Homelessness is both a public health issue and a deeply troubling sign of policy failures in a rich country such as the US. Yet what are the right ways to respond, both in the moment and on a larger scale?
In early November, the American Public Health Association (APHA) gathered for our annual meeting at the convention center in downtown Philadelphia. The area was alive with retail, industry, and nightlife. However, the effects of poverty in urban America were also on full display, with dozens of people – men and women, young and old – sleeping on the streets all around the convention center.
It is always a heartbreaking sight. Being a past chair of the APHA’s Caucus on Homelessness, I was asked for my thoughts on the issue. Some people wanted to know why they were there. Others wanted to know how they should react or what they could do to help. Although I don’t have all the answers, this post is an attempt to answer those questions.
Homelessness in Philadelphia, PA
Philadelphia has recently decriminalized the experience of homelessness and no longer arrests people for victimless behaviors like sitting and sleeping in public (although urination/defecation is still illegal, despite the fact that public restrooms are rarely available). The city also spends a lot of resources to provide affordable permanent or transitional housing, night and day shelters, and case management services for those in homelessness.
Philly’s permanent supportive housing programs boast an overall 90% success rate in preventing return to homelessness, which is impressive given how difficult the transition can be for some. In fact, of the ~5,700 individuals counted last January, only about 950 were unsheltered – giving Philadelphia the distinction of having the fewest number of unsheltered, or “street homeless”, individuals per-capita in the US.
Homelessness: The National Picture
Figure 1. Affordable rental homes per 100 extremely low-income renter households, by state (National Low Income Housing Coalition, 2019)
The majority of Americans consider homelessness a serious and growing problem in their community. They are likely to express compassion for homeless individuals and endorse external factors as causes of the condition. Three-quarters of survey respondents feel that the federal government should dedicate more funds to the issue, but a majority “rarely or never” donate to people when asked for money [PDF]. There are also clear differences between causes of homelessness suggested by the general public and those self-reported by individuals with lived experience [PDF].
Nationally, the number of homeless individuals has actually been trending downward (with the exception of 2017). Estimates by the US Dept. of Housing and Urban Development (HUD) place the point prevalence at <0.2% of the population.
However, the problem is getting worse on the west coast, with California now home to 47% of the unsheltered individuals in the US. Los Angeles alone comprises 19%, giving rise to the practice of street medicine. Up and down the West coast, vast resources are being directed at the problem at the same time as the affordable housing supply is vanishing.
Blaming the Victims
Homelessness is a dehumanizing experience. It inflicts lasting damage and trauma for those involved and it further isolates those who are being avoided.
People tend to respond to witnessing those in homelessness in one of two ways: turning away, or blaming those experiencing homelessness for their circumstance in order to reconcile our emotional reactions. This is a natural reaction to avoid confronting anger or sadness. It is difficult to reconcile notions of American exceptionalism and our own good intentions with the magnitude of the problem homelessness in America presents.
We rationalize the existence of “those people” by presuming faults, such as laziness or weakness, in those members of the community that fall victim. Therefore, people are able to blame homelessness on those it affects because of widespread, implicit attitudes that justify those in poverty as ‘deserving’.
The good news is that several studies suggest that even brief, prosocial interactions with those in homelessness can lead to more positive attitudes.
Homelessness in Austin, TX
My hometown, the city of Austin, Texas is dealing with this issue in a major way, at a community-wide level. Austin is trying hard to increase the housing and service resources for those experiencing homelessness but has not made the same strides as other cities in Texas and across the country.
In June 2019 the city council lifted criminal penalties for behaviors associated with homelessness, including camping and loitering in public view. This led to a noticeable rise in the visibility of people in homelessness in our community, as individuals began to relocate their camping spaces into open view. The relative safety of camping out in the open and the lifted threat of punishment brought people out of the woods and into view. The anxiety around rising homelessness in the community grew rapidly, far beyond what those of us recommending decriminalization ever anticipated.
Of course, the number of individuals experiencing homelessness in Austin wasn’t what changed, it was their visibility. People did not like having to see their neighbors while they suffered… and they complained, loudly. City council meetings routinely became overwhelmed with protests and counter-protests. The community became divided and the state government (Austin being the capital) is now trading shots with our mayor over the best path forward.
Now, service providers and advocates are playing catch up, working hard to correct the misconceptions stemming from poor communication about the decision ahead of time. Most recently, one of the fantastic providers on the street medicine team in Austin wrote an open letter to our community to remind us that there are people behind the homelessness experience that we see on the side of the road.
A Better Way
I have three personal recommendations for how to witness and interact with homelessness:
- Do not turn away. Attempting to ignore homelessness only supports the downward spiral of community experience. It has the simultaneous effect of numbing the witness and further isolating the person avoided. It lays one more brick in the wall that divides those experiencing homelessness from the rest of the community.
- Engage with the individual as a person. Action stemming from a recognition of the humanity in those who are homeless can be healing for both parties involved. I can also tell you it makes a difference to people who are not always regarded in that way, precisely because not everyone does. Treating someone with respect can be as simple as a nod or making casual eye contact.
- Act from a place of compassion. You can keep water bottles in your car, or hand out small donations (socks are a vital public health intervention in this instance). You can contribute financially. Or you can simply take time to ask them questions, talk to them about their day, the weather, whatever.
Beyond the three points above, I would point to this very practical list of what to try and what to avoid. If you aren’t available for a conversation, eye contact and a simple wave can still make for a real, human-to-human interaction.
Solutions
A recent post here at The Medical Care Blog reported on the disproportionate costs to society from homelessness – including how individuals in this condition disproportionately use health care, behavioral health care, social, and criminal justice services. At the same time, approaches are emerging that help provide housing and reduce overall costs. As a society, we are finally learning what works to end homelessness, and those lessons are disseminating across the country.
In 2017, the APHA approved a policy (which I co-authored) declaring housing and homelessness to be a significant public health issue. That policy called for wide implementation of the ‘Housing First’ model, broad increases to affordable housing, and services to help people recover from homelessness, such as income supports and job training. It also called for communities to decriminalize the behaviors that accompany the experience of homelessness, such as sitting on sidewalks and sleeping in public, as a means to lower the barriers to ending homelessness.
Medical Care has an open call for submissions to a special issue on multimorbidity and psychosocial factors among individuals experiencing homelessness (Deadline is March 15, 2020). If interested, please submit your paper through Medical Care’s online submission system, select the article type “Issue on Multimorbidity Among Homeless Populations,” and please indicate in the cover letter that the paper is to be considered for this special issue [See the Call for Submissions here: PDF].
Ben King