Caring as Communities

Addressing Homelessness and Healthcare

December 11, 2020
Caring as Communities
Addressing Homelessness and Healthcare
Show Notes Transcript

The COVID-19 pandemic has highlighted shortcomings in our systemic approach to homelessness. Join Dr. Jim O'Connell, Founder of the Boston Health Care for the Homeless Program, and Bobby Watts, MPH, MS, CPH, and CEO, National Health Care for the Homeless Council as they discuss what needs to happen at local, state, and federal levels to better house and care for the health of these vulnerable individuals. CORRECTION:  At 44:44, the statistic should be "only one out of every four households that qualifies receives assistance."

Enrique Enguidanos

Welcome to Caring As Communities, a monthly podcast addressing social determinants of health. 

Today we’re fortunate to have two of the nation's leading speakers out there say on the issue of homelessness. Dr. Jim O’Connell, founder of the Boston Healthcare for the Homeless program, and Mr Bobby watts CEO of the National Healthcare for the Homeless Council. 

Bobby, Jim. Welcome, and thank you.

 

Jim O’Connell

It's great to be here. Thank you.

 

Enrique Enguidanos

You know I want to give our listeners just a little deeper insight into each of your work, so bear with me for a second, Jim. You are the founding physician and president of the Boston Healthcare for the Homeless program, which serves over 11,000 homeless individuals throughout the Boston region. 

Back in 1985, you helped establish the nation's first medical respite program for the homeless, you served as national program directors for projects with the Robert Wood Johnson Foundation in HUD, and you've been editor and publisher of several articles in major journals. Thank you for all of your work. 

Is there anything else you'd like to add either about your work or the Boston Healthcare for the Homeless program?

 

Jim O’Connell

No, I appreciate that kind introduction and the only thing I would add is that you know I'm working with one of it turns out to be 350 Healthcare for the Homeless programs, all of whom are represented by Avi. And so, I owe everything in our lives to this kind of national network of people really interested in caring for people. And so I can say formally, Bobby, thank you, and the National Healthcare for the Homeless Council for being our guiding light.

 

Enrique Enguidanos

Amen. Amen. And with that, Bobby. Thank you for your decades of work, your current role as board president of the National Healthcare for the Homeless council you've served as executive director of New York City's care for the homeless program. You've been instrumental in supporting HIV and Medicaid admissions in New York and have been a nationally recognized leader and advocate for homelessness for almost three decades now. Thank you for that work. 

Would you like to add any additional information or any other thoughts about the national health care for the homeless Council, before we launch into questions.

 

Bobby Watts

Yes, I would thank you and just to pick up where Kim started the council is just a wonderful community of Healthcare for the Homeless programs and medical respite programs around the country, it's just a loving sharing community where we share best practices, we are, we work with our patients. They are an integral part of the Council. We call them consumers and also have many of the programs across the country, and Boston Healthcare for the Homeless program and Jim. They were one of the very first programs, and we're just grateful for their service, and their leadership, and how everyone just works together and shares our successes. 

We also share our failures so we can shorten the learning curve for each other, not competing at all, they're extremely collaborative and I often say I never would have left New York, or my former agency for anything, but the council, and I'm honored to be here.

 

Enrique Enguidanos 

We are honored to have you both here and also honored for the work of all of your team students well. I want to start out with some data. 

Data from HUD from this year identified that we have almost 600,000 actually 570,000 individuals living in homelessness in the US, at this point in time, and perhaps equally, or even more concerning. Today, we have over 54,000 US families living in homelessness, and greater than 40% of our country's homeless are over 50 years old. Over 17% of our country's homeless are veterans. 

Bobby you've been doing this work now for decades. What are some of the trends you're seeing are the numbers of homelessness, increasing and are the risk of funner ability changing who are perhaps the most vulnerable amongst the homeless.

