Homelessness, Health, and Human Needs (1988)

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1 Who Are the Homeless? INTRODUCTION There have always been homeless people in the United States. As economic circumstances and demographic forces have fluctuated, so have the size and composition of the homeless population, although relatively permanent skid rows where homeless people congregate have long been a feature of many large cities. In the past decade, however, the problem of homelessness has increas- ingly captured public attention. Not only has the number of homeless people increased dramatically within the last several years but the composition of the homeless population has also changed appreciably during that period: For example, middle-aged men make up a shrinking fraction of all homeless people, and families with young children are the fastest growing component of the homeless population (U.S. Conference of Mayors, 1987J. Growing public awareness of homelessness is also connected to changes in the geographic dispersion of homeless people, who are becoming more visible in neighborhoods and communities that would not have imagined their presence in the past. This chapter briefly describes homelessness in the United States. It begins by defining homelessness, assessing methodologies used to count homeless people, and reviewing recent scholarly literature on the subject. The chapter continues by examining the socio-demographic characteristics of homeless people, with emphasis on adult individuals, families and children, runaway and throwaway youths,* the elderly, and people in * "Throwaway" youths refers to children and adolescents who are evicted from their homes by their parents or another adult in a position of responsibility for them. 1

2 HOMELESSNESS, HEALTH, AND HUMAN NEEDS rural areas. In the course of this discussion the issues relating to the prevalence of health and mental health problems inevitably arise, but these are reviewed in greater detail in Chapter 3, Health Problems of Homeless People. DEFINITION OF HOMELESS For the purpose of this report, the definition of homeless or homeless person is the same as that in P.L. 100-77, the Stewart B. McKinney Homeless Assistance Act, enacted in July 1987 (U.S. Congress, House, 1987): (1) an individual who lacks a fixed, regular, and adequate nighttime residence; [or] (2) an individual who has a primary nighttime residence that is- (A) a supervised or publicly operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and tran- sitional housing for the mentally ill); (B) an institution that provides a temporary residence for individuals intended to be institutionalized; or (C) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings. This definition refers specifically to homeless individuals, but it is equally applicable to homeless families. COUNTING THE HOMELESS Even within the framework of a relatively straightforward definition, there is considerable uncertainty about the number of people who are homeless at any given time in the United States. Conventional methods of enumerating populations, such as the census, are based upon counting people where they live. Not only do people move in and out of homelessness but the methodological problems involved in counting people without a fixed residence are formidable. Studies that have attempted to count homeless people have been subject to severe criticism. For example, samples are generally small and may not be generalizable to other locales, data are often collected from single sites, samples often are not systematically drawn, measures and definitions of homelessness are inconsistent, and the rural population is virtually unidentified. For all these reasons, the various studies cannot be easily compared or gener- alized. (Appendix B of this report contains a detailed analysis of the three most common methods of counting homeless people and the technical strengths and weaknesses of each.)

WHO ARE TH: TABLE 1-1 National Estimates of the Homeless Populations E HOMELESS? 3 Source Estimate Assumptions Used Hombs and 2,200,000 Snyder (1982) U.S. Depart- ment of Hous- ing and Urban Development (1984) 1. 2. 3. 192,000 254,000 586,000 Tucker (1987) 700,000 Freeman and Hall (1986) Alliance Hous- ing Council (1988) 287~000 735,000 on a given night; 1.3 million to 2.0 mil- lion during 1988 Based on a small number of high local estimates. Apparently uses city popu- lations to estimate a rate of homeless- ness. Applies constant rate of home- lessness to the entire country. Applies a street-to-shelter ratio to ester mates of the sheltered population. Based on estimates for 60 cities. Uses metropolitan population as the base. Calculates rates separately for large, medium, and small areas. Takes highest local estimates. Uses metropolitan population as the base. Assumes a constant rate of homeless- . . ness nationwide. Based on estimates for 50 cities. Uses city populations as the base. Allows rates to vary for large, medium, and small cities. Applies a street-to-shelter ratio to esti- mates of the sheltered population. Based on reinterpretation and extrapola- tion from U.S. Dept. of Housing and Urban Development (1984) studies. Assumes suburban rate of 1/3rd the city rate. Assumes 20% growth in homelessness each year. aAdapted from Alliance Housing Council (1988). The range of estimates of the number of homeless people is wide (Table 1-1~. At the low end is the U.S. Department of Housing and Urban Development (1984) estimate of 200,000 to 300,000. At the high end are advocates' estimates of more than 2 million (Hombs and Snyder, 1982~. Whatever the absolute numbers, the number of homeless people has grown appreciably in recent years. Surveys conducted by the U. S. Conference of Mayors in 25 representative cities in each of the past 2

