New Public Health Report Shows Sharp Rise in Mortality Among People Experiencing Homelessness

Increase Driven by Fentanyl-Related Deaths, Traffic Deaths, and Homicides  

The Los Angeles County Department of Public Health has released its fourth annual report on mortality among people experiencing homelessness in Los Angeles County. The mortality rate, which accounts for the total number of people experiencing homelessness each year, increased by 55%, from 2,056 per 100,000 in 2019 to 3,183 per 100,000 in 2021, the most recent years of data analyzed in this report.

In 2019, 1,289 people experiencing homelessness died. This number increased to 1,811 in 2020 and 2,201 in 2021.

Leading causes of death

Drug overdose was, as in 2019, the leading cause of death for people experiencing homelessness, accounting for 37% of all deaths among unhoused individuals in 2020 and 2021 combined —about two deaths per day on average. Drug overdose was also the largest driver of the overall increase in mortality for people experiencing homelessness, with the overdose mortality rate doubling from 2019 to 2021.

The second leading cause of death continues to be coronary heart disease, although the coronary heart disease mortality rate decreased in 2021 after increasing from 2017 to 2020.  Coronary heart disease deaths accounted for 14% of all deaths among persons experiencing homelessness in 2020 and 2021 combined– about 5 deaths per week on average.

The third leading cause of death was traffic injuries, which increased by 47% from 2019 to 2021, accounting for 8% of all deaths of people experiencing homelessness in 2020 and 2021 combined —about 3 deaths per week on average.

The homicide rate, which has risen among people experiencing homelessness since 2017, increased by 49% in 2021 compared to the previous year. Homicides were the fourth leading cause of death in 2020 and 2021—about 2 deaths per week on average.

COVID-19, the second leading cause of death for all residents in LA County in 2020 and the leading cause of death in 2021, was the fifth leading cause of death among people experiencing homelessness for both of those years.

Overdose deaths

Overdose mortality rates are higher among white people experiencing homelessness than Black and Latinx people experiencing homelessness, and higher among male versus female people experiencing homelessness. From 2019 to 2020 overdose rates increased substantially across all three racial/ethnic groups and among both men and women, but 2021 saw a continued sharp rise only among white people experiencing homelessness and male people experiencing homelessness. In contrast, the overdose mortality rate among Black people experiencing homelessness slowed in 2021 and leveled off among Latinx and female people experiencing homelessness.

Fentanyl has been the drug type driving overdose deaths since the start of the pandemic, with the percentage of overdose deaths involving fentanyl almost tripling from 20% in 2019 to 58% in 2021. Fentanyl deaths almost always involved combinations of drugs. In 2021, 71% of all fentanyl deaths among people experiencing homelessness also involved methamphetamine.

Mortality rates of people experiencing homelessness compared to the general LA County population

For the combined years of 2020 and 2021, the mortality rate among people experiencing homelessness was 3.8 times greater than that of LA County residents. This represents a widening of the mortality gap since the three-year period prior to the pandemic when the mortality rate for people experiencing homelessness was 2.9 times greater.

In 2020-21, overdose mortality was 39 times greater among people experiencing homelessness when compared to LA County residents. Traffic injury and homicide mortality were, respectively, 20 and 15 times greater among people experiencing homelessness during the first two years of the pandemic, than among all other county residents. When comparing mortality rates for all the leading causes of death, the smallest gap was observed for COVID-19, with people experiencing homelessness dying at 1.8 times the rate of the general population.

“We have declared a state of emergency in Los Angeles County because there are far too many people on our streets,” said Supervisor Hilda Solis, co-author of the 2019 motion addressing rising homeless mortality. “The findings in this report reflect the urgency with which we must work to protect the most vulnerable among us. Each of the 2,201 unhoused people who died in 2021 was someone’s friend, family, and loved one and we must redouble our efforts to address this crisis. As part of our response, it is critical that we address the drug epidemic, particularly the rise of fentanyl on our streets. We must continue to ensure that harm reduction tools and services, such as naloxone, are widely available and accessible to our unhoused residents.”

“This is a tragedy upon a tragedy,” said Supervisor Janice Hahn, Chair of the Los Angeles County Board of Supervisors. “People are dying on our streets and this report only underscores how important it is that we continue to treat the homelessness crisis with a sense of urgency and move as many people as possible inside so we can begin to save their lives.”

“This report underscores the enormous destruction fentanyl is causing our communities. To know that people experiencing homelessness are 39 times more likely to die of a drug overdose compared to the overall population of LA County is yet another painful reminder of the harm our unhoused neighbors experience, and why we must continue to move with urgency to address the crisis on our streets,” said Supervisor Lindsey P. Horvath. “We need to get people inside, in treatment, and supported with wraparound services. We also need to expand the availability of Narcan for all who serve the public to use as a vital, life-saving tool.”

“The data from this report quantifies what we already intuitively know to be true: more people experiencing homelessness on our streets are suffering and dying,” said Supervisor Kathryn Barger. “Substance abuse is many times an attempt to mask and escape trauma. Our homeless are fighting a losing battle and need help. They aren’t going to heal themselves without proactive support. I am focused on increasing the County’s capacity to deploy outreach teams equipped with the expertise to lift people out of their addictions. I also believe federal and state law changes are needed, so we can provide more mental health treatment beds and increase our ability to operate them. The County’s role is to provide services and we need to answer that call, without barriers or hesitation.”

“Being homeless has always been associated with a greater risk of death; in this report, we see how big the mortality gap is between those housed and unhoused. For every leading cause of death in LA County, unhoused individuals are between 2 and 40 times more likely to die than those not experiencing homelessness.  And with more than one out of every three deaths among people experiencing homelessness attributed to drug overdose, urgent action is needed to ensure that unhoused individuals with substance use disorder have access to treatment and harm reduction services that meet people where they are,” said Barbara Ferrer, Ph.D., M.P.H., M.Ed., Director of the Los Angeles County Department of Public Health. “Moving forward, we need to recognize that people who are unhoused need both housing and services to reduce their risk of death, and for us to close the distressing mortality gaps, policy and system changes are in order.”

Data used

This new report uses data from the 2022 homeless count (suspended in 2021 due to the pandemic) to resume the estimation of trends in mortality rates. It also uses a variety of data from 2021. Data from 2022 will be presented in January 2024.

Looking ahead

The County’s plan for preventing future homeless deaths includes:

• Expanding and improving field-based, harm reduction-oriented substance use disorder treatment services.
• Increasing distribution of naloxone to people experiencing homelessness in street and shelter/interim housing settings, as well as those people experiencing homelessness exiting jails and prisons.
• Expanding and enhancing County-contracted substance-use disorder provider utilization of the homeless management information system to improve coordination of care and housing-focused case management for people experiencing homelessness with substance-use disorders.
• Increasing investments in recovery bridge housing to ensure people experiencing homelessness, including those exiting jails and prisons, receive outpatient substance use disorder treatment services and permanent housing placements.
• Increasing the provision of preventive healthcare and chronic disease management for people experiencing homelessness who are at risk for conditions that, when left unmanaged, increase their mortality rates.
• Collaborating with local jurisdictions to identify concentrations of fatal injury collisions involving people who are unhoused to inform local infrastructure, program, and policy interventions to prevent traffic deaths of people experiencing homelessness.

To view the full report online, visit: http://publichealth.lacounty.gov/chie.