HomeMy WebLinkAboutac-homeless-mortality-report-2018-2020
2018-2020 Homeless
Mortality Report
Alameda County Health Care Services Agency
Health Care for the Homeless Program
Community Assessment, Planning, and Evaluation
Alameda County Homeless Mortality Report 2018-2020 -- 3/20/2022
Alameda County Health Care Services Agency (HCSA)
Colleen Chawla, Director
Nicholas Moss, MD MPH, Health Officer
HCSA Office of Homeless Care and Coordination
Kerry Abbott, Director
Lucy Kasdin, Director, Health Care for the Homeless Program
HCSA Public Health Department
Kimi Watkins-Tartt, Director
Chuck McKetney, Interim Director, Community assessment, Planning, and Evaluation Unit
Acknowledgements
This report was produced by the Alameda County Health Care Services Agency’s Health Care for
the Homeless (HCH) program and Community Assessment, Planning and Evaluation (CAPE) unit.
Matt Beyers and Yilak Fantaye, CAPE, provided epidemiological direction and guidance. David
Modersbach, HCH, provided analysis, content, and writing. Special thanks to Wilma Lozada, HCH,
for records review, and all of the community partners who supported this effort.
Alameda County Health Care for the Homeless
1404 Franklin Street #200
Oakland CA 94601
510-891-8950
www.achch.org
Alameda County Health Care for the Homeless program is supported by the Health Resources
and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)
as part of an award totaling $4,064,392 and other non-federal funding sources. The contents are
those of the author(s) and do not necessarily represent the official views of, nor an endorsement,
by HRSA, HHS, or the U.S. Government. For more information, please visit www.HRSA.gov.
Original Cover Art by: Inti Gonzalez http://intigonzalez.com/
This report is available online at
https://www.achch.org/alameda-county-homeless-mortality.html
Alameda County Homeless Mortality Report 2018-2020 -- 3/20/2022
Contents
2018-2020 Alameda County Homeless Mortality Report
1. Executive Summary
2. Introduction
3. Overview of Methods
4. All Causes of Death — Homeless deaths by homeless status and demographics
5. Deaths by Region of Alameda County
6. Encampment & Shelter Deaths
7. Unattended Deaths
8. Major Underlying Causes of Death
a. Overdose and Drug/Alcohol Deaths
b. Acute/Chronic Medical Disease Deaths
c. Accidental Deaths
d. Homicide and Suicide
9. Mortality Rates and Comparisons to Alameda County General Population
10. Services Utilization
11. Next Steps
12. Appendix
Alameda County Homeless Mortality Report 2018-2020 4
Executive Summary
A responsible and just community must work to be closely aware of the deaths of all its members,
strive to learn from those deaths, implement policies and practices to reduce preventable deaths,
and work to reduce the harm that preventable deaths create for families, friends, caregivers, and
the community. A just community will look at the places and moments of death and ensure that
people who die do not die alone and experience death in as peaceful a manner as possible.
The Alameda County Health Care Services Agency’s Health Care for the Homeless (HCH) program
and Public Health Department Community Assessment, Planning, and Evaluation (CAPE) unit
carried out Alameda County’s first-ever homeless mortality report, a retrospective report on
homeless deaths from 2018 to 2020.
This innovative report is based on identification of homeless deaths through data matching
across homeless services utilization lists, community reporters and California Comprehensive
Death File (CCDF) records in the California Vital Records Business Information System.
Because of the methods used, Alameda County’s homeless death numbers will appear higher
than those of other localities that rely solely on Medical Examiner/Coroner’s reports of homeless
deaths.
Key Findings in the 2018-2020 Alameda County Homeless Mortality Report
Between 2018 and 2020, 809 people in Alameda County died while experiencing homelessness.
The number of annual homeless deaths grew considerably larger between 2018 and 2020.
Year
Known to be
homeless at
years of death, but
housed at time of
years of death, but
unknown housing
2018 195 57 189
2019 246 91 198
2020 368 102 211
Unattended Deaths: Fifty-seven percent (450 out of 809) of all homeless deaths took place
outside of a medical setting (i.e., hospital or nursing facility), occurring on streets/sidewalks,
outdoors, in vehicles, encampments, shelters, other’s residences and other locations. Forty-two
percent of deaths due to acute/chronic disease-related occurred in non-medical settings.
Disparities in Ethnicity & Gender: African American/Black persons represent 41% of total
homeless deaths, compared to 19% of general population deaths. Men represent 76.9% of
homeless deaths, compared to 51.4% of general population deaths.
Alameda County Homeless Mortality Report 2018-2020 5
Death Rates by Cause of Death: The age-adjusted mortality rate for people experiencing
homelessness in Alameda County in 2018-2020 was 4.4 times higher than that of the general
population of Alameda County, and most of the causes of death are many times higher for people
experiencing homelessness than the general population.
Causes of Death
• Overdose: Twenty-five percent of homeless deaths
between 2018 and 2020 (94) were directly due to
drug overdose, with the number of overdoses among
people experiencing homelessness rising sharply in
2020. Seventy percent of overdose deaths took place
in outdoor settings.
• Acute/chronic medical condition causes of death: Half of the homeless deaths from 2018-
2020 (403) were due to acute/chronic medical conditions, led by heart and cardiovascular
disease, and followed by cancer, liver disease, cerebrovascular disease, respiratory disease,
and others. 41.8% of these acute/chronic disease-related deaths occurred outside of
medical/clinical settings.
• Accidental injuries accounted for 82 (10%) homeless deaths, the large majority being
pedestrians and cyclists hit by automobiles, trains, and automobile transit-related deaths.
• Homicide accounted for 59 deaths of people experiencing homelessness, mostly due to
shootings and stabbings taking place in street and outdoors.
• Suicide: Thirty-five people experiencing homelessness took their own lives between 2018 and
2020.
• Shelter residents: At least 61 persons residing in homeless shelters died between 2018-2020.
Sixty percent died of acute/chronic diseases, 31% of overdoses, and 8% of suicide or accident.
• Encampments: At least 50 people died in homeless encampments between 2018 and 2020.
Sixty-two percent died of drug overdoses, 24% of acute/chronic diseases, 10% of homicide,
and 4% died of other causes including fire and exposure.
• COVID: COVID-19 was the cause of death for six persons experiencing homelessness in 2020.
One shelter resident died of COVID in 2020, the remainder were unsheltered, living in hotels,
or had an unknown housing status.
2018 35 17.2%
2019 61 24.7%
2020 94 25.6%
Alameda County Homeless Mortality Report 2018-2020 6
Next Steps
This first Alameda County homeless mortality report focuses on data and accurately enumerates
deaths among our unhoused communities. To advance this work, we plan to convene a
Community Homeless Mortality Task Force to further analyze these data, inform the
development of future mortality reports, and make recommendations to reduce preventable
deaths among people experiencing homelessness. If you or your organization are interested in
learning more, please reach out to achch@acgov.org.
Alameda County Homeless Mortality Report 2018-2020 7
Introduction
The experience of homelessness has well-documented long-term consequences on people’s
health and well-being.
A responsible and just community must work to be closely aware of the deaths of all its members,
strive to learn from those deaths, implement policies and practices to reduce preventable deaths,
and work to reduce the harm that preventable deaths create for families, friends, caregivers, and
the community. A just community will look at the places and moments of death and ensure that
people who die do not die alone and experience death in as peaceful a manner as possible.
This review marks the first attempt by Alameda County to carry out an accurate reporting and
review of the deaths of County residents experiencing homelessness. This initiative is joint work
of the Alameda County Health Care Services Agency’s Health Care for the Homeless program and
Community Assessment, Planning, and Evaluation unit. It also reflects collaboration and
partnership with numerous community, city, and County partners.
Our intention is that this first retrospective homeless mortality report, encompassing the years
2018-2020, will be followed by regular mortality reports and review processes that can grow to
include the multiple agencies, as well as the community of providers and residents who support
the health and wellbeing of people experiencing homelessness.
We plan to convene a Community Homeless Mortality Task Force to further analyze these data,
inform the development of future mortality reports, and make recommendations to reduce
preventable deaths among people experiencing homelessness
Across the country, more and more localities are working to carry out homeless mortality
reporting and review, to bring attention and analysis on a national level to the impacts of
homelessness on health and mortality and improve health care interventions as well as end-of-
life services for the most vulnerable in our society.
We are proud to be part of the National Health Care for the Homeless Council and the Homeless
Mortality Working Group which has been instrumental in this effort, and you can review national
efforts at www.nhchc.org/homeless-mortality.
Alameda County Homeless Mortality Report 2018-2020 8
Methods
All local health jurisdictions across the country have systems for review and determination of
death, generally reporting death data to their state health department. Generally, a county or
local jurisdiction will have one of two structures for evaluating deaths:
1. Medical Examiner: County-appointed office led by a physician, carrying out a variety of
mortality-related services including analysis and review of deaths in a community.
