Health and Poverty

Being poor is bad for your health!  At least that is what recent research shows.  In last week’s post I noted this startling fact (quoting an article from Business Week dated January 04, 2010): “people whose household earnings are in the bottom one-third of the U.S. population, or up to twice the federal poverty level, lost 8.2 years of perfect health.”  Further, it was noted that dropping out of high school, obesity, and smoking removed 5.1, 4.2, and 6.6 fewer years of perfect health respectively.  In addition, according to a recent article in Bostonia (Winter-Spring 2011) if you are homeless, you are particularly endangered: “The average life expectancy of an urban homeless adult is 48 years, compared to 78 years for the rest of the population.”  

To better define the problem I turn to a report on the health of New York City’s homeless population, issued in 2005 using data collected from 2001 – 2003.  This report noted five main contributors to lower health standards among the city’s homeless: heart disease and cancer, poor discharge planning and outcome from hospitalization, substance abuse and mental health problems, increased rates and poor treatment of infectious diseases including HIV/AIDS, and exposure (The Health of Homeless Adults in New York City, New York City Departments of Health and Mental Hygiene and Homeless Services report (December 2005): 20-23).  

Substance and alcohol use as well as mental illness accounted for 69% of hospitalizations among homeless adults, compared to 10% among non-homeless adults (p. 1).  Also, “The average rates of TB and new HIV diagnoses were 11 and 16 times higher, respectively, among those who used the single adult shelter system than among the NYC adult population.” (p. 1)   Homeless adults were hospitalized more often and for longer periods than non-homeless adults.  Deaths of homeless individuals occurred at roughly twice the rate of non-homeless (p. 1).  To add to all this, according to a brief issued by the National Coalition for the Homeless, “many homeless people have multiple health problems. For example, frostbite, leg ulcers and upper respiratory infections are frequent, often the direct result of homelessness. Homeless people are also at greater risk of trauma resulting from muggings, beatings, and rape.” (NCH Fact Sheet #8, National Coalition for the Homeless (June 2006): 1)

Poor health is a problem.  What’s more, it’s an expensive problem.  As stated by the National Health Care for Homeless Council,

Unacceptable costs result from poor access to health care. Because homeless people often are uninsured and lack access to low-cost preventive health care, they go without care until relatively minor problems become urgent medical emergencies. Ultimately, most homeless people do get treated, but it is treatment of the most expensive sort, delivered in hospital emergency rooms and acute care wards. Through taxpayer support of public institutions and through the cost-shifting inherent in the health insurance system, we all pay the high costs of care deferred. (“the Basics of Homelessness,” National Health Care for Homeless Council, http://www.nhchc.org/Publications/basics_of_homelessness.html, accessed March 26, 2011)

As stated in a previous posting, the chronically homeless usually account for 50 % of costs attributed to homelessness nationally, including hospital stays, and these costs are even higher here in Southeastern Connecticut, with a chronically homeless population roughly three to four times that of the national average.

There are many reasons for this.  The National Health Care for Homeless Council notes in particular two problems for homelessness; “people who are homeless are more concerned with meeting immediate needs for shelter, food, clothing, and safety than with seeking health care.” And “for some, the symptoms of their illnesses or bad experiences with the health care system in their past cause them to actually avoid health care.” (the Basics of Homelessness)  This, in turn, compounds a simple, easily solvable health concern, and leads to longer, more expensive hospital stays.  In addition, homeless populations often lack adequate health care or insurance, which means that the bill falls back on the hospital and ultimately other patients and the insurance industry.  

There are many causes to be sure, but a 2010 report issued by the Prevention Institute outlined several root factors contributing to health inequality among Americans, all of which boiled down to the communities which low income Americans live in; a result of “overt discriminatory actions on the part of government and the larger society, as well as to the present day practices and policies of public and private institutions that perpetuate a system of diminished opportunity for certain populations.” (“A Time of Opportunity: Local Solutions to Reduce Inequities in Health and Safety,” Prevention Institute Brief Report (April 2010): 1) This discrimination is not against any ethnic group, but against lower income populations in general, which often lack access to quality health care, employment, education, and other opportunities, some of which have been outlined in prior blog posts.  

So what can we do about this health care crisis among the homeless?  Well, it can be said that we have already begun to solve the problem.  First off, organizations like L & M or Backus Memorial Hospitals have a system of charitable care built into their system.  These are, however, limited by gifts and donations and do not completely answer the costs associated with health care among the uninsured.  Connecticut has made headway in answering the lack of insurance,with programs like HUSKY insuring children and Medicaid Low Income Adult and Title 19 helping many who cannot afford insurance. Finally, community health centers all over the state are bringing routine care to low income individuals and families.  

