Community and Public
Health Nursing
PRACTICUM
Poor families. Homelessness.
Vulnerable Populations. Poverty and Homelessness.
After studying this chapter, you should be able to:
·
Define
vulnerability
·
Describe
vulnerable population groups
·
Analyze
the effects of public policy on vulnerable populations.
·
Give
examples of how a community health nurse might plan interventions for
vulnerable groups.
·
Analyze
the concepts of poverty and homelessness.
·
Describe
the social, political, cultural, and environmental factors that influence
Poverty.
·
Discuss
community health nursing interventions for poor and homeless individuals.
Introduction
What is vulnerability?
A starting point for defining health-related vulnerability is the concept of
need. Social consensus may fray at the margin when one asks which medication or
service is most efficacious or cost-effective for a particular diagnosis. Yet
few would dispute the basic argument that lack of financial resources should
not block access to widely-accepted treatment that significantly extends life
or relieves morbidity. This goal of providing treatment and preventive
interventions is only partly based on observed consumer demand for health
services. Health care may be the most prominent "merit good" -- a
good for which social altruism includes a desire that all citizens receive a
certain minimum level.15 Health care is not the only such good. In-kind
subsidies for housing, preschool education, and food are often justified in
similar terms.16 Yet the fundamental nature of health for individual well-being
has led policymakers to pay special attention to the distribution of
health-status and to the distribution of health care services across the
population. Labeling health care a merit good does not imply a particular
institutional arrangement to provide insurance coverage or to provide health
care services. But it does indicate the social consensus in favor of assuring
access to some minimal quality and quantity of services for every member of American
society. the core idea underlying vulnerability is that individuals face
significant obstacles to the receipt of medical treatment and preventive
services, as well as obstacles to obtaining health insurance coverage.
For example, 27 percent of families
in which all family members are uninsured report that they had delayed or not
received needed health care, compared to only 8 percent of those with all
family members insured. Similarly, 15 percent of Hispanic families reported
delaying or not receiving care, compared to 11 percent for whites and 10
percent forblacks.
Differences in use of care are not simply a function of insurance status,
but also occur among those who have the same insurance coverage. So, a simple
comparison of 1987 expenditure levels for Medicare beneficiaries shows average
spending of $4,316 for whites compared to $4,049 for blacks; $4,523 for high
school graduates compared to $4,959 for college graduates, and $3,648 for those
who are poor, compared to $4,661 for those with high income.
Much of health services research on vulnerable populations has focused on
understanding the nature of the access and utilization barriers faced even by
individuals with insurance coverage.
Our focus here is on how vulnerable populations face barriers to insurance
coverage itself.
The obstacles to health insurance coverage can arise from many factors, but
several prove especially important for the populations of concern in this
paper:
__ medical and social needs that hinder access to traditional insurance
markets
__ general economic disadvantage, including both low income and limited
access to employment-related health insurance
__ discrimination based on race, ethnicity, language, or citizenship status
__ impaired decision-making and proxy decision-making.
To clarify these issues, consider an informal model of the factors
affecting the demand for medical services and health insurance.iii We can posit
that consumers demand for medical services can be represented through a demand
equation:
DemandCare = f (Health Status,
Income, Direct Costs, Indirect Costs, Knowledge, Social Norms, X)
while insurance demand is derived
from their demand for care and other factors:
DemandInsurance = f (DemandCare,
Price, Income, Alternative Sources of Care,
Information, Risk Preferences, X)
Medical services are supplied by medical providers:
SupplyCare = f (payment
rates, input costs, provider norms, X)
where X in each equation represents other factors, including
individual-specific preferences.
In this simple model, consumer demand for medical care
is a function of health status, income, the direct costs of paying for care,
the indirect costs (such as transportation or time costs) associated with
obtaining care, knowledge about medical care and health, and the relevant social
and cultural norms of one’s communities. Demand for insurance is derived from
the demand for medical care, plus additional factors, including the price of
insurance, income, the availability of alternative sources of care (such as the
availability of uncompensated care from
medical care services is related to insurance payment rates, the relevant
input costs, and provider norms concerning treatment.