2. Coroner’s Office: Law enforcement-based office, carrying out investigation of suspicious
or unattended deaths under supervision of Sheriff, a position held or appointed by an
elected Coroner/Sheriff, with no minimum medical training requirements.
Alameda County has a Coroner’s Office, with the coroner appointed and supervised by the
Alameda County Sheriff’s Office. The Coroner’s Office generally only investigates and reports
deaths that are either unattended (taking place outside of a hospital or other clinical setting such
as nursing facility) or suspicious in nature. Additionally, the Coroner may not have access to the
records of homeless deaths by “natural” causes taking place in a hospital or medical facility. Most
communities that carry out a homeless mortality review do so with death data provided through
cooperation and efforts of their local Coroner or Medical Examiner. See the Appendix for a list of
recent homeless mortality reports from neighboring jurisdictions.
Alameda County HCSA’s approach to identifying homeless deaths utilizes a comprehensive range
of data sources traditionally not used for mortality reviews. We used the state’s California
Comprehensive Death Files from Vital Records Business Information System (VRBIS) alongside
multiple countywide sources of homelessness-related data and mortality reports to arrive at an
accurate and comprehensive accounting of the deaths of county residents who have died in
homelessness. By applying this approach, a higher number of homeless deaths are identified.
Our method of determining homeless deaths was based on cross-systems data matching to
determine homelessness at time of death, evaluating cause of death, and comparing mortality
rates across the Alameda County general population and people dying in homelessness. In the
following pages, we break out total homeless deaths by geography and place, decedent
demographics, and underlying health conditions and cause of death.
Determining Homelessness at Time of Death
• Data matching: We used local homeless services utilization data to build a master list of
people known to have experienced homelessness in the past five years.
o Key data included:
Homeless Management Information System (HMIS): 30,000+ homeless
services utilization records for past five years in Alameda County.
Coordinated Entry System (CES) By-Name List: 15,741 names of persons
assessed for Alameda County Coordinated Entry System.
Health Care for the Homeless utilization: 28,751 utilizers of HCH services
between 2017-2020.
Alameda County Homeless Mortality Report 2018-2020 9
o We compared these lists of people known to be experiencing homelessness
against the California Comprehensive Death Files to find matches.
• California Comprehensive Deaths Files (CCDF) review: Staff reviewed state death records
data for information on homeless status inputted by physicians, medical
examiners/coroner, or funeral home staff. For example, the words “homeless,”
“encampment,” “transient,” etc., may indicate homelessness. We support efforts
underway at the California Department of Public Health to have homelessness status
added as a field in death records.
• Community reporters: We received reports of homeless deaths from:
o Coroner’s Office: 380 names of decedents labeled as transient (not all homeless).
o UCSF HOPE/HOME study: 88 deaths registered in ongoing study of aging
Oaklanders experiencing homelessness.
o Community reporters: 112 deaths reported to ACHCH over past years through
community reports and the ACHCH Homeless Mortality Reporting form.
o Santa Rita Jail list of homeless deaths.
o Project Roomkey reports of resident deaths in COVID isolation and Safer Ground
housing 2020-2021.
o Review of media reports of homeless deaths.
• Determining homeless status: ACHCH and CAPE staff carried out close analysis of each
possible homeless death, including review of HMIS notes and records where possible, and
used the HUD definition of “literally homeless” to determine housing status at time of
death, producing the following categories:
o Homeless at time of death
We used the HUD definition of homelessness, and included persons known
to be experiencing homelessness but who were hospitalized or in a nursing
facility at time of death.
o Recent (less than 5 years) history of homelessness, but housed at time of death
This includes persons known to be housed in permanent supportive
housing or in other permanent housing at time of death.
o Recent (less than 5 years) history of homelessness, unknown housing status at
time of death
This includes persons who may have been doubled-up, precariously
housed or permanently housed or even literally homeless at time of death,
but not enough information was available to determine homeless status.
Evaluating Cause of Death
• Underlying cause of death
o Staff reviewed the ICD-10 codes, the Underlying Cause of Death diagnosis code, in
the underlying cause of death field in the CCDF and categorized them.
• Location of death
o Staff evaluated the CCDF information for location of injury or location of death
and determined location of death for people experiencing homelessness, such as
Alameda County Homeless Mortality Report 2018-2020 10
streets, encampment, hospital, nursing facility, vehicle, another’s residence,
shelter, or outdoors, based on CCDF information.
• Contributing causes of death
o Staff reviewed CCDF data to analyze the contributing causes of death (such as
alcohol, drug use, or mental illness) which may or may not have been input into
the records via the state’s Electronic Death Registration System as reflected in the
CCDF.
Death and Mortality Rates
For this homeless mortality report, we used the same categories of underlying cause of death to
calculate mortality rates among both those experiencing homelessness and the full Alameda
County population. To accurately calculate the age-adjusted mortality rate, the population-years
at risk is needed as a denominator. The population-years at risk can be thought of as the average
number of people in the population over a specified period. To arrive at the average number of
people experiencing homelessness between 2018 and 2020, we generated an unduplicated list
of literally homeless persons who used County HMIS services in 2018-2020 and adjusted that
number up to account for people experiencing homelessness who did not use homeless services.
This estimated number of people experiencing homelessness on an average day between 2018
and 2020 – 9,100 persons – was used to generate overall and cause-specific mortality rates
among people experiencing homelessness and to directly compare to the general population of
Alameda County during that period. A mortality rate ratio divides the two age-adjusted rates.
What is Missing from This Report?
By using data matching in future efforts, we can get a better idea of who is and isn’t utilizing
systems and learn more about mortality among certain segments of the population:
• Additional Coroner’s data: We were not able to systematically access some Alameda
County Coroner’s Office data and notes (for example toxicology reports on overdoses) for
deaths investigated by that office.
• Additional homeless services utilization data: It is critical to review utilization of various
homelessness services to get a better idea of circumstances leading to death, and
opportunities to prevent death. Examples of utilization data sources we want to
incorporate in the future are itemized in Chapter 10.
Our goal is to continue to work to bring together the above providers and data systems to enable
better homeless mortality reporting and utilization analysis in the future.
Alameda County Homeless Mortality Report 2018-2020 11
All Deaths: Characteristics of Deaths
In 2018-2020, 809 people died while experiencing homelessness in Alameda County. An
additional 250 persons known to be housed after the recent experience of homelessness died
during this period. The analysis also revealed that some 598 persons with recent experience of
homelessness, but with unknown housing status at the time of death, died.
Alameda County Homeless Mortality, 2018-2020
Most of the following analysis of homeless causes of death will be focused on the 809 persons
who are known to have died in homelessness in Alameda County during 2018-2020.
The 809 deaths of Alameda County residents
experiencing homelessness equal an age-adjusted
homeless death rate of 2,366.1 per 100,000,
compared to the general population of Alameda
County (537.7/100,000). This means that persons
experiencing homelessness have an age-adjusted
mortality rate ratio of 4.4 times that of the general
population.
The number of homeless deaths increased by 88.7%
from 2018 to 2020.
2018 2019 2020
Homeless Deaths
Homeless Deaths by Region
Year
Berkeley/
Albany
Oakland/
Alameda, San Leandro,
San Lorenzo,
Fremont,
Newark,
Dublin,
Pleasanton,
19 102 49 16 9
18 141 55 18 14
25 215 84 26 17
195
246
368
50
150
250
350
450
2018 2019 2020
Homeless Deaths Per Year
2018-2020 Alameda County
Alameda County Homeless Mortality Report 2018-2020 12
Homeless Deaths by City/Place
Oakland 452 55.9%
Hayward 83 10.3%
Berkeley 60 7.4%
Fremont 46 5.7%
Castro Valley 44 5.4%
San Leandro 40 4.9%
Pleasanton 17 2.1%
Alameda 14 1.7%
Dublin 12 1.5%
Livermore 11 1.4%
Newark 8 1.0%
San Lorenzo 7 0.9%
Emeryville 7 0.9%
Union City 6 0.7%
Albany 2 0.2%
In addition to the 809 Alameda County homeless deaths, 42 Alameda County residents died in
California counties outside of Alameda County. These deaths are evaluated in the Deaths By
Region section of this report.
