It’s estimated that half a million Americans are experiencing homelessness. Even a brief period of housing insecurity can make existing health issues worse, and bring up new physical and mental traumas. Doctors and nurses who help patients navigate these issues have a prescription: More housing, and more services. Is it possible to end chronic homelessness, even as eviction moratoriums end and rents increase? And is a housing-first model the best way to achieve that goal?
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Ana Rausch, Vice President of Program Operations at Coalition for the Homeless of Houston/Harris County
Kimberley Richardson, therapist
Maggie Sullivan, family nurse practitioner, Boston Health Care for the Homeless and instructor and human rights fellow, FXB Center, Harvard University
Host/producer: Anna Fisher-Pinkert
The Better Off team: Kristen Dweck, Elizabeth Gunner, Pamela Reynoso, Stephanie Simon, and Ben Wallace
Audio engineering and sound design: Kevin O’Connell
Additional research: Kate Becker
Special thanks to Jim O’Connell, president of Boston Health Care for the Homeless
Anna Fisher-Pinkert: From the Harvard T.H. Chan School of Public Health, this is Better Off. A podcast about the biggest public health problems we face today. . .
Kimberley Richardson: I had so much anxiety. And I never had it that I knew of in my life until this, you know, this start of being homeless.
Anna Fisher-Pinkert: And the people innovating to create public health solutions.
Maggie Sullivan: Being able to ask and answer personal, sensitive questions, even being able to disclose “I’m sleeping in my car,” or “I haven’t eaten since yesterday,” that takes a high amount of trust. And trust requires a sense of safety.
Anna Fisher-Pinkert: I’m your host, Anna Fisher-Pinkert.
This season on Better Off, we’ve been talking about what it means to create a healthy home. But for many Americans, home is out of reach. According to a single-night census in 2020, roughly 580,000 Americans experience homelessness on a given night. Homelessness in the U.S. has been on the rise since 2016. And now as the last pandemic era eviction moratoriums come to an end, and the prices of gas and food continue to rise, experts are worried that even more people are at risk of becoming homeless.
Homelessness is such an enormous issue with so many intersecting parts, it can seem like there are no realistic solutions. But what if we didn’t treat it that way? Is it possible to provide everyone with a healthy home?
In a moment, we’re going to talk about one city that has had remarkable success in tackling this problem, reducing homelessness by more than 60% over the last decade. But first, I wanted to understand the bigger picture of who’s at risk of becoming homeless in America. Maggie Sullivan is a family nurse practitioner who works at Boston Healthcare for the Homeless, and she’s also an instructor and fellow at the FXB Center for Health and Human Rights at Harvard University
Maggie Sullivan: I have the unique vantage point of getting to talk about it and teach on the topic, as well as being in clinical spaces with patients who are experiencing homelessness. People who are BIPOC-identifying individuals, so Black, indigenous, people of color, people also who are gay, lesbian, transgender, disproportionately experience homelessness compared to others.
Anna Fisher-Pinkert: While the majority of people experiencing homelessness are single adults, around a third are families, many with children. On a given night, tens of thousands of unaccompanied youth and young adults are homeless. Many people experiencing homelessness have had a long series of traumas even before they lose housing.
Maggie Sullivan: So, we know from studies that children who’d experienced adverse childhood events, so major events, whether loss of a parent, divorce, removal from the household because of family instability, foster care, that the higher the number of those adverse childhood events, the higher the likelihood of homelessness as an adult.
Anna Fisher-Pinkert: Homelessness itself puts people at more risk for physical and psychological violence. Which means that as a clinician, Maggie is constantly thinking about how she can create a sense of safety and security for her patients.
Maggie Sullivan: Being able to ask and answer personal, sensitive questions, even being able to disclose, “I’m sleeping in my car,” or “I haven’t eaten since yesterday,” that takes a high amount of trust. And trust requires a sense of safety.
Anna Fisher-Pinkert: But the most effective treatment for people experiencing homelessness would be preventing them from becoming unhoused in the first place.