 

Bobby Watts

Thank you and they'll try to hit a few points, but still try to be succinct on the way I see both positive and negative trends over the 35 years. We're finding out there's a lot that works, we know that housing first works that we don't need to wait until someone is sober before putting them into housing but that we put them into housing and can address so many of their health care needs their mental health care needs. You have a lot of models that work, you know Supportive Housing Works. At the same time, um, we see that though we are putting more people into housing and helping them move from homelessness into housing, the number of people that are falling into homelessness, by and large, is increasing. And that really is due to a lack of affordable housing, or I would say of making housing affordable for poor people, as well as for mental health services and substance use disorder services. So, the answer of who's the most vulnerable is really hard to answer depending on your perspective you mentioned how many are children, and certainly we know that trauma can affect someone for life. So we really have to be concerned about that. 

We also know we have many people who have mental mental illness and substance use disorders, as well as really complex chronic health conditions and Jim was one of the pioneers and looking at what what precedes death, what are the conditions that put people at extreme risk which health conditions and so that's that's a quick answer both positive and negative trends and some thoughts about the most vulnerable.

 

Enrique Enguidanos

 Thank you Bobby; I appreciate that. Jim, I wanted to get your thoughts on the same question, but also perhaps you could elaborate. Bobby mentioned some terms, and I think most of our listeners would understand that but Housing First, and or supportive housing. Could you comment quickly on what those are and perhaps add your thoughts on how trends and homelessness might be changing?

 

Jim O’Connell

Certainly, we would start by you know underscoring everything he said but also one of the discouraging things for us that we are dealing with is that you know when bobby knight started in the 1980s and we actually true for this word homelessness which you know are underway with homelessness just in sort of in the early to mid 80s. We thought it was a temporary problem and we would figure out how to solve this and be out of our jobs and onto our regular Koreas, and much to our chagrin, you know, homelessness seems to be inexorably going up a little bit a little bit each year and we now see a worst problem in 2020, then we sort of 1985. So, we have a long way to go, even though I think I'll be underscored We know, we know what the directions are the solutions and housing first was very interesting for us because we're, I can certainly tell you for the first 1985 till 2004. 

Well, in my clinical life I care for people that are rough sleepers living outside, Boston, and that turns out to be a relatively small percentage of the population but a pretty, pretty complicated population, and we all saw almost none of them get housed during those first 25 years and then that was because to get into housing you had to you know go to detox and go to a mental health place get on medication, get sober prove to everybody that you were housing ready or housing worthy, and then down the line you would get in and for many of our folks that was an impossible journey. So housing first became like a gift from heaven. When it was shown pretty clearly by pathways in New York, we probably probably knows much better than any of us with a very mentally ill folks from, from the streets of New York City, people who've been out there for years, all over them according to an apartment brought them in, and then showered them with whatever services they may want or need. And that was shown to be incredibly successful, so it was give people the housing first and then bring in all of the things they need.

Afterwards, and we've been in the doing it in reverse we've been trying to bring all these services and at the end of all those services, maybe they were in the house. So it was, it has been a game changer for us throughout the country. And what we've learned is the key to housing first is not only the housing, but it's the support services. And I think the struggle that we have continued to have a struggle is twofold. One is it housing to scale has been very difficult to get. And second, once you get people into housing, providing those supportive services in whatever community alignment you choose is costly and needs to be consistent over many years. So, supporting people in certain housing is a, is a new challenge and we're all looking hard at that right now.

 

Enrique Enguidanos

Appreciate that. Bobby, the last two podcasts we did work on racial inequities in health care. And I'm wondering if you might be able to comment on the system, racial inequities. As far as the effects and consequences of homelessness.

 

Bobby Watts

Yes, I'll be glad to. and the most important thing to understand, with that question is that the way homelessness is pictured the way it exists in the United States would not exist except for structural racism. Right now African Americans make up 13% of the general population but over 40% of people are experiencing homelessness. And that's not an accident, that is the result of centuries, or and certainly decades of housing policy that intentionally segregated by race that intentionally denied African Americans the opportunity to accumulate wealth through home ownership, that forced African Americans into racial segregation and concentrated pockets of poverty. 

And we know that at least a study issued by someone at HUD of about 20 years ago, saw that segregation was in of itself, a driver of homelessness. So, we have to understand that. Homelessness at this scale does not happen by, it's not an individual it's not a matter of individuals weaknesses. It is a matter of societal weaknesses and we see such over representation among Native Americans among African Americans and other people of color among people experiencing homelessness, we have to understand that it’s not individual forces, these are social policies social forces that cause that. And if we're going to successfully in homelessness, we have to address racism, I believe.

