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Stephen W. Hwang, MD, MPH

JAMA. 2000;283:2152-2157.

Context  Homeless persons in US cities have high mortality rates. However, few comparison data exist for death rates among homeless persons in other developed countries.

Objectives  To compare mortality rates among men using homeless shelters and the general population in Toronto, Ontario, and to determine whether mortality rates differ significantly among men using homeless shelters in Canadian and US cities.

Design  Cohort study conducted from 1995 through 1997, with a mean follow-up of 2.6 years.

Participants  Men aged 18 years or older who used homeless shelters in Toronto in 1995 (n=8933).

Main Outcome Measure  Mortality rate ratios comparing age-specific mortality rates among men using homeless shelters in Toronto with those of men in the general population of Toronto and of men using homeless shelters in New York, NY; Boston, Mass; and Philadelphia, Pa.

Results  Men using homeless shelters in Toronto were more likely to die than men in the city's general population. Mortality rate ratios were 8.3 (95% confidence interval [CI], 4.4-15.6) for men aged 18 to 24 years, 3.7 (95% CI, 3.0-4.6) for men aged 25 to 44 years, and 2.3 (95% CI, 1.8-3.0) for men aged 45 to 64 years. In most cases, however, the risk of death was significantly lower for men using homeless shelters in Toronto than for those in US cities. For men aged 25 to 44 years using homeless shelters, mortality rate ratios were 0.52 (95% CI, 0.41-0.65) for Toronto compared with Boston and 0.61 (95% CI, 0.44-0.85) for Toronto compared with New York City. For men aged 35 to 54 years using homeless shelters, the mortality rate ratio was 0.42 (95% CI, 0.27-0.66) for Toronto compared with Philadelphia.

Conclusions  Mortality rates among men who use homeless shelters in Toronto, while higher than in the general population of Toronto, are much lower than mortality rates observed among men using homeless shelters in 3 major US cities. Further study is needed to identify the reasons for this disparity.

Author Affiliation: F. K. Morrow Inner City Health Research Unit, St Michael's Hospital, University of Toronto, Toronto, Ontario.

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