Homeless Deaths
outside of Alameda
San Francisco 15
San Jose 3
Richmond 3
Walnut Creek 2
Modesto 2
16 California cities with
one death each 17
General Causes of Death
Below are the general causes of death for the 809 persons who passed away while experiencing
homelessness in Alameda County in 2018-2020. Each of these general causes of death will be
discussed in further detail in later chapters:
Alameda County Homeless Mortality Report 2018-2020 13
Cause of Death 2018 2019 2020 2018-2020 Percentage
Total 195 246 368 809 100.0%
Underlying Causes of Death
Underlying Cause of Death is a manner of classifying the specific cause of death type, including
categories of disease and accident type. Below is the underlying cause of death for the 809
persons who passed away in homelessness 2018-2020:
Underlying Cause of Death 2018 2019 2020 2018-2020 Percentage
Total 195 246 368 809 100.0%
Alameda County Homeless Mortality Report 2018-2020 14
Demographics of Homeless Deaths
We were unable to categorize homeless deaths by sexual orientation or gender identity as this
information is unavailable in death records.
The average age of death of people experiencing homelessness 2018-2020 was 52.3 years, as
compared to the Alameda County general population average age of death of 75 years.
•
male and 51% female (2021).
• The population of people
experiencing homelessness is
61% male and 35% female
(2019 PITC).
• County deaths in 2018-2020
were 51% male, 49% female.
•
American/Black; 39% White; 32%
Asian; 23% Hispanic/Latino; and 19% all
other.
• The population of people experiencing
homelessness is 47% African
American/Black; 31% White; 17%
Hispanic/Latino; 2% Asian, and 20% all
other (2019 PITC).
• County deaths in 2018-2020 deaths
were 10% African American/Black; 47%
White; 19% Asian; 12% Hispanic/Latino;
3% all other.
African
American/Black
174
43.2%
Asian
12
3.0%
All other races
38
9.4%
Hispanic/Latino
50
12.4%
White
129
32.0%
Race/Ethnicity of Homeless Deaths
Female
187
23.1%
Male
622
76.9%
Sex of Homeless Deaths
Alameda County Homeless Mortality Report 2018-2020 15
Deaths by Month and Season
There does not appear to be a strong correlation between seasons and numbers of deaths.
Almost exactly half of deaths occurred between November-April (401) and between May-
October (408).
27
80
122
163
269
122
19 7
0
50
100
150
200
250
300
15-24 25-34 35-44 45-54 55-64 65-74 75-84 Unknown
Age Group of Homeless Deaths
60 62
79
46
65 69
58 62 65
89
71
83
0
10
20
30
40
50
60
70
80
90
100
Month of Homeless Deaths
Alameda County Homeless Mortality Report 2018-2020 16
Deaths by Region
Berkeley/Albany
Between 2018 and 2020, 62 people experiencing homelessness died in Berkeley and Albany.
Homeless Deaths in Berkeley-Albany 2018-2020 Count Percentage
City/place
Albany 2 3.2%
Berkeley 60 96.8%
Year
2018 19 30.6%
2019 18 29.0%
2020 25 40.3%
Cause of death
Acute/chronic disease 27 43.5%
Substance abuse and overdose 21 33.9%
Gender
Female 19 30.6%
Male 43 69.4%
Race/ethnicity
African American/Black 28 45.2%
Location of
death/injury
Outdoors 16 25.8%
Total 62 100%
Alameda County Homeless Mortality Report 2018-2020 17
Oakland/Emeryville
Between 2018 and 2020, 459 people experiencing homelessness died in Oakland and Emeryville.
Homeless Deaths in Oakland-Emeryville 2018-2020 Count Percentage
death/injury
Alameda County Homeless Mortality Report 2018-2020 18
Total 459 100.0%
Mid-County (Hayward, Alameda, San Leandro, San Lorenzo, Castro Valley)
Between 2018 and 2020, 188 people experiencing homelessness died in Hayward, Alameda, San
Leandro, San Lorenzo, and Castro Valley.
Homeless Deaths in Mid-County 2018-2020 Count Percentage
death/injury
Alameda County Homeless Mortality Report 2018-2020 19
Total 188 100.0%
South County (Fremont, Newark, Union City)
Between 2018 and 2020, 60 people experiencing homelessness died in Fremont, Newark, and
Union City.
Homeless Deaths in South County 2018-2020 Count Percentage
death/injury
Alameda County Homeless Mortality Report 2018-2020 20
Total 60 100.0%
Tri-Valley (Dublin, Pleasanton, Livermore)
Between 2018 and 2020, 40 people experiencing homelessness died in Pleasanton, Livermore
and Dublin. This includes 14 persons who died at Santa Rita Jail.
Homeless Deaths in Tri-Valley 2018-2020 Count Percentage
death/injury
Alameda County Homeless Mortality Report 2018-2020 21
Total 40 100.0%
Homeless Deaths Outside of Alameda County
By comparing homeless services utilization data from Alameda County against the CCDF data, we
reviewed deaths of 42 people experiencing homelessness who were Alameda County residents,
but who died, in homelessness, in other California counties between 2018 and 2020.
Homeless Deaths Outside of Alameda County 2018-2020 Count Percentage
death/injury
Alameda County Homeless Mortality Report 2018-2020 22
Fairfield, Los Angeles, McKinleyville, Menlo
Park, Milpitas, Rancho Cordova, Rio Vista,
San Bernardino, San Pablo, Santa Cruz,
16 (1
each) 2.4%
Total 42 100.0%
Alameda County Homeless Mortality Report 2018-2020 23
Shelter and Encampment Deaths
Shelter Residents
Analysis of CCDF records, HMIS notes, and community reports determined that 61 persons noted
as living in homeless shelters or programs died in Alameda County between 2018 and 2020.
Thirty-three of these deaths were determined to have taken place in a shelter or transitional
housing program. Twenty-two of these deaths occurred in a hospital, and nine deaths of shelter
residents took place outdoors (streets, park, vehicle, camp).
Cause of Death: Shelter Residents Count Percentage
Total 61 100.0%
Encampment Deaths
We were not able to determine mortality outcomes among those who were living in
unsheltered/encampment settings as it was not feasible to determine people’s exact homeless
location at time of death. In CCDF notes, descriptors for unsheltered settings such as camp, tents,
streets were used interchangeably, and encampments were rarely entered as a decedent’s home
address. However, we reviewed the deaths of 49 Alameda County residents who were specified
in CCDF as having died at an encampment setting.
Cause of Death: Encampment Deaths Count Percentage
Total 49 100.0%
Unattended Deaths
Of the 809 deaths of people experiencing homelessness in Alameda County in 2018-2020, 359
people (44.3%) died in a hospital or nursing facility. This means that overall, 450 deaths (55.7%)
occurred either unattended or with first responders in the case of traumatic death (accident,
homicide, suicide, overdose). Below are unattended homeless deaths by cause of death.
Cause of Death: Unattended Homeless Deaths Count Percentage
Alameda County Homeless Mortality Report 2018-2020 24
Total 552 100.0%
Note: The above chart includes 102 deaths by injury, homicide/suicide, or overdose that occurred in the field, but
were pronounced dead at emergency departments or hospitals.
Location of Unattended Homeless Deaths by General Cause of Death
Death Location Abuse and Chronic
Streets/sidewalk 141 25.5% 29.1% 17.0% 24.8% 24.1% 5.0%
Outdoors 83 15.0% 34.9% 41.0% 10.8% 10.8% 2.4%
Vehicle 65 11.8% 44.6% 43.1% 7.7% 1.5% 3.1%
Other’s residence 57 10.3% 45.6% 36.8% 3.5% 3.5% 10.5%
Encampment 49 8.9% 63.3% 24.5% 4.1% 8.2% 0.0%
Shelter 32 5.8% 40.6% 53.1% 3.1% 0.0% 3.1%
Unknown 30 5.4% 86.7% 10.0% 3.3% 0.0% 0.0%
Motel 26 4.7% 38.5% 42.3% 0.0% 3.8% 15.4%
Railroad 22 4.0% 4.5% 0.0% 68.2% 9.1% 18.2%
Jail 18 3.3% 16.7% 33.3% 5.6% 16.7% 27.8%
Public transit 16 2.9% 37.5% 25.0% 0.0% 12.5% 25.0%
Road accident 13 2.4% 7.7% 0.0% 84.6% 7.7% 0.0%
Alameda County Homeless Mortality Report 2018-2020 25
City/Place of Unattended Homeless Deaths
Oakland 314 56.9%
Hayward 50 9.1%
Berkeley 45 8.2%
San Leandro 28 5.1%
Fremont 26 4.7%
Castro Valley 18 3.3%
Pleasanton 15 2.7%
Dublin 12 2.2%
Newark 8 1.4%
Livermore 8 1.4%
San Lorenzo 7 1.3%
Emeryville 7 1.3%
Alameda 6 1.1%
Union City 6 1.1%
Albany 2 0.4%
Demographics of Unattended Homeless Deaths
Of the literally homeless who died in an unattended setting (not within a medical facility, hospital,
or nursing center):
• Sex: 81% were men, 19% were women.
• Race: African American/Black 40%, White 34%, Hispanic/Latino 16%; Asian 3%; other
7%.
