Marcel Slockers

14 Chapter 1 seen in a daytime shelter and emergency night shelter in Amsterdam. A third of these 364 visitors showed a combination of addiction, psychiatric and physical problems (tri-mor- bidity). During a ten-year follow-up after the first contact, one fifth of these visitors had died, with an over-representation of men around the age of fifty. This mortality rate is seven times higher than the mortality rate of the average inhabitant in Amsterdam, adjusted for age and gender. The mortality rate of homeless women was thirteen times higher, and the mortality rate of men and women between 18 and 34 was eighteen times higher than in the general Amsterdam population. Multi-variable analysis showed a significantly increased mortality risk in homeless people with HIV, alcohol problems, chronic lung diseases and drug addiction. 3. What is known about mortality and health problems among homeless people in Rotterdam? Since the early 1980s, there have been street doctor’s consultation hours at the Centrum voor Dienstverlening (CVD) – a large welfare organisation in Rotterdam – at the Salvation Army, and in the Pauluskerk, a diaconal centre which supports people who cannot survive without help. These consultation hours have been mostly operated by General Practitioners (GPs) or geriatric doctors. Despite these consultation hours, not much is known about health problems and morbidity among the homeless people of Rotterdam. In the early 1980s, large cities in the Netherlands deteriorated. The Gemeentelijke Gezondheidsdienst (GGD), the Dutch Municipal Health Authority in Rotterdam, started epidemiological research to monitor the health situation of homeless people. Since street doctors were more in need of support than research data, the GGD decided to initiate participatory research among their nurses who would support the street doctors at the CVD locations. In 1994, the GGD stated in a report on social-medical consultation hours that homeless people suffer from many different illnesses and conditions. 24 The GGD described large numbers of homeless people suffering from psychiatric problems, addiction problems and infectious diseases or a combination of these. The street doctor’s consultation hours alone were not sufficient to deal with these observed multiple problems: medicine needed to be applied to the skin of people with scabies; people needing antibiotics did not take them; and suspected cases of tuberculosis (TB) never reached the special TB centre. Besides, the con- sultation hours were considered unsafe for the doctor. Therefore, it was recommended to strengthen the social-medical consultation hours by having both a doctor and a street nurse. In the early 1990s, the CVD and Salvation Army set up nursing departments for homeless people, which led to more adequate medical care. In the yearly quality reports of the nursing department of CVD Havenzicht, however, still only numbers of people that were hospitalised or had died were recorded. The underlying problems and illnesses remained unspecified. 25 Not until 2005 were records kept of the diagnoses of 250 patient contacts