Journal articles on the topic 'Shelters for the homeless Homelessness Homeless persons and violence'

Exposure to violence, vulnerability due to lack of shelter, alienation due to stigma, the experiences of severe mental illness (SMI) and subsequent institutionalization, make homeless persons with SMI uniquely susceptible to trauma exposure and subsequent mental health consequences. This study aims to contribute to the development of culturally sensitive interventions for identifying and treating trauma in a population of homeless persons with SMI in Tamil Nadu, India by understanding the manifestations of trauma and its associated consequences in this population. Free-listing exercises followed by in-depth interviews were conducted with a convenience sample of 26 user-survivors who have experienced homelessness or were at risk of homelessness, and suffered from SMI. Topics explored included events considered to be traumatic, pathways to trauma, associated emotional, physical and social complaints, and coping strategies. Results indicate discrepancies in classification of traumatic events between user-survivors and the Diagnostic and Statistical Manual of Mental Disorders. Traumatic experiences, particularly relating to social relationships and poverty, mentioned by user-survivors did not match traditional conceptualizations of trauma. Positive coping strategies for trauma included being mentally strong, knowledge and awareness, whereas the main negative coping strategy is avoidance. User-survivors attributed their experiences of homelessness and SMI to past traumas. Differing views of trauma between user-survivors and mental health professionals can lead to misdiagnosis and under-recognition of trauma in this population of homeless persons with SMI.

The current study examined the potential relationship between homelessness, gender, and occurrence of Post-Traumatic Distress Disorder (PTSD) and Complex PTSD. Participants were 90 homeless persons from shelters located in a large, South Central Texas, metropolitan city of approximately 1.9 million persons. The study found that homeless participants reported high levels of childhood emotional, physical, and sexual abuse. Homeless women reported higher rates of childhood abuse and were affected by PTSD at a higher frequency than homeless males. PTSD, Complex PTSD, and traumatic experiences such as childhood abuse appear to be contributing factors to homelessness. Results suggest the need for increased advocacy among counseling and psychology professionals is warranted for homeless persons experiencing PTSD.

On a global scale, the number of families with homeless children is growing. Foreign research shows that homelessness is linked to social adjustment problems. In the Czech Republic there are no surveys on social adjustment in the homeless children population. This article presents partial data from a research survey focused on the situation of homeless mothers with children residing in shelters. The article aims to find out how mothers residing with their children in homeless shelters in the city of Ostrava interpret the social adjustment of their children. The research strategy is qualitative, based on a participatory approach (cooperation with two peer researchers). 33 interviews and 6 focus groups were implemented as part of the research. The research findings also point to a close link between the situation of homelessness and social adjustment of homeless children in the Czech environment, namely as a result of the necessity of socialization in a specific environment with negative consequences on the parenting style and success in school of the children combined with their experience of domestic violence. The research findings imply in practice the need to apply the concept of critical reflexivity in social work with children from homeless shelters.

Cardiovascular disease (CVD) in the United States disproportionally affects people who are homeless. This disparity is a critical concern that needs to be addressed to improve the health of individuals who are homeless. The connections between a history of homelessness, i.e., its duration and frequency, and CVD risk are not well understood. The present study sought to investigate how a history of homelessness is correlated with CVD risk factors in a sample of homeless persons in the Deep South. This study recruited participants who were homeless from two local adult homeless shelters in Birmingham, AL. Participants (n = 61) underwent interviews, physical measurements, and a capillary blood draw. Their mean age was 47 years, and 82% were men. Results showed the duration of homelessness was positively associated with several CVD risk factors (diabetes mellitus, total cholesterol, and low-density lipoprotein). However, there was no significant association between frequency of homelessness and any CVD risk factors. To get the more accurate estimate of CVD risk in this population, future research should incorporate additional risk factors related to homelessness and seek to develop a robust strategy to collect an accurate history of homelessness.

Background: While homelessness and problem gambling are both recognised as social and public health concerns and the prevalence of addictive disorders among homeless populations tends to be high. These questions have been studied predominantly independently. Aim: The aim of the study was to explore the co-occurrence of the two phenomena among the homeless population using shelters and night shelters in Warsaw, and, more specifically, to provide information about the forms and frequency of gambling in this homeless population. Method: Homeless persons ( N = 690) were interviewed in rehabilitation-shelters ( n = 17) and night-shelters ( n = 2) in Warsaw from November 2015 until January 2016. The core component of the questionnaire was a screening test (Problem Gambling Severity Index). In addition, data regarding the intensity of gambling and various types of games or settings were collected. Results: The prevalence of problem gambling in this population of homeless people was 11.3%, whereas the prevalence of problem gambling in the general population in Poland is much lower (0.7%). Similarly to the general population, the most prevalent gambling games in the homeless population were lotteries; however, homeless people gambled in lotteries almost three times more often compared to the general population. Conclusions: This is the first study examining the prevalence of problem gambling in the homeless population in Poland. The findings of the study suggest that problem gambling among the homeless is a significant social and public health concern. High rates of problem gambling in the homeless population show the need to identify and monitor this problem in shelters and consequently to provide easier access to gambling treatment or prevention programmes.

Persons experiencing homelessness have a high prevalence of severe mental health problems, alcohol dependence, substance misuse and infectious hepatitis C, and face up to twelve times higher mortality rates compared to the general population. They also face barriers to accessing healthcare. However, clinical pharmacy services are currently not available to homeless populations in England. The aim of this study was to conduct public involvement sessions with persons experiencing homelessness with a view to inform the design of patient-centred clinical pharmacy healthcare services. Qualitative methodology was used, using a focus group with homeless persons from emergency shelters and one to one engagement with those sleeping rough, using a topic guide. A total of nine homeless persons took part—seven males and two females. The participants of the sessions said that patient-centred clinical pharmacy services delivered for homeless persons would address many of their unmet needs around access to medicines, their understanding of prescribed medicines and holistic management of their health. The service would be able to make a positive impact on their health outcomes by screening for health conditions, facilitating better integration across services, referral and liaison with other services, and minimising misuse of prescribed medicines. The findings of this study will be used to inform the development, implementation and evaluation of a patient-centred clinical pharmacy service tailored to meet the specific needs of the homeless population.

Abstract Background Persons experiencing homelessness (PEH) often do not have sufficient resources to practice public health interventions. PEH may reside at overcrowded shelters, have poor access to health care, and often suffer from significant co-morbid conditions. In this study, we describe prevalence of COVID-19 amongst PEH and homeless service staff in Atlanta, Georgia, as well as demographic data, underlying conditions, and symptoms. Methods In response to the COVID-19 pandemic in Atlanta, PEH and homeless service providers were offered PCR testing for SARS-CoV-2 via nasopharyngeal, nasal mid-turbinate, and oropharyngeal swabs. Shelters identified as having a higher number of COVID-19 infections underwent re-testing 3–4 weeks after initial testing. Demographic information was collected, and individuals were screened for symptoms and underlying conditions. Results A total of 2,294 PEH and 544 staff underwent SARS-CoV-2 PCR testing from April 8 - May 6, 2020. 24 homeless shelters were included in this study. The majority of individuals were male (66.3% sheltered, 85.5% unsheltered, 55.3% staff), and 2,192 of 2,838 (78.3%) persons identified as black. Approximately half of individuals had no known underlying conditions (51.5% sheltered, 47.7% unsheltered, 55.5% staff). Cardiovascular disease was the most frequently reported condition (32.0%), followed by chronic lung disease (14.8%). In total, 45 of 2,823 (1.6%) individuals had detectable PCR results for SARS-CoV-2, including 35 of 1,666 (2.1%) sheltered clients, 3 of 614 (0.5%) unsheltered clients, and 7 of 543 (1.3%) staff. Among individuals with detectable SARS-CoV-2, 5 of 20 (25%) reported at least one symptom in the last week. Most shelters (16 of 24) had at least one individual with detectable SARS-CoV-2. The prevalence of SARS-CoV-2 in the majority of shelters (19 of 24) was < 3%, with a median prevalence of 0.2% across all shelters. Upon retesting 4 shelters with a higher number of COVID-19 infections, only 3 individuals from 2 shelters tested positive out of 357 total retested (0.8%). Conclusion We identified a low prevalence of SARS-CoV-2 infection among PEH in Atlanta, which was influenced by a pre-emptive testing strategy. Continued vigilance is necessary to limit spread in this vulnerable population. Disclosures All Authors: No reported disclosures

Introduction: Understanding how homeless patients interact with healthcare systems can be challenging. The nature of the population is such that identifying and following these persons can be severely limited by data. Previous studies have used survey data which relies on self-reporting and selected samples such as those persons admitted to homeless shelters (Gray et al. 2011). Other studies have been able to leverage administrative data but only for selected local geographic areas (Somers et al. 2016, Tompkins et al 2003). It is possible that the current literature has not examined a large proportion of homeless persons and their healthcare use. This is concerning because this population can have higher associated medical costs and greater medical resource utilization especially with regards to psychiatric and emergency department (ED) resources (Tulloch et al. 2012, Forchuk et al, 2015). Methods: Administrative health data (2010 to 2017) is used to analyze ambulatory care records for homeless individuals in Ontario, Canada. Uniquely, we are able to use ED contacts as a way of identifying homeless migrations from region to region within Ontario. Using a network analysis we identify high impact ED nodes and discrete hospital networks where homeless patients congregate. We are also able to more fully characterize this population's demographics, health issues, and disposition from the ED. Results: We provide a more complete understanding of migration patterns for homeless individuals, across Ontario and their concomitant ED use and hospitalizations. The three most frequented regions in Ontario (n = 640,897) were Toronto Central (35.96%), Hamilton Niagara Halimand Brant (8.9%) and Champlain (7.84%). In subsequent visits, the majority of patients presented to different EDs, however a subgroup who always presented to the same site was present. Over the 7 year period, migration between visits occurred most often between urban areas, and increased as a whole. Conclusion: The results of the study allow for the enhancement care coordination for vulnerable populations and enhance the availability and delivery of services for sub-groups of homelessness whose care needs may differ based on migration patterns. Services can be coordinated between jurisdictions for homeless individuals, and appropriate referrals can be made across the health care system. Further evidence is provided for a novel method of mapping migration among the homeless and its associations and effects on ED use.

This study aimed to analyse homeless women’s life experiences during pregnancy in shelters, drop-in centres and outreach services in Iran. In this qualitative study, thematic analysis was used to explore the experiences of 13 homeless women. The results showed that all participants were substance abusers, most commonly with methamphetamine. Consistent themes emerged from the data: (a) women’s understanding, feelings and actions regarding unplanned pregnancy, (b) violence in public places, (c) social rejection, (d) maintaining femininity through maternal roles within hegemonic masculinity, (e) social exclusion, and (f) addiction as an aggravation of homelessness. In conclusion, we encourage social welfare policy and policy makers to focus on street outreach.