The most basic vulnerability is the existence of
ill-health, disease, and disability. Insurance starts with the presence of
risk, and then spreads the financial burdens of these risks.mIn the model
above, demand for care is related to health status, and this demand for care
motivates the purchase of insurance. Hence the problem of adverse selection in
voluntary insurance markets. Although health status and the existence of
disease underlie consumer demand for medical care and health insurance, those
who are less likely to need medical care may act on this knowledge as well, and
therefore not purchase coverage.
This differential motivation for insurance purchase
presents important difficulties for risk-pooling within an unregulated
insurance market. In extreme cases the insurance market may unravel completely.
Even in less extreme cases, insurers respond to this asymmetric information by
imposing restrictions on insurance policies in terms of waiting periods,
pre-existing condition exclusions, and cost sharing requirements that impede
consumers in poor health from obtaining insurance.
A second vulnerability arises from economic
disadvantage. Families with low incomes are less able to buy insurance, and are
less able to purchase care directly. The problems of low income for medical
care and health insurance are multifaceted. The problem is, in the first
instance, one of constrained resources, and competing priorities in low-income
households for purchasing other necessities. Second, the primary mechanism for
obtaining health insurance for those under age 65 is through
employment-provided coverage. But many low-income Americans have a weak
connection to stable jobs, and the jobs that low income workers do hold often
not provide health benefits.18 Moreover, when health benefits are offered, they
may require premiums, especially to obtain coverage for dependents. People with
low incomes may place a higher value on purchasing other goods and services,
and are especially price-sensitive in
their purchase of health coverage. Economic disadvantage can also be caused
by poor health, which can hinder subsequent labor market performance, thereby
limiting income and access to employment-linked health insurance. From the
perspective of individual consumers, the lack of health insurance increases the
direct costs for obtaining medical services. The indirect costs of medical
services include the costs of transportation and the time costs for obtaining
services,
A third type of vulnerability arises from race,
ethnicity, language, and citizenship status. In part, the disadvantages associated
with race and ethnicity are due to poverty and low income. Yet these categories
are also distinct from economic need, raising both the issue of potential
discrimination, as well as issues concerning information, cultural norms, and
cross-cultural difficulties that may impede access to medical services and
health insurance. Discrimination based on race/ethnicity poses complex barriers
to insurance coverage and to the effective use of the health care delivery
system. Real and perceived discrimination has many effects for the individual
and for health care providers. This issue has received increasing research
attention, especially regarding medical encounters for African-American
patients. For many reasons, Hispanic/Latino citizens, non-citizens, and recent
citizens are the largest single population of uninsured men, women, and
children in the U.S.19 In addition, for members of many ethnic groups, language
barriers and complex barriers associated with immigration status pose
significant barriers to the take-up of nominally-provided public coverage, and
create difficulties for obtaining appropriate medical services.
A fourth aspect of vulnerability concerns individuals' ability to act as
effective agents on their own behalf. Although one usually assumes that
individuals are the best judges of their wellbeing, competent decisionmakers,
and able to negotiate with and advocate for themselves or their children, this
assumption comes into question for several populations of greatest policy
concern.
Individuals with psychiatric disorders, cognitive impairment, or substance
use disorders face important barriers to effective and informed
decision-making. They are unlikely to be sophisticated consumers, and may be
unaware of entitlements to health insurance coverage.
Individuals experiencing social stigma and those with social and economic
disadvantages are also likely to be less effective agents within the health
care delivery system. Moreover, social stigma associated with welfare and other
means-tested programs often impedes individuals from applying for the programs
for which they are eligible.
The main federal and federal-state programs that
currently provide health insurance are:
·
Medicare,
·
Medicaid,
·
the State
Children's Health Insurance Programs.
More than 80 percent of Medicare recipients are over the age of 65.
However, five million Medicare beneficiaries are of working age, making
Medicare a prominent source of coverage across the adult population.
