The Center of the Storm: Homelessness and Health

by Margot Kushel, MD

As the Bay Area is deluged with the biggest rainstorm in a decade, most of the region’s schools were cancelled and many workplaces allowed for flexibility, so that people could stay safe and dry in their homes. Churches and homeless service agencies opened their doors to provide temporary shelter for members of our community who are homeless. But the storm of the decade was another blow to those who have already been struck by the perfect storm of rising housing prices, loss of support for affordable housing, and lack of availability of living wage jobs for those without specialized skills.  

Evictions have been in the news a lot with stories of longtime residents, often elderly, being evicted from their apartments with nowhere to go.   The Bay Area is experiencing a more extreme version of what is seen throughout the country:  rents are rising at much faster rates than income and the supply of affordable housing and housing subsidies aren’t able to match the need. We are seeing larger proportions of people spending an unsustainable 50% of their income on rent, leading to severe stresses on other expenses and a high risk of homelessness. The housing trends are disproportionately affecting older Americans who have high rates of unemployment and/or fixed incomes that can’t keep up with housing prices.  With a huge mismatch between housing needs and affordable housing/subsidies, these trends show no signs of abating. In the Bay Area, with our tech-boom related gentrification, we are at the center of the storm.

This isn’t news to any of us who practice at San Francisco General.  It is rare for me to get through a half day of clinic without having at least one of my (generally older) patients tell me that he or she is at imminent risk of losing housing.  I ask about housing at every visit because I know that it is hard for my patients to concentrate on much else when they are worried about what will happen to their homes. And I ask because I know that losing one’s housing is catastrophic to one’s health.

The terrible effects of homelessness on health are well documented. Homelessness is stressful:  homeless individuals confront stigma and violence, and constantly must plan where to find their next meal, restroom, or place to sleep.   With severe food insecurity, difficulty obtaining and keeping medicines, and difficulty making, getting to and keeping medical appointments, homeless individuals have a near impossible task of trying to manage chronic illnesses.  The environment itself can be relentless:  in addition to being exposed to the elements, homeless individuals are at high risk of falling victim to violence.   Because homeless individuals have so little control of their environment, they experience high rates of unintentional injuries, including burns, falls and pedestrian injuries.  

All of these problems are compounded for older adults.  The homeless population is aging, with a median age of approximately 50. While 50 may not sound that old, we know that homeless people, by the age of 50, have health problems worse than those in their 70s and 80s.  With all of these challenges, it is not surprising that homelessness is associated with high rates of Emergency Department visits, inpatient hospitalizations and mortality.  Simply put, homelessness is devastating to people’s mental and physical health. 

I recently started taking care of a patient in her 80s who had just spent 3 months in a homeless shelter after having been evicted from the apartment that she had lived in for 30 years.  While homeless, her mild depression became incapacitating, she had severe incontinence, multiple falls, and her diabetes spiraled out of control.  Once she regained housing, I was able to do would do what I would for any elderly patient facing similar challenges.  I sent an occupational and physical therapist into her home and ordered durable medical equipment to help her reduce her risk of falling (she hasn’t fallen since), ordered a commode to help her toilet, arranged for wheels on meals to deliver healthy food to her home, engaged the help of a visiting nurse to help her get her diabetes under reasonable control, and collaborated with mental health colleagues to treat her depression (much better, now that she has housing).   Very little of this would have been possible while she was homeless.

The recognition of the negative effects of homelessness on health led to the development of an effective intervention to address chronic homelessness.  Housing First Permanent Supportive Housing (HF-PSH), pioneered in a few cities (including San Francisco) has been recognized by the US Interagency Council on Homeless as the primary strategy for ending chronic homelessness.   Chronic homelessness, (homeless for at least a year, or four of more episodes in the prior three years) affects a small segment of the homeless population; estimates are that approximately 20% of those who experience homelessness become chronically homeless, but a relatively large proportion of those who are homeless at any given time.  These individuals face the most severe challenges—they are the most likely to have high rates of substance use and mental health disorders as well as physical health problems—and are most likely to benefit from PSH. PSH is subsidized housing with on-site or closely linked supportive services. “Housing First” means that individuals are housed without preconditions such as sobriety.   Housing First PSH understands that it is difficult to treat someone’s mental health, substance use or physical health needs while they are living on the street.  Housing first has been remarkably successful; while expensive, much of the costs can be offset by decreased need for institutional care. The dramatic expansion of HF-PSH over the last five years has led to a decrease in the number of chronically homeless people in the US between 2010 and 2013. 

Yet, HF PSH was not designed for people like my 80-something year old patient who became homeless because of the extraordinary rise in the price of housing in San Francisco.  Thanks to PSH, we have seen some real successes in confronting chronic homelessness, but rates of new homelessness are wiping out many of the gains we should be seeing.  In a study my group is doing on homeless adults aged 50 and older in Oakland, CA, we have found that 41% of the participants first experienced homelessness in their 50s, 60s or 70s, suggesting that these individuals did not have lifelong chronic disabling conditions common amongst many of the chronically homeless.  But, for these individuals, even short episodes of homelessness are devastating to health.  In our city, when older people get evicted, they often wind up on the streets.  Once they are on the streets, all the things that we try to do for older patients to keep them safe stop working.  Nothing in my armamentarium is strong enough to overcome the overwhelming negative health effects of homelessness.

I wish that I could prescribe housing, as easily as I can prescribe a front wheeled walker or a blood pressure pill. But I can’t.  Small steps, like having an onsite medical-legal partnership would allow us to directly refer patients at risk of losing housing to lawyers to access possible legal remedies. But, fundamentally, what we need is a better match between the cost of housing and income, and housing protections for vulnerable individuals.  It won’t be easy (if it were, it would have been done), but I have to believe that if everyone could see what we who work in the safety net do—that the housing crisis is taking a major toll on the health of our community-- there would be more political will to seek a solution.   Health care providers can’t and won’t have the answers to this complicated problem, but we do have front row seats from which to watch the crisis unfold.  And, because of that, we have a responsibility to speak out about the devastating effects that the housing crisis is having on our patients’ health. Healthcare providers played major roles in advocating for and designing Housing First Permanent Supportive Housing interventions to end chronic homelessness.  In the Bay Area, we are sitting in the center of a housing storm that is affecting many throughout the country.  It is time for us to tell everyone what we know:  that it is impossible to keep people healthy and safe while homeless and that the toll of even short episodes of homelessness is unacceptably high.  For our patients, affordable housing is the best medicine.