 

Enrique Enguidanos

Thank you, Bobby. It is the latter part of today's session. I want to talk about things we might do moving forward and we will probably revisit that topic. Thank you. I do want to touch a little bit on COVID as its effect. Things CIM you've led whole efforts. Now through the onset and development of HIV, drug resistant TB Hep C on the streets, the opioid epidemic. How has COVID been different, both in the medical effects but also in issues such as employment and security and effects on issues such as Substance Abuse and Mental Health.

 

Jim O’Connell

Thank you for that question, I think, in saying an exuberant amen to what Bobby just said. COVID came upon us, and to no one's surprise, sort of magnified the inequities and the racial inequities in particular that we had been seeing for years when you try to care for homeless people. And I think most of us who have been engaged in trying to care for homeless people learned a long time ago that when you try to really focus on doing good health care for this particular very excluded, very stigmatized population, you learn the weaknesses in our healthcare system, and in our societal system really quickly, and studied COVID only magnified and I think showed much of the rest of the country what not only what homeless people have been going through, but what people who have been victims of structural racism and, and, and severe and persistent poverty, have been enduring for years. 

But COVID was an interesting challenge. We were sort of created in the crux of the crucible maybe of AIDS and TB between epidemics back in the 1980s and it was incredibly discouraging as a clinician, certainly as a doctor and nurse practitioner or nurse practitioners in that back in those days we barely knew what it was causing aids when we finally knew it was causing it as Bobby knows all too well we couldn't treat it and make virtually everybody died a very long slow death of opportunistic illnesses over several years, and we felt incredibly discouraged, but it did call us together as a community that we knew the only way we could take care of folks who was suffering from AIDS, was to be sure the specialists were working with the internist we're working with the shelters and we're working with the government and. And I think we've learned a lot in those days and I look around the country and most of the Healthcare for the Homeless programs that were there then are still part of those collaboratives that were set up in response to AIDS. So in many ways I think that COVID is calling us once again to work more closely with our communities. 

COVID is particularly difficult for us though because unlike aids and and to some degree, unlike TB. It has been spreading very easily throughout closed communities. So we in Boston, for example, as everyone else we dreaded the oncoming of the epidemic. we have a very sophisticated sophisticated shelter system in Boston, where 90, to 95% of all the adults in Boston who are homeless live in the shelters, and that's usually and we've shown lots of studies that show that if you live in the shelter you're four times less likely to die than someone who lives outside, particularly in our cold weather. So, generally speaking, the shelters have been life preserving while we're waiting for those folks to get the housing that they desperately need, but they are as a temperature it's sort of like the emergency room of the housing system. But when this epidemic came the first time we tested inside a shelter, we found that a third of everybody in the shelters in Boston was positive for COVID.

And that 90% of them had no symptoms whatsoever. So we were ablaze with a pandemic. That was spreading from person to person in close quarters, without even people being sick. So I think what that once again taught us is that while the shelters may be very good. They are not, they are not very, they're more deadly or more, what's the right word it dangerous in times of a communicable disease like that. So once again emphasize for everybody around the country that we really need. We need to get safer better, you know, housing, and public health measures for folks to take care of. And I kind of laugh now it's, it's, you know, it sounds trivial, but I remember when when our in my public health advocate, you know the measures are, you know, we're mask, fair enough but then social distancing isolating quarantining you know isolating when you've got the virus of quarantining when you've been exposed. But if you're one of 500 people living in a shelter, you can't do any of those things. And when you say wash your hands frequently that's nice but if there's only three sinks for 500 people they can't wash they have the right frequently. So we realized we had all the wrong public health structure for containing this and I hope that we're all learning now is that, you know, we are all you know we're all part of this together the homeless, the homeless folks in the shelters are part of our larger community and controlling this pandemic. 

