Over the last decade, cities up and down the West Coast have seen a tsunami of homelessness flood their streets. Encampments dot freeway underpasses, parks, and city downtowns. Distressed people languish on street corners and sidewalks. Cities, big and small, must grapple with what to do about it.
The most recent count by the federal government found that more than 200,000 people experienced homelessness in California, Oregon, and Washington in 2022. The growing crisis has become a pressing political concern for voters and politicians. The new mayor of Los Angeles and new governor of Oregon, for example, each declared homelessness a state of emergency on their first day in office. The governor of California has, similarly, made fighting homelessness a top priority.
Living in California, I've found the intractable homeless crisis to be heartbreaking and infuriating. And I've been inspired by public servants who are working to find solutions to the problem. Which is why I've been closely following the career of a former classmate of mine. His name is Andrew Boozary, and he's a primary care physician in Toronto who has become something of a rock star in health care. He serves as the executive director of the Gattuso Centre for Social Medicine at the University Health Network, the largest research hospital in Canada.
Boozary and his hospital have been doing innovative work to help people experiencing homelessness, including the launch of an exciting new project to build and provide permanent housing for the most vulnerable. It's part of a broader movement of hospitals, both in Canada and the United States, to improve health outcomes for homeless patients by providing them with what might be considered the ultimate in preventive care: the stability and dignity that comes with having a permanent home. The policy, obviously, benefits those struggling on the streets, but it also helps hospitals cut the massive costs of caring for homeless patients who frequent their emergency rooms. With the project slated for completion this year, Boozary will soon be able to essentially write a prescription for housing to those who need it most.
As his job title makes clear, Boozary is a practitioner of social medicine. It's a field that sees individual health as more than simply a function of our diet, exercise routine, genetics, and so on. It recognizes that our health is inextricably linked to our social and economic condition.
"The air you breathe, the job you have, the income and social connections you have, are a much larger driver of health outcomes than how many primary care visits or surgeries you get access to as a patient," Boozary says.
The social and economic determinants of health are devastatingly clear for the homeless population. "The life expectancy for people surviving homelessness is half that of the general public," Boozary says. "That's clear both in US and Canadian data. So this is a terminal condition. And so this is a moral imperative, but also an issue where we need to be clear about the cruelty we are imposing with the status quo."
There are many factors that can contribute to people living on the streets: poverty, childhood trauma, mental health issues, drug abuse, bad choices. But study after study finds a central factor behind the growing crisis is pretty simple: a lack of affordable housing. Economists at Zillow, for example, found that when the typical resident of a city must spend more than a third of their income on rent, homelessness begins to skyrocket. Another study, conducted recently by researchers at Stanford University, finds that the explosion of homelessness in California over the last decade can be largely explained by the growing housing affordability crisis in the state. "High housing costs and a low stock of affordable housing create a precarious situation, especially for lower-income families and individuals who are at higher risk of becoming homeless," the researchers write.
Researchers compare the effects of housing scarcity on homelessness to a game of musical chairs: when housing becomes scarce, high-income folks end up living in spots that used to be reserved for middle-income folks, middle-income folks start inhabiting formerly low-income units, and the most vulnerable low-income folks are pushed onto the streets. It's why advocates like Boozary call for a "housing first" approach to ending homelessness. Housing those who need it, Boozary says, is a necessary first step, providing people with the stability needed to solve other problems that may have resulted in them becoming homeless in the first place.
But, of course, building affordable housing is easier said than done. It costs lots of money, and, at the local level, homeowners show a propensity to fight tooth-and-nail against development projects that might bring low-income residents into their neighborhoods. Last year, for example, a proposal to convert a hotel into homeless housing in San Francisco's Japantown was shot down after fierce protests by residents of the neighborhood.
Our neighbors to the north, with their universal health care system and friendly disposition, may have a reputation for greater government support for those in need. But, Boozary says, Toronto also has a serious problem with high levels of homelessness. And like here, NIMBYism and lack of adequate taxpayer support have posed a challenge to tackling the issue. True, Toronto has a more extensive shelter system than many cities here, especially on the West Coast. But Boozary hardly sees shelters as the solution to the problem.