Introduction: As homeless people in general suffer from poor health and are at elevated risk for COVID-19 infections they have an indication for receiving COVID-19 vaccination. However, several barriers in accessing vaccination can be identified. There is no information on the willingness of homeless people to receive the COVID-19 vaccination, nor on the experiences with the vaccination process of homeless people and professionals involved. Therefore, this qualitative study aims to provide insight into vaccination willingness among homeless people in the Netherlands, in the barriers and facilitators in accessing vaccination, and in the experiences of professionals involved in the vaccination process. Methods: We performed semi-structured interviews with 53 homeless persons, 16 professionals involved in health care or shelter for homeless people as well as 7 public health professionals who were involved in the vaccination process for homeless people. Interviews were thematically analyzed. Results: Homeless people experienced a lack of understandable and consistent information, which resulted in distrust and vaccination hesitancy. Mistrust in the government was common. However, approximately half of them were vaccinated at the end of the first vaccination campaign, sometimes because not being vaccinated would restrict their possibilities to access public places. Barriers to access vaccination included the complicated process and forms and difficulties accessing the vaccination venue. Especially difficult turned out to be the bureaucratic process of acquiring the Corona virus entry pass. Identified key-elements for a successful vaccination campaign for homeless people: a strong collaboration between all stakeholders, easy to understand information by trusted professionals, the possibility of vaccination at out-reach sites like homeless shelters. Conclusion: Although the vaccination rate among homeless people in the Netherlands is estimated to be lower than among the general public, successful vaccination campaigns are possible if trusted people provide easy to understand information, all stakeholders work together and vaccination takes place at easy to reach locations.

Gender non-conforming and sexual minority youth are overrepresented in the homeless youth population and are frequently discriminated against in shelters and youth serving organizations. This paper provides a contextual understanding of the ways that institutional and governmental policies and standards often perpetuate the social exclusion of lesbian, gay, bisexual, transgender, queer, and 2-Spirit (LGBTQ2S) youth, by further oppression and marginalization. Factors, including institutional erasure, homophobic and transphobic violence, and discrimination that is rarely dealt with, addressed, or even noticed by shelter workers, make it especially difficult for LGBTQ2S youth experiencing homelessness to access support services, resulting in a situation where they feel safer on the streets than in shelters and housing programs. This paper draws on data from a qualitative Critical Action Research study that investigated the experiences of a group of LGBTQ2S homeless youth and the perspectives of staff in shelters through one-on-one interviews in Toronto, Canada. One of the main recommendations of the study included the need for governmental policy to address LGBTQ2S youth homelessness. A case study is shared to illustrate how the Government of Alberta has put this recommendation into practice by prioritizing LGBTQ2S youth homelessness in their provincial plan to end youth homelessness. The case study draws on informal and formal data, including group activities, questions, and surveys that were collected during a symposium on LGBTQ2S youth homelessness. This paper provides an overview of a current political, social justice, and public health concern, and contributes knowledge to an under researched field of study by highlighting concrete ways to prevent, reduce, and end LGBTQ2S youth homelessness.

Background: Homeless people are known to suffer disproportionately with health problems that reduce physical functioning and quality of life, and shorten life expectancy. They suffer from a wide range of diseases that are known to be painful, but little information is available about the nature and prevalence of chronic pain in this vulnerable group. This study aimed to estimate the prevalence of chronic pain among homeless people, and to examine its location, effect on activities of daily living, and relationship with alcohol and drugs.Methods: We conducted face-to-face interviews with users of homeless shelters in four major cities in the United Kingdom, in the winters of 2009-11. Participants completed the Brief Pain Inventory, Short Form McGill Pain questionnaire, Leeds Assessment of Neuropathic Symptoms and Signs, and detailed their intake of prescribed and unprescribed medications and alcohol. We also recorded each participant’s reasons for homelessness, and whether they slept rough or in shelters.Findings: Of 168 shelter users approached, 150 (89.3%) participated: 93 participants (63%) reported experiencing pain lasting longer than three months; the mean duration of pain experienced was 82.2 months. The lower limbs were most frequently affected. Opioids appeared to afford a degree of analgesia for some, but whilst many reported symptoms suggestive of neuropathic pain, very few were taking anti-neuropathic drugs.Interpretation: The prevalence of chronic pain in the homeless appears to be substantially higher than the general population, is poorly controlled, and adversely affects general activity, walking and sleeping. It is hard to discern whether chronic pain is a cause or effect of homelessness, or both. Pain is a symptom, but in this challenging group it might not always be possible to treat the underlying cause. Exploring the diagnosis and treatment of neuropathic pain may offer a means of improving the quality of these vulnerable people’s lives.

Persons struggling with housing remain significantly disadvantaged when considering access to health care. Effective advocacy for their needs will require understanding the factors which impact their health care, and which of those most concern patients themselves. A qualitative descriptive study through the lens of a transformative framework was used to identify barriers and facilitators to accessing health care as perceived by people experiencing homelessness in the regional municipality of Niagara, Canada. In-person, semi-structured interviews with 16 participants were completed, and inductive thematic analysis identified nine barriers and eight facilitators. Barriers included affordability, challenges finding primary care, inadequacy of the psychiatric model, inappropriate management, lack of trust in health care providers, poor therapeutic relationships, systemic issues, and transportation and accessibility. Facilitators included accessibility of services, community health care outreach, positive relationships, and shelters coordinating health care. Knowledge of the direct experiences of marginalized individuals can help create new health policies and enhance the provision of clinical care.

Abstract Based on an ethnographic survey conducted in services for the homeless in French-speaking Switzerland, this paper examines street-level social workers’ struggles between the implementation of official policies and their direct work with people. Beyond their common condition of homelessness, people looking for shelter are a very heterogeneous group: undocumented migrants and foreign workers rub shoulders with poor, local pensioners, or with persons suffering from drug addiction or mental illness. Guided by national and international residence and labour legislation, local authorities and institutions have their own policies – more or less strict in their exclusion of poor migrants – regarding the legitimate beneficiaries of a place in the emergency accommodation system. In this article, we analyse the encounters of street-level social workers with homeless people and examine the practical, value-based and ethical dilemmas they face, as well the use of their discretionary power in making more - or less - appropriate shelter available for destitute migrants.

This research includes a literature review, historical background and policy overview, as well as three interviews with women experiencing homelessness, and two interviews with shelter staff in Eugene, Oregon. The purpose of this research is to inquire into the unique nature of women’s homelessness using feminist ethics and urban anthropological methods. Notable facets of existing research include postfeminist and neoliberal perspectives, issues in defining “homelessness,” worthiness, mental health, domestic violence, and much more. This paper offers a place-based approach that is meant to lead to more specific and achievable local change for women in the Eugene homeless community. The findings include a rich and diverse array of stories that indicate the spectral nature of women’s homelessness, as well as highlight flaws in the current bureaucratic structures which are meant to support women out of homelessness both locally, and nationally. Stories and experiences within this paper include themes of resistance, addiction, victimhood, and relationships. The conclusions and recommendations indicate the need for more transitional housing, “wet” shelters, prevention and intervention initiatives, and increased opportunities for healthy relationship and skill-building.

Introduction While much of the literature on homelessness is centred on the experience of men, women make up over one-quarter of Canada’s homeless population. Research has shown that women experiencing homelessness are often hidden (i.e. provisionally housed) and have different pathways into homelessness and different needs as compared to men. The objective of this research is to identify evidence-based interventions and best practices to better support women experiencing or at risk of homelessness. Methods We conducted a scoping review with a gender and equity analysis. This involved searching MEDLINE, CINAHL, PsycINFO and other databases for systematic reviews and randomized trials, supplementing our search through reference scanning and grey literature, followed by a qualitative synthesis of the evidence that examined gender and equity considerations. Results Of the 4102 articles identified on homelessness interventions, only 4 systematic reviews and 9 randomized trials were exclusively conducted on women or published disaggregated data enabling a gender analysis. Interventions with the strongest evidence included post-shelter advocacy counselling for women experiencing homelessness due to intimate partner violence, as well as case management and permanent housing subsidies (e.g. tenant-based rental assistance vouchers), which were shown to reduce homelessness, food insecurity, exposure to violence and psychosocial distress, as well as promote school stability and child well-being. Conclusion Much of the evidence on interventions to better support women experiencing homelessness focusses on those accessing domestic violence or family shelters. Since many more women are experiencing or at risk of hidden homelessness, population-based strategies are also needed to reduce gender inequity and exposure to violence, which are among the main structural drivers of homelessness among women.

Introduction While much of the literature on homelessness is centred on the experience of men, women make up over one-quarter of Canada’s homeless population. Research has shown that women experiencing homelessness are often hidden (i.e. provisionally housed) and have different pathways into homelessness and different needs as compared to men. The objective of this research is to identify evidence-based interventions and best practices to better support women experiencing or at risk of homelessness. Methods We conducted a scoping review with a gender and equity analysis. This involved searching MEDLINE, CINAHL, PsycINFO and other databases for systematic reviews and randomized trials, supplementing our search through reference scanning and grey literature, followed by a qualitative synthesis of the evidence that examined gender and equity considerations. Results Of the 4102 articles identified on homelessness interventions, only 4 systematic reviews and 9 randomized trials were exclusively conducted on women or published disaggregated data enabling a gender analysis. Interventions with the strongest evidence included post-shelter advocacy counselling for women experiencing homelessness due to intimate partner violence, as well as case management and permanent housing subsidies (e.g. tenant-based rental assistance vouchers), which were shown to reduce homelessness, food insecurity, exposure to violence and psychosocial distress, as well as promote school stability and child well-being. Conclusion Much of the evidence on interventions to better support women experiencing homelessness focusses on those accessing domestic violence or family shelters. Since many more women are experiencing or at risk of hidden homelessness, population-based strategies are also needed to reduce gender inequity and exposure to violence, which are among the main structural drivers of homelessness among women.

Abstract Background California (CA) experienced a large hepatitis A OB in 2017–2018 associated with genotype IB strains, primarily among persons experiencing homelessness and/or using drugs. In October and November 2018, we identified a cluster of three HAV cases among persons linked by drug use and homelessness in the San Fernando Valley (SFV), CA. We describe how molecular epidemiologic methods linked an additional four OB cases that lived or were associated with a senior housing facility (SHF) and guided hepatitis A vaccine outreach. Methods Suspect HAV cases were reported to DPH through provider and electronic lab reports with positive serum HAV IgM and resided in a 2 mile2 area in SFV. A case report and extended interview were completed on suspects to assess risk factors associated with HAV transmission and contacts. HAV IgM positive serum specimens were sent to the CA DPH Viral and Rickettsial Disease Laboratory for HAV RNA detection and molecular sequencing. Extracted nucleic acids were amplified using nested, RT-PCR targeting the VP1-P2B region, and a 315 nt fragment was sequenced using Sanger sequencing. Contacts to cases received HAV prophylaxis and HAV vaccine outreaches occurred in at-risk settings. Results We identified 7 HAV cases with symptom onsets from October 2018 to January 2019. All 7 cases had positive serum HAV IgM, ≥ALT 3 X normal or had a specimen matching the OB strain and were epi- linked to a case previously identified. Of 3 homeless cases, 2 had genotype 1B, CA cluster A; one specimen was unavailable. Four additional SHF cases were 2 residents, one staff, and one visitor. Among the 4 cases associated with the SHF, three had genotype 1B, CA cluster A; one specimen was unavailable. Two elderly residents reported severe fatigue, without nausea, diarrhea and vomiting. Among the 3 homeless individuals, no direct link to the SHF was established. In total, 948 HAV vaccines were provided at the SHF, homeless shelters and other settings. HAV vaccine coverage for SHF residents and food handlers was 70% and 62%,, respectively. Conclusion Two clusters of HAV cases were identified among homeless persons and individuals associated with an SHF were linked through a common HAV genotype. Two elderly cases had atypical symptoms that may not have been confirmed as HAV without viral sequencing and prompted vaccine campaign to prevent additional HAV cases. Disclosures All authors: No reported disclosures.

