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| J. Scott Wagner |
In September 2019, Dr. Joshua Bamberger gave the
keynote speech at the Festival of Belonging in Santa Rosa California. One of the things he said was that there is no evidence to prove
that staying in a shelter is better than living on the street.
Then, in October, a UCLA study seemed to say something similar. The study said, “While individuals who are sheltered report on
average fewer health and mental health conditions, the data does not support
finding that shelter is the cause of improved health. In fact, it is just as likely that people who
are unsheltered for long periods of time are those who cannot access shelter
for a variety of reasons. The findings do reinforce the importance of stable
housing as a social determinant of health and as essential for ending
homelessness, for people in both groups.
Scott Wagner’s response follows.
Quality of Life and Resident Stability for Homeless People
In the UCLA study, two facts and an
assumption are being juggled, and the connection between the three is held
unrealistically to be impossible to ascertain causally:
1) people who are a challenge to
house never even get to shelters or housing, and have very bad health,
especially women;
2) people who are on the street who
can be successfully sheltered or housed have unknown health; and
3) the people in "safe
housing" have much better health than the average homeless person.
We are then asked to believe that,
since the study authors understandably couldn't divvy up populations 1) and 2),
that all the bad health outcomes of life on the street might only belong to 1),
the people who can't get housing. So therefore, we can't say that shelter
improves health, because population 2) might secretly be on the street but just
as healthy as population 3) anyway. Maybe shelter has nothing to do with
health. "There is no evidence."
Think about the stilted logic of
that for a second. And then think about how dangerous it is to pass on anything
like that lesson in the context of how we always try desperately to get people
out of the weather however we can.
There is a TON of evidence that
shelter, of any kind or quality, improves health.
The very best and most important evidence is that people who are staying in any
kind of a shelter are there voluntarily, precisely because they believe,
typically fervently, that it improves their health. Anyone trying to save
people on the street from death, abuse, and disease do not need any god damn study to clarify that. I just
spent two weeks with two evicted low income people, struggling mightily because all three
of us were deathly worried about the health implications of being outdoors. We
are happy that we were able to avoid that via a dorm shelter for one, and an
sober living environment for another.
It was counterproductive for Dr.
Bamberger to denigrate "shelters" the way he did. The study itself
says that homeless people "report worsening health conditions the longer
they are homeless." Does that sound like "there is no evidence"
that shelter improves health? The fact that emergency shelters are
sometimes deeply flawed should not blind us to their value to health, comfort,
service access, food, and a form of community. We must also stop the deep
prejudice against "temporary", in a world where a day out of a
freezing rain is a precious commodity, whether measured mentally or in terms of
health. Just because the shelter experience is months instead of years does not
make it valueless.
Shelters:
Quality and Funding
And where is the vital discussion about
how much of a difference quality and budget can make in a shelter? Maybe we
shouldn't bother with quality concerns, since "there is no evidence"
shelters do any good anyway---? How can we have drifted so far away from
reality that neither this study nor Dr. Bamberger even talked about shelter
quality as a key dimension of the story?
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| Dr. Joshua Bamberger |
What people hear when they hear
"there is no evidence" is that a shelter of any kind or quality is
worthless or a waste of money, that it doesn't improve health, or it's no
improvement over life on the street. That's not what "no evidence"
means, but that's what we hear, and I believe that's what Dr. Bamberger
deliberately conveyed as he tried to have us aim higher. We should all
repeat to ourselves when we hear this kind of thing that we know that voluntary
shelter of any kind saves lives and health relative to the alternate. We should
remember our friends struggling to get into and stay in those difficult
places.
The study does what Dr. Bamberger did:
"shelter" is damned with "there is no evidence" talk, while
the vague "stable housing" or "permanent housing" (which we
know is in reality a six month or one year lease, typically with poor case
manager support and double-digit eviction rates) is held up as the clear,
noble, only acceptable end. As if they two were night and day, evil and good.
They are not. They are along the continuum of shelter, and their qualitative
relationship is decidedly less clear-cut than implied.
Services
And where do services come into this
picture? How realistic is it to speak of shelter or stable housing without a
word about services, as they do here? How much confounding of data are we
wading through as we ignore homeless people's capability and needs this way, ignore the
fact that housing of any kind is fine for some without services, a nightmare
for others without services, and an unknown morass of difficultly for most
without targeted services?
The study says, "People with
the longest experiences of homelessness, most significant health concerns, and
greatest vulnerabilities are not accessing or being served by emergency
shelters." This is treated like a shocking secret that scientists are
revealing for the first time. But we
already knew this very well. We know
there are dozens of reasons for shelter unsuitability, most notably that people
are afraid of dorm shelters because they're somewhat dangerous, they're
depersonalizing and stressful, and because many of the most
"vulnerable" are dangers to others.
This limitation of shelters for various homeless people is an
entirely separate, unrelated point to health concerns. Most of that limitation
is not only perfectly understandable, it is often a very desirous limitation.
Yet this limitation is being swirled in with the other confusing points about
health outcomes so that the shelters' vital role in the housing ecosystem is
completely overlooked. Shelters don't
serve who they're "supposed" to, the "most vulnerable"– and
even if they did, "there is no evidence" that the many people who are
DYING to get into the shelter are improving their health outcomes there over
street life. It's so hard to tell if
emergency shelters help homeless resident's health that the careful scientists are stumped,
stumped, stumped.
Come on!!
