Every Grain of Sand: Preventing Homelessness Deaths (2021)

Dr Mark Furlong, Preventing Homelessness Deaths Project Worker

This article was originally published in the August 2021 edition of Parity magazine. Learn more about Parity including how to access full editions.

Introduction

Homelessness reduces life expectancy to around 50 years and multiplies the risk of early death between three and seven times. (1) More recent research has refined these general figures by discerning that nearly a third of the premature deaths that occur are preventable. Why? These deaths are the result of illnesses that are amenable to treatment. (2) That homelessness is this dangerous should provoke a compelling call to action. In this country, no such action is being considered.

Before action will occur, two conditions must be fulfilled. First, homelessness must be recognised as a threat to health (just as smoking and asbestos came to be). Second, effective responses to this problem need to be identified. This understanding stimulated The Council for Homeless Persons (CHP) to initiate a project:

• to investigate why premature death is not recognised as major health problem, and
• to identify responses that will minimise premature death amongst those experiencing homelessness.

This project was sponsored by The Salvation Army, Micah Projects Queensland, Jesuit Social Services, Sacred Heart Mission, Wintringham and Bolton Clarke. Two outputs were planned: a full report, and an abridged report – a summary – for this, the August 2021 edition of Parity.

An earlier CHP study – the 2019, The Last Mile of the Way of the Way (3) – was the foundation for the current project. This earlier study reported on what is known, and what remains unknown, about the relationship between homelessness and premature death in Australia. Simply put, it was found that we know very little about the metrics of the relationship between homelessness and premature death. We do not even know how many deaths each year can be attributed to homelessness. While it is said that statistics do not lie, the absence of clear and exact figures create a context for misrepresentation and misunderstanding of the issues.

First-hand reports, like the patchy research that is available in Australia, align with the findings of international studies. Everything points to the certainty that a great deal of premature mortality occurs in Australia. Why? Where ever the trouble is taken to count deaths – in the United Kingdom (UK); the United States (US); Scandinavia – similar results are reported. Although not adequately reported, these deaths are happening here too. That there is such an absence of attention prompts a question: what is the opposite of a high-priority population group? A group whose members are so invisible that the untimely death of many passes without notice.

Design

In seeking to investigate the above, it is clear that multiple domains are in-play: the material; the medical, the statistical; the legal; and so forth. For this reason, a ‘mixed method approach’ was chosen. (4) This design integrated elements from five research traditions:

(i) Ethnography: fieldwork was undertaken to map the procedures, the flows of people and data, and the key intersections that provide the pathways for people and data. The intention was to plot not only formal practices, but also the conceptual practices that operate in, and around, homelessness. 

(ii) Action research: The work of the project was not neutral. Grounded on the findings of the 2019 report, the current project set out to make a difference. (5)

(iii) Qualitative surveys: the project sought to identify the views of those with (a) lived experience, and (b) professional experience. The intention was to survey. (6) Sampling was designed to be ‘purposive’ for both groups.

(iv) Discourse analysis: As the project progressed we became convinced that discourse analysis (7) was a useful analytic for interrogating terms and phrases that acted as ‘switch-points’, (8) that is, that a death was ‘reportable, due to ‘natural causes’, etc.

 (v) A literature search. The current project was designed to ‘bank’ on the substantial body of literature surveyed in the 2019 project. Further searching was limited to (a) material published since 2019, and (b) what had a relevance to the aim of the current project: what concerned reducing premature mortality.

A fuller account of the above is presented in the full report.  

Limitations

The study was modest in resourcing and brief in duration. Sampling for the consultations was not intended to be representative, but a fundamental omission is readily acknowledged: no consultations were able to be undertaken with First Nations representatives. Given that the nature of the project – premature mortality for those who experience homelessness – is highly meaningful to, and also profoundly traumatic for, First Nations’ peoples. However, it was not possible to develop the kind of respectful, co-designed process that is required to host meaningful discussions on such a sensitive topic within the very constrained period within which the project had to operate. That this omission occurred impoverished the project and is deeply regretted. 

Other gaps also need to be acknowledged: there were no consultations undertaken with school-based practitioners, those who could speak on behalf of the LGBTI+ community, those who have been released from prison, those having histories leaving care or have a background as refugees and/or asylum seekers.

