In New York a 45 percent increase in shelter use in the last 8 years has been reported with over 39,000 homeless people, including 10,000 homeless families, checking in to city shelters every evening. This is a phenomenon that is not restricted to one major city as it also affects cities such as London where rough sleeping has risen by 15 percent in the last year, whilst being middle-class and homeless is escalating almost as quickly as the recession. In addition, once affluent areas such as California are seeing dramatic steep rises in the number of homeless.

There are some disquieting facts about the health concerns of being homeless. For a start, homeless people have a great increased risk of death. For instance, in Montreal mortality for street youths is nine times higher for men, 31 times for women. Many chronic diseases are prevalent including epilepsy, chronic airways disease, hypertension, diabetes which are often poorly controlled. Both respiratory infections and poor dental hygiene are common. Not to mention the traumatic experience suffered due to a lack of control over one’s housing situation. In this week’s BMJ a Canadian study of mortality among residents of shelters, rooming houses, and hotels reveals the probability of survival to age 75 years was 32 percent in men and 60 percent in women. For men and women, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases.

So, based on these facts you’d expect the four main parties in the US and UK to have comprehensive strategies for tackling the homeless problem.

UK Conservative party: Apparently Boris Johnson is going to end homelessness by 2012, his housing minister is already saying it isn’t as big a problem as it was. The Tory Shadow housing minister Grant Shapps says the payment of housing benefit is the major problem – sounds like cuts to me - the major issue is the homeless are too chaotic to handle their own money. They will probably have to house all the homeless in the Olympic village if they want to achieve their target. If you look at their blueprint the solution for a future Conservative Government is to work across Whitehall to ensure that policy is designed to help rather than hinder homeless people. Having completely ignored the issue in its 2001 and 2005 manifestos at least it is back on the agenda.

UK Labour party: The number of homeless families in Britain has reached a record of 100,000, more than double the total when Labour took office in 1997. Although, that’s nothing to shout about as the Tory’s doubled homelessness between 1979 and 1997. The National Rough Sleeping Count for 2009 shows there are 464 people sleeping rough on English streets on any single night, representing a 75% reduction since 1998. Although, the Government says it is committed to reducing rough sleeping to as near to zero as possible, I think the figures at best are dubious. Overall Labour has set a target to halve the number of households living in temporary accommodation by 2010. This commitment includes ending the use of bed and breakfast accommodation by local housing authorities, securing suitable accommodation for 16 and 17 year olds, improved access to homelessness mediation across the country and the creation of a new national supported lodgings development scheme for young people.

US Democratic party: Disappointingly the democrats seem to be overwhelmed with medical reform trying to provide healthcare for all, the environment and security. Obama in February 09 stated he is going to use $10 billion of Housing development money "to create green jobs, to revive housing markets with high rates of foreclosure, and curb homelessness." However, when you break the pledge down, there has been some criticism of how much real impact is actually delivered on the ground.

US Republican Party: Surprisingly in 2000 George Bush administrations began a radical and successful national campaign against chronic homelessness. “Housing first,” they called it offering rent-free apartments up front. This strategy got a lot of credit for a 30% decline in U.S. from 2005 to 2007. Giving housing up front gave the homeless an opportunity to seek work giving net worth to society. The problem was 9/11 took over policy initiatives and homelessness dropped off the radar.

Homelessness is a problem that affects health and society greatly. The worrying thing is it can affect anyone. Therefore the next time a politician turns up on my door I’m going to ask them what is their policy on such a preventable health problem?

I first came across this story a few weeks ago when Obama was asked questions about health care reform by Jon La Pook at CBS news. Here is the crucial bit of the interview

Dr. La Pook: “ …... So they have on the one side their intuition as a physician, in their bellies, and then there's the evidence-based medicine that we talk about, and they clash a lot at times, so how do you make that doctor do the right thing or give him the right incentives?”

What was interesting was how Dan reported the interview, changing from the usual one way interview to more of a conversation, in which Obama was potentially trying to get to grips with understanding the issues surrounding EBM, particularly with respect to the potential overuse of elective angioplasties (30% are deemed unnecessary). In the ensuing week we saw those opposed to Obama’s healthcare try to link the reforms with cost cutting measures and with EBM.

“If we don't drive down costs, then we're not going to be able to achieve all of those other things." Which ones he didn't say, before stressing the need for "evidence-based care”,

Later in the week Obama had obviously been working hard studying Evidence-Based Medicine. I’m not sure which text he’d read but at a press briefing on the 22nd of July Obama, in response to a question, said:

“Part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works…. Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. … 'You know what? I make a lot more money if I take this kid's tonsils out … I'd rather have that doctor making those decisions based on whether you really need your kid's tonsils out, or whether … something else would make a difference…. So part of what we want to do is to free doctors, patients, hospitals to make decisions based on what's best for patient care.”

Of course this brought a response from the American Head and Neck Surgery association who were adamant they make their decisions based on evidence. So in a week the republican movement, eminent cardiologists and ENT surgeons were pretty fed up with the idea of health coverage for all based on evidence. Possibly, maybe, perhaps or is it definitely? (I’ll let you the reader decide) this is due to income reductions for stopping unnecessary procedures that don’t benefit patients. Muir Gray refers to this as value and waste in healthcare, using the Toyota term muda to refer to waste - namely the use of resources that does not add value to the outcome. This is the reason Obama is turning to Evidence-Based Medicine to press ahead his healthcare agenda for determining value and waste in the US.