Report from the Annual Research Meeting

As it turns out, my most notable observation is from outside the conference hall. The pocket parks on the street corners in the heart of downtown Washington, by the convention center and the tourist hotels and Chinatown, are all filled with tent encampments. I've lived in D.C. for two different spells in the past, and visited regularly over the years, and I had never seen this before. I still follow the Boston news, and the biggest issue in the last mayoral race was a huge encampment at Massachusetts Avenue and Melina Cass Boulevard. We've also been reading about these encampments as a major issue in other cities, notably L.A.

There have always been unhoused people in the cities, but they've largely kept out of sight, sleeping in doorways or under bridges or in abandoned buildings. To conduct an annual census, or to get services to people, cities and agencies had to actively look for them, and knew they were missing more than few. So what has changed?

There are just a lot more unhoused people now, there aren't enough places for them to hide, and they are forming these communities. I did some reading in the local media and the D.C. authorities have been slowly but steadily removing the encampments. They recently cleared a large on near Union Station, the Amtrak gateway to the city. Supposedly, they are only doing it at the pace with which they can connect people with some sort of shelter placement and mental health services, so they hadn't gotten around to the convention center area yet. The Boston authorities made similar noises when they cleared Mass and Cass.

The unstated assumption is that this is a mental health problem -- all these people must be crazy, or why are they living in tents in the middle of the city? It is true that a portion of homeless people are, and historically have been, burdened with behavioral disorders. Back in the '80s and '90s people had this really great, progressive, humane idea that we should stop locking up people with serious mental illness in snakepit institutions and create supported housing in the community, which would be less restrictive and more integrative. So we did part A, and closed the mental hospitals, and didn't do Part B, creating the community housing and services. So a portion of that population ended up on the streets, in prison, or in nursing homes.

However, most unhoused people are not mentally ill, or if they do merit a diagnosis it's because they're depressed and anxious because they don't have housing, not the other way around. And in fact people with persistent mental illness generally can receive disability income. The problem now is that neither disability income or the income from a low wage job are sufficient to afford housing in many major cities. A lot of the people in those tents are working. We aren't suddenly having an epidemic of mental illness, we're having an epidemic of housing unaffordability. 

 

This is in part  a function of the bifurcation of incomes in the U.S. There are more people who can afford to pay high rents or purchase expensive properties, which drives prices up; but a lot of people are left behind. At the same time, the former group doesn't want cheap housing in their neighborhoods, and those neighborhoods now include places where housing used to be cheap, so they prevent it from being built. We also suffer from the assumption that people with substance use disorders shouldn't get housing until they are abstinent, when in fact it's the other way around: the best chance for people to overcome their problems is for them to be housed. That actually saves money because it keeps people out of the Emergency Department and the jail.

The lack of affordable housing is in fact an urgent public health and social crisis. But it's getting scant attention, and even less understanding.