Rohan Khazanchi: Hi, y'all. This is Rohan Khazanchi. And welcome back to another episode of the Antiracism in Medicine series of the Clinical Problem Solvers Podcast. As always, our goal on this podcast is to equip our listeners at all levels of training with the consciousness and tools to practice antiracism in their health professions careers. I am going to hop off the mic pretty quick today because I want to introduce you all to one of our newest team members who's going to be leading today's episode, and that's Sud Krishnamurthy. And Sud is an MSTP student at Wake Forest University. I will definitely let him tell you all a little bit more about himself and dive into introducing today's episode.
Sudarshan “Sud” Krishnamurthy: Thanks so much for that introduction, Rohan. I'm thrilled to be a part of this absolute powerhouse of a team and so excited to be hosting this episode today. I grew up for most of my life in India, where I saw a lot of health disparities firsthand. And this inspired me to really get involved in health justice work early on. With health justice work going hand in hand with antiracism work, I found myself being a very regular listener of this podcast and really just inspired by the work you all do. So I was really, really excited to be given an opportunity to join the team. But with that, I'll go ahead and introduce the episode we have planned for today. This episode is entitled Housing is Health: Racism and Homelessness from Clinician and Community Perspectives. Today, we're focusing on how homelessness impacts health and the racialized impacts of homelessness, along with some interventions to address these inequities. This is the last of three episodes interrogating the relationships between race, place, housing, and health. We're so excited to speak with our guests to gain insight about what brought them into their fields, how they do the important work that they do, and how these efforts can help us better understand solutions to the problems we see clinically. I'm also thrilled to be hosting this episode with two of my incredible teammates, Jazzmin and Alec. Alec and Jazzmin, do you mind going ahead and introducing our guests?
Jazzmin Williams: Awesome. Thank you so much for that. We're excited to have you here, Sud, and really excited for this episode and for our amazing guests that we have today. So with that, let's hear a little bit about them. So the first person that I'll introduce is Doctor Margot Kushel, who is a professor of medicine and division chief at the Division of Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, and also director of the UCSF Center for Vulnerable Populations and UCSF Benioff Homelessness and Housing Initiative. Her research focuses on reducing the burden of homelessness on health through examining efforts to prevent and end homelessness and mitigating the effects of housing instability on health care outcomes. She uses a variety of research methodologies with an aim towards informing the development of programs and policies to end homelessness via understanding the complex interactions between health and housing, and has a particular interest in homelessness in older adults and homelessness in medically complicated individuals. Doctor Kushel received her medical degree from the Yale School of Medicine and completed her residency and fellowship at the University of California, San Francisco. So thank you so much for joining us, Doctor Kushel.
Margot Kushel, MD: Thanks for having me.
Alec Calac: Thanks, Jazzmin. Next up, it is my pleasure to introduce Mister Bobby Watts. He is the current chief executive officer of the National Health Care for the Homeless Council, which supports the 300 federally funded Health care for the Homeless programs and 100 medical respite providers with training, technical assistance, sharing of best practices, research publications, and an active policy and advocacy program working to eliminate homelessness. He has over 30 years of experience in the administration, direct service, and implementation of homeless health care services, beginning as a live-in counselor at the New York City Rescue Mission. In February 2021, he was also appointed as a member of the Biden-Harris Administration's COVID-19 Health Equity Task Force. He is a graduate of Cornell University and the Columbia University Mailman School of Public Health, from which he holds a master's of public health degree in health care administration and a master of science degree in epidemiology. Thank you so much for joining us, Mister Watts.
Bobby Watts, MPH, MS: Oh, it's completely my honor. Thank you for having me.
Krishnamurthy: So I thought, for the first question, we can hit the ground running with kind of understanding both of your paths to studying homelessness. So as a clinician-researcher and a community administrative leader, I imagine that both of you have had pretty different paths to studying and working in the homelessness sphere. And I think I, and as well as our listeners, would love to hear about the why that drives each of you to do this work. What are the personal and professional experiences that really inspired and contributed to your why as you started a career in this space?
Kushel: So I'm going to show my age here. But I went to college in the '80s, which was at a time when we thought of homelessness as an emergency and one that, to be honest, I don't think anyone predicted we would still be in this state of crisis, in fact, worsening. Here we are 40 years later. And so certainly, during college and the like, I did a lot of work with homeless populations, and then sort of was doing other work and thought that when I went to residency that I was going to-- I was really motivated by this idea of the working poor and occupational health and things like that. And I did my residency at the incredible San Francisco General Hospital Primary Care Internal Medicine Residency Program, which is a residency program within the UCSF residency program, sort of more committed to looking at health disparities and health of populations historically excluded. And I worked most of my time at San Francisco General Hospital, which is a public hospital for the state and County of San Francisco. So this was, by this point in the mid-'90s. I was an intern and resident there. And at the time, about half of our inpatients were experiencing homelessness. And what we would do, as an intern, we would admit patients to the hospital. We would follow them through the ICU, into the floor. We would know the 25th differential diagnosis of what their medical problem was. We would provide, "perfect care".