While these programs are working to make health care more available, they don’t answer the root problems.  There is still an gap in health care quality, and the poorest among us, the homeless, are still bogged down with immediate concerns, and are unable or unwilling to receive help for even the smallest of problems.  An important step in solving this last problem is housing: provide low income housing, along with intensive case management, to the homeless (Cf. this post for more on housing).  As a study published in the Archive of General Psychiatry shows, housing the homeless significantly reduces the costs associated with homelessness, including medical costs:

Participation in Housing First was associated with substantial increases in outpatient visits and declines in use of inpatient and emergency services. Reductions in inpatient and emergency service costs partially offset the increased outpatient and housing costs. (“Effect of Full-Service Partnerships on Homelessness, Use and Costs of Mental Health Services, and Quality of Life Among Adults With Serious Mental Illness,” Archive of General Psychiatry Vol. 60, No. 6 (June 2010): 7-8.)

In addition, affecting change in the communities is important to solving these problems.  As summed up in the Prevention Institute brief quoted above (p. 3-4), strengthening the communities where people work and supporting community efforts to raise the quality of healthcare are integral to solving the roots of healthcare inequality.  Solving the problems associated with homelessness can be found in the community and relies on active engagement and support from the community we live in.

Education and Poverty

Income, education, and life expectancy seem to go hand in hand.  At least that is what an article in Business Week (January 04, 2010) informs us.  In fact, income and education are as important a factor as smoking and obesity:  “According to a study by researchers at Columbia University's Mailman School of Public Health, people whose household earnings are in the bottom one-third of the U.S. population, or up to twice the federal poverty level, lost 8.2 years of perfect health.”  Further, according to the same report, “High school dropouts had 5.1 fewer years of perfect health.”  Obesity and smoking dropped 4.2 and 6.6 years of perfect health respectively.  This is startling.  Being poor and undereducated is bad for your health.  In fact, according to a recent article in Bostonia (Winter-Spring 2011), “The average life expectancy of an urban homeless adult is 48 years, compared to 78 years for the rest of the population.”

Being poor and undereducated is bad for your health, that’s the bottom line.  I’ve discussed previously some causes of poverty in the past, but education has been little discussed.  A previous blog post noted that “62% of sheltered single adults and sheltered adults in families had a 12^th grade education or higher” in Southeastern Connecticut.  This means that 38 % of sheltered single adults did not graduate from high school, a large number.  This is compared to 8 % of persons between 16 and 24 years of age estimated in 2008 (as compared with 8.7 % in 2007 and 14.1 % in 1980) according The Condition of Education 2010 (NCES 2010-028), Table A-19-2 published by U.S. Department of Education, National Center for Education Statistics (2010).  These statistics seem to show that dropping out of high school increases your chances of winding up homeless and in a shelter. 

If a lack of education can lead to homelessness, what influences education?  This is a difficult question.  Race seems to have something to do with dropout rates.  According to the Department of Education report just cited, dropout rates were 4.8 % for white, non-Hispanic students, 9.9 % for black students, 18.3 % for Hispanic students, 4.4 % Asian or Pacific Islander students, and 14.6 for Native American students.  This means that a black student is twice as likely to drop out of high school as a white student, almost four times as likely if a Hispanic student.  Note also that in Connecticut, 5% of white children live in poor families, that is, families at or below 100 % of poverty level, 24 % of black children, and 31 % of Hispanic children.  What’s more, 50% of these childrens' parents do not have a high school diploma or GED (National Center for Children in Poverty, Connecticut Demographics of Poor Children, updated January 19, 2011).  Poverty and education seem to go hand in hand. 

