A 2023 report from the City of Baltimore Mayor’s Office of Homeless Services estimated that around 1,500 people experienced homelessness on any given night in Baltimore City. While this marks a decrease from previous years, it still affects a significant number of residents.
The report stated that around 73% of the population experiencing homelessness were Black or African Americans: a rate significantly higher than the 62% Black or African Americans who make up of Baltimore’s population.
People who experience homelessness tend to have poorer health outcomes compared to the population with stable housing. The former group has an increased risk for many infectious diseases, including tuberculosis and HIV. They show higher rates of mental health issues like substance use disorder and depression compared to the general population. These individuals also tend to have a higher duration of hospital stays, yet are less likely to receive sustained medical care and stay on necessary medications.
However, these inequities are not only limited to health outcomes but also to faulty data collection about these diseases and disorders, which further worsen the population’s overall wellness status. Multiple reports have shown that statistics regarding the people who experience homelessness tend to be misreported due to flaws and discrepancies in methodologies. For instance, the National Law Center on Homelessness & Poverty revealed in 2017 that the Department of Housing and Urban Development’s Point in Time count of the homeless population relied heavily on volunteer counts, missing out on the significant group of individuals who stay in unconventional and non-visible places. Additionally, people who cycle in and out of homelessness (known as episodic homelessness) or become situationally homeless through factors like losing a job or domestic violence might be undercounted.
Most cities, including Baltimore, do not have a standardized reporting system when it comes to mortality counts of people who experience homelessness, which is another obstacle in collecting accurate data. Forms or reports for death are limited or incompatible for unhoused individuals. For example, a death certificate from Maryland filled out by doctors or other healthcare workers does not have a specific field regarding if the individual was experiencing homelessness at the time of their death. This leads to a difficulty of developing an understanding of mortality causes and their patterns across age and other subgroups.
In an interview with The News-Letter, Dr. Katherine Koh from the Boston Health Care for the Homeless program offered a physician’s perspective on these “invisible deaths.”
“The inequities continue into death. There are often no funerals, no obituaries, death notices or memorial services.” she stated. “Often, you can't even find a next of kin, a family to claim the body or anyone to hold a funeral either.”
Koh described a specific example where an unhoused individual was unable to have a proper autopsy.
“The autopsies aren't done, or they're incomplete. There was this patient who died, and in the weeks leading up to his death, he had urinary retention with his abdomen expanding. My colleague thought his condition might have been urosepsis, which perhaps could have caused his death,” Koh said. “At the same time, he was an opioid user, and so he had opioid in his system when he died. That was said to be the cause of death, but they never checked for urosepsis.”
She emphasized the importance of proper autopsies, as homeless individuals often might not be prioritized due to their housing status.
“So often, medical examiners assume that the person died of drugs. That could be true, but [the patient] also might have died of a heart attack, or died of urosepsis, or died of another cause,” she emphasized.
Koh also highlighted the mental toll endured by those facing homelessness, one possible reason being witnessing the deaths of those around them. Risks for mental health disorders can increase when an individual is homeless, and around 70% of them experience mental health disorders such as substance use disorder and depression.
Koh referenced a practice that Boston Health Care for the Homeless program conducts in response to their patient deaths and to potentially provide comfort to others in their grief, in addition to the many services provided.
“We honor all the people who have died in the past year: We read their names and we have some chaplains that we partner with. It’s always well-attended by other homeless people: they really care about and look after each other, and when other people die, they're really affected,” she said. “I think they come to honor the people that they knew and loved and spent time with, but also, I think it also gives them solace to know that if that were to happen to them, they'd also be remembered.”
One response to lowering disease and mortality rates in this population is through harm reduction. Patrick Winguth — a Hopkins alumni who graduated in 2024 who currently works as a harm reduction volunteer and organizer at the School of Public Health — spoke about his experiences in Baltimore regarding the relationship the homeless population has with health care.
“This varies from person to person – some people have said because they’re using or have a history of drug use, they were negatively treated by hospital staff, and it wasn’t a comfortable setting [for them]. Numerous people describe an inequitable power dynamic where they feel like they’re disregarded as people,” he said.
Winguth explained how harm reduction aims to be focused around empathy.
“We’ll help you if you want our help. We won’t try to force you into any sort of care, but providing a space where people can get basic needs taken care of opens the door for them to take their next step. There’s an empowerment through choice, which is what engages people with us,” he emphasized. “A big thing in harm reduction (yet not all-encompassing) is that [harm reduction] is also carried by people who use drugs too, providing a common area of trust. A lot of people in the space know what you're going through, they’ve been there, they know what you’re looking for in this current moment.”
