By Kyle Jones
In an article in the February 22nd issue of the Los Angeles Times titled “Feds try to curb outbreak of TB on skid row”, authors Anna Gorman and Andrew Blankstein described a new coordinated operation by Los Angeles county Public Health officials on a persistent outbreak of tuberculosis in the skid row area of downtown LA. The Center for Disease Control and Prevention has sent officials and scientists to the city to discover the source and contain the outbreak, which has potentially been exposed to over 4,500 people . A majority of the disease cases are among the homeless people that live in the skid row area, complicating the treatment and containment of the outbreak. The homeless population is more susceptible to communicable diseases because of their limited access to health care, poor living conditions, and poor hygiene and nutrition . Efforts to increase the access of health to the homeless have been ongoing, yet this recent outbreak reveals an underlying consequence of poor health of those living on the streets. Beyond the importance of providing the right to health for homeless people, the threat of uncontained outbreaks can have implications to medical service providers and surrounding populations.
Homelessness in the United States is a major public health issue, with 633,782 people homeless on a single night in the U.S. in 2012 . Around the world, an estimated 100 million people are homeless according to a United Nations Commission on Human Rights in 2005. Additionally, the prevalence of communicable diseases such as HIV, hepatitis B and C, and tuberculosis is higher among the homeless population than the general population. In fact, although the overall incidence of tuberculosis in the United States has been declining, among the homeless population it is rising . Medical treatment for these diseases for homeless people is a difficult task. Many do not have access to health care and few are insured. Additional health issues, such as mental illness or diabetes, often complicate treatment. Furthermore, because of the inconsistency of living conditions and locations of homeless people, follow-up and monitoring appointments are challenging for drug treatment plans. The inability of homeless people with active cases of TB to seek successful treatment and complete drug regiments increases likelihood of outbreaks and progression of multi-drug resistant strains. Thus, not only are the health of the homeless population in jeopardy, but also the health of the general community.
Access to health care for the homeless and interventions to control TB outbreak has increased in recent years. Homeless shelters are now setting up tuberculosis screenings upon entrance and medical outreach programs are taking health care to the streets. With the Affordable Care Act, Medicaid coverage will be expanded to individuals with incomes up to 138% of the federal poverty level. This increase in coverage will significantly help extend health care access to homeless people. Yet barriers still exist in providing treatment to those who live on the streets. Documentation and application to receive Medicaid funds prove difficult for homeless people who often have no forms of identification. Also the avoidance of shelters, which can be overcrowded and unsafe, prevents homeless people from receiving beneficial health screenings.
Increasing access to medical care and treatment of infectious diseases for the homeless population is essential. The homeless are a sub-group of the general population that is often neglected despite having a large impact on the health of the community. For many people that live on the streets, poor health or inability to pay for health care have lead them to their homelessness. Yet addressing the lack of medical care of the homeless is not enough. Developing programs and providing resources to tackle the other issues that often accompany homelessness, including instable housing and unemployment, must occur for the medical care to be effective. These programs together can reduce the prevalence of both communicable diseases among the homeless population as well as homelessness itself. Better health of the homeless will result in better health of the general population. It is time we stop ignoring the men and women on the streets of our cities and provide them with the help and care that every human deserves.
 United States Department of Housing and Urban Development
 Badiaga, Sekene, et al. Preventing and Controlling Emerging and Reemerging
Transmissible Diseases in the Homeless. Emerg Infect Dis. 2008 September; 14(9): 1353–1359
 Beijer, Ulla, et al. Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis. Lancet Infect Dis. 2012 November; 12(11): 859–870