A tent in the woods is a symbol of defiance. Whether among towering trees, on a rocky beach, or next to an icy lake, it is a marker of someone intruding upon the natural world. Even if the tent and its occupants leave no trace, the tent itself is a trace, a brightly colored sign of someone who is passing through and does not naturally belong there.
A tent on a cracked sidewalk, underneath a concrete bridge, or tucked into the corner of a parking lot is a symbol of resignation. The tent and its occupants often have no other place to go. They do not belong there and everyone—including them—wishes that they were only passing through. Alas, the tent is their home.
A tent on a college campus is a symbol of defiance. It is not their home. The tent is a vivid icon of someone who is expressing their displeasure with the status quo. The occupants want progress, they want change. Through occupying their tent in a place where it does not belong, they hope that change will come to pass.
A tent in a besieged city, its buildings in ruins and its surviving residents terrified, is a symbol of resignation. They, too, have nowhere to go. Alas, the tent is their home.
I worry how people in power, people who lie, and people who have agendas kept in shadows will manipulate the symbol of the tent. It is much easier to target tents than to recognize the humans within.
Tomorrow (April 22) the United States Supreme Court will hear oral arguments in the case City of Grants Pass, Oregon, v. Gloria Johnson. This article, 5 things to know about the Grants Pass homelessness case before the US Supreme Court, summarizes the issue well: “The repercussions could have national implications for how cities can regulate homelessness.” In short, if the Supreme Court sides with the City of Grants Pass, it could essentially be a crime to be homeless. (Note: “Homelessness” here refers strictly to street homelessness. The federal definition includes other populations that are not as visible, such as people living in shelters, people about to be evicted, etc.)
This brings to mind other information:
California Statewide Study of People Experiencing Homelessness. This came out in June of 2023. It’s one of the few recent surveys that examines mental health conditions and substance use among people experiencing homelessness. Over 3,000 people in various parts of California answered surveys and over 300 people participated in detailed interviews. They didn’t administer technical interviews to determine whether people met diagnostic criteria for psychiatric conditions. They instead asked people if they had ever experienced certain symptoms (e.g., hallucinations, anxiety, depression) or engaged in certain behaviors (e.g., used any substance three or more times a week) in the past or at the time of the interview. More than half of the people who responded said that they either had a mental health condition in the past or were experiencing one now. More than half reported that they had used substances in the past; about one-third reported that they were currently using any substance at least three times a week. (Note that “substance” here does not include alcohol or tobacco.)
JAMA Psychiatry: Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness.I have yet to read this paper. It’s a review and analysis of past research related to this topic (a research study of past research studies, if you will). It looks like they looked at specific diagnoses, with a call out of 44% of people experiencing homelessness experiencing any substance use disorder. Other highlights included in the abstract include prevalence rates for antisocial personality disorder (26%) (one of my most popular posts—from 2013!—is about this condition, for whatever reason… and I’ve been wondering about this one again), major depression (19%), schizophrenia (7%), and bipolar disorder (8%).
Open drug scenes: responses of five European cities. This paper is from 2014, though it holds lessons that we in the US can and should learn from. The information within disappoints everyone, which means it is probably a reasonable map to use.
Open drug scenes are gatherings of drug users who publicly consume and deal drugs.
To be clear, as evidenced by data shared above and from anecdotes from those of us who do this work, not everyone who is homeless uses drugs. Not everyone who uses drugs is homeless, either. Much of the current discourse about homelessness is related to drug use, though, which is why I bring up this paper.
The five cities described in the paper vary in size (Zurich, Switzerland, at around 415,000 people to Lisbon, Portugal, at 2.7 million people), though they each use similar strategies to reduce and eliminate open drug scenes:
drug dependence is a health problem
drug use behavior is a public nuisance problem
need for low threshold health services, outreach social work, and effective policing
appropriate combinations of harm reduction and restrictive measures
Law enforcement is needed to address the public nuisance problem. Robust health and social services that include harm reduction are needed to address the health problem. (At least two of the cities legalized heroin so people can use drugs safely in monitored settings, with hopes that they will one day use less and perhaps stop. Recall that this paper came out before the destructive wave of fentanyl overcame us.) Most cities have yet to find the “appropriate combinations” to reduce open drug scenes. (Just to reiterate, these strategies did not eliminate homelessness, only open drug scenes.)