Consultations

The intention of the project’s consultations was to access the views and experiences of those with lived experience as well as a range of practitioners, managers and researchers.

Representatives of Those Who Have Lived Experience

The project was committed to honouring personal experience as a significant form of knowledge. This being clear, the focus of the project – the relationship between homelessness and premature mortality – presented an especially troubling subject, that is, the 2019, The Last Mile of the Way report documented that ‘Feared or directly encountered, death is an unwanted companion for many experiencing homelessness’. (9)

Being aware that discussions might be troubling, representatives were made clear that the aim was not to ‘dig deep’, but to hear from them about what might reduce premature mortality.

Prior to the consultation a ‘prep sheet’ was circulated. As well as cautionary points, this document signalled that attention would be given to three topic areas:

• Everybody seems to agree that homelessness is dangerous. What do you think?
• Accessing health care, and
• What can be done to reduce mortality?

The full report sets out material concerning the first two headings and also documents material that emerged around two unsolicited themes: ‘Consumers often disguise their homelessness’ and ‘Stigma and despair.’ For current purposes, only the material concerning ‘What can be done to reduce mortality? is reproduced.

• ‘We need more community housing, more social housing, but just more (housing) won’t be enough on its own’
• ‘Some kind of hub. A place where there are docs, and mental health people. Nurses. Where everything is like 24/7.’;
• ‘Having some kind of (non-hospital) place, somewhere where they know you. That would be great, it would make a difference’;
• ‘Dental care. That’s really big. Homelessness wrecks your teeth. You can’t move on, get normal – whatever you want to call it – when your teeth are s***.
• ‘You lose your bag, get robbed, whatever, (then) and you’ve lost your script (for pain medication). Unless you have a regular doctor, someone who understands your situation, you’re screwed.’
• ‘more outreach nurses’
• ‘It’s about the (intersecting) system too … (about) who talks to who, and who doesn’t. It’s all got to fit together’
• ‘storerooms for blankets and pillows’; ‘somewhere to keep medication’
• ‘Why do we accept homelessness? This collective irresponsibility has to stop.’

The above first-person data speaks for itself.

Consultations with Practitioners

A semi-structured interview schedule was developed for the twenty-seven practitioner consultations that were undertaken. The full report sets out material relating to eight themes. Due to length constraints, what follows is restricted to a summary of responses to ‘What is the impact of homelessness? and ‘What can be done to reduce mortality?

The Impact of Homelessness

Similar views were reported concerning the effects of homelessness. A comment offered by one consultee sums-up this position: ‘It (homelessness) is definitely not a part-time problem … it completely wraps people up. Like being in a total war.’ With some variation in emphasis, all consultees spoke of the following:

• shame and stigma
• the sense of hopelessness, of chronic timelessness, and
• the unstable, and very stressful, dynamic between chaos, danger and boredom.

A point commonly repeated was that those who have been homeless for an extended period tended to become increasingly unwell and to exhibit a fatalistic ‘what’s the point?’ disposition. Many consultees linked this despairing ‘I’ve lost hope’ sentiment to their clients reporting that they feel abandoned. This ‘I’ve lost touch with my kids (and-or siblings/ parents/ friends)’ status was said to involve conflictual feelings of loss and hurt, resentment and guilt.

All but one of those interviewed rejected the idea that suicide was always the product of mental illness. Self-harm, it was thought, was on a continuum. As one person put it ‘A person does not need to slash-up or OD to do themselves some damage. You can do that (self-harm) in slow-motion.’

What would help reduce early mortality?

Although there was a difference in emphasis between those from community/specialist homelessness roles and those in health services, there was agreement that the precondition for ‘really’ solving the problem of early mortality is the availability of appropriate housing: ‘depending on the person, it might be a (simple) independent living unit (that is needed), but somebody else might need housing plus intensive support. And there are heaps where it is in the middle of these two (extremes).’ Accommodation options that are disability-sensitive, gender-sensitive and culturally appropriate for First Nations’ people were also understood to be essential.

Two other points of consensus were:

(i) come-to-us, appointment-based health services are inappropriate

(ii) bridging options – there was agreement that forms of respite care, and step-up/step-down care options were needed.

