One Doctor’s Prescription to Solve Homelessness Would Continue the Catastrophe

A doctor named Katherine A. Koh — who treats homeless people with Harvard Medical School’s Boston Health Care for the Homeless Program — cares deeply about her patients. But her policy prescriptions to help them become the formerly homeless will just keep the ongoing catastrophe rolling along.

In the New England Journal of Medicine, she tells of the tragic death of one of her patients and the indifference of society to the tragedy. From “Invisible Deaths: Mortality Among People Experiencing Homelessness“:

Jack died on a street corner. A larger-than-life figure, he stood more than 6 ft, 4 in. tall, exuded charismatic energy, and embraced the role of “king of the streets.” Then, at 49, he died without warning on a busy sidewalk in Boston, not far from Massachusetts General Hospital.

As a street physician caring for people experiencing homelessness, I had just finished residency training when Jack slipped away — the first of my patients to die on the street. I spent the next few days privately grieving his untimely death and searching the local newspapers for any mention of it. Surely if someone else — a student, a health care worker, a regular passerby — had died suddenly in plain view, a stone’s throw from a renowned academic medical center, there would have been some recognition in the press. It never came. No obituary was published, and more than 4 years later, there is no trace of him online.

The homeless, unsurprisingly, have a shorter lifespan than the general public:

The epidemic of premature death among people who experience homelessness in the United States is staggering and has continued to grow. The mean age at death in this population is 51 years — nearly 25 years younger than that in the general population and an age at which Americans commonly died in 1900. The statistics are particularly striking for certain subgroups, such as people who sleep on the street. Age-adjusted mortality in this group is nearly 10 times that in the general housed population and nearly 3 times that among people who sleep primarily in shelters.

It is indeed tragic that many deaths on the street go unremarked. But that is because there are so many in places like San Francisco, Seattle, and other cities governed by political progressives that have policies in place that unintentionally increase the toll.

Alas, Koh’s prescription for ameliorating the problem is more of the same old, same old:

Meanwhile, increased investments in Housing First, street-medicine, and harm-reduction programs are critical to reduce rates of disease and premature death. Clinicians should also be trained to help patients who are suffering on the street. Finally, society needs to make a sustainable commitment to increasing the availability and affordability of housing and to preventing early-life trauma.

Most of these efforts have not only failed but Housing First and so-called harm reduction programs are prime causes of the increasing problem!

Housing First approaches homelessness as exclusively an issue of providing shelter. Never mind that the crisis is primarily caused by anti-social and dysfunctional personal behaviors. The fix is merely a matter of giving people a free place to live.

But here’s the fatal flaw: Housing First forbids organizations receiving funding from imposing any conditions in return for housing assistance. Recipients of such aid, for example, can’t be required to attend drug rehabilitation programs, look for work, or even take their mental health medicines as directed by a doctor. It’s all carrot and no stick.

Housing First has been an abject failure. When adopted federally in 2013, advocates predicted that Housing First would eliminate homelessness in 10 years. We now know that the exact opposite occurred. What a calamity.

Making matters worse, federal policy forbids funding homelessness programs of religiously-based organizations such as the Salvation Army and many rescue missions — even though they have a much better success rate than programs following the Housing First approach.

As for so-called “harm reduction,” giving addicts drugs and paraphernalia has resulted in more street deaths, not fewer.

If we genuinely care about those living on the streets, we will pursue a different policy that doesn’t only help homeless people find proper shelter but also places a concomitant duty on them to participate in programs aimed at improving their own lives, which can be the key to regaining self-respect.

Homelessness activists call that approach “punitive.” No, it is loving. Make no mistake, self-respect is what’s required to cure the underlying causes of homelessness — and that means people have to be persuaded to at least attempt to help themselves. At the very least, those receiving help owe that much to a society that is, at great cost, attempting to ameliorate their misery.

With a new administration about the begin, and with Republicans in charge of Congress, let’s hope that Housing First quickly becomes a policy of the past. A proposal known as Housing PLUS would prohibit HUD from refusing federal grants to housing providers that require recipients to participate in programs to overcome the behavioral causes of their own homelessness and/or participate in job counseling. Nor could the government forbid programs from requiring sobriety among participants. Perhaps just as importantly, Housing PLUS would eliminate the current discriminatory policy that forbids providing homelessness program grants to faith-based organizations. More will be needed, of course, but these reforms would be a good start in a better direction.

So, good on Dr. Koh for caring so much about our brothers and sisters who are homeless. But her prescription for doing more of what is clearly not working won’t make for fewer of her patients’ anonymous deaths. It’s time for a different approach.