At least 315 people who were unhoused died before their time in Multnomah County in 2022. Their early deaths — occurring an average of three decades earlier than the average American — surface the fault lines of a profoundly unequal society.
We know about these deaths because of a commitment since 2010, when Israel Bayer, then-Street Roots executive director, approached Dr. Paul Lewis of the Multnomah County Health Department, imploring him to begin tracking these deaths. He wasn’t hard to convince, and neither was Deborah Kafoury, then-Multnomah County Commissioner, still years from becoming the Multnomah County Board chair.
They all saw the importance of tracking and sharing this knowledge in order to both grieve these lives and build policy addressing the causes of death.
Since then, the Multnomah County Medical Examiner’s death investigators research every unattended or violent death to see if a person has a stable address when they die, and if they don’t, the examiner adds the data field “domicile unknown.”
Over the past six years that I’ve been involved with this report, I’ve come to value the commitment of the medical examiner’s staff to find the facts and the health department to analyze and identify trends to ensure that people don’t die in anonymity. Their research, which includes reaching out to family members and other social contacts, sketches out a fuller picture of why people die so early on the edge of society.
This is the first year the report includes hospital deaths because, beginning in 2022, the Oregon Legislature requires funeral directors to record “domicile unknown” on death certificates. We now have more robust knowledge of the infections, heart disease, cancer, strokes, COVID-19, chronic liver and respiratory illness, although this funeral-director reporting does not include the level of research undertaken by the medical examiner. Even people experiencing homelessness dying in hospitals have an average life expectancy of 58 — two decades less than the national average.
The production of the Domicile Unknown report allows the community to understand more about the people who are homeless and dying. This includes an understanding of when and how people die, including deaths by hyperthermia and hypothermia, which over the years has informed the county’s response to opening extreme weather shelters. The number of people who died of hyperthermia and hypothermia decreased this year from the previous year.
Consistently, American Indian and Alaska Native residents experiencing homelessness die at about five times the rate of their county population, about the same rate they are homeless in Multnomah County. Black Multnomah County residents compose about 6% of the county population, but represent 10% of all homeless deaths and about 10% of the homeless population.
We can and must keep finding policy fixes and keep fighting for people to stay alive. But the fact a person dies homeless almost every day in Multnomah County is also an indictment of something deeper, societal and national. Poverty is a leading cause of death in the United States, according to a recent study in the Journal of the American Medical Association demonstrating poverty increases risk of death by 42%, and by 71% if a person has been in poverty for 10 years.
People suffering from poverty in this nation are vulnerable to guns, lethal driving, a toxic drug supply and despair.
Living so much of one’s life outside of secure housing is deadly, vulnerable to both guns and cars. About a quarter of all people who died in Multnomah County homicides in 2022 were homeless.
The number of people who die by traffic fatalities continues to rise for the general population, but people experiencing homelessness — who are excluded from many spaces — die at a rate 45 times higher than the general population. Efforts to expand daytime spaces such as the one-year-old Multnomah County Behavioral Health Resource Center must multiply.
Despair and suffering are, in fact, killers. Twice as many people experiencing homelessness took their own lives in 2022 compared to 2021, and this report also demonstrates the devastating impact of fentanyl.
The first year I worked on this report — 2016 — fentanyl was not associated with any deaths. In 2020, four deaths were tracked to fentanyl or any illicit opioid, and in 2021, that number rose to 36 deaths. This year, the number skyrocketed to 91 deaths. In other words, fentanyl alone contributed to about as many deaths in 2022 as the total number of medical examiner-certified deaths of homeless county residents in 2018. Fentanyl poisoning is killing people across North America.
Like a body that, under stress, feels its vulnerable spots acutely, so too does society. At a structural level, people in poverty are sacrificed in this country, while others of us never face that same fate. That is the raw truth.
This report provides data, but that data is also a collective grieving. We fight to solve for the future but grieve people suffering in our county dying an average three decades before the rest of us.
Know this, feel this, and refuse to accept this.
correction: The original verison of this column stated that Israel Bayer approached Dr. Paul Lewis in 2011. He approached him in 2010, and the first Domicile Unknown report covered deaths in 2011.
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