Vinayak Bharne: Mainstream definitions of ‘health’ have seen a significant broadening in recent times and the term ‘wellness’ has now come to the forefront. If health is the absence of disease, then wellness is about taking one’s health to the highest potential through daily habits and choices. As someone working closely with vulnerable populations who simply do not have the circumstances to make such choices, how do you see this broader issue?
Anne Miskey: While it is true that definitions around health and wellbeing have broadened over the past few years, the very fact that we think of them from a framework of self-care and self-actualisation creates problems for those experiencing homelessness. It feeds into the idea that it is solely about people making personal choices that negatively affect their wellbeing, rather than them being victims of a system and society that has excluded them from accessing those very things, which help create health and opportunity.
There is overwhelming evidence that total wellbeing is as much about where you live, as it is about personal choices. Improving health – both mental and physical – starts with stable housing and then ensuring access to healthy food, good schools and jobs that provide adequate incomes for individuals and families. Often, however, our society has been guilty of sending poor people to live in urban ghettos with poor schools, no jobs, little access to health care, lack of green spaces and constant housing insecurity, leading to poor health and ultimately, for many, to homelessness.
On top of limited access or lack of access to these basic determinants of health, those who have been relegated to poorer areas often lack access to what we sometimes think of as ‘nice to haves’ but which, in actual fact, are vital to a vibrant and healthy community. Access to arts and recreation create wellbeing, human connections and opportunities for self-expression. These things, along with stable housing, food, education and jobs build health, resilience and possibilities for people to grow, expand and thrive.
The causes of homelessness change across geographies and societies because histories, policies, governance mechanisms and socio-cultural perceptions are different from one society to another.
What are the principal causes for homelessness in the United States, the wealthiest nation in the world?
Unlike in many other parts of the world, homelessness is a relatively new phenomenon in the United States. It arose in the late 1970s and early 1980s as a direct result of the disinvestment in affordable housing by the federal government, the ongoing lack of investment in social programmes, the for-profit healthcare system and policies like the war on drugs and mass incarceration.
We know how to end homelessness for individuals and families, but due to many complex systemic aspects, it is an uphill battle
But what, perhaps, has exacerbated the issue in this country and which has led to an increase in the numbers of those experiencing homelessness is the strong individualism that is part of the fibre of the American psyche – the idea that the United States is the land of opportunity, and if you are not successful, then it is your own fault. This view has created a pervasive stigma that attaches to those living in poverty and especially towards those experiencing homelessness. They are poor or homeless because they are ‘lazy’, or because they ‘choose’ that lifestyle, or choose to become addicted to drugs or alcohol. This idea was clearly articulated by Ronald Reagan, often seen as the father of homelessness in America, who talked repeatedly about ‘welfare bums’. His views on poverty and homelessness have suffused successive local, state and federal government policies since his administration and have led to the consistent underfunding of affordable housing, healthcare and other measures that could reduce or prevent homelessness.
Sadly, this same individualism also permeates the world view of those who experience poverty and homelessness themselves causing a sense of isolation and personal failure. This, in turn, exacerbates trauma, lowers self-esteem and makes it more difficult for people to turn to others for help.
Tell us about Union Station Homeless Services. How has it tackled the issue of homelessness in its region? What are its most significant success stories that others could learn from?
Union Station Homelessness Services has been in existence for almost 50 years. Based in Pasadena, California, it acts as a lead county agency, coordinating homeless services in 32 communities, with a combined population of over 1.5 million in NE Los Angeles County.
Like many organisations of its kind, Union Station was started in the 1970s by a handful of good-hearted members of a local faith group who were disturbed by the reality of people in their community living on the streets. After a few years as a church-led programme, it eventually became licensed as its own, non-church affiliated non-profit in 1984, with an independent board of directors and full-time staff.
The organisation grew to be one of the pre-eminent homeless-serving non-profits in Pasadena and Los Angeles County due to the quality of its services. In the early years of its service, Union Station was primarily focused on providing emergency support such as meals and temporary housing (shelters). It did offer a number of programmes, but these were based on a compliance model, which required people to adhere to specific behavioural programmes and to graduate from these programmes before they were deemed ‘housing ready’.
This compliance model was standard in most parts of the western world and was predicated on the belief that it was the individual’s own behaviour that was the cause of their homelessness, rather than external forces or systems, such as racism or lack of affordable housing. The focus was less about ending homelessness than it was on ‘fixing’ the individual or family.