• Age: Average age of death is 50 years. 17% under age 35; 20% 35-54 years; 11% 55
years or older.
Unattended Deaths: Acute/Chronic Disease
Where cause of death was acute/chronic disease, 41.8% of these deaths were unattended. In
2018-2020, 173 people experiencing homelessness died of acute/chronic disease in unattended
settings. Among unattended acute/chronic disease deaths, 80% were men, average age was 57
years.
Cause of Death: Unattended Acute/Chronic Deaths Count Percentage
Alameda County Homeless Mortality Report 2018-2020 26
Total 173 100.0%
Location of Death: Unattended Acute/Chronic
Deaths Count Percentage
Total 173 100.0%
Causes of Death
Acute/chronic disease 99 119 186 403 49.9%
Substance abuse and overdose 49 76 104 229 28.3%
Accidental injury 21 27 34 82 10.1%
Homicide 16 15 28 59 7.3%
Suicide 10 9 16 35 4.3%
In the following pages, we will more closely review deaths of people experiencing homelessness
by general cause of death.
Underlying Cause of Death: Drug Overdose and Alcohol Overdose
Drug overdose is the single leading cause of death among people experiencing homelessness
in Alameda County between 2018 and 2020 and increased greatly through that time.
What is drug overdose? Drug overdose is one of the fastest-growing causes of death in the
country and in Alameda County. Drug overdose deaths are most frequently due to opiates
Alameda County Homeless Mortality Report 2018-2020 27
(mainly synthetic opiates such as fentanyl and fentanyl compounds), heroin, and increasingly due
to psychostimulants such as methamphetamine. Many persons are not aware of the presence of
fentanyl-laced compound drugs in their drug supply or the powerful potency of fentanyl.
Most drug overdoses can be reversed— and death prevented — by rapid action by nearby persons
calling 911 and/or administering naloxone (Narcan) before death occurs.
You can learn more about statewide analysis of overdose deaths in a 2022 California Overdose
Crisis Policy Brief from the State of California.
What is alcohol overdose? Alcohol poisoning is caused by drinking large quantities of alcohol in
a short period of time. Very high levels of alcohol in the body can shut down critical areas of the
brain that control breathing, heart rate, and body temperature, resulting in death. Between 2018
and 2020, 12 people experiencing homelessness died of an alcohol overdose in Alameda County
at an average age of 49, and with an age-adjusted death rate of 36.4/100,000, a rate 72.9 times
that of the general population.
Drug Overdose and Homeless Mortality
In Alameda County between 2018 and 2020, 203 persons experiencing homelessness died
because of acute drug or alcohol overdose. This represents 25.1% of all homeless deaths. Of
these deaths, 191 were drug overdoses for an age-adjusted death rate of 555.0/100,000, 43.0
times that of the general population.
The average age of overdose death for homeless persons is 48 years, as compared to the average
for the general population of 45 years.
Location of Overdose Deaths
Overdose deaths almost happened in an unattended setting; 25 deaths were pronounced at a
hospital after transport from unknown locations.
Here are the locations in which people experiencing homelessness died by overdose as reported
in CCDF:
Location of Homeless
Overdose Deaths Count Percentage
Alameda County Homeless Mortality Report 2018-2020 28
Total 191 100.0%
Demographics
Literally homeless at but housed at unknown housing
Total 191 16 34
Of the literally homeless who died of drug overdose:
• Sex: 81% were men; 19% women
• Race: African American/Black 40%; White 38%; Hispanic/Latino 12%; Asian 2%; Other
8%
• Age: Average age of death 48 years; 15% under age 35; 46% between 35-54 years;
37% 55 years or older; 1.6% unknown.
• Geography: Homeless overdose deaths were reported in the following cities:
City/Place of Overdose Death Count Percentage
Total 191 100.0%
Alameda County Homeless Mortality Report 2018-2020 29
Co-factors in Overdose Deaths
• We did not get toxicology reports from the Coroner’s Office. Examination of toxicology
reports should enable a better ability to track fentanyl- and methamphetamine-involved
fatal overdoses.
• We are also unable to precisely map the exact locations where fatal overdoses occurred,
analyze if/when naloxone was administered, nor determine if an overdose was alone or
with other persons. All of these are important in analyzing overdose fatalities.
Cause of Death: Sequelae of Chronic Alcohol and Drug Use
What are Sequelae of Chronic Alcohol and Drug Use?
Sequelae (or results) of chronic alcohol and drug use refers to deaths that are attributed by a
doctor as resulting directly from the impact of excessive long-term drug or alcohol use. These
deaths are different from overdose deaths, which are directly caused by immediate excessive
ingestion of alcohol or drugs.
Excessive alcohol use: Most deaths that are caused by the health effects of drinking excessive
alcohol over time are directly attributed to acute/chronic diseases such as cardiovascular disease,
cancers, stroke, and liver disease. In CCDF, notations of excessive alcohol use are indicated as a
secondary factor, if reported. Between 2018 and 2020, nine deaths were indicated as having
been directly caused by chronic excessive alcohol use. This small sample gives us a mortality rate
among people experiencing homelessness of 26.8/100,000, or 20.6 times the rate of the general
population rate of death due to chronic excessive alcohol use. The average age of death is 61
years, older than the county general population average of 58 years. Eighty-nine percent of
chronic alcohol abuse-related deaths took place in an unattended setting, in vehicles, a shelter,
on the street, or in an encampment.
Excessive drug use: Most deaths caused by the effects of long-term excessive drug use are
generally directly attributed by physicians to the acute/chronic disease-causing death, such as
cancers, liver disease, kidney disease, heart disease, hypertension, and diabetes. Incidence of
these acute/chronic disease deaths are higher among people excessively using drugs over time.
However, between 2018 and 2020, 18 homeless deaths were directly attributed to the long-term
excessive drug use. This represents a homeless mortality rate of 53.5/100,000, 53.5 times that of
the general population. The average age of death was 52 among homeless persons and 54 among
the general population. Sixty-seven percent of these deaths took place in medical facilities and
33% on streets, outdoors or vehicle.
Sequelae of Chronic Alcohol and Drug Use and Homeless Mortality
In Alameda County between 2018 and 2020, 27 people experiencing homelessness died of
sequelae of chronic alcohol and drug use, or 3.3% of all homeless deaths.
The average age of death for homeless persons dying from chronic alcohol or drug use is 56 years,
as compared to the average for the general population of 58 years.
Alameda County Homeless Mortality Report 2018-2020 30
Forty percent of homeless persons who died from chronic alcohol or drug use were engaged in
the HMIS system of care.
Location of Death of Sequelae of Chronic Alcohol and Drug Use
Between 2018 and 2020, 48% of the homeless persons who died from chronic alcohol and drug
use died within a medical facility. Fifty-two percent died unattended, in vehicles, on the streets,
in a shelter, or in an encampment.
Demographics
Literally
homeless at
Recently
homeless but
homeless;
unknown housing
Total 26 4 12
Of the 27 persons homeless at time of death who died from chronic drug or alcohol use in
2018-2020:
• Sex: 70% were men; 30% women.
• Race: 37% African American/Black; 37% White; 15% Hispanic/Latino; 11% other.
• Age: Average age of death 56 years. Five occurred in persons less than 45 years of
age, and 15 deaths (56%) of deaths were among persons over 55 years of age.
• Geography: 52% of homeless chronic alcohol and drug use deaths occurred in
Oakland; 15% in in Berkeley, followed by Alameda, Castro Valley, and Hayward.
Cause of Death: Acute and Chronic Medical Conditions
In Alameda County between 2018 and 2020, 403 deaths (or 50%) of people experiencing
homelessness were due to acute or chronic medical conditions, also known as natural causes.
Epidemiologists categorize these deaths into categories by the Underlying Cause of Death
diagnosis code (ICD-10 code) determined by the coroner, pathologist or treating physician. These
are the following categories of underlying cause of death for people experiencing homelessness
who died between 2018 and 2020:
Underlying Cause of Death: Acute/
Chronic Disease Homeless Deaths 2018 2019 2020 2018-2020 Percentage
Alameda County Homeless Mortality Report 2018-2020 31
Total 99 119 185 403 100.0%
Demographics of People Experiencing Homelessness Who Died of Acute/Chronic Diseases
Age: Average age at death: 52.7 years. The average age of death of the Alameda County general
population by acute/chronic is 77 years.