4 HOMELESSNESS, HEALTH, AND HUMAN NEEDS years identified no city in which the numbers were falling; most cities reported annual increases of 15 to 50 percent (U.S. Conference of Mayors, 19871. A substantial majority of the cities reported that families were the fastest growing component of the homeless population. One recent estimate of the number of homeless people in the United States, published in June 1988 by the National Alliance to End Home- lessness, calculates that currently, on any given night, there are 735,000 homeless people in the United States; that during the course of 1988, 1.3 million to 2.0 million people will be homeless for one or more nights; and that these people are among approximately 6 million Americans who, because of their disproportionately high expenditures for housing costs, are at extreme risk of becoming homeless (Alliance Housing Council, 19881. For the purposes of this study, the question of precisely how many homeless people there are was not of central importance because home- lessness is not a static condition; poor people move in and out of a state of homelessness. Therefore, the committee devoted a major part of its effort to analyzing the composition of the homeless subpopulations and the health-related needs of each group. STUDIES OF HOMELESSNESS Since the early 1980s, an extensive body of literature about homeless people has emerged. Although some have described homelessness in the United States impressionistically, a number of scholars have conducted substantial surveys and performed extensive data analyses in order to describe the characteristics of homeless people. The earliest publications on the "new" homeless have focused on the demographic and social characteristics of homeless adults living in large cities, such as New York (Hoffman et al., 1982; Crystal and Goldstein, 1984), Phoenix (Brown et al., 1982, 1983), Portland, Oregon (Multnomah County, Oregon, Depart- ment of Human Services, 1984, 1985), Los Angeles (Robertson et al., 1985; Farr et al., 1986), Chicago (Stevens et al., 1983; Rossi et al., 1986), St. Louis (Morse et al., 1985), Milwaukee (Rosnow et al., 1985), Boston (Bassuk et al., 1984), Philadelphia (Arce et al., 1983), and Baltimore (Fischer and Breakey, 19861. Wider in geographic scope are the studies of the states of Ohio (Roth et al., 1985) and Vermont (Vermont Department of Human Services, 19851. Although the sites at which data were collected often differed shelters, streets, single room occupancy hotels as did the sampling strategy and operational criteria for studying homelessness, the data collected from these different areas showed surprising similarities. Research has also been conducted on subpopulations of homeless people as well as on specialized topics related to homelessness. A

WHO ARE THE HOMELESS? 5 substantial number of reports have focused on the homeless mentally ill and on homeless people who suffer from alcohol abuse. A much smaller body of literature exists on other health-related issues. In fact, it was only 3 years ago that the first book on this issue, Health Care of Homeless People (Brickner et al., 1985), was published; the importance of the issue and the growth in our knowledge are reflected by the fact that the authors already have begun work on the second edition. There is also a growing body of scholarly work on subpopulations, especially homeless families (Bassuk et al., 19861. Studies on the demographic and social characteristics of the homeless in the United States have almost always been based upon research conducted in urban areas. Except for the Ohio and Vermont reports, which included both urban and nonurban areas, very little has been published on the homeless in suburban and rural communities except in newspapers (Washington Post, September 27, 1987; New York Times, October 16, 19871. There is a similar, though less pronounced, paucity of information about certain subpopulations among the contemporary homeless, such as the elderly, youths, individual adult women, the physically disabled, the mentally retarded, and those addicted to illicit drugs. CHARACTERISTICS OF HOMELESS PEOPLE Homeless people are a diverse and varied group in terms of age, ethnicity, family circumstances, and health problems. Moreover, the characteristics of the homeless population differ dramatically from one community to another. Even the recent increase in homeless families is not uniform throughout the country. Although homeless families headed by women are predominant among the homeless throughout the country, there are many more homeless two-parent families in the West and Southwest than in New York and other large eastern cities (U.S. Conference of Mayors, 19871. Every city has homeless adults, but the demographics are not uniform throughout the country. Most cities report that adult homeless men tend to be long-term residents of the city. However, during a site visit to San Diego, committee members were informed by both public officials and advocates for the homeless that San Diego's adult homeless male population was composed largely of young men from the West and Midwest who had come to the Southwest in search of jobs. To make the needs of homeless people more understandable, we describe several subgroups separately: individual adult men and women, families with children, youths, the elderly, and people in rural areas.

6 HOMELESSNESS' HEALTH, AND HUMAN NEEDS Homeless Individual Adults Although families may represent the fastest growing subgroup among the homeless, individual adults still make up the single largest group among the homeless population. The documented characteristics of homeless adult men and women contradict some popular conceptions of what such people are like. The U.S. Conference of Mayors (1987) reported that individual men made up 56 percent of the homeless population and individual women made up 25 percent. (The remainder are adolescents or families with children.) Of the 25 cities in the study, 7 reported recent increases in the numbers of homeless women. In 1963, homeless women represented only 3 percent of the homeless population (Bogue, 19634. Researchers indicate that a high proportion of homeless women suffer from serious problems including chronic mental illness and pregnancy-related problems (Wright, 1987; Wright and Weber, 1987; Wright et al., 19871. In addition, homeless women are frequently victims of physical assault, especially rape (Brickner et al., 19851. Individual homeless men and women have an average age of between 34 and 37 (Morse, 19861; this is significantly lower than those found in previous decades. Homeless women are from 2 to 6 years younger (both mean and median) than homeless men (Multnomah County, Oregon, Department of Human Services, 1984; Robertson et al., 1985; Rossi et al., 19861. Reports from several cities indicate that the sheltered male population is younger still and that homeless women appear to be either very young or elderly. This is important because, unless they are disabled, the age of homeless adults in many parts of the country helps to determine their eligibility for entitlements, especially general assistance and Med . . calc .. Homeless adults are likely never to have been married. Reported levels range from 40 percent in Portland, Oregon (Multnomah County, Oregon, Department of Human Services, 1984) to 64 percent in New York City (Hoffman et al., 1982~. Homeless women are more likely than homeless men to have been married: In the Portland study, only 29 percent of homeless women had never married compared with 44 percent of homeless men. Never-married homeless adults are generally not members of households and often lack strong family ties. The absence of family ties removes the possibility of finding shelter with family members. Minorities are overrepresented among homeless people in the nation's larger cities (TabIe 1-21. This distribution reflects the overrepresentation of minorities in the poorest strata of American society (Morse, 19861. The proportion of homeless people with a high school diploma has increased during the past 25 years. For example, in 1963, only 19 percent