Maggie Sullivan: As practitioners and advocates, we talk about trying to shorten the duration of exposure to homelessness to be as little as possible because it’s almost like exposing somebody to a high degree of illness or trauma. And so, the shorter that exposure can be, the better and the less traumatizing for the person.
Anna Fisher-Pinkert: Maggie introduced me to Kimberley Richardson who became homeless in the 1990s shortly after moving to Boston from Chicago.
Kimberley Richardson: I’m about eight months pregnant at this point. And I remember going to the pay phone, looking through, newspaper ads, looking for a place to live.
Anna Fisher-Pinkert: Kimberley, her husband, and her two older sons bounced between apartments of family or friends, squeezing into twin beds in tiny spaces.
Kimberley Richardson: And I was able to find an apartment in Dorchester above a pizza shop. I signed the lease the day I went into labor. It was infested. Rats, uh, not rats, but mice and roaches. It was really bad. And also, I really couldn’t afford it.
Anna Fisher-Pinkert: Around this time, Kimberley started having new and worrying health problems.
Kimberley Richardson: I remember not knowing what was happening with me, but going to the emergency room, like quite often with chest pains. And finally, I was diagnosed with anxiety and had to go on anti-anxiety medication and I had to stop breastfeeding my son because I, I had so much anxiety. And I never had it that I knew of in my life until this, you know, this start of being homeless, being pregnant, trying to figure out where I would go with my children.
Anna Fisher-Pinkert: When her landlord sold her Dorchester apartment, Kimberley and her family became homeless. Through Massachusetts Temporary Housing Assistance, she and her kids were put up in a hotel about an hour outside of Boston. Then later, they moved to a scattered site shelter, a kind of temporary housing meant for families with children. The shelter was in a neighborhood where she felt unsafe, and she was desperate to get out. So desperate she took an apartment that turned out to have even more problems
Kimberley Richardson: I remember one of my sons, he was afraid to use the restroom because soon as you go into the restroom, there were roaches everywhere and there were sometimes mice. He would sometimes use the bathroom on himself because he was afraid to go to the bathroom. Right so that was. . . and I, you know, I remember like yelling like, “you’re peeing the bed, like, what is that all about?” And later he said to me, “this is why.” No kids should be afraid to go to the restroom because of unhealthy living conditions.
Anna Fisher-Pinkert: Eventually Kimberley qualified for public housing in the wealthy enclave of Brookline, Massachusetts. In the intervening years she earned a master’s degree in social work, and now she does in-home and outpatient therapy. She’s also a Brookline town meeting member. When Kimberley hears people in her town resist affordable housing measures or complain about panhandlers, she thinks that they’ve forgotten that no one chooses to lose their home.
Kimberley Richardson: When we see people begging for change or they’re living on the streets and we treat them poorly, that person was probably a paycheck away from being homeless. We don’t know people’s stories, so we need to really, really stop being a society that’s so judgmental.
Anna Fisher-Pinkert: Ana Rausch vice-president for program operations at the Houston Coalition for the Homeless would agree.
Ana Rausch: It really bothers me when I hear people talk about how people that are homeless want to stay homeless. That is absolutely not true. And when I hear people saying, “How are we gonna solve this problem? Look, it’s, it’s marring my beautiful city.” I just want everybody to remember that these are human beings just like you and just like me. They were someone’s child when they were born. And so, something has happened to these individuals to get them to where they are.
Anna Fisher-Pinkert: The coalition in partnership with local government and nonprofits decided to take a very direct approach to addressing homelessness, a strategy called “housing first.”
Ana Rausch: So, the idea of around housing first is that you take that individual and you get them safe. You put them in an apartment or a house, wherever it may be. And then once they’re safe and they’re housed and they have clothes and they have a way to shower, and they have someplace where they can be private and not having to, you know, look over their shoulders, and they’re not feeling as vulnerable, then we can work with them to address all of those issues, whether it be employment, or mental health services, or physical health services, or substance use services.
Anna Fisher-Pinkert: To get access to housing, the Coalition does not require that people maintain sobriety or find a job. And the housing provided isn’t in a scatter site but a fair market rate apartment.
