“With the resources, the evidence of what works, and the coordination, the commitment and collaboration – we know that you can solve homelessness.”

Linda Gibbs,
Principal for Social Services at Bloomberg Associates and Former Deputy Mayor for Health and Human Services for New York City

Introduction

According to the Universal Declaration of Human Rights Article 25.1 (1948), “Everyone has the right to a standard of living adequate for the health and well-being of [themselves] and of [their] family…” This raises the question, why are so many people sleeping rough?

Homelessness is a complex human rights and public health issue that affects people living in cities across the world. In Episode 87, the Public Health Insight Podcast Team together with Linda Gibbs and Tamiru Mammo of Bloomberg Associates examine the intricacies of addressing homelessness. In Episode 88, the group continues their discussion by exploring opportunities that emerged from the COVID-19 pandemic and highlight some unique solutions to homelessness from Linda and Tamiru’s co-authored book, “How Ten Global Cities Take on Homelessness: Innovations That Work.”

In this blog post, we’ll be examining:

• Challenges of Addressing Homelessness
• Impact of Homelessness
• Evidence-Based Strategies to Tackle Homelessness
• Opportunities Presented by the COVID-19 Pandemic

Challenges of Addressing Homelessness

The right to safe, adequate accommodation is enshrined in multiple human rights documents with countries obligated to ensure access to acceptable shelter (OHCHR, 2022). Regardless, the issue of homelessness is often dismissed as an unsolvable problem or included as an addendum to loosely related agendas such as public safety or mental health. Countries are rarely, if ever, held to account for dismissing their human rights obligation to address homelessness, to the detriment of public health (OHCHR, 2022).

Defining Homelessness

One of the major difficulties in addressing homelessness is the lack of a universal definition which hinders the ability to gather quality data and define the scope of the issue. Countries, regions, research initiatives, and advocacy groups all use different definitions based on language, cultural norms, and the populations of interest (OHCHR, 2022; The Homeless Hub, 2021c). It is very difficult to solve an issue with only a vague idea of the magnitude of the problem.

An individual’s experience with homelessness is often fluid where a person may access a shelter for a few nights, crash at a friend’s place, then spend some time sleeping rough before seeking temporary accommodation in a low-cost nightly rental. Often no one term will fully describe a person’s homelessness experience.

Measuring Homelessness

Beyond the challenge of defining homelessness, gathering concrete data on the numbers of people experiencing homelessness is difficult with official statistics potentially only capturing a portion of people who are experiencing some form of housing insecurity.

Different countries and areas may rely on data from:

• shelter intake registries,
• outreach organizations,
• police data,
• faith-based organizations providing services, and
• volunteers 

to determine the number of ‘literally homeless’ on any given night. This still misses a significant number of people who experience homelessness but may not be counted (Ortiz-Ospina & Roser, 2017). As a result, the true number of homeless people is difficult to determine making homelessness all the more difficult to address. 

Determining Causes of Homelessness

The causes of homelessness are complex and each person or family’s pathway to insecure housing is unique (Oudshoorn, Dej, Parsons, & Gaetz, 2020; The Homeless Hub, 2021c). Some of the often cited causes of homelessness include:

• substance abuse disorders,
• mental health crises, and
• inadequate discharge planning from hospitals, prisons, and other facilities (MacKinnon & Socias, 2021; The Homeless Hub, 2021a).

While the above remain common contributors to homelessness, people ultimately lose their access to a secure home due to a complex interplay of multiple factors. For example…

Inadequate affordable housing coupled with stagnant wages or unemployment can result in precarious living conditions with families unable to keep up with rising costs or

Domestic violence victims may have no safe accommodation, particularly if their abusive partner controls the lease/mortgage or

Young people, one of the most ‘at risk’ groups of homelessness, can be pushed out of the family home following unresolved conflicts, with LGBTQIA+ youth considerably at risk or

One of many other interwoven reasons a person or family may suddenly find themselves without secure accomodation

The common theme behind the various pathways into homelessness is the failure of public health and social services to adequately support individuals and families through a crisis (Oudshoorn et al., 2020). 