Of late it seems that blame for this disparity is put on school faculty.  This, at least, is the approach taken by Arne Duncan, Education Secretary of the United States (“Start Over: Turnarounds Should Be the First Option for Low-Performing Schools,” Education Week, June 17, 2009, 36.).  However, TCF Senior Fellow Richard Kahlenberg sees a much bigger problem, involving more than just the teachers (Turnaround Schools That Work: Moving Beyond Separate but Equal, The Century Foundation, November 11, 2009).  Kahlenberg sees three separate factors that determine the a student’s success in school:  students (classmates), parents, and faculty (p. 1).  He notes on each:

In high-poverty schools, a child is surrounded by classmates who are less likely to have big dreams, and, accordingly, are less academically engaged and more likely to act out and cut class. In such schools, peers are less likely to do homework and graduate, and more likely to watch television and cut class—all of which have been found to influence the behavior of classmates. (p. 2)

Low-income parents, who may be working several jobs, may not own a car, and may have had a bad experience themselves as students, are four times less likely than more-affluent parents to be members of a PTA. They are only half as likely to volunteer in the classroom or serve on a school committee. Finally, low-income parents are less likely to have the political power to push for adequate resources, which helps explain why even within school districts, spending disparities exist, generally to the disadvantage of low income students. (p. 3)

Research consistently finds that the best teachers, on average, avoid high-poverty and high-minority schools. Teachers in disadvantaged schools are less likely to be licensed, to be teaching in their field of expertise, to have high teacher test scores, to have considerable teaching experience, and to have extensive formal education. Principal turnover also is higher in high-poverty schools. (p. 3)

In short, it is not only school faculties that are failing, it is the entire culture found in low income schools and our inability or unwillingness to answer these problems that are leading schools to fail.  Living in a low income community leads to lower education standards.

Kahlenberg also outlines an approach to solving these problems:

The most promising turnaround model is one that seeks to turn high-poverty schools into magnet schools that change not only the faculty but also the student and parent mix in the school. Failing schools can be shuttered, reinvented, and reopened with new themes and pedagogical approaches that attract new teachers and a mix of middle-class and low-income students. Some low-income students from the old school would be given the opportunity to fill the spots in more-affluent schools vacated by middle-income children who were transferring to the magnet school. (p. 5)

In short, let low income family students attend classes with middle and high income family students—economic integration. 

Another interesting study, produced by Heather Schwartz (Housing Policy Is School Policy: Economically Integrative Housing Promotes Academic Success in Montgomery County, Maryland, The Century Foundation, Oct 15, 2010), would seem to confirm this hypothesis.  This study followed 858 elementary students residing in public housing dispersed throughout Montgomery from 2001 to 2007, half of whom attended schools where less than 20 % of students were qualified for free or reduced priced meals, the other half at schools with populations of up to 75 % qualified for these meals, but in which the school system heavily increased funding (p. 8ff).  The results showed that:

After seven years (the end of elementary school), children in public housing in Montgomery County’s most affluent half of elementary schools performed eight points higher in math (…) and five points higher in reading (…) than otherwise similar children in public housing who attended schools with greater than 20 percent poverty. Within education research, these are large effects since relatively few educa­tional reforms demonstrate positive effects of this magnitude. (p. 32)

The interesting thing about this report is that children weren’t trucked into higher income schools; low income housing was provided within higher income communities:

A singular feature of Montgomery County’s zoning policy is that it allows the public housing authority, the Housing Opportunities Commission, to purchase one-third of the inclusionary zoning homes within each subdi­vision to operate as federally subsidized public housing, thereby allowing households who typically earn incomes below the poverty line to live in afflu­ent neighborhoods and send their children to schools where the vast majority of students come from families that do not live in poverty. (p. 4)

The results of this study and that previously cited show that poverty and education is a community issue, with answers within the community. 

Education is important.  Without it a person’s outlook in life is grim.  A lack of education leads to poverty, a lower quality of life, and a shorter life.  What’s more, if a parent dropped out of high school, a child is more likely to drop out.  Poor education can be an epidemic, following a family from generation to generation.  The good news is that there is a solution, but it relies on our taking ownership of the problem, and for us to welcome subsidized housing into our community.  This means that we have to face poverty head on, not just throw money at it, to solve our education crisis.  

Of Despair and Hope

This week I was struck by a conversation with a man.  He was filled with a host of emotions, from despair to envy to anger.  His day was a rocky one, a day that started out with high aspirations and hopes that were almost immediately dashed.  He had a job interview that morning, an interview for a position that he would have loved.  It was a job he was well qualified for, he knew going in that he was the man for the job and would probably be hired.  He was excited all weekend for the interview and we were all happy for him.  But all this hope was dashed to pieces right away in the interview.  The interviewer asked him, “Do you own a car?”  He said no and the interview ended right there.  Unbeknownst to him, unwritten in the job description, was a very important detail:  he needed to be able to travel all over the state.  This gentleman was not qualified for the position simply because he was poor!  He could not afford a car, a home, anything.  That evening at the shelter it seemed to him that, no matter his qualifications, no matter how hard he tried, he would never find a good job or a way out of the shelter.  He was not drunk by this point.  In his despair he did not turn to drinking, or drugs, or any other stereotype we apply to the homeless.  He was in despair but was dealing with it.  He tried his best and would go out the next day and search for a job again.  But at that moment, all he wanted to do was think about his life.