It was during the late 1990s and early 2000s that this compliance model began to die out as it was shown to be much less effective than the new Housing First approach. This approach prioritises providing permanent housing to people experiencing homelessness and then offering, but not mandating, wraparound services to help them stabilise, pursue personal goals and improve their health and quality of life. Additionally, Housing First accepts that personal choice and client leadership is essential and results in a higher success rate for clients in obtaining stability and remaining housed.
Creating social health means intentionally looking at ways to develop a supportive and nurturing environment that welcomes rather than excludes those who are most vulnerable
By 2010, Union Station had embraced the Housing First model, and while it still continued to provide emergency services, its efforts were redirected towards permanently ending homelessness for those it serves.
Along with this new focus on housing and permanent solutions, Union Station also embraced a model that focused on building authentic relationships of trust with clients and acknowledging that they were best able to direct their own path towards personal wellbeing. Union Station and its staff became partners with clients, listening and learning from them and their experiences, and walking beside them on their own personal journeys, rather than attempting to ‘save’ them based on the idea that the staff knew what was best for them.
This new model recognises that trauma, broken systems and lack of support have led people into extreme vulnerability and homelessness – but that human beings are, by nature, resilient and can, with the right supports and opportunities, move towards personal goals of health, stability and wellness.
Since adopting the Housing First model of care, and with a focus on client-informed services, Union Station has seen a success rate of 97% in its programmes. In other words, 97% of clients who have been housed do not return to homelessness.
What are some of the biggest challenges you face?
We know how to end homelessness for individuals and families, but due to many complex systemic aspects, it is an uphill battle to deal with the overwhelming magnitude of some of these issue which include:
Cost of housing
One of the most basic causes of homelessness is the high cost of housing throughout much of the United States. In California, for example, a family has to have an annual income of over $78,000 to afford a modest two-bedroom apartment. There is an estimated shortage of close to a million affordable housing units within the state.
At Union Station there is an entire department devoted to finding housing for clients, something that is increasingly difficult due to the high cost of rent as well as the hesitancy of landlords to rent to people experiencing homelessness.
Racism and system failures
One cannot discuss the issue of homelessness without addressing racism in the United States. The effects of redlining and the systemic denial of mortgages, insurance, loans or other financial services forced communities of colour into the rental market, dramatically and negatively affected by rising rents and gentrification.
The criminal justice system, with its war on drugs and mass incarceration, has resulted in large numbers of individuals – predominantly African American men – who cannot access housing due to their criminal records and who end up becoming homeless often for years or decades.
The child welfare system is another major driver, with estimates that show that up to 45% of young adults leaving the system will become homeless by the time they turn 26.
The for-profit healthcare system in the United States also contributes to homelessness. The lack of affordability and accessibility means that many people do not receive the help they need, whether for physical or mental health issues.
These are just a few of the failed systems and policies, along with the lack of investment in the social safety net, that have generated homelessness in the United States.
Not in My Back Yard (Nimbyism) and homelessness as a pathology
Finally, and perhaps the most insidious barrier to ending homelessness is Nimbyism, which is based on the myths and stigma that surround this issue. Sadly, many people view homelessness as a pathology – as something inherent in the person rather than a temporary situation. They see people living on the street and decide they don’t want them living next door. This results in constant backlash from local residents and puts intense pressure on local elected officials not to take action, or to actively vote against measures that mitigate homelessness.
How do you see the role of urban governance within the broader issue of the social health of the city?
While many of the systemic causes of homelessness are beyond the ability of local urban governments to solve, there is much they can do to deal with this issue.
Perhaps the most important step is to recognise that those experiencing homelessness are members of their community. Creating social health means intentionally looking at ways to develop a supportive and nurturing environment that welcomes rather than excludes those who are most vulnerable and provide access for all people to those things which create health and wellbeing. These include things such as safe housing, green space and access to good schools, transportation, healthy food and other social determinants of health.
We have seen a number of communities implement local ordinances and strategies that have been very effective in creating opportunities for vulnerable populations. One example of this is the national effort to end veterans’ homelessness in the US. Between 2010 and 2019 the numbers were reduced by 50% (from 74,087 to 37,085). In fact, 79 communities and three states effectively ended veterans’ homelessness through a combination of housing, supportive services and community reintegration.