WHO ARE THE HOMELESS? 7 of homeless people in Chicago had completed high school (Bogue, 1963), compared with 35 percent of the general population of Chicago (U.S. Bureau of the Census, 19634. In 1985, 55 percent of the homeless population in that city were high school graduates (Ross) et al., 19861; the comparable figure for the entire population of Chicago was 56 percent, almost identical to that for the homeless population. While there was a greater divergence between the educational level of homeless and general populations in other cities (Roth et al., 1985; Farr et al., 1986), nationally the proportion of homeless adults with high school diplomas is approxi- mately 45 percent. Contrary to the fears expressed by public officials that their city may attract increasing numbers of homeless people if they do more to help, several recent studies indicate that the great majority of homeless people have been long-term residents of the city in which they are sheltered (Table 1-34. This was confirmed during the site visits. It was also reported that when a city did attract transients, it was generally not by virtue of its entitlement programs but, rather, because of a favorable economic climate and the possibility of employment. People working directly with the homeless in various cities reported to the committee that transient persons failing to find employment in one city tended not to stay long and soon moved on in search of jobs. Since the mean age of homeless men is approximately 35, it is not surprising that a large number are Vietnam veterans (Table 1-41. Studies of homeless veterans in Los Angeles (Robertson, 1987) and Boston (Schutt, 1985) indicate that they are older than nonveterans, better educated, and more likely to have been married, factors that normally would indicate greater stability. They also tend to be white, although the percentage of ethnic minorities increases substantially among those who served in Vietnam. As discussed in detail in Chapter 3, psychiatric problems and alcohol and drug abuse are common among homeless veterans. The Los Angeles and Boston studies both reported higher rates of psychiatric hospitalization than among nonveteran homeless people. The Boston study, as well as a study of homeless veterans in San Francisco (Swords to Plowshares, 1986), reported that veterans were more likely to identify substance abuse as a reason for homelessness. The San Francisco study reported that 45 percent suffered from alcohol abuse (19 percent reporting severe alcohol problems) and 23 percent from drug abuse. The most recent statistics on homeless veterans come from the Homeless Chronically Mentally Ill outreach program conducted by the Veterans Administration as mandated by P.L. 100-6 (Rosenheck et al., 19871. The program is targeted specifically to mentally ill homeless veterans (and therefore does not present a valid sample of all homeless

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10 HOMELESSNESS, HEALTH, AND HUMAN NEEDS veterans), but it is both the most recent research on homeless veterans and the most geographically comprehensive. The outreach effort was conducted in 26 states and included Veterans Administration medical centers serving rural, suburban, and urban areas. In its first 4 months of operation (May-September 1987) the program made contact with 6,342 homeless veterans. Of the veterans contacted, 98.6 percent were men; 1.4 percent were women. The average age was 43; 75 percent were either divorced or had never married. Sixty percent were white, 30 percent were black, and 9 percent were Hispanic. In regard to education, 82 percent were high school graduates. Thirty percent had served in combat, and 1.7 percent had been prisoners of war; 9 percent were diagnosed as having combat- related posttraumatic stress disorder. With regard to the time of their military duty, 38 percent were veterans of the Vietnam era, 21 percent served in the post-Vietnam period, and 18 percent served in the period between the Korean and Vietnam conflicts. Only 9 percent served in World War II and 10 percent in Korea. Several authors have reported that between 5 and 10 percent of the homeless are employed full-time and between 10 and 20 percent are employed part-time or episodically (Brown et al., 1982,1983; Multnomah County, Oregon, Department of Human Services, 1984, 1985; Rossi et al., 19864. These people frequently perform unskilled labor; are on the bottom rung of the economic ladder; and often lack job security, health insurance, and the skills necessary to succeed in a high-tech economy. TABLE 1-3 Length of Residency of Homeless Adult Individuals City or State Percent No. of Years Source New York Citya 82 ~5 Crystal et al. (1982) Los Angelesb 74 ~2 Robertson et al. (1985) New York Citya 75 ~5 Hoffman et al. (1982) Chicago 72.3 ~10 Rossi et al. (1986) Milwaukee 71 ~1 Rosnow et al. (1985) Los Angelesa 64.5 ~1 Farr et al. (1986) Ohio 63.5 ~1 Roth et al. (1985) Baltimore 60 ~10 Fischer et al. (1986) Portland 59 ~2 Multnomah County, Oregon (1984) aMen only. bThe 10.5 percent differential between the studies by Robertson et al (1985) and Farr et al. (1986) in Los Angeles can be accounted for based on the populations sampled. Robertson and colleagues sampled the downtown skid row and the Venice Beach/Santa Monica areas; Farr and colleagues sampled only the downtown skid row area.