Textbook Talk: Dr. Van Yu on Housing First and the Role of Psychiatry in Supported Housing.One significant way to eliminate homelessness is to ensure that people have places to live. Lemme tell ya: It is hard to effectively treat someone’s mental health or substance use disorder if they don’t have a stable place to live. If the person can’t or won’t come to you, that means you have to go to them. If you can’t find them (because they don’t have a place to live so they move around a lot), it’s hard to make a connection to help them. Even if they want to participate in treatment, it’s challenging to Do All the Things when you don’t know where you are going to sleep. Can you imagine what you’d do or how you’d feel if you didn’t know where you were going to sleep tonight? Seeing a health care professional likely won’t be your priority. Working in a Housing First or other public setting also changes the way you think about health care: Your interventions don’t just affect one person; they affect a whole community. Conversely, the community influences your interventions as a health care professional. We naturally become systems thinkers. (Full disclosure: Dr. Yu was once my boss. I learned and continue to learn a lot from him.)
I will follow the City of Grants Pass, Oregon, v. Gloria Johnson case with interest. The problem of homelessness is complex because people experiencing homelessness each have distinct challenges. They are not a monolith. I believe that there are government officials who are sympathetic to their circumstances. I still wonder, though, what problem are they trying to solve? Is it that they don’t want people to live outside? Or that they don’t want to see people living outside?
“Down and Out” refers to people who live in impoverished urban areas. More specifically, people who live on “skid row” are “down and out”. (The term “skid row” likely originated in Seattle. As noted in both the Underground Tour and Beneath the Streets Tour in the Pioneer Square neighborhood, tree logs cut from the hills were pushed down Yesler Way towards the waterfront. Logs skidding down Yesler Way led to the name “skid row”.) These days, “skid row” typically refers to centers of poverty in cities where homeless people often reside. This is paired with…
“On the Road” refers to people who were homeless and, in trying to search for work, rode the trains. They often did not ride in the train, but rather on or under the train. These same individuals might reside in “down and out” areas upon arriving in a city. During the 1800s, people who were homeless were often associated with riding the rails than living in skid rows.
The term “the jungle” has been used to describe homeless encampments for nearly 200 years. In recent years here in Seattle, “the jungle” has referred specifically to a large encampment tucked under many trees in an undeveloped area near Interstate 5. This “jungle” was also notorious in the local press for violence (and was subsequently razed, though it seems that there are evergreen efforts to revive it). Over the past 200 years, people who had no place to live set up camp in forested areas (“jungles”) outside of urban centers, which developed into communities.
Cycles of romanticizing and vilifying homeless people are not new. People with no place to live are poor. Because the working class recognized how similar their struggles were with people who were homeless, they were (and continue to be) consistently more sympathetic, empathetic, and generous to them. Other classes, though, have swung between perceptions that people who are homeless are harmless—perhaps even charming (see Norman Rockwell) to lazy, deviant, and dangerous. (Other indicators include The Way It Is and Mr. Wendal, both excellent songs.)
Homelessness is a consequence of poverty. When I first received the book, I confess that I was dismayed to see in the index that “mental illness” is mentioned on only four pages of this ~250 page text. Kusmer, the author, provides a compelling historical account that various systems, including government policy (or lack thereof), economic forces, and cultural values are the chief drivers that lead to people becoming poor. Poverty is a major risk factor for homelessness. (I know this from my own anecdotal experience: Most people who are homeless do not have a severe psychiatric illness like schizophrenia. People often develop psychiatric symptoms because of homelessness. Even if every single psychiatrist in the nation worked with people who are homeless, homelessness would persist: There are plenty of people who are unhoused who do not need psychiatric treatment. They need a place to live and ways to have money to pay for living expenses.)
There was a federal program to address homelessness! Homelessness has been and continues to be a nationwide problem (regardless of the size of the US throughout time) that requires a federal response. The Federal Transient Service (FTS) was the first (and only?) federal agency in US history whose goal was to aid people who were homeless and unemployed. It started in 1933 and only lasted two years, in part because it seemed “successful”: The number of homeless people dropped, so everyone thought the problem of homelessness was solved. FTS funds were swept to support public works and Social Security. (In theory, public works and Social Security seemed like better investments to prevent homelessness.)
The disproportionate number of homeless people who are Black is not new. This is another legacy of slavery. A number of minority populations (e.g., Native Americans, Mexicans, women) suffer from homelessness because of policies and practices related to economic and class exclusion.
Down and Out, On the Road: The Homeless in American History was published in 2002. My sense is that the author, when viewing the current state of homelessness in the US, would continue to argue that the forces that contribute to poverty remain the primary driver of homelessness. I think he would continue to view mental illness and substance use as distractions and not significant causes of homelessness. (To be clear, I don’t think he’s discounting psychiatric conditions as contributors to homelessness for specific individuals, particularly since psychiatric conditions, both directly and indirectly, can pull people into poverty.) I appreciate how he ends the text:
The compulsion to stereotype the homeless as dependent and deviant turns the poorest Americans into an abstract “other,” separate and inferior from everyone else. Although their problems are more severe, however, destitute people living on the streets and in homeless shelters are not so different from the rest of us. They never have been. Any genuine effort to end homelessness must begin with a recognition of that essential truth.
