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early a decade ago, David Modersbach had what he thought was a straightforward question: How many unhoused people had died that year?

The grants manager and his team at Alameda County Health Care for the Homeless knew people were dying on the streets, but they wanted more than anecdotal evidence; they wanted data that could show them the big picture and help them hone their strategies.

They queried the coroner’s bureau and were stunned by the response: only a single death had been reported.

“We realized there’s a lot of work to do,” Modersbach said.

What followed was a bootstrap campaign to fill the data gap. It took years, and the work was sometimes lonely, often tedious and consistently heartbreaking. When the team finally released its first report in 2022, detailing deaths from 2018–20, they counted 195 people in Alameda County who died while homeless in 2018, plus another 189 people with recent histories of homelessness whose housing status couldn’t be verified at their time of death.

As more Californians have fallen into homelessness — a number greater than 181,000 at last count (PDF) — more have died while unhoused, but the state’s ability to track these deaths and assess the scope of the problem hasn’t kept pace.

Spurred in part by Alameda County’s efforts, which are considered a national model for the field, the state recently began taking steps toward collecting this data. In 2022, California added a field to death records for homelessness status, and this year, a law went into effect that empowers counties to set up homeless death review committees to determine the root causes of homeless mortality.

California is among several jurisdictions across the country seeking this data. The pandemic put a spotlight on the health vulnerabilities accompanying homelessness, and that has led to growing national interest in the topic, said Barbara DiPietro, senior director of policy for the National Health Care for the Homeless Council. A recent study from researchers at the University of Pennsylvania and NYU found the death rate of people experiencing homelessness increased 238% between 2011 and 2020.

“One of the things that hopefully we took away from COVID is that homelessness is a public health issue,” she said. “Not only is living unhoused very dangerous and high risk for people experiencing homelessness, this isn’t good for communities either.”

Researchers said the data is critical in assessing whether the state’s public health interventions for people on the streets work.

“That is how we work to change things,” said Dr. Margot Kushel, director of the UCSF Benioff Housing and Homelessness Initiative. “One of the problems with not reporting it is that it makes it harder to act.”

But getting statewide — let alone national — data detailing the number of unhoused deaths requires meticulous reporting on the part of local agencies. In the case of Alameda County, it was a system Modersbach had to build from scratch.

How they count

For each homeless mortality report, Modersbach and his colleagues first scour thousands of county death records, searching for clues that suggest homelessness: words like “encampment,” “tent” and “shelter.” They then cross reference that list with a database of everyone in the county who has experienced homelessness in the past five years — itself a bespoke repository that draws on the agency’s healthcare data and records from the county’s shelter and homeless assistance programs. To capture anyone they might miss, they cull information from service providers, media accounts and a public online portal for submitting tips about deaths.

Since they began tracking homeless mortality, the team has traced an 80% increase in the number of deaths, which rose from 195 in 2018 to 351 in 2022, the most recent year for which data was reported. Over the same period, homelessness in the county jumped by nearly the same amount — or 77% — from 5,496 people to 9,747.

Behind the numbers are snapshots of how and where people are dying. A body found in a car. An overdose at an encampment. People mangled by cars or trains; others charred. Modersbach finds the tableau at once unsurprising and shocking.

“We see the same inequities in our mortality data that are reflected in homelessness,” he said. Black people are overrepresented, comprising 48% of the unhoused population and accounting for 44% of the deaths — though they represent only 19% of deaths in the county’s general population.

People who are unhoused die at five times the rate of those with housing and do so more than two decades sooner — at an average age of 52.

The data shapes decisions

Most of the deaths could be prevented, said Amy Garlin, Medical Director for Alameda County Health Care for the Homeless.

“You could say almost all of these deaths are preventable if you go far enough upstream,” Garlin said.

The largest share, 44% of the deaths among the homeless population, were caused by acute or chronic medical conditions, like heart disease, cancer, diabetes and infections. Some of those appear to have been more immediately avoidable, Garlin said. “If these people had had medical care, they may not have died this year.”

At an encampment along East 12th Street in Oakland, Angel Gonzalez, 40, remembered the friends he’d known there who had died. An asthma attack claimed one, exposure another and a third succumbed to a fever. Though Gonzalez said he didn’t know what had caused the fever, he said people are often sick, and rat bites are common.

