Homelessness kills but how – and why is this relationship between homelessness and poor health such a challenge to health practitioners and homelessness services?

Life on the Streets

Ask any person rough sleeping in the UK to describe their experience and ‘cold’ is a frequently used term. Being cold is known to increase people’s vulnerability to infection and early mortality. Cold reduces the body’s ability to cope with invading bacteria, inhibits adequate profusion of the peripheries of hands and feet and hinders ability to think clearly and avoid danger.

Alcohol, some medications, drug use and smoking reduce blood flow which can negatively affect cardiovascular function. Longer term exposure damages mental and physical health. As a result, drug and alcohol use multiplies as a superficial means of coping with the deeper social, emotional and physical distress that underpin many a homeless existence.

Poor physical and mental health needs may pre-exist the chaos of being homeless. Over 40% of people recognise that they use alcohol and illicit drugs to cope. So too, physical health and mental wellbeing are negatively affected by self-harm, depression and addictive behaviours. Fuelled by the vulnerability that comes from living without home security, health conditions are worsened by exposure to cold and wet weather, lack of personal hygiene opportunities such as showers or daily dental care, physical assault and third party drug abuse by smoking or injecting poor quality and often spiked illicit substances.

People who live in hostels have a higher than average risk of becoming host to virulent or resistant organisms capable of causing disease such as Group A Streptococci and MRSA. Assault, self-harm and injecting site wounds can become chronic and regressive, which increases complications such as invasive bacterial infections and septicaemia. Bartering and sharing of possessions such as clothing or bed space is not uncommon, nor is the sharing of preparatory drug paraphernalia such as spoons and foil. This increases the risk of cross-transmission of pathogenic skin-based flora: hostels and prisons have been implicated in outbreaks of community infections as a result.

Tough Choices

Understanding that a choice must be made between the basic need of being safe versus being warm may be difficult to grasp for health and social care providers. For those with no security for their meagre possessions, this is the reality of their health choice. Rough sleepers own very little and what they do own has a worth to them which is undervalued by those agencies with whom they come into contact.

A sleeping bag, a mattress, a plastic sheet which protects them from the wet ground are critical life-saving items that people are reluctant to risk by accepting a place offering dormitory-style living. The crisis nature of current agency intervention for short term provision of accommodation over Christmas or during extreme cold does not provide a longer term commitment.

Poor behaviour or breaking hostel rules such as having undeclared visitors, fighting or drug abuse, may push people into a seemingly intractable lifestyle which limits their options. Dogs are frequently the substitute companion for people failed by human relationships. These dependents are unlikely to be abandoned for the sake of a night’s accommodation perceived as less safe than a secluded bush or isolated pavement doorway.

Listen and Learn

Making every contact count requires all agencies to reflect on the relevance of their service to address these challenges.

April 2018 saw the Homelessness Reduction Bill become law, placing a duty on local authorities and other agencies, to act in a planned preventative way to reduce the end point of homelessness. As health and social care workers and volunteers, it is recognised there are many opportunities to influence, signpost, pre-empt and refer to protect against the deteriorating social, financial, physical or emotional conditions which may render a household or individual at risk of homelessness.

A final word of caution on behalf of those who may not be able today to fully articulate their story: listen to the needs of your community. Action can be taken locally to ensure the engagement of multiple benefactors with their valuable singular focus whether domestic abuse, police and prison services, housing officers or national agencies.

Listen to those who have experienced first-hand the harsh contradictory choice of health versus homelessness.

Alison Phillis, Queen’s Nurse


Photo by Oliver Roos on Unsplash.

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