She was unprepared: One woolen blanket was wrapped around her shoulders. The other one was spread out so she did not have to sit directly on the ivy and weeds crawling across the hillside. A nylon sheet was rumpled by her side. Behind her was a pushcart that held a thin roll of garbage bags and a small empty cardboard box. There was no tent or sleeping bag. Though there were other people higher on the hillside, there was no one within earshot.
Most of the pages in her notebook were blank. The pen ink was bright turquoise; her penmanship was small and neat.
Small metal studs adorned her ears and a chunky chain was around her slender neck. Her hair was dyed an unnatural color and showed no signs of fading. The only hints that revealed that was not brand new to the hillside were the dust on her fashionable sneakers and the dirt that was collecting underneath her short fingernails. She also said that her phone had run out of charge.
She is not yet 20 years old.
I don’t expect that they are still alive, though I still think of them even when I’m not visiting New York City.
I met her when she was in her mid-60s. She never told us where she slept, though we reliably found her at the ferry terminal. Her fingers moved the needle and thread with ease to close the hole in her sock. She kept spools of thread in a plastic container that sat on the bundle of clothes she packed into her pushcart. Despite our best efforts for over two years, she never accepted housing: “The aliens will exterminate me if I go inside.”
I met him when he was in his 70s, or so we thought. No one knew his birthdate; he never shared this information. He buried himself between mounds of full trashbags or folded himself into cardboard boxes lining the curb. On the few occasions he spoke, the thinness of his voice—sometimes so faint that it seemed that only wisps of his speech reached my ears—betrayed his age.
Back here in Seattle, as elsewhere, there are people in their 70s and 80s who live outside or in shelters.
Why do we consider “extremes” of age (though being in your late teens or your 70s is not actually “extreme”) as a factor that contributes to vulnerability when homeless? If you’re a 51 year-old man and you don’t know where you’re going to sleep tonight, doesn’t the variable of not knowing where you’re going to sleep tonight automatically make you vulnerable? Sure, you may have the size and mass to successfully defend yourself if someone attacks you or the ability to endure nighttime temperatures, but is that really where we’ve set the bar for vulnerability?
The reason behind my recent silence here is I am attending to a beloved family member whose health continues to deteriorate. Surely other medical professionals have written about the difficulties of our roles and responsibilities: We are not (and should not be!) doctors or nurses for the ones we love, though it is difficult to push the professional knowledge out of our minds. Sometimes (often?) it doesn’t feel like love is enough, even as we realize that our professional knowledge isn’t enough, either.
I have spent most of my career working with people experiencing homelessness. I don’t recall newspapers and other media writing about this topic as much as they do now:
Homelessness is a federal problem. Was there ever a time when the feds tried to solve the problem of people having no place to live? What is the history of homelessness in the US?
Well, there’s actually a FREE, short paper (it’s an appendix!) from a long report about permanent supportive housing with the title “The History of Homelessness in the United States“. That article led me to the book Down and Out, On the Road: The Homeless in American History. I’m about 80 pages in and, so far, it’s not encouraging. The arguments and opinions about homelessness from 100 and 200 years ago are similar to what we hear now in 2023 (deserving vs. undeserving poor, work tests, etc.). I’m hoping the author will describe the intersections of homelessness (“vagrancy”) and health, including substance use (alcohol? opium?) and mental illness.
If this problem were easy to solve, we would have already solved it… right?
The inimitable Ed Yong is leaving The Atlantic! His stellar writing about Covid over the past three years were invaluable to me: Not only did he provide meaningful analysis about how Covid was affecting individuals and populations, but he also accurately captured the horror of what was happening.
In his recent newsletter, he shared the following:
… I want to double down on my journalistic values: not only describing what is happening but helping people actually make sense of it; bearing witness to suffering; speaking truth to power; revealing wonder in the obscure; and pushing for a more just and equitable world.
He has succeeded in adhering to his values (and received a well-deserved Pulitzer along the way). This has prompted me to consider what values I hold in my writing. (Are the values I hold in my professional role transferrable to my writing? Is writing part of my professional role? Why am I mincing my life into roles when they are interconnected, as per the first paragraph of this post?)
If you’ve seen the Barbie movie: I know most people are fawning over the song “I’m Just Ken”, but “Push” is the underrated gem. I’ll never hear the word “granted” the same way again.
Maria Yang, MD 