Impact of Homelessness

We, as a great human society, we are diminished, we lose the gift of their creativity, the gift of their curiosity, the gift of their potential when it is marooned by all the downstream consequences of homelessness.” – Mary McAleese, Former President of Ireland, at the first-ever United Nations Resolution on Homelessness, 19 February 2020

Experiencing homelessness is a sharp blow to a person’s dignity that has far reaching health and social consequences. Physical and mental health deterioration is intertwined with homelessness as both a contributing cause and a consequence (NHCHC, 2019).

People without adequate shelter are at risk of multiple health conditions including HIV, Hepatitis A, tuberculosis, alcohol and drug addiction, and other serious conditions (Liu & Hwang, 2021; Sleet & Francescutti, 2021). People who are homeless also have a higher prevalence of diabetes, hypertension, asthma, and depression than the general population (NHCHC, 2019). Lack of adequate shelter places individuals at a higher risk of assault and accidents with homelessness considered a significant contributor to premature death (Liu & Hwang, 2021; NHCHC, 2019). Those who are housing insecure have significant stress-related health concerns with foreclosure, eviction, or the threat thereof connected to depression and suicide (Liu & Hwang, 2021).

Homeless people also have difficulty navigating and accessing health services, often experiencing discrimination by services and providers (Liu & Hwang, 2021; Sleet & Francescutti, 2021). People who are homeless can often only access emergency health services and have no safe place to store medications making chronic conditions difficult to manage (Liu & Hwang, 2021; NHCHC, 2019). Further, when rationing resources, any available funds are likely to be earmarked for food and shelter while health care costs are considered a low priority (Liu & Hwang, 2021).

Discrimination against people with ‘no fixed address’ can limit work and education opportunities, furthering the cycle of insufficient funds leading to unstable housing. The criminalization of homelessness (making sitting, sleeping, or staying in certain areas illegal despite lack of alternatives) can lead to those experiencing homelessness having a criminal record. Criminal records can prevent people from accessing certain housing assistance schemes and specific jobs (OHCHR, 2022). By contrast, people that are able to escape homelessness or move to a secure housing situation are more likely to attend university, have higher incomes, and live in better areas in the future (Healthy People 2020, 2022).

Evidence-Based Strategies to Tackle Homelessness

Strategies to address homelessness have shifted over the past several decades. While previous generations focused on supplying emergency food and sleeping arrangements – the traditional ‘three hots and a cot’ – modern day homeless shelters provide more integrated services including addiction management, transitional housing, and other support. Still, many cities struggle to effectively combat the rise in homelessness and its subsequent health impact demonstrating the need for effective, evidence-based solutions.

Housing First

Housing First is a strategy to address homelessness that focuses first on getting a person into a house before focusing on possible contributors such as addiction or unemployment. Where many traditional services require a person to demonstrate that they are ‘housing ready’ by passing hurdles such as sobriety or participation in mental health treatment before they can access an indepent living space, the Housing First philosophy is based on the idea that, as a right, permanent, safe, stable accommodation should be the priority (MacKinnon & Socias, 2021; The Homeless Hub, 2021b). Addiction recovery, health problems, and employment can all be supported once a person is in a stable, independent home (Goering et al., 2014; MacKinnon & Socias, 2021; The Homeless Hub, 2021b).

The Housing First strategy has shown to be largely successful. A large, randomized control trial in Canada, At Home/Chez Soi, compared Housing First with traditional services for homeless people. Participants enrolled in the Housing First group overwhelmingly had better outcomes than those enrolled in the group receiving the usual support (Goering et al., 2014; The Homeless Hub, 2021b). A crucial finding of the study was that participants with substance abuse disorders had similar abilities to remain housed as those that did not, supporting the idea that treating addiction should not be a prerequisite to housing (Goering et al., 2014; MacKinnon & Socias, 2021).

This model of providing permanent housing for those experiencing homelessness has been adopted in a variety of settings with many success stories. In the United States, multiple cities eliminated or dramatically reduced veteran homelessness utilizing a Housing First strategy. Permanent housing strategies have been widely adopted in Nordic countries with Finland nearly ending street homelessness as a result (Brand, 2017).

Preventative Strategies

While Housing First initiatives have proven effective (Goering et al., 2014), one major criticism is the reactive nature of the strategy. Intervention only begins after a person or family is homeless (Oudshoorn et al., 2020). By contrast, preventing homelessness from occurring in the first place can reduce the associated negative health and social outcomes.

