by David Pearson, CEO, Australian Alliance to End Homelessness, Shannen Vallesi, Research Associate, School of Population and Global Health, University of Western Australia and Lisa Wood, Associate Professor, School of Population and Global Health, University of Western Australia.
This article was originally published in Parity magazine. Learn more about Parity magazine including how to access full editions.
Dying and Homelessness
You can’t change what you don’t measure — so goes the saying. We frequently measure metrics such as the unemployment rate and road fatalities, which in turn, are used to drive government policy and budget decisions. However, there remains a vast gap in our knowledge base about dying homeless in Australia. And without concrete evidence, how can you drive and measure change?
Life expectancy and causes of death are fundamental indicators of health and health equity, and such metrics have been widely used to galvanise efforts to improve health outcomes for many different groups.1 The enumeration of the life expectancy gap for Aboriginal and Torres Strait Islander people in Australia has for example made us accountable as a nation for ‘closing the gap’, with annual report cards tracking progress (or not) on this.
Disparities in mortality for other population groups are also reported on nationally, such the differences in average median age of death between metropolitan, regional and remote areas in Australia, and life expectancy differences associated with socioeconomic status. Currently however, we do not measure mortality rates, life expectancy, causes of death, or indeed any deaths data for people experiencing homelessness in Australia. But we do know from international evidence, that experiencing homelessness can reduce life expectancy by approximately 30 years. Moreover, in a recent United Kingdom (UK) study of homeless deaths, one in three deaths were attributable to conditions that could have been prevented or treated.
If we are to make significant improvements in this area, we must measure and report publicly what is a frequent but hidden occurrence in our communities — that people are literally dying without a safe place to call home. To be clear, whilst people don’t literally die of homelessness, they are dying while experiencing homelessness and from the associated complications of homelessness, including the erosion of both health and hope.
The Reasons to Count Deaths Are Clear
While the reasons are not limited to the four below, they are particularly salient to this special issue of Parity on preventing homeless deaths in Australia:
We need know the extent of a problem to inform how best to address it. There is Australian data on life expectancy gaps and mortality rates by socioeconomic quintile, geography and between Indigenous and non-Indigenous Australians, but there is currently no Australian data on mortality and homelessness. By contrast, the UK’s Office of National Statistics has reported annually on homeless deaths since 2018 (with data back to 2013) and recorded 778 deaths of people who were homeless recorded in 2019 for England and Wales, with their most recent data indicating a mean age at death of 45.9 years for males and 43.4 years for females.
Health for all Australians has to mean health for ALL. The hope of living a long and healthy life is not equally distributed in this country but a recent Medical Journal of Australia editorial argues that health for all Australians by the year 2030 is within our grasp if we act now. Robust data on homeless deaths (including preventable deaths), is needed to measure what progress (if any) is being made to ensure that people experiencing homeless are not further left behind on health inequality measures.
Many homeless deaths are shown to be preventable in international data, but we have no equivalent Australian metrics. Australia’s successes in public health are often couched in terms of reducing preventable mortality (such as deaths from tobacco use, infectious diseases, road accidents), but we have no baseline or robust national data on preventable homeless deaths. The UK finding that one third of homeless deaths are preventable is a conservative estimate, and not necessarily generalisable to the Australian context. Not all deaths among people experiencing homelessness are preventable, but many will be, and we need data on this to guide interventions and track progress.
COVID: we are not safe until we are all safe. So goes the Commonwealth Government’s vaccine advertising campaign, but this is equally true with regard to preventing all deaths in Australia, including those among people experiencing homelessness. Despite this population having high rates of comorbidities that are known COVID-19 risk factors. the Federal Government silence on vaccine roll-out for this vulnerable group, sadly echoes the wider silence on preventable homeless deaths more broadly.
Estimating Homeless Deaths in Australia
Homelessness has deadly consequences — to demonstrate this more clearly and galvanise action, Australia needs to follow the lead of the UK and others and start enumerating the number of deaths among people experiencing homelessness. There are obviously challenges to doing this, but it can be done. And something is better than nothing, otherwise homeless deaths and the imperative to prevent them, remains invisible to governments and decision makers.
