Marcel Slockers

13 General introduction of countries. According to available literature, psychiatric problems, infectious diseases and cardiovascular diseases account for the most important diagnoses among homeless people. 9,14,15,16,17 Since the 1980s, some research has been conducted into health problems and mortality among homeless people in the Netherlands. In 1985, Quispel described three groups of homeless people with the following problems: the classical tramp, often with alcohol problems; the poly drug users (especially opiates); and psychiatric patients, often recently discharged from an institute without adequate support after discharge. Many of the issues raised by Quispel are still relevant today. Quispel described, sometimes in slightly different words, care avoidance, poor patient compliance, problems in continuity of care and a lack of known medical history. The improper requests of homeless people for opiates and tranquillizers were also highlighted. In addition, Quispel described health insurance problems. He stated that it is hard to provide healthcare in the gap between the homeless shelters and the hospital and indicates that physicians tend towards medicalisation of homeless people. 18 Since the 1980s, harm reduction has been an important concept in addiction studies. This approach aims to reduce health and social damage by tolerating drugs and not just prohibiting them. Harm reduction has not only had positive effects on the people who use drugs, but their family, community and society benefit as well. 19 In 1995, descriptive research by the Dutch Health Council among a small group of homeless people showed a higher incidence of respiratory illnesses and musculoskeletal problems, gastro-intestinal, neurological, dermatological illnesses and infectious diseases. The report described the medical needs of homeless people and recommended a separate health insurance for this group. 20 In subsequent years, a number of incidental studies followed, aimed at specific health problems among homeless people such as alcohol problems, foot conditions and dental problems. 21,22 A study in Utrecht among psychiatric patients – including homeless people – showed a three times higher mortality risk compared to the general population. 15 Another study among homeless people showed a 29% higher prevalence of intellectual disability in this group. This intellectual disability, in turn, has a negative impact on substance abuse and overall health. 3 In 2009, Van Laere’s thesis on social medical care before and during homelessness was published. 23 He described characteristics of homeless people that contribute to evictions. Besides, he described excess mortality especially among rough sleepers who had been