African
American/Black
174
43.2%
Asian
12
3.0%
All other races
38
9.4%
Hispanic/Latino
50
12.4%
White
129
32.0%
Race/Ethnicity of Acute/
Chronic Disease Deaths
Female
187
23.1%
Male
622
76.9%
Sex of Homeless Acute/Chronic
Disease Deaths
Alameda County Homeless Mortality Report 2018-2020 32
3
17
41
67
175
82
17
4
0
20
40
60
80
100
120
140
160
180
200
15-24 25-34 35-44 45-54 55-64 65-74 75-84 Unknown
Age Group of Acute/Chronic Disease Deaths
Location of Death Count %
Total 403 100.0%
No HMIS
Utilization
147
36.5%HMIS
Utilization
256
63.5%
Homeless Services Utilization, Acute/Chronic
Disease Deaths
Alameda County Homeless Mortality Report 2018-2020 33
Geography of Acute/Chronic Disease Deaths
Unattended Acute/Chronic Disease Deaths
Of the 403 homeless acute/chronic disease deaths, 173 (42%) occurred outside of a medical
facility (hospital or nursing facility).
Location of Death Count Percentage
Total 173 100.0%
City/Place of
Death Count Percentage
Total 403 100.0%
City of Death Count Percentage
Total 15 100.0%
In 2018-2020, 15 acute/chronic
disease deaths in other California
counties of Alameda County residents
experiencing homelessness were
reported.
Alameda County Homeless Mortality Report 2018-2020 34
The leading cause of death among unattended deaths was heart disease.
Unattended
Deaths by
Acute/Chronic
Disease by
City/Location
Oakland 87 50.0%
Hayward 18 10.3%
Berkeley 15 8.6%
Fremont 11 6.3%
San Leandro 9 5.2%
Pleasanton 7 4.0%
Dublin 6 3.4%
Alameda 4 2.3%
Union City 3 1.7%
San Lorenzo 3 1.7%
Emeryville 3 1.7%
Livermore 3 1.7%
Newark 2 1.1%
Castro Valley 2 1.1%
Albany 1 0.6%
In 2018-2020, eight
experiencing homelessness were reported:
City of Death Deaths %
Total 8 100.0%
Unattended Deaths by Acute/Chronic Disease Demographics
• Sex: 81% were men; 19% women
• Race: 41% African American/Black; 36% White; 13% Hispanic/Latino; 7% other; 3%
Asian.
Cause of Death Count Percentage
Total 173 100.0%
Alameda County Homeless Mortality Report 2018-2020 35
• Age: Average age of death 57 years. 3.4% aged 15-34; 16% 35-54; 45-54; 37% 55-64;
and 28% aged 65 and over
Cause of Death: Heart Disease
What is Heart Disease?
Heart disease is the second-leading cause of death in Alameda County, and the leading cause of
death nationwide. Risk factors of heart disease include unhealthy diet, physical inactivity,
tobacco use, harmful use of alcohol and genetics. These result in raised blood pressure, high
blood glucose, high cholesterol, and overweight/obesity. In turn, these conditions can lead to
chronic congestive heart failure, valve and artery blockage, and acute heart attacks.
Heart Disease and Homeless Mortality
In Alameda County between 2018 and 2020, 116 people experiencing homelessness died of heart
disease. This represents 14.3% of all homeless deaths, and an age-adjusted homeless death rate
of 347.2/100,000, 3.3 times that of the general population.
The average age of death for homeless persons with heart disease is 59 years as compared to the
average for the general population of 78 years.
Location of Death of Heart Disease
Fifty-six percent of people experiencing homelessness who died of heart disease passed away on
the streets, in a vehicle, in a shelter, in another’s residence, outdoors, in a motel, or in an
encampment. Forty-four percent died within a medical facility.
Demographics
Literally
homeless at homeless but unknown housing
Total 116 58 124
Of the 116 persons homeless at time of death who died of heart disease:
• Sex: 82% were men; 18% women
• Race: 49% African American/Black; 32% White; 8% Hispanic/Latino; 5% Asian; 6%
other.
• Age: Average age of death 59 years. 2% under age 35; 10% 35-54; 29% aged 35-54;
53% 55-64 years; 35% 65 years or over.
Alameda County Homeless Mortality Report 2018-2020 36
• Geography: 53% of homeless heart disease deaths occurred in Oakland; 15% in
Hayward, 9% Fremont; 6% San Leandro; 5% Berkeley, 13% rest of county. Five
homeless heart disease deaths occurred out of the County.
• Homeless services: 36% of deaths occurred among persons who had not utilized HMIS
services.
Co-factors in Homeless Heart Disease Deaths
• Forty-two percent of homeless heart disease deaths included alcohol or drug use as a
significant co-condition.
• Tobacco use is much higher in the population of people experiencing homelessness, but
decedent smoking status was not available for analysis in this report.
• Eighty-seven of the 414 (21%) of all homeless chronic or acute disease deaths contained
reference to diabetes as other significant condition.
Related Cause of Death
• Hypertensive diseases (essential hypertension and hypertensive renal disease): In 2018-
2020, seven persons experiencing homelessness died of hypertensive diseases.
Hypertension (high blood pressure) if untreated can lead to many other causes of death,
including heart disease, strokes, and other causes. A death directly attributed to kidney
failure due to hypertension it is classified this way. People experiencing homelessness
died at 1.5 times the rate of the general population.
Other Acute/Chronic Disease Causes of Death
In 2018-2020 there were a total of 117 deaths whose records note other causes of death
attributed as Other Diseases, Other Communicable Diseases, or an Undefined (ICD-10 code R99)
cause of death.
All Other Diseases Including Other Communicable Diseases
These categories include 61 different listed acute/chronic disease causes of death. These causes
of death can include both specific causes, such as hepatitis C, causes of death (sepsis, pneumonia,
kidney failure) linked to other conditions or diseases, internal hemorrhage, thrombosis, and
many other medical conditions.
• In 2018-2020, 84 people experiencing homelessness died of All Other Diseases, with an
average age of 56, compared to the Alameda County general population average of 78
years. The mortality rate was 2.2 times that of the general population.
• In 2018-2020, 16 people experiencing homelessness died of Other Communicable
Diseases at an average age of 55 vs. the Alameda County general population average age
of 72. The homeless death rate is 37.1/100,000 or 4.1 times the rate of the general
population. These deaths included five deaths directly attributed to Hepatitis C disease.
Location of Death
Alameda County Homeless Mortality Report 2018-2020 37
Between 2018 and 2020, 75% of people experiencing homelessness who died of all other
diseases including other infectious diseases died in a medical facility. The remaining 25% died on
the streets, outdoors, in a vehicle, in jail, in a motel, in an encampment, in another’s residence,
and on public transit.
Demographics
Communicable Diseases or Ill-defined/Unknown Cause:
Literally
homeless at
Recently homeless
but housed at
homeless;
unknown housing
Total 117 44 118
Of the 117 persons homeless at time of death who died of other diseases including other
communicable diseases:
• Sex: 80% were men; 20% women
• Race: 43% African American/Black; 32% White; 12% Hispanic/Latino; 11% other; 1%
Asian.
• Age: Average age of death 56 years. One death aged 12-24; seven aged 25-34; 11 35-
44; 14 45-54; 43 55-64; and 23 deaths aged 65-74
• Geography: 56% of homeless deaths occurred in Oakland; 9% in Hayward; 7% Castro
Valley; 6% Berkeley; 5% Tri-Valley and 17% in other locations in County. Two
additional homeless Alameda County residents died in other cities in California.
Ill-Defined and Unknown Causes of Death (ICD-10 code R99)
17 homeless deaths in 2018-2020 were classified as ill-defined or unknown causes of death. This
includes eight persons found decomposed or skeletal for whom homicide was not suspected and
a natural cause of death could not be determined. These also include cases of probable cause of
death including three probable drug overdoses and one probable death by hypothermia. An
additional five had cases pending at the time of this report. All the R99 deaths were persons who
passed away outdoors in an unattended setting.
Cause of Death: Cancer
What is Cancer?
Alameda County Homeless Mortality Report 2018-2020 38
Cancer includes malignant tumors and neoplasms creating abnormal cells which grow and invade
other parts of the body, leading to metastasis which is the primary cause of cancer death. Cancer
is a leading cause of death in Alameda County, and risk factors for cancer include tobacco use,
alcohol use, unhealthy diet, physical inactivity, and pollution.
Cancer and Homeless Mortality
• In Alameda County between 2018 and 2020, 49 people experiencing homelessness died
of cancer. This represents 5.2% of all homeless deaths, and an age-adjusted homeless
death rate of 130.4/100,000, a rate slightly higher (MRR=1.1) than that of the general
population. Unlike other diseases such as heart disease, cancer is more likely to go
unreported as a cause of death if it is not diagnosed before death. Those who die while
experiencing homelessness may be less likely to receive the full autopsy necessary to
identify undiagnosed cancer
The primary types of cancer deaths among people experiencing homelessness include prostate,
lung, liver, colon, and uterine.
The average age of death for homeless persons with cancer is 60.4 years, as compared to the
average for the general population of 71.8 years.
