Chapter 7
Health and Hunger

HEALTH OF POOR PEOPLE

Connection between Poor Health and Poverty

The National Center for Health Statistics of the U.S. Department of Health and Human Services (HHS) points out in Health, United States, 2006 (2006, http://www.cdc.gov/nchs/data/hus/hus06.pdf) that poverty causes poor health because of its connection with a nutritionally poor diet, substandard housing, exposure to the elements and environmental hazards, unhealthy lifestyle, and decreased access to and use of health care services. Jane Knitzer, the director of the National Center for Children in Poverty, testified before the House Committee on Ways and Means on January 27, 2007, that economic hardship in childhood is linked to poor health and that poor health adversely impacts educational attainment and future productivity, leading to a cycle of poverty (http://www.nccp.org/pub_wmt07.html).

Poor people are more likely to suffer from chronic conditions that limit their activities. According to Health, United States, 2006, in 2004, 11.9% of the population had such conditions. However, almost a quarter of people living below the poverty line (23%) suffered from chronic health complaints, compared with 16.3% of those whose household incomes were 100% to 199% of the poverty level and 9.2% of those whose incomes were 200% or more of the poverty level. In addition, 14.2% of adults with incomes below the poverty line had difficulty seeing even with corrective lenses, compared with 12% of people with incomes 100% to 199% of the poverty line and 7.4% of those with incomes 200% of the poverty line or higher.

Health, United States, 2006 also reports that poor respondents were much more likely to rate their health as only fair or poor, compared with their more affluent peers. In 2004 more than one in five people (21.3%) with incomes below the poverty level rated their health as fair or poor, compared with 14.4% of people with incomes 100% to 199% of the poverty level and only 6.3% of people with higher incomes.

Poor people also have more mental health problems. Only 1.7% of people with incomes 200% of the poverty level or higher reported they suffered from serious psychological distress in 2004. However, 5.4% of people with incomes 100% to 199% of the poverty line and 8.8% of people with incomes below the poverty level reported such psychological distress.

Access to Care

Health, United States, 2006 also reports that poor people have limited access to medical care. In 2004, 11.5% of those living below the poverty level reported not receiving care because of cost, and 13.5% reported delaying receiving health care because of cost in the previous year. In contrast, of those with incomes 100% to 199% of the poverty level, 10% reported not receiving care and 12.8% reported a delay in receiving care, whereas among those with incomes 200% of the poverty level or more, 3.3% reported not receiving care and 5.5% reported a delay in receiving care in the previous year. In addition, 14.2% of people with incomes below the poverty level did not get prescription drugs because of the cost, compared with 12.8% of people with incomes 100% to 199% of the poverty level and only 4.5% of those with higher incomes. The percentage of people unable to get prescription drugs because of their costs has risen markedly in all socioeconomic groups since 1997.

A higher percentage of poor and low-income children in 2003–04 had not visited the doctor in the previous twelve months than children in higher income families; this was particularly true among Hispanic children. According to Health, United States, 2006, over one in five Hispanic children living in households with incomes below the poverty level (21.8%) or with incomes 100% to 199% of the poverty level (20.9%) had not visited a doctor in the previous year, whereas 14.9% of Hispanic children living in households with incomes 200% or more of the poverty level had not visited a doctor in the past year. Among white, non-Hispanic children, 12.3% of those living below the poverty level, 12.4% of those living at 100% to 199% of the poverty level, and 8.3% of those living at 200% or more of the poverty level had not seen a doctor in the previous year. Among African-American children, 12.9% of those living below the poverty level, 13.4% of those living at 100% to 199% of the poverty level, and 10.2% of those living at 200% or more of the poverty level had failed to see a doctor within the past year.

HEALTH INSURANCE

The scope of health issues regarding the impoverished and homeless in the United States is related in part to the number of uninsured Americans. Figure 7.1 shows that in 2005 the number of uninsured people was higher than it had been in decades. At that time 46.6 million people were uninsured. Figure 7.2 shows the average number of people from 2003 to 2005 who were without health insurance coverage by state. Texas (24.6%) had the highest percentage of uninsured people, whereas Minnesota (8.7%) had the lowest. Comparisons of two-year averages (2003–04 and 2004–05) show that the percentage of people without health insurance rose in eight states (California, Utah, Arizona, Florida, Georgia, South Carolina, Delaware, and Vermont) and dropped in only three (Idaho, Iowa, and New York). (See Figure 7.3.)

Children in poverty were much more likely than children in general to be uninsured in 2005 (19% and 11.2%, respectively). (See Figure 7.4.) However, this rate varied greatly by race. Hispanic children (21.9%) were far more likely to be uninsured than African-American children (12.5%), Asian children (12.2%), or white, non-Hispanic children (7.2%).

People without insurance are less likely to seek medical care. In "Out of Pocket Medical Spending for Care of Chronic Conditions" (Health Affairs, November-December 2001), Stephen W. Hwang et al. note that "among chronically ill persons the uninsured had the highest out-of-pocket spending and were five times less likely to see a medical provider in a given year."

At the same time that overall money spent on health care in the United States is growing rapidly, government spending to help the uninsured has remained stagnant or declined. The Kaiser Commission notes in "Covering the Uninsured: Growing Need, Strained Resources" (January 2007, http://www.kff.org/uninsured/upload/7429-02.pdf) that between 2001 and 2004 health care expenses rose by nearly 14%, whereas federal spending on safety net programs—a network of hospitals, clinics, and health centers that are largely supported by government resources—increased from $19.8 billion in 2001 to $22.8 billion in 2004, an increase of 15.4%. However, because the number of uninsured grew by nearly five million people over that period, federal spending per uninsured person actually declined, from $546 per person to $498 per person in constant 2004 dollars. The Kaiser Commission concludes, "As critical to the care of the uninsured as safety net providers are, they are unable to meet all the needs of the uninsured, particularly if resources continue to decrease as the number of uninsured increases."

Medicaid

Medicaid, which is authorized under Title XIX of the Social Security Act, is a federal-state program that provides medical insurance for low-income people who are aged, blind, disabled, or members of families with dependent children and for certain other pregnant women and children. Within federal guidelines, each state designs and administers its own program. For this reason there may be considerable differences from state to state as to who is covered, what type of coverage is provided, and how much is paid for medical services. States receive federal matching payments based on their Medicaid expenditures and the state's per capita income. The federal match ranges from 50% to 80% of Medicaid expenditures. Table 7.1 shows the number of recipients, the amount of payments, and the average payment per recipient for each state or territory in fiscal year (FY) 2002.

Although Medicaid eligibility had been linked to receipt of, or eligibility to receive, benefits under Aid to Families with Dependent Children or Supplemental Security Income, legislation gradually extended coverage in the 1980s and 1990s. Beginning in 1986 benefits were extended to low-income children and pregnant women not on welfare. States must cover children less than six years of age and pregnant women with family incomes below 133% of the federal poverty level. Pregnant women are only covered for medical services related to their pregnancies, whereas children receive full Medicaid coverage. The states may cover infants under one year old and pregnant women with incomes more than 133%, but not more than 185%, of the poverty level. As of January 1, 1991, Medicaid also began to cover aged and disabled people receiving Medicare whose incomes were below 100% of the poverty level.

States may deny Medicaid benefits to adults who lose Temporary Assistance for Needy Families (TANF) benefits because they refuse to work. However, the law exempts poor pregnant women and children from this provision, requiring their continued Medicaid eligibility. In addition, the welfare law requires state plans to ensure Medicaid for children receiving foster care or adoption assistance.