And then, suddenly, we'd be told, "It's time to discharge them. They don't qualify being in the hospital anymore." And as an intern, you have to walk into their room and say, "Ready to go." Now, most people, when you say, "You're ready to leave the hospital," they're like, "Hooray." But of course, when you're telling someone that they're going back to the street where it's cold, it's their risk of being assaulted, they have no food, they were sort of saying, "Please, don't discharge me." And I remember feeling like this is cruel. I mean, this is just horrible. And frankly, at a certain point, we would be forced to discharge them, which often meant escorting them against, really, their wishes to the elevator. It felt horrible. And I knew it was horrible. Inevitably, two or three days later-- and this is the time where, once the patient was yours, if they came back within two or three days, whether you were on call or not, they were yours again. So you were very aware of when patients came back. Two or three days later, your beeper would go off. Mister so and so is back. And usually, they were back in worse shape. And so then, you would go through the whole process again. And there was this part of me that was partially motivated by moral injury, partially motivated by this doesn't make any sense. Then, I realized, if I actually cared about people's health, what was less important was that 20th item on the differential diagnosis. And what was much more important was solving this fundamental human right that was really causing such catastrophic health outcomes. So I sort of switched what I do, and I've been there ever since.
Watts: That is fascinating, Margot. I'm so glad to hear that and to learn more about that. I am not a clinician. I am a public health professional. And I really began my public health career after I was exposed to homelessness. And they kind of have been intersected from the very beginning of my career. I actually deferred starting graduate school in public health to start as a live-in counselor at a rescue mission in New York City, where I grew up and lived my whole life until a few years ago when I moved to Nashville, Tennessee, for this position. One of the first things I noticed was that the people were in really poor health. And I saw that it was very interesting. My second week there, it was a Friday, and the guys said, "You're not standing outside." It was about 2 o'clock. I said, "What do you mean?" He said, "You have to stand outside on Fridays because that's when the ambulances will start from 2:00 until 7:00 to try to dump people off." And I had to say, "No, we can't take care of-- we welcome everyone, but we aren't equipped to take care of this person." And part of my job was to-- I should say, this is right when the Health Care for the Homeless program was starting.
It was started by two large foundations, the Pew Memorial Trust and Robert Wood Johnson Foundation in 19 cities as a pilot program. One of the cities was New York. And the New York City program had a clinic in the rescue mission. And part of my guise was to get the guys to come and see the doctor who actually was a physician assistant. And it was so invaluable. I knew this was a ministry. I knew we would not be able to do our ministry well if we weren't able to make sure people's health was taken care of. So when I started graduate school for public health, I continued to live there for the next year. And anytime I had an option to do a paper, an elective, it was around health care for people experiencing homelessness. And this was when some researchers were just starting. And I became like a star without trying because I fell in with them and I would say, "No, no, that's not going to work." "Why?" "You're not going to get a representative sample on a Friday afternoon. People will be out. Or this time of the month, they would've just gotten their Social Security check if they were on disability. You're not going to get a representative sample. They won't be in the shelter. They may be renting a room for the night, etc."
So when I finished graduate school, I did an internship at the Health Care for the Homeless program in New York. After the internship, they hired me. I told my boss I would work for two years and then leave. I did leave after two years but then returned. And so from the very beginning, I saw two things that intersected my work. One, I saw when I was at the rescue mission-- this was right when the crack epidemic was starting. And I saw the demographics change before my eyes in those two years, from like 75 to 90 percent older White alcoholics to about 50/50 young African American and Latinx, where crack was what was driving them. Or they were just being released. They were being released from prison. So I really saw the racial dynamics. Some of these were guys I grew up with, playing basketball with on the playground, went to public school with. And I just really saw the difference that just a little bit can make in your life circumstances. I grew up in a poor neighborhood, but my mother was a teacher. So I always was aware that I had more than those around me. And I just saw we do not get an equal shot in life. And I saw a lot of it was driven by racism. So I was fortunate that, from the very beginning, my mentor, Susan Neibacher, a White woman, was one of the first to speak about racism as a cause of homelessness. And I can connect that with what I was seeing before my eyes.
Krishnamurthy: Thank you both so much for sharing that. I think hearing your stories really helps us to get to know more about you, but also helps us get to know more about the field. And I think that, while parts of your stories are really sad, I think they're also inspiring. And for those of us to go into these same fields, it's really promising to hear. For our next question, we wanted to ask a little bit about vocabulary. So we know that language matters, and that stigmatizing language leads to the formation of implicit biases. And kind of on that note, we thought it'd be good to start with a quick primer in the vocabulary around describing homelessness. Both of you, I've noticed from your talks, are very intentional in using person-first language. And I was wondering if you could elaborate on what you would consider good language for health care providers to use when talking about those experiencing homelessness.
Kushel: Yeah. Sure. I mean, and I want to lead by saying that I think that the experts in this are the people who are experiencing homelessness. Those are the experts. And as much as possible, I try to follow the lead of people experiencing homelessness. And I just want to say that there's no consensus on this. I'm a strong believer in person-first language, and I'm a strong believer that there is no such thing as a homeless person. Homelessness is an experience that people have. And the reason why I feel really strongly about that is that it sort of reifies that there's something different about the person when there really isn't something different about the person. It is a part of their life. And I also think it leads people to this cognitive dissonance of people are stuck in homelessness, and you hear policymakers-- people transition in and out and back in and back out of homelessness. So I personally like to use people experiencing homelessness. I'm hearing more now of the use of the word unhoused as opposed to homeless. I think that there's no consensus. Many of the individuals who are currently experiencing homelessness that I work with on my community advisory boards and who I just know as activists and friends and mentors, to me, some really love that term and some really don't. So I just try to sort of not be dogmatic about it. But I do really try to use person-first language to really emphasize that this is a moment in people's lives. Sometimes that moment lasts a really long time. But it's not an inherent quality of the person. It is a structure that they are being sort of excluded from, oppressed from, etc. So that's what I use.