Abstract Background Jointly and independently, HIV and homelessness are strong risk factors for acquiring tuberculosis (TB) in the United States (US). However, public health programs geared towards addressing TB among persons experiencing homelessness (PEH) are often not used as prime opportunities to also actively address HIV among PEH. Here, we describe the prevalence and risk factors associated with HIV among PEH who were screened during a city-wide TB screening program among PEH initiated in response to a multi-shelter TB outbreak in Atlanta, Georgia. Methods Retrospective analysis of data on 18,605 PEH screened for TB between 2008 and 2018 was done. HIV status was either self-reported (SR) or laboratory-confirmed (LC). Modified Poisson regression models with robust error variances were used to assess associations between socio-demographic characteristics and being HIV-positive. Results Of 18,605 PEH screened for TB, 9,308 (53%) had a known HIV status. Of these, 38% (n=3,559) received a HIV test while 62% (n=5,749) were only SR HIV status. The prevalence of HIV positivity among all PEH who SR a HIV status (n=7,404) was 4.0% (296/7404) while the prevalence of LC HIV infection was 3.6% (129/3559). Among PEH with LC HIV results, gender (male, transgender), year of screening (2008–2010, 2011–2013) and location of screening (onsite) were independently associated with higher HIV prevalence (p< 0.05). Adjusted analysis showed statistically significant interaction between gender and age [Adjusted prevalence ratio for men vs. women: young PEH (0–29 years) 8.47 (5.13, 14.00), p< 0.0001]. Year of screening and shelter of residence also remained significant in the adjusted model. Conclusion The prevalence of HIV among PEH in Atlanta is more than four times higher than the prevalence in the general Atlanta population (0.86%). In addition to essential TB control measures needed in congregate settings like homeless shelters, strong efforts to concurrently increase access to HIV prevention and care at homeless shelters may also help reduce both HIV transmission and TB acquisition in this at-risk population in the South and move the South closer to achieving the US End TB and Ending the HIV Epidemic goals. Disclosures All Authors: No reported disclosures

Purpose This paper presents an analysis of how health intersects with the experience of housing insecurity and homelessness, specifically for migrant women. The authors argue that it is important to understand the specificities of the interplay of these different factors to continue the advancement of our understanding and practice as advocates for health and housing security. Design/methodology/approach An exploratory, qualitative, methodological approach was adopted, using a broad definition of housing insecurity: from absolute homelessness (e.g. residing rough) to invisible homelessness (e.g. couch surfing) to those at risk of homelessness. In total, 26 newcomer (foreign-born women who came to live in Canada during the previous ten years, regardless of their immigration status) women were recruited in Montreal, Canada. Participants were recruited directly through advertisements in public places and in collaboration with community organizations (women’s centers, homeless shelters, crisis centers, domestic violence shelters, immigrant settlement agencies and ethnic associations) and they self-identified as having experienced housing insecurity. Efforts were made to include a diversity of immigrant statuses as well as diversity in ethnicity, race, country of origin, family composition, sexual orientation, age and range of physical and mental ability. Women were engaged in semi-structured, open-ended interviews lasting approximately 1 h. Interviews were conducted in English or French in a location and time of participants’ choosing. Findings The findings are presented around three themes: how health problems instigate and maintain migrant women’s housing insecurity and homelessness; ways in which women’s immigration trajectories and legal status may influence their health experiences; and particular coping strategies that migrant women employ in efforts to maintain or manage their health. The authors conclude with implications of these findings for both policy and practice in relation to migrant women who experience or are at risk of housing insecurity and homelessness. Originality/value Intersections of women experiencing migration and housing insecurity in Canadian contexts have rarely been examined. This paper addresses a gap in the literature in terms of topic and context, but also in terms of sharing the voices of migrant women with direct experience with housing insecurity.

The article describes, quoting a popular Danish song from the 1980s,' bad company, those the others don't want to play with'. Bad company in this case refers to alcohol abusers, persons with long-lasting drinking problems and complicated social problems (unemployment, social marginalisation, homelessness). The article builds on an empirical study in which the clients and personnel of 34 treatment institutions and shelters for homeless people in the Copenhagen area were interviewed. The main finding is that heavy alcohol abusers gradually have been excluded from the treatment system and that this exclusion is connected to a neo-moralistic perspective on substance abuse. The Danish treatment system today operates with a marked division of abusers into two separate groups: those who are ‘suited for treatment’ and those who are not. This division has no empirical or theoretical scientific base; it is a ‘subjective’ classification that gradually has been ‘objectified’, and thus ‘institutionalised’ in the sense de-scribed by Berger and Luckmann. Institutionalised resignation in the alcohol and drug treatment field is part of a complex development consisting of socio-political changes and ideological shifts during the last two decades. These trends are discussed within a theoretical frame inspired by Jock Young and Zygmunt Bauman.

Objectives Tuberculosis (TB) outbreaks disproportionately affect persons experiencing homelessness (PEH) in the United States. During 2014-2016, a resurgent TB outbreak occurred among PEH in Atlanta, Georgia. To control the outbreak, citywide policies and educational interventions were implemented in January 2015. Policy changes standardized and enforced TB screening requirements for PEH in homeless shelters. Educational campaigns informed PEH of the outbreak and encouraged TB screening. We evaluated factors associated with, and the effect policy changes and educational interventions had on, TB screening and awareness among PEH in Atlanta. Methods Questions related to TB screening and awareness of the outbreak were added to an annual US Department of Housing and Urban Development survey of PEH in Atlanta in 2015 (n = 296 respondents) and 2016 (n = 1325 respondents). We analyzed the 2016 survey data to determine characteristics associated with outcomes. Results From 2015 to 2016, reported TB screening increased from 81% to 86%, and awareness of the TB outbreak increased from 68% to 75%. In 2016, sheltered PEH were significantly more likely than unsheltered PEH to report being evaluated for TB in the previous 6 months (prevalence odds ratio [pOR] = 3.18; 95% confidence interval [CI], 2.28-4.47) and to report being aware of the TB outbreak (pOR = 4.00; 95% CI, 2.89-5.55). Conclusions Implementation of required TB screening and educational interventions may reduce the incidence and severity of TB outbreaks among PEH in other communities. Furthermore, the annual survey of PEH offers an opportunity to collect data to better inform practices and policies.

For various reasons, but mostly because of violence, millions of people all over the world have been forced to leave their homes and are looking for security and shelter elsewhere. They have either crossed a border, and are called refugees, or they have remained within their own country and are known as internally displaced persons (IDPs). The crossing of a border is important, since this has several legal and practical implications. In general, the level of assistance for IDPs is on a lower scale. The majority of the refugees and IDPs consists of women and children. Homeless women are very vulnerable. They are especially prone to rape and sexual abuse. Moreover, sexual discriminatory practices may take place with regard to the distribution of food, goods and services. When they are housed in emergency camps and shelters, relief workers, international organisations and host countries should be made aware of these special needs and circumstances. Once awareness is created, solutions must be found. Several recommendations are made, some of them consisting of pragmatic measures, like illumination at night and sex segregated latrines and washing facilities. Since both UNHCR and the Special Rapporteur on IDPs have acknowledged the special plight of women, and both mechanisms have analysed the specific problems, much attention is paid to their findings.

Families with children represent more than one third of the homeless population nationally and more than 50% of the homeless population in many cities. Lack of a permanent dwelling deprives children of the most basic necessities for proper growth and development. Homeless children have unique risks that compromise their health status. Pediatricians are encouraged to be aware of this growing population of children and include them in their service and advocacy efforts. BACKGROUND A homeless person is defined by the National Governors Association as "an undomiciled person who is unable to secure permanent and stable housing without special assistance." The US General Accounting Office defines homeless individuals as those persons who lack resources and community ties necessary to provide for their own adequate shelter. Estimates of the number of people who lacked access to conventional dwelling or residence in 1987 range from 350,000 to more than 3 million.1 Although there is disagreement concerning the exact number of homeless persons, there is consensus that the numbers are large and continuing to increase.2 The average increase from 1986 to 1987 in the number of people needing shelter was 20%, and one quarter of this need could not be met with existing emergency shelters. (US Conference of Mayors, unpublished data, December 1987). Several societal problems contribute to the increasing rate of homelessness among American families, including lack of affordable housing; decrease in availability of rent subsidies; unemployment, especially among those who have held only marginal jobs; personal crises such as divorce and domestic violence; cutbacks in public welfare programs; substance abuse; and deinstitutionalization of the mentally ill.

Background: Homelessness among people with mental illness has grown to become a common phenomenon in many developed and developing countries. Just like in any other country, the living conditions of homeless people with mental illness in Ghana are unwholesome. Despite the increased population of these vulnerable individuals on the streets, not much is known about the perspectives of the general public towards this phenomenon in Ghana. Aim: This research was conducted to explore the perspectives of community members on homeless people with mental illness. The main study objectives were (a) to find out the impacts of the presence of persons with mental illness on the streets and (b) to ascertain the reasons accounting for homelessness among persons with mental illness. Method: Utilizing a qualitative research design, twenty community members were sampled from selected suburbs in Nsawam and interviewed with the use of a semi-structured interview guide. The audio data gathered from the interviews were transcribed verbatim and analysed thematically. Results: Majority of the participants asserted that homeless people with mental illness had no access to good food, shelter, and health care. They further stated that some homeless people with mental illness perpetrated physical and sexual violence against the residents. Moreover, the participants believed that persons with mental illness remained on the streets due to neglect by their family members, and limited access to psychiatric services. Conclusion: This paper concludes by recommending to government to make mental health services accessible and affordable to homeless persons with mental illness nationwide.

Homelessness is a public health crisis both nationally, in the United States, and internationally. Nevertheless, due to the hidden vulnerabilities of persons who are without shelter, little is known about their experiences during periods of homelessness. The present research adopts a network approach that conceptualizes how the major risk factors of homelessness interact, namely substance abuse problems, poor mental health, disability, and exposure to physical or sexual violence by an intimate partner. Our analysis draws on a large demographic survey of over 5,000 unsheltered homeless persons conducted in 2017 by the Los Angeles Homeless Services Authority. We estimated a network structure for 12 survey items tapping individual risk using the graphical least absolute shrinkage and selection operator algorithm. We then examined network centrality metrics and implemented a community detection algorithm to detect communities in the network. Our results indicated that mental illness and intimate partner violence (IPV) are central measures that connect all other mental and physical health variables together and that post-traumatic stress disorder and IPV are both highly affected by changes in any part of the network and, in turn, affect changes in other parts of the network. A community detection analysis derived four communities characterized by disability, sexual victimization and health, substance use, and mental health issues. Finally, a directed acyclic graph revealed that drug abuse and physical disability were key drivers of the overall system. We conclude with a discussion of the major implications of our findings and suggest how our results might inform programs aimed at homelessness prevention and intervention.

