Health Problems of Homeless Children in New York City
GARTH ALPERSTEIN, MB CHB, MPH, CLAIRE RAPPAPORT, MA,
Abstract: We reviewed the outpatient medical records of 265
homeless children less than 5 years of age in New York City and
compared them with children of similar low socioeconomic status
(SES) attending the same pediatric clinic. The frequency of health
problems among the homeless children, including delayed immuni-
zations, elevated blood lead levels, the rate of admission to hospital,
and the rate of child abuse and neglect reports, exceeded those for
the comparison groups. (Am J Public Health 1988; 78:1232-1233.)
Introduction
Homelessness has become a major problem in the
United States. Nationwide, estimates of the numbers of
homeless people vary between 250,000 and 3 million." 2
Today, the fastest growing segment of the homeless is
families.3 During 1960-1980 the average number of homeless
families in the New York City temporary shelter system was
approximately 600 per month.4 By July 1987, however, this
number had risen to 5,020 families containing 12,303
children.5 These figures reflect only those children in the New
York City temporary shelter system. The number of children
living in the streets, in abandoned buildings, or on the
subways, who do not seek publicly funded shelter, is not
known.
It is well known that children of low socioeconomic
status (SES) have medical problems in excess of those with
high SES.6 Little is known of the health status and medical
problems of children less than 5 years of age who, in addition
to being poor, are also homeless. The present study emerged
from our contact with this homeless population in the
Pediatric Clinic of St. Luke's-Roosevelt Hospital Center,
New York City.
Methods
We conducted a retrospective chart review on 265
homeless children less than 5 years of age who attended the
St. Luke's-Roosevelt Hospital Pediatric Primary and Ambu-
latory Care Clinic from January 1982 to May 1985, and who
lived in "welfare hotels" in the midtown area of Manhattan,
New York City. Welfare hotels are those hotels whose
owners agree to accept payment funneled through the city's
welfare agency. Payment may be as high as $1800/month to
house a family of four in one small room. For these children,
we collected information on height, weight, free erythropro-
toporphyrin (FEP) and blood lead levels, and immunization
status.
We compared the homeless children to children attend-
ing the same pediatric clinic who were less than 5 years of
From the Pediatric Service, St. Luke's Roosevelt Hospital Center, New
York City, and the Department of Pediatrics, Cotlege of Physicians and
Surgeons, Columbia University. Address reprint requests to Joan M. Flanigan,
MD, Pediatric Primary and Ambulatory Care, St. Luke's-Roosevelt Hospital
Center, 428 West 59th Street, New York, NY 10019. This paper, submitted to
the Journal August 17, 1987, was revised and accepted for publication March
29, 1988.
C) 1988 American Journal of Public Health 0090-0036/88$1.50
1 232
AND JOAN M. FLANIGAN, MD
age, roughly of similar SES, and who lived at home. The
majority (56-60 per cent) of clinic visits were paid by
Medicaid and the rest were uninsured. These children were
not matched for age by year or sex. Three comparison groups
(all drawn from the pediatric clinic) were utilized:
Group 1-Sixteen hundred children who were enrollees
in the WIC (women, infants and children) program during
calendar year 1984, for whom height and weight data were
available.
Group 2-One thousand and seventy-two children who
received blood lead and FEP determinations during the
calendar year 1985. We defined iron deficiency as an FEP >
50 mcgms/lOOml in the absence of an elevated lead level. An
elevated lead level was defined as a blood level >30 mcgms/
mil.
Group 3-One hundred consecutive clinic records of
children living at home and who attended the clinic during
1985, to compare immunization data. A delay in immuniza-
tion status was defined as any child under the age of 5 years
who was delayed by three months or more in receiving
immunizations according to the schedule recommended by
the American Academy of Pediatrics.
Comparison groups 1 and 2 may have contained some
homeless children who attended the clinic during the years
mentioned.
In addition, St. Luke's-Roosevelt Hospital emergency
room records of homeless children living in these welfare
hotels and non-homeless children living in the corresponding
health districts, up to 18 years of age, were reviewed from
January through October of 1985 for evidence of child abuse
and neglect, and for admission to St. Luke's-Roosevelt
inpatient service. We obtained New York City census data
for 1982 to determine that there were ±6,000 children under
age 18 years living in the same health districts as the welfare
hotels in our study. In March 1985, there were ±2,500
homeless children in these hotels.7
Statistical analysis was performed by calculating the
ratio of the proportions and the 95% confidence intervals.
Results
One hundred and thirty-eight homeless children (52 per
cent) were Black, 93 (35 per cent) Hispanic, 21 (8 per cent)
White, 3 (1 per cent) other, and 10 (4 per cent) unknown. The
age distribution of the homeless children was as follows: 95
(36 per cent) were under 1 year of age, 170 (64 per cent) were
1 to 4 years of age.
Tables 1 and 2 compare nutritional status, immunization
status, and selected health problems between the homeless
children and comparison groups. There was little difference
between the two groups in the percentage of children with a
height or weight below the 5th percentile, and in elevated
FEPs. No children had frank kwashiorkor and/or marasmus.
The proportions of homeless children with lead levels
greater than 30 mcgms/ml, and the rates of reports of child
abuse and neglect and hospital admissions were higher than
those in the comparison groups. The difference in immuni-
zation delay was substantial.
AJPH September 1988, Vol. 78, No. 9
 PUBLIC HEALTH BRIEFS