WHO ARE THE HOMELESS? 1l TABLE 1-4 Homeless Veterans Percentage of Homeless Vietnam-Era Veterans as Men Sampled Who Are Percentage of Homeless City (Source) Veterans Veterans Baltimore 51 35 (Fischer et al., 1986) Boston 37 (Schutt, 1985) Los Angeles 47 33 (Robertson et al., 1985) Los Angeles 33 43 (Farr et al., 1986) Net York City 32 (Crystal et al., 1982) Detroit 36 16 (Solarz and Mowbray, 1985) Many are homeless because their incomes have not kept pace with the dramatic increase in housing costs. The loss of a day or two of pay may make the difference between paying rent and being evicted. Homeless Families As mentioned previously, the fastest growing subgroup among the homeless population consists of families with children. In late 1986, the U.S. Conference of Mayors estimated that such families made up 28 percent of all homeless people in the 25 cities participating in the conference's annual survey of hunger, homelessness, and poverty in America. Most homeless families are headed by women with two or three children (Bassuk et al., 19861. Most of the children are under the age of 5 and are spending their critical developmental years without the stability and security of a permanent home (Towber, 1986a,b; Bassuk and Rubin, 1987; Wright and Weber, 19871. The literature on the characteristics and needs of homeless families is largely anecdotal, although there are a few systematic studies describing the status and unmet needs of homeless families and the health status (Wright and Weber, 1987), emotional problems (Bassuk et al., 1986; Bassuk and Rubin, 1987; Bassuk and Gallagher, in press; Boxill and Beatty, in press), nutritional status (Acker et al., 1987), and problems in education and learning (Bassuk et al., 1986; Bassuk and Rubin, 1987) of

~~ if: 12 HOMELESSNESS, HEALTH, AND HUMAN NEEDS homeless children. To date, the findings are generally descriptive, and there are large regional differences; only a few attempts have been made to generate and test hypotheses about the antecedents, course, and consequences of family homelessness by studying appropriate comparison groups. Despite limitations of the data base, reports of shelter providers, clinicians, agencies, advocates, and policymakers (Simpson et al., 1984; Gallagher, 1986), as well as the committee's site visits to sheltering facilities, tend to support the findings of existing studies. The combined information allows for some generalizations about the characteristics and needs of homeless families. The vast majority of homeless families are headed by women, but the percentages vary by region. In western regions there are more intact homeless families than in eastern regions (Bassuk et al., 1986; Towber, 1986a,b; McChesney, 1986; Dumpson, 19871. Homeless families that include both parents appear to be more common in rural areas than in urban areas (see Appendix C). Because there is a lack of systematic information about the characteristics of intact homeless families, partic- ularly the fathers, the following discussion concentrates primarily on mothers and children. Homeless mothers tend to be in their late 20s (Bassuk et al., 1986; McChesney, 1986; Towber, 1986a,b; Dumpson, 1987), are either single or divorced, and have completed at least several years of~high school (Bassuk et al., 1986; Towber, 1986a,b; Dumpson, 19871. Their ethnic status tends to mirror the ethnic composition of the area where they are living, with minorities overrepresented in the cities and whites predom- inating in suburban and rural areas (Bassuk et al., 19861. The vast majority of homeless families are recipients of Aid to Families with Dependent Children (AFDC). A Massachusetts study indicated that long-term AFDC users (those receiving benefits for longer than 2 years) are overrepresented among homeless families (Bassuk et al., 19864. Researchers have reported that homeless mothers typically are quite isolated and have few, if any, supportive relationships. McChesney (1986) studied the support networks of homeless mothers with at least one child who were living in five Los Angeles County family shelters. She described their slide into homelessness as including ". . . many varied and creative means to shelter themselves and their children" in an effort to stave off homelessness. Most striking was the fact that many families could not call on their own parents, brothers, or sisters as resources. There were three major reasons: "either their parents were dead, their parents and siblings didn't live in the Los Angeles area, or their parents and siblings were estranged" (McChesney, 19861. Bassuk and colleagues (1986), in their study of 80 homeless families living in family shelters in Massachu- setts, also described fragmented support networks. When asked to name

WHO ARE THE HOMELES S ? 13 three persons on whom the mothers could depend during times of stress, 43 percent were unable to name anyone or could name only one person, and almost a quarter named their minor child as their principal source of emotional support (Bassuk et al., 19861. In addition to economic and support system factors, serious health problems may also increase a family's risk of becoming homeless. Many homeless mothers are victims of family violence, which suggests considerable overlap between families residing in family shelters and those residing in battered women's shelters (Ryback and Bassuk, 1986~. Generally, a woman fleeing directly from an abusive mate turns to a battered women's shelter rather than to a family shelter. According to Bassuk et al. (1986), 45 percent of the women they interviewed in Massachusetts family shelters had a history of an abusive relationship with a spouse or mate, but this was generally not the immediate cause of their homelessness. In the only study reporting data about probable child abuse, Bassuk and coworkers found that 22 percent of homeless mothers were currently involved in an investigation or follow-up of child neglect or abuse (Bassuk et al., 1986; Bassuk and Rubin, 19871. Many families had histories of residential instability and moved several times prior to their current shelter stay; most moved within the community where they were sheltered. A majority of families had been doubled up in overcrowded apartments with friends or relatives, while some had previously resided in other shelters or welfare hotels (Bassuk et al., 1986; Towber, 1986a,b). A substantial proportion of homeless families using the sheltering system can be characterized as multiproblem families (Bassuk et al., 19861. These families have chronic economic, educational, vocational, and social problems; have fragmented support networks; and have difficulty accessing the traditional service delivery system; ". . . these families use a disproportionally large amount of social services and . . . traditional techniques of treating them fail or, at best, are only marginally successful . . . " (Kronenfeld et al., 19801. The multiproblem family typically seeks assistance when a crisis occurs, but ceases contact with the agency when the crisis abates (Gallagher, 19861. Studies specifically describing the characteristics and needs of homeless children are quite sparse; studies seeking to provide an estimate of the number of homeless children nationwide are nonexistent. However, the magnitude of the problem can be seen in even the most conservative estimates: If there are approximately 735,000 people homeless on any given night (ICE Inc., 1987), and 25 percent of these people are members of intact families (U.S. Conference of Mayors, 1986), of whom 55 percent are children (Barbanel, 1985), then a minimum of 100,000 children are homeless on any given night of the year. This figure includes only children

