number of unsheltered people has dropped 15% since 2005. Of the remaining unsheltered residents, 1,624 of them live in the city’s subway system. In comparison to Los Angeles County, New York has a much lower homeless population to general population ratio. New York City’s is one in 1,209 while Los Angeles’ is one in 137 according to 2006 data .

The demographics of New York City’s homeless population are much more polarized than Los Angeles’. In New York, 60% of the homeless are African American, 25% are Hispanic and 15% are Caucasian. In terms of gender, New York’s single homeless population is 76.8% male and 23.2% female.

Like Los Angeles, New Yorks’ homeless population is aging. Since 1999, individuals over the age of 40 have made up more than 53% of the homeless population.

Nearly 1.7 billion is spent in New York from general funds to combat homelessness. On January 30, 2006, the City of New York released a report titled The Health of Homeless Adults in New York City which outlined five general recommendations including increasing the availability of permanent supportive housing and an immediate action plan to help improve the health of homeless adults in New York.

By comparison, in 2005 the City and County of Los Angeles, in combined local, state, federal and private funds spent only $600 million on homelessness.  Los Angeles Mayor Villaraigosa is proposing to spend a paltry .001% in new funds compared to what NYC spends annually.  New York has built over 16,000 units of permanent supportive housing, reducing their homeless population significantly; and allowing them to close one of their large shelters of nearly 1,000 beds because they have been successful in ending homelessness for thousands of people.

ii. San Francisco:
The City of San Francisco has released a report on homeless deaths every year since 1987. The study is conducted by the Community Health Epidemiology Section of the City and County of San Francisco Health Department. They do this for two reasons: “so that their names won’t be forgotten and—for more practical purposes—to help us identify the gaps in our City’s system of care where we can best focus our efforts to prevent future homeless deaths. ” In the years ranging from 1990-1999 San Francisco experienced an average of 131.8 homeless deaths per year. Los Angeles, in contrast, averaged 380 deaths per year from 2000-2007, a rate nearly three times as high as San Francisco.

In terms of gender, San Francisco’s homeless deaths have been similar to those of Los Angeles. Homeless deaths have been around 85% male and 15% female.  However, in terms of race, San Francisco had higher rates of Caucasian (55%) and African American (28%) homeless deaths than Los Angeles, where Caucasians made up 41% of deaths, while Hispanics made up 31% and African Americans 25%.   The homeless population of the Los Angeles study (48.1 years) lived an average of six years longer than population of San Francisco’s study (42.3 years).

San Francisco created the Local Homeless Coordinating Board in 1996. On August 1, 2007 the City of Coordinating Board released a five year strategic plan titled Toward Ending Homelessness in San Francisco which addresses the health of homeless people by providing “temporary respite to the medically frail and works towards finding permanent housing for these clients .” These initiatives have created homes for thousands of San Francisco’s homeless.

iii. Seattle:

In 2003, the Health Care for the Homeless Network in Seattle-King County released their first King County Homeless Death Review which aimed to elucidate the problem of homeless deaths and health in their area. The Network released another study in 2005 which found there were 82 homeless deaths in Seattle-King County in 2004, 80% of which were men and 20% female. People of color, especially African Americans (15%) and Native Americans (10%), were disproportionately represented in relation to the area’s general population, however 63% of the deaths were Caucasian. The top three leading causes of death were: acute intoxication, traumatic injuries, and cardiovascular disease. Illness and other chronic conditions accounted for 33% of deaths. The average age of the homeless was 47 years, with 76% of deaths coming between the ages of 30 and 59 years of age. Most of the deaths occurred in Seattle (71%), followed by South King County (17%). The average life span of 47 fell 30 years short of the national average in 2004 of 77.6 years.

The report outlined five critical steps that aim to alleviate suffering and prevent premature deaths for the County’s homeless. The steps call to first, make strategic increases in outreach and engagement. Second, to promote recovery by ensuring that people in homeless shelters, day centers, and housing programs can and do access health care services—including addiction services, mental health care, and medical care. Third, to increase and sharpen strategies to address chronic health conditions such as cardiovascular disease and diabetes among homeless people. Fourth, to increase access to housing and prevent loss of housing: housing is health care. And fifth, to support future homeless death reviews.

iv. Boston:

In 1997, a study was conducted on 606 homeless deaths that occurred in Boston from 1988 to 1993. The sample was comprised of persons who sought medical attention through the Boston Health Care for the Homeless Program between 1 July 1988 and 31 December 1993. The age at time of death ranged from 18 to 86 with an average age of 47 years. An interesting fact brought to light in the study was that while the population of the sample was 68% male and 32% female, the makeup of homeless deaths was 86% male and 14% female.

Nearly half (48%) of the deaths were of people ages 25 to 44 years. Homicide was the leading cause of death for persons between the ages of 18 and 24, followed by traumatic injuries and poisonings (such as drug overdoses). Between the ages of 25 and 44, AIDS was the leading cause of death, however heart disease was also a major contributor. The rate of death from heart disease was more than three times higher than the general population. For older homeless persons, heart disease and cancer were the major causes of death.
From their analysis, the study’s authors outlined action steps and recommendations to reduce fatal health problems among Boston’s homeless population. The report statistically showed the devastating impact of the AIDS epidemic on Boston’s homeless population. Efforts to reduce the rate of AIDS-related deaths in homeless persons and early treatment to prevent HIV infection were made a focus of homeless death prevention. Since pneumonia and influenza were frequent causes of death, even in younger age groups, efforts to vaccinate all homeless persons against such diseases were made into a strong issue. The authors concluded that the efforts to reduce mortality rates among homeless persons should focus on treatable and preventable conditions. The treatment of underlying problems, such as substance abuse, would also need to be addressed .