It's going to be a community wide approach that's going to be one of our lessons. One of the interesting things I could share with you that you probably know already, but when we had these wonderful people at the Broad Institute at MIT and Harvard actually looked at the genomics of the spread around the shelters in Boston back in the spring. And it turned out that the strain of the virus that was going to the shelters, had come directly from the Biogen conference. So I was thinking, Well, you know, here's a conference for the highest level you can imagine. And where is that virus going straight into the shelter's of density so that no irony was lost on that and this is a virus that does not distinguish who's been sick, dignitize from who has not, but it clearly preys on those who are poor and impoverished and the victims of race.

 

Enrique Enguidanos 

As you were speaking it dawned on me that there were so many instances in which—with COVID—we were learning to fly the plane as it was in the air, as the saying goes, and Bobby I think your organization was was key to helping spread information successful information particularly early on as organizations like were having success or failures. I recall being on several COVID presentations that the council gave early on. Do you want to add anything to Jim's insight as far as COVID? And again, thanks for the work that Council has done throughout the pandemic. You touched a little bit on how we might identify things sooner. I'm thinking about prevention issues around homelessness and I'm struck by some August, 2020 census data that came out recently that suggest that, perhaps, up to 30 million Americans are going to be at risk of some form of eviction in the coming months due to a variety of issues loss of employment layoffs, eviction moratoriums—there's a potential tsunami of homelessness that we see coming on the horizon. Bobby I know we can't have an absolute answer for that but I'm just wondering if you have any thoughts on how we as a society can better anticipate homelessness, and perhaps even provide some better prevention.

 

Bobby Watts

Well you know one of the things that COVID has really underscored is that housing is healthcare for the first time in many cities. As Jim mentioned realized that putting vulnerable people in a congregate setting in the midst of of a pandemic was not good for them it's not good for the public's health and took really extraordinary measures and nice in the sense of unprecedented measures of moving people from shelters into individual motel rooms or setting up other areas in a part of an arena where people can be safe in space, taking people out of encampments where they can be safe, we even see that underscored by the CDC moratorium on evictions, think about that the premier public health agency in the, in the world, saying, to protect the public, we have to make sure people stay housed. So anything that is not making that link is so important and I think we will continue with that recognition least I certainly hope so. And some of the things that we've done for people experiencing homelessness through this pandemic should continue the things that we can do to prevent evictions should continue. And I hope this society that we will do that, that we will recognize housing as healthcare, that we end up for for contagious disease as Jim says does not discriminate from scientists at MIT and Harvard or someone sleeping on the street, that we're only as strong as the weakest person, and we all share the same hospital system health system. And if it's overstressed because we could have prevented things and we didn't, we will all suffer. Of course, poor people will suffer more, but you will, no one will be untouched.

 

Enrique Enguidanos 

Thank you, Bobby. The whole podcast next month is dedicated to going to use the term solutions on homelessness not that we've solved it but at least touching on certain communities that have provided innovative solutions. But when I think of today's what's worked, what we're using today I think of tours of long term housing Jim. I'm wondering if you might touch on what you see as current practices shelters respite care. How are we, addressing homelessness, currently as far as getting housing, getting folks in housing across our country most commonly.

 

Jim O’Connell

Sure enough, like, if you'll allow me to get into the habit of being a doctor taking care of a group of people. Then I think of healthcare and this is on that individual level of, you know, this is a population we're caring for that has an exquisite burden of CO occurring medical psychiatric and substance use issues. And the challenge and caring for them in a setting where they have no safe homes, and they are wandering the city exposed to all sorts of trauma extremes of weather etc. that you, it's a challenge to any system about how you would care for them. And what we've learned we lead by the way the leading cause of death. prior to the opioid epidemic can now be equally leading cause of death for folks is cancer. So when you think of, if you have cancer or anybody in your family has cancer, what do you need, you know, and that's the kind of stuff we're staying out of how do we make sure a homeless person has that. And it means good Specialty Care Access to chemotherapy, radiation surgery, all of that stuff.

