Report of the 6th National Conference

No Pulgi – Urban Indigenous Homelessness and its Effect on Health

Page last updated: 07 July 2008

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Joan Clark, Dr Katina D’Onise, No Pulgi, Nunkuwarrin Yunti.

Homelessness is a serious population health issue that has been increasing over time in Australia. The extremely poor health experienced by homeless people represents the severe end of the spectrum of poor health from inadequate housing and health hardware.

There is a lot of debate about definitions of homelessness, as a home means different things for different people. What is consistent is that being homeless is not as simple as inadequate or no housing. A home means a person has access to shelter and good, functioning, health hardware. It also includes the security and social connectedness that having a home can provide. Homelessness is a lack of any of these integral aspects of a home.

The concept of homelessness to Indigenous people is broader, and incorporates both spiritual and physical dimensions. Spiritual homelessness can mean a number of different things. It can mean a separation from traditional land, a separation from family and kinship networks, or a crisis of personal identity, wherein one’s understanding or knowledge of how one relates to country and Aboriginal identity systems is confused[1]. People may move around at significant times for important cultural reasons, and due to a lack of accommodation options, may be homeless while in Adelaide.

In the 2001 census, there were 86 homeless Indigenous people, with 48 people sleeping rough (no adequate shelter)[2]. A second study using the capture-recapture technique in 2005 found that Indigenous people made up 35.8% of homeless people sleeping rough in Adelaide, with at least 108 Indigenous people sleeping rough in the city[3].

The Uwankara Palyanyku Kanyintjaku (UPK) 9 Healthy Living Practices provides a set of basic principles required for good health. When any number of these practices fail or are completely absent for homeless people, issues such as lack of shelter, storage facilities, safety, cleaning facilities, cooking facilities or a lack of sense of wellbeing and self control all combine in different ways to contribute to extremely poor health. This extremely poor physical environment, combined with the unhealthy social and cultural environment in homeless communities, results in significant health problems including psychiatric problems, social marginalisation
and even early death. Many Indigenous people who are homeless live in more ‘visible’ public places. This can increase the social marginalisation and discrimination that homeless Indigenous people experience from the general community.

Within the different levels of homelessness, there is more ill health seen in those people who have no shelter at all, compared with those with sub-standard shelter. A review of the literature indicates that homeless people are 3-4 times more likely to die than the general population. The average age of death is between 42 and 52 years old[4].

The No Pulgi program in Adelaide is an example of a primary health care service specifically set up to address these issues. The program in Adelaide works with homeless people to offer holistic primary health care services that acknowledge the complex environment in which homeless people live. It was developed to address the largely unmet health needs for homeless people in Adelaide, particularly their chronic health care needs. The philosophy of the program is that individuals experiencing homelessness - or at risk of homelessness - have the right to comprehensive primary health care that is accessible, equitable, empowering, encourages inter-sectoral collaboration, and is selfdetermined.

No Pulgi is a collaborative effort initiated by Nunkuwarrin Yunti, Aboriginal Sobriety Group and RDNS and supported by the South Australian Department of Health and The Central Western Adelaide Aboriginal Primary Health Care Access Program (APHCAP). Other key agencies involved with the service include Drug and Alcohol Services South Australia and the Street to Home service. The partnership was developed to better address the health needs of homeless people, acknowledging that this is a difficult and complex task that would best be tackled by a partnership model.

Services commenced in March 2005. No Pulgi provides outreach primary health care services in a variety of different environmental settings including Day Centres and other places where people live and gather in the city, including the Adelaide city parklands. The service is free, flexible, and has strong links with homeless service providers to ensure integrated, holistic care that also includes social and environmental domains. It considers the whole person and the environment they live in when managing health issues. The team consists of an Aboriginal Health Worker, General Practitioners, an Intra Venous Drug Use Outreach Worker (Nunga HIV Intervention Team), and a Community Health Nurse.

An important learning from the program is that shelter, food and safety are the immediate pressing needs for homeless people, and so all other issues become secondary. In order to be successful, a service for homeless people needs to be easily accessible, including going to people in their own environment, and it needs to consider the whole person and the environment they live in to be effective. Homeless people often need support to attend to their social and physical health needs (transport, accompany people to appointments) and advocacy in dealing with mainstream services.

Structurally, homeless services need to work in partnership with other groups in the sector, including social services, to ensure seamless service delivery and best quality of care.
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Reference:

  1. Memmot, P., et al., Categories of Indigenous "Homeless" people and good practice responses to their needs. 2003, Australian Housing and Urban Research Institute.
  2. Chamberlain, C. and D. MacKenzie, Counting the Homeless 2001; South Australia. 2004, Swinburne University and RMIT University: Hawthorn.
  3. D'Onise, K., Y. Wang, and R. McDermott, The importance of numbers: Using capture-recapture to make the homeless count in Adelaide. Australian Journal of Primary Health, 2007. 13(1).
  4. O'Connell, J., Premature mortality in homeless populations: A review of the literature. 2005, National Health Care for the Homeless Council: Nashville.

Ms Joan Clarke
Worked for 20 years as a health worker and nurse. Working as an Aboriginal Health worker for the No Pulgi program since 2005. Joan is an Adnyamathanha/Nurrunga woman.

Dr Katina D’Onise
MB BS, MPH andTM, FRACGP
Advanced Public Health Registrar
Worked for No Pulgi 2005-2006, and is now working in the South
Australian Department of Health

Questions

Q1. “With homelessness, are there are any centres for them where they can sleep at night”?

A1. Joan Clark - “At the sobering up unit. They are breathalysed on the way in, fed in the morning, and then they can go. There aren’t enough beds (there is only one). It is on a first-in first-served basis. A lot of people camp just outside the building as it is a little bit safer there because there are workers and stuff around there all the time. A lot of people are just sleeping outside.

Q2. “What is the breathalysing and sobering up for”?

A2. Joan Clark - “They have to be at a certain limit before they can get in. The only way people can get in sober is if we advocate for that to happen. That is pretty hard for us, because we will save those spots for people who are sick. However, they do have a transitional room. When Doc and I go there on a Monday or Friday we can refer clients into that room if they want to start rehab, and they can stay there as long it takes for them
to move onto somewhere else”.

For further information
Dr Katina D’Onise
SA Dept of Health
PO Box 6, Rundle Mail, Adelaide, SA 5000
Ph: 08 8223 5217 Email: Katina.D'Onise@health.sa.gov.au

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