Boozary says Toronto's homeless population now numbers nearly 10,000 people. The city's shelters are overflowing and their public housing has multi-year waiting lists. More importantly, he says, at best, shelters and other forms of short-term housing are only a temporary fix. "Unless we actually address the pathologies of poverty — with proven treatments like housing for all — this crisis will only compound in the coming years," Boozary says.
As a doctor, Boozary has come face-to-face with the health challenges of the homeless population. He and his colleagues have spent years feeling the frustration of "prescribing things that we know aren't gonna work" and knowing "with a high degree of precision, who's at the highest risk of being back at the hospital in 10 to 20 days," Boozary says. "It's the person who has no fixed address, who doesn't know where they're going, who is leaving with some plastic shopping bags versus someone who's being picked up by family members or an Uber black car."
Which is why Boozary and his hospital partnered with their city government and the United Way of Greater Toronto to build a new, four-story building on hospital land to provide permanent housing to those grappling with homelessness. This multimillion-dollar project, scheduled to open this summer, is essentially a form of public housing where doctors are triaging and identifying who most needs a home.
The first phase of this new program, he says, will amount to more than 50 units that will provide people with their own bathroom, kitchen, and bed. Boozary hopes to see the program scale and dramatically reduce the number of homeless people.
Boozary says it's not only a matter of social justice, but sound economics. "It could cost about $30,000 or more to have a patient on a hospital ward for a month, or nearly $7,000 to be in a sheltering system for the month versus $2,500 to $2,800 per month for supportive housing," he says.
Other hospitals in the United States that are getting into the housing business have come to a similar conclusion. "Many hospitals realize it's cheaper to provide a month of housing than to keep patients for a single night," Kaiser Health News reports. But while other hospitals have focused on providing temporary housing to homeless people, University Health Network is focusing on making permanent units.
In addition to the program aimed at providing permanent housing to homeless people, Boozary's hospital also funded a program that provided food boxes to them during the depths of the pandemic economic downturn.
"I, in my medical training, never thought that I would be prescribing food or housing," Boozary says. "This should not be the case. But that's the desperate state of poverty we're in. What would you have us do as health workers?"
Boozary is quick to point out that the programs his hospital is pursuing won't alone solve the problem of homelessness in Toronto. But he hopes his program will prove effective and scalable. At the end of the day, Boozary says, only political will and large public investments in housing and community social work will end the homeless crisis.
Of course, there are people on the other side of the aisle who don't think the problem, at its root, is housing. They paint this crisis as more about drugs and mental health than structural and political problems in our society. They argue that the focus should more simply be on breaking up encampments and enforcing laws.
But that, Boozary says, won't really solve the problem. It will only prove to be like a game of whack-a-mole, where encampments just sprout up in other locations. It's easy, Boozary says, to stigmatize the homeless. To paint them as merely a bunch of lazy drug addicts or people with severe mental health problems. "This is the systemic discrimination against people in poverty in play. How else could you accept the health outcomes of people living half as long?" Boozary says. "My point back is try to spend a week in a shelter, sleep there and then let me know how your mental health is doing a week later."
Boozary was inspired during the pandemic, when he saw the political will to address the problem of homelessness finally manifest itself. Many cities did things like convert empty hotels into housing and provide resources directly to homeless people.
"It seemed like for a moment, we understood the issue when we were trying to prevent the spread of an airborne pathogen," Boozary says. "Of course, our policymakers got people into housing, establishing hotels in place to ensure that we can stop the spread."
But now, Boozary says, with the pandemic effectively being treated as over, the political will to provide immediate access to housing has waned. Many of the hotel programs have ended. But the crisis confronting people on the streets has not.
Politicians up and down the West Coast declare that solving this problem is a top priority. But NIMBYism and political dysfunction continue to block progress. Maybe a doctor in the house is just what we need to prescribe the cure.