Summary

There was a great deal of agreement between the two groups about what would make a difference. There was also a clear alignment concerning the effect of homelessness – that in and of, itself, being homeless is harmful – and that shame, stigma and despair are associated with being homeless.

Findings

Data from the above lived-experience and practitioner accounts was complemented by a consideration of published material and the results of the project’s field work. Set out below is a summary of the results of the review of the academic and grey literature, and the data that was obtained by ethnographic and discursive investigation.

The effects of, and the extent to which, homelessness is under-reported.

The residential status ‘homeless’ tends to be under-reported in official records. That is, there is a system-wide pattern of inaccurate data entry. This error has effects at multiple levels.

Firstly, if someone is homeless, and this is not identified by the relevant professionals, this will tend to compromise the effectiveness of their intervention. A stark generalisation holds if homelessness is not identified or disclosed – prospects of effective intervention darken.

Many examples can be cited, but the following is perhaps emblematic of the scenario where homeless status is not identified or disclosed: ‘keep the wound clean, regularly change the dressings, and make sure you stay off your feet for the next week.’ 

The non-reporting of homelessness has effects beyond compromising the outcome of the care that is provided to individuals. In so much as homelessness is under-reported at a case level, hospital (and other recording systems) underestimate the scale of the category ‘homeless’ in their data sets. Based on a systemic error – the count is always an under-estimate and the organisation’s data compilations as a result, misrepresent the reality. What is the magnitude of the error? In a carefully conducted study of those attending an inner Melbourne Emergency Department it was found that hospital records incorrectly registered almost 90% of those who should have had ‘homeless’ entered as the correct residential data point. (10)  

Multiple factors feed into why homelessness is systematically under-reported – for the living, and for those who have died. First, homelessness does not present with one homogenous face. Beyond the effect of the stereotype of the older and dishevelled male, accurate identification is constrained for person-centred, family-centred and system-centred reasons:

• those who are homeless have an incentive to retain out-of-date documents and to misrepresent their housing status, for example, if applying for bail; in encounters with the police
• there is a stigma associated with being homeless. It follows that disclosing that one is homeless, is embarrassing, as it can also lead to a biased and/or judgmental responses
• especially in emergency presentations, a low priority tends to be given to ensuring that the residential data point entry is accurately captured; often an on-file address is simply re-cycled
• if there is a death, inaccurate data concerning residential status tends to be relayed from one point in the chain of data custody without review to the next, for example, from police to coroner to Registries of Births, Deaths and Marriages, and
• next-of-kin have an incentive to not document homelessness in being led through the process of completing death certification documents by funeral directors.

The cumulative effect of the above is the production of non-recognition of homelessness as a key contributing factor as causal factor in premature deaths.

Recognition

A failure to identify homelessness means that the system-wide problem of premature mortality cannot be seen in its true perspective. Shrunken by a consistent pattern of under-reporting, this phenomenon is so under-recognised that to all intents and purposes, it disappears. In effect, the very many who have died are literally, not counted. How is this possible?

By tradition, Australia’s peak data bodies – the National Mortality Dataset, state-based Registries of Births, Deaths and Marriages, The Coronial Information Service (and more) – do not allocate dedicated attention to the phenomenon of early death amongst those who are homeless. Unlike other categories of concern, these deaths are not counted arithmetically. Symbolically, they do not count. 

Medico-legal and coronial convention also plays a role. This is particularly the case in relation to interpretations of ‘cause of death.’ Decisions on this matter act as a ‘switch-point’ (11) whose operation is governed by a convention: do not consider the bio-psycho-social circumstances of a death; focus on the immediate medical presentation. In so much as this is the case, the disposition, ‘due to natural causes’, becomes the default option. 

Analysis suggests that customary language practices used in coronial processes occasion a particular attribution: rather than potentially preventable, the non-violent deaths of those who are homeless are assumed to be ‘acts of god.’ In so much as a death is understood as a natural event, it becomes a normative occurrence that is beyond human control.

Transformed into what is both unchangeable and unremarkable, such deaths are legally non-reportable. This meaning-making process shapes the outcome that the (non-violent) deaths of those who are homeless slip unnoticed over the horizon. 