So, one appeal we have when we look at it on an individual level is healthcare problems. People really require the best we have in health in our healthcare system. We need good hospitals, good emergency rooms, and then good rehab, etc. One failure in the continuum of care that has existed forever, and it was pointed out, we started our rescue program in 1985 in the corner of a shelter, because the homeless people that put our grant together with the mayor set were really angry with the doctors and the hospitals, because we'd admit somebody was very sick as soon as they're healthy enough to be able to walk, we would say no, you're gonna leave the hospital and ordinarily they go home with a family and supports and all that, but these are folks that were going back to the streets of the shelters. And so after major surgery after major and dimensions heart attacks, all of that, it wouldn't be back walking the streets and really Fred. So respite care was a homeless people pleasing to the system to say, Please let us go somewhere where we can be taken care of and Bobby and then the council, you know, have organized.

What I think is one of the most important things going is to try to get the government to pay attention to how respite care is a vital need in every city rock country, it's currently not paid for by Medicaid not paid for by Medicare, but it's an essential part of the continuum of care so I would say that's, you know, sitting there that was one of the, one of the needs that I think is really, really important. We now have 124 beds and sort of 24 hour respite care in Boston. And that's not even scratching the knee that we have so end of life care pre and post operative care chemotherapy recovering from pneumonia recovering from orthopedic injuries. Those are all things, almost people can't do. And in that setting, you can do is, Bobby in the Council have been so articulate about you can bring all sorts of other services to when they are in respite care, including better access to housing so it's a win win for everybody, but that doesn't exist around the country and we're really working with Bobby in the in the council to just bring that to people's consciousness. And then the other.  

The other thing I think of it would be my, my addition to what Bobby's saying as well I certainly think housing is healthcare. 

I'm worried that just plain old housing is not necessarily healthcare. And when I think about this COVID epidemic there's some interesting twist. So, the shelters were an astonishing thing so we have 3000 shelter beds and 1000 homeless people got killed during during that April during April May and June, and the only place in Massachusetts that at a higher rate of covid infection, was the city of Chelsea, which has almost no homeless people, but it has housing that is multi generational to crowded. It’s mostly failed public housing from the old days, so there is a real fear I have of that if we just say “housing,” we're going to miss it. It's the services and it's got to be safe housing, it's going to be housing it's done right. 

So, I don't want to think solutions to homelessness can be made without adequate housing, but I think we also need to be sure we add the support and other public health measures that we need. So we're really partnering with the pump house and everything else it's really housing first being supportive housing. We're worried that if we don't have that support, those people who are placed in housing will fall back into homelessness if they don't have that safety net. So that's one of our, you know, our bigger picture things on how healthcare is going to have to work closely with housing and closely with society.

 

Enrique Enguidanos

Thank you, Jim. As I hear you talking Is it fair to think of this as we can do very little without a roof over our head but the roof, without the wraparound services won't be as effective as it could have been Is that a fair summary.

 

Jim O’Connell

Yeah, and one of my, you know, when I think of my early life. I never forget doing logic like inspecting your high school. So I think now housing as an absolutely necessary but not sufficient part of the solution.

 

Enrique Enguidanos

I often find myself with the thought level about second year high school so I'm glad you was making me laugh itself for your life for all sorts of reasons.

I am glad you touched on the interaction between healthcare and homelessness. An article jumped out at me. Just recently, in the annals of emergency medicine article, October of this year, it was titled the homeless shelter entry in the year after an ED visit. And it was done out of a couple of emergency departments in inner city New York, where they found that 5% of emergency department patients that were that had homes had houses would within a year, become homeless, and it just dawned on me that we have to integrate, health care, healthcare, and homelessness, as far as finding solutions healthcare has to be part of that connectivity. Bobby, I'm wondering if you have any thoughts to add on to Jim's comments on the engagement between health care and homelessness.

 

Bobby Watts

Yes, I do. I piggyback off of the article that you cited—and that was by, you know, a wonderful team in New York and Kelly Duran is a really wonderful emergency room doctor and advocate for homelessness as the lead author of that.  