Counting known deaths in a capital city is a good start, and this is what has been happening in Western Australia. Since 2017, the University of Western Australia Home2Health team have been documenting deaths among the Perth homeless population that have been recorded by health services the team works with as part of an ongoing homelessness and health longitudinal study. During 2020, there were 56 deaths known deaths among people experiencing homelessness in Perth. This is equivalent to 1.1 deaths every week in the Perth homeless population alone. The average age of death was 47 years among these 56 individuals; tragically, not one of these people reached anywhere near Australia’s current life expectancy of 83 years. This is a sobering counter to the overall progress that Australia has made in increasing longevity. Whilst this data from WA is not comprehensive and includes only deaths the team has confirmed notification of and does not include outer areas of Perth nor regional or remote WA, it is — as far as we are aware — the best and most recent we have in the country. To that end we have used these figures to give us a sense of what the national problem looks like, invoking the principle that something is better than nothing, and a starting point:
With best available data, we have estimated that around 424 people died whilst experiencing homelessness last year. (2020)
This estimate has been calculated using the actual figures from WA and extrapolated using the national 2016 Census Data on homelessness, which is unfortunately years out of date, but the best available until the forthcoming census data has been collected and released. This national estimate of homeless deaths has been calculated to raise awareness of the unknown number of people who die while sleeping rough or with a long-term experience of sleeping rough in Australia, not to be a rigorous and scientifically enumeration exercise. To put this 424-annual figure into context, this is just shy of half the number of people that have ever died of COVID-19 in Australia as at June 2021.
So what is needed to get actual figures for the whole country? Both government action and community action.
Government action
1 / Action on data
For a consistent national approach, we propose that the Commonwealth Government take a leadership role and commission the Australian Institute of Health and Welfare (AIHW), to develop a national homelessness deaths and life expectancy gap reporting framework. Such a framework should:
set out how we can improve data capture
drive more accurate measures of homelessness in hospital and coronial administrative data
articulate the number of deaths among people experiencing homelessness (all types of homelessness), the age of death, and cause of death (direct and indirect) at both the local, state/ territory and national level
seek to report such data in as close to real-time as possible.
The development of such a framework should also support the data capture efforts of the homeless sector and others in establishing by-name lists through the Advance to Zero Campaign — which seeks to identify everyone sleeping rough by-name in a community as a first step towards preventing and ending homelessness in that community.
Deaths data are a vital measure of a population’s health… Examining death patterns can help explain differences and changes in health status, evaluate health strategies, and guide planning and policy-making
AIHW, Deaths in Australia, June 2021
2 / Action on housing
Despite growing Housing First traction in Australia, whereby individuals are rapidly housed and then connected with support to address underlying problems, there are many impediments to this in reality. The biggest of these is the dire shortage of social housing and long waitlists for this across the country. The longer people are homeless, the more their health deteriorates, as grimly illustrated in the Adelaide example below.
Analysis of the Adelaide Zero Project’s By-Name List data revealed in 2020 that Aboriginal people from remote communities all over Australia had been sleeping rough in the Adelaide City Park Lands. Reasons for coming into the city varied, including for health needs (such as coming for medical appointments), kinship and cultural reasons, accommodation difficulties (such as liquor licensing rules) and our lack of appropriate responses to trauma and grief in the community.
A recent research report found that to date responses have insufficiently met the needs of this group of people and as a result 15 chronic rough sleeping Aboriginal people slowly passed away in the parklands, despite collectively having had over 800 interactions with the housing department.
Community action
Whilst we are waiting for the preceding government action to recognise and prevent homeless deaths, all of us concerned with homelessness in Australia can play a role in bringing into the light what for too long has been ‘unseen’. Things that we think will help include:
More communities committing to keeping track of exactly how many people are homelessness in their community through the use of real-time by-name-list data (and including in that the deaths data).
Though the newly established Australian Health, Housing and Homelessness Network collaborating, sharing, and coordinating efforts to bring the health and homelessness sectors together to support efforts to enumerate homelessness deaths and other interrelated issues.
Continued advocacy and awareness raising. In SA and NSW for example, annual memorial services have been held for those who have lost their lives whilst experiencing homelessness. Elsewhere some homeless services have plaques commemorating homeless clients who have passed away. While homeless death statistics are important, so too is reminding society about the human face of lives lost prematurely.
Imagine for a moment a plane crashing killing 424 people and the government admitting they didn’t know what caused the crash and not investigating it. Or imagine a terrorist attack that killed 424 people in Australia. A vivid imagination is not required to recognise that the reaction of governments would be swift.
It is a national emergency when at least 424 Australians are dying without a place to call home every year — and this must change.
We need to remind all governments, but particularly the Commonwealth Government that keeping people safe is one of the most fundamental and basic responsibilities of government. If they can afford to allocate funding for our defense budget as a proportion of Gross Domestic Product — then why should the homelessness sector have to continue to run fundraisers and virtually beg for donations to provide the most basic of services to some of our community’s most vulnerable people. This inequity has to change. If it does not, we will be having this same conversation in a few more years’ time about how tragic it is that people die homeless, but with little demonstrable change to show for it.
Ultimately, until something is counted, it is hard for it to truly ‘count’ and whilst Governments could fix this quickly, if they truly wanted to, there is much that we all can and should do right now to bring about the change that too many are dying for.
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