Infectious Diseases

Tuberculosis incidence is about ten times greater among people who experience homelessness, and treatment in this group is compromised by lack of compliance as well as substance abuse (Bamrah et al., 2013). Testing for HIV requires informed consent, making it more difficult to obtain accurate estimates of HIV prevalence (Caton et al., 2013). A study of homeless patients admitted to a New York City psychiatric inpatient unit found an HIV sero- prevalence rate of 6.4 percent, using anonymous discarded blood samples. Seropositivity has been found to be greater among people who were younger and who used injection drugs (Empfield et al., 1993). Infections such as HIV, HBV, and HCV are a threat to homeless people with severe mental illness, particularly if they are intravenous drug users or engage in unprotected sex (Caton et al., 2013; Rahav et al., 1998). Co-infection of HIV and TBC among homeless people with mental illness often occurs (Haddad et al., 2005; Saez et al., 1996). A study of people with severe mental illness and substance use comorbidity found that about 6 percent were HIV-positive, and slightly under half were positive for either HBV or HCV (Klinkenberg et al., 2003).

episode of homelessness may have a particular precipitant, the many factors that destabilize lives and conduce to homelessness become visible over the course of time. In an Institutional Review Board approved pilot study of pathways into men’s and women’s shelters for unaccompanied adults in New York City, narrative interviews revealed both the specific event or circumstance—an eviction, a fire, a falling out with relatives—that brought individuals into shelter, as well as the larger life contexts in which such events were embedded. The three abbreviated narratives that follow offer specific examples of how abstractions like homelessness, mental illness, childhood adversity, medical comorbidities, substance abuse, and family disruptions intersect in the lived experience of individuals. Pseudonyms are used to protect participants’ privacy.


Jeanette, a 46-year-old African-American woman, arrived at the women’s shelter after a fire destroyed her apartment building. This was not her first shelter stay. Within the past ten years, she had twice before stayed in shelters as she struggled with overcrowded and dangerous housing, several chronic health conditions, and schizophrenia.

Jeanette grew up in the Bronx with her parents and seven younger siblings, but says, “I started living with my grandmother [next door] when I was 12 years old because I had seizures and my mother couldn’t take it.” While the seizures have continued, Jeanette now also contends with asthma, type 2 diabetes, hypertension, and arthritis. Since coming to the shelter, she has experienced several panic attacks.

Jeanette has been married for 28 years. Her husband moved in with her at her grandmother’s apartment. Over the next 20 years they raised two children there, while he worked in construction and she had periodic jobs in retail and as a home health aide. The two-bedroom apartment was crowded, accommodating Jeanette’s grandmother, the couple, their two children, and eventually her daughter’s first child. When Jeanette’s preventive interventions to avert homelessness among single adults. Consecutive samples of 40 adults (24 men and 16 women) who resided in upper Manhattan prior to entering New York City single-adult assessment shelters consented to participate in the study. In-depth interviews lasting 90 minutes on average elicited detailed narratives of family, residential, employment, health, and mental health histories, as well as demographic information, current mental health symptoms, experiences in shelters, and expectations for the future. Diagnoses of serious mental disorders (bipolar disorder, schizophrenia, major depression) were reported by 23% of participants. The portraits presented here were drawn from this group and were selected to exemplify how factors identified in epidemiological studies play out in individual lives.

grandmother died, the family lost the apartment and entered a family shelter for a few weeks, then moved to an apartment in upper Manhattan where they remained for about six years. The building was a magnet for squatters and drug dealers, and was infested with rats and other vermin. Once Jeanette was robbed at knifepoint. There were winters without heat, and months with no elevators or electricity. Jeanette’s daughter became pregnant with her second child and moved with her children to an apartment in the Bronx, but Jeanette, her husband, and her son remained.

During this time, Jeanette began to hear voices, and her husband’s aunt encouraged her to go to a psychiatric emergency room. She was admitted to the hospital and was diagnosed with schizophrenia. After discharge two weeks later, she returned to the apartment, where conditions continued to deteriorate. She began to withhold her rent and took her landlord to court, but she lost the case and was evicted. Her daughter found the family an apartment in the Bronx near her own, but soon after moving there, Jeanette’s son was incarcerated, and her daughter decided to move her own family down south. Jeanette and her husband drove to South Carolina with a U-Haul and stayed with their daughter for several weeks before driving back to New York. Upon returning, they learned their building had burned down: “Somebody told me that [the landlord] had poured gasoline all over her apartment and all over her crippled daughter, a little girl that couldn’t do for herself. She went across the street, just looking at her daughter burn up. They arrested her for murder.”