It was very interesting just reading parts of it that many of the people who were became homeless, they were not homeless at the time that they visited the emergency room but they had a prior history of homelessness, which speaks to the episodic nature and the tenuousness of housing when you're poor, and living in areas where rents are much higher than can be supported by someone working at the minimum wage. So we see people coming in and out of homelessness, a lot, and especially when there are health issues that can really precipitate a decline, and helping them fall out of the housing if that could mean that they are sick and they may have to miss some time at work, and just missing a paycheck or two can be all that is done, or they couldn't be there for a substance use disorder or mental health episode, which also could indicate that they are in distress and unless it's corrected they may not have the support they need. And I'm so glad Jim spoke about support to stay in touch in housing. 

One of the wonderful things about the Healthcare for the Homeless movement when it first started, was that it had to be interdisciplinary teams that had to treat the whole person, and that is still the framework and the bedrock today. So you have social workers love caseworkers health educators along with primary care physicians and hopefully linked in to specialists, but the whole idea is that we have to treat the whole person, and that is not the case in most of the medical system, and most of the healthcare system. You'll hear doctors, and I'm talking about well, they'll refer to a person as a body part that they operate on, but we really have to view the whole person, and healthcare when it's done right has an opportunity to do that to meet people if you need it. 

Bringing around the other services that are part of that team or, or linking them to the needed services. So, someone coming into the emergency room is obviously in distress, and that can be a really important way. And many emergency rooms are looking at taking leads into that, especially if they find someone who they know is homeless to link them up into care right right away. There are some pilots around the country that are doing that to help move people out of homelessness. And we can do a lot better as a healthcare system, we're doing a lot more on many of managed care organizations many hospital systems are investing in housing investing in medical respite because they see the importance of addressing the whole person and their social and their other determinants of health, but we need to do a lot better.

 

Enrique Enguidanos

Thank you for bringing that up Bobby. I do commend the emergency departments around the country, most of them will have social workers now available, and many have navigators that are already thinking about what to do with next steps and you think of the role of an emergency department we're there to address crises, but I do see that we're starting to recognize that we're all part of a bigger picture that needs to work together. 

I did want to get both of your thoughts on an issue before I move into, maybe a futuristic type. 

Next month I mentioned, we'll be talking about some, some solutions that have worked. But in today's world, you know when we're looking at long term housing options and even some shelters. I'm sure you both have found occasions where we struggle with zoning regulations or local and regional and and federal ordinances and you can community resistance to the building of housing options and I'm wondering if you can comment on that a little bit. Jim maybe, could you. Do you have any thoughts in that regard?

 

Jim O’Connell

I have pages of thoughts on this one and, you know, and it's probably, I should really bet it's probably much more Bobby's expertise. But, you know what I worry about. When I think about that and I, when you get into the discussion of solutions that we're very interested to see because I think there's a problem of urban inner city homelessness in a world where apartments is so expensive you can't possibly rent one, even if you're a couple working in a minimum wage job 40 days and you just can't do it. 

I think that this is the first time in our country's history that if you didn't work hard, 40 hours a week for a minimum wage and you couldn't afford an apartment in our major cities. 

There are many cities where we still can do that. But when I think of you know I think it's Bobby and helped me on this. Maybe 80% of all adult homeless live in the major metropolitan areas of LA, San Francisco, Seattle, Portland Boston, Chicago Philadelphia New York. And those are the cities where it is impossible now even with a good job to break into the housing market. And there I keep thinking, of course, people that don't have not been able to build up equity. But I worry that unless we change our attitudes in those cities, we will not be able to build affordable housing to the scale that we need to take care of our own folks. So, I'll give you an example when we looked around the country at how much it costs to build a unit of housing in San Francisco, or a unit of new housing in LA and Seattle. The average cost was somewhere around 400 to $700,000 per unit, by the time you've done all the zoning regulations, and consulted lawyers, and then built it. So that's just the bill for a unit in a building with about 50 units. So that's prohibitive. 

We can't live like that and solve the problem. So we have to change the zoning regulations, and lots and lots of rules and regulations about housing, we have to do that very carefully and really well, and that's where Bobby’s at. I know he knows we have a lot of work to do in fixing local biases against who can live in my neighborhood.

 

Enrique Enguidanos

Thank you, Jim, Bobby. Any thoughts.