More than 90 percent of under-65 Medicare beneficiaries are eligible by
virtue of disability. A smaller number are Medicare eligible through the
end-stage renal disease program or are eligibleas widows or widowers of
Medicare beneficiaries.21
Medicaid serves a more varied range of recipient
groups, including families receiving cash welfare benefits, people with
disabilities who receive federal Supplemental Security Income (SSI), and
children in low-income families. Medicaid also serves certain persons with high
medical expenses, some of whom live in the community, and many others who are
residents of nursing homes.
Important expansions of means-tested insurance
programs occurred during the 1980s and 1990s, which were largely directed
towards children. The most important of these requirements were mandates
enacted as part of the Omnibus Budget Reconciliation Acts (OBRA) of 1989 and
1990, which required that the states extend Medicaid eligibility to all
children under the age of six with family income below 133 percent of the
poverty line, as well as children born after September 30, 1983, with family
income below 100 percent of the poverty line.
These government programs are an important part of the
current approach for providing health insurance for the vulnerable. Potential
recipients face decisions regarding whether to enroll in programs. Recipients’
behavior while enrolled affects their further eligibility for insurance
coverage. Welfare reform also changed the complex policy and administrative
relationships across programs. Even before welfare reform, public insurance
programs reflected significant institutional complexity inherited from the
history of policy enactments. The range of American social welfare programs
includes health insurance programs that may overlap with each other, as well as
various cash assistance, social policy, employment and training, etc. programs
that may serve, separately, the needs of vulnerable groups. Because eligibility
for one program might be conditioned on eligibility for another, or
non-eligibility for a related program, the programs can serve as enrollment
vehicles for each other. For example, cash assistance has
traditionally been the main outreach vehicle to enroll low-income women and
children into Medicaid programs
Some populations are considered
vulnerable if there are legitimate concerns about their competency to
understand information presented to them and make reasoned choices. These
populations include people with psychiatric, cognitive, or developmental
disorders and substance abusers.
Health of Vulnerable Populations
As our state prospers in many ways, some segments are invariably left
behind. Some have chronic illness. Some are migrant workers. Others live in
rural communities with limited access to health care. Most are hardworking and
aren’t looking for a handout. But they could use a hand. Through our Health of
Vulnerable Populations focus area, we are committed to improving the well-being
of
The health care debate is focused on achieving universal access through a
restructured payment system. Final acceptance will be dependent on meeting the
needs of the employed and educated. The special needs of vulnerable
populations, though included in the Health Security Act, are less likely to be
given priority.
which may also be important for the economically disadvantaged in
geographically isolated
areas.
A third type of vulnerability arises from race, ethnicity, language, and
citizenship status.
In part, the disadvantages associated with race and ethnicity are due to
poverty and low income. Yet these categories are also distinct from economic
need, raising both the issue of potential discrimination, as well as issues
concerning information, cultural norms, and cross-cultural difficulties that may
impede access to medical services and health insurance. Discrimination based on
race/ethnicity poses complex barriers to insurance coverage and to the
effective use of the health care delivery system. Real and perceived
discrimination has many effects for the
individual and for health care providers. This issue has received
increasing research attention, especially regarding medical encounters for
African-American patients. For many reasons, Hispanic/Latino citizens,
non-citizens, and recent citizens are the largest single population of
uninsured men, women, and children in the U.S.19 In addition, for members of
many ethnic groups, language barriers and complex barriers associated with
immigration status pose significant barriers to the take-up of nominally-provided
public coverage, and create difficulties for obtaining appropriate medical
services. A fourth aspect of vulnerability concerns individuals' ability to act
as effective agents on their own behalf. Although one usually assumes that
individuals are the best judges of their wellbeing, competent decisionmakers,
and able to negotiate with and advocate for themselves or their children, this
assumption comes into question for several populations of greatest policy
concern.
Individuals with psychiatric disorders, cognitive impairment, or substance
use disorders face important barriers to effective and informed
decision-making. They are unlikely to be sophisticated consumers, and may be
unaware of entitlements to health insurance coverage. Individuals experiencing
social stigma and those with social and economic disadvantages are also likely
to be less effective agents within the health care delivery system. Moreover,
social stigma associated with welfare and other means-tested programs often
impedes individuals from applying for the programs for which they are eligible.