Location of Death of Cancer
Eighty-eight percent of people experiencing homelessness who died of cancer died within a
medical facility. The remaining 12% died outdoors or in someone else’s residence.
Demographics
Literally
homeless at homeless but unknown housing
Total 49 39 125
Of the 49 persons homeless at time of death who died of cancer in 2018-2020:
• Sex: 69% were men; 31% women
• Race: African American/Black 45%; White 35%; Hispanic/Latino 12%; Multirace 6%;
Asian 2%
• Age: Average age of death 60.4 years. 2% under age 35, 10% 35-54 years; 82% 55
years or older.
Alameda County Homeless Mortality Report 2018-2020 39
• Geography: 47% of Alameda County homeless Cancer deaths occurred in Oakland,
followed by Castro Valley 24.5%, Hayward 10%, Berkeley 6%, and others 8%.
Co-factors in Homeless Cancer Deaths 2018-2020
• Tobacco use is much higher in the population of people experiencing homelessness, but
decedent smoking status was not available for analysis in this report.
• Thirty-one percent of cancer deaths included alcohol/substance use as other significant
conditions.
• Hepatitis C infection was a significant co-condition, listed in 19% of cancer deaths.
Cause of Death: Chronic Liver Disease
What is Chronic Liver Disease?
Chronic liver disease (CLD) is ongoing damage and deterioration of liver function, which can lead
to scarring (fibrosis), severe fibrosis (cirrhosis), liver failure, and death. Causes of liver disease can
be largely divided into:
1. Viral (hepatitis A, B, C).
2. Alcoholic (caused by long-term alcohol use).
3. Non-alcoholic metabolic (causes include obesity, diabetes, and other factors).
Chronic Liver Disease and Homeless Mortality
In Alameda County between 2018 and 2020, 47 people experiencing homelessness died of
chronic liver disease. This represents 5.8% of all homeless deaths, and an age-adjusted homeless
death rate of 126.8/100,000, 13.5 times that of the general population.
The average age of death for homeless persons with CLD is 51.8 years, as compared to the
average for the general population of 60 years.
Location of Death of Chronic Liver Disease
Forty-seven percent of people experiencing homelessness died of chronic liver disease outside
of medical facility (outdoors, on streets, in a vehicle or encampment, or in a shelter). The
remaining 53% died in hospital or a nursing facility.
Alameda County Homeless Mortality Report 2018-2020 40
Demographics Chronic Liver Disease
Literally
homeless at
time of
Recently
homeless but
homeless;
unknown housing
Total 47 12 27
Of the literally homeless at time of death (47) who died of chronic liver disease:
• Sex: 70% were men; 30% women
• Race: African American/Black 40%; White 34%; Hispanic/Latino 15%; Multiracial 4%;
Native American 2%; Asian 2%
• Age: Average age of death 51.8 years. 7% under age 35; 26% 35-54 years; 68% 55
years or older.
• Geography: 55% of Alameda County Homeless CLD deaths occurred in Oakland,
followed by Fremont (13%), Hayward (11%), Tri-Valley (9%), Berkeley (4%) and others
(9%).
Co-factors in Chronic Liver Disease Deaths
• Alcoholic liver disease including cirrhosis was specifically noted in 75% of CLD deaths, and
alcohol or drug use noted in 82% of all CLD deaths.
• The six homeless deaths due to acute/chronic Hepatitis B-C infection were classified
under Other Communicable Disease.
• Nearly all deaths of chronic liver disease are preventable – especially if attributable to
alcohol, drug use, or hepatitis C. Additionally, the root causes of non-alcoholic liver
disease include obesity and poorly managed diabetes.
Cause of Death: Cerebrovascular Disease
What is Cerebrovascular Disease?
Cerebrovascular diseases include stroke, transient ischemic attack (TIA), aneurysm, and vascular
malformation. In the Alameda County, cerebrovascular disease is the fifth-most common cause
of death. Anyone with symptoms of a cerebrovascular attack (FAST: Face drooping; Arm
weakness; Speech difficulty; Time to call 911) needs urgent medical care to prevent death or
long-term damage.
Cerebrovascular Disease and Homeless Mortality
Alameda County Homeless Mortality Report 2018-2020 41
In Alameda County between 2018 and 2020, 24 people experiencing homelessness died of
Cerebrovascular Disease. This represents 3% of all homeless deaths, and an age-adjusted
homeless death rate of 62.4/100,000, or 1.7 times that of the general population.
The average age of death for homeless persons with cerebrovascular disease is 57 years, as
compared to the average for the general population of 81 years.
Location of Death of Cerebrovascular Disease
Seventy-one percent of people experiencing homelessness who died of cerebrovascular disease
died within a medical facility. The remaining 29% died outdoors, in someone else’s residence, or
in a vehicle.
Demographics
Literally
homeless at
time of
Recently
homeless but
homeless;
unknown housing
Total 24 10 28
Of the 24 persons homeless at time of death who died of cerebrovascular disease 2018-2020:
• Sex: 43% were men; 57% women
• Race: African American/Black 68%; White 18%; Hispanic/Latino 11%; Asian 4%
• Age: Average age of death 59 years; 4% under age 35 4%; 35-54 years 25%; 71% 55
years or older.
• Geography: 43% of Alameda County Homeless Cerebrovascular Disease deaths
occurred in Oakland, followed by Berkeley 21%, Castro Valley 21%, San Leandro, and
Alameda 14%. Four Alameda County homeless residents died in other counties 2018-
2020.
Co-factors in Homeless Cerebrovascular Disease Deaths 2018-2020
• 24% of homeless cerebrovascular disease deaths included alcohol or drug use as a
significant condition.
• Hepatitis C infection was a significant co-condition in two cerebrovascular disease deaths.
• HIV infection was a co-condition in one cerebrovascular disease deaths.
Cause of Death: Chronic Lower Respiratory Disease
Alameda County Homeless Mortality Report 2018-2020 42
What is Chronic Lower Respiratory Disease (CLRD)?
Chronic lower respiratory disease (CLRD) includes chronic bronchitis, emphysema, and asthma.
CLRD is the sixth-most common cause of death in Alameda County. CLRD is progressive, getting
worse with age. Tobacco use is by far the most important risk factor for CLRD, as well as
environmental exposures and genetic influences.
CLRD and Homeless Mortality
In Alameda County between 2018 and 2020, 21 people experiencing homelessness died of CLRD.
This represents 2.6% of all homeless deaths, and an age-adjusted homeless death rate of
59.4/100,000, or 2.9 times that of the general population.
The average age of death for homeless persons with CLRD is 59 years, as compared to the average
for the general population of 78 years.
Location of Death of CLRD
Fifty-seven percent of people experiencing homelessness who died of CLRD passed away in
vehicles, others residence, streets, encampments, motels, or a shelter; 45% died within a medical
facility.
Demographics
Literally
homeless at
time of
homeless but
housed at death
unknown housing
status at death
Total 21 16 28
Of the 21 persons homeless at time of death who died of CLRD 2018-2020:
• Sex: 67% were men; 33% women
• Race: 48% African American/Black; 43% White; 5% Hispanic/Latino; 5% other.
• Age: Average age of death 59 years. 29% aged 35-54; 71% 55 years or over.
• Geography: 52% of homeless CLRD deaths occurred in Oakland, followed by Berkeley
19%, Hayward 19%; San Leandro and Livermore 10%.
Co-factors in Homeless CLRD Deaths
• Twenty-four percent of homeless CLRD deaths included alcohol or drug use as a
significant co-condition.
• Tobacco use is much higher in the population of people experiencing homelessness, but
decedent smoking status was not available for analysis in this report.
Alameda County Homeless Mortality Report 2018-2020 43
Cause of Death: Diabetes
What is Diabetes?
Diabetes is a chronic disease that occurs either when the pancreas does not produce enough
insulin or when the body cannot effectively use the insulin it produces. Uncontrolled diabetes
over time leads to serious damage to many of the body's systems, especially the nerves and blood
vessels. Exercise, healthy diet, and weight control are ways to prevent or delay the onset of
diabetes, and diabetes can be treated with diet, exercise, medication, and regular care to avoid
complications and death. Diabetes is the seventh leading cause of death in Alameda County.
Diabetes and Homeless Mortality
In Alameda County between 2018 and 2020, 11 people experiencing homelessness died of
diabetes. This represents 1.4% of all homeless deaths, and an age-adjusted homeless death rate
of 29.0/100,000. This means that in Alameda County, people experiencing homelessness die of
diabetes at a rate 1.6 times that of the general population.
The average age of death for homeless persons with diabetes is 56 years, as compared to the
average for the general population of 72 years.
Location of Death of Diabetes
Fifty-five percent of people experiencing homelessness who died of diabetes passed away in
shelters, outdoors, or other’s residence; 45% died within a medical facility.
