无家可归与健康.

公共卫生的一个核心目标是照顾我们社会中最脆弱的成员——被边缘化和被剥夺财产的人。 At this festive season, when friends and family gather together, and “丰富快乐,” it seems to me especially important that we focus on these vulnerable groups—people who find themselves excluded from the resources and community ties that generate health. 出于这个原因，我们将运行一个“三部曲”的迪恩笔记，澳门威尼斯人注册造成这种边缘化的条件，本周从无家可归开始。 目标是在这个节日期间激发人们对弱势群体的反思，他们面临的挑战是公共卫生的核心关切。

在美国，无家可归是一个持续存在的、显而易见的健康挑战。 While we are fortunate to have many programs dedicated to caring for the homeless here in Boston, including the 波士顿无家可归者医疗保健项目—an organization 我们荣幸, along with its founder 吉姆·奥康奈尔, at our recent gala—we nevertheless are daily confronted by the problem of 无家可归. The US Department of Housing and Urban Development conducts an 无家可归者的年度统计 in the US, and found an average of 564,708 people living on the streets per night in 2015年1月. This number had declined overall in the preceding years (2007年有651142人无家可归), but increased in various places, importantly in 纽约市, where about 14 percent of the national homeless population resides. 下面的图1显示了近年来全国无家可归者的变化。

大多数无家可归的人只被认为是短期的无家可归者，但一小部分无家可归者长期无家可归30至40年。 In 2015年的统计, 83,170 individuals and 13,105 people in families with children nationwide had either been continuously homeless for a year, or experienced at least four episodes of 无家可归 in three years. 此外，36%的无家可归者是有孩子家庭的一部分。 如图2所示。

有大量证据表明无家可归对健康的影响。 At a fundamental level, the homeless have 更高的过早死亡率 than those who are appropriately housed, with injuries, unintentional 过量, and extreme weather events being important drivers of this mortality. The homeless also have poor quality of life, characterized, as noted in various studies, by 慢性疼痛 associated with poor sleeping conditions and limited access to medications and other salutary resources. 皮肤和足部问题在无家可归的人群中，也很容易出现牙齿问题和慢性传染病。 For a comprehensive review of the health of the homeless, I would refer to this 出版工作.

无家可归的难处——我们都知道无家可归是一种挑战，它威胁着健康——对我们如何看待无家可归及其后果，以及我们如何设想解决方案提出了挑战。 也许一个有用的框架是通过强调与无家可归相一致和促成无家可归的因素，来考虑整个生命过程中的无家可归问题。

美国23%的无家可归者年龄在18岁以下。 无家可归的青年尤其容易吸毒； 一项澳门威尼斯人注册网站研究 发现55%的街头青年和34%的收容青年在离开家后使用过非法药物，相比之下，从未无家可归的青少年中这一比例为13%。

Importantly, and signaling one of the central contributors to 无家可归, a 洛杉矶无家可归青少年的样本 showed that 32 percent reported a need for help with mental health problems and 15 percent met criteria for emotional distress. 在男同性恋、女同性恋、双性恋青年和黑人青年中，有情绪困扰的比例更高。 据估计，与其他青少年相比，无家可归的青少年患抑郁症的人数大约是其他青少年的三倍。 Homeless adolescents are also likely to 经历暴力: 21 percent to 42 percent report sexual abuse, compared to one percent to three percent of the general population, and about 40 percent have reported being 被武器袭击. 大约40%的人认为自己是LGBT。

As with youth, homeless adults are also at greater risk of 物质使用障碍 and 过量 compared with the general population. They are also very likely to 吸烟. Homeless adults are disproportionately affected by 精神疾病, though it is difficult to estimate the true burden among this population, considering they are usually excluded from national surveys. 患有精神疾病的无家可归者往往与家人或朋友的联系较少，而且更有可能在更长时间内无家可归。

由于缺乏收入，老年人在以后的生活中有无家可归的风险。 具体来说，那些年龄在65岁以下、尚未获得医疗保险或社会保障福利、失业的人可能特别容易受到伤害。 Additionally, older veterans make up a large portion of the homeless population, although the proportion of veterans who are homeless has 减少 since 2009. In 2015年1月, 47,725 veterans were considered homeless on a given night.

因此，无家可归与社会经济脆弱性和不良行为健康（包括精神疾病和药物使用）在很大程度上是一致的。 这就引出了我们可以考虑采取的减轻无家可归后果的方法。 Much of the literature in the area suggests that 干预措施 that provide case management for substance use and mental illness and critical time intervention approaches to mitigate the consequences of acute stressors can be effective in reduction of 无家可归. 然而，这些方法依赖于卫生保健和卫生保健系统中的干预措施。 然而，它们并没有排除，也没有取代解决社会政策和结构性因素的方法的中心地位——包括缺乏经济适用房和针对弱势和低收入个人的社会安全网——这些最终为边缘化人群无家可归和住房不稳定创造了条件。 对于任何对这个话题感兴趣的人，我最近有幸在多伦多为我们的校友主持了一场澳门威尼斯人注册这个话题的谈话。 事件被归档 在这里。

我希望每个人都有一个美好的一周。 下周见。

温暖的问候,

桑德罗

桑德罗 Galea, MD, DrPH
Dean and Robert A. Knox Professor
波士顿大学 公共卫生学院
推特: @sandrogalea

Acknowledgement: I am grateful for the contributions of Laura Sampson and Eric DelGizzo to this Dean’s Note.

以前的院长笔记存档于： /sph/tag/deans-note/