Health Care

Defining a Diverse Population with an Elusive Denominator

Despite an emerging and impressive body of literature on homelessness, a striking lack of data exists on the health and health status of this vulnerable population. Several reasons can be surmised, including the exasperating difficulty in defining “the homeless.” The often romanticized hoboes and skid row denizens of American lore have yielded to a crosssection of our society, including families with children, runaway and throwaway adolescents, young men of color, middle-aged workers, and the fragile elderly.

Homelessness has proven a complex social phenomenon that thwarts simple definition, a murky chasm beneath the safety net known to a heterogeneous cross-section of society's most vulnerable persons. Darwinian rules apply; housing is a scarce and valued commodity in our market economy. Those people least able to compete—impoverished individuals and families beset with problems—fail in this intense competition for housing. Opportunity and choice are limited not only by abject and persistent poverty, but also by the challenges of chronic mental illness, substance abuse, physical and sexual violence, illiteracy, complex acute and chronic medical problems, the nightmares of recent and remote wars, and advancing years with meager financial reserves and atrophied gray matter. Extreme poverty and a lack of housing are perhaps the only shared characteristics of this eclectic population, and the complexity of need and rich diversity of the homeless have confounded and bewildered researchers.

The corollary to an imprecise definition of “homelessness” has been an elusive denominator. No research methodology has been able to accurately enumerate the homeless. Estimating the size of this population in the United States and in any particular city has been contentious, hampered by the geographic and temporal transience of homeless persons as well as daunting logistical difficulties with sampling techniques. Estimates have ranged from 250,000 to 3 million on any specific night; some researchers estimate that 13.5 million U.S. citizens have experienced “literal” homelessness in their lifetimes.

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