Demographics
Literally
homeless at
time of
Recently
homeless but
homeless;
unknown housing
Total 11 14 21
Of the 11 persons homeless at time of death who died of diabetes 2018-2020:
• Sex: 73% were men; 27% women
• Race: 91% African American/Black; 9% White.
• Age: Average age of death 56 years. 29% aged 35-54; 71% 55 years or over.
• Geography: 82% of homeless diabetes deaths occurred in Oakland, one death in
Fremont. One death took place out of the county.
Alameda County Homeless Mortality Report 2018-2020 44
Co-factors in Homeless Diabetes Deaths
• Twenty-four percent of homeless diabetes deaths included alcohol or drug use as a
significant co-condition.
• Tobacco use is much higher in the population of people experiencing homelessness, but
decedent smoking status was not available for analysis in this report.
• Eighty-seven of the 414 (21%) of all homeless chronic or acute disease deaths contained
reference to diabetes as other significant condition.
Cause of Death: COVID-19
What is COVID-19?
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. Most
people infected with the virus experience mild to moderate respiratory illness and recover
without requiring special treatment. However, some become seriously ill and require medical
attention. Older people and those with underlying medical conditions like cardiovascular disease,
diabetes, chronic respiratory disease, or cancer are more likely to develop serious illness or die.
In 2020, COVID-19 was the fifth-leading cause of death among the Alameda County population.
COVID-19 and Homeless Mortality
In Alameda County between 2018 and 2020, six people experiencing homelessness died of
COVID-19. This represents 0.7% of all homeless deaths, and an age-adjusted homeless death rate
of 14.3/100,000, or 1.3 times the rate of the general population.
The average age of death for homeless persons with COVID-19 is 58 years, as compared to the
average for the general population of 77 years.
Location of Death of COVID-19
All of the people experiencing homelessness who died of COVID-19 passed away in a medical
facility. Only one person known to be living in a congregate homeless shelter in Alameda County
died of COVID-19 in 2020.
Demographics
Literally
homeless at
time of
Recently
homeless but
homeless;
unknown housing
Of the six persons homeless at time of death who died of COVID-19 in 2018-2020:
• Sex: 83% were men; 17% women
Alameda County Homeless Mortality Report 2018-2020 45
• Race: 50% were Hispanic/Latino; 17% African American/Black; 17% White; 15% other.
• Age: Average age of death 58 years. one aged 35-54; four aged 55-64; one aged 65+.
• Geography: One homeless COVID-19 death occurred in Oakland; two in Castro Valley,
two in Hayward, one in San Leandro.
Co-factors in Homeless COVID-19 Deaths
• An additional four homeless deaths by other causes in 2020 included references to
COVID-19 co-infection.
• COVID-19 deaths can be greatly prevented through full vaccination and rapid detection,
isolation, and treatment of cases.
Cause of Death: HIV
What is HIV?
HIV deaths have fallen dramatically in the general population since the mid-1990’s due to
successful treatments. However, deaths directly attributable to HIV infection (AIDS) continue
among those who are not able to access or carry out HIV treatment.
HIV and Homeless Mortality
In Alameda County between 2018 and 2020, five people experiencing homelessness died of HIV.
This represents 0.6% of all homeless deaths, and an age-adjusted homeless death rate of
11.9/100,000, or 9.2 times that of the general population.
The average age of death for homeless persons with HIV is 56 years, as compared to the average
for the general population of 58 years.
Location of Death
Between 2018 and 2020 all people experiencing homelessness who died of HIV passed away
within a medical facility.
Demographics
Literally
homeless at
Recently
homeless but
homeless;
unknown housing
Total 5 6 7
Of the five persons homeless at time of death who died of HIV 2018-2020:
Alameda County Homeless Mortality Report 2018-2020 46
• Sex: 80% were men; 20% women
• Race: 60% African American/Black; 20% White; 20% other.
• Age: Average age of death 56 years. One death occurred in person less than 45 years
of age.
• Geography: 60% of homeless HIV deaths occurred in Oakland; 40% in San Leandro.
For more information about HIV in Alameda County, please refer to HIV in Alameda County 2016-
2018.
Alameda County Homeless Mortality Report 2018-2020 47
Underlying Cause of Death: Accidental Death
Accidental Deaths and Homeless Mortality
In Alameda County between 2018 and 2020, 82 persons experiencing homelessness died by
traumatic accidental death. This number does not include accidental drug or alcohol overdose.
Included in the category of accidental deaths are the following causes of death:
Cause of Death: Homeless Accidental
Deaths 2018 2019 2020 2018-2020 Percentage
Total 21 29 32 82 100.0%
10.1% of all homeless deaths were due to accidental death. By far, pedestrian deaths are the
most frequent (non-drug overdose) accidental cause of death among people experiencing
homelessness. In Alameda County people experiencing homelessness have a pedestrian death
rate 44.9 times higher than the general population, 104 times the rate of being struck by a train,
and 7.7 times the rate of dying by other unintentional injuries.
The average age of accidental death for homeless persons is 47 years, as compared to the average
for the general population of 59 years.
Location of Accidental Deaths
Most accidental deaths do not take place in hospitals or facilities and are thus unattended except
by emergency responders. Here are the locations in which people experiencing homelessness
died by homicide as reported in CCDF:
Setting/Location of Injury: Homeless
Accidental Deaths Count Percentage
Alameda County Homeless Mortality Report 2018-2020 48
Total 82 100.0%
Demographics
Literally homeless
homeless but
housed at
Recently homeless;
unknown housing
Total 82 6 16
Of the literally homeless who died due to accidental injury:
• Sex: 84% were men; 16% women
• Race: African American/Black 35%; White 33%; Hispanic/Latino 21%; Asian 5%; Other
6%
• Age: Average age of death 47 years. 13% under age 35; 39% 35-54 years; 35% 55 years
or older.
• Geography: 44% of accidental deaths occurred in Oakland; 14% in Hayward, 12% in
Berkeley; 11% in San Leandro; 6% Fremont; 5% Tri-Valley and 8% other cities.
Alameda County Homeless Mortality Report 2018-2020 49
Underlying Cause of Death: Homicide
Homicide and Homeless Mortality
In Alameda County between 2018 and 2020, 59 persons experiencing homelessness died by
homicide. This represents 7.3% of all homeless deaths, and an age-adjusted death rate of
196.1/100,000, or 33.8 times that of the general population.
The average age of homicide death for homeless persons is 41 years, as compared to the average
for the general population of 35 years.
Homicide deaths were most frequently due to gunshot (70%), stabbing (12%), and drowning, fire,
and other means.
Location of Homicide Deaths
Here are the locations in which people experiencing homelessness died by homicide as reported
in CCDF:
Homeless Homicides Count Percentage
Total 59 100.0%
Demographics
Year
Literally
homeless at but housed at unknown housing
Total 59 5 17
Of the literally homeless who died due to homicide:
• Sex: 85% were men; 15% women
Alameda County Homeless Mortality Report 2018-2020 50
• Race: African American/Black 59%; White 14%; Hispanic/Latino 22%; Other 5%
• Age: Average age of death 41 years. 37% under age 35; 44% 35-54 years; 19% 55 years
or older.
• Geography: 69% of homicide deaths occurred in Oakland, followed by Hayward (9%),
Tri-Valley (7%), San Leandro (5%), Berkeley (4%), and others (6%).
Underlying Cause of Death: Suicide
Suicide and Homeless Mortality
In Alameda County between 2018 and 2020, 35 persons experiencing homelessness died by
suicide. This represents 4.3% of all homeless deaths, and an age-adjusted death rate of
116.9/100,000, or 14.1 times that of the general population.
The average age of suicide death for homeless persons is 42 years, as compared to the average
for the general population of 48 years.
The most common method of suicide was hanging/suffocation, followed by jumping in front of
traffic or train, gunshot, drug, and others.
Location of Suicide Deaths
Here are the locations in which people experiencing homelessness died by suicide:
Location of Suicide Count Percentage
Total 35 100.0%
Demographics
Year
Literally
homeless at
Recently homeless
but housed at
homeless;
unknown housing
Alameda County Homeless Mortality Report 2018-2020 51
Total 35 4 5
Of the literally homeless who died by suicide:
• Sex: 74% were men; 26% women
• Race: African American/Black 17%; White 46%; Hispanic/Latino 23%; Asian 9%; Other
6%
• Age: Average age of death 42 years. 35% under age 35; 43% 35-54 years; 14% 55 years
or older.
• Geography: 37% of suicide deaths occurred in Oakland, followed by Tri-Valley (17%),
Berkeley (9%), Newark (9%), Fremont (9%), Hayward (9%), and others (12%).