Ana Rausch: Since Hurricane Harvey, we’ve had a landlord engagement team on staff. And what they do is, their primary role is to go out and recruit landlords, that have market rate units to house our clients. So, they’re essentially the case managers for the landlords. They explain the process, they demystify the assumptions, and then we pay a landlord incentive fee for each client that is housed.
Anna Fisher-Pinkert: Ana says the landlord engagement team is key to overcoming those stereotypes around people experiencing homelessness.
Ana Rausch: So, if the individual has a criminal background of whatever it may be, if they have no income, zero income, and if they have multiple evictions on their records or even just one, then the, the landlord’s like, “Nope, I’m not gonna do it.” So, what our landlord engagement team does is they explain what it means to house someone that was formerly homeless.
Anna Fisher-Pinkert: In addition, each client is paired with a case manager who helps them address any issues that lead to homelessness, whether they need help finding work, getting mental health support, or addressing substance use disorder. For people who have recently become homeless the Coalition’s housing and supportive services last 12 to 24 months, with subsidies slowly decreasing over time as they are able to stabilize financially. For people who have experienced chronic homelessness the support is permanent.
Ana Rausch: Chronic homelessness means that someone has been on the streets, or emergency shelter, but most of them are on the streets for a long time, more than a year, a long, long time. And they have some kind of a disabling condition that prevents them from working and living independently. The success rate for permanent supportive housing here in our continuum of care in our community is over 96%. That means that individuals stay housed.
Anna Fisher-Pinkert: This housing first approach has netted dramatic results. Since 2011, the Houston Coalition for the Homeless has placed almost 26,000 people in permanent housing and has reduced homelessness by 63% in the Houston area. Houston and Harris County have invested hundreds of millions of dollars in this program, including $65 million from the city and the county dedicated specifically to increase housing access during the COVID-19 pandemic, and another $100 million pledged in 2022 to house more than 7,000 people over the next two years.
Ana Rausch: The success I believe that the coalition has had is really due to, it’s, it’s really Houston’s success. It’s our continuum of care’s success, not the Coalition’s success. We wouldn’t be able to do this without our partners. But it’s really about a shared vision of permanent housing with supportive services as the answer to homelessness.
Anna Fisher-Pinkert: Listening to Ana, it’s easy to start imagining every city following a housing-first model, and homelessness just disappearing. But Maggie Sullivan says that not every housing-first model is guaranteed to work.
Maggie Sullivan: A lot of it comes down to the details of how much support are people actually getting. How much outreach? How much case management? How much follow through? How much counseling or therapy supports? And the way that those are packaged together, tailored to the individual. And so, not all housing first models look the same because of that, ‘cause when you pop up the hood of housing first, there are really different nuts and bolts.
Anna Fisher-Pinkert: Maggie says that people who are unhoused need coordinated care from providers they can trust.
Maggie Sullivan: So, if it’s somebody who’s been chronically homeless, then they’re likely going to need more case management, behavioral health, perhaps substance use treatment in order to maintain housing and not just four walls around them. And the more tightly knit and coordinated those services are, the better the outcomes.
Anna Fisher-Pinkert: That said, Maggie does think that housing first represents a more person-centered approach than other models.
Maggie Sullivan: There’s other models where you have people meet these certain benchmarks and requirements and you have to do all of these things first before you “deserve” or get housing. When I have patients who are really struggling with alcohol use, and if that struggle has been happening for years and years and years, the idea that somebody does not deserve housing until they can maintain abstinence, I don’t find helpful.
Anna Fisher-Pinkert: For someone who has a history of trauma, even offering up a social security number or an address history could be a barrier to getting help.
Maggie Sullivan: If you are somebody who was in the foster care system a lot and you went from home to home, maybe you have difficulty trusting, maybe you have difficulty attaching. Maybe you are an immigrant and you come from someplace where disclosing sensitive or personal information could be used against you. It is recorded, it’s saved, it’s tracked. You don’t know what happens to that information.