Towards recognising that too many deaths occur, and that many of these are preventable rather than inevitable ‘acts of god’, the project engaged in a limited set of targeted actions.

This advocacy involved:

• raising the possibility data might be matched between two centers the Australian Institute of Health and Welfare (AIHW) hosts: the National Mortality Dataset and the Specialist Homelessness Services Collection (SHSC). This exercise would access important, and currently unavailable, data on the number of deaths of those who have been in contact with SHS. This request resulted in the promising response that this innovative idea is technically feasible, albeit as a major project, and
• forwarding a request for information on ‘homelessness’ and ‘cause of death’ to the National Coronial Information Service. This request returned a low set of figures that, in effect, indicates coronial services are reviewing only a fraction of the deaths of those who are homeless.

Turning from official sources to those in the public arena, the media play a key role in recognition and non-recognition. For example, The West Australian reported:

A spate of deaths of homeless people has swept Perth over the past three months, with at least 15 people losing their lives since July — the equivalent of more than one a week. … The average age of those who died was just 47. This year alone at least 30 people have died — already more than the total recorded for 2019. (12)

While this situation had prompted media interest, those involved in service delivery had been aware of this problem for some time. Researchers from the University of Western Australia (UWA), in collaboration with Homeless Healthcare, the Royal Perth Hospital Homeless Team and the Mental Health Homeless Pathways Project, had also been tracking this issue. Correspondence between the current project and Lisa Wood, one of the above researchers, goes some way to clarifying the above figures:

‘… we know that our data under-estimates deaths (as we register) only the ones we have confirmed notification of from a health/medical source, but the 56 we had recorded for 2020 was much higher than the previous year’ (personal correspondence; also see also Pearson, Vallesi and Wood, in press. (13)

Statistics are able to trace the outline of a problem, but figures cannot put a face to premature death. A recent article in the Sydney Morning Herald was able to personalise, to give an individual face to, this problem.

Under the headline “He was someone’s son”: ‘Suburb farewells a friend and gentle giant’, and accompanied by a picture of ‘Peter’ as a young man, and another of impromptu mourners gathered near where he had been a regular (rough) sleeper, the opening paragraph read:

Peter, a homeless man who had turned an alcove on windy Arthur Street into his makeshift abode for the past year, died last week on a cold winter’s night. He was 48. (14)  

Public attention is given to the relationship between homelessness and early death in the above. While such reports are rare, they fit into a larger pattern: that is, those who are homeless and who die an early death are not members of a priority population group. While being recognised as vulnerable, that vulnerability does not translate into being valued. 

As examined above, non-recognition occurs at multiple recursive levels. Not least of these is public policy. Unlike smoking or COVID-19, the risks to health occasioned by homelessness have not been announced and their effects disseminated. Rather than good health policy, there is de facto neglect. That Australia continues not to have a register of homelessness deaths, goes hand-in-glove with this neglect.

Beyond the Metrics

The multi-dimensional impact of homelessness is increasingly well understood. Particularly if homelessness continues beyond six months, negative effects tend to be cumulative: material factors (poor nutrition, loss of sleep, access to exercise, and more) combine with psycho-social factors (high levels of stress; the impact of stigma, and more) to impact on immunological function and wellbeing. (15) (16) (17) In combination with these effects, the experience of ‘despair’ has been put forward as a concomitant of homelessness.

A critically acclaimed recent text – Deaths of Despair (18)– has proposed that despair promotes premature mortality. Notably, the authors of this work, one of whom has been awarded a Nobel prize, are high-profile economists. Their central argument is that practices of (more-or-less overt) self-harm – intravenous drug use; suicide; excessive alcohol misuse – are the key drivers in the spike in early mortality that has been recorded in the US. Based on statistical records, these authors present a wide-angle socio-political analysis.

It is important to note that despair presented as an ‘uninvited’ theme in the project’s consultations with representatives of those with lived experience, as it was also a non-invited topic in consultations with practitioners, managers and researchers. That is, despair was noted by each of these participant groups as a key phenomenon in the lives of those experiencing homelessness. More than a simple ‘idea’ or passing ‘feeling’, despair was put forward in these discussions as kind of a pervasive worldview. For example, in discussions with professionals, the point was repeatedly made that those who have been homeless for an extended period tended to present a fatalistic ‘what’s the point?’ face to the world.

