On Tomorrow Global, when we talk about tomorrow, we – of course – aren’t literally talking about the day that will come after today.  We’re talking about a bigger, broader tomorrow: the months, years and decades that will come after this, and what global health development will have to do to keep pace with the changing environment.

But in this post, let’s take a moment to discuss one group of people for whom tomorrow can pose very real, life-threatening problems: individuals experiencing homelessness.  For the world’s homeless populations, tomorrow may mean the challenge of where to sleep, how to secure even the most basic of nutrients, how to deal with pressing health problems that have long gone untreated.  While being homeless can look quite different around the world, the challenges for health programming can be remarkably similar.

Considering the issue of health and homelessness always brings to mind  Maslow’s hierarchy of needs, which describes levels of motivation that individuals experience and use to establish priorities in their lives.  In the traditional hierarchy, the bottom of the pyramid deals with the priorities of basic physical safety, while the top of the pyramid – the last level of motivation – contains items of self-actualization; the point is, we’ll worry about all of our most basic survival needs before we worry about the more complex needs that make us healthier, happier people.

Because I often view things from an HIV lens, I’m partial to an adapted version of the hierarchy, which places HIV at the very pinacle.  It’s a reminder that individuals will address almost all other needs – basic safety, shelter, food, health needs including addiction, etc – before they will think about HIV.  In other words, sometimes HIV diagnosed 5 years from now just doesn’t seem that important, compared to the violence/hunger/drug withdrawal/drug overdose that an individual might face tomorrow.

This same line of logic has been used by PEPFAR and others to address poverty and provide for basic needs for some groups at risk for HIV, including orphans and vulnerable children in sub-Saharan Africa – in fact, efforts in this area are being redoubled and strengthened.  However, the issue of highly vulnerable adults – and even adolescents – sits in a black hole of programming.  Targeted interventions may address discrete HIV prevention needs (such as condoms, clean injecting equipment), but no large scale efforts are made to address the basic needs of many most at risk populations, who often experience homelessness and housing instability.

So the questions are many:

1. When we’re planning interventions to assure that the coming generations experience healthier, happier lives, how do we bring our concept of tomorrow in line with that of the world’s most vulnerable?  How do we structure our global health development policy to address some of the short-term needs (shelter, food, security from violence) that prevent people from considering their long-term health future?

2. If we get our policy in line, what interventions do we use?  Who has done this successfully, and where?  Can some lessons from high income countries be applied to low and middle income countries?

3. In the ever-defensive world of donor-driven programming, how do we prove impact of any programming that addresses homelessness and basic needs?  How do we show that alleviation of shelter concerns leads to increased attention to HIV infection?

**Please stay tuned for Parts II & III of this piece for answers to these questions!**