For today,
my colleague Conor Dougherty spoke with Dr. Margot Kushel, a leading
homelessness researcher:
Margot
Kushel is having the moment she never wanted to have.
Dr. Kushel
is an internist at the University of California, San Francisco. She started
specializing in low-income populations shortly after graduating from the Yale
School of Medicine, and has spent two decades researching the underlying causes
and consequences of homelessness in relative anonymity.
Lately,
however, she’s seen her profile rise, as the problem she has spent her career
trying to solve has escalated.
Last year,
Dr. Kushel was named director of the Benioff Homelessness Initiative at
U.C.S.F., which was endowed with $30 million from Marc Benioff, the billionaire
founder of Salesforce. The initiative is focused on translating proven homeless
solutions into widespread adoption and continuing to research what isn’t known.
Dr. Margot
KushelNoah Berger
Here’s the
conversation, edited and condensed for length:
Tell me
about your career and how you ended up specializing in homelessness.
When I
started residency, I realized that approximately half of the inpatients we
cared for were homeless. We would admit patients to the hospital, give them all
this very high quality, expert medical care, and then, eventually, we would
have to discharge patients back to their homelessness, meaning to outside.
Patients would ask me to please not discharge them, but eventually we wouldn’t
have a choice. Inevitably, a few days later, the patient would be back, often
in worse shape than they had been in before. I remember thinking that there had
to be a different way and decided to change my career plans.
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What was the
state of understanding of homelessness when you first got started versus what
we know now?
When we
first started, people believed that to provide housing, people needed to go
through steps. First, a shelter. Then, if they “behaved well” (didn’t use
drugs, took medicines, etc.), they could get to transitional housing. If they
did everything “right” then they could be offered permanent housing. As a
result, only a tiny proportion of people with behavioral disabilities became
housed.
Housing
First turned that upside down, recognizing that when people were homeless, they
couldn’t attend to their mental health or substance use needs (or anything
else). This has been enormously successful, housing about 85 percent of the
most complex folks. There is overwhelming and incontrovertible evidence that
this works — people are housed successfully, and then the other things follow.
What are
some of the myths around homelessness?
You hear
people saying things like, “You can’t just house people who have addiction
problems.” You can, and you must. Another is that homelessness is caused by
mental health and substance use problems. We know that most homelessness is
driven by economic forces. The vast majority of people who become homeless
could be easily housed if there were housing that they could afford on their
income. Yes, having mental health and substance use problems are risk factors.
But, most people with these disabilities are housed.
[Read more
about who becomes homeless and how to help them in The Times’s Your Lead
series.]
What don’t
we know about homelessness?
There is a
lot more work to be done in homelessness prevention. We know that for some
people, a small infusion of resources (cash, services) can prevent
homelessness. But, for every 100 or so people at high risk, only one will
become homeless. So, we need to do a better job of figuring out how we can
target efforts.
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Most people
who become homeless “self-resolve,” meaning they find housing. We don’t know
how long that takes, and whether we could shorten it substantially by
intervening. We know that for most people, long-term subsidies are the answer,
but there may be people who need shorter term help. We are going to try to
figure out who needs what, while working to solve the main problem, which is
the shortage of extremely low-income housing.
What would
it take to end homelessness?
We’ve always
known that most homelessness is a result, pure and simple, of poverty: the lack
of a living wage, the lack of affordable housing and the insidious impact of
racism. If we don’t fix the fundamentals, we are just patching a leaking ship.
And that is what has happened.
It would
take an investment in creating and sustaining extremely low-income housing and
efforts to increase the minimum wage and to close the existing housing gap.
Right now in California there are 22 units available and affordable for every
100 households with extremely low incomes.
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Some people
will have disabilities that require assistance, and we need to provide that.
The V.A. has leaned in hard to the Housing First principle and has seen huge
reductions. Taking a page from what the V.A. has done, we can solve chronic
homelessness by fully funding permanent supportive housing.
For everyone
else, we need to focus on increasing the supply of extremely low-income housing
by building very low-income housing, preserving what exists, and providing
sufficient vouchers (right now, only a quarter of households who qualify get
them).
It has been
profoundly dispiriting to see, for so many years, the issues of housing
affordability/living wage, and homelessness ignored on the federal level. And,
it has been hard to see the disconnect in people’s mind between housing and
homelessness.
My stomach still felt bad. I hit the toilet
again and did some clean-up.
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