The diverse nature of the causes of homelessness can make prevention difficult – how can we prevent something with such complex, intertwined causes? However, some prevention strategies that have proven beneficial include:

• Rental subsidies

Evidence indicates that deep, permanent rental subsidies or housing vouchers can help struggling families avoid homelessness (Burt, Pearson, & Montgomery, 2007; Shinn & Cohen, 2019).

• Eviction Prevention Programs

A record of eviction can significantly reduce future rental options. Financial assistance, legal representation, and landlord-tenant mediation have been shown to prevent people and families from becoming evicted (Burt et al., 2007; Shinn & Cohen, 2019).

• Community-Based Services

Community programs that can help link people struggling to maintain housing with essential homelessness prevention services such as financial help, relocation services, and employment assistance, have been shown to prevent homelessness (Shinn & Cohen, 2019).

Systems Level Coordinated Response

The common thread among pathways into homelessness is a failure of social and public health services to support a person or family in crisis – whether related to addiction, finances, health, stress, interpersonal conflict, or another trigger that causes the loss of secure housing.In the book, “How Ten Cities Take On Homelessness: Innovations that Work,” co-authors Linda Gibbs and Tamiru Mammo stress that a collaborative systems based approach was crucial to addressing homelessness. Although the book examines cities across the globe with differing demographics, cultures, languages, and governmental structures, a common theme of success was collaboration across different sectors and a commitment to work together to solve homelessness. The authors stress that systems need to acknowledge where and how they have failed homeless people, agree to address these failures, and commit to working towards systematic change while maintaining transparency and accountability in their initiatives.

Opportunities Presented by the COVID-19 Pandemic

As the unprecedented COVID-19 crisis unfolded, homeless people were one of many vulnerable groups at an increased risk from the disease due to overcrowding in shelters, high prevalence of chronic conditions, and poor access to personal preventive equipment. Stay-at-home mandates are difficult to follow with no home.

While multiple new challenges faced this group due to the pandemic, COVID-19 also provided a rare opportunity for the urgent, creative rethinking of services.

When New York City’s subway line infamously closed for the first time in history, thousands of homeless people were left without their usual shelter. Shelter workers rapidly shifted to virtual intake procedures which dropped a major barrier to accepting a shelter placement – starting many on the pathway to housing.

In the UK, the COVID-19 crisis sparked a directive to find emergency accommodation for rough sleepers ‘by the end of the week’ in what became known as ‘Everyone In.’ At the time, many people who were sleeping rough or in danger of losing a place to stay were classified as ‘no recourse to public funds,’ meaning they were considered low priority for assistance and shelter if they received any. ‘Everyone In’ involved suspending this eligibility hurdle which allowed services to help homeless people access shelter and services. The result was a substantial drop in the number of rough sleepers across the country (Boobis & Albanese, 2020; Gray, 2022).

Multiple countries suspended evictions for the duration of the pandemic. Efforts in Huston went even further, where targeted assistance programs were launched to help people facing evictions. These programs, which included rent assistance and support for relocation to alternative housing, diverted thousands from homelessness (Gray, 2022).  

Overall, the COVID-19 crisis provided a situation where the urgent need for solutions facilitated the breaking down of communication and bureaucratic barriers. Harnessing this energy from the pandemic and continuing to treat homelessness as an emergency that requires an urgent solution can hopefully produce further creative, timely solutions to end homelessness permanently.

Key Takeaways

• Homelessness is a complex and dynamic challenge with an ever-evolving demographic of those impacted. While some countries have made progress, many areas around the world have fallen short of their human rights obligation to ensure every person has a safe, secure, appropriate place to live.

• Promising campaigns such as Housing First offer evidence that providing shelter to those in need can substantially reduce the number of people on the streets. Prevention methods are likewise vital to keeping people and families from becoming homeless. Crucially, collaboration across all sectors has shown to be vital in homelessness reduction success stories. 

• The COVID-19 crisis, while presenting numerous challenges, also allowed for unprecedented collaboration between sectors to rapidly find creative solutions for housing people in need. This demonstrates that homelessness is not an unsolvable problem.

Other Related Material:

The Conversation – Five lessons the pandemic taught us about ending homelessness permanently

Vox – Inside SanFrancisco’s Housing Crisis

Yes! Magazine – This New York Program Is Getting Ahead of Homelessness

Written by: Malissa Underwood