14 HOMELESSNESS, HEALTH, AND HUMAN NEEDS of intact families; it does not include runaway, throwaway, or abandoned children on the streets or in institutions. Not surprisingly, researchers have reported erratic school attendance among homeless children. Shelters are frequently located far away from a school, and transportation may be lacking. Preliminary data reported by the Traveler's Aid Program and Child Welfare League (1987) indicate that of 163 families with 331 children in eight cities, only 57 percent of the homeless children attended school regularly. A study of 52 families residing in five New York City welfare hotels reported that, according to parents, 60 percent of their children missed less than 3 days of school per month, 30 percent missed between 4 and 10 days of school per month, and 10 percent missed more than 10 days a month, which is over half of the school days (Columbia University Masters of Public Administration Program, 19851. Homeless Runaway and Throwaway Youths The amount of systematic data describing the characteristics of home- less adolescents is even scantier than those for other homeless subpop- ulations. In addition to its site visits, the committee reviewed three recent studies of runaway and throwaway youths: · the 1985 Greater Boston Adolescent Emergency Network (GBAEN) study (1985) of 84 adolescents using 11 shelters throughout Massachus- setts; · the 1983 study of 118 adolescents in 7 shelters in New York City completed by David Shaffer and Carol L. M. Caton (19841; and · the 1984 study of 149 adolescents in a crisis center in Toronto, conducted by Mark-David Janus and colleagues (1987) and funded by the U.S. Department of Justice. Each study identified running away not so much as an event but as a process; adolescents leave home several times (each successive incident being of longer duration than the previous ones) before actually living on the streets. As Shaffer and Caton (1984) reported, "most adolescents start running away some years before they start to use shelters." With regard to throwaway youths, the Boston study found that 17 percent of subjects who had left home for the first time had been "evicted by their parents" (for the entire population in the Boston study, the proportion evicted, including those with multiple running away incidents, was 12 percent). The fundamental issue in trying to determine the extent of the throwaway youth population is to determine the line between a parent forcing a teenager out of the home and a parent creating a situation so intolerable that the youngster has no option but to leave. To quote

WHO ARE THE HOMELESS? 15 Reverend Leonard A. Schneider, executive director of The Emergency Shelter in New York City: It is just possible that running away may be an indication of a very healthy mind, and depression may be a very natural response to an intolerable situation. (Community Council of Greater New York, 1984) Additional issues regarding the throwaway youth population are dis- cussed in successive chapters: the dynamics of the running away process as it relates to homelessness (Chapter 21; the health problems of runaway youths (Chapter 3~; and the current state of services for this population (Chapter 5~. Homeless Elderly People The percentage of elderly people among the homeless population is less than that among the general population. In all but one recently published study, the elderly made up less than 10 percent of the homeless population (Table 1-5~. The figure of 19.4 percent reported by Rossi et al. (1986) for the homeless in Chicago is the highest, but it is still low compared with the 29.6 percent elderly for that city's domiciled popula- tion. The contrast is even greater in Ohio, where 6.4 percent of the homeless were over age 60, in contrast to 21.7 percent of the population of the state as a whole (Roth et al., 19851. In the skid row area of Los Angeles, 5 percent of the homeless population is over age 61, in comparison with 17 percent domiciled elderly for the entire county (Parr et al., 19861. Nationwide, only 3 percent of the homeless people who presented themselves for care at the Johnson-Pew Health Care for the Homeless projects were over 65, even though 12 percent of the population of the United States is elderly (Wright and Weber, 19871. Three hypotheses have been proposed to explain the small percentages of elderly homeless. The first suggests that on turning 65, many homeless people become eligible for various entitlements (Social Security, Medi- care, senior citizen housing, etc.~. It is possible that such programs generate enough income in benefits, lower housing costs, or both that neoole are able to leave the streets or at least are nreventecl from hec~.omin~ homeless to begin with (Wright and Weber, 19874. The second possibility is that homeless people do not survive to old age, because the realities of a homeless existence are so severely debilitating (Wright and Weber, 1987~. A 1956 study of men living on Chicago's skid row revealed an annual death rate of 70 per 1,000, in contrast to the national death rate for white men of 11 per 1,000 (Bogue, 19631. However, a third explanation for the small percentage of homeless elderly may be related to sampling. The subjects of most studies are self-selected and include residents of