Watts: I agree with Margot completely. And I change my exact wording depending on the circumstance. But in addition to what Margot has said, I often like to incorporate the term neighbor, especially in talking to communities, for a few reasons, to indicate that they are living in close proximity to us. It also taps into almost every moral system. Every religion says we should care for our neighbors, that we should love our neighbors, so really want to emphasize that maybe our neighbors without homes, our unhoused neighbors, our neighbors experiencing homelessness. I also like to use the term instead of-- depending on the circumstances, of people with the lived experience of homelessness. I really like to emphasize the expertise. So I'll say people with the lived expertise of homelessness. That's especially if we're talking about with research or we want to say we want to get their opinion. They are the experts. It's not just an experience. They are experts in what it means. And in many cases, those who have exited homelessness, what it took for them and for others to get out of homelessness, which is really the end, the goal. We want to end homelessness one life at a time for those in direct service. But also, system-level, we want to eliminate, destroy the systems that are causing mass homelessness in the richest country on Earth.
Kushel: Love that, Bobby. And I love the framing of neighbor. I think that that is so important. I was on a talk once where someone called in and said-- it was someone from a ritzy suburb in the Bay Area saying, "How many homeless people do we have to have in our neighborhood?" It was just such a shocking question. I mean, it was like-- and I think that using that framing of neighbor, there's so much. The language is this language of every community in the country is convinced that homeless people are like-- that they're the magnet for homeless people, that people experiencing homelessness are coming to them because they're so great. I mean, literally, every place thinks that. And it is such a denial of our own complicity. And by our own complicity, I would say those of us who benefit from White supremacy, those of us who are housed. Our complicity in creating the system by using this sort of language of-- and it's often really dehumanizing language, right, this language of-- I don't even want to repeat it. But I think using that term neighbor is so great. And I will say that our community advisory boards, we call them the lived expertise advisory boards, not the lived experience. It has the same acronym, LE, but it's lived expertise. And I think that's-- I get really uncomfortable where I get introduced to things as an expert in homelessness. I'm not an expert in homelessness. I am a professor of medicine. I have really good research methods, and I partner with people to study the experience of homelessness and the outcomes of homelessness. The people with the expertise are the people who have survived it and really know what that experience is like.
Calac: Yeah. That's really powerful. And I think I really appreciate the kind of relational connotation that goes with neighbor, especially as an indigenous person, really aligns with my worldview and how I view taking care of those who have less than I do, but also acknowledging the privilege and kind of resources that I have and can redistribute to those who could benefit from them. And thinking again, I think what we just heard about language, it's really taking that kind of burden off of the individual. It's not an individual failure. It's a systemic failure. And I think that ties together really nicely with our previous episodes in the series where we go in and discuss the history of systemically racist housing policy and its effects on present-day disparities in housing with our previous guests, Mister Richard Rothstein and Doctor Fernando De Maio, where we start to think about the legacies of older policies and how that has really kind of furthered these disparities, often along racial and ethnic lines. Right here in San Diego, the city of La Joya used to bar individuals with Jewish ancestry from owning homes. And we can also think about the intersections with intergenerational wealth and which populations are more likely to own their household as opposed to rent or lease it. So I'm wondering if either of you could kind of share with us the effects of kind of decades of systemically racist policy and how that kind of contributes to health in the present day.
Khazanchi: There's just so much there, and I'm so glad. And I hope your listeners, if they weren't there to hear the podcast with Richard Rothstein, would go back and listen to it. That is a foundational text. When we look at this, we use that as part of our work, where we are educating our community and equipping health centers, health care for the homeless programs to undo racist structures within their health centers to understand some of the dynamics. There's also a great 17-minute animated video where Richard Rothstein narrates, if you don't want to read the book. But the information is so foundational. So I won't go over that, but I will just talk about how important housing and place is. I grew up in inner-city Brooklyn, in Williamsburg, Brooklyn, at a time when it was really bad. It was like the gang capital of New York City. And again, just saw-- not until I left my neighborhood, when I went to high school in Manhattan outside of my neighborhood, did I really see the discrepancy. But I will just say, the way that we finance public education in this country is largely based upon property taxes.
Watts: So though we say public education is a great leveler, it really is not. And studies have shown that richer communities can, and in fact do, spend more per capita on their richer students when, if we wanted it to be the leveler, we would actually spend more on poorer students. Where I went to junior high school, intermediate school, it was from sixth to eighth grade. The average reading level there was three point eight when I was there. Most of them were immigrants. English was not their native language that they spoke at home. And it just really made it hard, and we did not have the educational resources that we needed to bridge that gap for most of the students. I will also say, where you live, which we've already established, is largely based upon redlining and racist housing policy, also affects your interaction with the criminal justice system. And very few things affect the trajectory of your life as whether or not you have a criminal record. And we have seen that you are more likely to-- though drug use, let's say, is pretty standard, is pretty uniform across races, you are much more likely to be arrested for marijuana possession, for drug possession, if you are Black or Latinx. And it's not a function of use. It's a function of which communities are policed.