“Health-wise here, it’s bad,” he said.

There’s frequent violence, too. Gonzalez described a drive-by shooting that killed one friend and wounded others. But what claims most people in the camp, he and others said, is overdoses.

“The fentanyl is killing mostly everybody,” Gonzalez said, explaining that people unwittingly use fentanyl-laced meth or other drugs. “It’s kind of scary.”

The mortality data compiled by Modersbach’s team reflects this, with an alarming rate of overdose deaths among unhoused residents that is 44 times the general population’s. In response, they’ve expanded their harm reduction services, focusing on naloxone distribution and installing dispensers in shelters.

At the East 12th Street camp, Gonzalez pointed out a purple dispenser on the street corner. Though Modersbach’s team had not installed it, it still proved lifesaving, Gonzalez said, when a friend recently used one of the naloxone sprays to reverse an overdose.

Alameda County Healthcare for the Homeless received a grant from the Centers for Disease Control and Prevention in 2023 to fund overdose response, a key part of their strategy to reduce mortality, and Modersbach credits their data for helping them get it.

In Minnesota, the only state with a statewide robust system for tracking homeless mortality, public health officials took a similar approach. A report on deaths between 2017 and 2021 showed unhoused people in the state were 10 times more likely than the general population to die of an overdose. Shortly after that data was released in 2023, state lawmakers passed drug overdose prevention legislation that expanded harm reduction and housing programs for people experiencing homelessness, decriminalized drug paraphernalia — a first for the U.S. — and funded “safe recovery sites” that offer clean needles, fentanyl testing and will eventually offer supervised drug consumption.

“Having the data was really useful in making the case for some of those things, both with legislators and with the public and advocates,” said Josh Leopold, senior advisor on health, homelessness and housing at the Minnesota Department of Health.

Alameda County’s latest homeless mortality report is now prompting the team to focus on how to extend palliative care services to unhoused people with terminal illnesses. Garlin estimates almost one-fifth of those who died in 2022 would likely have been eligible for hospice care.

What’s next in the ‘labor of love’

Modersbach’s team is also working to automate the most tedious aspects of compiling the county’s homeless mortality report and aims to launch a public dashboard later this year that will make information available quarterly.

“The biggest challenge is that we do not have timely data that we can act upon more quickly because of the workarounds that we have to do to get an accurate count,” Modersbach said. “We’re almost always looking backwards.”

The county’s latest tally, for 2022, was released at the beginning of 2024.

Santa Cruz, San Diego, San Mateo, Sacramento, Los Angeles and San Francisco are among the counties with varying degrees of reporting on homeless deaths. In Santa Clara County, an early champion of this work, a public dashboard tracking homeless mortality is updated nightly. A spokesperson for the Medical Examiner’s Office credited its partnership with a third-party vendor with allowing it to return results so quickly. So far this year, the dashboard listed 51 deaths.

Across the country, about two dozen jurisdictions have homeless mortality reports that are issued with some regularity, according to DiPietro of the National Healthcare for the Homeless Council, which tracks these efforts. But because the reporting isn’t standardized, it’s difficult to draw comparisons between them, she said.

In California, despite the recent efforts to improve this tracking, limited resources will likely continue to hamper the reporting of homeless deaths. Since 2022, when the state added a field on death reports to indicate a person’s housing status, Modersbach has seen some evidence people are filling it out, but he worries many unhoused deaths will continue to go uncounted around the state because the funeral directors, coroners and physicians filling out the reports don’t often have the resources to determine whether someone was housed.

“This is a lonely, costly battle to just put all this information together, not a funded mandate,” he said. “It’s kind of a labor of love.”

In counties with well-established systems for tracking these deaths, Modersbach hopes AB 271, by Assemblymember Sharon Quirk-Silva (D-La Palma), will make a difference. The new law allows counties to create homeless death review committees and access sensitive information about people who died. The data, which includes medical, mental health and criminal records, goes beyond what Modersbach and his team have so far been able to collect, giving them greater insight into the circumstances surrounding a person’s death.

Alameda County assembled its death review committee last year, bringing together officials from several county agencies, homeless service providers and formerly unhoused people with the aim of finding ways to keep more people experiencing homelessness alive.

“It’s just getting started,” Modersbach said, “but this is the future for us.”