In terms of this project’s aim – to reduce premature deaths be prevented – if despair is a central dimension in the lives of those who are homeless, this prompts a question: in so much as despair is a threat to, or has taken dominion over, the subjectivity of those who we seek to serve – what are the implications of this for practice? For example, if despair is seen as central in the understanding of the inner life of the client, this experience of despair might then impact on how choice and responsibility, self-determination and duty of care, are understood. If the premise is to ‘start where the client is’ (Goldstein, 1983), in the same way that appointment-based health services presents a miss-match with the sensitivities of those experiencing homelessness, so does the premise that right now, in this moment, the person experiencing despair occasioned by homelessness is able to arrive at sensible, self-determining choices.

If a person knows no sense of control, their only power is negative: ‘No, I’m not interested’ or, more likely, ‘bugger off.’ In so much as this is the dynamic, it will not be appropriate to over-value the possibilities of choice. In contrast to choice being over-valued, Moll (2008) argues that the worker should not be ‘indifferent’ to the implications of a client’s situation. Being able to exercise choice and self-determination may therefore represent longer-term goals more than a here-and-now option.

A Summary Statement

Recent research has proposed a startling idea: that many of the deaths of people who are homeless are not the result of so called “natural causes”. The take-away is that these deaths could be prevented if appropriate medical care had been accessed. (19)

One reason this finding is startling is because it brings into high relief what has been hidden in plain sight: in so much as ‘natural causes’ has acted as the de fault attribution for many homelessness deaths, explanations of, and responsibility for, many deaths amongst the homeless have been masked, made invisible to us and rendered unaccountable.

Words can have great power. Certain terms and phrases impose meaning. In these cases, it is not a parlour game to carefully examine the terms and phrases that are accorded extreme authority. ‘Natural causes’ – a rubric encompassing misadventure, sickness, bad luck; a catch-all for the workings of the hand of god – is one such phrase. Unreflected on, this attribution imposes a framework for interpretation and action. More than a take-it-or-leave-it implication, there is a stipulation: ‘These deaths could not be helped. No one was at fault. Neither human nor state agency was involved.’ This reading has a powerful effect. The community, the relevant authorities, you and I, are left off the hook.

The idea that many deaths are preventable, mirrors an argument with which we are now familiar: that the increasing frequency and scale of natural disasters – fires; floods; droughts – are not the result of chance, of random acts of nature, but rather are the expression of anthropogenic climate change. Similarly, it can be argued that many of the premature deaths of those who are homeless are not in fact, chance events, but are subject to policy choices that humans make, or choose not to make. If this line of thought is followed, much can be done, whether action takes the form of abatement, adaptation or system change. In contrast, a ‘natural cause’ explanation maintains an alibi that generates invisibility, and rationalises and justifies inaction. Not seen, not counted, this transgression dissolves culpability and responsibility. 

Responses

A range of responses can be expected to directly, or indirectly, reduce the rate of premature death. Mindful that what is presented is a compressed summary from the full report, set out below are actions that could be exercised at seven levels of response.

(i) The identification of homelessness

Although multi-sited constraints will remain, simple steps can still be taken to improve the identification of those at risk of premature and preventable deaths as a result of homelessness. Doran and Raven (20) suggest that sensitively asking, ‘Where are you sleeping these days?’/‘Where did you sleep last night?’ improves the reliability of consumer replies. Broadly, the literature recommends standardised brief housing screens such as the two-question universal screener suggested by Sahli et al. (21) or the five-question screening tool used by Feldman et al. (22)

Non-disclosure of homelessness by consumers is often related to the fear of stigma and/or that a service might be denied or provided in a compromised form. If this sensitivity is attended to or, better still, if a person is given an incentive to disclose their homeless status, this will improve the accuracy of data capture, for example ‘In this hospital if someone is homeless they are eligible for …’

A different situation is present if a person has died. Indicators such as:

• signs of aging that are not consistent with the chronological age of the deceased
• a significant gap between the age of the deceased and the average life spans for women and men

are a ‘flag’ for possible homelessness. Perhaps, most importantly, a spirit of active curiosity will stimulate an inductive, yet also critical, process of data capture and review.