Carmen DeNavas-Walt, Bernadette D. Proctor, and Cheryl Hill Lee report in Income, Poverty, and Health Insurance Coverage in the United States: 2005—Current Population Reports (August 2006, http://www.census.gov/prod/2006pubs/p60-231.pdf) that 8.3 million children, or 11.2%, are uninsured. In an effort to reach these uninsured children, many states are simplifying the Medicaid application process. In addition, the 1996 welfare law gives states the option to use Medicaid to provide health care coverage to low-income working parents. About half (47%) of poor adults without children, 42% of poor parents, and 22% of poor children were uninsured in 2005. (See Figure 7.5.) Although the income of these households is below the federal poverty line, working poor parents have been ineligible for publicly funded health insurance. In addition, low-wage jobs often do not offer affordable employer-sponsored coverage. The number of uninsured working poor parents is likely to grow as welfare recipients move into the workforce, as required under the welfare reform law, unless states expand Medicaid to cover this group.

Medicaid accounted for 13% of all health coverage in 2005. (See Figure 7.6.) Medicaid is the single largest source of health insurance coverage for all children from families earning below 200% of the poverty line. African-American and Hispanic children were far more likely to have Medicaid coverage than were white or Asian and Pacific Islander children. DeNavas-Walt, Proctor, and Hill Lee note that in 2005, 44.9% of African-American children and 39.3% of Hispanic children were covered by Medicaid, compared with 18% of non-Hispanic white children and 15.9% of Asian children.

Of the 49.7 million people enrolled in Medicaid in 2002 (the latest year for which detailed statistics are available), the majority were dependent children under twenty-one years of age (24.6 million) and adults in families with dependent children (13.2 million). (See Table 7.2.) The remainder of Medicaid recipients were disabled (8 million) or elderly (4.7 million). The number receiving Medicaid coverage had more than doubled since the mid-1970s, when approximately 22 million people were enrolled.

The rapid growth in spending for Medicaid has contributed to the concern over the rising cost of health care. Not accounting for inflation, spending skyrocketed from $6.3 billion in 1972 to $37.5 billion in 1985 to $213.5 billion in 2002. (See Table 7.2.) Of the $213.5 billion spent on Medicaid payments in 2002, most went for the disabled ($91.9 billion, or 43%) and the elderly ($51.7 billion, or 24.2%). In addition, considerable amounts were spent on dependent children under age twenty-one ($31.2 billion, or 14.6%) and adults in families with dependent children ($23.5 billion, or 11%). On average, in 2002 the Medicaid program spent $10,870 on every elderly recipient, $1,271 on each dependent child under twenty-one, and $11,408 on each disabled person in the program.

Medicare and Medicaid payments to physicians were cut after the year 2000. In "Bush Seeks Big Medicare and Medicaid Saving, but Faces Hard Fight" (New York Times, February 2, 2007), Robert Pear reports that more deep cuts in physician reimbursement in January 2007 were followed by the announcement that the Bush administration planned to ask Congress in February 2007 to cut more than $70 billion from Medicare and Medicaid over the following five years, as well as institute cuts in federal funding of Children's Health Insurance Programs. As a result of these cuts, some medical providers turned Medicaid and Medicare patients away. In "New AMA Survey Shows Medicare Cuts Will Harm Seniors' Access to Physician Care" (March 16, 2006, http://www.ama-assn.org/ama/pub/category/16117.html), the American Medical Association finds that 45% of physicians said they would either decrease or stop seeing new Medicare patients because of the pending 2007 cuts. As a result, access to health care for many low-income people has been compromised.

State Child Health Insurance Program

The Balanced Budget Act of 1997 set aside $24 billion over five years to fund the State Children's Health Insurance Program (SCHIP) in an effort to reach children who were uninsured. This was the nation's largest children's health care investment since the creation of Medicaid in 1965. SCHIP requires states to use the funding to cover uninsured children whose families earn too much for Medicaid but too little to afford private coverage. States may use this money to expand their Medicaid programs, design new child health insurance programs, or create a combination of both.

States must enroll all children who meet Medicaid eligibility rules in the Medicaid program rather than in the new SCHIP plan. They are not allowed to use SCHIP to replace existing health coverage. In addition, states must decide on what kind of cost-sharing, if any, to require of low-income families without keeping them from accessing the program. The only federal requirement is that cost-sharing cannot exceed 5% of family income. In SCHIP Program Enrollment: June 2005 Update (December 2006, http://www.kff.org/medicaid/upload/7607.pdf), Vernon K. Smith, David Rousseau, and Caryn Marks note that over four million children were enrolled in the SCHIP plan in 2005. As noted earlier, however, the Bush administration proposed in 2007 to cut funding for the program.

Health Care for the Homeless

In 1987 Congress passed the Stewart B. McKinney Homeless Assistance Act to provide services to the homeless, including job training, emergency shelter, education, and health care. Title VI of the act funds Health Care for the Homeless (HCH) programs. The HCH has become the national umbrella under which most homeless health care initiatives operate. According to the HHS (March 7, 2006, http://bphc.hrsa.gov/hchirc/about/face_homelessness.htm), in 2004 about six hundred thousand people were served by HCH programs. In 2000 the government appropriated $88 million for HCH programs; by 2005 the appropriations had been increased to $145 million.

Nonprofit private organizations and public entities, including state and local government agencies, may apply for grants from the program. The grants may be used to continue to provide services for up to one year to individuals who have obtained permanent housing if services were provided to them when they were homeless.

The goal of the HCH programs is to improve the health of homeless individuals and families by improving access to primary health care and substance abuse services. The HCH provides outreach, counseling to clients explaining available services, case management, and linkages to services such as mental health treatment, housing, benefits, and other critical supports. Access to around-the-clock emergency services is available, as well as help in establishing eligibility for assistance and obtaining services under entitlement programs.

The HHS reports that of the six hundred thousand homeless people the HCH served in 2004, most of the clients (58%) were male. Almost two-thirds (63%) of homeless clients were members of minority groups: African-Americans made up 37%; Hispanics, 22%; Asians and Pacific Islanders, 2%; and Native Americans and Alaskan Natives, 2%.

The HHS indicates that clients between the ages of twenty and forty-four represented the largest portion of people served by the HCH programs in 2004 (51%), followed by individuals between the ages of forty-five and sixty-four (30%), and children up to age nineteen (15%). Homeless people over age sixty-five made up 2% of clients served.

Of clients seen in HCH centers, the HHS notes that 40% lived in shelters at some point during treatment, 19% lived doubled up with family or acquaintances, 11% lived in transitional housing, and 11% lived on the street. The majority (71%) of HCH users had no medical care coverage. Of those who had some type of insurance, 23% were enrolled in Medicaid, 3% were enrolled in Medicare, 2% had private insurance, and 2% had some other type of insurance.

LIVING IN PUBLIC: INCREASED HEALTH PROBLEMS

Poor people can be catapulted into homelessness because of the expenses and missed work caused by poor health. Homelessness itself causes a person's health to deteriorate further. Thus, health problems can both cause and result from homelessness. For example, a health problem that prevents an impoverished person from working can result in a loss of income that leads to homelessness. For those living on the streets, lack of adequate shelter and proper facilities for maintaining personal hygiene can exacerbate illness. Alcoholism, mental illnesses, diabetes, and depression become visible and more pronounced in homeless people. Other serious illnesses (for example, tuberculosis [TB]) are almost exclusively associated with the unhealthy living conditions brought on by poverty. In general, experts agree that homeless people suffer from more types of illnesses, for longer periods of time, and with more harmful consequences than housed people. In addition, according to "Homelessness and Health" (2006, http://www.nhchc.org/Advocacy/PolicyPapers/HomelessHealth2006.pdf), a policy statement by the National Health Care for the Homeless Council (NHCHC), health care delivery is complicated by a patient's homeless status, making management of chronic diseases such as diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and hypertension more difficult. Most Americans suffer illness and disease at some time in their lives, but for people experiencing homelessness and poverty, illness more often leads to serious health concerns or premature death.