ObjectiveWe sought to measure the burden of emergency department (ED) visits associated with injection drug use (IDU), HIV infection, and homelessness; and the intersection of homelessness with IDU and HIV infection in Massachusetts via syndromic surveillance data.IntroductionIn Massachusetts, syndromic surveillance (SyS) data have been used to monitor injection drug use and acute opioid overdoses within EDs. Currently, Massachusetts Department of Public Health (MDPH) SyS captures over 90% of ED visits statewide. These real-time data contain rich free-text and coded clinical and demographic information used to categorize visits for population level public health surveillance.Other surveillance data have shown elevated rates of opioid overdose related ED visits, Emergency Medical Service incidents, and fatalities in Massachusetts from 2014-20171,2,3. Injection of illicitly consumed opioids is associated with an increased risk of infectious diseases, including HIV infection. An investigation of an HIV outbreak among persons reporting IDU identified homelessness as a social determinant for increased risk for HIV infection.MethodsTo accomplish our objectives staff used an existing MDPH SyS IDU syndrome definition4, developed a novel syndrome definition for HIV-related visits, and adapted Maricopa County's homelessness syndrome definition. Syndromes were applied to Massachusetts ED data through the CDC’s BioSense Platform. Visits meeting the HIV and homelessness syndromes were randomly selected and reviewed to assess accuracy; inclusion and exclusion criteria were then revised to increase specificity. The final versions of all three syndrome definitions incorporate free-text elements from the chief complaint and triage notes, as well as International Statistical Classification of Diseases and Related Health Problems, 9th (ICD-9) and 10th Revision (ICD-10) diagnostic codes. Syndrome categories were not mutually exclusive, and all reported visits occurring at Massachusetts EDs were included in the analysis.Syndromes CreatedFor the HIV infection syndrome definition, we incorporated the free-text term “HIV” in both the chief complaint and triage notes. Visit level review demonstrated that the following exclusions were needed to reduce misspellings, inclusion of partial words, and documentation of HIV testing results: “negative for HIV”, “HIV neg”, “negative test for HIV”, “hive”, “hivies”, and “vehivcle”. Additionally, the following diagnostic codes were incorporated: V65.44 (Human immunodeficiency virus [HIV] counseling), V08 (asymptomatic HIV infection status), V01.79 (contact with or exposure to other viral diseases), 795.71 (nonspecific serologic evidence of HIV), V73.89 (special screening examination for other specified viral diseases), 079.53 (HIV, type 2 [HIV-2]), Z20.6 (contact with and (suspected) exposure to HIV), Z71.7 (HIV counseling), B20 (HIV disease), Z21 (asymptomatic HIV infection status), R75 (inconclusive laboratory evidence of HIV), Z11.4 (encounter for screening for HIV), and B97.35 (HIV-2 as the cause of diseases classified elsewhere).Building on the Maricopa County homeless syndrome definition, we incorporated a variety of free-text inclusion and exclusion terms. To meet this definition visits had to mention: “homeless”, or “no housing”, or, “lack of housing”, or “without housing”, or “shelter” but not animal and domestic violence shelters. We also selected the following ICD-10 codes for homelessness and inadequate housing respectively, Z59.0 and Z59.1.We analyzed MDPH SyS data for visits occurring from January 1, 2016 through June 30, 2018. Rates per 10,000 ED visits categorized as IDU, HIV, or homeless were calculated. Subsequently, visits categorized as IDU, HIV, and meeting both IDU and HIV syndrome definitions (IDU+HIV) were stratified by homelessness.ResultsSyndrome Burden on EDThe MDPH SyS dataset contains 6,767,137 ED visits occurring during the study period. Of these, 82,819 (1.2%) were IDU-related, 13,017 (0.2%) were HIV-related, 580 (<0.01%) were related to IDU + HIV, and 42,255 visits (0.6%) were associated with homelessness.The annual rate of IDU-related visits increased 15% from 2016 through June of 2018 (from 113.63 to 130.57 per 10,000 visits); while rates of HIV-related and IDU + HIV-related visits remained relatively stable. The overall rate of visits associated with homelessness increased 47% (from 49.99 to 73.26 per 10,000 visits).Rates of IDU, HIV, and IDU + HIV were significantly higher among visits associated with homelessness. Among visits that met the homeless syndrome definition compared to those that did not: the rate of IDU-related visits was 816.0 versus 118.03 per 10,000 ED visits (X2= 547.12, p<0. 0001); the rate of visits matching the HIV syndrome definition was 145.54 versus 18.44 per 10,000 ED visits (X2= 99.33, p<0.0001); and the rate of visits meeting the IDU+HIV syndrome definition was 15.86 versus 0.76 per 10,000 visits (X2= 13.72, p= 0.0002).ConclusionsMassachusetts is experiencing an increasing burden of ED visits associated with both IDU and homelessness that parallels increases in opioid overdoses. Higher rates of both IDU and HIV-related visits were associated with homelessness. An understanding of the intersection between opioid overdoses, IDU, HIV, and homelessness can inform expanded prevention efforts, introduction of alternatives to ED care, and increase consideration of housing status during ED care.Continued surveillance for these syndromes, including collection and analysis of demographic and clinical characteristics, and geographic variations, is warranted. These data can be useful to providers and public health authorities for planning healthcare services.References1. Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017. MMWR Morbidity and Mortality Weekly Report 2018; 67(9);279–285 DOI: http://dx.doi.org/10.15585/mmwr.mm6709e12. Massachusetts Department of Public Health. Chapter 55 Data Brief: An assessment of opioid-related deaths in Massachusetts, 2011-15. 2017 August. Available from: https://www.mass.gov/files/documents/2017/08/31/data-brief-chapter-55-aug-2017.pdf3. Massachusetts Department of Public Health. MA Opioid-Related EMS Incidents 2013-September 2017. 2018 Feb. Available from: https://www.mass.gov/files/documents/2018/02/14/emergency-medical-services-data-february-2018.pdf4. Bova, M. Using emergency department (ED) syndromic surveillance to measure injection-drug use as an indicator for hepatitis C risk. Powerpoint presented at: 2017 Northeast Epidemiology Conference. 2017 Oct 18 – 20; Northampton, Massachusetts, USA.

Abstract Background People experiencing homelessness are at increased risk of coronavirus disease 2019 (COVID-19), but little is known about specific risk factors for infection within homeless shelters. Methods We performed widespread severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction testing and collected risk factor information at all homeless shelters in Chicago with at least 1 reported case of COVID-19 (n = 21). Multivariable, mixed-effects log-binomial models were built to estimate adjusted prevalence ratios (aPRs) for SARS-CoV-2 infection for both individual- and facility-level risk factors. Results During March 1 to May 1, 2020, 1717 shelter residents and staff were tested for SARS-CoV-2; 472 (27%) persons tested positive. Prevalence of infection was higher for residents (431 of 1435, 30%) than for staff (41 of 282, 15%) (prevalence ratio = 2.52; 95% confidence interval [CI], 1.78–3.58). The majority of residents with SARS-CoV-2 infection (293 of 406 with available information about symptoms, 72%) reported no symptoms at the time of specimen collection or within the following 2 weeks. Among residents, sharing a room with a large number of people was associated with increased likelihood of infection (aPR for sharing with &gt;20 people compared with single rooms = 1.76; 95% CI, 1.11–2.80), and current smoking was associated with reduced likelihood of infection (aPR = 0.71; 95% CI, 0.60–0.85). At the facility level, a higher proportion of residents leaving and returning each day was associated with increased prevalence (aPR = 1.08; 95% CI, 1.01–1.16), whereas an increase in the number of private bathrooms was associated with reduced prevalence (aPR for 1 additional private bathroom per 100 people = 0.92; 95% CI, 0.87–0.98). Conclusions We identified a high prevalence of SARS-CoV-2 infections in homeless shelters. Reducing the number of residents sharing dormitories might reduce the likelihood of SARS-CoV-2 infection. When community transmission is high, limiting movement of persons experiencing homelessness into and out of shelters might also be beneficial.

Abstract Background Violence against women places them in a vulnerable position with regard to homelessness. Although sometimes invisible, women’s homelessness is a complex reality shrouded in dramatic biographies that should be sensitively addressed to avoid revictimization. Methods With the aim of understanding the chaotic discourse of homeless women’s experiences of violence, a qualitative single-case study was conducted using the photo-elicitation technique. Data were analyzed in accordance with grounded theory. Results The participant’s discourse could be summarized in the following categories: “Living in a spiral of violence”, “Confronting vulnerability and violence”, “Being a strong woman”, “New family networks”, “Re-building mother–child relationships”, and “Nurturing spiritual wellbeing”. Conclusions Supporting homelessness women requires an approach that focuses on the prevention of re-victimization and the consequences of violence in terms of physical and mental health. Shelters are spaces of care for recovery and represent referential elements for the re-construction of self.

Objectives: To record the prevalence and risk factors of substance use amongst homeless persons during the COVID-19 pandemic.Methods: The ECHO study consisted in two independent cross-sectional waves of data collection in the regions of Paris, Lyon, and Strasbourg during the Spring of 2020 (n = 530) and 2021 (n = 319). Factors associated with substance use were explored using generalised logistic regression models.Results: The most prevalent substance used was tobacco (38%–43%), followed by alcohol (26%–34%). The use of both substances positively associated with each other, although risk factors varied depending on the substance. The only factors consistently associated with alcohol and tobacco use were being male, exposure to theft/assault and participants’ region of origin. Whilst the rate of tobacco use was relatively stable between Spring 2020 and 2021, alcohol use was more common in 2021.Conclusion: These findings highlight a high prevalence of substance use amongst homeless persons. People experiencing homelessness face specific challenges in the context of the pandemic, alongside greater vulnerability to illness and low healthcare access, therefore the need to improve prevention and support services for substance abuse within this population is vital.

Homeless communities have garnered recent public attention in Canada due to their high rates of violence, victimization, and being reported as missing. There have been several high-profile cases, investigations, and inquiries involving missing homeless persons, yet very little is known about what cases are reported to the police, under what circumstances they go missing, and the outcomes of those cases. As a result, the purpose of this study is to provide some insights into some of these unresolved issues by offering an exploratory, descriptive analysis of 291 closed missing person cases from the records of a municipal police service. What this analysis reveal is a somewhat more mundane picture. Specifically, results indicate that the majority of missing person reports are of those who are female and White, have a drug/alcohol addiction, are residing at homeless shelters/missions, and have a history of being reported as missing. As well, it was revealed that most people are reported as missing due to shelter/mission reporting issues with curfews and that all are located alive. This study extends the minimal existing scholarship on the missing homeless population by providing some preliminary insights on the vulnerabilities and factors that can impact these cases.

