Marcel Slockers

83 Changes in the causes of death of homeless people in Rotterdam The Dutch social policy measures were not accompanied by a mortality reduction in chronic diseases. We previously hypothesized that our cohort of homeless persons carries the burden of a long previous history of homelessness, unhealthy living circumstances and lifestyles (e.g. long-term use of alcohol and illicit drugs, heavy smoking) and related chronic health problems (e.g. atherosclerosis and chronic obstructive lung disease). 16 This may have induced permanent damage to several organ systems that cannot be reversed by any social policy and explains why a short-term effect on chronic disease mortality was not found. This is in line with previous research, suggesting that adverse health outcomes among long-term homeless persist after individuals obtain housing. 22 But why did total mortality among homeless people remain unchanged in spite of large and significant mortality reductions related to intentional injury? After 2006, homeless people started to lead safer lives with community guidance in protected housing. Their lifestyles, however, have not necessarily become healthier as well and novel habits and conditions (e.g. lack of movement, sugar addiction and obesity) could have further compromised their bad health status. This could have induced an increase in cardiovascular disease mortality. In our study, we observed this type of trend, which was however not significant. We therefore hypothesize that after the implementation of social policy measures a substantial number of suicides and homicides could be prevented among homeless persons already suffering from a severely compromised health status due to a variety of natural causes. Within this very vulnerable group unnatural deaths prevented are instantaneously replaced by competing natural death risks and total mortality remains unchanged. In our cohort similar mechanisms could be involved as in Housing First (HF) participants in the USA, who have a higher disease burden and are more vulnerable to death than those who remain on the street. 10 This mechanism is called ‘vulnerability indexing’: individuals with the most severe medical conditions and the highest risk of deathreceive priority for placement in housing or other support. 23 We hypothesize that vulnerability indexing may have prioritized social help for homeless with the highest care needs and may have induced suicide and homicide prevention in—mainly—the most severely ill persons in our cohort. Our findings have implications for policymakers, public health professionals, and general practitioners and clinicians serving this population. Reducing unnatural death should be an important target in social policies aimed at improving the health of homeless people. We generated the hypothesis that social policies providing housing, supporting the acquisition of a legal income and improving contacts with community and (mental) health care services could be accompanied by less suicides and homicides within this vulnerable group.