Ill health, disease, and disability interact with many of these concerns to
create especially significant vulnerability for individuals experiencing
chronic illness. Chronic conditions limit access to insurance, and often limit
individuals' ability to act on their own behalf. Adding to these burdens,
chronic disease often creates additional needs for both formal and informal
caregiving. The severely disabled must often rely on others for basic activities
of daily living, creating another important vulnerability for policy.
These characteristics of vulnerability create dependence: a reliance on
family and other caregivers, on medical providers and social service
organizations, and on government programs for economic support. Some
vulnerability is common. Many people face the risks of illness and may have
insufficient financial resources to pay for needed services. Many individuals
face potential discrimination. Children rely on their parents as proxy
decision-makers, and every person faces the risk of at least temporary loss of
cognitive faculties, as well as the long-term risk of developing cognitive and
physical disabilities.
Along each dimension, if the limitations are severe enough, we can classify
a person as being a member of a particular "vulnerable" population.
Although many people face a single challenge due to chronic illness,
low-income, or other challenges, the vulnerable populations frequently face
multiple challenges, often in different domains of personal well-being or
social functioning. These vulnerabilities affect how patients obtain medical
care services and purchase health insurance, as well as the ways that the
supply of services responds to these consumer demands.
Program responses
to needs and vulnerability
Under appropriate competitive conditions, insurance markets provide for
efficient resource allocation. They do not, however, provide a vehicle to
address distributional concerns that are central public policy goals. Some market
failures arise because markets are missing. As Richard Zeckhauser has noted,
many of life’s most important lotteries are run before one is born. One cannot
buy insurance against the possibility that one will be born mentally retarded,
Competitive markets do not normally provide cross-subsidies across different
risk classes of health insurance consumers. An uncoordinated market will not,
therefore, protect
chronically-ill consumers from the burden of actuarially-fair premiums.
Competitive markets also fail to address important traditional externalities
such as infectious disease transmission or the social costs that attend
substance dependence and abuse.
These familiar market failures create a need for public action, and there
is a history of such responses: the needs of vulnerable populations have long
been the focus of public and private interventions. Public programs include the
creation of hospitals for the mentally ill, programs to provide medical and
preventive services, as well as income transfer and social insurance programs.
Alongside these public responses to vulnerability is a rich history of
involvement by voluntary and non-profit organizations. Non-profit Blue Cross
and Blue Shield plans were central to the 20th century development of health
insurance. Partly for historical reasons, and partly as a result of deliberate
public policy, many safety-net providers that serve vulnerable populations
operate under non-profit and public ownership.
In many different ways, the history
of health insurance and related programs shows that the problems of vulnerable
populations have drawn forth many kinds of programs, institutions, and
interventions.
The main federal and federal-state programs that currently provide health
insurance are Medicare, Medicaid, and the State Children's Health Insurance
Programs. More than 80 percent of Medicare recipients are over the age of 65.
However, five million Medicare beneficiaries are of working age, making
Medicare a prominent source of coverage across the adult population.
More than 90 percent of under-65 Medicare beneficiaries are eligible by
virtue of disability. A smaller number are Medicare eligible through the
end-stage renal disease program or are eligible as widows or widowers of
Medicare beneficiaries.21
Medicaid serves a more varied range of recipient groups, including families
receiving cash welfare benefits, people with disabilities who receive federal
Supplemental Security Income (SSI), and children in low-income families.
Medicaid also serves certain persons with high medical expenses, some of whom
live in the community, and many others who are residents of nursing homes.
Important expansions of means-tested insurance programs occurred during the
1980s and 1990s, which were largely directed towards children. The most
important of these requirements were mandates enacted as part of the Omnibus
Budget Reconciliation Acts (OBRA) of 1989 and
1990, which required that the states extend Medicaid eligibility to all
children under the age of six with family income below 133 percent of the
poverty line, as well as children born after September 30, 1983, with family
income below 100 percent of the poverty line.
The 1997 Balanced Budget Act supplemented these Medicaid expansions with
the creation of grants to the states to fund State Children's Health Insurance
Programs (SCHIP).
