Correspondence
Health Care and the Homeless
N Engl J Med 1995; 332:64-65January 5, 1995
- Article
To the Editor:
The recent study by Hibbs et al. (Aug. 4 issue)1 addresses the important question of the mortality rate among homeless people in a large U.S. city. Their finding of a mortality rate nearly four times that of the general population may unfortunately be an underestimation of the true mortality rate due to the design of their study.
During the three years of the study, an unknown number of persons returned to their former social-support network or obtained new housing, and thus ceased to be homeless. By assuming that all 10,715 study subjects remained homeless throughout the study period, the authors may have overestimated the person-years of follow-up, and consequently the mortality rate may have been underestimated by an unknown amount.
Mortality data should have been collected for at least two years after the last date of recruitment into the study. From their Figure 1 it can be seen that there is a delay between the entry of a group into the study and subsequent deaths in that group. Because data on mortality were not collected beyond the last date of entry into the study, the mortality rate of the study population has been underestimated.
1 ReferencesWajahat Z. Mehal, M.D., D.Phil.
Yale–New Haven Hospital, New Haven, CT 065041
Hibbs JR ,Benner L ,Klugman L , et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med 1994;331:304-309
Full Text | Web of Science | Medline
To the Editor:
We appreciate Dr. Redlener's comments in his editorial (Aug. 4 issue)1 about the health status and health care needs of homeless children in New York City. The horrific living conditions of children in welfare hotels and the lack of organized health care for such children prompted a novel response, the Children's Health Project. Dr. Redlener correctly points out that homeless children are but one example of chronically underserved children.
The health care status of children in foster care in our community is not much different from that of the homeless children in New York City. In our clinic, children have a myriad of problems resulting from medical neglect, including delays in immunization (29 percent), dental caries (11 percent), and uncorrected vision problems (7 percent). Prenatal exposure to cocaine was documented in 22 percent of infants, and 4 percent tested positive for the human immunodeficiency virus; both prevalence rates are 25 times higher than the rates in our county. Developmental delay was identified in 35 percent of children less than five years of age.2 Others who care for children in foster care report similar findings.3,4
Almost 450,000 children nationwide are in foster care, yet there are few specialized clinics serving this medically, developmentally, and psychologically vulnerable population. Many children in foster care do not have access to high-quality medical care. Society must provide adequate financial resources and health care so that all children have a chance for optimal growth and development.
4 ReferencesSteven D. Blatt, M.D.
Victoria Meguid, M.D.
State University of New York, Syracuse, NY 132101
Redlener I . Health care for the homeless -- lessons from the front line. N Engl J Med 1994;331:327-328
Full Text | Web of Science | Medline2
Blatt SD ,Meguid V ,Saletsky R , et al. Health care needs of children in foster care (FC): a multidisciplinary approach. Am J Dis Child 1993;147:440-440 abstract.3
Flaherty EG ,Weiss H . Medical evaluation of abused and neglected children. Am J Dis Child 1990;144:330-334
Web of Science | Medline4
Chernoff R ,Combs-Orme T ,Risley-Curtiss C ,Heisler A . Assessing the health status of children entering foster care. Pediatrics 1994;93:594-601
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: As we stated in the Discussion section of our article, my coauthors and I agree that our methods probably resulted in an underestimation of mortality among the homeless. Because of people who cease to be homeless, mortality could have been either underestimated or overestimated, since some people who died may have ceased being homeless before their deaths. This raises the important question of whether mortality declines among homeless people who obtain housing — a question that our data do not permit us to resolve.
Longer follow-up would probably have revealed additional deaths among the homeless people first identified early in the winter of 1988, since summer was the period of highest mortality. Several limitations not mentioned by Dr. Mehal also contribute to the underestimation of mortality. In particular, homeless people who died outside Philadelphia or whose names were incorrectly identified on their death certificates would not have been included in our numerator.
These limitations all point in the same direction, which is to emphasize our central observation. People who are homeless at a given time are several times more likely to die in the coming year than are members of the general population. This difference persists after stratification for age, sex, and race, and it is large enough to constitute an important public health problem.
Jonathan R. Hibbs, M.D.
University of Minnesota, Minneapolis, MN 55455Author/Editor Response
Drs. Blatt and Meguid's response to my editorial on health care for the homeless is, of course, right on target. The homeless are but one example of groups that tend to have substantial unmet health needs and to have a particular problem locating accessible, appropriate resources to meet these needs within traditional medical service systems.
Children in foster care, particularly those with special health care needs, have a wide range of health and health-related problems that require special programs and services. Our own experience with a group of “difficult to place” foster children 10 to 14 years of age made this point dramatically. Many of these patients had unnecessarily complicated medical problems that resulted from simple acute conditions that were poorly recognized or insufficiently followed. For example, otitis media was often chronic or complicated by hearing loss by the time medical attention was obtained. Overall, more than 20 percent of foster children seen by one of our primary care providers needed additional services, including those of specialists, mental health workers, and others.
Medical professionals caring for homeless people, foster children, migrant populations, poor people in the inner city or isolated rural areas, or other high-risk groups would probably agree on two basic strategies for providing services to populations with special needs. First, universal access to an appropriate range of health care services should be guaranteed. Second, special populations require targeted programs to ensure that “enabling services,” from translation and transportation to case management, are available as needed.
Finally, certain government programs, such as the National Health Service Corps, have been particularly effective in providing the resources of health professionals in areas where needs are greatest. One of the lessons, however, is that although underserved populations clearly need primary care resources, there is almost invariably a concomitant need for linkages to specialists, special service providers, and tertiary medical systems. This point must not be forgotten in the planning of health care for the medically underserved.
Irwin Redlener, M.D.
Montefiore Medical Center–Albert Einstein College of Medicine, Bronx, NY 10467