Locally, in Pasadena, Union Station worked together with City officials, including the Pasadena Housing Department, volunteers and other service providers to reduce homelessness by 50% between 2011 and 2019. Again it was the Housing First model, which provided access to housing and services within the community, along with professional and community supports that created this positive momentum.
Local ordinances
One of the most effective ways to integrate those experiencing homelessness into the broader community is through an inclusionary housing ordinance. This requires developers to reserve a certain percentage (often 15 to 20%) of housing units for very low, low- and moderate-income households in new residential developments.
Other measures of increasing the supply of affordable housing within communities include easing restrictions and costs for homeowners to build accessory dwelling units (additions, garage conversions, tiny homes), motel/hotel ordinances that allow for their conversion into affordable housing and special zoning to enable faith groups to build affordable housing on their properties. The success of these models is that they integrate housing into the community, rather than separating vulnerable, low-income individuals or those experiencing homelessness into ‘ghettos’ or industrial areas.
Finally, and most importantly, local elected officials and people of influence can play an extremely important role in creating health and wellbeing by standing against Nimbyism and advocating for integrated and inclusive communities.
The mark of a truly healthy community is how it treats those who are the most vulnerable
What are your aspirations for a healthy city?
All of us want to live in a community that is healthy and that provides a sense of safety, security and wellbeing. These are things that many of us take for granted, and yet sadly, are out of reach for many in our society. As we look to maintain or design healthy cities, we cannot and must not ignore issues of poverty and homelessness. It is by welcoming these people into our communities that we will lift them up, provide a pathway to wellness and hope, and in turn, we will uplift ourselves.
But the question remains, what are the elements of a healthy – and vibrant – community?
Access to opportunity
A healthy community is one in which all people – regardless of background, demographic or economic status – have the resources they need to thrive; everything from jobs, transportation, green spaces, healthcare, schools and more. But resources must start with the foundation of a permanent, stable and healthy home for every resident. In the words of the American poet, Maya Angelou, “The ache for home lives in all of us, the safe place where we can go as we are, and not be questioned.”
Heritage and beauty
The celebration of heritage and beauty is an important aspect to a vibrant community and can be both healing and provide a connection to our past as well as our future. Citizens can, and should take pride in what was created before them – the beauty of buildings, spaces and institutions within a city. But what must not be kept is the heritage of exclusion, discrimination and intolerance. We must not put buildings or neighbourhoods before people but rather build on what was good to create an even better future for everyone.
Interconnectedness
A healthy community is one which both celebrates others and creates opportunities for people to connect and learn from one another. This can be done through physical spaces – areas for people to congregate or areas that bridge neighbourhoods and create an environment that is welcoming of all people. It can also occur by creating opportunities for celebrations of other people and cultures as well as through dialogue, events and artistic expression in music, visual arts, architecture, theatre and great food.
Growth and Innovation
Too often there is the fear that growth and change will destroy what is good about a community. Often this fear leads to the Nimbyism spoken about earlier – the idea that I love my backyard the way it is, and allowing in others, especially those who are different, will destroy my way of life. The fact is that growth – and change – can be good, if planned for and implemented in a way that shows respect for both place and people. The creation and maintenance of beautiful spaces and institutions as well as creating new opportunities, are not exclusive, but can be done together.
Nurture and support
The mark of a truly healthy community is how it treats those who are the most vulnerable – children, seniors, those with disabilities, people living in poverty and those experiencing homelessness.
A community where people care for one another, provide resources, support and human connections work to lift everyone up – both the person giving and the one receiving.
In conclusion, homelessness is an issue, which affects all our cities and is, sadly, growing. While there are many strategies and actions that can end homelessness for individuals and families, in the end, it is recognising and celebrating the humanity of every person, regardless of race, religion – or housing status – that will create healthy communities where everyone has a safe place where they can go and be themselves.
Anne Miskey is the Chief Executive Officer of Union Station Homeless Services, the largest agency working to end homelessness in the San Gabriel Valley (SGV) in Los Angeles County. A nationally recognised speaker and a leading voice on system’s change and homelessness, she has been invited on numerous occasions to speak at the White House and worked on First Lady Michelle Obama’s Joining Forces initiative in support of veterans. She also worked with the Department of Housing and Urban Development (HUD) and the United States Interagency Council on Homelessness (USICH) to develop a national strategy on youth homelessness.
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