These programs are targeted at those families with children whose incomes
are just above the Medicaid income thresholds of 100 or 133 percent of poverty.
States are granted flexibility in implementing these programs, and can choose
not only the upper income limits (typically around 300 percent of poverty), the
nature of premiums and cost sharing requirements, and the administrative form
of these new programs. Finally, an important related program is welfare. In
1996, Congress enacted and Bill Clinton signed the welfare reform law that
repealed Aid to Families with Dependent Children (AFDC), replacing it with
Temporary Assistance to Needy Families (TANF) block grants to the states. While
there had been proposals to include Medicaid as part of these welfare block
grants, this alternative was rejected. Instead, the legislation preserved
Medicaid as a federal-state entitlement and explicitly maintained for the
Medicaid program both the pre-welfare reform, AFDC-related eligibility rules
for adults in families with dependent children, as well as the implementation
schedule for the child-related expansions established in 1989-90.
These government programs are an important part of the current approach for
providing health insurance for the vulnerable. Potential recipients face
decisions regarding whether to enrol in programs. Recipients’ behavior while
enrolled affects their further eligibility for insurance coverage. Welfare
reform also changed the complex policy and administrative relationships across
programs. Even before welfare reform, public insurance programs reflected
significant institutional complexity inherited from the history of policy
enactments. The range of
American social welfare programs includes health insurance programs that
may overlap with each other, as well as various cash assistance, social policy,
employment and training, etc. programs that may serve, separately, the needs of
vulnerable groups. Because eligibility for one program might be conditioned on
eligibility for another, or non-eligibility for a related program, the programs
can serve as enrolment vehicles for each other. For example, cash assistance
has
traditionally been the main outreach vehicle to enrol low-income women and
children into Medicaid programs.
A second complexity emerges from the overlapping medical and social needs
of vulnerable populations. Many private or public interventions address one
need of vulnerable individuals. This existing patchwork of organizations and
programs form the environment in which health insurance policy occurs. This
patchwork arose due to historical accident, the dynamics of competing funding
streams, the unique political, social, and health circumstances facing
particular populations.
Governmental programs are created and administered through political
decision-making. The political economy of this process is therefore important
to the provision of health coverage.
Who are “the vulnerable?"
With this framework in place, we can more narrowly identify particular
groups that areexemplars of these problems of vulnerability. These vulnerable
populations include:
·
__ people
with low incomes
·
__ children
·
__
racial/ethnic minorities, and immigrants
·
__
individuals with chronic disease
·
__ individuals
with psychiatric or substance abuse disorders
Each group has a characteristic combination of the vulnerabilities
discussed above. For those with low incomes, the primary vulnerability is
economic disadvantage, in which job insecurity and low income hinder market
health insurance coverage for low-income workers.
While children typically obtain insurance through parental employment,
these policies do not necessarily cover them. Children are also dependent on
parents and guardians to serve as proxy decisionmakers. Of course, low-income
children share the additional difficulties faced by those with low incomes. For
racial and ethnic minorities, the issues include general economic disadvantage,
discrimination, language competence, and immigration status and program
eligibility.
Those with chronic disease face the general difficulties of obtaining
insurance because they are less likely to be employed, and the special
difficulties that come with the combination of poor health and low income. The
near elderly are experiencing the age-related rising incidence of acute and
chronic illness at the same time that the employment connection for insurance.
Poverty
Poverty (also called penury)
is deprivation of common necessities that determine the quality of life,
including food, clothing, shelter and safe drinking
water, and may also include the
deprivation of opportunities to learn, to obtain better employment to escape
poverty, and/or to enjoy the respect of fellow citizens. According to Mollie Orshansky who developed the poverty measurements used by the
Although poverty is generally considered to be undesirable due to the pain
and suffering it may cause, in certain spiritual contexts "voluntary poverty," involving the renunciation of material goods is seen by some
as virtuous.
Poverty may affect individuals or groups, and is not confined to the developing nations. Poverty in developed
countries is manifest in a set of
social problems including homelessness and the persistence of "ghetto" housing clusters.