Today I write about the despair and hope I see weekly in the shelter I work.  There are a lot of both.  First, it must be repeated that fifty percent here in Southeastern CT are the transitional homeless: those who are experiencing a temporary difficulty that can be overcome.  These are people who are just down on their luck.  They’ve been out of a job for months on end, have a disease that has eaten their resources, lost everything in a disaster, a divorce, etc.  It is telling to note that many reasons associated with this type of homelessness are also those associated with bankruptcy.  These people are desperate, a storm of bad luck has hit and they are simply unable to weather it alone.

The same evening I spoke to the man above, I met another couple.  They were in the shelter for a different reason:  the husband was sick.  He applied for assistance, but the way things are social services is overworked and he has not received a response to his application, neither approving nor disapproving it.  His wife couldn’t work, she had to take care of him and so, finances exhausted they found themselves in the shelter, the only safe place to stay while they sought assistance.   These two were among the 42% of sheltered adults who reported suffering from a health condition limiting their ability to work, get around, or even just care for themselves.  The only hope they have is for him to be cared for so that she can get a job.

These two people, as well as the one noted above, are at the bottom.  But there is hope.  I did an intake a few months back for a gentleman.  The day was a terrible one; a snow storm had closed the city down and I was one of the few people within range to actually walk to the shelter to keep it running and keep our guests out of the elements.  This man was a fairly normal person: as he stated, “I shouldn’t be here!  I’ve never done drugs, am not an alcoholic, none of that stuff you hear about homeless.  I’m clean and shouldn’t be here!”   He was just out of work and for one month, then two, then several months, he couldn’t find a job.  His savings were exhausted and he was at a low in his life.

The thing about this man was that he really shouldn’t have been in the shelter.  Talking with him he had an amazing work history:  He was a very skilled carpenter with a constant, long work history.  He had been steadily employed in carpentry since high school.  His only problem was, like so many others, he just did not know how to look for a job.  I talked with him that day, helped him put together a resume, gave him a list of all the places I could find to perform an online job search and upload his resume.  For about two hours I talked to him, helped him, and advised him then he was on his way.  The next evening I was doing a volunteer orientation for a couple of new volunteers when he came up to me thanking me; he had taken my advice and within a 24 hours had five separate responses to his applications.  I never saw him again. 

The very same day I talked to this man I did an intake for another gentleman.  He found himself in the shelter for the first time the night before as well.  He had one felony and had been released from prison recently.  They set him free from prison with no support and sent him in the opposite direction of his home town.  This man had already hit the bottom and was really eager to get his life back together again.  There was a drive in him that I could see right away.

Years ago he was an independent contractor, a small business owner and successful.  A difficult divorce changed all that and he slowly went down a hill of loss until he found himself broke.  He turned to alcohol and just screwed up.  When I met him he wanted to get out of the shelter.  He was happy the shelter was there but he really wanted to get back to a normal life, to what he once had.  He had a happy life once, and he was ready to find a new one.  I talked with him, but he didn’t want help and he left.  I didn’t see him again until last week.  He had found a place to live within a week of entering the shelter.  He was surviving and making the changes he needed to his life.  Last week he came in to see me again, this time ready to finish what we had started, to take my advice and use my help.  I really do think he will succeed.

I think a volunteer at the shelter hit the nail on the head:  most of what he does is listen to the problems of others, give them a little advice, but more importantly reassure them.  He helps them get where they need immediately by helping them with a resume or to get some benefit.  But his biggest impact is that he reassures his guests that they are doing things right, that there is help, and that they can get out of the shelter.  The gentleman I wrote about at the beginning of this post was working very hard to get out of the shelter.  He just needed someone to talk to for a little bit.  He needed to voice his frustrations.  He didn’t want advice, but he did need to know that there was someone to go to.  I listened to him as he cursed his lot in life, then as he finished and as I was about to leave, I let him know he could always talk to me or one of the other volunteers.  That’s what we’re here for.  I know he’ll find a job soon, one that he actually wants.  But it’s frustrating sometimes.