My sons, I raised my three sons in the Bronx. They were stopped and frisked, most upstanding people, young men, you ever want to meet just because of where they lived. And so which cars are more likely to be stopped? It depends on the race of the driver, so not use but policies. And the last thing I'll just say is talk about environmental justice. Where you live will greatly affect. Richard Rothstein talks about where communities that were segregated, where they were placed, where they were more likely to be near landfills or bus depots and so forth with environmental pollutions. My three sons have what I call the scourge of the Bronx. All of them had childhood asthma, as did many people in our neighborhood. And all this is just based upon where you live, which, in this country, is largely affected by race.
Kushel: [inaudible]. I mean, Bobby, that is so on point, as always, and I think really compelling. And I think I'm going to sort of talk about some things we learned partly with CPSolver's Antiracism series' cofounder Derek Paul's work that we did together and that Derek really led, and and other work, to really draw that direct line from those policies that Richard Rothstein talks about so well and present-day homelessness. In fact, there's so many different ways it operates. One of them is that, in this country, home-ownership has been one of the primary means of wealth building. And there's just a really recent, incredible study by a Yale professor who just was denied tenure. But that's a story for another day, really incredible work showing that White Americans way overestimate the wealth of Black Americans. But what we know is that, not only is there active and ongoing discrimination through the criminal justice system and through the educational system, which is, of course, place-based, as Bobby said, and things but there's an enormous wealth gap. And much of that wealth gap is actually due to the exclusion from home-ownership, that inability to build wealth through housing. And that wealth gap really is a direct line from that into current modern-day homelessness because, if your family has family wealth, they are able to protect people going through a rough time from homelessness, right?
The other thing is that home-ownership is a very powerful protector for your entire social network because, if you own your home and someone else in your social network is going through a hard time, you can take them in. If you're a renter, taking somebody into your house who's not on the lease is a lease violation. So what we see in all these really rapidly gentrifying areas-- and when I think about gentrification, you think about it as the opportunity gap between what has it cost and what it could cost. So these are often-- we see in the Bay Area massive displacement of the Black population, right, as gentrification occurred, but. So everybody who's in the gentrifying area who's a renter is often at risk of being evicted, right, because that homeowner knows that they can flip that place and make more money when they get that renter out of there. Taking in a family member is a lease violation. So there's this mythology that goes around. And so much of it-- I want people to interrogate how whiteness and sort of White supremacy operate in the space. There's this whole language around homelessness, that it's all about mental health and substance use disorders. And I think it's so important, particularly for us as health care providers, to really push back against that.
Clearly, it's a precipitate, right? People who have these disabilities are going to lose out compared to everybody else in rough housing markets. But that is not the underlying driver of homelessness. If that were, you would see the worst homelessness in West Virginia and other Mid-Atlantic Rust Belt States that have the highest rates of substance use and mental health problems. It's all about the disconnect between housing cost and income, right, which is much bigger in these big cities. So we really need to push back against this individual narrative and realize this is all about the end result of these racist housing policies intertwined with all of these other racist policies, that you have these enormous disparities. Even though fair housing laws have been passed - it's no longer legal to discriminate - we have really good evidence that that discrimination continues to this day, both in terms of renters-- if you're a Black household and you have the very same renter resume as a White household does, you're less likely to be offered the apartment. Therefore, Black households pay more for the same quality apartment through things like predatory lending. In 2008, predatory lending really was targeted at Black and Brown households. I think it's really important to lift up the incredible disparities amongst Native Americans, which is probably the most overrepresented group in homelessness at like an eight-fold increased risk. Black Americans, three or four-fold increased risk.
It really makes me sick to my stomach because I give lots of talks on homelessness of the general public. And I would say White people sort of like are talking about mental health and substance use. I'm like, "Why are we even having that conversation? The conversation is about structural racism and the ongoing impacts of that in Black and Native American populations." That is what has led to this crisis. If we don't grapple with that, we're not solving this crisis. And maybe the one last point I would make is that, when you talk to people who are experts in homelessness, meaning they are people with the lived experience and the lived expertise, they tend to blame themselves. And that is how sort of White supremacy works, right? It is a very individualizing thing. And because the people who are victimized by that internalize those messages doesn't mean that the structures aren't impacting. In fact, that is how structural racism works, right, is it causes people to blame themselves. When you listen to their stories, you're like, "Oh, my gosh. You never had a chance. Every deck was stacked against you." And yet, people blame themselves. That is how these narratives that you read about, this is about mental health and substance use, highly stigmatized conditions, are at fault. This is what you read when people allied the effects of structural racism in creating and maintaining this crisis.