Abstract Introduction Housing is a critical determinant of health that operates synergistically with other social determinants of health (SDH), like food and nutrition. The urban homeless count among the most neglected and marginalized groups; they live and work in conditions that make them prone to disease. We conducted a study to understand the role and interplay of various SDH among the urban homeless in India. Methods A qualitative study was undertaken to understand the social determinants of health among homeless people in Delhi, India. Organizations working with the population were initially consulted. Criterion sampling was used to draw a convenience sample of participants for 24 in-depth interviews and five focus group discussions. Field observations were also done. Data were analysed using a grounded theory approach using Atlas.TI 8 software. Results The homeless lived in proximity in shelters making them susceptible to infectious disease such as Tuberculosis, or on the roadside making them prone to road-traffic accidents owing to intake of drugs and alcohol. Injuries caused by violence were common and homeless people lined up each morning for first aid services. Single homeless women were vulnerable to being stalked and raped. At a homeless recovery shelter, where a large number of homeless people had Tuberculosis or HIV, poor nutrition was reported as a leading factor that lowered immunity and affected chances of recovery. Lack of coordination between the different departments of the government for taking effective measures for ensuring better health of the urban poor was also reported. Conclusions The conditions of living clearly affected the lives of homeless people. The settings - the quality of housing and social environment in addition to the ineffective role of the state played a prominent role in impacting the health of the urban poor. There clearly is a need for policy measures that can address factors that shape the health of poor people. Key messages Homelessness is a crucial determinant of health: it severely affects the health and well-being of homeless people. The lack of a political will to address SDH is a leading challenge.

Abstract Background In 2021, there were approximately 1300 people on a given day who have experienced homelessness within the city of Detroit, Michigan. Sheltered beds within the 24 homeless shelters in the city were drastically cut in half during the COVID-19 pandemic due to concerns of overcrowding perpetuating SARS-CoV-2 outbreaks. We aimed to describe the outreach efforts made by Street Medicine Organizations (SMO) of Detroit during the SARS-CoV-2 pandemic, highlighting infection prevention and control strategies, and promotion of COVID-19 vaccinations amongst the unsheltered homeless. Methods Health promotion interventions were directed at individuals who were unsheltered (defined as those living on the streets of Detroit, encampment sites and abandoned buildings). Education, which was provided through in-person sessions, as well as targeted COVID-19 informational pamphlets were distributed with every street-based run. Hygiene kits, which included masks, hand sanitizer and gloves were distributed thrice weekly at shelters and encampment sites. Since access to hand hygiene was drastically limited, the SMO constructed 10 hand washing stations throughout the city. COVID-19 vaccination in people experiencing homelessness started in April 2021. Results SMO prioritized a 60 square mile range within the city of Detroit, providing care to approximately 500 persons over the months of April 2020 to April 2021. Demographics for this population varied; age ranged from 23 to 76 years old, sex was 70% males, race were 67% Black, 29% White and 4% Hispanic. More than 2000 hygiene kits were distributed throughout this period. Ninety-one individuals experiencing unsheltered homelessness were provided the COVID-19 vaccine in April 2021. Conclusion Individuals experiencing unsheltered homelessness face unique challenges to accessing timely medical care, which has been further exacerbated during the pandemic. These individuals have limited or no access to necessary measures needed to prevent the spread and severity of diseases of SARS-CoV-2. We describe a focused and effective approach to preventing infection among these individuals as a model for organizations nationally. Disclosures All Authors: No reported disclosures.

Abstract Background Medication adherence is a common reason for treatment deferment in persons experiencing homelessness. We evaluated adherence to HCV therapy following HCV education in a shelter-based care model. Methods Prospective study conducted at 4 homeless shelters in Minneapolis, MN and San Francisco, CA from 11/2018–1/2021. Sixty-three patients underwent HCV education and treatment. Multivariable modeling evaluated factors associated with (1) medication and (2) overall (composite score of medication, laboratory, and clinic visit) adherence. Results Median age was 56, 73% male, 43% Black, 52% had psychiatric illness, and 81% used illicit drugs and 60% used alcohol in the past year. Following education, 52% were extremely confident in their ability to be adherent to HCV therapy. Medication adherence by patient and provider report was 88% and 48% respectively and 81% achieved HCV cure. Active alcohol use was associated with less confidence in medication adherence (43% vs. 78%, P=0.04). Older age was positively (Coef=0.3) associated with overall adherence to HCV treatment while prior therapy was associated with both medication (OR=0.08) and overall treatment (Coef=-0.87) non-adherence. Conclusions Despite imperfect adherence, SVR rates were still high. Expanding opportunities to treat persons experiencing homelessness in a structured and supportive setting is critical to HCV elimination efforts.

Background: Marginalization is a multidimensional social construct that influences the mental health status of individuals and their use of psychiatric services. However, its conceptualization and measurement are challenging due to inconsistencies in definitions, and the lack of standard data sources to measure this construct. Aims: To create an index for screening marginalization based on an existing comprehensive assessment system used in inpatient psychiatry. Method: Items anticipated to be indicative of marginalization were identified from the Resident Assessment Instrument-Mental Health (RAI-MH) that is used in all inpatient mental health beds in Ontario, Canada. Principal Component Analysis (PCA) and cluster analysis of these items was performed on a sample of 81,232 patients admitted into psychiatric care in Ontario between 1 January 2011 and 31 December 2016 to identify dimensions being measured. Various weights and scoring methods were tested to assess convergent validity on multiple outcomes of marginalization. Receiver Operating Characteristic (ROC) curve analysis was utilized to determine optimal cut-offs for the index by modeling the likelihood of different marginalization outcomes, including homelessness. Results: Fifteen items were identified for the development of the Marginalization Index (MI). PCA and cluster analysis identified that the items measured five dimensions. ROC curve analysis among homeless individuals identified an Area Under the Curve of 0.76 and an optimal cut-off of five on the MI. Frequency analysis of the index by different characteristics identified homeless individuals, frequent mental health service users, persons with a history of violence and police intervention, and persons with addictions issues, as groups with the highest scores, confirming the convergent validity of the index. Conclusion: The MI is a valid measure of marginalization and is strong predictor of risk of homelessness among psychiatric inpatients. MI provides a resource that can be used for social and health policy, decision-support and evaluation.

Abstract Background Digital health has expanded during the COVID-19 pandemic, while the exclusion of vulnerable populations with limited access to these technologies widens the gap to receive proper care. There is very little data available on the feasibility of telemedicine solutions regarding the chronic care of homeless persons. Methods In our study, 75 participants experiencing homelessness were recruited from four social institutions in Budapest, Hungary. The telecare pilot service consisted of six online consultations with a physician and was available in shelters biweekly. Self-developed questionnaires were used after every online session on the originating and remote sites as well, while a follow-up study was also completed among patients after four to six months of pilot closure. Parameters as frequencies, averages, and percentage distributions were analyzed and two linear regression models were built on explaining the doctors’ and patients’ overall rating of visits. Results During the pilot, 92.2% (n = 415) of originally planned visits were delivered and 55 clients (73.3%) attended the full program. Both the patients’ and physicians’ overall satisfaction was very high (4.52 and 4.79, respectively, on a 5-point Likert scale) and the patients’ overall rating remained similarly high during the follow-up. Comparing the first and sixth visits, physicians reported significant improvements in almost all aspects. The linear regression models proved that confidence in the patients’ assessment and diagnosis had the most prominent effect on the physicians’ overall rating, while ease of use and lack of communication gaps influenced positively the patients’ rating. Conclusion The results suggest that telehealth services represent a promising tool to ensure better care continuity while using shelter infrastructure and on-site assistance might reduce the digital exclusion of people experiencing homelessness.