Measuring poverty
Poverty can be measured in terms of absolute or relative
poverty. Absolute poverty refers to
a set standard which is consistent over time and between countries. An example
of an absolute measurement would be the percentage of the population eating
less food than is required to sustain the human body (approximately 2000-2500 calories per day for an adult male).
Causes of poverty
Many different factors have been cited to explain why poverty occurs.
However, no single explanation has gained universal acceptance.
Environmental Factors
- Erosion. Intensive farming often leads to a vicious cycle
of exhaustion of soil fertility and decline of agricultural yields and
hence, increased poverty[
- Desertification and overgrazingApproximately 40% of the world's agricultural land is seriously
degraded. In Africa, if current trends of soil degradation continue,
the continent might be able to feed just 25% of its population by 2025,
according to UNU's Ghana-based Institute for Natural Resources in
- Deforestation as exemplified by the widespread rural poverty in
- Natural
factors such as climate change. or environment
- Geographic factors, for example access to fertile land, fresh water, minerals,
energy, and other natural resources. Presence or absence of natural
features helping or limiting communication, such as mountains, deserts,
navigable rivers, or coastline. Historically, geography has prevented or
slowed the spread of new technology to areas such as the
- On the other
hand, research on the resource curse has found that countries with an abundance of natural resources creating quick wealth from exports tend to have
less long-term prosperity than countries with less of these natural
resources.
- Drought and water crisis.
Economics
- Unemployment. Some countries' governments are believed to purposefully maintain a
2-10% unemployed populace to act as a 'replacement threat' to unskilled
private sector workers, by way of maintaining an existing thriving service
economy.
- As of late
2007, increased farming for use in biofuels,along with world oil prices at nearly $130 a barrel has pushed up the price of grain. Food riots have recently taken place in many countries
across the world.
- Capital flight by which the wealthy in a society shift their assets to off-shore tax havens deprives nations of revenue needed to break the vicious cycle of poverty.
- Weakly
entrenched formal systems of title to private property are seen by writers
such as Hernando
- Unfair
terms of trade, in particular, the very high subsidies to and protective tariffs for agriculture in the developed world. This drains the taxed money and increases the
prices for the consumers in developed world; decreases competition and
efficiency; prevents exports by more competitive agricultural and other
sectors in the developed world due to retaliatory trade barriers; and undermines the very type of industry in which the developing
countries do have comparative advantages. Tax havens which tax their own citizens and companies but not those from other nations
and refuse to disclose information necessary for foreign taxation. This
enables large scale political corruption, tax evasion, and organized crime in the foreign nations.
- Unequal
distribution of land. Land reform is one solution.
Health Care
Hardwood surgical tables are commonplace in rural
Nigerian clinics.
- Poor access
to affordable health care makes individuals less resilient to economic
hardship and more vulnerable to poverty.
- Inadequate
nutrition in childhood, itself an effect of poverty, undermines the
ability of individuals to develop their full human capabilities and thus
makes them more vulnerable to poverty. Lack of essential minerals such as iodine and iron can impair brain development. It is estimated that 2 billion people
(one-third of the total global population) are affected by iodine deficiency, including 285 million 6- to 12-year-old
children. In developing countries, it is estimated that 40% of children
aged 4 and under suffer from anemia because of insufficient iron in their
diets. See also Health and intelligence.
- Disease, specifically diseases of poverty: AIDS, malaria, and tuberculosis and others overwhelmingly afflict developing nations, which
perpetuate poverty by diverting individual, community, and national health
and economic resources from investment and productivity. Further, many tropical nations are affected by parasites like malaria, schistosomiasis, and trypanosomiasis that are not present in
temperate climates. The Tsetse fly makes it very difficult to use many animals in agriculture in
afflicted regions.
- Clinical depression undermines the resilience of individuals and
when not properly treated makes them vulnerable to poverty.
- Similarly substance abuse, including for example alcoholism and drug abuse when not properly treated undermines resilience and can consign
people to vicious poverty cycles
Demographics and Social
Factors
- Overpopulation and lack of access to birth control methods. Note that population growth slows or even become negative as poverty is
reduced due to the demographic transition.