There is a growing belief in the health care field that homelessness must be considered in epidemic terms—that massive increases in homelessness may result in a hastened spread of illness and disease, overwhelming the health care system. John Lozier, in The Health Care of Homeless Persons (2004, http://www.bhchp.org/BHCHP%20manual/pages/chapters.html), writes that "primary care clinics for indigent people generally operate beyond their capacity, are not well-located to serve people staying in shelters, and are not prepared to deal with the complex conditions often presented by homeless people." He conveys the sense of many public health officials that the health care system is facing a crisis because of homelessness when he states, "The public health system, which made great strides in the 20th century by eliminating unhealthy living conditions, seems ill-equipped to contend with the teeming shelters that are a throwback to the 19th century."

The rates of both chronic and acute health problems are disproportionately high among the homeless population. Except for obesity, strokes, and cancer, homeless people are far more likely than the housed to suffer from every category of chronic health problems. Conditions that require regular, uninterrupted treatment, such as TB, HIV/AIDS, diabetes, hypertension, malnutrition, severe dental problems, addictive disorders, and mental disorders, are extremely difficult to treat or control among those without adequate housing.

Street living comes with a set of health conditions that living in a home does not. Homeless people fall prey to parasites, frostbite, leg ulcers, and infections. They are also at greater risk of physical and psychological trauma resulting from muggings, beatings, and rape. With no safe place to store belongings, proper storage or administration of medications becomes difficult. In addition, some homeless people with mental disorders may use drugs or alcohol to self-medicate, and those with addictive disorders are more susceptible to HIV and other communicable diseases.

Homeless people may also lack the ability to access some of the basic rituals of self-care: bed rest, good nutrition, and good personal hygiene. For example, the luxury of taking it easy for a day or two is almost impossible for homeless people; they must often keep walking or remain standing all day to avoid criminal charges.

Unwell homeless people also remain untreated longer than their sheltered counterparts because obtaining food and shelter takes priority over health care. As a result, relatively minor illnesses go untreated until they develop into major emergencies, requiring expensive acute care treatment and long-term recovery.

At least one study suggests that the health of homeless people may be getting worse. In "A Comparison of the Health and Mental Health Status of Homeless Mothers in Worcester, Mass: 1993 and 2003" (American Journal of Public Health, August 2006), Linda F. Weinreb et al. report that between 1993 and 2003 homeless women and their families exhibited more acute and chronic mental health problems, especially major depression and posttraumatic stress disorder, their overall health declined, and their physical functioning became more limited. Their social functioning also became more impaired because of all of those factors. In addition, homeless women and their families were poorer in 2003 than in 1993 when inflation was taken into account. Weinreb et al. speculate that cuts in welfare spending and the decrease in the availability of affordable housing might be responsible for this trend.

Mortality Rates

James J. O'Connell, a physician with the Boston Health Care for the Homeless program, concludes in "Death on the Streets" (Harvard Medical Alumni Bulletin, Winter 1997) that even though the causes of the higher morbidity and mortality rates among Boston's homeless people are complex, there are elements of the homeless life that encourage early death. Some of these are exposure to extremes of weather and temperature; crowded shelter living, which increases the spread of communicable diseases such as TB and pneumonia; violence; the high frequency of medical and psychiatric illnesses; substance abuse; and inadequate nutrition. Stephen W. Hwang et al., in "Health Care Utilization among Homeless Adults Prior to Death" (Journal of Health Care for the Poor and Underserved, February 2001), find that of 558 deaths among the homeless population in Boston in 2001, within one year before death 27% of homeless people had no outpatient visits, emergency department visits, or hospitalizations. Hwang et al. conclude that even homeless people at high risk of death are underutilizing health care services.

In King County 2003: Homeless Death Review (November 2004, http://www.metrokc.gov/health/hchn/hchn-death-review.pdf), a 2003 study of homeless deaths in King County, Washington, the Health Care for the Homeless Network identifies seventy-seven people who had died while homeless in the county that year. Major causes of death included acute intoxication (26%), cardiovascular disease (17%), and homicide (9%). Most of the homeless deaths involved several illnesses before death; on average, those who died had had three health conditions before death.

In "The Risk of Death among Homeless Women: A Cohort Study and Review of the Literature" (Canadian Medical Association Journal, April 13, 2004), a study of deaths among homeless women in Toronto, Angela M. Cheung and Stephen W. Hwang find that homeless women aged eighteen to forty-four were ten times more likely to die than women in the general population of Toronto. Another key finding of the study is that the risk of death among young homeless women was nearly the same as the risk of death among homeless men of the same age.

James J. O'Connell, in Premature Mortality in Homeless Populations: A Review of the Literature (December 2005, http://www.nhchc.org/PrematureMortalityFinal.pdf), reviews the literature concerning the connection between homelessness and mortality. He finds that "a remarkable consistency … transcends borders, cultures and oceans: homeless persons are 3-4 times more likely to die than the general population." In addition, he notes that the average age of death of homeless people in the studies reviewed was between forty-two and fifty-two years, despite a life expectancy of around eighty years in the United States. These premature deaths were highly associated with the coexistence of acute and chronic medical conditions with either mental illness or substance abuse.

Access to Care

Martha R. Burt et al. analyze in Homelessness: Programs and the People They Serve, Findings of the National Survey of Homeless Assistance Providers and Clients (December 1999, http://www.urban.org/UploadedPDF/homelessness.pdf) the results of the 1996 National Survey of Homeless Assistance Providers and Clients, the only survey of its kind (studies of the homeless tend to focus on local populations). The analysis shows that in the year preceding the survey, 25% of the clients studied had needed medical attention but were not able to see a doctor or a nurse. The study also reveals that newly housed people were even less likely to receive medical help when needed.

Burt et al. attribute the higher rate of health problems among newly housed people to several factors, including:

1. The loss of convenient health care in centers or shelters
2. The habit of enduring untreated ailments
3. A lack of health care benefits (common among people below the poverty level)

Figure 7.7 shows that the lower the income range of a household, the greater possibility the household would be uninsured in 2005. Among households with an annual income of less than $25,000 in 2005, almost a quarter (24.4%) were uninsured. Moreover, health insurance is becoming harder to obtain. Between 2004 and 2005 the percentage of uninsured people rose in every income bracket.

Lillian Gelberg et al. report in "The Behavioral Model for Vulnerable Populations: Application to Medical Care Use and Outcomes for Homeless People" (Health Services Research, February 2000) the results of a study on the prevalence of certain disease conditions among homeless adults, which revealed that 37% suffered from functional vision impairment, 36% from skin/leg/foot problems, and 31% tested positive for TB. Gelberg et al. indicate that homeless people who had a community clinic or private physician as a regular source of care exhibited better health outcomes. Gelberg et al. also suggest that clinical treatment of the homeless be accompanied by efforts to help them find permanent housing.

