Syndemics and Street Medicine: How Framing Homeless Health-Care Through a Public Health Lens Saves Lives
“Wow…homelessness in California is really bad”. An all too common mantra chanted by out of towners as they visit our “left coast”.
Let’s unpack this statement. A state of communal anomie should not be described with judgmental qualifiers (ie ‘bad’). The homeless are not “bad” and being homeless is not necessarily “bad”, despite the common myth. Is there an issue of homelessness in California? Indeed, there are over 170,000 that we are aware of (note this data is poorly collected and based on something described as a Point in Time, PIT, count, and reported through something called a Homeless Management Information System, or HMIS) and that number has increased by over 30% in the last 5 years. Los Angeles has the largest homeless population in the U.S. Skid Row is the epicenter of that epidemic. In the greater county of LA, the LA Homeless Services Authority 2022 count revealed there were approximately 70,000 unhoused people (an increase of 4.1% from 2020) and 41,980 unhoused people in the City of LA (up 1.7% from 2020). However, the RAND corporation[1] published an analysis of the methodology used by LAHSA and has shown dramatic increases in the population estimates not accounted for by LAHSA. This report found that on average homeless populations had actually increased by 18% from 2022 to 2023 in Los Angeles in areas that reported decline. The UN even wrote a scathing report regarding the state of homelessness in California in 2018, calling it cruel and inhuman. Let that settle in.
So, yes, it’s an issue. Why we’re discussing this here is because of the health implications for people experiencing homelessness (PEH). In general, homeless men are up to 8 times more likely to die - a statistic that is skewed by certain factors, including suicide, opioid overdose and sudden cardiac death. Other important health-related issues are poorly controlled chronic diseases, high prevalence of traumatic brain injury, disproportionate victimization and high rates of tobacco use. The COVID-19 pandemic has further threatened the health of PEH.
Let us be clear, being homeless is not a clear cause and effect relationship as it so popularly described. One does not simply wake up being unhoused as the result of one (or even a string) of poor decisions. And it’s not all drugs. Much of this state is socially or politically determined - both in the US and beyond. What this means is that the upstream causes of poor health in the homeless population include extreme poverty, harsh living environments, trauma in childhood and structural barriers to care. So, juvenile efforts to cast blame on millions of folks is just not grounded in reality or science.
We’re writing this piece as we are a group of passionate public health doctors (including infectious diseases specialists, psychiatrists and cardiologists) who are actually doing something about it. Let’s be honest. The most effective antidote to the health issues experienced by the unhoused is relatively straightforward - housing. As it turns out, medicine is never really that simple, and we must therefore devise a complex formula for those falling somewhere through this vast spectrum - from those surfing couches to others living in squalid conditions in encampments. Sometimes in medicine, we must simply embrace the imperfection and do what is colloquially described as “meeting folks where they are”. One powerful manifestation of this is something we describe as “street medicine”.
Street medicine has largely been defined by the Street Medicine Institute, a nonprofit organization providing support for street medicine programs around the world. The Street Medicine Institute defines the model as “health and social services developed specifically to address the unique needs and circumstances of the unsheltered homeless delivered directly to them in their own environment.” Much like harm reduction—the philosophy of meeting people who use drugs where they are, both mentally and physically, and treating them with dignity and respect—street medicine is also a philosophy, combining service delivery with a social justice commitment to flattening the power dynamic between health care providers and the patients they serve. The clinical service delivery model created by street medicine focuses on the unsheltered homeless, but the model has also been successfully used to provide care to other socially complex populations—including rural communities (for example, migrant farmworkers) both in the US and beyond.
Street medicine practitioners leave the walls of the conventional clinic, donning backpacks filled with clinical supplies and diagnostic equipment to provide care on the street. While this deconstructed clinic model can be a more labor- and resource-intensive endeavor than a traditional clinical practice, it pays off. Bringing care directly to people has helped street medicine programs engage individuals who would simply not receive services if the only entry point was via a traditional clinical setting. While the objective for many clinical care settings is to engage marginalized populations into more conventional brick-and-mortar settings, the delivery model of street medicine works well for certain populations that cannot engage with conventional delivery systems.
There are a number of permutations of the street medicine model. As public health experts at Wellness Equity Alliance, we believe the most effective are ones that can sufficiently address the syndemics that afflict the unhoused. A syndemic is a relatively new and timely term that describes the synergy of multiple colliding epidemics causing an amplified outcome. Behavioral health (this includes mental health and substance use disorder treatment, like opioids and alcohol) is often a core driver of this model. They are driven by disparities that are largely sociopolitically determined. We are deploying this model in certain areas - including the streets of South Los Angeles (largely known as some of the poorest neighborhoods in LA) through an innovative funding opportunity provided by the Substance Abuse and Mental Health Services Administration (SAMHSA).
It is often challenging to adapt US systems of health care delivery and financing to support individualized and nimble models such as street medicine. HIV care in particular often sits at the intersection of public health systems (namely the RWHAP) and broader health care systems. There are challenges to both models. While public health programs are often more nimble and dynamic, they are chronically underfunded. And while broad health care systems are larger and more stably financed, they may not embrace their role in public health management and are more limited in their support for community-based delivery models. Federal policy makers can help bridge that gap in their efforts to support ending the HIV epidemic. We have a long way to go to end the HIV epidemic. Getting there will require creative health care delivery tools that frame and address the problem through a multidimensional lens. The COVID-19 pandemic has provided us with seemingly limitless examples of why this was important during the proverbial gray skies. Investing in street medicine and other innovative delivery models has the potential to help us achieve our goals of meaningfully addressing syndemics during bluer skies in order to prevent the impending storms from circling again.
[1] https://www.rand.org/pubs/research_reports/RRA1890-2.html