1991 An afternoon in late 1991 found me on a Sydney bus reading Brett Easton Ellis’ American Psycho (1991). A disembarking passenger paused at my side and, as I glanced up, hissed, ‘I don’t know how you can read that filth’. As she continued to make her way to the front of the vehicle, I was as stunned as if she had struck me physically. There was real vehemence in both her words and how they were delivered, and I can still see her eyes squeezing into slits as she hesitated while curling her mouth around that final angry word: ‘filth’. Now, almost fifteen years later, the memory is remarkably vivid. As the event is also still remarkable; this comment remaining the only remark ever made to me by a stranger about anything I have been reading during three decades of travelling on public transport. That inflamed commuter summed up much of the furore that greeted the publication of American Psycho. More than this, and unusually, condemnation of the work both actually preceded, and affected, its publication. Although Ellis had been paid a substantial U.S. $300,000 advance by Simon & Schuster, pre-publication stories based on circulating galley proofs were so negative—offering assessments of the book as: ‘moronic … pointless … themeless … worthless (Rosenblatt 3), ‘superficial’, ‘a tapeworm narrative’ (Sheppard 100) and ‘vile … pornography, not literature … immoral, but also artless’ (Miner 43)—that the publisher cancelled the contract (forfeiting the advance) only months before the scheduled release date. CEO of Simon & Schuster, Richard E. Snyder, explained: ‘it was an error of judgement to put our name on a book of such questionable taste’ (quoted in McDowell, “Vintage” 13). American Psycho was, instead, published by Random House/Knopf in March 1991 under its prestige paperback imprint, Vintage Contemporary (Zaller; Freccero 48) – Sonny Mehta having signed the book to Random House some two days after Simon & Schuster withdrew from its agreement with Ellis. While many commented on the fact that Ellis was paid two substantial advances, it was rarely noted that Random House was a more prestigious publisher than Simon & Schuster (Iannone 52). After its release, American Psycho was almost universally vilified and denigrated by the American critical establishment. The work was criticised on both moral and aesthetic/literary/artistic grounds; that is, in terms of both what Ellis wrote and how he wrote it. Critics found it ‘meaningless’ (Lehmann-Haupt C18), ‘abysmally written … schlock’ (Kennedy 427), ‘repulsive, a bloodbath serving no purpose save that of morbidity, titillation and sensation … pure trash, as scummy and mean as anything it depicts, a dirty book by a dirty writer’ (Yardley B1) and ‘garbage’ (Gurley Brown 21). Mark Archer found that ‘the attempt to confuse style with content is callow’ (31), while Naomi Wolf wrote that: ‘overall, reading American Psycho holds the same fascination as watching a maladjusted 11-year-old draw on his desk’ (34). John Leo’s assessment sums up the passionate intensity of those critical of the work: ‘totally hateful … violent junk … no discernible plot, no believable characterization, no sensibility at work that comes anywhere close to making art out of all the blood and torture … Ellis displays little feel for narration, words, grammar or the rhythm of language’ (23). These reviews, as those printed pre-publication, were titled in similarly unequivocal language: ‘A Revolting Development’ (Sheppard 100), ‘Marketing Cynicism and Vulgarity’ (Leo 23), ‘Designer Porn’ (Manguel 46) and ‘Essence of Trash’ (Yardley B1). Perhaps the most unambiguous in its message was Roger Rosenblatt’s ‘Snuff this Book!’ (3). Of all works published in the U.S.A. at that time, including those clearly carrying X ratings, the Los Angeles chapter of the National Organization for Women (NOW) selected American Psycho for special notice, stating that the book ‘legitimizes inhuman and savage violence masquerading as sexuality’ (NOW 114). Judging the book ‘the most misogynistic communication’ the organisation had ever encountered (NOW L.A. chapter president, Tammy Bruce, quoted in Kennedy 427) and, on the grounds that ‘violence against women in any form is no longer socially acceptable’ (McDowell, “NOW” C17), NOW called for a boycott of the entire Random House catalogue for the remainder of 1991. Naomi Wolf agreed, calling the novel ‘a violation not of obscenity standards, but of women’s civil rights, insofar as it results in conditioning male sexual response to female suffering or degradation’ (34). Later, the boycott was narrowed to Knopf and Vintage titles (Love 46), but also extended to all of the many products, companies, corporations, firms and brand names that are a feature of Ellis’s novel (Kauffman, “American” 41). There were other unexpected responses such as the Walt Disney Corporation barring Ellis from the opening of Euro Disney (Tyrnauer 101), although Ellis had already been driven from public view after receiving a number of death threats and did not undertake a book tour (Kennedy 427). Despite this, the book received significant publicity courtesy of the controversy and, although several national bookstore chains and numerous booksellers around the world refused to sell the book, more than 100,000 copies were sold in the U.S.A. in the fortnight after publication (Dwyer 55). Even this success had an unprecedented effect: when American Psycho became a bestseller, The New York Times announced that it would be removing the title from its bestseller lists because of the book’s content. In the days following publication in the U.S.A., Canadian customs announced that it was considering whether to allow the local arm of Random House to, first, import American Psycho for sale in Canada and, then, publish it in Canada (Kirchhoff, “Psycho” C1). Two weeks later, when the book was passed for sale (Kirchhoff, “Customs” C1), demonstrators protested the entrance of a shipment of the book. In May, the Canadian Defence Force made headlines when it withdrew copies of the book from the library shelves of a navy base in Halifax (Canadian Press C1). Also in May 1991, the Australian Office of Film and Literature Classification (OFLC), the federal agency that administers the classification scheme for all films, computer games and ‘submittable’ publications (including books) that are sold, hired or exhibited in Australia, announced that it had classified American Psycho as ‘Category 1 Restricted’ (W. Fraser, “Book” 5), to be sold sealed, to only those over 18 years of age. This was the first such classification of a mainstream literary work since the rating scheme was introduced (Graham), and the first time a work of literature had been restricted for sale since Philip Roth’s Portnoy’s Complaint in 1969. The chief censor, John Dickie, said the OFLC could not justify refusing the book classification (and essentially banning the work), and while ‘as a satire on yuppies it has a lot going for it’, personally he found the book ‘distasteful’ (quoted in W. Fraser, “Sensitive” 5). Moreover, while this ‘R’ classification was, and remains, a national classification, Australian States and Territories have their own sale and distribution regulation systems. Under this regime, American Psycho remains banned from sale in Queensland, as are all other books in this classification category (Vnuk). These various reactions led to a flood of articles published in the U.S.A., Canada, Australia and the U.K., voicing passionate opinions on a range of issues including free speech and censorship, the corporate control of artistic thought and practice, and cynicism on the part of authors and their publishers about what works might attract publicity and (therefore) sell in large numbers (see, for instance, Hitchens 7; Irving 1). The relationship between violence in society and its representation in the media was a common theme, with only a few commentators (including Norman Mailer in a high profile Vanity Fair article) suggesting that, instead of inciting violence, the media largely reflected, and commented upon, societal violence. Elayne Rapping, an academic in the field of Communications, proposed that the media did actively glorify violence, but only because there was a market for such representations: ‘We, as a society love violence, thrive on violence as the very basis of our social stability, our ideological belief system … The problem, after all, is not media violence but real violence’ (36, 38). Many more commentators, however, agreed with NOW, Wolf and others and charged Ellis’s work with encouraging, and even instigating, violent acts, and especially those against women, calling American Psycho ‘a kind of advertising for violence against women’ (anthropologist Elliot Leyton quoted in Dwyer 55) and, even, a ‘how-to manual on the torture and dismemberment of women’ (Leo 23). Support for the book was difficult to find in the flood of vitriol directed against it, but a small number wrote in Ellis’s defence. Sonny Mehta, himself the target of death threats for acquiring the book for Random House, stood by this assessment, and was widely quoted in his belief that American Psycho was ‘a serious book by a serious writer’ and that Ellis was ‘remarkably talented’ (Knight-Ridder L10). Publishing director of Pan Macmillan Australia, James Fraser, defended his decision to release American Psycho on the grounds that the book told important truths about society, arguing: ‘A publisher’s office is a clearing house for ideas … the real issue for community debate [is] – to what extent does it want to hear the truth about itself, about individuals within the community and about the governments the community elects. If we care about the preservation of standards, there is none higher than this. Gore Vidal was among the very few who stated outright that he liked the book, finding it ‘really rather inspired … a wonderfully comic novel’ (quoted in Tyrnauer 73). Fay Weldon agreed, judging the book as ‘brilliant’, and focusing on the importance of Ellis’s message: ‘Bret Easton Ellis is a very good writer. He gets us to a ‘T’. And we can’t stand it. It’s our problem, not his. American Psycho is a beautifully controlled, careful, important novel that revolves around its own nasty bits’ (C1). Since 1991 As unlikely as this now seems, I first read American Psycho without any awareness of the controversy raging around its publication. I had read Ellis’s earlier works, Less than Zero (1985) and The Rules of Attraction (1987) and, with my energies fully engaged elsewhere, cannot now even remember how I acquired the book. Since that angry remark on the bus, however, I have followed American Psycho’s infamy and how it has remained in the public eye over the last decade and a half. Australian OFLC decisions can be reviewed and reversed – as when Pasolini’s final film Salo (1975), which was banned in Australia from the time of its release in 1975 until it was un-banned in 1993, was then banned again in 1998 – however, American Psycho’s initial classification has remained unchanged. In July 2006, I purchased a new paperback copy in rural New South Wales. It was shrink-wrapped in plastic and labelled: ‘R. Category One. Not available to persons under 18 years. Restricted’. While exact sales figures are difficult to ascertain, by working with U.S.A., U.K. and Australian figures, this copy was, I estimate, one of some 1.5 to 1.6 million sold since publication. In the U.S.A., backlist sales remain very strong, with some 22,000 copies sold annually (Holt and Abbott), while lifetime sales in the U.K. are just under 720,000 over five paperback editions. Sales in Australia are currently estimated by Pan MacMillan to total some 100,000, with a new printing of 5,000 copies recently ordered in Australia on the strength of the book being featured on the inaugural Australian Broadcasting Commission’s First Tuesday Book Club national television program (2006). Predictably, the controversy around the publication of American Psycho is regularly revisited by those reviewing Ellis’s subsequent works. A major article in Vanity Fair on Ellis’s next book, The Informers (1994), opened with a graphic description of the death threats Ellis received upon the publication of American Psycho (Tyrnauer 70) and then outlined the controversy in detail (70-71). Those writing about Ellis’s two most recent novels, Glamorama (1999) and Lunar Park (2005), have shared this narrative strategy, which also forms at least part of the frame of every interview article. American Psycho also, again predictably, became a major topic of discussion in relation to the contracting, making and then release of the eponymous film in 2000 as, for example, in Linda S. Kauffman’s extensive and considered review of the film, which spent the first third discussing the history of the book’s publication (“American” 41-45). Playing with this interest, Ellis continues his practice of reusing characters in subsequent works. Thus, American Psycho’s Patrick Bateman, who first appeared in The Rules of Attraction as the elder brother of the main character, Sean – who, in turn, makes a brief appearance in American Psycho – also turns up in Glamorama with ‘strange stains’ on his Armani suit lapels, and again in Lunar Park. The book also continues to be regularly cited in discussions of censorship (see, for example, Dubin; Freccero) and has been included in a number of university-level courses about banned books. In these varied contexts, literary, cultural and other critics have also continued to disagree about the book’s impact upon readers, with some persisting in reading the novel as a pornographic incitement to violence. When Wade Frankum killed seven people in Sydney, many suggested a link between these murders and his consumption of X-rated videos, pornographic magazines and American Psycho (see, for example, Manne 11), although others argued against this (Wark 11). Prosecutors in the trial of Canadian murderer Paul Bernardo argued that American Psycho provided a ‘blueprint’ for Bernardo’s crimes (Canadian Press A5). Others have read Ellis’s work more positively, as for instance when Sonia Baelo Allué compares American Psycho favourably with Thomas Harris’s The Silence of the Lambs (1988) – arguing that Harris not only depicts more degrading treatment of women, but also makes Hannibal Lecter, his antihero monster, sexily attractive (7-24). Linda S. Kauffman posits that American Psycho is part of an ‘anti-aesthetic’ movement in art, whereby works that are revoltingly ugly and/or grotesque function to confront the repressed fears and desires of the audience and explore issues of identity and subjectivity (Bad Girls), while Patrick W. Shaw includes American Psycho in his work, The Modern American Novel of Violence because, in his opinion, the violence Ellis depicts is not gratuitous. Lost, however, in much of this often-impassioned debate and dialogue is the book itself – and what Ellis actually wrote. 