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Show of daily shelter or because they are living in emergency shelter settings that may present some inherent and very real public health problems, including increased risk of exposure to tuberculosis (TB), hepatitis, HIV, and the annual rounds of viruses. More importantly, because of problems of cost and access to health care through insurance, and because of the significantly greater incidence of mental illness among the homeless, their vulnerability to and probability of a fragile state of health is compounded. In short, homeless people are more adversely affected than non-homeless people by the stress, instability, and mental health effects of their living conditions. It is both physically and emotionally dangerous to live on the streets. As suggested above, an unknown but significant segment of the homeless population has evidence of untreated mental illness. Some recent federal and state sources suggest that 40 percent of the Salt Lake County area homeless population have at least one or more diagnoses of untreated mental illness. In some cases mental illness is the reason for homelessness, and in other cases people have developed diagnosti-cally discernible mental illness as a result of being on the streets for months or years. The state of homelessness further compounds problems of obtaining preventive services that could reverse potential deterioration in health status. The longer a person is homeless, the more complex the health care problems become and the more expensive the treatment regimen. The state of Utah would greatly benefit from preventive programs to this population. The decreased incidence of TB among this population between 1993 and 1994 in Utah is a great example of how the state, county, federal and private resources can greatly benefit Utah when such a working consensus is established. Reaching out to homeless people and getting them enrolled into a managed health care system as it is currently developing, however, will be a huge challenge. Among the reasons for the difficulty of enrolling homeless people into a managed system of care are that a growing sector of Utah's poor are episodically homeless or at risk for homelessness (less than one month's financial reserve), and are moving about within the state or across the country seeking employment. Many have been previously classified as uninsurable. It is from among this population that underedu-cated, chronically unemployed or underemployed, and other marginalized peoples can be found. This is a pool of people that is very difficult to reach, much less to educate in any sort of meaningful preventative manner about health care. Utah's homeless population has grown each year since 1985, with the most alarming segment of people comprising families with children and a geriatric population. As stated above, more and more people are falling into the category of episodic homelessness, which means that at various times throughout the course of a year people are doubling up with relatives and friends, living in cars, or staying in emergency shelters. This is especially significant when shelters begin to see people who were military participants in the Gulf War and Somalia, and when the state begins to experience the human side of cutbacks and layoffs in the defense industry. What Have We Learned to Date? Lack of access to health care, especially preventive services, affects the ability of the individual or family to gain independence from the revolving door of poverty by reducing the children's ability to learn and the adults' ability to work. This is one of the most pressing issues in addressing health care for Utah's poverty population. Among the acute medical conditions experienced by homeless men, for example, are job-related accidents. Many jobs held by homeless men are "off the books," and accidents which occur are therefore not filed under Workmen's Compensation laws. These jobs are generally temporary day labor jobs (over 40 percent of men staying at shelters are working at such jobs), and usually pay at or below minimum wage. Further, the jobs are often physically very dangerous and have no fringe benefits. This means that other programs must fund the health care of temporary workers. Another generally unaddressed but vitally important issue continues to be lack of cultural sensitivity and language barriers that are characteristic of middle-class health care settings. Providers and staff at these clinics are often unequipped to understand the health beliefs and philosophy of the patient in poverty, and no staff are provided to translate from English into the growing numbers of languages spoken by Utah's citizens. Currently, the percentage of homeless people from various ethnic groups is approximately double the percentage each group constitutes of the state's total population, with the exception of those characterized as "White," which makes up almost 70 percent. If these issues continue to be left unaddressed, the overall level of public health risk increases, particularly in the area of communicable diseases such as TB. The condition of homelessness continues to be first and foremost an issue of lack of housing. A recent memorandum from the National Health Care for the Homeless Council stated: Utah's Health: An Annual Review 1995 19 |