Counting the deaths of people experiencing homelessness: why is this challenging work so important?

People living on the street in France die 30 years too soon – aged 50 years on average. Their deaths are also disproportionately due to violent causes – more than one in every five deaths in this population are the result of assaults, suicides, or accidents. This key message is repeated insistently by ‘Collectif Morts de la Rue’ (The Dead of the Street) – an organisation founded almost two decades ago by a group of associations that were involved in providing social and housing support to people experiencing homelessness across France. 

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Since its inception, the goal of the organisation has been to raise public awareness about the phenomenon of disproportionate mortality among the homeless; to ensure that people who have experienced homelessness have the right to decent funerals and remembrance; and moreover, to provide support and assistance to bereaved families and friends. Each year, the collective takes many actions, one of which is conducting the study soberly titled ‘Dénombrer & décrire la mortalité et les parcours’ otherwise known as ‘Counting & Describing.’ The aim of the study is to count how many people experiencing homelessness die in France and to describe their lived experiences (e.g., prior housing conditions, medical history, employment, and social assistance). These discernments are based on reports from social workers and the work of a volunteer team which I am happy to be part of.

Is the study novel?  

Many previous studies from a range of countries have described the extent to which homelessness increases mortality, as well as the cost it imposes on individuals and societies (1 2 3 4 5 6 7 8 9 10). However, not enough is being done to maintain a surveillance system to account for the diverse and changing faces of homelessness and the mortality rates of those experiencing homelessness. In France, for example, the latest study conducted by a public body dates back to 2012 – a context wherein it was unlikely that a study could fully capture the effects of the 2008 crisis, not to mention those of the current pandemic.  

Shouldn’t our primary concern be for the living?  

While some appreciate the effort to document these mortality rates, they also believe that the energy and resources would be better spent helping people who are alive. There is no denying that it is an enormous undertaking and that it is challenging. Yet, we argue that it is worth the effort. First, it ensures that this reality does not remain hidden by virtue of its complex and difficult-to-capture nature. Second, and as we know in public health, looking at deaths can be a means of better understanding the challenges and needs of the living.  

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Isn’t this a social issue rather than a public health matter?  

Social work is central to this topic, yet public health is also at stake. To improve health, we need to address broad determinants, including housing. Homelessness, in turn, results from a complex interplay of factors: individual circumstances; institutional and systemic failures; structural factors; or a combination of these. People might be temporarily or chronically without a home, with different needs as a result. Thus, social workers and public health practitioners have a shared interest in fighting homelessness and advocating for vulnerable populations.  

What are the challenges we face in this research endeavour?  

Ascertaining and describing homelessness data is not an easy feat. The reason for this is twofold. First, homelessness is itself an elusive concept and there is no universally accepted definition. Definitions even vary within countries, according to policy or administrative purposes. Thus, the study applies a broad definition of homelessness, drawing on the ETHOS typology (European Typology of Homelessness and Housing Exclusion) and including people ‘living rough’ (i.e. in public or external spaces) as well as people ‘living in emergency accommodations, institutions or temporarily with family and friends due to lack of housing’.  

Second, even once you have agreed upon a definition, identifying that a deceased person was experiencing homelessness is not an easy task: homelessness is neither a status nor a disease; even if homelessness can theoretically be reported as a cause of death on death certificates, practices vary. Additionally, many people experiencing homelessness have registered addresses for administrative reasons, and thus looking at administrative registers often provides little information. 

Surveillance largely relies on deaths being reported by a network of associations operating nationwide, by media, or by institutional sources. When we learn about the death of a person that may have been homeless, we first try to confirm their identity; then, we try to identify several persons that may have known them, mostly social workers. Eventually, we conduct one-on-one interviews based on a questionnaire shaped to ascertain homelessness and to collect information about lived experiences.  

Study shortcomings 

The report is not comprehensive. The study includes around 600 deaths, out of an estimated 2,000 deaths occurring among people experiencing homelessness each year. Moreover, results might be biased towards highly-publicised and violent cases, or those occurring where social services are present. However, despite these limitations, and after researching for other comparable work, the study was deemed the most reliable source of information on the topic by public authorities in 2012 and received financial support from the Ministry of Health. Today, the quality of the research keeps improving. 

Do you want to know more? 

Go to the website Dénombrer & décrire la mortalité et les parcours - Collectif Morts de la Rue. Similar initiatives may exist where you live, I am happy to share further!  

Contact: nicolas-julien.noiriel1@student.lshtm.ac.uk / www.linkedin.com/in/nicolasnoiriel