Watts: I might just pick up on one more thing when we talk about housing policy. And Margot did a great job of talking about the importance of wealth building and home-ownership. But I also want to talk about our public policies of the discrepancies of how we subsidize home-ownership versus apartments. We already see there's a racial gap because of our policies and who owns versus who rents. And right now, we subsidize private home-ownership to the tune of about $250 billion a year. This is even after the tax changes in 2017. And that's through the home interest deduction, and that's unlimited. So it is the most regressive, the most inefficient tax loophole that there is. It does almost absolutely nothing to promote home-ownership. What it does, it means whether you have a bigger home or a smaller home. Meanwhile, for those who rent, who are poor, we only give enough funding so that those who qualify for federal subsidies, only one out of four households get that. And that is to the tune of about $50 billion a year to subsidize that. So we have massive homelessness because we are not allowing and subsidizing people, making it affordable for them to keep a roof over their head. And we're spending five times as much to promote home-ownership for those who really don't need it. And the bigger the home you buy, the more tax subsidy you get, so. And again, looking at the impact of race on who owns versus who rents, we are just compounding and accelerating the inequity and the racial gap.
Kushel: You guys asked before about language. And I now have taken as a practice when I give talks to announce I live in subsidized housing. Say if this is a podcast, you can't see me. I'm a White woman. I'm White presenting. And you see this kind of look on people's face. They're trying to figure it out, right, because it's-- and then I'm like, "I live in subsidized housing." Well, I'm actually lucky enough to be a homeowner. Therefore, I live in massively subsidized housing. The men and women who do the absolutely essential work in our community, the people who are cleaning our hospitals, the people who are serving our foods, the people who are doing the very valuable, highly skilled but low-wage work that makes our society run mostly live in rental housing completely unsubsidized. As Bobby said, just to make that point, you've probably heard the word Section 8. The formal name for that is Housing Choice Vouchers. Lots of problems with the program in terms of it can be hard to use those vouchers in high-cost areas. Many people who really need them don't qualify. But as Bobby said, out of the people who qualify, only one in four gets it. We could solve that overnight with about a 50 billion, 70 billion annual spend. That is rounding error for the federal government. That is a tiny percentage of what we spend to subsidize people like me to live in our houses. And it would be a game-changer. Overnight, the crisis, family homelessness would pretty much end. The crisis would change overnight if we could just get the federal government to make that small change. So I think it's really important for those of us who benefited from the system to own up to it and to say. We can get into talk about reparations and all those things if we have time, but also to claim it and to say it, "I live in subsidized housing," because I do.
Williams: I really appreciate this conversation because, in talking about the different structural policies and practices that really create this condition of homelessness, it not only clarifies who is most at risk for experiencing homelessness, and it really shows us where we can intervene. And in thinking about that, I am also just trying to think a little bit more about what does this population-- who exactly are our neighbors that are experiencing homelessness, and what do they look like? And I know that, Dr Kushel, so your research has really highlighted that this population is aging. And so sort of in talking about these structural factors that create homelessness itself, I'm curious to learn more from you about what are those factors that lead to the aging state of folks who are experiencing homelessness.
Kushel: Sure. Thanks for asking about that because I've been in this field long enough that-- I used to give talks and say homeless people are mostly 25 to 44. And then I was working in the hospital. And this is what's great about being like an active clinician while you're doing it, working in the hospital, working in the clinic, and my eyes were deceiving me. I was like, "Well, this person isn't 25 to 44. This person isn't 25-44." And I was like, "Something's going on." We had access to data from a research group that I was working in that looked at the median age of the population basically from the early '90s to 2003. Early '90s in San Francisco, 11% were 50 older. By 2003, 37% were. Now, I'm doing a statewide study of homelessness, and I've looked inside data also from homeless management systems across it. Now, among single homeless adults, the median age is much closer to 50, meaning about half are under 50 and half are over 50. I did this work. And then we passed it back to our colleague in University of Pennsylvania, Dennis Culhane and others, who basically looked at shelter data from across the country. They looked at men thinking that they were less likely to be family-- adults and families, more likely to be single, and found that there was this big bubble of people who were born in this decade, the second half of the Baby Boom, 1954 to 1964, this big population amount.
When that bubble was in their mid-30s, that was the spike of people experiencing homelessness. And it's kind of continued way up. [inaudible] back to me. This is sort of how science is done. We've been doing this big NIH-funded study on homelessness. And we were interested in the question of, are these people who became homeless in their 30s and just stayed homeless as they aged, or is there something weird going on here? And what we found, looking only at people who are 50 and older and homeless, that 44% of them had never once been homeless before the age of 50. So about half the people had been homeless and stayed homeless or gone in and out of homelessness, half were new to homelessness. And those folks were very different in some ways. They were folks who-- the folks who were homeless before 50 were folks who had really terrible childhoods, really afflicted by every structural vulnerability, really had trouble sort of launching into "mainstream society", struggled with mental health problems, physical health problems, substance use problems from early on, never married or partnered, spent a lot of time in prison, and were sort of doing poorly and going in and out of homelessness throughout their lives.
Those half who first became homeless after 50 were really low-wage workers who had been working their whole lives just scraping by and doing essential, physically demanding work. Somewhere after the age of 50, one of four things happened, and sometimes two or four things. They lost their job, or their spouse or partner lost their job. They became sick, or their spouse or partner became sick. Their marriage broke up, or their spouse or partner or their parent died. A lot of folks living with mom, mom passed at 78. They didn't have their name on the lease. They were suddenly out on the street. Why has this age group done so poorly? We think again. Think about all the many ways that age group caught a bad deal. They came of age during a recession. We know that people who enter the job market during a recession never make up the lost income. They came of age at the beginning of a couple huge federal policy changes. One was the beginning of the era of mass incarceration. This was a generation that got punished, punished, punished by disastrous criminal justice policies. We see amongst those first homeless after 50 many of them, few of them had long prison sentences, but many of them had "caught a charge".