 

Bobby Watts

Yeah. I happen to be in a small meeting with the governor of California where he wanted to talk about homelessness. And, you know, he said that he wants to respect local governments and city governments, but not to the point where it is denying people of a basic human right, or at least a basic need for housing. And I really think we have to understand that, that there are some things that in this day everyone around the world needs. And in this country, we are rich enough to afford it. And if we say we want to give people an opportunity, we say we're the land of opportunity people who have an equal shot. There's a certain baseline that, as a society, we have a responsibility to provide, and certainly basic, secure housing is one of them. 

The fact is that most homelessness is locally grown throughout the country in New York City. Most of the people who are experiencing homelessness, grew up in New York where they've lived there for several years.  

The same is true, by and large, for most of the country. So it really is reflective of us as a nation, don't we care for our neighbors. You know, what are we going to do to help to make sure that people have an opportunity to succeed to reach their potential. So, you know, and this is true throughout the country. We, my former agency operated a shelter in the Bronx, and most of the residents were going to come from the Bronx, but the community was opposed to it at first and we operated it, and by, you know, we did the right things, and then we were a good neighbor to the community and we were welcomed and then more than welcome. They really valued us, but there is a tendency to look at people who are down on their luck, people who have life controlling issues as not deserving basic shelter basic housing, and that has to change. I'm just putting ourselves, our family members in those shoes of we want to be treated.
 

Enrique Enguidanos

Thank you, Bobby. In fact, I want to build a little bit, I was going to move into next, what we might image as a future state, as we start looking at wrapping up today's session but I would be remiss if I didn't ask this question and Bobby I'm gonna ask you maybe to start out with it I hear often the term criminalization of homelessness and want to get both of your thoughts on that topic.

 

Bobby Watts

So I'll be brief but we make illegal things that are basic for human existence: eating, sleeping, going to the bathroom. 

For people who don't have homes in society, I will say society has not made housing affordable for them, they have to do that in public spaces, and then we say those things are against the law. And so they will get fined, they may get thrown into jail, that does absolutely nothing for the problem, it doesn't solve it, it actually makes it extremely worse. 

In some cases, recently, I believe that the Eighth Circuit, and I know it was Idaho, said that that was a violation of constitutional rights, if, if there are no shelters in that area. It's unconstitutional to penalize people for things that they need to do to exist—basic activities of living I think was the phrase—eating, sleeping, lying down. So it reflects a desire to just push the problem away instead of solving it. And hopefully we will have more enlightened communities that will help lead the way. 

 

Enrique Enguidanos

Thank you, Bobby. The work both of you do is helping us to move forward. Jim, any additional comments to move forward with what Bobby said? 

 

Jim O’Connell: 

Just a few. I think Bobby was quite eloquent in what he said. A practical example to illustrate: we have been trying to find out where the public bathrooms are that the homeless can go into. 

Before COVID, there were very few. Now, it's virtually impossible to find a place these individuals can go into and use the bathroom. 

We had a man, who recently passed away from cancer a few years ago, who had some misdemeanors for urinating in public. Somewhere along the line, it was demonized and considered "exposure." So he was picked up a few times for "exposure" and labeled as a sex offender, and so he spent his life until his death as a registered sex offender. And that's what happens when we don't have solutions. If we had solutions, he wouldn't be labeled as that, and he wouldn't have had to spend any time in jail. But that's an example of what Bobby is talking about.


Enrique Enguidanos:

In the last few minutes, I’d like to get your ideas on what an ideal community relationship would look like for you? Where can communities start to focus on early wins? What approaches have you found successful in targeting communities? 


Bobby Watts

Matthew Desmund in his work has talked about how disruptive, painful, and counterproductive it is whenever there is an eviction. New York has made a right to council in tenant court for tenants because they wanted to make sure every tenant had a right to an attorney. Often landlords would come with an attorney, and the tenant would not. Now tenants can have one as well.

This crisis, in its current form, is only twenty years old and it dates back to its former retreat at the federal level of making funding available for poor people. That funding decreased 77% from 1979 to 1982, and we’ve never come close to the level of where it was in real dollars since then.

