As of 2020, Seattle has an estimated homeless population of more than 8,000, which is thought to be the third largest in the country. While debates rage over whether, or how to best address the housing needs of those living on our streets, there is another issue: the health of our houseless neighbors and their lack of access to health care.
Josephine Ensign is a professor of public health who focuses on homelessness and health care. Ensign recently wrote a book titled “Skid Road: The Frontier of Health and Homelessness in an American City,” which traces the history of homelessness and health care in Seattle.
The link between health and homelessness is well documented, Ensign said in an interview.
“The experience of being homeless, not having a safe place to stay, contributes to not only mental health exacerbation but also physical health challenges,” she said.
Homeless people can have a hard time getting and maintaining health insurance or even qualifying for Medicaid, the government insurance program for low-income people. If someone is able to get health insurance, which is the first step to obtaining health care, seeing a doctor who is willing to treat unhoused patients with possibly complicated medical issues can be challenging. As Ensign points out, due to the nature of living unhoused, many homeless people have difficulty keeping and making medical appointments. Ensign says that throughout the course of her career she has encountered many homeless people who struggle to manage chronic conditions like asthma and diabetes, in part due to their living conditions.
People who are homeless or unhoused also often don’t have adequate storage for what they need even if they have medications, such as access to refrigeration. Moreover, the city’s policy of “sweeping” unsanctioned homeless camps makes it difficult for homeless people to keep track of medications.
“An encampment sweep comes along [and] medications disappear,” Ensign said. Personal effects like identification or proof of health insurance may also be thrown away during a sweep, making it difficult for someone to replace lost medication.
Multiple studies have found that early childhood trauma is a significant risk factor for homelessness. But, as Ensign points out, because of the stigma associated with homelessness and seeking treatment for mental illness, children from families living in unhoused or insecure housing “don’t get the access to good mental health treatment” that they need. This leads to a continuation of the problem into the next generation, contributing to the cycle of homelessness and even reducing opportunities for children.
According to Ensign, the COVID-19 pandemic shed light on the possible impact that homelessness can have on health. She states that we know from past pandemics, and the current one, that crowded shelters with little private space do not promote good health.
“When you get people together — especially with the mats on the floor in congregate shelters with poor ventilation, — you’re going to have increased outbreaks of infectious diseases” including COVID-19, Ensign said.
She says that one of the reasons there wasn’t more community spread among homeless people was that the city and county moved quickly to address the issue by closing the really crowded congregate shelters and requiring the ones that stayed open to have mitigation efforts such as locating mats or beds further apart. The decision to open quarantine units during the pandemic had a positive impact on the health of homeless community members. During the pandemic, not surprisingly, people who were experiencing homelessness and got into the isolation quarantine units with support had better health outcomes. Ensign noted those who had access to quarantine rooms in motels or hotels during the pandemic reported they “felt supported and that they were able to think about what they wanted or needed.” In some cases, people were able to find stable housing.
While access to health insurance, and by extension health care, has improved since the implementation of the Affordable Care Act, more commonly known as Obamacare, especially in states that have expanded Medicaid coverage, there are still barriers to accessing care for those who are unhoused and struggle with homelessness. One particular barrier is the reliance on what Ensign calls “scientific charity” — the idea that with enough data or science we can get rid of poverty and homelessness. She questions the concept of the deserving versus undeserving needy, an idea that dates back to the implementation of “poor laws” in both England and America which has had a significant impact on the ability of homeless people to access health care. For instance, “able bodied men (often) come last in terms of any kind of entitlement” and, she says, they were a population that came last in Medicaid expansion.
In order to address the needs of people experiencing homelessness in Seattle, Ensign believes it is important to look at what’s worked. Nonprofits, community leaders and politicians need to stop tokenizing homeless people — instead, she stresses, the homeless community should be included in the discussion.
“Having leaders who have the lived experience can help us move to better and more compassionate solutions to all of the different overlapping issues that impact poverty and homelessness,” Ensign said.
Community members must avoid having a knee-jerk reaction to seeing homeless people on our city streets. We must “treat people as people,” or as we would like to be treated if we found ourselves having to survive on the city streets with no place to call home.
Kat Smithson is a freelance writer who also hosts a bi-weekly radio show on community station Hollow Earth Radio.
Josephine Ensign will be speaking on this issue at the Seattle Public Library, Oct. 20, 6-7 p.m.
Read more of the Oct. 13-19, 2021 issue.