It should go without saying that homelessness elevates an individual’s risk of illness, injury and death. Having little access to health care or healthy food, even homeless people living in milder climates like, for example, the Bay Area, pass away decades earlier than people who have access to housing and health-care.

According to data provided by the National Health Care for the Homeless Council, the average age of death for a homeless person is 50 - which was the average age of deaths for all Americans in 1900, before the discovery of modern antibiotics.

But while the bitter reality that homeless people face is evident to every American who feels the sting of guilt every time they ignore a panhandler on a busy city street,, few state and local governments accurately collect comprehensive data specifically identifying a deceased individual as homeless - meaning that the data is incomplete.

In rapidly gentrifying Oakland, an investigation by the San Francisco Chronicle determined that thousands of homeless who die within the city limits aren’t officially identified as homeless on their death certificates, making it easier for public officials to ignore a worsening crisis as rising property values and rents increasingly push the most vulnerable individuals out onto the streets.

Meanwhile, Mayor Libby Schaaf is more concerned with protecting undocumented immigrants, even immigrants with violent criminal histories than she is with ensuring the city’s most vulnerable legal residents are attended to - or, at least, that some degree of outreach or acknowledgement is extended to this steadily rising population.

In its story, the Chronicle, opens with the example of Larry Bothelo, whose dead body was discovered decomposing in his truck, which he kept parked near the Oakland Airport. Nothing in Bothelo’s documents indicated that he was homeless. In fact, the corner listed his address as the streetcorner from which his truck was eventually towed away.

It had been weeks since Larry Joseph Botelho was spotted outside the box truck he lived in and kept parked near the Oakland airport. By the time someone asked police to check on him, the 63-year-old homeless man’s body was decomposing on a makeshift bed in the truck.

The Alameda County coroner’s office determined he died of natural causes. An investigator tracked down doctors, social workers and former employers, ran fingerprints, reviewed government records and an ancestry website, but found no relatives.

Botelho was cremated as an indigent — his ashes sent to Holy Cross Cemetery in Antioch, and his truck towed. Coroner’s case No. 01378 was closed.

Nothing in the official record shows he died homeless. His death certificate lists a home address: the spot on 98th Avenue where his truck was parked.

As the Chronicle notes, Alameda County - a county that encompasses Oakland and the surrounding area - does not collect data on how many homeless people die each year or their causes of death. And even if it did - neither the state nor the federal government track these data, or require them to be collected, meaning that even the figures cited above constitute very rough estimates.

However, even without clear data, advocates for the homeless agree that the twin problems of homelessness and homeless mortaility are rapidly getting worse - not just in the Bay Area, but across the US. In New York City and many other cities across the country, homeless people are dying in obscurity at increasingly high rates.

The Chronicle checked with coroners’ and medical examiners’ offices, county public health departments, the California Department of Public Health, U.S. Health and Human Services, and the Centers for Disease Control and Prevention and found that none had records on how many homeless people die — or mandates to collect the information.

The California Electronic Death Registration System, a database run by the state Department of Public Health, occasionally gets a death certificate where "homeless" or "encampment" is listed in place of a person’s residence, said spokeswoman Theresa Mier. But there aren’t any guidelines for doctors or medical examiners on when to use the designation.

Likewise, the U.S. Health and Human Services Department doesn’t have information or know of any national estimates on deaths of homeless individuals, said spokeswoman Carla Daniels.

What’s left is a smattering of local agencies and nonprofits that track homeless death rates in a piecemeal way. Their data lack a standardized definition of what constitutes homelessness, rendering their numbers erratic and unrealiable.

One local official justified this approach by arguing that it helps keep the dignity of the deceased intact - and that often, in cases when a next of kin can be found - it shows that the police aren’t judging them.

Once a homeless person dies — usually decades earlier than the U.S. life expectancy — investigators proceed with the same steps they do for any deceased person, said Lt. David Vandagriff, who runs the Alameda County coroner’s bureau.

First, they identify the dead. Next, they track down the family. Autopsies are conducted and reports are made. But a person’s housing status often does not make it into the official record.
If investigators can track down an address associated with the dead — where an estranged spouse lives or the place they would pick up mail — they often won’t be marked as homeless in the paperwork that documents how they died and who they were. If they find no address, they may write “homeless” or “transient” in that section of a death record.