Kushel (cont): This was that over-policing that Bobby talked about in these redlined neighborhoods, where they caught a charge, usually a drug-related nonviolent charge, that then haunted them throughout their lives, limiting their employment opportunities, limiting their housing opportunities. They were a big population, Baby Boom. They sort of came of age when a lot of the jobs had been taken by the first half of the Baby Boom, so right? So they had a harder time entering the job market. They also came of age in the first era of modern life, starting in the late 1970s, early 1980s, where there was this massive federal switch in support of public housing and supportive affordable housing. And so they sort of came of age when there was less affordable housing. So they lost out in every way possible. The one other thing you might say is, "50 doesn't sound that old. I'm in my mid-50s. I don't feel that old." But what we found is that, for homeless folks in their early 50s, their health status looks much more like the general population in their 70s and 80s. They basically have experienced premature aging, weathering from all of this exposure to racism and other things like that. And so when you see 55, think 75 or 80. When you see 52, think 75.
Watts: I would also add, the effects of age, or just what Margot said about the premature aging. We see that also in the most important feature, mortality. So on average, the average age of someone who dies while experiencing unsheltered homelessness is about 25 years younger than the average person who dies in the general population. So we're losing 20 to 30 years of life expectancy because we are not providing housing as a nation.
Kushel: And this is one of the ways, right, that racism plays out. First of all, housing is on the pathway between-- in health disparities, right? This disproportionate access to housing is one of the reasons we have these. It's not the only reason, but it's a really important contributor to one of the reasons why we have these disastrous health outcomes. I want to remind everyone that our Social Security system works that you pay and pay and you pay in, and then, when you're either 62 or 65, you get paid back. You talk about populations, Black Americans, Native Americans, who have a much earlier mortality rate. That means that they're paying in, but they're dying before they're getting that money back. It is another really insidious ways that this works. And this ties into their aging, too. My job, I can sit down a lot. I can rest. A lot of it is not that physically demanding. I can easily work probably until I'm in my 70s or 80s. If my work were really backbreaking, really difficult, physically demanding work, and I have premature aging, my work career might end a lot earlier. And yet, we don't adjust for that. If anything, you hear this conversation in congress about raising the retirement age. Well, it's like a bunch of, frankly, White attorneys thinking, "Oh, yeah. I'm going to work until I'm 75." That isn't really how it works if you're doing physically demanding work and you have premature agents.
Williams: Yeah. I really appreciate this as well because I think, especially when you make this connection between the policies that are putting people at risk of experiencing homelessness, drawing the connection to the fact that a lot of them are rooted in racism, you really see how our government is honestly complicit in this early aging and in this excess mortality of people who are really just getting the short end of the stick policy-wise and being put in these positions. By recognizing that the government is complicit in this, it really shows that they should be also equally complicit in creating interventions that actually undoes this harm that they've honestly created. And then, this is just a little bit like a pivot. But in speaking about the health status of folks who are experiencing homelessness, I've recently learned about something called medical respite on my rotations on the wards. And it was something that I honestly didn't have any exposure to until an inpatient dermatology elective that I had randomly. And the main impetus was, well, our clinics are really overbooked for months out. So if we give medical respite then, at least, this person is experiencing a really intense skin infection or something is able to get care for a little bit longer. And I'm just curious to know from both of your perspectives, from a clinician perspective and from a community leader perspective, how can medical respite be used to adequately care for patients who are experiencing homelessness?
Watts: Wow. I know we are both passionate about this. So Margot, I'll let you go first from a clinical point of view, and I'll address larger.
Kushel: So we know that people experiencing-- first of all, Bobby's one of the world's experts in this. So just it's awesome to get to ask him this question. But we know that people experiencing homelessness have elevated hospitalization rates. This is because they're sicker, more comorbidities. Things don't get caught earlier. So small skin infections that you could treat as an outpatient become big infections - they get infected - and because we lower admission thresholds. There are many things that, in a housed person, I can manage as an outpatient where, if I'm sending someone out to the streets where they're not going to get any sleep or they're going to be exposed to elements, where their medicines are going to get stolen, where really hard to do, what are you going to do? Home IV antibiotics in a street corner, that doesn't happen. So we have all these reasons why we have higher admission rates. We also, and evidence has shown this, have prolonged hospitalizations where, once people get hospitalized, it's harder to discharge them because we need to complete an entire treatment inpatient instead of doing what we usually do, which is send people home. So medical respite is really our response to that. It is a way of treating people. It can be done in shelters. It can be done in hotel rooms.