To fully understand why health care may not be readily available to the homeless population, one must look at the U.S health care system in general. In "U.S. HealthCare System Faces Cost and Insurance Crises: Rising Costs, Growing Numbers of Uninsured and Quality Gaps Trouble World's Most Expensive Health-Care System" (Lancet, August 2, 2003), Michael McCarthy describes a system "lurching towards crisis." Health care costs continue to rise, as do the numbers of people who do not have insurance. DeNavas-Walt, Proctor, and Hill Lee note that between 2004 and 2005, even though the number of Americans living below the poverty line decreased by about ninety thousand, the number of uninsured Americans grew by 1.3 million.

McCarthy notes that even though most hospitals by law must provide care for the indigent, in reality an uninsured patient is less likely to receive any care at all and, if hospitalized, is less likely to receive a high quality of care than an insured patient. He cites Care without Coverage: Too Little, Too Late (2002), a study by the U.S. National Academy of Sciences Institute of Medicine. The study found that "uninsured patients who are hospitalized for a range of conditions are more likely to die in the hospital, to receive fewer services when admitted, and to experience substandard care and resultant injury than are insured patients."

AILMENTS OF HOMELESS PEOPLE

In the Hartford Homeless Health Survey (March 22, 2000, http://www.hchp.org/pdf/homeless.pdf), a survey of the homeless in Hartford, Connecticut, Eileen B. O'Keefe, Rose Maljanian, and Katherine M. McCormack counted 1,365 homeless people on the evening of December 13, 1999. The vast majority (87%) of survey respondents reported a prior diagnosis of at least one of seventeen chronic conditions. The most prevalent of these chronic conditions were drug and alcohol abuse, depression and other mental illnesses, hypertension, chronic bronchitis and emphysema, HIV/AIDS, asthma, and arthritis. Comparing the responses from the homeless survey against the rates for the general Hartford population revealed that homeless people suffered almost twice the rate of depression (41%) as the general population (23%) and three times the rate of chronic bronchitis and emphysema (22.7%). Even though these chronic diseases exist throughout the general population, difficulty in providing treatment to the homeless makes them worse, as do hunger and malnutrition.

Gillian Silver and Rea Pañares summarize in The Health of Homeless Women: Information for State Mental and Child Health Programs (2000, http://www.jhsph.edu/WCHPC/Publications/homeless.PDF) one study's findings regarding the health problems faced by homeless women, who made up about one-third (32%) of the homeless population. This group was prone to the same physical ailments reported by the general homeless population in Hartford but also reported high rates of gastrointestinal problems, neurological disorders, chronic obstructive pulmonary disease, and peripheral vascular disease. (See Table 7.3.)

Physical Disorders and Diseases

A description of a few chronic problems suffered by homeless people follows.

TUBERCULOSIS

Several kinds of acute, nonspecific respiratory diseases are common among homeless people. These diseases are easily spread through group living in overcrowded shelters without adequate nutrition. TB, a disease at one time almost eliminated from the general American population, has become a major health problem among the homeless. This disease is associated with exposure, poor diet, alcoholism, HIV, intravenous drug use, and other illnesses that lower the body's resistance to infection. TB is spread by long personal contact, making it a potential hazard not only to shelter residents but also to the general public.

The Centers for Disease Control and Prevention (CDC) notes in Reported Tuberculosis in the United States, 2005 (September 2006, http://www.cdc.gov/tb/surv/surv2005/PDF/TBSurvFULLReport.pdf) that from 1953 to 1984 the United States experienced a decrease of 73.6% in the number of reported TB cases (from 84,304 cases to 22,255 cases). However, in 1984 the number of TB cases began to rise, reaching 25,701 cases in 1990. Rising homelessness and poverty account, in part, for the resurgence of TB. Poor ventilating systems in shelters and impoverished homes, as well as the inability to quarantine poor or transient victims, contribute to the rise. In 2005 the CDC found that 6.1% of those infected with TB were homeless, a much higher rate of infection than among the general population. (See Table 7.4.) State-by-state breakdowns showing high rates of infection among the homeless populations of some states give one indication of the contagious nature of the disease. In 2005, for example, Montana reported that 20% of those testing positive for TB were homeless, whereas Arkansas, Delaware, Maine, New Hampshire, North Dakota, and Vermont had no cases of TB among their homeless populations.

Clinical data from the federally funded HCH programs find prevalence rates for TB to be one hundred to three hundred times higher among the homeless than among the overall population. Maryam B. Haddad et al. report in "Tuberculosis and Homelessness in the United States, 1994–2003" (Journal of the American Medical Association, 2005) that many of the risk factors for tuberculosis in the United States overlap with the risk factors associated with homelessness, including having a history of incarceration or substance abuse. An additional contributing factor was the emergence of drug-resistant strains of TB. Experts report that to control the spread of TB, the homeless population must receive frequent screenings for TB, and the infected must get long-term care and rest. Few if any among the homeless can get such care.

A campaign for increased public awareness, particularly among members of the medical community, was launched in 1990 to identify and screen those at the greatest risk for TB. Some researchers, such as Po-Marn Kong et al. in "Skin-Test Screening and Tuberculosis Transmission among the Homeless" (Emerging Infectious Diseases, November 2002), tested pilot programs to better identify and treat homeless people infected with TB. Other studies, such as J. P. Tulsky et al. in "Can the Poor Adhere? Incentives for Adherence to TB Prevention in Homeless Adults" (International Journal of Tuberculosis and Lung Disease, January 2004), investigated how best to help homeless adults adhere to treatment for latent TB infection. In Reported Tuberculosis in the United States, the CDC notes that the number of reported TB cases in the United States declined to 14,097 in 2005, a 2.9% decrease from the year before.

SKIN AND BLOOD VESSEL DISORDERS

Frequent exposure to severe weather, insect bites, and other infestations make skin lesions fairly common among the homeless. Being forced to sit or stand for extended periods results in many homeless people being plagued with edema (swelling of the feet and legs), varicose veins, and skin ulcerations. This population is more prone to conditions that can lead to chronic phlebitis (inflammation of the veins). A homeless person with circulatory problems who sleeps sitting up in a doorway or a bus station can develop open lacerations that may become infected or maggot-infested if left untreated.

Regular baths and showers are luxuries to most homeless people, so many suffer from various forms of dermatitis (inflammation of the skin), often because of infestations of lice or scabies (a contagious skin disease caused by a parasitic mite that burrows under the skin to deposit eggs, causing intense itching). The lack of bathing increases the opportunity for infection to develop in cuts and other lacerations.

HIV/AIDS

The CDC reports in HIV/AIDS Surveillance Report, 2005 (2006, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/2005SurveillanceReport.pdf) that in 2005, 35,537 new cases of HIV infection and 17,011 deaths of people with AIDS were reported. Since the beginning of the epidemic, 249,950 HIV cases that had not progressed to full-blown AIDS had been reported. In addition, at the end of 2005, 437,982 people were living with AIDS. The number of HIV/AIDS cases decreased each year between 2001 and 2004, but then increased in 2005; the number of AIDS cases actually increased each year between 2002 and 2005.

According to the news release "FDA Approves New Rapid HIV Test Kit" (November 7, 2002, http://www.fda.gov/bbs/topics/NEWS/2002/NEW00852.html), in November 2002 the U.S. Food and Drug Administration approved a rapid test for HIV infection that can provide results in twenty minutes. The HHS secretary Tommy G. Thompson explained the significance of the test: "Each year, 8,000 HIV-infected people who come to public clinics for HIV testing do not return a week later to receive their test results. With this new test, in less than a half an hour they can learn preliminary information about their HIV status, allowing them to get the care they need to slow the progression of their disease and to take precautionary measures to help prevent the spread of this deadly virus."