"We are duty bound to show them respect and dignity," Vandagriff said. "Quite often when we’re interacting with next of kin, we want to show them that this is not something that we’re judging your departed on. We’re not classifying them as anything other than a departed member of your family."

Unlike Oakland, San Francisco and Contra Costa County do keep track of homeless mortaility data - but in each case, officials cautioned that the data are likely a significant underestimation.

In San Francisco, a woman named Alice, who for years lived on the sidewalk outside a Burger King, likely will not be included in the city’s 2018 count because she moved into a single-room-occupancy hotel in the Mission before she died last month, said Rachael Kagan, spokeswoman for the city’s Department of Public Health.

Unlike Oakland, San Francisco compiles the number of homeless people who die each year. But officials caution that their count is probably a significant underestimation because homeless people who spend their last days in housing or a hospital may not make the tally.

In Contra Costa County, Capt. Steve Simpkins of the coroner’s office provided numbers but emphasized they aren’t perfectly accurate. They showed that an average of 33 homeless people died each year over the past decade, but last year the figure jumped to 64. He said nothing was readily apparent to explain the increase.

The lack of systematic data — or any data at all — when it comes to people dying on the streets is in sharp contrast to the concerted effort to count how many people are living on the streets.

One recent attempt to conduct an informal census of the homeless population in Oakland revealed an alarming figure: Last year in Alameda County, the so-called point-in-time census revealed a 25% jump in the homeless population in Oakland and a nearly 40% increase countywide.

Bobby Watts, CEO of the National Health Care for the Homeless Council, said it’s vital to know the mortality rate of the homeless population.

"It’s the first and most basic measure of health or public health: Is someone alive or dead?" he said. "It’s an extremely important measure. It’s something we need to know. Some localities do a better job than others."

Cities that do make efforts to collect data noted an increase in homeless deaths last year, Watts said.

The collection of uniform and reliable homeless death data could help create policies to prevent deaths, say some health and homeless services providers. It could also help spur action to tackle the crisis.

"This is information that can be used to create interventions and just to underscore the long-term solution of housing," Watts said. “It doesn’t have to be 100 percent accurate, but it’s better to have some good information than none at all.”

Maria Foscarinis, executive director of the National Law Center on Homelessness and Poverty, said if more people knew how dire homelessness is — by way of mortality statistics, for instance — there might be a heightened sense of urgency.

"A lot of people don’t understand how serious a problem this is and who is affected and why," she said. "When people are dying — that’s just another piece of evidence that it’s a public health emergency."

Lucy Kasdin, deputy director of Alameda County’s Health Care for the Homeless unit, said statistics on homeless deaths would be “incredibly valuable” in developing interventions and figuring out how to best allocate resources.

But even as city officials pour money into clinics for the homeless, one researcher says data conclusively show that the only real remedy for improving longevity would be to provide housing - everything else is like putting  a band-aid on a bullet wound.

Josh Bamberger, a UCSF physician who has been treating homeless patients for the past two decades, said there’s already sufficient data on the perils of homelessness.

"We have mountains of data to tell us why homelessness is bad," he said. "It’s bad for your health, it’s expensive, and it kills you at a younger age."

He pointed to a 2009 research paper he co-authored that examined the impact of housing on the survival of homeless people with AIDS. Only two out of 71 placed in housing died after five years. In the same period, three-quarters of the 610 people without housing had died. Some studies have indicated that homelessness is correlated with a 25-year decrease in one’s life expectancy.

“If the health care system embraced housing as the one and true treatment to improve the health of homeless people, that money would be well spent,” Bamberger said. “I used to believe I should put my energies in providing the best care. … But there’s an absurdity in having a patient with perfect blood pressure, perfect control of their sugar and treatment of their cancers and then rolling them out in their wheelchair into the rain.”

But as mayors like Schaaf risk losing federal block-grant funding over their categorical defenses of “sanctuary cities” and the undocumented, the downside of this is the population that is truly the most vulnerable is shunted aside and ignored.

Which begs the question: How many bodies in the streets will it take before city officials decide to take a closer look at homeless mortality and the steps that could be taken to ameliorate it.