The Hidden and Undetected Can Be Deadly
June 15, 2018
Dear Colleagues and Students:
With summer in full swing, climbing temperatures have put the nation’s homeless at a new set of risks. I am surely not alone in noticing many more homeless people on the streets and in parks here in New York City, sleeping outdoors and foraging for food.
So it was with great interest that I read last week how nine communities are working to establish a new standard for homelessness called “functional zero,” which indicates that homelessness is rare and much briefer than in the past for their populations.
According to the New York Times, “For the first time, many communities across the country are collecting and maintaining real-time data and lists of the names of people experiencing homelessness, and from those are deepening their understanding of the dynamics of a complex and ever-changing problem. They’re also imitating the kind of command-center-led coordination efforts that have been crucial to historic public health victories, such as the eradication of smallpox and the near-eradication of polio. And they are linking in a national network, capturing and sharing effective strategies, as they emerge, to improve their performance."
Examining what ultimately eradicated smallpox might hold the key. “Ms. Haggerty of Community Solutions said, “it was the construction of a surveillance system — a culture of iteration, habits of ongoing problem solving, understanding that it needs to be a team, data to keep you connected and focused. We’re finding that that’s at the core of ending homelessness, too. There will always be people having housing emergencies, but we can shrink it to a totally manageable number so that homelessness becomes rare, brief when it happens, and doesn’t recur."
Some of the world’s most pressing problems are persistently visible – like people curled up in doorways or begging for change. Others are harder to detect and address, and indeed due to similar stigma they remain hidden.
I know that legions of women, fashion-industry followers, family and friends were reminded of hidden problems last week when Kate Spade took her own life, and her years of anxiety and depression were made public. Then on Friday came the shocking news of Anthony Bourdain’s death. As underscored in this Washington Post article, “Increasingly, suicide is being viewed not only as a mental health problem but a public health one. Nearly 45,000 suicides occurred in the United States in 2016 — more than twice the number of homicides — making it now the 10th-leading cause of death. Among people ages 15 to 34, suicide is the second-leading cause of death."
Picture source: CDC https://www.cdc.gov/media/releases/2018/p0607-suicide-prevention.html
Both Spade’s and Bourdain’s deaths coincided last week with the release of a troubling new study by the US Centers for Disease Control and Prevention finding that “suicide rates rose in all but one state between 1999 and 2016, with increases seen across age, gender, race and ethnicity.” (Nevada is the state with the lowest rate of suicide.) The research concluded that “in more than half of all deaths in 27 states, the people had no known mental health condition when they ended their lives. The most common method used across all groups was firearms.” As we discussed in a recent forum on gun violence here at the College, many of these acts are spontaneous reactions to short-term circumstances, and the presence of "lethal means" as cited in the Mortality and Morbidity Weekly Report contributes substantially.
We still may be speaking in Orwellian terms when our highest public health agency has difficulty directly highlighting the role of guns in household suicide. Hopefully we are on the brink of some much-needed change in this regard.
The American Psychological Association’s former president put it this way: “Suicide is a public health crisis when you look at the numbers, and they keep going up. They're up everywhere. And we know that the rates are actually higher than what’s reported. But homicides still get more attention."
Dr. David Satcher, our graduation speaker last month, issued a report in 1999 on the state of mental health in the US when he served as the US Surgeon General. That study identified suicide as "a significant public health problem." The latest data at that time showed about 30,000 suicides a year. Today, they number 45,000 -- a mammoth increase fueled by many factors, including the recession and its associated job loss and housing dislocation.
Mental illness is often the culprit behind homelessness, homicides and suicides, but as we in public health know, mental illness and substance abuse is fueled by social determinants including lack of access to early intervention; gaping income inequalities; and a lack of adequate mental health services and access to them. Add to this the grinding stigma that keeps people away from services.
We must do more to find innovative solutions to address these interrelated problems. Far too many lives are at stake if we fail.
Cheryl G. Healton, DrPH