Alameda County Homeless Mortality Report 2018-2020 52
Mortality Rates and Comparisons to the Alameda County General Population
Age-Adjusted Mortality Rate for the Alameda County General Population Compared to Persons
Experiencing Homelessness with Mortality Rate Ratio
The overall age-adjusted mortality rate for people experiencing homelessness is 2,266 deaths per
100,000 persons. This is compared to the age-adjusted mortality rate for the Alameda County
general population of 538 per 100,000 persons. The Mortality Rate Ratio (MRR) for persons
experiencing homelessness is 4.4, meaning that people experiencing homelessness in Alameda
County die at a rate 4.4 times that of the general population.
The mortality rate for persons experiencing homelessness is based on a denominator of 9,100
people experiencing homelessness in Alameda County per day in 2018-2020. This number was
arrived at through HMIS utilization for 2018-2020 and adjusting that number upwards based on
the number of homeless decedents who died with no records of HMIS or Health Care for the
Homeless utilization.
A mortality rate ratio (MRR) of 1.0 indicates equal rates in the two groups. An MRR ratio greater
than 1.0 indicates an increased risk for the group in the numerator, and a rate ratio less than 1.0
indicates a decreased risk for the group in the numerator. For example, in 2018-2020, people
experiencing homelessness died of unintentional drug overdoses at a rate 43.0 times that of the
general Alameda County population.
Cause of Death
Deaths 2018-2020 Mortality
Rate Ratio
Homeless
General
Population Homeless
General
Population
All causes 809 30,309 2,366.1 537.7 4.4
Unintentional overdose 191 677 555.0 12.9 43.0
Heart disease 116 5969 347.2 104.9 3.3
All other diseases 83 4579 228.1 81.3 2.8
Homicide 59 288 196.1 5.8 33.8
Cancer (malignant neoplasms)49 6549 130.4 114.4 1.1
Chronic liver disease/cirrhosis 47 530 126.8 9.4 13.5
Suicide 35 437 116.9 8.3 14.1
Unintentional or undetermined
pedestrian or bike crash 33 123 100.9 2.3 43.9
All other unintentional injuries 29 617 87.8 11.4 7.7
Cerebrovascular disease 24 2,101 62.4 37.2 1.7
CLRD 21 1,177 59.4 20.7 2.9
Sequelae of drug abuse &
dependence 18 58 53.5 1 53.5
R99 (ill-defined and unknown
cause of mortality)17 59 48.1 1.1 43.7
Alameda County Homeless Mortality Report 2018-2020 53
12 21 41.4 0.4 103.6
Alcohol overdose 12 28 36.4 0.5 72.9
Diabetes, metabolic 11 1,023 29.0 17.8 1.6
Sequelae of alcohol abuse &
dependence 9 77 26.8 1.3 20.6
Hypertensive renal
disease/essential hypertension 7 747 20.3 13.1 1.5
All other injuries 5 58 16.3 1 16.3
COVID 6 632 14.3 11.1 1.3
HIV 5 73 11.9 1.3 9.2
Exposure 3 9 8.6 0.2 42.8
Cause of Death Comparison between People Experiencing Homelessness and Alameda County
General Population
Acute/chronic disease 403 27,904 49.8% 92.1%
Accident 82 828 10.1% 2.7%
Homicide 59 288 7.3% 1.0%
Suicide 35 437 4.3% 1.4%
Substance abuse and overdose 230 840 28.4% 2.8%
Deaths by Ethnicity Comparison between People Experiencing Homelessness and Alameda
County General Population
Count Percentage
Race/Ethnicity Homeless
General
Population Homeless
General
Population
White 267 14,114 33.0% 47.0%
African American/Black 333 5,695 41.0% 19.0%
Asian 24 5,909 3.0% 19.0%
Hispanic/Latino 118 3,735 15.0% 12.0%
All other races 67 858 8.0% 3.0%
Total 809 30,311 100.0%100.0%
Alameda County Homeless Mortality Report 2018-2020 54
Deaths by Gender Comparison between People Experiencing Homelessness and Alameda
County General Population
Male 622 15,565 76.9% 51.4%
Female 187 14,745 23.1% 48.6%
Total
Mean Age of Death Comparison between People Experiencing Homelessness and Alameda
County General Population
Cause
Mean Age
Homeless (Years) General Population (years)
All causes 52 years 75 years
Homicide 41 35
Suicide 42 48
Accident 47 59
Substance abuse and overdose 49 47
Acute/chronic disease 57 77
Alameda County Homeless Mortality Report 2018-2020 55
Services Utilization
A key element of analyzing and learning from homeless mortality is to review the utilization of
homeless, health care and other services among people experiencing homelessness who have
died. Services used by people experiencing homelessness can include:
• Primary care clinics and providers
• Hospitalization and emergency department
• Housing services (emergency shelter and housing services)
• Outreach services
• Behavioral health services (mental health and substance use disorder)
• Harm reduction services
• Criminal justice system involvement
• Social services utilization
• Veteran status and services utilization
• Foster care system utilization
In this 2018-2020 report, we were not able to fully “connect the pieces” between people
experiencing homelessness and the services they utilized – or didn’t utilize – in the times leading
to their deaths. This type of data analysis is a strong goal for future Alameda County homeless
mortality efforts. A good example of services utilization reporting is carried out by San Francisco:
https://nhchc.org/wp-content/uploads/2020/12/San-Francisco-2019-Homeless-Mortality-
Health-Commission.pdf
Homeless Services Utilization: Homeless Management Information System (HMIS)
In this report, we were able to evaluate how many of the people experiencing homelessness who
died between 2018 and 2020 had utilized Alameda County Homeless Management Information
System (HMIS) which is the system used to track users of HUD-funded homeless shelter and
services in Alameda County. We also matched decedents to the Alameda County Health Care for
the Homeless (ACHCH) program data of people who had received health care at ACHCH mobile
or clinic sites.
Through this data matching, we found that 69% of the 809 persons deemed to be literally
homeless at time of death between 2018 and 2020 had a history of services utilization with the
HMIS system or the ACHCH program. Of the 248 persons without history of HMIS or ACHCH
contact, 164 were deaths reported by the Coroner’s Office as “transient”.
We hope in future reports to evaluate much more closely utilization of homeless services and the
above services to gain a better understanding of the relationships between homeless services
and mortality.
Alameda County Homeless Mortality Report 2018-2020 56
Homelessness System Implications and Next Steps
This 2018-2020 report is a data report for review and analysis, which will be useful in informing
policy and practice across the homelessness system of care, including health care, government
and community partners.
Next steps for our County and partners include:
• Regular homeless mortality reporting. HCSA will regularly update and improve this
report, ideally on an annual basis.
• Establishment of Countywide Homeless Mortality Task Force. HCSA’s homelessness
programs are considering bringing together leads from varied County and city
departments, and community organizations to meet regularly to review and analyze
homeless mortality data, trends, cases, and best practices, and provide policy and
practical recommendations and feedback to homeless health care and services providers.
• Continuous data quality improvement.
o HCSA’s team will continue to partner with the Alameda County Coroner’s Office
to access and integrate more robust data, especially regarding overdose data and
associated toxicology reporting.
o HCSA’s team will continue to leverage service utilization data from touchpoints
across the homelessness system of care, including housing, health clinics,
hospitals, emergency room, behavioral health, social services, outreach, and
criminal justice.
• Provider-based Mortality Review is the process by which health and services providers
review the circumstances of deaths of individuals that they have treated or served, to
explore root causes and identify interventions to prevent future deaths. When carried out
systematically by providers such as health clinics, outreach providers and homeless
shelters, mortality review can improve care and future health outcomes among people
experiencing homelessness. A key element of provider mortality review also includes
responding to the trauma and effects of mortality upon services providers themselves.
For more information about clinic or site-based mortality review, please go to:
https://nhchc.org/wp-content/uploads/2020/12/Section-4-Toolkit.pdf
If you are interested in providing input or guidance to the Alameda County Health Care for the
Homeless program around the issues of homeless mortality, please reach out to
achch@acgov.org.
The Alameda County Health Care for the Homeless program also maintains a webpage with
homeless mortality information and a form for submitting the names and some data around
people known by community providers to have died in homelessness. These community reports
help us carry out a more accurate and effective homeless mortality reporting:
https://www.achch.org/alameda-county-homeless-mortality.html
Alameda County Homeless Mortality Report 2018-2020 57
Appendix
Other California/Regional Homeless Mortality Reports
Location Type of Report Homeless Deaths Notes/Links:
medical examiner 2019 Countywide Advisory Group to
examiner-180 in 2020 report. Working on a mortality
Francisco examiner-
reported deaths
2019; 331 deaths
between 3/2020
analysis; deaths only for literally
homeless who died in streets or
report 1,307 since 2002 Coalition to End Homelessness
Barbara reports Homeless Deaths Review Team