Anna Fisher-Pinkert: People who don’t have government-issued IDs or who have criminal records often can’t get access to basic services.
Maggie Sullivan: You can’t get into emergency housing, you can’t get into Section 8. You can’t often access jobs. And so that, that is a whole other piece of the pie that makes it difficult to get out of an experience of homelessness.
Anna Fisher-Pinkert: In addition to lowering the barriers to get support, Maggie also thinks that people deserve choices in how they’re housed.
Maggie Sullivan: If you’re able to allow somebody choice: Would you like to be in a studio by yourself in a building where you don’t know anybody? Is that okay? Would you rather be in a congregate setting, where you have some sense of community and you can rely on some people around you, does that feel better? Would you rather be in a scattered site place that’s kind of out, you know, 25 miles from what you know? And maybe that’s the new slate start that you need. I think that everybody, most people, know themselves pretty well as to what they would prefer to try first.
Anna Fisher-Pinkert: Choice and location really matters, too. If the only low-cost or subsidized options are far from places where you can find a job, access health care or get support from friends and loved ones, then it will be that much harder to stay in that housing long-term.
Kimberley told me that when she was homeless, she felt she had to take whatever she could get, even if that meant an apartment where she felt unsafe. Even now living in public housing and Brookline, she feels her choices are limited. Recently, her now-adult daughter moved out and tried to make a life in Georgia. She wound up living out of her car and eventually asked if she could come back home to Kimberley.
Kimberley Richardson: And so, when I reached out to the housing manager and I said, “My daughter needs to move back home, can you add them back to my lease?” And it’s like, “No.” And I’m like, “What do you mean, no?” “Well, how long has she been gone?” “A year?” “Well, I don’t, I don’t see how, I don’t think they will do that.” I said, “My daughter is homeless. You need to do that.”
Anna Fisher-Pinkert: Eventually the housing manager agreed to let Kimberley’s daughter live in the apartment again, but this experience made Kimberley feel even more strongly that she wants to own her own home, so she can provide her children with a softer place to land.
Kimberley Richardson: It wouldn’t be like this if I had my own home. And like, “You come here, you live here, and you can save your money so that you can go find your own.” ‘Cause that’s what we should be able to do, right? But I can’t do that because this is not my house. And because everything costs so much, right? Don’t get me started about like not being able to access home, buying homes, ‘cause the dynamics would be different for me had my ancestors, my family, been able to do that when I was a kid.
Anna Fisher-Pinkert: Kimberley envisions a healthy home this way.
Kimberley Richardson: A healthy home is a place where when the doors close, and all the stress of life just goes away. Because this is your sanctuary, this is your peace. And a healthy home should be . . . you shouldn’t have to worry about mice and roaches, mold in your apartment. You shouldn’t have to worry about a high cost of rent because you can’t afford to be there.
Anna Fisher-Pinkert: Addressing homelessness isn’t just about four walls and a roof. It’s about community.
Maggie Sullivan: A healthy home incorporates at the core of it, a sense of belonging. Whether that means with children, with a partner, with your chosen family. Having a sense of belonging is something that is deeply felt and embodied that can help create a sense of health and safety.
Anna Fisher-Pinkert: It seems like the place to start when addressing homelessness is reframing the problem. Instead of asking why people are living on the street or in their cars, why don’t we ask where there is space for them within our communities? What can we provide to make our communities, places where people belong?
Thanks for listening to Better Off. We’re better off with our team: Kristen Dweck, Elizabeth Gunner, Stephanie Simon, Pamela Reynoso, and Ben Wallace. Audio engineering and sound designed by Kevin O’Connell. Additional research from Kate Becker. I’m host and producer Anna Fisher Pinkert. Thanks to our guests today: Maggie Sullivan, Ana Rausch and Kimberley Richardson. Special thanks to Jim O’Connell for sharing his expertise and valuable insights with us as we put together this podcast.
If you liked this episode, please visit our website, hsph.me/better-off. Also, please rate and review us on your favorite podcast app and tell your friends about the podcast, too. That’s it for this week. Thanks for listening.