(ii) National peak data bodies

Each of the key national data bodies could develop actions that respect, and investigate, the relationship between homelessness and premature death. For example, the Australian Bureau of Statistics (ABS) could commit to producing annual national reports on the health and wellbeing of this population group.

(iii) Coronial processes

Coronial processes produce what might be termed ‘signal decisions.’ These decisions – that a death is either ‘preventable’ or ‘due to natural causes’ – distribute outcomes that have powerful consequences. This is not a criticism; it is the business of a coronial process to act as a discursive switch-point. What is at issue is that current coronial practices are complicit in re-cycling meanings (that is natural causes) that disguise and even deny, the impact of homelessness as a socially constructed circumstance that impinges on health.

By more fully exercising their inquisitorial role – coroners would have a potentially far-reaching capacity to investigate the ‘circumstances’ that might be relevant to a death. This might lead to de-centering customary processing. Options include:

• instigating limited research programs that investigate the relationship between homelessness and non-violent death
• using brief homelessness screening tools to better assess homelessness, and
• ‘tinkering’ with information systems to adjust for known ‘bogus’ addresses

also seem desirable.

The current project has had very constructive discussions with coronial officers in two states. As well as raising awareness of the relationship between homelessness and premature death, this contact has generated positive results, for example, a more accurate count of the reported deaths of those who were homeless in one state jurisdiction.

(iv) Health care

In terms of the focus of the project – to reduce premature deaths of those experiencing homelessness – the full report details suggestions with respect to the following:

• the adoption of ‘inclusion health’ as a policy setting
• the further development of a spectrum of primary health care facilities
• more respite/step-down facilities
• better screening for illnesses
• the effective use of homelessness screening tools
• introducing indicator measures for assessing success in reducing early deaths, and
• improved complementary specialist services.

It was noted that discontinues, if not resource gaps, will remain even if the above were implemented. For example, responsibility for ensuring there is access to detoxification facilities presents as an ‘in-between’ contingency in the current environment. These difficulties belong to the ‘whose problem is this?’ class of issue. For example, who owns the problem that admission to some detoxification program is contingent on the applicant having a valid exit address?

(v) Specialist Homelessness Services

The full report details suggestions with respect to the following categories of action:

• making the assessment of the risk everyday business
• promoting conversations about safety and death
• staff support
• learning from deaths
• registering, and compiling records, of all deaths
• professional development, training and resource material
• material issues: access to medication, blankets, etc,

(vi) The network of services

There is a consensus that those who experience homelessness require holistic care. Putting access to housing, employment and social security to one side, what is required is a co-ordinated network of services that includes primary health, specialist mental health/AOD (‘behavioural health’), respite/step-down facilities, and case management where the latter is generally said to require ‘single point case co-ordination.’

Perhaps, the most powerful example of inter-sectorial non-coordination is the prevalence of the ‘exit to homelessness.’ A number of fatalities resulting from non-communication between SHS and relevant partner bodies, particularly health and justice, have been documented. Mindful that SHS bodies do not have standing as legal guardians, communication flow between ‘partner’ services will remain an issue. Nonetheless, it seems imperative that a spirit of collaboration is fostered, and protocols to streamline interactions are developed, between all service nodes. Particular inter-sectorial issues seem to be of concern regarding access to aged care assessments between SHS and the NDIS.

(vii) Minimising specific cause of death

‘Cause of death’ sub-categories are misadventure (falls; poisoning, pedestrian injury), homicide (voluntary and involuntary including family violence), illness and disease, drug overdose (accidental), suicide, and extreme weather. Mindful that the immediate cause of death rarely tells the whole-story, several causes seem amenable to technical intervention. For example, deaths due to treatable illness can be reduced if access to primary health care is available – see (iv) above – and overdose deaths will be reduced if safe injecting rooms and take home naloxone are available. Other deaths, such as those attributed to misadventure, are likely to entail more obdurate challenges as risk is built into the material circumstances of homelessness. That the frequency of extreme heat events is increasing is definitely in this category of concern.