The CDC estimates that up to one-fourth of people infected with HIV are not aware of their condition. The CDC is working with health officials to make the rapid test widely available, particularly in places where likely victims reside, such as homeless shelters, drug treatment centers, and jails.

According to "Study: Disparity between Rich and Poor Mortality" (AIDS Alert, August 1, 2003), poor AIDS patients in San Francisco die sooner from AIDS. Within five years of diagnosis, fewer than 70% of people living in the city's poorest neighborhoods were still alive, compared with more than 85% of people who lived in the richest neighborhoods. Poor people with HIV usually have a number of co-occurring disorders, such as drug dependence, mental illness, and unstable housing arrangements. The lack of affordable and appropriate housing can be an acute crisis for these individuals, who need a safe shelter that provides protection and comfort, as well as a base from which to receive services, care, and support.

The National Alliance to End Homelessness points out in "Homelessness and HIV/AIDS" (August 10, 2006, http://www.endhomelessness.org/content/general/detail/1073) that HIV/AIDS is more prevalent in homeless populations. As many as 3.4% of homeless people are HIV positive, a rate that is three times higher than that of the general population. The high costs of medical care may even put individuals with HIV/AIDS at a greater risk of homelessness. Furthermore, the homeless life poses a grave threat to the health of those with HIV/AIDS, whose immune systems are compromised by the disease. Shelter conditions expose people to dangerous infections, while exposure to the elements and malnutrition exacerbate chronic illness. In addition, homeless people have difficulty obtaining and using common HIV/AIDS medications.

Mental Health and Substance Abuse

Before the 1960s people with chronic mental illness were often committed involuntarily to state psychiatric hospitals. The development of medications that could control the symptoms of mental illness coincided with a growing belief that involuntary hospitalization was warranted only when a mentally ill person posed a threat to him- or herself or to others. Gradually, large numbers of mentally ill people were discharged from hospitals and other treatment facilities. Because the community-based treatment centers that were supposed to take the place of state hospitals were often either inadequate or nonexistent, many of these people ended up living on the streets.

In "Prevalence and Risk Factors for Homelessness and Utilization of Mental Health Services among 10,340 Patients with Serious Mental Illness in a Large Public Mental Health System" (American Journal of Psychiatry, February 2005), David P. Folsom et al. find that 15% of patients treated for serious mental illness were homeless at some point during a one-year period. Twenty percent of patients with schizophrenia, 17% of patients with bipolar disorder, and 9% of patients with depression were homeless. Folsom et al. find that mentally ill people are at a much higher risk of homelessness than the general population. They emphasize that homelessness among the mentally ill was associated with two other factors: substance use disorders and a lack of Medicaid insurance. Folsom et al. state, "Although it would be naïve to assume that treatment for substance abuse disorders and provision of Medicaid insurance could solve the problem of homelessness among persons with serious mental illness, further research is warranted to test the effect of interventions designed to treat patients with dual diagnoses and to assist homeless persons with serious mental illness in obtaining and maintaining entitlement benefits."

Many mentally ill homeless people do not realize how ill they are and how dependent they are on regular treatment. Others no longer believe the system can or will help them. This seems to have been borne out by Olga Acosta and Paul A. Toro's "Let's Ask the Homeless People Themselves: A Needs Assessment Based on a Probability Sample of Adults" (American Journal of Community Psychology, 2000), a 1999 survey of 301 homeless adults in Buffalo, New York. When Acosta and Toro asked homeless people what their greatest needs were, respondents listed affordable housing, safety, education, transportation, medical/dental treatment, and job training/placement. Formal mental health and substance abuse services were rated as unimportant by comparison, easy to obtain, and not satisfactory to people who had used them.

Table 7.3 shows the results of a study of one hundred homeless women with schizophrenia and one hundred nonhomeless women with schizophrenia. The study, which is summarized by Silver and Pañares, finds that homeless schizophrenic women had higher rates of co-occurring disorders, including alcohol and/or drug abuse and antisocial personality disorder.

Silver and Pañares note that families with children make up about 40% of the total homeless population, and the vast majority (about 90%) are female-headed. They report on a study of 436 sheltered homeless and low-income housed mothers. The study found that 84% of all these women had a history of having been severely assaulted at some point in their lives. Research shows that mothers with a history of abuse are more likely to have children with mental health problems.

PREVALENCE AND TREATMENT

There is some debate over the rate of mental disorders among homeless populations, but there is general agreement that it is greater among the homeless than the general population. The U.S. Conference of Mayors reports in Hunger and Homelessness Survey: A Status Report on Hunger and Homelessness in America's Cities, a 23-City Survey (December 2006, http://www.usmayors.org/uscm/hungersurvey/2006/report06.pdf) that an average of 16% of the homeless in the twenty-three surveyed cities were mentally ill and 26% were substance abusers in 2006. The National Resource and Training Center on Homelessness and Mental Illness indicates in "Get the Facts: Why Are So Many People with Serious Mental Illnesses Homeless?" (2007, http://www.nrchmi.samhsa.gov/facts/facts_question_3.asp) that a disproportionate percentage of the homeless population suffers from serious mental illnesses of the most "personally disruptive" kind, "including severe, chronic depression; bipolar disorder; schizophrenia; schizoaffective disorders; and severe personality disorders." An estimated 20% to 25% of the homeless population is afflicted, compared with only 4% of the general population.

Mentally ill homeless people present special problems for health care workers. They may not be as cooperative and motivated as other patients. Because of their limited resources, they may have difficulty getting transportation to treatment centers. They frequently forget to show up for appointments or take medications. They are often unkempt. The addition of drug abuse can make them unruly or unresponsive. Among people with severe mental disorders, those at greatest risk of homelessness are both the most severely ill and the most difficult to help.

The National Alliance on Mental Illness states in "Dual Diagnosis and Integrated Treatment of Mental Illness and Substance Abuse Disorder" (2003, http://www.nami.org/Template.cfm?Section=By_Illness&Template=TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049) that mental illness and substance abuse frequently occur together; clinicians call this dual diagnosis. Experts explain that in the absence of appropriate treatment, people with mental illness often resort to self-medication—that is, using alcohol or drugs to silence the voices or calm the fears that torment them. Approximately 50% of individuals with severe mental disorders also abuse drugs or alcohol. Homeless people with dual diagnoses are frequently excluded from mental health programs because of treatment problems created by their substance abuse and are excluded from substance abuse programs because of problems in treating their mental illness. Experts explain that the lack of an integrated system of care plays a major role in these people's recurrent homelessness and stress that transitional or assisted housing initiatives for homeless substance abusers must realistically address the issue of abstinence and design measures for handling relapses that do not place people back on the streets.

HEALTH OF HOMELESS CHILDREN

Evangeline R. Danseco and E. Wayne Holden, in "Are There Different Types of Homeless Families? A Typology of Homeless Families Based on Cluster Analysis" (Family Relations, 1998), seek to identify different types of homeless families and to examine children from these families. They studied 180 families, with a total of 348 children, participating in a comprehensive health care program for children of homeless families. The results show that homeless children consistently exhibited greater behavior problems and showed a trend of poorer cognitive, academic, and adaptive behaviors than children in the general population.