- Crime, both white-collar crime and blue-collar crime, including violent gangs and drug cartels.
- Historical factors, for example imperialism, colonialism and Post-Communism (at least 50 million children in Eastern Europe and the former Soviet Union live in poverty).
- Dalits in Jaipur, India.
- Brain drain
- Matthew effect: the phenomenon, widely observed across advanced welfare states, that
the middle classes tend to be the main beneficiaries of social benefits
and services, even if these are primarily targeted at the poor.
- Cultural
causes, which attribute poverty to common patterns of life, learned or
shared within a community. For example, Max Weber argued that the Protestant work ethic contributed to economic growth during the industrial revolution.
- War, including civil war, genocide, and democide.
- Discrimination of various kinds, such as age discrimination, stereotyping,gender discrimination
, racial discrimination, caste discrimination.
- Individual beliefs,
actions and choices.
Effects of poverty
The effects of poverty may also be causes, as listed above, thus creating a
"poverty cycle" operating across multiple levels, individual, local,
national and global.
Those living in poverty and lacking access to essential health services,
suffering hunger or even starvation,experience mental and physical health problems which make it harder for
them to improve their situation. One third of deaths - some 18 million people a
year or 50,000 per day - are due to poverty-related causes: in total 270
million people, most of them women and children, have died as a result of
poverty since 1990. Those living in poverty suffer lower life expectancy. Every year nearly 11 million children living in poverty die before their
fifth birthday. Those living in poverty often suffer from hunger 800 million
people go to bed hungry every night.Poverty increases the risk of homelessness There are over 100 million street children worldwide. Increased risk of drug abuse may also be associated with poverty.
Diseases of poverty reflect the dynamic
relationship between poverty and poor health; while such infectious diseases result directly from
poverty, they also perpetuate and deepen impoverishment by sapping personal and
national health and financial resources. For example, malaria decreases GDP growth by up to 1.3% in some developing nations, and by
killing tens of millions in sub-Saharan
Those living in poverty in the developed world may suffer social isolation. Rates of suicide may increase in conditions of poverty. Death of a breadwinner may decrease
a household's resilience to poverty conditions and cause a dramatic worsening
in their situation. Low income levels and poor employment opportunities for
adults in turn create the conditions where households can depend on the income
of child members. An estimated 218 million children aged 5 to 17 are in child labor worldwide, excluding child domestic labor Lacking viable employment
opportunities those living in poverty may also engage in the informal economy,
or in criminal activity, both of which may on a larger scale discourage
investment in the economy, further perpetuating conditions of poverty.
Low income and wealth levels undermine the ability of governments to levy
taxes for public service provision, adding to the 'vicious circle' connecting
the causes and effects of poverty. Lack of essential infrastructure, poor
education and health services, and poor sanitation contribute to the
perpetuation of poverty. Poor access to affordable public education can lead to
low levels of literacy, further entrenching poverty. Weak public service
provision and high levels of poverty can increase states' vulnerability to natural disasters and make states more
vulnerable to shocks in the international economy, such as those associated
with rising fuel prices, or declining commodity prices. Areas strongly affected
by poverty tend to be more violent. In one survey, 67% of children from
disadvantaged inner cities said they had witnessed a serious assault, and 33% reported witnessing a
homicide. 51% of fifth graders from New Orleans (median income for a household: $27,133) have been found to be victims of
violence, compared to 32% in Washington, DC (mean income for a household: $40,127).
The capacity of the state is further undermined by the problem that people
living in poverty may be more vulnerable to extremist political persuasion, and
may feel less loyalty to a state unable to deliver basic services. For these
reasons conditions of poverty may increase the risk of political violence, terrorism, war and genocide, and may make those living in poverty vulnerable to human trafficking, internal displacement and exile as refugees. Countries suffering widespread poverty may experience loss of population,
particularly in high-skilled professions, through emigration, which may further
undermine their ability to improve their situation.
