Introduction

Homelessness is a widespread issue affecting individuals and communities across North America. In the United States of America alone, over half a million individuals are unhoused each night (Mosites et al., 2022). The debate over proposed solutions to homelessness has recently become highly visible to me as this issue has risen to the forefront of city council meetings in my hometown of Bend, Oregon. I was able to discuss issues around homelessness, such as public health and safety concerns, with city officials who expressed the immense difficulty and complexity of finding solutions to this issue that are both effective and agreeable. Unfortunately, due to Bend being a relatively small community, there is no significant research on methods of addressing homelessness in the town and its surrounding areas. However, there are anecdotes such as this in towns big and small across North America, asserting the stark reality of the current homelessness crisis. In this article, I would like to address homelessness from a public health perspective, providing insight into potential causes, adverse effects on health, and proposed ways forward. To make lasting progress in combating this crisis, homelessness must be addressed through a comprehensive approach led by a multi-disciplinary group of leaders from public health, policy, and humanitarian organizations. With each field contributing their experiences and expertise it would be possible to work towards a conclusive, successful effort to confront homelessness.

Potential Causes and Risk Factors

Potential causes of homelessness in North America are innumerable, as such a broad issue affects countless individuals across the continent, however, trends have been identified relating to determinants of homelessness. Often, these broad determinants can be found in flaws in public infrastructure, such as high unemployment rates or a lack of affordable housing (Allegrante & Sleet, 2021). Community resources such as access to education, public transportation, and affordable health care also play a role in determining which communities and individuals are more susceptible to homelessness (Allegrante & Sleet, 2021). Additionally, it is important to note that racial inequities and discrimination can exacerbate the prevalence of homelessness among minority groups who are overrepresented among unhoused individuals (Mosites et al., 2022). One in twenty non-Hispanic white individuals report experiencing homelessness in their lifetime as compared with one in twelve Hispanic individuals and a striking one in six non-Hispanic Black individuals (Fusaro et al., 2018). The disparity in rates of homelessness between Black and white individuals remained significant despite data adjustments to account for variables such as education and veteran status (Fusaro et al., 2018). Veterans are also statistically at higher risk of becoming unhoused (Donovan & Shinseki, 2013). In the United States, Veterans have a higher risk of experiencing PTSD, unemployment, and substance abuse which contributes to their likelihood of becoming homeless (Donovan & Shinseki, 2013). Specifically, “among US veterans who were diagnosed with opioid use disorder in 2012, 35% were experiencing homelessness,” (Mosites et al., 2022). These potential causes and risk factors will inform an improved understanding of the effects of homelessness with regard to public health and proposed solutions to this crisis.

Adverse Effects

In examining the epidemic of homelessness from a public health perspective, I found it generally unsurprising to discover the extreme health risks associated with being unhoused. For example, unhoused individuals are reported to have increased rates of invasive cancers with significantly lower survival rates compared to housed individuals (Mosites et al., 2022). Additionally, those experiencing homelessness report higher rates of cardiovascular disease, human immunodeficiency virus (HIV), and infectious diseases such as COVID-19 and group A Streptococcus (Mosites et al., 2022). Substance abuse is also a disease that unhoused people are statistically associated with in higher numbers than housed populations, “homeless persons experience high rates of health problems such as […] alcohol and drug addiction” (Francescutti & Sleet, 2021). The reality of the severe risk of potentially life-threatening health issues experienced at high rates by unhoused individuals, in comparison to housed people, points to a significant need for a public health-led response to the crisis of homelessness in North America.

