Editor’s Note: This is the first of three parts.

More than 400 homeless people have died on Oahu in the past eight years, a Civil Beat review of medical examiner’s death records has found.

Nearly once a week on average, the body of a homeless person is wheeled into the Honolulu morgue for investigators to verify who they were and how they died.

Some passed away in hospitals under the watchful eyes of doctors and nurses. Others were found on beaches, at bus stops and in backyards.

In July alone, at least eight homeless people lost their lives on the streets of Honolulu, including two who were murdered and another whose body was found on the concrete porch of St. Mary’s Episcopal Church on King Street.

But officials say there are likely many more, because not every homeless person ends up in the city morgue.

More than 400 homeless people have died on Oahu in recent years, their bodies taken to the Honolulu city morgue for identification and investigation into the cause of death.

Cory Lum / Civil Beat

The data shows that about one-third died of natural causes, such as heart disease and pneumonia. More often the homeless met desperate, lonely ends punctuated by violence, addiction and mental illness.

Drugs and alcohol were the biggest killers of the city’s homeless, but suicide and murder were also frequent causes of death.

“It’s not an easy life,” said John Lozier, executive director for the National Health Care for the Homeless Council. “It’s a very hard life, and certainly not one that people really choose.”

“People die of things that are preventable and they die because of the exposures on the streets that make the conditions they arrived there with much worse.” — John Lozier, National Health Care for the Homeless Council

Studies show that the homeless — no matter the city, state or country they live — have a higher risk of dying than the general population. Their life expectancy is closer to 50, about 30 years less than the national average.

But Lozier is one of many experts who believe high death rates among the homeless can be reduced.

His organization, which pushes for increased access to health care for the homeless, stresses that placing people in permanent, stable homes is the most effective way of treating conditions that might have led to a life outdoors in the first place.

Once you put someone in a home, many of the threats of living on the streets can be mitigated. Social workers can do house calls instead of waiting for someone to walk through their door, violence is more easily avoided and the innocuous cut that can turn into a nasty infection is more easily treated.

“Homeless mortality reflects the general level of poor health that homeless people suffer,” Lozier said. “People die of things that are preventable and they die because of the exposures on the streets that make the conditions they arrived there with much worse.”

Death, Drugs and Disease

Civil Beat obtained eight years of homeless death records through a public information request to the Honolulu Medical Examiner Department, and logged them into a database for analysis.

The records included the names of the dead along with the suspected cause of death and a brief description of where the bodies were found.

The data shows that at least 417 homeless people died on Oahu from March 2006 to July 2014, including four infants and a preschooler who was run over by a drunk driver in 2012.

According to the most recent data from the U.S. Department of Housing and Urban Development, there were 4,712 homeless living on Oahu in 2014.

While most of the dead were white and predominantly male, there was also a disproportionate number of people identified as Native Hawaiian.

Honolulu’s homeless died at the average age of 50, the same as they do nationally. Nearly 60 percent of all the deaths, or about 246, occurred among those ages 40 to 59.

Drugs and alcohol were contributors to the most deaths, playing a role in at least 142 cases. Methamphetamine, a contributing factor in 67 deaths, was the drug most frequently identified.

Medical examiners attributed an additional 44 deaths to opiates, such as heroin, morphine and oxycodone. Alcohol was at least partially to blame for 26 deaths, mostly due to long-term abuse.

At least 55 deaths were suicides, another 22 were classified as homicides. Sixteen people were run over by cars, sometimes while on their bicycles.

Heart disease and other cardiovascular complications were by far the leading causes of death for the 139 people who died of natural causes, killing more than half.

‘No Local Address’

The Honolulu Medical Examiner Department began logging homeless deaths in 2006, but only for individuals who came through the morgue for an investigation or autopsy.

For example, if someone was in the hospital and died of natural causes it wouldn’t necessarily be reported because the attending physician would sign off on the death certificate.

While it can be difficult to classify who is homeless, medical examiners often consider a wide range of factors before making a determination.

Often they use information gleaned from family, friends or medical care providers unless there are other circumstances that make it obvious an individual was homeless.