It can be done in different ways where basically, you are providing light-touch medical services to people who are too sick to be experiencing unprotected homelessness but not sick enough that they require inpatient hospitalization, to try to equalize these hospital rates between folks who are homeless and not homeless. It can be really, really impactful. With the aging of the population, we've seen some challenges of-- when we set ours up in San Francisco, the idea was that there would be a turnover of about two to six weeks. People would complete antibiotics and then go back. But we sort of said, "Well, if we know that they're just going to bounce back to the hospital, hold on to them, and let's get them into housing." As the population has aged and more people have chronic conditions that aren't actually going to get better, many folks then sort of landed in respite and have been unable to be discharged. So that's a discussion for another day. But let me turn it over to one of the world's experts, Bobby.
Watts: Well, I'll say one, of the strengths of the council is that everything that we do is informed by those on the front line, either the clinicians or the people with the lived expertise or the administrators or advocates. So the council holds the collective knowledge of our community, and I benefit from being close to it. And I will say that we just know that medical respite, a simple way to put it is that it's a safe place to heal. And we know that, if people experiencing homelessness who don't have a home, who would otherwise be discharged home with home care or just discharged home, if they don't have a safe place to heal, they will decompensate. They will end up back in the emergency room, back admitted inpatient, and with poor health outcomes. So we know that medical respite short-circuits that cycle. And it's better for the patient. It's better for the health system, and it saves money for society. I will also say, speaking from my previous role as the executive director of a health center that also operated a shelter as well as clinics and shelters, medical respite is needed for our homelessness response system.
I've been a shelter director, had two stints as a shelter director. And one of the worst things is when you have residents there in your shelter that your staff is not really equipped to handle. And it makes it harder for that person to complete their plan to get into housing, and it makes it harder for your staff to take care of everyone else. So one of the things we really need to see is medical respite expand. And it needs to be integrated into the continuum of care, the local homeless response system, in every community. And one of the things we saw in COVID was that, for the first time, we became really concerned as a nation to an extent that I've never seen before in how are we going to protect the health of our homeless neighbors. And one of the response was for people look to medical respite. And so at the beginning of the pandemic, the National Health Care for the Homeless Council, which for 30 years has housed a respite care provider's network-- those who, like Margot, were on the front lines of providing medical respite care. We created the National Institute for Medical Respite Care to raise the profile of this as a solution. And it has succeeded far beyond our wildest dreams. More and more people and more and more communities are looking to start medical respite programs because it is successful. It works. And we just need more of it.
Calac: That was really something that I'm going to have to play back a few times because you can get so much understanding from a textbook. But when you hear people involved in these kinds of services, it really humanizes it. But it also makes it just easier to really just kind of sit with you and understand the impact that it can have among the most marginalized. And as we start to kind of transition towards the end of the episode here, I think there are so many different topics to discuss and intersections with COVID-19, thoughts about policing and its intersections with homelessness. And as a kind of shout-out right here, I'm really excited to kind of see how intentional you two have been with language. We've said this a few times, especially for the experiences of Black and indigenous individuals in the US, because you often see this kind of passive inclusion of Black and American Indian and Alaskan Native individuals. And sometimes we have the data. Sometimes we don't have the data. Often, it's undercounted or misrepresented, or it's hidden in other, multiracial, etc. But I remember, when we do have the data, it's shocking. There was a report out from the Brookings Institution, I believe, last year that talked about how, in the states with the highest American Indian and Alaskan Native population, COVID-19 mortality rates for those individuals were the same as non-Hispanic Whites 20 to 30 years older than them. So when we can see how powerful COVID-19 is--
Dr Kushal, you also pointed out how powerful housing can be, where 50 is the new 75. And that's a long-standing disparity, not a new disparity. So for this question here and thinking about how we've talked about-- each of you have actually talked about very personal and professional stories about policing and how it intersects with health. We've seen a number of calls from city leadership from San Diego to New York that call for the removal of persons experiencing homelessness from temporary camps, subways, and shelters, all in the name of public health and safety during the pandemic. And I mean, we even saw last night with the State of the Union President Biden calling for funding the police to address some of these challenges, which I think many would disagree with. Some might agree. But unfortunately, I think police-driven solutions have also included the threat of arrest. And to me, and I think many who are listening, you would think that, in a way, we are criminalizing homelessness and kind of moving back to that individual failure. So for the two of you, in the time that we have left, where do police fit into this? Should they be a part of this process, or how can we re-envision the status quo to make sure that we are lifting everyone up?
Watts: I think the question is they do-- there is a role for policing. The question is, what is that role? What is the proper role? And we see that the efforts of many localities of taking a shortcut of addressing homelessness by criminalizing it is counterproductive. Oftentimes, it has been found to be unconstitutional, but they still do it. Localities still do it because it's a way of doing something. So what should the role of police be? I think we have seen some pilots where there are social workers and sometimes people with the lived expertise of homelessness going out with the police when they know they're going to homeless encampments are going to interact with people experiencing homelessness. By and large, it's not a policing problem. It is a social work or public health problem. And so we really should have the right tool for this problem. So I was speaking with some editors of a newspaper chain to get some background, give them background information. And one of my recommendations was, do not report the-- if someone has committed a crime, do not report that they are someone who's experiencing homelessness unless it's relevant to the alleged crime. Otherwise, we're just going to have further stigmatization of people without homes.