Jeanette went to stay at the women’s shelter while her husband went to a men’s shelter. The fire was traumatic and destabilizing for Jeanette: “Right after I came here, I didn’t even stay one day and I ended up in the [psychiatric] hospital for a week. When I was released from the hospital, I came straight back here.”

Her husband, who remains at the men’s shelter, visits her daily after work. Since returning to the shelter, Jeanette has been hearing voices again: “When I had my apartment [in the Bronx], I didn’t hear them as much. Now I hear them a lot in here. During the build-up to sleep, that’s when they want to talk to me.”

Sometimes the voices are benign, telling her to check on whether another resident is okay; but often the shelter dormitory room stinks, and the voices tell her to hit or throw a chair at the woman who refuses to bathe. She describes herself as being unable to concentrate, feeling like a failure, and believes she would be better off dead: “[I feel] hopeless in not finding a place to live. I go to all the real estate [offices] and they turn me down.” She thinks frequently about cutting her wrists—most recently just before our interview, following a verbal altercation with a shelter staff member.

Yet she maintains hope that the shelter can help her find an apartment in a quiet neighborhood in the Bronx.


Luis, who identifies himself as Puerto Rican, celebrated his 22nd birthday at a men’s shelter, two weeks after his eviction from a supported housing program. The shelter and housing program are the latest of the institutional and quasi-institutional settings where he has resided his entire life.

Luis was placed in foster care at birth, while his mother struggled with drug addiction and his father was in and out of prison. He remained in the child welfare system until he was 19, moving through multiple placements before age five, when his mother’s parental rights were terminated: a six- year stint with one foster family (age 5-11); a series of group home placements, occasionally interrupted by child psychiatric hospitalizations (age 11-17); and two transitional housing programs for youth aging out of foster care (age 17-19). Evicted from transitional housing at age 19, Luis was diagnosed with bipolar disorder and spent the next three years in the mental health system: two and a half years at an adult psychiatric center as an inpatient, a few months in an adult care facility on the same premises, and three months in a supported housing program where he shared an apartment with another program participant. When he was evicted for using and selling drugs and refusing to meet with his case manager, he entered the city’s homeless shelter system.

Despite his institutional trajectory, Luis stayed in contact with family members. Periodic "visitation” with his mother and siblings stopped when he was six, but other relatives kept in touch: “My whole family has been supportive in their own different ways. My grandmother, she has been in contact with me growing up, my uncle keeps a lock on me since birth ... my aunt lives in the same area as my grandma, my other aunt is in the same building, and my older sister is in Florida right now. My other siblings, I really want to find them but don’t have any means of knowing where they are at.”

As a birthday surprise, his aunt arranged a reunion with his mother, but it ended badly:

You can’t patch things up within a week, not [after] the past 14 years or so. My mother’s in a shelter, like a shelter hotel. It was hard seeing her again and we got into a little altercation. I have her counselor’s number but I don’t speak directly with her. It might be awhile.. I gotta fix my life before I can fix her life. Plus she is HIV positive. She’s getting a bit better but she is not really taking her medication. So when I was with her those couple of days, I was telling her, “Ma,

I love you and everything, but you got to take your medicine.” And she was like trying to sell her medicines and other stuff so she can make me happy. And I’m like, “No, the only way that you are going to make me happy is to see you [alive] the next time I come.” I’m trying to convince her to take care of herself and that is very hard for me, me being 22 and her being 46.

Luis enjoyed high school, had a good academic record, and held parttime and summer jobs since age 14. He started working on an associate’s degree in business management but was derailed by knee surgery resulting from a sports injury from his high school years.