In "Homeless Children: What Every Health Care Provider Should Know" (2006, http://www.nhchc.org/Children/), Catherine Karr notes that homeless children experience a variety of behavioral and/or health disorders, including depression, developmental delay, asthma, respiratory infections, and gastrointestinal problems. Homeless children may also lack preventive care, such as immunizations, which leaves them vulnerable to preventable diseases. Failure to treat certain childhood conditions early (for example, ear infections) can lead to a lifetime of health problems. They also frequently suffer from malnutrition.

HEALTH OF HOMELESS VETERANS

According to Robert E. Klein and Donald D. Stock-ford, in Data on the Socioeconomic Status of Veterans and on VA Program Usage (May 2001, http://www1.va.gov/vetdata/docs/sesprogramnet5-31-01.ppt), in 1990 veterans were present in shelters at a rate of 149 per 100,000, compared with 126 per 100,000 of other males. The National Coalition for Homeless Veterans, citing U.S. Department of Veterans Affairs (VA) sources, states in "Background and Statistics" (2005, http://www.nchv.org/background.cfm) that of all homeless veterans, 4% are female, 45% suffer from mental illness, and half abuse drugs or alcohol. An estimated 200,000 veterans are homeless on any single night, and over the course of a year, nearly 400,000 experience homelessness at least one night. Almost half (47%) of homeless veterans served in Vietnam, two-thirds (67%) served in the military for three years or more, and a third (33%) were stationed in a war zone.

The VA operates many outreach programs designed specifically to help homeless veterans in areas of health, housing, and employment. Programs include outreach to homeless veterans who would not otherwise seek assistance; clinical assessment and referral for medical, psychiatric, or substance abuse treatment; supportive living programs; employment assistance; and transitional housing assistance.

VICTIMS OF VIOLENCE

Violence toward Homeless Women

Angela Browne and Shari Bassuk, in "Intimate Violence in the Lives of Homeless and Poor Housed Women: Prevalence and Patterns in an Ethnically Diverse Sample" (American Journal of Orthopsychiatry, April 1999), find that lifetime prevalence rates of physical and sexual assault among homeless women are particularly high. After surveying both homeless and poor, housed women, Browne and Bassuk find that although violence by intimate male partners is high in both groups, homeless women experience violence at a somewhat higher rate (63.3%) than poor, housed women (58%).

Homeless women (41%) are also more likely than poor, housed women (33%) to report a male partner threatening suicide. More than one-third (36%) of homeless women said their partner had threatened to kill them, compared with 31% of poor, housed women. Almost 27% of homeless women and 19.5% of poor, housed women needed or received medical treatment because of physical violence. Table 7.3 summarizes other studies related to violence and homeless women.

Hate Crimes

The National Coalition for the Homeless (NCH), in Hate, Violence, and Death on Main Street, USA: A Report on Hate Crimes and Violence against People Experiencing Homelessness, 2006 (February 2007, http://www.nationalhomeless.org/getinvolved/projects/hatecrimes/2006report.pdf), reports "an alarming, nationwide sustained increase in reports of homeless men, women and even children being killed, beaten, and harassed." The NCH identifies 189 deaths and 425 nonlethal attacks on homeless people between 1999 and 2006—142 attacks in 2006 alone. The crimes occurred in 200 cities in 44 states and in Puerto Rico.

The NCH recommends the following actions to address the problem of violence against homeless individuals:

• "A public statement by the U.S. Department of Justice acknowledging that hate crimes and/or violence against people experiencing homelessness is a serious national trend"
• Justice Department guidelines "for local police on how to investigate and work with people experiencing homelessness" and recommendations for improvements to state law that would "better protect against violence directed against people experiencing homelessness, including tougher penalties"
• "Inclusion of housing status in the pending state and federal hate crimes legislation"
• "Awareness training at police academies and departments nationwide for trainees and police officers on how to deal effectively and humanely with people experiencing homelessness in their communities"
• "A U.S. Government Accountability Office … study into the nature and scope of hate crimes and/or violent acts and crimes that occur against people experiencing homelessness"

Homeless advocates have demanded that crimes against homeless people be defined as hate crimes, which may result in harsher penalties in federal courts. However, determining how many of these crimes occur is difficult. Some factors that affect the accuracy of the count are:

• The bodies of the victims are not always discovered.
• Bodies may be badly decomposed when found, preventing accurate identification of the cause of death.
• Local authorities may rule causes of death other than violence.
• Survivors do not always report crimes, and murdered victims cannot tell their own stories.

HUNGER

Extent of the Problem

During the 1980s a number of studies found that some Americans, especially children, were suffering from hunger. Many observers did not believe these reports or thought they had been exaggerated. In 1984 a Task Force on Food Assistance appointed by President Ronald Reagan found that it could not find evidence on the extent of hunger because there was no agreed-on way to measure hunger.

In response, the Food Research and Action Center (FRAC) in Washington, D.C., an advocacy group for the poor, launched the Community Childhood Hunger Identification Project (CCHIP) to determine the extent of hunger in the United States. The first FRAC survey conducted interviews in 2,335 households with incomes at or below 185% of poverty and with at least one child under twelve years of age. The results of this survey, as reported by Cheryl A. Wehler et al. in Community Childhood Hunger Identification Project: A Survey of Childhood Hunger in the United States (1991), indicated that 32% of U.S. households with incomes at or below 185% of the poverty level experienced hunger. At least one child out of every eight under twelve years of age suffered from hunger. Another 40% of low-income children were at risk for hunger.

Between 1992 and 1994 FRAC sponsored a second round of CCHIP surveys in nine states and the District of Columbia (5,282 low-income families with at least one child aged twelve or under). For the purposes of its report, FRAC defined hunger as food insufficiency—skipping meals, eating less, or running out of food—that occurred because of limited household resources. The results were reported by Cheryl A. Wehler et al. in Community Childhood Hunger Identification Project: A Survey of Childhood Hunger in the United States (1995). Based on the findings of the second CCHIP surveys, FRAC concluded that about four million children aged twelve and under experienced hunger in some part of one or more months during the previous year. Another 9.6 million children were at risk of becoming hungry.

The 1995 CCHIP survey studied one child in each household (the child with the most recent birthday) and found that, in comparison with nonhungry children, hungry children were:

• More than three times as likely to suffer from unwanted weight loss
• More than four times as likely to suffer from fatigue
• Almost three times as likely to suffer from irritability
• More than three times as likely to have frequent headaches
• Almost one and a half times as likely to have frequent ear infections
• Four times as likely to suffer from concentration problems
• Almost twice as likely to have frequent colds

Based on the findings from the 1991 and 1995 CCHIP surveys, FRAC concluded that although federal food programs are targeted to households most in need, a common barrier to program participation is a lack of information, particularly about eligibility guidelines. FRAC contended that if federal, state, and local governments made a greater effort to ensure that possible recipients were aware of their eligibility for food programs, such as Women, Infants, and Children (WIC) and the School Breakfast Program, there would be a large drop in hunger in the United States.

In 1997 the Urban Institute conducted the National Survey of American Families (NSAF; 2006, http://www.urban.org/center/anf/snapshots.cfm). Nearly half of low-income families (those with family incomes up to 200% of the federal poverty line) who were interviewed in 1997 reported that the food they purchased ran out before they got money to buy more or they worried they would run out of food. More children than adults lived in families that worried about or had trouble affording food—54% of low-income children experienced the problem. The NSAF was repeated in 1999 (2006, http://www.urban.org/publications/900841.html), and families reported fewer problems affording food than in 1997. Four in ten low-income families were either concerned about or had difficulty affording food, down from nearly 50% in 1997. However, approximately half of all low-income children still lived in families with difficulties affording food or concern about lack of food. A third NSAF was conducted in 2002, and results were released in 2004. According to Sandi Nelson, in "Trends in Parents' Economic Hardship" (Snapshots of America's Families, March 2004), the 2002 report showed that 51.3% of low-income parents faced food hardship, 59.3% of single parents experienced food hardship, and the gains between 1997 and 1999 had been all but erased.

