On Tuesday, for the fifth time this year, Kaia Sand hosted a memorial in her office.

This week, it was for a man named Brantley Field, who used to be a vendor for Street Roots, the homeless advocacy nonprofit Sand runs. Staff ordered donuts, lit candles and displayed pictures of Field in cardboard frames. Before that, the service was for a woman named Francine who liked to put on her makeup in the back room — an area that’s now been affectionately renamed “Francine’s beauty parlor.”

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“If you work with people who are unhoused you end up taking on what it means to memorialize their death.” Sand said. “This is a part of our work.”

Since 2012, Multnomah County, with the assistance of Street Roots, has been using records from the medical examiner’s office to determine just how many homeless individuals die within the jurisdiction each year. This Wednesday, the county released its numbers for 2018.

The final tally is the highest ever: 92 homeless people died last year, nearly double the death toll released in 2012, when the county started keeping track.

Drugs — usually methamphetamines or opioids — and alcohol contributed to more than half of the deaths, according to the report. Ten of the people had been murdered, up from four the year prior. Nine died by suicide, the report found.

To Sand, the fact that so many deaths were connected with substances came as no surprise. At Street Roots, she said she regularly sees people medicating to bear the trauma of living on the street, often using meth to stay alert after dark.

She said she found it shocking that that so many deaths were violent, though.

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“I could feel it,” she said. “People end up getting beat up in their sleep with objects. ... They’re treated really badly out there.”

Paul Lewis, who has spearheaded the report for the last eight years as a health officer for the county, said this year’s death toll, like the years preceding it, is almost certainly an underestimate.

For this report, investigators combed through all the deaths in 2018 where the county’s medical examiner marked the person as homeless. They then weeded out all of the deaths where they couldn’t confirm the person’s housing status or the person seemed to be living on the streets outside of Multnomah County. Any deaths that don’t come through the medical examiner’s office go uncounted in the report.

Lewis said 92 deaths is “the minimum number but a solid number.”

Still, he said, that the minimum number is far too high.

“There are too many, too young, and they’re preventable,” he said. “These are things in your heart, you think, this shouldn’t be happening.”

The report found people on the streets died, on average, in their 40s. Two-fifths died of what the report classifies as “accidental” causes, mainly related to drugs or alcohol. A little more than a third died of “natural” causes, often uncontrolled diabetes and complications from chronic substance use. Two died from hypothermia.

Lewis said he was struck that a third of all deaths were connected to methamphetamines. Just a few years ago, he said, heroin was the most commonly used drug.

In a statement, Andy Mendenhall, Central City Concern's chief medical officer, warned against the dangers inherent with meth, which he said is “cheaper and more pure than ever.”

“When we’re talking about methamphetamines, you see death from a variety of causes,” he said. “Stroke, heart attack, arrhythmia. And that’s in addition to any of the traumas that result from becoming acutely psychotic. Once you’re under the influence of methamphetamines, you are no longer of sound mind.”

At least 530 people have died on the streets of Multnomah County since 2011, according to the report.