Conclusion

What is the solution if the challenge is to reduce premature mortality? The obvious answer of ‘improved access to medical care’ is but a starting point as the majority of the social determinants of health lie outside the health system.

Drug overdose, for example, is the cause of many deaths amongst those experiencing homelessness. How should these deaths be understood and responded to? This is not a straightforward issue for many reasons. Not least of these reasons is that many overdose deaths, most likely the majority, have an uncertain causation. Frequently, there is an unstable mix of elements present where knowing self-destruction – suicide – is only one, and likely the lesser part, of the explanation. That is, it is often not clear if the overdose involved a deliberate decision, was a pure accident, involved conscious high risk taking, or was a signal expression of hopelessness and negative self-regard.

Two high profile researchers argue that many overdose fatalities are ‘deaths of despair’. (23) These authors propose that structural shifts – in the labour market; escalating educational inequity; the mechanics of social exclusion – are driving a rise in self-harming behaviours which, in effect, is the immediate cause of the marked increases that are being recorded in deaths of middle aged, non-university educated men. This is not a medical explanation.

The orthodox view is that a person must be mentally ill to take their own life. Professor Ian Hickie, co-director, Health and Policy at The University of Sydney’s Brain and Mind Centre, seemed to be saying this in the following quote: ‘… to prevent suicide and other acute mental health events, health care practitioners need to better understand what works.’ (24) That the Federal Government has an assistant minister for Mental Health and Suicide Prevention implies that this assumption – that suicide is a medical issue – has a government warrant.

In the twenty-seven consultations undertaken for this project, only one consultee thought that mental illness was always the cause of suicide. Whilst all too aware that mental illness can cause acts of self-harm and suicide, these practitioners argued that context is crucial. Homelessness, they knew, is not a take-it-or-leave-it problem; it is not a clip-on. In contrast to a part-time problem, such as intermittent headaches, homelessness is a 24/7 condition, that is the more destructive the longer it persists. This socio-genic recognition unsettles the comforting idea that suicide can be cured by medicine.  

However accessible, ‘medical care’ can only provide a part-solution to the effects of social exclusion. This understood, a progressive philosophy of care – ‘inclusion health’ – offers a bio-psycho-social role for health care. Marmot (25) writes:

Multiple intersecting causes and multiple forms of morbidity characterise social exclusion. The result is people with little hope or prospects and considerably shortened lives. The challenge is to bring socially excluded populations in from the cold—literally and metaphorically … A welcome feature of the inclusion health approach … is user involvement, which aims to enable people to improve their own health.

Marmot’s final point – user involvement – invites the question: what is known about the views of consumers? The most comprehensive account of the consumer view located by the current project is ‘Homeless persons’ experiences of health‐and social care: A systematic integrative review. (26) This study reported that three themes emerged from a meta-analysis of the literature:

‘(i) unmet basic human needs

(ii) interpersonal dimensions of access to care, and

(iii) structural and organisational aspects to meet needs.

A commitment to inclusion health prompts the follow-up question: why are we failing to offer what the consumer tells us they need? The recognition that too many deaths are occurring and that these are not natural events that many can be prevented – demands this kind of reflection.

Once a problem is recognised and reflected upon, evidence-based interventions can be summoned. A recent feature in The Medical Journal of Australian summarised what has been found to positively impact on the relationship between health and homelessness: the first, and most basic, component is ‘prioritising access to stable housing’. (27) As is well understood, most – but not all – of the social determinants of health lie outside the health sector.

Endnotes

1. Morrison, D.S., 2009. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. International journal of epidemiology, 38(3), pp.877-883.

2. Aldridge, R.W., Story, A., Hwang, S.W., Nordentoft, M., Luchenski, S.A., Hartwell, G., Tweed, E.J., Lewer, D., Katikireddi, S.V. and Hayward, A.C., 2018. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. The Lancet, 391(10117), pp.241-250.

3. Council to Homeless Persons, 2019. The Last Mile of the Way: Homelessness, death and dying project report, Melbourne.

4. Axinn, W.G. and Pearce, L.D., 2006. Mixed method data collection strategies. Cambridge University Press.

5. Whitehead, D., Taket, A. and Smith, P., 2003. Action research in health promotion. Health Education Journal, 62(1), pp.5-22.