16 HOMELESSNESS, HEALTH, AND HUMAN NEEDS TABLE 1-5 Elderly Homeless People Location (Source) Age (yr) Men Women Both St. Louis 60+ 2.5 (Morse, 1986) Portland 55+ 4 0 (Multnomah County, Oregon, 1985) Los Angeles 61 + 4.8 (Farr et al., 1986) Los Angeles 60+ 6.0 (Robertson et al., 1985) Milwaukee 61 + 6.0 (Rosnow et al., 1985) New York City 60+ 6.0 (Crystal et al., 1982)a Ohio 60 ~ 6.4 (Roth et al., 1985) Portland 60 + 7.0 (Multnomah County, Oregon, 1984) New York City 60+ 7.0 (Hoffman et al., 1982)a Chicago 56 + 8.0 (Stevens et al., 1983) Phoenix 9.0 (Brown et al., 1983) Chicago 55 + 19.4 (Ross) et al., 1986) United States 65 + 3.0 (Wright, 1987) aMen only. shelters, those who appear for medical treatment, people on the streets willing to be interviewed, and the like. The homeless elderly are partic- ularly reluctant to use certain sheltering facilities that they view as dangerous (Coalition for the Homeless/Gray Panthers of New York City, 19841. To quote Joseph Doolin, the director of the Kit Clarke Senior House, which operates the Cardinal Medeiros Day Center for the homeless elderly of Boston, "younger homeless people tend to 'squeeze out' older street people Efrom the shelters]" (Doolin, 1986~. To the extent that the

WHO ARE THE HOMELESS? 17 homeless elderly do not participate in various programs for the homeless, they will be underrepresented in most studies. The Rural Homeless Since its first meeting, the committee has been concerned with the fact that almost all the scholarly literature describes the urban homeless. Only two studies, the statewide study of Ohio, Homelessness in Ohio: A Study of People in Need (Roth et al., 1985), and the statewide study of Vermont, Homelessness in Vermont (Vermont Department of Human Services, 1985), begin to address the physical and mental health problems of homeless people living in rural areas. As a result, the committee com- missioned a special study of this population. Subsequently, the Health Resources and Services Administration of the U.S. Department of Health and Human Services, in cooperation with the committee, funded a more detailed analysis of this issue. This included site visits to rural areas in Alabama, Mississippi, Minnesota, and South Dakota. The results of this joint effort of the Institute of Medicine and the Department of Health and Human Services are included in Appendix C of this report. Briefly, the problems of the rural homeless differ from those of their urban counterparts in several important ways. The rural homeless are far less visible than those in the cities; many live with relatives or others who are part of an extended family network. Some are officially domiciled because they pay a nominal token rent for the use of a shack or other substandard form of housing. However, they are even less likely than their urban counterparts to obtain assistance during times of economic or personal crisis. Rural areas do not have the range of social and financial supports available in most urban areas. Often, homeless people migrate to the cities in search of work; when they fail in that effort, they become a part of the growing numbers of homeless people in the cities. Those who stay in rural areas remain hidden until some event causes them to lose their housing, at which point they can be found living in, for example, cars, abandoned buildings, and woods. Even those communities with previously adequate social service systems are finding it increasingly difficult to serve the growing numbers of homeless people, especially in areas where the decline of agriculture, forestry, and mining is severe. SUMMARY The homeless population is heterogeneous. While there is considerable controversy about the number of homeless people, there is general agreement that the number is becoming greater as each year passes. As the number increases, so do the complexities of the homelessness problem:

18 HOMELESSNESS, HEALTH, AND HUMAN NEEDS Why do people become homeless? Which interventions can be used to prevent or resolve the state of homelessness? What strategies must be developed to address the long-term issues involved with this problem? As has been seen in this chapter, there are several subgroups among the general population of homeless people: individual adults, families with children, adolescents and young adults, the elderly, and people in rural areas. While together they all share one common problem the lack of a stable residence they each have specific needs. As will be seen in the next chapter, the long-established system that has traditionally addressed homelessness now finds itself confronted with a seemingly overwhelming set of problems. REFERENCES Acker, P. J., A. H. Fierman, and B. P. Dreyer. 1987. An assessment of parameters of health care and nutrition in homeless children. American Journal of Diseases of Children 141(4):388. Alliance Housing Council. 1988. Housing and Homelessness. Washington, D.C.: National Alliance to End Homelessness. Arce, A. A., M. Tadlock, and M. J. Vergare. 1983. A psychiatric profile of street people admitted to an emergency shelter. Hospital and Community Psychiatry 34(9):812-817. Barbanel, J. 1985. Judge bars city from using offices to shelter homeless. New York Times, August 28: A-1. Bassuk, E. L., and E. Gallagher. In press. The impact of homelessness on families. Journal of Child and Youth Services. Bassuk, E. L., and L. Rubin. 1987. Homeless children: A neglected population. American Journal of Orthopsychiatry 5(2): l-9. Bassuk, E. L., L. Rubin, and A. S. Lauriat. 1984. Characteristics of sheltered homeless families. American Journal of Public Health 75(9): 1097-1101. Bassuk, E. L., L. Rubin, and A. Lauriat. 1986. Characteristics of sheltered homeless families. American Journal of Public Health 76(September): 1097-1101. Bogue, D. 1963. Skid Row. Chicago: University of Chicago Press. Boxill, N., and A. Beatty. In press. An exploration of mother~hild interaction among homeless women and their children using a public night shelter in Atlanta, Georgia. Journal of Child and Youth Services. Brickner, P. W., L. K. Scharer, B. Conanan, A. Elvy, and M. Savarese, eds. 1985. Health Care of Homeless People. New York: Springer-Verlag. Brown, C. E., R. Paredes, and L. Stark. 1982. The Homeless of Phoenix: A Profile. Phoenix, Ariz.: Phoenix South Community Mental Health Center. Brown, C. E., S. MacFarlane, R. Paredes, and L. Stark. 1983. The Homeless of Phoenix: Who Are They and What Should Be Done? Phoenix, Ariz.: Phoenix South Community Mental Health Center. Clark, A. L. 1985. Health care needs of homeless women in Baltimore. Seminar paper submitted to the faculty of the graduate school of the University of Maryland, College Park, in partial fulfillment of the requirements for the master of science degree. Coalition for the Homeless/Gray Panthers of New York City. 1984. Crowded Out: Homelessness and the Elderly Poor in New York City. New York: Coalition for the Homeless.