Proposed Solutions

A myriad of solutions has been proposed to confront the issue of homelessness from a public health perspective. One such proposal calls on the Housing First Model in its most simplistic form, by advocating for the provision of a minimum of temporary housing before addressing any other aspects of experiencing homelessness (Francescutti & Sleet, 2021). The Housing First Model is founded on the premise that housing is a universal human right as established by the United Nations in 1991 (Elder & King, 2019). Housing is a critical determinant of any individual’s health, so it is understandable for housing to be addressed urgently in any approach to the current homelessness crisis. Past implementations of the Housing First Model at the federal level in the United States resulted in more than 80% of individuals remaining housed a year after assistance (Thompson, 2013). The Housing First Model addresses the adverse effects of homelessness by providing shelter alongside services that support housing stability, healthcare access, and employment (Donovan & Shinseki, 2013). It is important to note, however, that there are potential barriers to proper implementation of the Housing First Model. Particularly resource limitations such as poor access to housing and inadequate program staffing (Thompson, 2023). By confronting additional aspects of homelessness outside of a need for shelter such as health risks, income, and quality of life, the Housing First Model can effectively engage with homeless and unhoused individuals.

A comprehensive effort to alleviate rates of homelessness while supporting the unhoused is offered in the article “Public Health and Homelessness: A Framework”, in which a layered approach to the crisis of homelessness is offered (Mosites et al., 2022). More specifically, the authors, whose associations with the Centers for Disease Control and Prevention (CDC) demonstrate their expertise, propose first expanding healthcare access and disease prevention for the unhoused through the implementation of pop-up clinics, vaccination efforts, and handwashing stations among other suggestions (Mosites et al., 2022). Due to the recency of this framework, there is not yet data to inform the success of the proposed approach. This focus on health is echoed in the article “Homelessness is a Public Health Issue”, in which the authors advocate for the implementation of the Housing First Model in a way that would provide “access to health care, employment, and other supportive services that promote long-term housing stability, reduce recidivism, and improve quality of life” (Donovan & Shinseki, 2013). More comprehensive ways of addressing homelessness are compelling in that they look at the whole experience of homelessness to best support unhoused individuals.

An additional key aspect of any complete effort to address homelessness is an emphasis on future stability. The United States federal strategy, Home Together, is focused on economic security as a way of obtaining and maintaining stable housing (Elder & King, 2019). The Home Together program works to increase financial independence and allow unhoused individuals to become self-sufficient by advocating for the incorporation of these interventions alongside efforts to provide healthcare and housing (Elder & King, 2019). This need to account for future financial independence and stability is echoed by authors Donovan and Shinseki who also advocate for efforts toward long-term stability to improve quality of life for unhoused individuals (2013). According to Elder and King, living in temporary housing is associated with exacerbated health difficulties (2019). In keeping with the literature, I firmly believe that promoting the long-term success of unhoused individuals is critical. Simply providing temporary housing or health care services will not succeed in ensuring stable futures with a lessened risk of once again becoming unhoused.

Of course, many programs have already been implemented to address homelessness. In the United States specifically, housing subsidies and the National Housing Trust Fund, which was established by Congress following the recession of 2008 with the goal of providing safe and affordable housing, are just two examples of such efforts (Elder & King, 2019). It cannot be denied that efforts already made to combat homelessness have not been entirely unsuccessful, “the United States reduced homelessness by 13% between 2010 and 2018,” (Elder & King, 2019). However, the fact remains that rates of homelessness have begun to increase, resulting in staggering statistics such as, “On a single night in January 2020, 580,466 people (about 18 out of every 10,000 people) experienced homelessness across the United States—a 2.2% increase from 2019” (Francescutti & Sleet, 2021). Despite some success emanating from program implementations over the last decade, current rates of homelessness along with the risk of adverse health effects suggest the need for a comprehensive effort to support the unhoused and decrease overall rates of homelessness.

Concluding Thoughts

If we as communities believe that there is an obligation to care for community members experiencing homelessness, then it is critical for comprehensive solutions to be considered and implemented effectively. There can be no debate that homelessness is a growing crisis across North America. After reviewing several proposed solutions to homelessness from a public health perspective, the literature points to a multi-faceted approach, aimed at completely addressing the wellness of the unhoused while also targeting root causes of homelessness, as being the best way to move forward. With the participation of multi-disciplinary leaders from public health, policy, and humanitarian organizations, significant progress could be made towards combating the homelessness crisis in a complete and compassionate way.