The Biden administration plan is to make housing vouchers available for every household that qualifies. Right now, only one in four houses qualify. So I think that a base of stable housing is necessary—though not sufficient—in going a long way in addressing the homelessness crisis. Yes there’s still substance use disorder, mental health disorders, but at least these individuals can be housed and treated better than they would be in the shelter or on the street. 


Enrique Enguidanos

Thank you. Jim, I know you talked about wrap-around services for housing. Any additional thoughts?


Jim O’Connell

We are eternal optimists. I’d like to underscore what Bobby is saying by emphasizing that it starts with acknowledging that housing and healthcare are basic, human rights—no matter what they cost. Arguments about “saving money” make me nervous, because these are basic rights. 

If you can provide people with basic decent housing and the services they need—and some people won’t need any additional services, others will need many additional services—then I can see a solution coming down the line.

Two questions I have. When I look at solutions, I need to know the causes of homelessness. This is such a complicated program, and it requires a lot of serious examination. The solution is only going to come when we look at it at a university level. We need to get the schools involved to make them better, the businesses involved to make them better business opportunities and job opportunities for people. We need agriculture involved to fix the inaccuracies involved in food insecurity. And we need medical, nursing, and public health schools all in this together. And that’s the big challenge.

We’ve learned these things on individual levels—as organizations and social workers—but I can see that being multiplied throughout a community to improve how we provide consistent medical homes for these people.

The second and last question I have, with some lingering anger, is how the government got away from the role of building and providing low-income housing and subsidies. What I get nervous about as a doctor is when we’re taking care of people on the street, we’re trying to get them good insurance. Massachusetts has great insurance. BUT even in Massachusetts, Medicaid doesn’t pay for psychiatric care and very little dental care, and I see that money going toward housing, I wish it was coming from the federal government instead of our state Medicaids. Because we need those dollars in healthcare for mental health and substance use care to get these individuals the care they need. We should be complimenting each other, and I think that’s a fatal flaw in the way our system is set up right now. 


Enrique Enguidanos

Thank you Jim, and I want you to know that we at CBCS will join in the work you and Bobby have been leading for so long. 

I want to close with one more question. What can each of us do on an individual level to address homelessness on a day-to-day basis? 


Jim O’Connell

Yes, I can start with this. I think the solutions and guidance are in the National Homelessness Council. We should go to their website, learn what the issues are, and get involved.

And then the second part is when we see from Barbara Guiness, who pointed out to us that most homeless people live a life of abject isolation. In fact, one of the silver linings of the COVID epidemic was that it has helped the rest of the country see how isolated and stigmatized we homeless people are. They lack so much comfort and connection. So one of the things we can do when we pass them by on the street is to look them in the eye and acknowledge who they are, and that more than anything else (although money, coffee, etc does help) is the most important thing we can be doing. As we acknowledge them as human beings, it will be easier for us to recognize how courageous they’ve been at dealing with this forced hand. 


Bobby Watts

Jim has said a lot of what I would have said about caring on a personal level. And thank him for his plug for the council. Much of what we have, we only have because of organizations like his that are on the front lines sending us info. 

The other thing I would say is that, on a policy level—because we will not solve homelessness by treating patients or by putting individuals in houses—we need to change the policies that have created homelessness at the scale we have it now. Really advocate for your congress person to support more funding for housing for homeless people. That will really help people from falling into homelessness, which we have to do. 

So, care, support, and advocate. 


Enrique Enguidanos

We often ask our panelists for resources where listeners can go to learn more. I encourage you to take a look at the National Healthcare for the Homeless Council website and the myriad of suggestions and resources they have available. 

I can’t tell you how grateful I am, not only for the time you spent with us today, but for the decades of work you have put into helping address this issue. 


Jim O’Connell

Thank you for having us, and for bringing this to people’s consciousness because it is one of the most pressing societal issues we face today. 


Bobby

I’d also like to thank you for the work you do addressing the intersection of health and other needs. 


Enrique

Thank you—we’ll definitely have you back for additional podcasts. For our listeners, join us next month as we talk through some of the solutions that organizations are creating around the country for addressing homelessness, pero es todo para ahora—that’s it for now. We’ll see you next month!