Nearly two decades ago, Barbara DiPietro, Ph.D., was a special assistant doing policy work in the Maryland governor’s office. The issue of homelessness was becoming increasingly prioritized in the United States. The year was 2002, and former President W. Bush was asking states to develop 10-year plans to end homelessness. Dr. DiPietro and her colleagues responded by establishing an interagency council on homelessness through the governor’s office as an executive order. It was during this time that she realized how the issue of homelessness touches on every aspect of society, including “housing, healthcare, education, our corrections system, and transportation.” She became passionate about all of the public policies that could be changed to address homelessness and make a fundamental difference in people’s lives. “It felt really possible to do so.”
Today, Dr. DiPietro is the senior director of policy for the National Health Care for the Homeless Council and says what she knows now is that, without housing, the services communities try to deliver are less effective. “It’s that much harder for someone to experience stabilization when they are sleeping under a bridge, in a crowded shelter, or even in a transitional housing program that gives them a six-month deadline.” The mental health benefits that come from stable housing is the “platform that all other services should be built on.” Conversely, Dr. DiPietro says that living in a situation of homelessness is detrimental to a person’s overall well being. People often decompensate, both physically and mentally. They are also at higher risk of dying from an overdose. In fact, in a Boston study, participants experiencing homelessness were nine times more likely to die from an overdose than those living in stable housing. The vast majority of overdose deaths, 81%, among participants experiencing homelessness were a result of opioids. Dr. DiPietro says that’s why it’s become a priority for Health Care for the Homeless (HCH) programs, a segment of the community health center program funded out of HHS, to provide medication-assisted treatment (MAT). They serve 4% of health care program patients but provide 40% of MAT services. “Our clients disproportionately have opioid use disorder.” Fortunately, HCH programs are already integrated care models—including primary care, mental health, and addiction services—so MAT works well. “Providers for homeless populations are well poised to meet medication and support service needs, particularly when a person is in crisis. Averting an overdose needs to be our priority. We have to keep people alive.”
Chronic medical issues, such as diabetes, hypertension, and cardiovascular disease are common conditions in the United States, but they exist at heightened rates among people experiencing homelessness. If left untreated, these medical issues exacerbate mental health challenges. They can even create behaviors that look like mental health conditions but are, in fact, byproducts of deteriorating physical health. Furthermore, the experience of homelessness in itself is traumatic. “If you didn’t have mental health issues before, you’re probably going to have them after you become homeless.” Dr. DiPietro says this is, in part, because homelessness is highly stigmatized in the United States, which further dehumanizes people who may already be marginalized, but also because people who are homeless exist in a heightened state of survival. “They are living in crisis: uncertain where they are going to get their next meal, sleep, or find transportation to get to wherever they need to go.”
What society may perceive as a choice is not. For example, why a person doesn’t go to a shelter but sleeps outside on a cold night seems illogical. That is until examining the possible reasons for doing so, such as vulnerability and safety. “In some communities, people have a higher risk of assault or theft in a shelter than in a public space. They are making individualized decisions based on the resources that exist where they live.” Unfortunately, the threat of violence is part and parcel of the homeless experience, regardless if people are living on the street or going to a shelter. That means sleep deprivation is a daily, continual reality. “It’s tough to sleep in a shelter or in public spaces because of worry of harm. On the street, people also fear that a police officer will arrest them or tell them to move.” Sleep deprivation can exacerbate physical and mental health issues. While the general public often perceives homelessness as a choice, it comes with a tremendous lack of autonomy. That doesn’t just apply to finding the safest place to sleep but also a lack of food options. Soup kitchen, groups that distribute food, food pantries, and eating food out of trash cans or dumpster gives little choice. “Much of the food they have access to is high in salt and sugar, low in quality proteins, and absent of leafy greens. We shouldn’t wonder why they have frequent emergency room visits and hospitalizations.” She notes that this clashes against the concept of personal responsibility for our health esteemed in the United States. Without options, people experiencing homelessness can’t manage their diets, resulting in glaucoma and foot amputations. “People don’t have the choices we assume they do.”
In the United States, there are over 1.5 million kids K-12 who are homeless, which is a 15 percent increase from 2015 to 2018. Chapin Hall researchers at the University of Chicago found that 700,000 (1 in 30) youth ages 13-17 experience homelessness over a year, and 3.5 million (1 in 10) young adults ages 18-25 experience homelessness over that same period. The majority live with other families while others reside in shelters, motels or hotels, or are unsheltered and live in cars, abandoned buildings, on the street, or in substandard housing. Dr. DiPietro says schools are increasingly able to identify trauma and whether a child is homeless, but that neither can be looked at in isolation. “It isn’t just the child who is going through a crisis, so we must connect the whole family to an interagency pool of resources, including child welfare, healthcare services, the school system, and juvenile justice if they are involved. We need to come together to be able to do a family stabilization plan.”
The solution, says Dr. DiPietro, is not waiting until people are homeless and decompensate in both their physical and mental health before offering assistance. Instead, there should be coordinated care and housing stability. Not just for individuals but for their families. Childhood trauma is endemic among the adult patients Dr. DiPietro and her colleagues treat. Yet, nationwide, there is nominal support of families to ensure that they have stable housing. Housing can often mitigate other issues a family is experiencing, while not being able to pay rent or living under constant threat of eviction adds to the chaos. “Stability invites more stability, and the inverse is true. A 7-year-old whose family doesn’t receive adequate assistance becomes a 27-year-old tumbling into a dehumanized and stigmatized space where she doesn’t have access to any of the things she needs to pull her up into stability.”
The affordable housing crisis is increasing the risk of homelessness in the United States. There are 11 million households that spend more than half their income on rent, revealing a housing crisis with many families living just one step away from homelessness. “It can be one illness, an extra cold winter and high heating bill, or a flat tire that can push people out of the tenuous housing that they are in. It’s in the public’s interest to close the fissure between housing costs and what people earn.” Without addressing the gap, she says it’s hard to deescalate a mental health crisis if it doesn’t fundamentally change the nature of the challenges a family is facing.