21-years-old when Less than Zero was published, Ellis was still only 26 when American Psycho was released and his youth presented an obvious target. In 1991, Terry Teachout found ‘no moment in American Psycho where Bret Easton Ellis, who claims to be a serious artist, exhibits the workings of an adult moral imagination’ (45, 46), Brad Miner that it was ‘puerile – the very antithesis of good writing’ (43) and Carol Iannone that ‘the inclusion of the now famous offensive scenes reveals a staggering aesthetic and moral immaturity’ (54). Pagan Kennedy also ‘blamed’ the entire work on this immaturity, suggesting that instead of possessing a developed artistic sensibility, Ellis was reacting to (and, ironically, writing for the approval of) critics who had lauded the documentary realism of his violent and nihilistic teenage characters in Less than Zero, but then panned his less sensational story of campus life in The Rules of Attraction (427-428). Yet, in my opinion, there is not only a clear and coherent aesthetic vision driving Ellis’s oeuvre but, moreover, a profoundly moral imagination at work as well. This was my view upon first reading American Psycho, and part of the reason I was so shocked by that charge of filth on the bus. Once familiar with the controversy, I found this view shared by only a minority of commentators. Writing in the New Statesman & Society, Elizabeth J. Young asked: ‘Where have these people been? … Books of pornographic violence are nothing new … American Psycho outrages no contemporary taboos. Psychotic killers are everywhere’ (24). I was similarly aware that such murderers not only existed in reality, but also in many widely accessed works of literature and film – to the point where a few years later Joyce Carol Oates could suggest that the serial killer was an icon of popular culture (233). While a popular topic for writers of crime fiction and true crime narratives in both print and on film, a number of ‘serious’ literary writers – including Truman Capote, Norman Mailer, Kate Millet, Margaret Atwood and Oates herself – have also written about serial killers, and even crossed over into the widely acknowledged as ‘low-brow’ true crime genre. Many of these works (both popular or more literary) are vivid and powerful and have, as American Psycho, taken a strong moral position towards their subject matter. Moreover, many books and films have far more disturbing content than American Psycho, yet have caused no such uproar (Young and Caveney 120). By now, the plot of American Psycho is well known, although the structure of the book, noted by Weldon above (C1), is rarely analysed or even commented upon. First person narrator, Patrick Bateman, a young, handsome stockbroker and stereotypical 1980s yuppie, is also a serial killer. The book is largely, and innovatively, structured around this seeming incompatibility – challenging readers’ expectations that such a depraved criminal can be a wealthy white professional – while vividly contrasting the banal, and meticulously detailed, emptiness of Bateman’s life as a New York über-consumer with the scenes where he humiliates, rapes, tortures, murders, mutilates, dismembers and cannibalises his victims. Although only comprising some 16 out of 399 pages in my Picador edition, these violent scenes are extreme and certainly make the work as a whole disgustingly confronting. But that is the entire point of Ellis’s work. Bateman’s violence is rendered so explicitly because its principal role in the novel is to be inescapably horrific. As noted by Baelo Allué, there is no shift in tone between the most banally described detail and the description of violence (17): ‘I’ve situated the body in front of the new Toshiba television set and in the VCR is an old tape and appearing on the screen is the last girl I filmed. I’m wearing a Joseph Abboud suit, a tie by Paul Stuart, shoes by J. Crew, a vest by someone Italian and I’m kneeling on the floor beside a corpse, eating the girl’s brain, gobbling it down, spreading Grey Poupon over hunks of the pink, fleshy meat’ (Ellis 328). In complete opposition to how pornography functions, Ellis leaves no room for the possible enjoyment of such a scene. Instead of revelling in the ‘spine chilling’ pleasures of classic horror narratives, there is only the real horror of imagining such an act. The effect, as Kauffman has observed is, rather than arousing, often so disgusting as to be emetic (Bad Girls 249). Ellis was surprised that his detractors did not understand that he was trying to be shocking, not offensive (Love 49), or that his overall aim was to symbolise ‘how desensitised our culture has become towards violence’ (quoted in Dwyer 55). Ellis was also understandably frustrated with readings that conflated not only the contents of the book and their meaning, but also the narrator and author: ‘The acts described in the book are truly, indisputably vile. The book itself is not. Patrick Bateman is a monster. I am not’ (quoted in Love 49). Like Fay Weldon, Norman Mailer understood that American Psycho posited ‘that the eighties were spiritually disgusting and the author’s presentation is the crystallization of such horror’ (129). Unlike Weldon, however, Mailer shied away from defending the novel by judging Ellis not accomplished enough a writer to achieve his ‘monstrous’ aims (182), failing because he did not situate Bateman within a moral universe, that is, ‘by having a murderer with enough inner life for us to comprehend him’ (182). Yet, the morality of Ellis’s project is evident. By viewing the world through the lens of a psychotic killer who, in many ways, personifies the American Dream – wealthy, powerful, intelligent, handsome, energetic and successful – and, yet, who gains no pleasure, satisfaction, coherent identity or sense of life’s meaning from his endless, selfish consumption, Ellis exposes the emptiness of both that world and that dream. As Bateman himself explains: ‘Surface, surface, surface was all that anyone found meaning in. This was civilisation as I saw it, colossal and jagged’ (Ellis 375). Ellis thus situates the responsibility for Bateman’s violence not in his individual moral vacuity, but in the barren values of the society that has shaped him – a selfish society that, in Ellis’s opinion, refused to address the most important issues of the day: corporate greed, mindless consumerism, poverty, homelessness and the prevalence of violent crime. Instead of pornographic, therefore, American Psycho is a profoundly political text: Ellis was never attempting to glorify or incite violence against anyone, but rather to expose the effects of apathy to these broad social problems, including the very kinds of violence the most vocal critics feared the book would engender. Fifteen years after the publication of American Psycho, although our societies are apparently growing in overall prosperity, the gap between rich and poor also continues to grow, more are permanently homeless, violence – whether domestic, random or institutionally-sanctioned – escalates, and yet general apathy has intensified to the point where even the ‘ethics’ of torture as government policy can be posited as a subject for rational debate. The real filth of the saga of American Psycho is, thus, how Ellis’s message was wilfully ignored. While critics and public intellectuals discussed the work at length in almost every prominent publication available, few attempted to think in any depth about what Ellis actually wrote about, or to use their powerful positions to raise any serious debate about the concerns he voiced. Some recent critical reappraisals have begun to appreciate how American Psycho is an ‘ethical denunciation, where the reader cannot but face the real horror behind the serial killer phenomenon’ (Baelo Allué 8), but Ellis, I believe, goes further, exposing the truly filthy causes that underlie the existence of such seemingly ‘senseless’ murder. But, Wait, There’s More It is ironic that American Psycho has, itself, generated a mini-industry of products. A decade after publication, a Canadian team – filmmaker Mary Harron, director of I Shot Andy Warhol (1996), working with scriptwriter, Guinevere Turner, and Vancouver-based Lions Gate Entertainment – adapted the book for a major film (Johnson). Starring Christian Bale, Chloë Sevigny, Willem Dafoe and Reese Witherspoon and, with an estimated budget of U.S.$8 million, the film made U.S.$15 million at the American box office. The soundtrack was released for the film’s opening, with video and DVDs to follow and the ‘Killer Collector’s Edition’ DVD – closed-captioned, in widescreen with surround sound – released in June 2005. Amazon.com lists four movie posters (including a Japanese language version) and, most unexpected of all, a series of film tie-in action dolls. The two most popular of these, judging by E-Bay, are the ‘Cult Classics Series 1: Patrick Bateman’ figure which, attired in a smart suit, comes with essential accoutrements of walkman with headphones, briefcase, Wall Street Journal, video tape and recorder, knife, cleaver, axe, nail gun, severed hand and a display base; and the 18” tall ‘motion activated sound’ edition – a larger version of the same doll with fewer accessories, but which plays sound bites from the movie. Thanks to Stephen Harris and Suzie Gibson (UNE) for stimulating conversations about this book, Stephen Harris for information about the recent Australian reprint of American Psycho and Mark Seebeck (Pan Macmillan) for sales information. References Archer, Mark. “The Funeral Baked Meats.” The Spectator 27 April 1991: 31. Australian Broadcasting Corporation. First Tuesday Book Club. First broadcast 1 August 2006. Baelo Allué, Sonia. “The Aesthetics of Serial Killing: Working against Ethics in The Silence of the Lambs (1988) and American Psycho (1991).” Atlantis 24.2 (Dec. 2002): 7-24. Canadian Press. “Navy Yanks American Psycho.” The Globe and Mail 17 May 1991: C1. Canadian Press. “Gruesome Novel Was Bedside Reading.” Kitchener-Waterloo Record 1 Sep. 1995: A5. Dubin, Steven C. “Art’s Enemies: Censors to the Right of Me, Censors to the Left of Me.” Journal of Aesthetic Education 28.4 (Winter 1994): 44-54. Dwyer, Victor. “Literary Firestorm: Canada Customs Scrutinizes a Brutal Novel.” Maclean’s April 1991: 55. Ellis, Bret Easton. American Psycho. London: Macmillan-Picador, 1991. ———. Glamorama. New York: Knopf, 1999. ———. The Informers. New York: Knopf, 1994. ———. Less than Zero. New York: Simon & Schuster, 1985. ———. Lunar Park. New York: Knopf, 2005. ———. The Rules of Attraction. New York: Simon & Schuster, 1987. Fraser, James. :The Case for Publishing.” The Bulletin 18 June 1991. Fraser, William. “Book May Go under Wraps.” The Sydney Morning Herald 23 May 1991: 5. ———. “The Sensitive Censor and the Psycho.” The Sydney Morning Herald 24 May 1991: 5. Freccero, Carla. “Historical Violence, Censorship, and the Serial Killer: The Case of American Psycho.” Diacritics: A Review of Contemporary Criticism 27.2 (Summer 1997): 44-58. Graham, I. “Australian Censorship History.” Libertus.net 9 Dec. 2001. 17 May 2006 http://libertus.net/censor/hist20on.html>. Gurley Brown, Helen. Commentary in “Editorial Judgement or Censorship?: The Case of American Psycho.” The Writer May 1991: 20-23. Harris, Thomas. The Silence of the Lambs. New York: St Martins Press, 1988. Harron, Mary (dir.). American Psycho [film]. Edward R. Pressman Film Corporation, Lions Gate Films, Muse Productions, P.P.S. Films, Quadra Entertainment, Universal Pictures, 2004. Hitchens, Christopher. “Minority Report.” The Nation 7-14 January 1991: 7. Holt, Karen, and Charlotte Abbott. “Lunar Park: The Novel.” Publishers Weekly 11 July 2005. 13 Aug. 2006 http://www.publishersweekly.com/article/CA624404.html? pubdate=7%2F11%2F2005&display=archive>. Iannone, Carol. “PC & the Ellis Affair.” Commentary Magazine July 1991: 52-4. Irving, John. “Pornography and the New Puritans.” The New York Times Book Review 29 March 1992: Section 7, 1. 13 Aug. 2006 http://www.nytimes.com/books/97/06/15/lifetimes/25665.html>. Johnson, Brian D. “Canadian Cool Meets American Psycho.” Maclean’s 10 April 2000. 13 Aug. 2006 http://www.macleans.ca/culture/films/article.jsp?content=33146>. Kauffman, Linda S. “American Psycho [film review].” Film Quarterly 54.2 (Winter 2000-2001): 41-45. ———. Bad Girls and Sick Boys: Fantasies in Contemporary Art and Culture. Berkeley: University of California Press, 1998. Kennedy, Pagan. “Generation Gaffe: American Psycho.” The Nation 1 April 1991: 426-8. Kirchhoff, H. J. “Customs Clears Psycho: Booksellers’ Reaction Mixed.” The Globe and Mail 26 March 1991: C1. ———. “Psycho Sits in Limbo: Publisher Awaits Customs Ruling.” The Globe and Mail 14 March 1991: C1. Knight-Ridder News Service. “Vintage Picks up Ellis’ American Psycho.” Los Angeles Daily News 17 November 1990: L10. Lehmann-Haupt, Christopher. “Psycho: Wither Death without Life?” The New York Times 11 March 1991: C18. Leo, John. “Marketing Cynicism and Vulgarity.” U.S. News & World Report 3 Dec. 1990: 23. Love, Robert. “Psycho Analysis: Interview with Bret Easton Ellis.” Rolling Stone 4 April 1991: 45-46, 49-51. Mailer, Norman. “Children of the Pied Piper: Mailer on American Psycho.” Vanity Fair March 1991: 124-9, 182-3. Manguel, Alberto. “Designer Porn.” Saturday Night 106.6 (July 1991): 46-8. Manne, Robert. “Liberals Deny the Video Link.” The Australian 6 Jan. 1997: 11. McDowell, Edwin. “NOW Chapter Seeks Boycott of ‘Psycho’ Novel.” The New York Times 6 Dec. 1990: C17. ———. “Vintage Buys Violent Book Dropped by Simon & Schuster.” The New York Times 17 Nov. 1990: 13. Miner, Brad. “Random Notes.” National Review 31 Dec. 1990: 43. National Organization for Women. Library Journal 2.91 (1991): 114. Oates, Joyce Carol. “Three American Gothics.” Where I’ve Been, and Where I’m Going: Essays, Reviews and Prose. New York: Plume, 1999. 232-43. Rapping, Elayne. “The Uses of Violence.” Progressive 55 (1991): 36-8. Rosenblatt, Roger. “Snuff this Book!: Will Brett Easton Ellis Get Away with Murder?” New York Times Book Review 16 Dec. 1990: 3, 16. Roth, Philip. Portnoy’s Complaint. New York: Random House, 1969. Shaw, Patrick W. The Modern American Novel of Violence. Troy, NY: Whitson, 2000. Sheppard, R. Z. “A Revolting Development.” Time 29 Oct. 1990: 100. Teachout, Terry. “Applied Deconstruction.” National Review 24 June 1991: 45-6. Tyrnauer, Matthew. “Who’s Afraid of Bret Easton Ellis?” Vanity Fair 57.8 (Aug. 1994): 70-3, 100-1. Vnuk, Helen. “X-rated? Outdated.” The Age 21 Sep. 2003. 17 May 2006 http://www.theage.com.au/articles/2003/09/19/1063625202157.html>. Wark, McKenzie. “Video Link Is a Distorted View.” The Australian 8 Jan. 1997: 11. Weldon, Fay. “Now You’re Squeamish?: In a World as Sick as Ours, It’s Silly to Target American Psycho.” The Washington Post 28 April 1991: C1. Wolf, Naomi. “The Animals Speak.” New Statesman & Society 12 April 1991: 33-4. Yardley, Jonathan. “American Psycho: Essence of Trash.” The Washington Post 27 Feb. 1991: B1. Young, Elizabeth J. “Psycho Killers. Last Lines: How to Shock the English.” New Statesman & Society 5 April 1991: 24. Young, Elizabeth J., and Graham Caveney. Shopping in Space: Essays on American ‘Blank Generation’ Fiction. London: Serpent’s Tail, 1992. Zaller, Robert “American Psycho, American Censorship and the Dahmer Case.” Revue Francaise d’Etudes Americaines 16.56 (1993): 317-25. Citation reference for this article MLA Style Brien, Donna Lee. "The Real Filth in : A Critical Reassessment." M/C Journal 9.5 (2006). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0610/01-brien.php>. APA Style Brien, D. (Nov. 2006) "The Real Filth in American Psycho: A Critical Reassessment," M/C Journal, 9(5). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0610/01-brien.php>.