With mental health system experiences in inpatient, outpatient, clubhouse, and supportive housing facilities, Luis says that he has had “about 20 psychiatrists, 20 psychologists and about 30 therapists” in his life, but he is wary of mental health professionals. He describes his extended psychiatric hospitalization as “like incarceration. It was like no windows to be open, supervision wherever you go, and you had to sneak cigarettes.” Some groups were good, if he liked the group leader. But as a 19-year-old among much older adults, “I was basically tangled up with people of different ages who had different issues.” His subsequent outpatient treatment in a different unit at the same facility “was a lot better because I can go outside,” and outpatient staff assisted with money management and career planning. After years on and off psychiatric medications, his doctor recently discontinued his medication because of weight gain and skyrocketing cholesterol levels.

Luis described the shelter environment as stressful but hopes it will lead to stable housing with “a sense of comfort, familiarity, good qualities of the neighborhood, in a clean apartment with my girlfriend.”


Ardella is a 41-year-old African-American woman who came to the shelter from her sister’s home where she had stayed for a month. She had recently graduated from a drug treatment program and feared that her sister’s drinking would precipitate her own drug relapse. It had been 20 years since Ardella had housing of her own, when she shared an apartment with her sister, her brother, and the first three of the nine children she ultimately had. When her siblings fell behind on their share of the rent, the family was evicted, and Ardella and her children moved in with her grandmother.

While she remained there for 12 years, it was an unsettled period: she gave birth to her fourth daughter, ended her relationship with a boyfriend who tried to kill her, and lost custody of all four children when her sister reported her to child welfare for using drugs. Three more children were born to her there, but two were taken at birth by child welfare authorities. When her grandmother died, she and her seventh child, a daughter, moved in with that child’s father. When her eighth child was born with drugs in her system, Ardella gave the two girls to their father and entered a women’s shelter for the first time. When she became pregnant with her only son, she and his father moved to a family shelter, but her son was removed from her custody soon after birth. She left the shelter and stayed on the streets and with friends until she was arrested. Charged with felony drug possession, she accepted a plea bargain mandating her to the drug treatment program, and after graduating 14 months later, she lived with her sister until entering the shelter.

Ardella submitted an application for public housing almost ten years ago when she was living with her grandmother. By the time she was called for an interview, she was in the drug treatment program, and her application for housing was denied because of the felony charge, which would stay on her record until she completed treatment. She has now applied for a new hearing and hopes she will finally get her own housing.

Ardella keeps in contact with her brother, who is in prison out of state, and speaks with her sister every few days. She is in touch with four of her nine children—her two oldest daughters who share an apartment of their own, and her two youngest daughters, whose father has promised to return them to her once she has an apartment of her own. She has lost track of two daughters, but her older daughter was able to trace the other two:

I know where they are, but I’m too scared to go there right now. I want to go when I get my apartment so I can let them know the doors are open wide if you feel like you want to come home. But I just gotta face what they going to say, you know? “Why wasn’t you coming to see me?” and all this stuff. In my heart, I don’t think they hate me [but] whatever happens, happens. If [they] don’t want to come home, well, it’s something I got to deal with.

She talks about seeking custody of her son, but acknowledges that success is improbable:

When I was in the program I went to get a birth certificate for him, and the birth certificate place told me they changed his name. I go through this emotion every day, I’m learning how to deal with it, because there’s really nothing I can do about it. And I kept my head up strong. I didn’t go use or anything. I just kept moving. And I just be like, wed, it is what it is. Something I gotta deal with, that’s all, for the rest of my life. If my son want to see me, he will find me, just like my other daughters have found me.

Born with a congenital heart problem, Ardella has had three heart attacks and a stroke. She has had open-heart surgery twice, cervical cancer followed by a hysterectomy, and asthma. Five years ago, after losing custody of her son, she attempted suicide and was diagnosed with bipolar disorder. She was hospitalized for three months and now takes psychotropic medication, along with multiple medications for her other health problems. Ardella expressed hope that she can eventually obtain her own housing, reunify with her youngest daughters, and perhaps marry the boyfriend she’s been seeing for the last eight months.

Jeanette, Luis, and Ardella experienced years and even decades of severe disruptions in housing, health, mental health, and family life. Their stories offer a small sample of the multiple ways in which such disruptions cooccur and compound each other—not only in these three lives, but in those of their parents, siblings, partners, and children. Creating the conditions for fulfilling their modest hopes for more routine, stable lives in decent housing and quiet neighborhoods remains an urgent challenge.

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