WHO ARE THE HOMELESS? 19 Columbia University Masters of Public Administration Program. 1985. Homeless families living in hotels: The provision of publicly supported emergency temporary housing services. Paper prepared for the Human Resources Administration of New York City. New York: Columbia University. Community Council of Greater New York. 1984. Runaway and Homeless Youth in New York City: Findings from Recent Research, R. L. Leavitt, ed. New York: Community Council of Greater New York. Crystal, S. M., and M. Goldstein. 1984. The Homeless in New York City Shelters. New York: Human Resources Administration of the City of New York. Crystal, S. M., M Goldstein, and R. Levitt. 1982. Chronic and Situational Dependency: Long-Term Residents in a Shelter for Men. New York: Human Resources Adminis- tration of the City of New York. Doolin, J. 1986. Planning for the special needs of the elderly homeless. The Gerontologist 26(3):229-231. Dumpson, J. R. 1987. A Shelter Is Not a Home. Report of the Manhattan Borough President's Task Force on Housing for Homeless Families. New York: Manhattan Borough President's Task Force on Housing for Homeless Families. Farr, R. K., P. Koegel, and A. Burnam. 1986. A Study of Homelessness and Mental Illness in the Skid Row Area of Los Angeles. Los Angeles: Los Angeles County Department of Mental Health. Fischer, P. J., and W. R. Breakey. 1986. Characteristics of the Homeless with Alcohol Problems in Baltimore: Some Preliminary Results. Baltimore: Department of Health Policy and Management, School of Hygiene and Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins Univer- sity. Fischer, P. J., W. R. Breakey, S. Shapiro, J. C. Anthony, and M. Kramer. 1986. Mental health and social characteristics of the homeless: A survey of mission users. American Journal of Public Health 76(5):519-524. Freeman, R. B., and B. Hall. 1986. Permanent Homelessness in America? Working paper no. 2013. Cambridge, Mass.: National Bureau of Economic Research. Gallagher, E. 1986. No Place Like Home: A Report on the Tragedy of Homeless Children and Their Families in Massachusetts. Boston: Massachusetts Committee for Children and Youth, Inc. Greater Boston Adolescent Emergency Network. 1985. Ride a Painted Pony on a Spinning Wheel Ride. Boston: Massachusetts Committee for Children and Youth, Inc. Hoffman, S. F., D. Wenger, J. Nigro, and R. Rosenfeld. 1982. Who Are the Homeless? A Study of Randomly Selected Men Who Use the New York City Shelters. Albany: New York State Office of Mental Health. Hombs, M. E., and M. Snyder. 1982. Homelessness in America: Forced March to Nowhere. Washington, D.C.: Community for Creative Non-Violence. Janus, M.-D., A. McCormack, A. W. Burgess, and C. Hartman. 1987. Adolescent Runaways: Causes and Consequences. Lexington, Mass.: D. C. Heath, Lexington Books. Kronenfeld, D., M. Phillips, and V. Middleton-Jeter. 1980. The forgotten ones: Treatment of single parent multi-problem families in a residential setting. Prepared under Grant no. 18-P-90705/03. Washington, D.C.: U.S. Department of Health and Human Services, Office of Human Development Services. McChesney, K. Y. 1986. New findings on homeless families. Family Professional 1(2). Morse, G. A. 1986. A Contemporary Assessment of Urban Homelessness: Implications for Social Change. St. Louis: Center for Metropolitan Studies, University of Missouri-St. Louis.