Since 1995 the Food and Nutrition Service (FNS) of the U.S. Department of Agriculture (USDA) and the U.S. Bureau of the Census have conducted annual surveys of food security, low food security (or food insecurity), and very low food insecurity (previously called hunger). (Food-secure households are those that have access at all times to enough food for an active, healthy life. Low food security households are uncertain of having, or unable to acquire, enough food to meet basic needs at all times during the year.) According to Mark Nord, Margaret Andrews, and Steven Carlson, in Household Food Security in the United States, 2005 (November 2006, http://www.ers.usda.gov/Publications/ERR29/ERR29.pdf), the survey is based on an eighteen-item scale:

1. Worried food would run out before (I/we) got money to buy more
2. Food bought did not last and (I/we) did not have money to get more
3. Could not afford to eat balanced meals
4. Adult(s) cut size of meals or skipped meals
5. Respondent ate less than felt he or she should
6. Adult(s) cut size or skipped meals in three or more months
7. Respondent hungry but did not eat because could not afford food
8. Respondent lost weight
9. Adult(s) did not eat for whole day
10. Adult(s) did not eat for whole day in three or more months
11. Relied on few kinds of low-cost food to feed child(ren)
12. Could not feed child(ren) balanced meals
13. Child(ren) were not eating enough
14. Cut size of child(ren)'s meals
15. Child(ren) were hungry
16. Child(ren) skipped meals
17. Child(ren) skipped meals in three or more months
18. Child(ren) did not eat for whole day

Figure 7.8 shows that the low food security rose steadily from 1999 to 2004, but dropped in 2005 to 1995 levels. The prevalence rate of very low food security also dropped in 2005. (Households with very low food security often worry that their food will run out, report that their food does run out before they have money to get more, cannot afford to eat balanced meals, often have adults who skip meals because there is not enough money for food, and report that they eat less than they should because of lack of money.) In 2005, 11% of households reported low food security at some time during the year, and 3.9% reported being very low food security. (See Figure 7.9.)

Unsurprisingly, poor and low-income households were more likely to experience very low food security during the year than were households with higher incomes. In 2005, 13.5% of households below the poverty line reported very low food security. (See Figure 7.10.) In comparison, 10.6% of households with an income-to-poverty ratio under 1.85 experienced very low food security, and only 1.7% of households with higher incomes experienced very low food security.

About 15.6% of all households with children experienced low food security in 2005; 0.7% experienced very low food security among the children. (See Table 7.5.) The poorest families experienced low food security most often; only 57.8% of households with an income-to-poverty ratio under 1.00 were food secure, compared with 59.4% of families with income-to-poverty ratios under 1.30, 65.8% of families with income-to-poverty ratios under 1.85, and 93% of families with income-to-poverty ratios of 1.85 and over. Families headed by married couples are much less likely to experience low food security than families headed by single females; only 9.9% of married-couple households compared with 30.8% of female-headed households reported low food security in 2005. Low food security was also more prevalent among African-American and Hispanic families, 27.4% and 21.6%, respectively, of whom experienced low food security, than among non-Hispanic whites, 11.8% of whom experienced low food security.

Emergency Food Assistance

America's Second Harvest (A2H; 2007, http://www.hungerinamerica.org/) is the nation's largest charitable hunger-relief organization, serving over twenty-five million people per year. In 2005 a study based on 52,878 interviews with clients and 31,342 questionnaires from A2H agencies was conducted, and findings were reported in Hunger Study, 2006 (2007, http://www.hungerinamerica.org/key_findings/). The study finds the following characteristics of recipients of emergency food assistance:

• More than a third (36.4%) of the members of households served by the A2H National Network were children; and 8% were children age zero to five years.
• About a third (36%) of all emergency client households had at least one member working.
• More than two-thirds (68%) of the households had incomes below the poverty level.
• More than one in ten (12%) clients were homeless.
• About a third (35%) of client households also received Food Stamp Program benefits; 51% of families with young children participated in the WIC program, and 62% of households with school-age children participated in school lunch programs.

• About 40% of recipients at all program sites were non-Hispanic whites, 38% were African-American, 17% were Hispanic, and the rest were from other racial groups.
• Twenty-nine percent reported that at least one household member was in poor health.
• A significant proportion of clients had to choose between food and other necessities; 42% reported having to choose between paying for food and paying for utilities; 35% had to choose between paying for food and paying their rent or mortgage; and 32% had to choose between paying for food and paying for medical care.

Malnutrition among the Homeless

Homeless people face a daily challenge to fulfill their basic need for food. They often go hungry. This is borne out by Burt et al. in Homelessness. Clients of homeless assistance programs are found to have higher levels of food problems than poor people in general; 28% reported not getting enough to eat sometimes or often, compared with 12% of poor American adults. More than one-third of the homeless clients had been hungry in the past thirty days but did not eat because they had no money for food (39%), and 40% reported going at least one whole day without eating. Undernourishment and vitamin deficiency can cause or aggravate other physical conditions.

Meg Wilson finds in "Health-Promoting Behaviors of Sheltered Homeless Women" (Family and Community Health, January-March 2005) that despite being homeless, many homeless women practiced "health-promoting behaviors." However, because of their homelessness, they had difficulty getting adequate nutrition.

The diet of homeless people, even those who live in shelters or cheap motels, is generally not balanced or of good quality. Homeless people often rely on ready-cooked meals, fast-food restaurants, garbage cans, and the sometimes infrequent meal schedules of free food sources, such as shelters, soup kitchens, and drop-in centers. However, many soup kitchens serve only one meal per day, and many shelters that serve meals—and not all them do—serve only two meals per day.

The Conference of Mayors reports that 74% of the twenty-three cities it surveyed in 2006 reported an increase in requests for emergency food assistance over the course of the year by an average of 7%. Nearly half (48%) of those requesting food assistance were children or their parents—and 18% of these requests went unmet. Even though 53% of the survey cities reported that they were able to provide an adequate quantity of food, almost two-thirds of the cities (63%) had to reduce the number of bags of food provided or the number of times people could receive food. Officials cited unemployment or underemployment, high housing, utility and transportation costs, medical or health costs, poverty, and lack of education as causes of hunger in their cities.

GOVERNMENT PROGRAMS TO COMBAT HUNGER

Food Stamps

The Food Stamp Program, which is administered by the USDA, is the United States' largest food assistance program. Food stamps are designed to help low-income families purchase a nutritionally adequate, low-cost diet. Generally, food stamps may only be used to buy food to be prepared at home. They may not be used for alcohol, tobacco, or hot foods intended to be consumed immediately, such as restaurant or delicatessen food.

The typical U.S. household spends about a third of its monthly income on food purchases. The Food Stamp program uses this fact in determining the amount of benefits to provide to a family. It calculates 30% of the family's earnings, and if that amount is insufficient to pay for an adequate diet then it supplies enough benefits to make up the difference. In many cases the "food stamps" benefit are actually provided electronically using a card similar to a bank debit card.

