Deaths Among Homeless Persons -- San Francisco, 1985-1990

In San Francisco (1990 population: 723,959), an estimated 6000-18,000 persons are homeless. To characterize the causes of death among homeless persons in San Francisco during 1985-1990, the Health Care for the Homeless Program, San Francisco Department of Public Health, reviewed records of homeless decedents from the city medical examiner's (ME's) office. This report summarizes the results of that study.

The San Francisco ME's records were reviewed for January 1, 1985, through December 31, 1990. ME cases were classified as "homeless" if, after thorough investigation, no residence could be established for the decedent or if the residence listed was a shelter for homeless persons or one of the single-room occupancy (SRO) hotels used by the San Francisco Department of Social Services to temporarily house homeless persons. Although this methodology was consistent during the study period, the study could not include homeless persons who obtained a residence shortly before their deaths and some persons who were hospitalized at the time of death.

During the 6-year period, 644 deaths were identified among homeless persons (Table 1), of whom 567 (88%) were men. Four hundred thirty-eight (68%) were white; 155 (24%), black; 26 (4%), Hispanic; 13 (2%), American Indian/Alaskan Native; six (1%), Asian/Pacific Islander; and six (1%), undetermined. The average age at death was 41 years (standard deviation=plus or minus 12 years). Location of Death

Deaths occurred most commonly outdoors (e.g., on the street or sidewalk or in parks) (225 (35%)); 155 (24%) occurred in an emergency room or a hospital (approximately half of these persons were probably dead when they were found but were declared dead at the emergency room to which they were transported (San Francisco ME, personal communication, April 1991)). One hundred thirty-five (21%) were found in a building (usually a SRO hotel in which they did not live or an abandoned building); 90 (14%) were found in a SRO hotel in which they lived, and 32 (5%) were found in vehicles in which they lived; for seven (1%) decedents, the location of death was undetermined. Manner of Death

The manner of death is determined by the ME to be natural, "accidental," * homicide or suicide (i.e., intentional), or undetermined. The ME determined that 254 (39%) deaths were natural, for an average annual crude death rate of approximately 235-705 (using the estimates of 18,000 and 6000, respectively) per 100,000 homeless persons. Of the other 390 deaths, 216 (34%) resulted from unintentional injuries, 81 (13%) from homicides, 36 (6%) from suicides, and 57 (9%), from undetermined causes (Table 1). Presence of Alcohol or Drugs

Either drugs or alcohol were detected in 503 (78%) decedents (Table 2). Based on a blood alcohol concentration (BAC) greater than or equal to 0.1 g/dL as the definition,** one third of decedents were legally intoxicated at the time of death.

Morphine (i.e., the breakdown product of heroin) was the most common illicit drug detected (137 (21%) of all deaths). Cocaine was detected in 93 (14%) and amphetamines in 53 (8%). Evidence of drug use among decedents increased during the 6-year period (Table 2); in 1985, evidence for use of cocaine, amphetamines, and morphine was detected in five (4%), five (4%), and 21 (19%) decedents, respectively, compared with 22 (24%), 13 (14%), and 30 (32%), respectively, in 1990. Adapted from: San Francisco Epidemiologic Bulletin 1991;7(4), as reported by: DM Wlodarczyk, MD, F Teng, MD, R Prentice, PhD, Health Care for the Homeless Program; F Taylor, MD, Bur of Epidemiology and Disease Control, San Francisco Dept of Public Health; BG Stephens, MD, Chief Medical Examiner, City and County of San Francisco. Office of the Director, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The patterns of death among homeless persons in San Francisco are similar to those reported from an ME investigation in Atlanta (1). Based on that study, natural causes, homicide, and suicide accounted for 40%, 10%, and 3%, respectively, of deaths among homeless persons in Atlanta during July 1985-June 1986 (compared with 39%, 13%, and 6%, respectively, of deaths in San Francisco). In Atlanta, however, the proportion of deaths resulting from unintentional injuries (48%) was greater than in San Francisco (34%).

The study in San Francisco also provides an indication of patterns of use of alcohol and illicit substances among homeless persons in that community. In particular, although the proportions of decedents in whom alcohol was detected remained relatively constant during the 6-year period, cocaine, morphine, and amphetamines were detected in increasing proportions of persons. This trend underscores the need for outreach services and other innovative approaches to address substance abuse in homeless populations.

Because of the circumstances of homelessness, public health agencies and other organizations cannot readily quantify or characterize the health status of homeless persons. Although the report from Miami (2) describes one approach to characterizing the health status of and risk factors among the homeless, that approach may not be practical as a routine method for many communities. As the study in San Francisco illustrates, however, findings from ME investigations provide other means for assessing the public health status of this population. In California and other states, MEs and coroners are responsible for investigating and certifying all deaths resulting from other than natural causes, as well as apparently natural deaths for which there was no attending physician or an attending physician could not determine the cause (3,4). Public health agencies and other organizations providing health services to the homeless may find ME and coroner data useful in guiding the delivery of services to these persons.

References

1. CDC. Deaths among the homeless--Atlanta, Georgia. MMWR 1987;36:297-9.

2. CDC. Characteristics and risk behaviors of homeless black men seeking services from the Community Homeless Assistance Plan--Dade County, Florida, August 1991. MMWR 1991;40:865-8.

3. CDC. Death investigation--United States, 1987. MMWR 1989;38:1-4.

4. Combs DL, Parrish RG, Ing RT. Death investigation in the United States and Canada, 1990. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1990.

• When a death occurs under "accidental" circumstances, the preferred term within the public health community is "unintentional injury."

** Until 1990, a person with BAC greater than or equal to 0.1 g/dL was considered legally intoxicated in California; in 1990, this was reduced to greater than or equal to 0.08 g/dL.

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