Quality of Life and Resident Stability for Homeless People

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?

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.

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.

www.sonomavillages.org