CPSolvers: Anti-Racism in Medicine Series

Episode 15: Housing is Health: Racism and Homelessness – Clinician + Community Perspectives

Show Notes by: Victor Anthony Lopez-Carmen, MPH

April 5, 2022

Summary: This episode highlights homelessness’ impact on health, the structural and racialized nature of homelessness, and practical interventions to address housing inequities. This is the last of three episodes interrogating the relationships between race, place, housing, and health. During this episode, we gained insight from special guests Dr. Margot Kushel and Mr. Bobby Watts about what brought them into their fields, how their work reaches the most marginalized, and what can be done at the community and structural level to address homelessness. Dr. Margot Kushel is a Professor of Medicine and Division Chief at the Division of Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center and Director of the UCSF Center for Vulnerable Populations and UCSF Benioff Homelessness and Housing Initiative. Mr. Bobby Watts is the chief executive officer of the National Health Care for the Homeless Council. This episode was hosted by Sudarshan Krishnamurthy, Jazzmin Williams, and Alec Calac.

Episode Learning Objectives:

After listening to this episode, learners will be able to:

Learn about non-stigmatizing language for healthcare providers when talking about individuals experiencing homelessness
Understand how systemic racism, including injust housing policies and over-policing, are at the root of homelessness and its disproportionate impact on Black and Brown communities
Understand the systemic factors that have increasingly led to the aging population experiencing homelessness today
Learn how homelessness contributes to adverse health outcomes, especially in the context of the COVID-19 pandemic
Describe the utility of medical respite care when working with patients experiencing homelessness

Credits

Written and produced by: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac, Victor A. Lopez-Carmen, MPH, Naomi F. Fields, LaShyra Nolen, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins
Hosts: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac
Infographic: Creative Edge Design
Audio edits: David Hu
Show notes: Victor Anthony Lopez-Carmen, MPH
Guests: Dr. Margot Kushel and Mr. Bobby Watts

Time Stamps

00:00 Introduction

04:31 Guest career paths

11:58 Non-stigmatizing language around homelessness

19: 30 Structural racism and homelessness

33:09 Increasingly older population experiencing homelessness

42:01 Medical respite care

48:30 Criminalizing and over-policing homelessness

53:19 Key takeaways

Episode Takeaways

We must know the housing status of our patients, and how to ask about it.

Our guests remind us to ask our patients about their housing status using non-judgmental and non-stigmatizing language. If we do not know the housing status of our patients, then we do not know one of the most fundamental things that is going to affect their health and wellbeing.

2. Know your community resources.

Our guests emphasize that physicians must be familiar with community resources. Do you have a medical respite center? Do you have a coordinated entry system (CES) in your community? Can you refer your patient there?

3. If we are not part of the solution, we are complicit in structural injustice.

Dr. Kushel and Mr. Watts remind healthcare providers to speak out about the structural causes of homelessness. Push back against individual narratives that blame individuals for systemic injustice. Push back against dehumanizing language. Push back against discussions that homelessness is caused by substance use or mental health problems.

4. Disaggregated data on homelessness is vital.

Missing racial and ethnic data on homelessness is an example of structural racism. We must know who we are serving to truly be able to tackle the systemic injustices that cause disproportionate rates of homelessness in America.

Pearls

Formative Career Moments:

Dr. Kushel explained how discharging patients experiencing homelessness only for them to come back a few days later in worse shape was unacceptable. This pattern led Dr. Kushel towards work on solving the systemic failures causing “catastrophic” health outcomes in populations experiencing homelessness.
Mr. Watts added a tangible example where people experiencing homelessness would be dropped off by ambulances in front of the center for homelessness where he worked, which was not equipped to deal with their medical circumstances. They would eventually end up back at where the hospitals they came from. Experiences like this made him want to contribute to solutions in the community.

Speaking about Homelessness:

Dr. Kushel encouraged people to go past the textbooks and learn from people on the frontlines of homelessness. This humanizes the crisis and also centers the lived experiences of persons experiencing homelessness as the experts who can teach us more than any textbook.
Dr. Kushel emphasized that we should use person-first language because homelessness is an experience and there is no such thing as an inherently homeless person. Some people also prefer to use unhoused instead of homeless.
Mr. Watts encouraged use of the term neighbor, such as “neighbors without homes, unhoused neighbors, or neighbors experiencing homelessness. Another term he uses is “people with the lived expertise of homelessness,” which centers them as experts in solution-making.
Dr. Kushel detailed how the use of dehumanizing language equates to complicity in a narrative that systemically harms our neighbors with lived expertise in homelessness.
Dr. Kushel emphasized that we must speak to the structural racism at the root of disproportionate rates of homelessness in communities of color, instead of just focusing on mental health and substance use.

Restrictive Housing Policy and Homelessness Today:

Mr. Watts described how property tax laws give more public funding to school districts in higher socioeconomic neighborhoods than poorer neighborhoods, leading to worse educational outcomes and thus higher rates homelessness in low-income neighborhoods.
Dr. Kushel and Mr. Watts remarked that housing, especially expensive house ownership, is massively subsidized in comparison to apartment renting, meaning populations who are less likely to own houses receive less financial support from state and federal housing programs.
Dr. Kushel described how the wealth gap created by discriminatory housing policies also means that more racial minorities are renting properties, making them more vulnerable to gentrification and eviction, contributing further to the housing crisis.
Mr. Watts explained that predatory home or apartment lending targets Black and Brown people, leading to higher rates of poverty and homelessness in those communities. He also described how other policies like redlining and racist policing practices contribute to the mass incarceration of Black and Brown people, increasing homelessness in those communities.