The system labels the file with “No Local Address.” It’s the same phrase used by the Honolulu Police Department when someone is homeless or refuses to provide residency information.

Sometimes the homeless die in jail or while receiving treatment at the state’s only public mental health facility, the Hawaii State Hospital in Kaneohe. Records show at least five cases of the homeless dying in jail or at the State Hospital since 2006. At least six people died in shelters or transitional homes.

Often their names are known, perhaps because they had identification or were known to someone in the neighborhood where they wandered the streets.

On rare occasions a homeless person’s body can’t be identified. It’s only happened twice since 2006, according to the data — both occurrences were this year.

‘It Helps Inform Our Thinking’

While Honolulu tracks homeless deaths, homeless advocates and program managers say the information is not widely shared or used for any substantive reason, unlike some other major metropolitan areas with large homeless populations.

Many cities — including Seattle, New York and San Francisco — have used homeless death data to better understand the causes and consequences of homelessness and how best to serve the population.

Boston undertook long-range studies that tracked homeless mortality from 1988 to 1993, and again from 2003 to 2008. Officials found that the leading cause of death shifted from HIV and AIDS to drug overdoses caused by prescription painkillers and heroin.

“A lot of the deaths are due to drug use, mental illness and violence, all of which we consider preventable.” — Paul Lewis, health officer, Multnomah County, Oregon.

This prompted homeless health care providers to reevaluate how they treated patients, especially when it came to prescribing painkillers.

Multnomah County, Oregon, which includes Portland, recently began preparing its own annual reports to get a better handle on the challenges facing its homeless population.

The reports, called “Domicile Unknown,” rely on data similar to that collected by the Honolulu Medical Examiner Department. The reports are the result of a partnership between the county and a nonprofit newspaper that assists the homeless.

Interim Multnomah County Health Officer Paul Lewis said the reports provide only a glimpse into illness and suffering on the streets. But the analyses also help show where the system is failing.

“It helps inform our thinking,” Lewis said. “A lot of the deaths are due to drug use, mental illness and violence, all of which we consider preventable.”

The Need to Get Indoors

A common theme in the Multnomah County reports — as well as studies in other cities — is the need for permanent, supportive housing. It’s easier to provide people with services, such as substance abuse treatment and mental health care, if they have a place to live.

Advocates for the homeless say Honolulu falls short when it comes to helping people find housing, although plans are in the works to improve the situation.

Both Gov. Neil Abercrombie and Mayor Kirk Caldwell have made homelessness a priority, and funding has been made available to implement housing programs that aim to get some of the state’s most visible and troubled homeless off the streets.

In Honolulu, the mayor and City Council have put in place controversial prohibitions on sitting or lying on sidewalks in an attempt to discourage people from living outdoors in public places. Caldwell has also stepped up the city’s enforcement of its stored property ordinance to seize the personal belongings of the homeless who are living on the sidewalks.

“All of our data tells us that the streets substantially shorten a person’s life.” — Colin Kippen, Hawaii’s homelessness coordinator

Colin Kippen is the state’s homelessness coordinator. He’s charged with organizing the efforts of government and service providers to improve the current state of affairs. Hawaii has the second highest rate of homelessness in the nation.

Kippen is a big believer in the Housing First model, considered a national best practice to get people off the streets.

But he also talks of the importance of providing immediate aid to people who are newly homeless. The hope is to get them living indoors as quickly as possible so they don’t become entrenched in a lifestyle that can quickly turn deadly.

“All of our data tells us that the streets substantially shorten a person’s life,” Kippen said. “Living on the streets has a negative impact on all health indicators.”

Hawaii must become more adept at “triaging” the state’s homeless, he said. This is particularly true of the segment of the population that he considers most vulnerable, and in need of permanent housing.

People in that group have a median age of 61, Kippen said, and have lived on the streets for at least eight years. Many also have underlying medical concerns, including mental illness and addiction to drugs or alcohol.

“The ultimate measure of a person’s health is whether they survive,” Kippen said. “And these folks are having a difficult time surviving.”

Coming Thursday: Medical care can be a serious problem for Honolulu’s homeless.