It's not a minor point that these
points are addressed so poorly. We have to understand and promulgate the
subtleties of these things, and stop getting swept into toxic Housing First
generalizations. As I told Dr. Bamberger, there is a terrible manipulation of
concepts and terminology. What are: shelter; housing; evidence; permanent;
wraparound; vulnerability? Denigrating
emergency shelter feeds right into conservative and hardcore Housing First
mindsets that we are morally obligated to not spend money on
"shelter" because "there is no evidence" it does any good,
and it's stealing money from permanent housing. Dr. Bamberger implied exactly
what I hate hearing from some local leaders, that any form of
shelter other than some high-gloss house-on-the-hill with wraparound whatever
is a waste of time.
Tiny
Home Villages
There is a related
danger for SAVS* in all this
thinking that I alerted Dr. Bamberger to. Let me ask this: do we seriously
think what SAVS is doing will be considered anything other than "emergency
shelter" or the "shelters" which Dr. Bamberger castigated so
enthusiastically? We are just considered a twist on Sam Jones by almost
everyone. "There is no evidence" that what we are trying to do will improve
health outcomes.
Perhaps you heard
Dr. Bamberger lump tiny homes in with "shelters" in his "there
is no evidence" point. "Maybe it'll be better, who knows, we can try
it" was the damning faint praise, as I recall. Not a word about case management
quality, or self-management, or resident-centered approaches, or consolidated
services, or the advantage of privacy, or community integration, or any
useful distinction between shelter forms along the dimensions
that we know determine life quality and resident stability. Yet these are
characteristics that no doubt are part of the Lyons community he glossed
quickly over as successful.
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| Tiny House in Seattle, similar to those planned by SAVS |
I tried in a few
minutes to sketch for Dr. Bamberger that a home is something you can have partially,
as in containing many of the deli of characteristics of an optimally healthy,
permanent home and community – that a shitty emergency shelter provides say
40%, if you will, for those who can stand being in it. That we are trying to
provide a 75-80% solution. That both shelter types are noble and vital attempts
to supplant the police and criminal abuse, lack of shelter, and often
toxic community bonds of the street. That a 75% solution might give us amazing
outcomes, and can be refined through time. That 75% solutions may end up being
all that are realistically doable in the coming decade or two, since providing
a 75% solution is a tenth or a twentieth or thirtieth of the cost of the 100%
solution.
The worst of it for me: Dr.
Bamberger's unspoken assumption that there is 1) some set amount of money for
homes and emergency shelters and services combined, and 2) it's tragically so
very limited, and so 3) we must be moral and choose between these programs, to
allocate the precious available capital to "evidence-based" outcomes
(which everyone mouths together is: "permanent supportive housing with
wraparound services.")
This is a terrible set of
assumptions, and it is a kindler and gentler version of an exact set
of assumptions that I dealt with month after month in conversations with a
local leader. In reality, permanent housing and related services and emergency
housing and its related services must be considered two separate budget items,
as different in purpose and technique as physical and mental health are. The
two must each be funded adequately based on need and ability, with only small
regard to each other. There isn't a tradeoff between them. They're not even
funded the same way! Permanent housing is mostly a long-term investment funded
almost solely by bonds, while the other is funded through various year-by-year
taxes and (hopefully) assessments. Pretending they require endless zero-sum
choices between them is a game our enemies like to lure us into to keep our
efforts sidelined.
Housing
First
"Housing First" is
accurate in the simple, pedestrian sense that the housing budget line item
should be bigger than spending on emergency services; "Housing First"
is dead wrong in the sense that, if you are trading away emergency services and
shelter because you are prioritizing permanent housing over it, you are
engaging in a cruel abuse that is no different than spending that money on
computers or roads instead.
I think it's urgent to defend
emergency shelters and any other form of shelter from "there is no
evidence" talk, if for no other reason than to sketch this big picture for
people accurately. We must remember that local homeless people are clamoring for all of
it, because they know things that scientists apparently can't begin to grasp.
Keep these problems and issues we have separate and clear from the overall
need. Yes, we have problems with dorm shelters– but we need MORE local,
hopefully smaller emergency shelters, dorm or not. We have so few that we
can't segregate the populations commonsensically for safety and quality of life
purposes. This is an example of where Housing First pretends we can mix
high and low vulnerability willy-nilly, no matter the particulars of the
"vulnerability."
Elsewhere,
Housing First pretends
that we should spend massive amounts on high vulnerability and not even
budget
money for low vulnerability people, in an almost conscious attempt to
ignore resident capability as a vital dimension of success. These twin
abuses of
vulnerability and capability upend the whole system, and will give SAVS
lots of
challenges in the years ahead.
I
agree very much with most of the
spirit of Dr. Bamberger's talk, but I am concerned at how we mistake the
game
we're playing, and we fall into the pitfalls of the
Housing First morass. Let's be clear: we need more and better of it all –
villages, shelters, downtown bathrooms, day centers, safe parking,
organized
tent encampments, and case management. There is no competition between
these
things, only a throbbing, blindingly large need across the whole
spectrum. We need
to strategize success at SAVS by wisely considering both capability and
vulnerability of the formerly homeless residents. And we need to
emphasize that targeted services are the key to making progress for
homeless people in the long-term.
* SAVS (Sonoma Applied Village Services) is a 501(c)3
nonprofit organization committed to creating safe villages where formerly
unsheltered residents live with dignity and self-worth. SAVS, in partnership
with housed individuals, neighbors, health care providers, volunteers, and
local officials, facilitates a shared understanding of needs, perceptions,
responsibility, and accountability in order to create these villages. SAVS
leverages that understanding to provide basic shelter and security in a
cooperative atmosphere to support village residents to attain their personal self-improvement
goals. SAVS also advocates for homeless rights as a whole and works with
its sister organization, Homeless Action!, a Santa Rosa grass roots activist
group.