Homelessness is the condition and social category of people who
lack housing, because they cannot afford, or are otherwise unable to maintain,
regular, safe, and adequate shelter. The term "homelessness" may also
include people whose primary nighttime residence is in a homeless shelter, in an institution that provides a temporary residence for individuals
intended to be institutionalized, or in a public or private place not designed
for use as a regular sleeping accommodation for human beings. A
small number of people choose to be homeless nomads, such as some Romani
people (Gypsies) and members of some
subcultures. An estimated 100 million people worldwide are homeless.
The United States Department of
Housing and Urban Development (HUD) defines a
"chronically homeless" person as "an unaccompanied homeless
individual with a disabling condition who has either been continuously homeless
for a year or more, or has had at least four episodes of homelessness in the
past three years.
The term "homelessness" includes the people whose primary
nighttime residence is in an institution that provides a residence for
individuals intended to be institutionalized, or in a public or private place
not designed for use as a regular sleeping conditions for human beings.
The term used to describe homeless people in academic articles and
government reports is "homeless people". Popular slang terms, some of
which are considered derogatory, include: vagrant, tramp, hobo (
Main causes of homelessness
The major reasons and lack of causes for homelessness as documented by many
reports and studies include.
- Lack of affordable housing
- Unavailability of employment
opportunities, which becomes a vicious circle due to the
initial problem of being homeless
- Poverty, caused by many factors
including unemployment and underemployment
- Lack of affordable healthcare
- Substance abuse and unavailability
or lack of needed services
- Mental illness and unavailability
or lack of needed services
- Domestic violence
- Prison release and re-entry into
society
- Natural disaster
- Forced eviction - In many
countries, people lose their homes by government order to make way for
newer upscale high rise buildings, roadways, and other governmental needs.]
The compensation may be minimal, in which case the former occupants cannot
find appropriate new housing and become homeless.
- Mortgage foreclosures on
homes in the
A substantial percentage of the
Increased wealth disparity and income inequality
causes distortions in the housing market that push rent burdens higher, making
housing unaffordable.Problems faced by homeless people
Homeless people face many problems beyond the lack of a safe and suitable
home. They are often faced with many social disadvantages and reduced access to
private and public services such as:
- Reduced access to health care
- Limited access to education
- Increased risk of suffering from
violence and abuse
- Discrimination
- Not being seen as suitable for
employment
Health care for the homeless
Health care for the homeless is a major public health challenge.
Homeless people
are more likely to suffer injuries and medical problems from their lifestyle on
the street, which includes poor nutrition, substance abuse, exposure to the
severe elements of weather, and a higher exposure to violence (robberies,
beatings, and so on). Yet at the same time, they have little access to public
medical services or clinics. This is a particular problem in the
Homeless persons often find it difficult to document their date of birth or
their address. Because homeless people usually have no place to store
possessions, they often lose their belongings, including their identification
and other documents, or find them destroyed by police or others. Without a
photo ID, homeless persons cannot get a job or access many social services.
They can be denied access to even the most basic assistance: clothing closets,
food pantries, certain public benefits, and in some cases, emergency shelters.
Obtaining replacement identification is difficult. Without an address,
birth certificates cannot be mailed. Fees may be cost-prohibitive for impoverished
persons. And some states will not issue birth certificates unless the person
has photo identification, creating a Catch-22. This problem is far less acute
in countries which provide free-at-use health care, such as the
The conditions affecting the
homeless are somewhat specialized and have opened a new area of medicine
tailored to this population. Skin conditions and diseases abound, because
homeless people are exposed to extreme cold in the winter and they have little
access to bathing facilities. Homeless people also have more severe dental
problems than the general population. Specialized medical textbooks
have been written to address this for providers.
There are many organizations providing free care to
the homeless in countries which do not offer free medical treatment organised by
the state, but the services are in great demand given the limited number of
medical practitioners. For example, it might take months to get a minimal
dental appointment in a free-care clinic. Communicable diseases are of great
concern, especially tuberculosis, which spreads more easily in crowded homeless
shelters in high density urban settings
In 1999, Dr. Susan Barrow of the Columbia University Center for
Homelessness Prevention Studies reported in a study that the "age-adjusted
death rates of homeless men and women were 4 times those of the general US
population and 2 to 3 times those of the general population of New York
City".