6. Jansen, H., 2010. The logic of qualitative survey research and its position in the field of social research methods. In Forum Qualitative Sozialforschung/Forum: Qualitative Social Research (Vol. 11, No. 2).

7. Gee, J.P., 2004. An introduction to discourse analysis: Theory and method. Routledge.

8. Rose, N., 2000. Government and control. British journal of criminology, 40(2), pp.321-339.

9. Council to Homeless Persons, 2019, op cit.

10. Lee SJ, Thomas P, Newnham H, Freidin J, Smith C, Lowthian J, Borghmans F, Gocentas RA, De Silva D, Stafrace S. Homeless status documentation at a metropolitan hospital emergency department. Emergency Medecine Australasia. 2019 Aug; 31(4):639-645. doi: 10.1111/1742-6723.13256. Epub 2019 Mar 28. PMID: 30920164.https://pubmed.ncbi.nlm.nih.gov/30920164/

11. Rose, N., 2000. Op cit.

12. Hennessy, A. 2020. ‘15 homeless people have died on Perth streets since July’, The West Australian, 19.09.2021; https://thewest.com.au/news/perth/15-homeless-people-have-died-on-perth-streets-since-july-ng-b881670074z

13. Pearson D, Vallesi S, Wood L. (2021). Dying homeless in Australia: we have to measure it better Parity: Preventing Homelessness Deaths; in press.

14. Koziol, M. 2021. ‘He was someone’s son’: Suburb farewells a friend and gentle giant, Sydney Morning Herald Sun, 29.06.21: accessed 29.06.2021. https://www.smh.com.au/national/nsw/he-was-someone-s-son-suburb-farewells-a-friend-and-gentle-giant-20210628-p584xx.html

15. Fazel, S., Geddes, J.R. and Kushel, M., 2014. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384(9953), pp.1529-1540.

16. Aldridge, et al 2018, op cit.

17. O’Carroll, A. and Wainwright, D., 2019. Making sense of street chaos: an ethnographic exploration of homeless people’s health service utilization. International journal for equity in health, 18(1), pp.1-22.

18. Case, A. and Deaton, A., 2020. Deaths of Despair and the Future of Capitalism. Princeton University Press.

19. Aldridge, R.W., Menezes, D., Lewer, D., Cornes, M., Evans, H., Blackburn, R.M., Byng, R., Clark, M., Denaxas, S., Fuller, J. and Hewett, N., 2019. Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England. Wellcome Open Research, 4.

20. Doran, K.M., Vashi, A.A., Platis, S., Curry, L.A., Rowe, M., Gang, M. and Vaca, F.E., 2013. Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless. American journal of public health, 103(S2), pp.S355-S360.

21. Salhi, B.A., White, M.H., Pitts, S.R. and Wright, D.W., 2018. Homelessness and emergency medicine: a review of the literature. Academic Emergency Medicine, 25(5), pp.577-593.

22. Feldman, B.J., Calogero, C.G., Elsayed, K.S., Abbasi, O.Z., Enyart, J., Friel, T.J., Abunamous, Y.H., Dusza, S.W. and Greenberg, M.R., 2017. Prevalence of homelessness in the emergency department setting. Western Journal of Emergency Medicine, 18(3), p.368.

23. Case, A. and Deaton, A., 2020, op cit.

24. Davey, M. 2021. Reaching vulnerable people earlier the focus of national suicide prevention report; 20.04.2021; https://www.theguardian.com/australia-news/2021/apr/20/reaching-vulnerable-people-earlier-the-focus-of-national-suicide-prevention-report;

25. Marmot, M., 2018. Inclusion health: addressing the causes of the causes. The Lancet, 391(10117), pp.186-188.

26. Omerov, P., Craftman, Å.G., Mattsson, E. and Klarare, A., 2020. Homeless persons’ experiences of health‐and social care: A systematic integrative review. Health & social care in the community, 28(1), pp.1-11.

27. Davies, A. and Wood, L.J., 2018. Homeless health care: meeting the challenges of providing primary care. Medical Journal of Australia, 209(5), pp.230-234.

This article was originally published in Parity magazine. Learn more about Parity including how to access full editions.