Aging Compositions of the Population Experiencing homelessness across the US:

Dr. Kushel explained that in the early ’90s in San Francisco, 11% of those experiencing homelessness were 50 and older. By 2003, 37% were 50 and older. Now, among single adults experiencing homelessness, the median age is much closer to 50, meaning about half are under 50 and half are over 50. 44% had never once been homeless before the age of 50. So, the population experiencing homelessness is increasingly older.
Mr. Watts noted that the aging population experiencing homelessness came of age during mass incarceration, over policing, and thus many of them had histories with the prison system. Most were due to drug-related non-violent crimes that haunted them and limited employment opportunities throughout their lives.
Dr. Kushel also noted that housing became less and less affordable, adding on to the vulnerability of those in this generation who could not obtain well-paying jobs due to non-violent criminal histories.
Mr. Watts described how life expectancy among those experiencing homelessness is 20-30 years shorter than those with stable housing. This means they don’t benefit from social security because they are dying before they can receive it.

Health and Homelessness:

Dr. Kushel emphasized that people experiencing homelessness have elevated hospitalization rates and longer stays due to more comorbidities, and are more likely to be re-hospitalized.
Mr. Watts described how care for people experiencing homelessness needs to take into account the realities of being without a house, such as having medications stolen or going bad because of lack of refrigeration (e.g. insulin), greater decompensation after discharge because of a lack of a place to rest, and other factors that lead to poorer health outcomes.
Our guests explained that inpatient and outpatient treatment plans need to prioritize knowing the patients’ housing status, shared decision-making, and creating plans that take homelessness into account so treatment regimens are effective.
Dr. Kushel commented that in order to create systemic changes that will decrease rates of homelessness and improve the health outcomes of those experiencing homelessness we need disaggregated data to fully understand which groups in society are most impacted and why.

Medical Respite Care:

Mr. Watts advocated for medical respite, a safe place to heal and “short circuit” the street-emergency room-street-emergency room cycle as a way to treat people experiencing homelessness who are not sick enough for inpatient service, but too sick to send back out to the streets, only for their sickness to worsen. Because of less hospitalization return rates, Dr. Kushel emphasized that medical respite programs also save taxpayer money.
Dr. Kushel and Mr. Watts emphasized that respite medical care needs to be integrated into the continuum of care and homeless response systems.
Dr. Kushel explained that medical respite care via the National Institute for Medical Respite Care was very successful during the COVID-19 pandemic and is inspiring more and more communities to integrate respite care into their practices.

Policing:

Mr. Watts noted how the crack cocaine epidemic shifted the race demographics of homelessness in NYC from largely older, white drinkers to “50/50 young African American and Latinx”, with many cycling in and out of the carceral system due to over-policing and mass incarceration, which only made the crisis worse.
Mr. Watts emphasized that to this day, you are still more likely to be arrested for drug charges if you are Black or Brown, even though rates of drug use are equal across races. This is due to over policing of Black and Brown communities, which leads to higher rates of homelessness in those populations.
Mr. Watts and Dr. Kushel described how criminalizing homelessness is counter-productive and increases stigma, especially when the media focuses on one’s homelessness in the context of a crime. He states that people who are experiencing homelessness are actually more vulnerable to crimes happening to them, so they deserve more protection and service from the criminal justice system. Mr. Watts highlighted a program called CAHOOTS (Crisis Assistance Helping Out On The Streets) as a great, evidence-based mobile response model for addressing urgent needs among those experiencing homelessness.

References

Margot Kushel, M.D. UCSF Profiles. https://profiles.ucsf.edu/margot.kushel
G. Robert (Bobby) Watts, M.P.H., M.S., National Healthcare for the Homeless Council, Who We Are. https://nhchc.org/who-we-are/staff/ceo/
Hahn JA, Kushel MB, Bangsberg DR, Riley E, Moss AR. BRIEF REPORT: the aging of the homeless population: fourteen-year trends in San Francisco. J Gen Intern Med. 2006;21(7):775-778. doi:10.1111/j.1525-1497.2006.00493.x
Semere W, Kaplan L, Valle K, Guzman D, Ramsey C, Garcia C, Kushel M. Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study. J Gen Intern Med. 2022 Feb 15:1–9. doi:10.1007/s11606-022-07438-z
Studying Homelessness: Using Research to Impact Social Determinants of Health by Margot Kushel, MD. https://www.youtube.com/watch?v=O4LMVx1WiKs
Caring for Homeless People During COVID-19 Pandemic. An Interview with Bobby Watts. AMA Journal of Ethics. https://www.youtube.com/watch?v=E7Z80jADnrg&t=495s
Homeless community in San Diego resists police terror and demands safe housing – Liberation News
Lopez, M., Rothstein, R. Segregated by Design. Silkworm Studio. Published April 5, 2019. Accessed April 3, 2022. https://vimeo.com/328684375
Swift, C. Crisis Assistance Helping Out On the Streets. Community Access. January 18, 2019. Accessed April 3, 2022. https://www.communityaccess.org/storage/images/Miscellaneous/Community_Feedback_Forum_2019/3_Crisis_Assistance_Helping_Out_on_the_Streets_CAHOOTS_presentation.pdf
Kushel M. Older homeless adults: can we do more?. J Gen Intern Med. 2012;27(1):5-6. doi:10.1007/s11606-011-1925-0

Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

Watts B, Kushel M, Krishnamurthy S, Williams J, Calac AJ, Lopez-Carmen VA, Fields NF, Nolen L, Tsai J, Ogunwole SM, Onuoha C, Watkins A, Essien UR, Khazanchi R. “Episode 15: Housing is Health: Racism and Homelessness – Clinician and Community Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. April 5, 2022.

Show Transcript

Samir Okasha, "Agents and Goals in Evolution" (Oxford UP, 2018)