Towards Better Health

Germany claims for itself that it has a healthcare system that is shaped by solidarity and that is high-performing. In principle, all members of statutory health insurance companies are entitled to comparable services, independently of the amount of membership fees paid. Health for all is a human right that Germany strives to achieve (§ 12 UN social covenant). And yet, serious and group-specific differences exist regarding the risk of illness and life expectancy, and this is the case especially for homeless people in Germany.

Stefanie Schreiter et al. found on the basis of their systematic review that the prevalence of mental disorders is notably higher in homeless people than in the general population (1). In homeless people, the prevalence of substance misuse related disorders is 60.9%—which is 21 times the rate seen in the general population. The prevalence of mental disorders is 3.8 times that in the general population. The authors rightly call for more targeted healthcare services. This is equally true for the general medical care for homeless people, which is often impossible to provide within the context of standard healthcare services. This is the result of a review article reported by Hanna Kaduszkiewicz and colleagues, who studied the medical treatment of homeless people (2).

Increasing numbers of homeless people

Germany does not have a consistent statutory reporting system for housing emergencies in place, and for this reason, the numbers of homeless persons and those at risk of homelessness can only be estimated. What is certain is that the numbers will rise—the estimated number of 335 000 homeless people in 2014 is expected to rise to 536 000 in 2018 (3). And these numbers include far more than just the cliché of the bearded vagrant on the park bench: migrants, young people, and even women are increasingly affected by homelessness (3). However, at the last estimate the proportion of men (72%) was still notably higher than that of women. The number of persons who live in the streets, entirely without a roof over their heads (“sleeping rough”), was about 39 000 in 2014 (3).

Homeless people are very often in poor health. In addition to mental disorders, skin problems, asthma and other lung diseases, and poor teeth are predominant. Older homeless persons (over age 50) are often found to be prematurely old. Estimates assume that life expectancy in this age group is reduced by 10 years (4). The German Federal Task Force on Homelessness even suspects that life expectancy for homeless men is reduced by three decades.

Many homeless people shy away from accessing medical practices—this leads to delays in diagnosing their illness, which may spread as a result. Systemically, it is obvious that homeless persons do not have adequate access to traditional healthcare services; the system of services available is inappropriate for this target group.

Difficulty in accessing services

According to the social code, homeless persons are entitled to basic social benefits and social participation services as well as health insurance. But the absence of a fixed abode makes accessing such services difficult—for example, if state offices refuse to accept a claimed address. Many helpers have reported that homeless people were referred to authorities in neighboring municipalities after a limited amount of time. Studies and data collections of various institutions, associations, and research groups confirm that access to healthcare for this group of people is notably difficult and the health risks therefore higher (5). Persons who live in the street, sleep in hostels, or are at acute risk of imminent homelessness will access medical services only in emergencies (in spite of multiple pathologies), and often they do not have the safety net of health insurance to enable them to access regular healthcare services. For this reason, certain institutions, associations, and registered associations/clubs in many cities provide easy-access—and even visiting—healthcare services, such as street outpatient clinics. North Rhine–Westphalia, for example, offers diverse projects providing mobile medical and psychiatric services to homeless people, according to a concept agreed with the medical associations of North Rhine and Westphalia–Lippe, statutory sickness funds, and municipal authorities (6). Unfortunately, to date this model has not been adopted widely.

The recently published study SEEWOLF (7) on rates of mental disorders seen in institutions collaborating within the homeless assistance network (“Wohnungslosenhilfe”) in the Munich area gives an insight into different disorders and treatment options. The study showed that what is required is care/attention, medical treatment, ongoing support, and communication that are specifically tailored to the needs of this target group:

• Physical illnesses: The somatic disorders affecting homeless persons require more consistent ambulatory nursing care. For this reason alone, cooperation with hospices, nursing homes, and hospitals will need to be intensified.

• Mental illnesses: The spectrum of mental symptoms in homeless people is wide—ranging from withdrawal and a tendency to personal neglect to a lack of distance and disorderly conduct towards staff. All this means that the staff in homeless support organizations and also medical staff are faced with a difficult task. Exchanges of practical information between social workers and medical staff should be intensified, in order to develop appropriate strategies/patterns for action.

• Addiction disorder and motivation to change: addiction services, which work with the program “controlled drinking” are primarily directed at groups of persons who are not, or not yet, ready for abstinence.

Requirements and consequences

The pivotal point for moving towards a healthier life is the provision of appropriate accommodation/housing for homeless persons. This will eliminate the causes of many diseases and is part of providing humane conditions for lives lived on the breadline—this should be subsidized by the federal, state, and municipal governments. Housing policy should be understood as an existential provision, closely linked to health and social policies. By guaranteeing living quarters, existential health risks that go hand in hand with homelessness can be avoided.

It would be medically helpful and effective to intensify the provision of visiting and easy-access treatment services, in order to enable entering and transitioning into the “normal” health care system.