Photo by Sharon McCutcheon on Unsplash ABSTRACT COVID-19 highlighted a disproportionate impact upon marginalized communities that needs to be addressed. Specifically, a focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can provide this great benefit but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. INTRODUCTION COVID-19 disproportionately impacted communities of color and lower socioeconomic status, sparking political discussion about existing inequities in the US.[1] Some states amended their guidelines for allocating resources, including vaccines, to provide care for marginalized communities experiencing these inequities, but there has been no clear consensus on which guidelines states should amend or how they should be ethically grounded. In part, this is because traditional justice theories do not acknowledge the deep-seated institutional and interpersonal discrimination embedded in our medical system. Therefore, a revamped distributive justice approach that accounts for these shortcomings is needed to guide healthcare decision-making now and into the post-COVID era. BACKGROUND Three terms – health disparity, health inequities, and health equity – help frame the issue. A health disparity is defined as any difference between populations in terms of disease incidence or adverse health events, such as morbidity or mortality. In contrast, health inequities are health disparities due to avoidable systematic structures rooted in racial, social, and economic injustice.[2] For example, current data demonstrate that Black, Latino, Indigenous Americans, and those living in poverty suffer higher morbidity and mortality rates from COVID-19.[3] Finally, health equity is the opportunity for anyone to attain his or her full health potential without interference from systematic structures and factors that generate health inequities, including race, socioeconomic status, gender, ethnicity, religion, sexual orientation, or geography.[4] ANALYSIS Health inequities for people of color with COVID-19 have led to critiques of states that do not account for race in their resource allocation guidelines.[5] For example, the Massachusetts Department of Public Health revised its COVID-19 guidelines regarding resource allocation to patients with the best chance of short-term survival.[6] Critics have argued that this change addresses neither preexisting structural inequities nor provider bias that may have led to comorbidities and increased vulnerability to COVID-19. By failing to address race specifically, they argue the policy will perpetuate poorer outcomes in already marginalized groups. As the inequities in COVID-19 outcomes continue to be uncovered and the data continue to prove that marginalized communities suffered disproportionately, we, as healthcare providers, must reconsider our role in addressing the injustices. Our actions must be ethically grounded in the concept of justice. l. Primary Theories of Justice The principle of justice in medical ethics relates to how we ought to treat people and allocate resources. Multiple theories have emerged to explain how justice should be implemented, with three of the most prominent being egalitarianism, utilitarianism, and distributive. This paper argues that distributive justice is the best framework for remedying past actions and enacting systemic changes that may persistently prevent injustices. An egalitarian approach to justice states all individuals are equal and, therefore, should have identical access to resources. In the allocation of resources, an egalitarian approach would support a strict distribution of equal value regardless of one’s attributes or characteristics. Putting this theory into practice would place a premium on guidelines based upon first-come, first-served basis or random selection.[7] However, the egalitarian approach taken in the UK continues to worsen health inequities due to institutional and structural discrimination.[8] A utilitarian approach to justice emphasizes maximizing overall benefits and achieving the greatest good for the greatest number of people. When resources are limited, the utilitarian principle historically guides decision-making. In contrast to the egalitarian focus on equal distribution, utilitarianism focuses on managing distributions to maximize numerical outcomes. During the COVID-19 pandemic, guidelines for allocating resources had utilitarian goals like saving the most lives, which may prioritize the youthful and those deemed productive in society, followed by the elderly and the very ill. It is important to reconsider using utilitarian approaches as the default in the post-COVID healthcare community. These approaches fail to address past inequity, sacrificing the marginalized in their emphasis on the greatest amount of good rather than the type of good. Finally, a distributive approach to justice mandates resources should be allocated in a manner that does not infringe individual liberties to those with the greatest need. Proposed by John Rawls in a Theory of Justice, this approach requires accounting for societal inequality, a factor absent from egalitarianism and utilitarianism.[9] Naomi Zack elaborates how distributive justice can be applied to healthcare, outlining why racism is a social determinant of health that must be acknowledged and addressed.[10] Until there are parallel health opportunities and better alignment of outcomes among different social and racial groups, the underlying systemic social and economic variables that are driving the disparities must be fixed. As a society and as healthcare providers, we should be striving to address the factors that perpetuate health inequities. While genetics and other variables influence health, the data show proportionately more exposure, more cases, and more deaths in the Black American and Hispanic populations. Preexisting conditions and general health disparities are signs of health inequity that increased vulnerability. Distributive justice as a theoretical and applied framework can be applied to preventable conditions that increase vulnerability and can justify systemic changes to prevent further bias in the medical community. During a pandemic, egalitarian and utilitarian approaches to justice are prioritized by policymakers and health systems. Yet, as COVID-19 has demonstrated, they further perpetuate the death and morbidity of populations that face discrimination. These outcomes are due to policies and guidelines that overall benefit white communities over communities of color. Historically, US policy that looks to distribute resources equally (focusing on equal access instead of outcomes), in a color-blind manner, has further perpetuated poor outcomes for marginalized communities.[11] ll. Historical and Ongoing Disparities Across socio-demographic groups, the medical system exacerbates historical and current inequities. Members of marginalized races,[12] women,[13] LGBTQ people,[14] and poor people[15] experience trauma caused by discrimination, marginalization, and failure to access high-quality public and private goods. Through the unequal treatment of marginalized communities, these historic traumas continue. In the US, people of color do not receive equal and fair medical treatment. A meta-analysis found that Hispanics and Black Americans were significantly undertreated for pain compared to their white counterparts over the last 20 years.[16] This is partly due to provider bias. Through interviewing medical trainees, a study by the National Academy of Science found that half of medical students and residents harbored racist beliefs such as “Black people’s nerve endings are less sensitive than white people’s” or “Black people’s skin is thicker than white people’s skin.”[17] More than 3,000 Indigenous American women were coerced, threatened, and deliberately misinformed to ensure cooperation in forced sterilization.[18] Hispanic people have less support in seeking medical care, in receiving culturally appropriate care, and they suffer from the medical community’s lack of resources to address language barriers.[19] In the US, patients of different sexes do not receive the same quality of healthcare. Despite having greater health needs, middle-aged and older women are more likely to have fewer hospital stays and fewer physician visits compared to men of similar demographics and health risk profiles.[20] In the field of critical care, women are less likely to be admitted to the ICU, less likely to receive interventions such as mechanical ventilation, and more likely to die compared to their male ICU counterparts.[21] In the US, patients of different socioeconomic statuses do not receive the same quality of healthcare. Low-income patients are more likely to have higher rates of infant mortality, chronic disease, and a shorter life span.[22] This is partly due to the insurance-based discrimination in the medical community.[23] One in three deaths of those experiencing homelessness could have been prevented by timely and effective medical care. An individual experiencing homelessness has a life expectancy that is decades shorter than that of the average American.[24] lll. Action Needed: Policy Reform While steps need to be taken to provide equitable care in the current pandemic, including the allocation of vaccines, they may not address the historical failures of health policy, hospital policy, and clinical care to eliminate bias and ensure equal treatment of patients. According to an applied distributive justice framework, inequities must be corrected. Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-sexist, anti-transphobic, and anti-discriminatory. Evidence has shown that the health inequities caused by COVID-19 are smaller in regions that have addressed racial wealth gaps through forms of reparations.[25] Distributive justice calls for making up for the past using tools of allocation as well as tools to remedy persistent problems. For example, Brigham and Women’s Hospital in Boston, MA, began “Healing ARC,” a pilot initiative that involves acknowledgement, redress, and closure on an institutional level.[26] Acknowledgement entails informing patients about disparities at the hospital, claiming responsibility, and incorporating community ideas for redress. Redress involves a preferential admission option for Black and Hispanic patients to specialty services, especially cardiovascular services, rather than general medicine. Closure requires that community and patient stakeholders work together to ensure that a new system is in place that will continue to prioritize equity. Of note, redress could take the form of cash transfers, discounted or free care, taxes on nonprofit hospitals that exclude patients of color,[27] or race-explicit protocol changes (such as those being instituted by Brigham and Women’s Hospital that admit patients historically denied access to certain forms of medical care). In New York, for instance, the New York State Bar Association drafted the COVID-19 resolutions to ensure that emergency regulations and guidelines do not discriminate against communities of color, and even mandate that diverse patient populations be included in clinical trials.[28] Also, physicians must listen to individuals from marginalized communities to identify needs and ensure that community members take part in decision-making. The solution is not to simply build new health centers in communities of color, as this may lead to tiers of care. Rather, local communities should have a chance to impact existing hospital policy and should also use their political participation to further their healthcare interests. Distributive justice does not seek to disenfranchise groups that hold power in the system. It aims to transform the system so that those in power do not continue to obtain unfair benefits at the expense of others. The framework accounts for unjust historical oppression and current injustices in our system to provide equitable outcomes to all who access the system. In this vein, we can begin to address the flagrant disparities between communities that have always – and continue to – exist in healthcare today.[29] CONCLUSION As equality focuses on access, it currently fails to do justice. Instead of outcomes, it is time to focus on equity. A focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can gain traction in clinical decision-making guidelines and system-level reallocation of resources but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. There should be an emphasis on implementing a distributive justice framework that treats all patients equitably, accounts for historical harm, and focuses on transparency in allocation and public health decision-making. [1] APM Research Lab Staff. 2020. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race. [2] Bharmal, N., K. P. Derose, M. Felician, and M. M. Weden. 2015. “Understanding the Upstream Social Determinants of Health.” California: RAND Corporation 1-18. https://www.rand.org/pubs/working_papers/WR1096.html. [3] Yancy, C. W. 2020. “COVID-19 and African Americans.” JAMA. 323 (19): 1891-2. https://doi.org/10.1001/jama.2020.6548; Centers for Disease Control and Prevention. 2020. “COVID-19 in Racial and Ethnic Health Disparities.” Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html. 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