The cash value of these benefits is based on the size of the household and how much the family earns. The FNS notes in Food Stamps Make America Stronger (September 2006, http://www.fns.usda.gov/fsp/outreach/Translations/English/313Brochure-06.pdf) that households without an elderly or disabled member generally must have a monthly total (gross) cash income at or below 130% of the poverty level and may not have liquid assets (cash, savings, or other assets that can be easily sold) of more than $2,000. (If the household has a member aged sixty or older, the asset limit is $3,000.) The net monthly income limit (gross income minus any approved deductions for child care, some housing costs, and other expenses) must be 100% or less of the poverty level, or $1,667 per month for a family of four between 2006 and 2007. (See Table 7.6.)

With some exceptions, food stamps are automatically available to Supplemental Security Income and TANF recipients. Food stamp benefits are higher in states with lower TANF benefits because those benefits are considered a part of a family's countable income. To receive food stamps, certain household members must register for work, accept suitable job offers, or fulfill work or training requirements (such as looking or training for a job).

Even though the federal government sets guidelines and provides funding, the Food Stamp Program is actually carried out by the states. State agencies certify eligibility as well as calculate and issue benefit allotments. Most often, the welfare agency and staff that administer the TANF and Medicaid programs also run the Food Stamp Program. The regular Food Stamp Program operates in all fifty states, the District of Columbia, Guam, and the Virgin Islands. (Puerto Rico is covered under a separate nutrition-assistance program.)

Except for some small differences in Alaska, Hawaii, and the territories, the program is run the same way throughout the United States. The states pay 50% of the administrative costs, the federal government pays 100% of food stamp benefits and the other 50% of the operating costs. In 2001 the federal government paid $15.5 billion in food stamp benefits, but by 2006 it paid $30.2 billion in food stamp benefits, or an estimated average monthly benefit of $94.06 per recipient (based on preliminary data). (See Table 7.7.)

Food stamp participation decreased significantly after the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, from a high of 27.5 million program participants in 1994 to a low of 17.2 million in 2000. (See Table 7.7.) However, after 2001 the economy began to worsen; as a result, participation rates crept up to near 1994 levels by 2006.

The Food Stamp Program is the nation's largest source of food assistance, helping about 6% of all Americans. The FNS reports in "Characteristics of Food Stamp Households, Fiscal Year 2005—Summary" (September 2006, http://www.fns.usda.gov/oane/MENU/Published/FSP/FILES/Participation/2005CharacteristicsSummary.pdf) that in 2005, 50% of participants were children and 8% were aged sixty or older. Only four out of ten food stamp recipients lived in a household with earnings as the primary source of income, but most food stamp households did not receive cash welfare benefits. Most food stamp households were poor; only 12% of food stamp households had incomes above the poverty level and 40% had incomes at or below half the poverty line.

Average monthly benefits per person rose from $34.47 in 1980 to a preliminary estimate of just over $94 in 2006, not accounting for inflation. (See Table 7.7.) Table 7.8 shows the maximum monthly food stamp allotments for 2006 to 2007 for households of varying sizes within the continental United States. During this period the maximum monthly benefit for a four-person household was $518.

National School Lunch and School Breakfast Programs

The National School Lunch Program (NSLP) and the School Breakfast Program (SBP) provide federal cash and commodity support to participating public and private schools and to nonprofit residential institutions that serve meals to children. Both programs have a three-level reimbursement system. Children from households with incomes at or below 130% of the poverty line receive free meals. Children from households with incomes between 130% and 185% of the poverty level receive meals at a reduced price (no more than $0.40). Table 7.9 shows the income eligibility guidelines, based on the poverty guidelines, effective from 2006 to 2007. The levels are higher for Alaska and Hawaii than in the forty-eight contiguous states, the District of Columbia, Guam, and other U.S. territories. Children in TANF families are automatically eligible to receive free breakfasts and lunches. Almost 90% of federal funding for the NSLP is used to subsidize free and reduced-price lunches for low-income children.

The NSLP was created in 1946 under the National School Lunch Act. In the school year 1996–97 the USDA changed certain policies so that school meals would meet the recommendations of the Dietary Guidelines for America, the federal standards for what constitutes a healthy diet. About thirty million children, or 59.3% of all children served lunch, received free or reduced-price lunches in 2006. (See Table 7.10.) According to the Physicians Committee for Responsible Medicine, in "National School Lunch Program Background" (2006, http://www.healthyschoollunches.org/background/index.html), over 99,800 public and nonprofit private elementary and secondary schools and residential child care institutions participate in the program.

The SBP, which was created under the Child Nutrition Act of 1966, serves far fewer students than does the NSLP. The SBP also differs from the NSLP in that most schools offering the program are in low-income areas, and the children who participate in the program are mainly from low- and moderate-income families. In 2006 about 9.8 million students, or about 81.2% of all children served breakfast, participated. (See Table 7.11.)

Special Supplemental Food Program for Women, Infants, and Children

The Special Supplemental Food Program for Women, Infants, and Children (WIC) program provides food assistance as well as nutrition counseling and health services to low-income pregnant women, to women who have just given birth and their babies, and to low-income children up to five years old. Participants in the program must have incomes at or below 185% of poverty (all but five states use this cutoff level) and must be nutritionally at risk.

Under the Child Nutrition Act of 1966 nutritional risk includes abnormal nutritional conditions, medical conditions related to nutrition, health-impairing dietary deficiencies, or conditions that might predispose a person to these conditions. Pregnant women may receive benefits throughout their pregnancies and for up to six months after childbirth (up to one year for nursing mothers).

Those receiving WIC benefits get supplemental food each month in the form of actual food items or, more commonly, vouchers (coupons) for the purchase of specific items at the store. Permitted foods contain high amounts of protein, iron, calcium, vitamin A, and vitamin C. Items that may be purchased include milk, cheese, eggs, infant formula, cereals, and fruit or vegetable juices. Mothers participating in WIC are encouraged to breast-feed their infants if possible, but state WIC agencies will provide formula for mothers who choose to use it.

The USDA estimates that the national average monthly cost of a WIC food package in 2006 was $37.15 per participant, including food and administrative costs. (See Table 7.12.) In FY 2006 estimated federal costs for the WIC program were $5.1 billion, and the program served

approximately 8.1 million women, infants, and children. WIC works in conjunction with the Farmers' Market Nutrition Program, which was established in 1992, to provide WIC recipients with increased access, in the form of vouchers, to fresh fruits and vegetables.

WIC is not an entitlement program. That is, the number of participants is limited by the amount of funds available rather than by eligibility. In WIC Participant and Program Characteristics, 2004 (March 2006, http://www.fns.usda.gov/oane/MENU/Published/WIC/FILES/pc2004.pdf), the FNS notes that of the approximately 8.6 million participants in 2004 (the most recent year for which detailed data are available), half (49.8%) were children and 25.7% were infants. In that year 24.5% of WIC participants were women; 11% were pregnant, 6% were breastfeeding, and 7.5% were postpartum. Only about 7.9 million enrollees picked up their vouchers.

The FNS finds that 67% of WIC participants have household incomes at or below the poverty line, compared with 13% of the general population. In 2004, 9.4% of WIC recipients were also receiving TANF, 19.8% were also receiving food stamps, and 61.6% were also receiving Medicaid.

The FNS also notes that the ethnic composition of WIC recipients has been changing since 1992 as the percentage of Hispanic enrollees has risen and the percentage of non-Hispanic white and African-American enrollees has declined. In 2004, 39.2% of all WIC participants were Hispanic, 34.8% were non-Hispanic white, and 20% were African-American.