By Carey L. Biron
WASHINGTON - When Catherine Crosland sees patients in the U.S. capital, her key concern is whether they have somewhere to live.
"The biggest social determinant of health is housing status," the doctor told the Thomson Reuters Foundation at a clinic below a Washington D.C. shelter.
Being homeless, she said, "causes risks to your health, lack of access to food and hygiene, the threat of violence, depression and substance abuse".
Crosland is the medical director for homeless outreach services at Unity Health Care, a non-profit focused on low-income communities in the capital. In that role she sees patients in clinics, on sidewalks and at encampments - and the effect a lack of housing has.
Last year, she said, one patient with several chronic medical problems lost her apartment in a fire. That forced her to move with her son to a motel housing homeless families.
For a month, Crosland said, the woman was dependent on fast food and soup kitchens — and in that time gained 20 pounds (9kg). She died two days after going to hospital showing signs of heart failure and high blood pressure.
"To me, she died because she lost her housing — absolutely, 100 percent," Crosland said.
That fits research - most recently data from a 2018 study that found "rough-sleeping" adults in Boston were three times more likely to die than those of the same age living in shelters, and 10 times more likely than the state's general population.
Being homeless puts more strain on health and other public services: the homeless tend to be readmitted to hospital more than the general population, and they stay longer, according to research published in Health Affairs, a journal focused on health policy issues.
When Oregon provided stable housing, the research showed, it cut certain medical expenditures on the affected population by 12 percent. Their use of emergency rooms declined 18 percent.
Last year's annual government survey showed about 553,000 people were homeless nationwide. About a third lived outside of shelters.
People without homes are three to four times more likely to die prematurely than the general population, according to the National Health Care for the Homeless Council, a network of over 200 groups nationwide.
Such findings are pushing officials, housing advocates and doctors to embrace the idea that housing must be considered a health issue.
"The homelessness crisis isn't a social one. It's a health issue," said the council's Rick Brown.
"Homelessness doesn't just hurt — all too often it kills," said Brown, adding that the health system had for decades failed to take into account housing issues.
"Thankfully, we're seeing increasing recognition of the importance of the social determinants of health - and that we need broader solutions to this," he said.
Those determinants are a globally agreed list of factors that affect inequalities linked to health - among them, housing. In November, the World Health Organization updated that list to show how improving housing conditions could cut health risks.
Valerie Agostino of Mercy Housing recalled one ex-colleague complaining that, while he could write a prescription for a $100,000 drug, "what his patients needed was a place to live, and he couldn't write a prescription for $20,000 for a year".
"That was incredibly frustrating for him."
A shift to link housing and health means practitioners can tap a larger pool of potential funding, said Agostino, adding that a lack of affordable housing remained a central problem.
For Mercy Housing, a non-profit that focuses on housing low-income and other vulnerable communities, a key point came with the 2010 passage of the Affordable Care Act, a signature policy for then-President Barack Obama.
Many felt that the incentives and other policies in the law - better known as Obamacare - would help bring health and housing closer, Agostino said.
Five years later, the federal government announced that Medicaid — which provides health insurance for the poor — could be used for housing-related services for the chronically homeless.
But under the Trump administration much of the Affordable Care Act has been weakened, removing some of the momentum seen earlier this decade, Agostino said.
And yet, at the same time other partnerships between the health and housing communities have taken off, she said.
"There's a recognition on the part of healthcare providers that they can be part of the solution."
Those partnerships include investments by insurers and hospital systems in creating affordable housing, such as a joint $100-million national affordable housing fund unveiled in January by health system Kaiser Permanente.
"We believe ... both in the direct connection of health and housing, and what effect not having that has on physical, mental health and wellbeing," said chief executive Bernard J. Tyson.
"Our position is we need to solve (homelessness) in this country — and that it is solvable," Tyson told the Thomson Reuters Foundation.
Hospitals are also getting involved, said think-tank the Urban Institute, with several working to build low-cost housing.
Early results from a survey of nearly 70 cities by the Urban Institute found most hospitals indicated that housing issues were a community or patient need, and about half of them thought the healthcare sector should be involved in housing.
This shift has affected the work of doctors on the ground: Crosland has been in her post for nearly a decade in Washington, D.C., but it was only recently that she began interacting with the city on housing issues.
"I didn't even know how housing worked until a couple of years ago," she said.
"For seven years I felt like I was in the weeds meeting the needs of my patients who are experiencing homelessness — and I really felt like it was a Band-Aid approach."
Crosland said the medical community could play a key role in helping homeless people access housing, adding that she was working to build a database to gather information that could be used to that end.
"Then hopefully we can be a more effective voice at the table to advocate for housing for these vulnerable patients."