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Understanding Public Health and Homelessness

The pandemic highlighted that public health and homelessness are locked together in a shared fate.
June 25, 2020

Homelessness is a public health crisis. This has always been true, but never clearer than during the current pandemic, when people experiencing homelessness were identified among those at highest risk for infection, transmission, and death.

The COVID-19 pandemic has exposed the vulnerability of our public health infrastructure and its relationship to housing. During this pandemic, the ability to shelter in place has been key to protecting ourselves and others from the spread of COVID-19. Those who are homeless lack a place to shelter, which puts them not only at higher risk of contracting the coronavirus, but also of spreading it to other vulnerable community members. 

This crisis has highlighted that the actors involved in upholding public health — from agencies to health care providers to social safety-net organizations — and homeless services are locked together in a shared fate. They must now create a permanent mandate, vision, and agenda for ending homelessness together. This primer serves to provide more information on public health and its intersection with homelessness.

What is public health?

According to the CDC Foundation, “public health is the science of protecting and improving the health of people and their communities …. by promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing and responding to infectious diseases.” 

Most local public health departments provide these set of services:

  • Clinical prevention – through vaccinations and screenings
  • Medical treatment services – to treat communicable diseases and sexually transmitted infections; maternal and child health services
  • Population-based interventions – such as pandemic or emergency response planning, disease surveillance, food safety inspections, school and day care inspections, and tobacco prevention. 

What is the difference between public health and health care?

While public health focuses on the health of communities and populations, the health care sector is focused on treating individuals. Aptly described by Health and Human Services Secretary Donna Shalala in 1996, “medicine and public health have been likened to trains on parallel tracks — with windows facing opposite directions, looking out on the same landscape. Those on the medical train see the individual trees: the subtle differences in size, color, age and health. Those aboard the public health train see the forest: populations of similar trees, growing together and weathering the same storms.”

The American health care system is an interwoven network of health care providers, insurance companies, government programs, public health agencies, safety-net programs, and a myriad of other players. Because of these intertwined systems, the public health and medical health sectors overlap, impact, and reinforce each other. 

How is public health funded?

While the public health sector encompasses federal, state, county, tribal, and city entities, a large percentage of its funding comes from the federal government, specifically the Department of Health and Human Services (HHS). Generally, federal agencies provide the majority of funding to state health departments, which then direct it to local health agencies at the county, city, and tribal levels, with some exceptions. State and local fees and taxes also fund some public health programs. 

Despite its importance, funding for public health pales in comparison to the overall health care system. In 2017, public health funding represented 2.5% of the roughly $3.5 trillion spent on health care, an average of $274 per person/year. Historically, public health funding has increased in times of crisis, like the one we are currently experiencing. However, due to years of underfunding, public health is always in a cycle of catch-up and unable to effectively respond when needed.

How is homelessness a public health crisis?

The connections between homelessness and health outcomes have long been documented. According to the American Public Health Association, people experiencing homelessness have high rates of chronic mental and physical health conditions. They also face many barriers to accessing health care and complying with health care directives, such as correctly taking prescription medications. People experiencing homelessness die, on average, 17 years earlier than those who are housed.

Further, due to lack of shelter and ability to practice good hygiene, people experiencing homelessness are at greater risk of contracting and spreading communicable diseases, such as hepatitis, typhoid, and, as we are currently seeing, COVID-19. When people are provided adequate and safe shelter, they have improved health outcomes, which relieves pressure on our health care facilities and safety-net resources. In turn, these individuals are better able to remain stably housed. 

Public health programs often focus on the social determinants of health — elements that impact why a person or groups of people have less optimal health outcomes. Social determinants of health include social and environmental factors such as race, income, and education level, as well as access to housing, transportation, and healthy foods. The social determinants of health are often the same factors leading to homelessness, so both sectors serve many of the same populations and communities. 

The Opportunity 

This pandemic is highlighting the critical linkage between homelessness and public health that must be understood and strengthened to ensure healthy communities. During the pandemic, leaders in the homeless response system  have worked with public health departments and actors to ensure people experiencing homelessness — and their broader communities — are safe. 

Further, the success of communities in Built for Zero has demonstrated that the public health approach is the necessary solution to ending homelessness. This involves using data to measure and understand the problem, setting population-level aims, and identifying systems-level changes. 

The link between optimal health outcomes and safe, stable housing is no secret. But with better understanding the structure, funding, and connections, we can strengthen the link between the health sector and homelessness sector to create a lasting end to homelessness that leaves no one behind.