20 HOMELESSN ESS, HEALTH, AND HUMAN NEEDS Morse, G. A., N. M. Shields, C. R. Hanneke, R. J. Calsyn, G. K. Burger, and B. Nelson. 1985. Homeless People in St. Louis: A Mental Health Program Evaluation, Field Study and Followup Investigation. Jefferson City, Mo.: State Department of Mental Health. Mowbray, C. V., S. Johnson, A. Solarz, and C. J. Combs. 1985. Mental Health and Homelessness in Detroit: A Research Study. Lansing: Michigan Department of Mental Health. Multnomah County, Oregon, Department of Human Services. 1984. The Homeless Poor. Multnomah County, Oreg.: Social Services Division, Department of Human Services. Multnomah County, Oregon, Department of Human Services. 1985. Homeless Women. Multnomah County, Oreg.: Social Services Division, Department of Human Services. New York Times. October 16, 1987. New Reagan policy to cut benefits for the aged blind and disabled. Al. Robertson, M. J. 1987. Homeless veterans: An emerging problem. Pp. 64-81 in The Homeless in Contemporary Society, R. D. gingham, R. E. Green, and S. B. White, eds. Newberry, Calif.: Sage Publications. Robertson, M. J., R. H. Ropers, and R. Boyer. 1985. The Homeless of Los Angeles County: An Empirical Evaluation. Basic Shelter Research Program, Document no. 4. Los Angeles: Psychiatric Epidemiology Program, School of Public Health, University of California, Los Angeles. Rosenheck, R., P. Gallup, C. Leda, P. Leaf, R. Milstein, I. Voynick, P. Errera, L. Lehman, G. Koerber, and R. Murphy. 1987. Progress Report on the Veterans Administration Program for Homeless Chronically Mentally Ill Veterans. Washington, D.C.: Veterans Administration. Rosnow, M. J., T. Shaw, and C. S. Concord. 1985. Listening to the Homeless: A Study of Homeless Mentally Ill Persons in Milwaukee. Prepared by Human Services Triangle, Inc. Madison: Wisconsin Office of Mental Health. Rossi, P. H., G. A. Fisher, and G. Willis. 1986. The Condition of the Homeless in Chicago. A report prepared by the Social and Demographic Research Institute, University of Massachusetts at Amherst, and the National Opinion Research Center, University of Chicago. Roth, D., G. J. Bean, Jr., N. Lust, and T. Saveanu. 1985. Homelessness in Ohio: A Study of People in Need. Columbus: Office of Program Evaluation and Research, Ohio Department of Mental Health. Ryback, R., and E. L. Bassuk. 1986. Homeless Battered Women and Their Shelter Network. Pp. 55-61 in The Mental Health Needs of Homeless Persons, E. L. Bassuk, ed. San Francisco: Jossey-Bass. Schutt, R. K. 1985. Boston's Homeless: Their Backgrounds, Problems, and Needs. Boston: University of Massachusetts. Shaffer, D., and C. L. M. Caton. 1984. Runaway and Homeless Youth in New York City: A Report to the Ittleson Foundation. New York: The Ittleson Foundation. Simpson, J. H., M. Kilduff, and C. D. Blewett. 1984. Struggling to Survive in a Welfare Hotel. New York: New York City Department for Services to Families and Individuals Solarz, A., and C. Mowbray. 1985. An examination of physical and mental health problems of the homeless. Paper presented at the annual meeting of the American Public Health Association, Washington, D.C. Stevens, A. O., L. Brown, P. Colson, and K. Singer. 1983. When You Don't Have Anything: A Street Survey of Homeless People in Chicago. Chicago: Chicago Coalition for the Homeless. Swords to Piowshares. 1986. Transitional Housing Program for Veterans: A Proposal. San Francisco: Swords to Plowshares. Towber, R. I. 1986a. A One-Day `'Snapshot" of Homeless Families at the Forbell Street

WHO ARE THE HOMELESS? 21 Shelter and Martinique Hotel. New York: Human Resources Administration of the City of New York. Towber, R. I. 1986b. Characteristics and Housing Histories of Families Seeking Shelter from HRA. New York: Human Resources Administration of the City of New York. Traveler's Aid Program and Child Welfare League. 1987. Study of Homeless Children and Families: Preliminary Findings. Conducted by P. L. Maza and J. A. Hall. Tucker, W. 1987. Where do the homeless come from? National Review 39(18):32. U.S. Bureau of the Census. 1963. 1960 Census of Population. Volume One: Characteristics of the Population, Chapter B: General Population Charactersitics; Part XV: Illinois. Washington, D.C.: U.S. Government Printing Office. U.S. Bureau of the Census. 1980. 1980 Census of Population. Volume One: Characteristics of the Population, Chapter B: General Population Characteristics; Table 15, Persons by Race. Washington, D.C.: U.S. Government Printing Office. U.S. Conference of Mayors. 1986. The Continued Growth of Hunger, Homelessness and Poverty in America's Cities: 1986. A 25-City Survey. Washington, D.C.: U.S. Conference of Mayors. U.S. Conference of Mayors. 1987. Status Report on Homeless Families in America's Cities: A 29-City Survey. Washington, D.C.: U.S. Conference of Mayors. U.S. Congress, House. 1987. Stewart B. McKinney Homeless Assistance Act, Conference Report to accompany H.R. 558. 100th Cong., 1st sess. U.S. Department of Housing and Urban Development. 1984. A Report to the Secretary on the Homeless and Emergency Shelters. Washington, D.C.: U.S. Department of Housing and Urban Development. Vermont Department of Human Services. 1985. Homelessness in Vermont. Montpelier: Vermont Department of Human Services. Washington Post. September 27, 1987. Homeless in the suburbs: They are different from the street people. D8. Wright, J. D. 1987. Special Topics in the Health Status of America's Homeless. Special report prepared for the Institute of Medicine by the Social and Demographic Research Institute, University of Massachusetts, Amherst. Wright, J. D., and E. Weber. 1987. Homelessness and Health. New York: McGraw-Hill. Wright, J. D., E. Weber-Burdin, J. W. Knight, and J. A. Lam. 1987. The National Health Care for the Homeless Program: The First Year. Report prepared by the Social and Demographic Research Institute, University of Massachusetts, Amherst.