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Enumerating Deaths Among Homeless Persons: Comparison of Medical Examiner Data and Shelter-Based Reports -- Fulton County, Georgia, 1991

Characteristics of causes of death and mortality patterns in homeless populations have been constrained by limitations in both the accuracy of estimates of the size of the homeless population and enumeration of the number of deaths of homeless persons (1,2). For example, studies of mortality among homeless persons in Fulton County (Atlanta), Georgia, based on medical examiner records estimated approximately 40 deaths of homeless persons annually (1,3); in contrast, a media report based on information supplied by shelters for homeless persons reported 191 deaths of homeless persons in Atlanta during 1991 (4,5). As a basis for improving characterization of mortality patterns in the homeless population of Fulton County, Emory University and CDC assessed the differences in the estimates of deaths among homeless persons that were obtained from medical examiner records and those based on death reports from shelters that are in or adjacent to Fulton County (1990 population: 648,951) during 1991. This report summarizes the findings of that study.

The office of the Fulton County Medical Examiner (FCME) and the Atlanta Task Force for the Homeless (ATFH) each attempt to monitor mortality in the homeless population of Fulton County (estimated homeless population: 10,000-15,000 {3}). Since 1987, the FCME has maintained computerized death investigation records that can be used to categorize a deceased person as homeless if the person resided in an official shelter for homeless persons, had no regular residential address, or resided at a place not generally recognized as a habitable dwelling. The ATFH, which defines a homeless person as a person with "no predictable address," maintains a list of names of homeless persons whom the FCME or shelters for homeless persons have reported to the ATFH as having died. However, there is no mechanism to enable the ATFH to routinely verify the occurrence or location of deaths reported to it by the shelters.

Fulton County death certificates were searched for persons who died in 1991 to locate records for persons who were categorized as homeless based on FCME investigations for deaths that occurred in 1991 or who were reported by the FCME or shelters to the ATFH as having died during 1991. Death certificates were reviewed to determine where death was pronounced, the agency affiliation of the certifier of death, alterations in the decedent's name during the death certificate filing process, and the number of certificates identifying decedents as homeless.

During 1991, the ATFH received reports of 188 deaths exclusive of stillbirths. Fulton County death certificates confirmed 37 (20%) deaths. Of the 37 confirmed deaths, 31 (84%) had been reported to the FCME. Of the six deaths not listed in FCME records, two were certified by the medical examiner in an adjacent county (death occurred in Fulton County but the incident leading to death occurred in the adjacent county), two were certified by private physicians, and two were certified by physicians at the county public hospital. Of three deaths reported to but not certified by the FCME, two were certified by physicians at the county public hospital, and one was certified by the medical examiner in an adjacent county (death occurred in Fulton County but the incident that led to death occurred in the adjacent county). Medical examiners certified 31 (84%) of all deaths.

Of the 37 decedents, eight (22%) were pronounced dead by the FCME, two (5%) were pronounced dead at private hospitals, and 27 (73%) were pronounced dead at the county public hospital. A nonshelter, residential address was listed as the home address on 28 death certificates (76%); five (14%) death certificates for homeless persons contained information alluding to the homeless condition of the decedent. The address was listed as unknown for four (11%). Two (5%) of 37 death certificates listed the decedent's name differently than it appeared in FCME or shelter records. Reported by: R Hanzlick, MD, Dept of Pathology and Laboratory Medicine, Emory Univ School of Medicine; Fulton County Medical Examiner's Office; Fulton County Vital Records Office; Atlanta Task Force for the Homeless. Surveillance and Programs Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: In Fulton County, no routine, comprehensive mechanism exists to document deaths of homeless persons that are unknown to both the FCME and shelters for homeless persons. Therefore, the sensitivity of medical examiner and shelter data for enumerating deaths among homeless persons cannot be clearly established.

The difference in the number of death certificates filed for homeless persons in Fulton County and the number of deaths reported by shelters may reflect factors such as transiency (i.e., death in a county other than Fulton County) and the use of aliases; in addition, some persons may not have died during the period studied. Because only two of 37 death certificates involved changes of decedents' names, the use of aliases is unlikely to be the sole explanation. However, because the purpose of this study was to compare the usefulness of FCME data and shelter reports for enumerating deaths of homeless persons in Fulton County only, a determination was not made of the number of deaths reported by shelters that occurred in other counties.

If a mechanism had been in place to routinely document, in a retrievable form, when homeless persons were pronounced dead at the county public hospital, 95% of the decedents in this report could have been detected through medical examiner or county hospital records. Death certifiers or funeral directors (who often complete the residential address and personal information on death certificates) also could assist in documenting when a homeless person dies by indicating homelessness on the certificate -- either in place of or in addition to a previous residential or current shelter address. Development of a mechanism to verify the occurrence and location of deaths reported by shelters also may assist in public health monitoring, particularly if information is included regarding the county of death.

Using the existence of a completed death certificate filed in Fulton County as the standard, shelter-based data were slightly more sensitive than FCME data for enumerating deaths that occurred in Fulton County among the homeless population; however, death reports from shelters were less specific for that purpose. As an alternative to shelter-based reports, and especially because they contain cause-of-death information, medical examiner records may be useful to agencies that monitor mortality of the homeless and that plan mortality-prevention strategies for these persons. Additional efforts are required in different geographic areas or jurisdictions to enumerate all deaths of homeless persons, to evaluate the sensitivity of medical examiner data and shelter-based reports for detecting such deaths, and to assist in planning efforts for public health services for homeless persons.


  1. CDC. Deaths among the homeless -- Atlanta, Georgia. MMWR 1987;36:297-9.

  2. CDC. Deaths among homeless persons -- San Francisco, 1985-1990. MMWR 1991;40:877-80.

  3. Hanzlick R, Parrish RG. Deaths among the homeless in Fulton County, GA, 1988-90. Public Health Rep 1993;108:488-91.

  4. Goldstein A. Lower life expectancy found among homeless, high rates of illness reported in study. The Washington Post, December 22, 1991.

  5. National Coalition for the Homeless. Mourning in America. Washington, DC: National Coalition for the Homeless, 1991.

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