TABLE 1-Hesith Problems of Homeless Children and Comparison TABLE 2-Heafth Problems of Homeless Children-Emergency Room
Group, New York City Pediatric Clinic Records*

Companson Population Base No. Cases Rate/i 000

Homeless Group
Admission to Hospital
Total Cases Total Cases Homeless Children 2500** 29 11.6
(No.) N (%) (No.) N (%) Ratio (95% Cl) Comparison Group 6000*** 45 7.5
Child Abuse and Neglect
Homeless Children 2500 22 8.8
Ht. < 5th percentile 265 20 (7.5) 1600 123 (7.7) 0.96 (0.58-1.64) Comparison Group 6000 14 2.3
Wt. < 5th percentile 265 23 (8.7) 1600 102 (6.4) 1.40 (0.85-2.29)
FEP > 50 mcgms.% 265 39 (14.7) 1072 151 (14.1) 0.87 (0.71-1.57)
Delayed Immunizations 265 72 (27.2) 100 8 (8.0) 4.29(1.90-10.07) *For the 10-month period, January-October 1985.
Pb. > 30 mcgms.% 265 10 (3.8) 1072 18 (1.7) 2.30(0.97-5.32) **HRA, March 198511.
***New York City Census data, 1982.

Discussion children above the 5th percentile. A prospective study

This study suggests that homeless children have medical
and health problems in excess of children of low SES living
at home. However, since the homeless group was incom-
pletely matched, the comparisons must be interpreted with
caution. Furthermore, because this is a retrospective clinic-
based study, our sample may not be truly representative of all
homeless children.
The high rate ofimmunization delay seen in the homeless
children is most likely due to multiple factors. Homeless
families in NYC may be moved to several hotels throughout
the city and have difficulty maintaining ongoing comprehen-
sive care services or utilizing nearby medical facilities.
The prevalence of elevated lead levels in the homeless
children may reflect the conditions in the hotels or the
impoverished areas from which the children originate. Ele-
vated lead levels have been correlated with deficits in
psychological and classroom performance in children.8
High hospital admission rates for homeless children may
suggest an increased number and severity of medical prob-
lems or the deferral of problems by the family until hospi-
talization is necessary.
The high rate of reports for child abuse and neglect found
among homeless children must be viewed with caution since
we are unaware of what proportions of homeless and non-
homeless children use the emergency room, and as well as the
possible reporting bias by emergency room personnel.
Homeless families in welfare hotels receive only $34
per person per day for food. Although little difference in
growth parameters was found between the two groups, we
did not measure differences in percentile distributions in
looking at growth parameters over time or specific nutrient
intake may reveal nutritional deficiencies and growth retar-
dation.
In conclusion, these data suggest that some of the health
problems of homeless children may be remediable by good
preventive health care, whereas others would require broad-
er political, social, and economic changes. With the rapidly
growing homeless population, this may present a major
public health problem for the City of New York.
ACKNOWLEDGMENTS
An earlier version ofthis manuscript was presented at the American Public
Health Association Annual meeting in New Orleans, October 1987.
REFERENCES
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4. New York City: A Comprehensive Plan for the Temporary and Permanent
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Engl J Med 1979; 300:689-695.

AJPH September 1988, Vol. 78, No. 9 1233

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