But on the other hand, we need to point out that people experiencing homelessness are much more likely to be a victim of crime than a perpetuator of crime. And that is because they lack the very simple thing that all of us take for granted. Most of us, when we go home, we close the door and we lock the door. They don't have a door to lock. They are exposed, not just to the elements for health but also to other people, whether they are people in their encampment or people from outside who just want to take advantage of someone experiencing homelessness. So the focus of the police should be protection of people experiencing homelessness, as well as part of the larger community. And it really is to also-- if we say the model protect and serve, then they may not be the best one to meet their social service needs. But that should be part of the overall response. So I believe there is a role for police, though not the one that is usually filled by most police departments. Fortunately, there are some models, such as Cahoots - I forget what the acronym is, but it's C-A-H-O-O-T-S - that is linking police officers with other members of the social service community and people experiencing homelessness to address this as a really good model.
Krishnamurthy: Thank you so much, both of you, for this just absolutely illuminating conversation. I think we've discussed so many systemic factors that go into creating and perpetuating the cycle of homelessness. And I think a way we like to wrap up all of our episodes is for our clinicians and our listeners and our trainees heading back into the clinical world tomorrow, just putting their stethoscopes back on and going back into the hospital. What is one key takeaway that they can put into practice starting tomorrow?
Kushel: Gosh, great question. And thank you so much for including me in this incredible discussion with one of my heroes, Bobby Watts. But I will say, first of all, ask patients about their housing. Ask them in a non-judgmental way. I tend to try to normalize it and avoid the use of the term homelessness, which is so stigmatized that often, patients will say no if you just ask, "Are you homeless?" So I try to say, "I know housing is really expensive here in the Bay Area. Tell me about how that's been for you." And it really opens up a whole discussion. Some people are afraid to ask it because they think it's a Pandora's box. I will tell you, if you don't ask it, you are not knowing one of the most fundamental things that is going to determine your patient's health and wellbeing. Once you know it, you can plan together. You really want to know your resources. Do you have a medical respite center? Do you have coordinated entry in your community, which you do? Can you refer that patient there? Understand your resources in your community.
And my last plea to all health care providers is we are complicit in this if we're not part of the solution. And we have a voice that is perhaps outsized, but people trust us and they listen to us. Use that platform. Speak about the structural causes. Push back against this individual narrative that blames individuals for having these systemic-- basically being on the receiving end of systemic injustice. Push back against the language, the dehumanizing language. Push back against discussions that this problem is caused by substance use or mental health problems. I say those are illnesses, problems, complex social constructions, however you want to say it. And they don't scare me. I know how to manage them. I'm not afraid of them. These are not moral failures. These may be, in some cases, precipitates. But these are not the cause. We need every health care provider to push back against an individual narrative. And if it works for you, please borrow my personal tagline, which is there is no medicine as powerful as housing. I say that every time I can. There is nothing we can do in health care that makes as big a difference in getting someone safe and stable housing. And we need to join our voices and our political power and our moral authority to rectifying this huge racially racialized-motivated injustice.
Watts: I have to also agree that the data is the most important. I ask rhetorically. I've been asking this question for like 20 years and never get an answer because it's a rhetorical question. How, as a clinician, can you know that your treatment plan is effective if you don't know the housing status of your patient? And the simple answer is you can't. We know that, for every condition, it is harder to treat someone who is unhoused. And if they are housed, you may tell them to go and rest. How can you rest if you're sleeping on a park bench? Say get a good night's sleep? How can you if you don't have an environment where you can do that? Say take this three times a day with meals if someone doesn't have control over their meals? You say, "Take this medicine, but it needs to be refrigerated." So what we have done at the council for many years is what we call clinical adapted guidelines. So our clinicians have taken regular guidelines and saying, "When you're treating someone who is experiencing homelessness, here's how you need to adapt it to address their condition effectively." We are having a webinar series in March 2022. It'll continue as a three-part webinar series with the American College of Emergency Physicians, where we'll be looking at how they can use some of these guidelines and other ways clinicians can treat people in emergency departments effectively.
One of the takeaways -- there are many takeaways. But one of the big takeaways from my time on the federal COVID-19 Health Equity Task Force was the importance of data. And if there was a T-shirt, it would be disaggregated data. That is what we've talked about, the importance of knowing who you are serving, what people are. And one of the subject matter experts that addressed us-- and I can't remember which one, though I quote it often, is that missing race data is a form of racial oppression. If you aren't collecting the data, then you won't see the problem. And more importantly, then you can deny the problem, and with credibility because there's no data to show that it doesn't exist. So you can take that racially. You can put it in for any category. I like to say missing housing data, housing status data, is a form of housing oppression. We won't be able to treat, and we won't be able to show that this is a problem when we're looking at systems. So there are ICD-10 codes to document the housing status that should go in the electronic medical record, that it can follow the person, the patient, if the other clinicians are willing to look for it. But it is really one of the most important things that a clinician can do starting tomorrow, to ask and then code.
Krishnamurthy: Wow. There have been so many pearls dropped during this conversation, and I know I'm going to have to revisit this discussion several times before I'm able to synthesize all of this. This has just been so powerful and illuminating, frankly. And I can't thank you both enough for joining us today.
Kushel: Thank you, guys, such an honor to be with you. Really, thank you so much for inviting me.
Watts: Thank you. It's a great honor. And when I saw I was paired with Margot, I didn't know that was your intentional practice. It's a great practice, so continue it. And thank you for all you do. [music]
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