 

Comparison of L.A. to other homeless reports: L.A. findings consistent with other studies:

 

Los Angeles

Atlanta [1]

Atlanta [2]

SF

Philadelphia

Boston

NYC

 

 

 

 

 

 

 

 

Year

2000-2007

1985

1988-1990

1985-1990

1994

1988-1993

1987-1994

Homeless deaths

2815

40

128

644

96

606

164

 

 

 

 

 

 

 

 

Average age

48

44

46

41

 

47

 

 

 

 

 

 

 

 

 

Gender

 

 

 

 

 

 

 

     Male

85%

92%

98%

89%

 

68%

78%

     Female

15%

8%

2%

11%

 

32%

22%

 

 

 

 

 

 

 

 

Ethnicity

 

 

 

 

 

 

 

     White

41%

 

38%

68%

 

62%

 

     Latino

31%

 

 

2%

 

7%

 

     Black

25%

56%

60%

24%

 

30%

 

     Asian

1%

 

 

1%

 

 

 

     Native American

1%

 

 

1%

 

 

 

 

 

 

 

 

 

 

 

Cause of death

 

 

 

 

 

 

 

     Natural

n/a

40%

55%

39%

 

 

 

          Alcohol

22%

15%

47%

33%

 

 

 

          Drugs

20%

 

 

 

 

 

 

               Heroin

35%

 

 

 

 

 

 

               Cocaine

20%

 

 

14%

 

 

 

               Morphine

14%

 

 

21%

 

 

 

          Seizures

 

7%

 

 

 

45-64 yrs

 

          Heart  disease

24.4%

10%

 

 

 

 

 

          Liver

3.6%

 

 

 

 

 

 

          Brain

n/a

 

 

 

 

 

 

          Lung disease

4.1%

7%

 

 

 

 

 

     External causes

n/a

60%

42%

53%

 

 

 

          Accidental injuries

 

48%

50%

34%

 

 

 

          Intentional injuries

18%

 

 

18%

 

 

 

          Homicides

.3%

12%

8%

13%

 

18-24 yrs

 

          Suicides

n/a

 

3%

6%

 

 

 

 

 

 

 

 

 

 

 

b.               Policy Recommendations:
1.         Annual report from LA County: 

The Los Angeles County Board of Supervisors should instruct the appropriate County departments, including the Coroners office, Department of Health Services and the Public Health Department, to conduct an annual analysis of homeless deaths and issue a report along the lines of this report.  Deeper analysis into selected homeless death cases can reveal specific weak points in homeless response efforts, and promote more effective work across the systems of care that are organizing to end homelessness in our community. In addition, analysis of homeless cases that are not captured by this methodology may provide greater integrity for comparison between years.  In addition, further analysis needs to be done of what week of the month has the highest death rates.  For example, Seattle found that it was the first week of the month.  The increased number of deaths during the first week of each month may indicate that the arrival of disability checks at the beginning of the month leads to a flurry of substance abuse, injury, and death. If so, mortality in homeless persons might be reduced by carefully monitored payee programs that administer funds on behalf of disabled persons

  • Increase access to Primary and Preventive Care:

 

The leading causes if death reported here are preventable and treatable.  Regrettably, well documented barriers – chiefly lack of health insurance or ability to pay – continue to block homeless persons’ access to care.  Local, state and national legislative bodies and health authorities should move immediately to assure that everyone has health care coverage and access to the quality health that can avoid unnecessary deaths.  For example, pneumonia and influenza were frequent causes of death, even in younger age groups. Homeless persons may be at increased risk for these infections because of a high prevalence of alcoholism, smoking, HIV infection, and chronic disease. Efforts to vaccinate all homeless persons against pneumonia and influenza should be a priority. 

3.         Support overdose prevention programs: 

Los Angeles County should support and fund overdose prevention programs in emergency shelters, jails, substance abuse programs and other programs where those at high risk for overdose congregate.  This would include support for a countywide Naloxone overdose prevention and distribution program as well as support for needle exchange programs countywide.

4.         Promote recovery:
Promote recovery by ensuring that people in homeless shelters, day centers, and housing programs can and do access health care services—including addiction services, mental health care, and medical care.

 

5.         Improved discharge planning: 
Improve discharge planning from county facilities including hospitals, jails and foster care to ensure that people are not discharge into homelessness.
6.         Regional priority to end and prevent homelessness through creating permanent housing: 
The high risk for death from homicide and accidental injury is a predictable result of poverty, substance abuse, and living on the streets. Increasing the availability of adequate low-income housing could conceivably reduce this risk.   Los Angeles City, County and surrounding cities should pool their funding to begin to create 50,000 units or permanent housing over the next ten years.  These jurisdictions should provide interim housing, not shelters, until permanent housing is available.  
7.         Increase economic stability:

Los Angeles City and County and surrounding cities in greater LA should increase the economic stability of homeless people through increasing employment services, mainstream financial entitlements and education.

Finally, the Los Angeles County Board of Supervisors must raise LA Countys’ General Relief level [$221 a month- the same level as in 1984] to an amount that will house GR recipients for the entire month.

footnotes:

http://www.nyc.gov/html/dhs/downloads/pdf/hope_presentation-final.pdf

http://www.sfdph.org/press/1999PR/pr122299.htm

http://www.sfgov.org/site/uploadedfiles/lhcb/documents/SFCoCDraft.pdf

http://www.annals.org/cgi/content/full/126/8/625

 

 *RETURN TO TABLE OF CONTENTS*

National Coalition for the Homeless
2201 P Street NW
Washington, DC 20037-1033
202-462-4822
info@nationalhomeless.org

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