Every month, the King County Medical Examiner’s Office (MEO) sends out a spreadsheet. Most people don’t like looking at spreadsheets, but this spreadsheet is a particularly unpleasant one. It contains the names, ages and causes of death for every presumed homeless individual who has died in the county so far that year. It’s not difficult to understand that being unhoused is bad for your health, but it is far more difficult to be faced with a well-organized list of the frequently brutal ways in which people die when they don’t have housing.
As deeply sad as it is to scroll through those names, remembering that each line represents a life, it’s extremely important to do. On Sep. 29, the county published a 10-year review of death data — from 2012 to 2021 — offering broader insights into how people experiencing homelessness die, how that’s changed and how we can best stop those deaths now.
Counting deaths, considering cohorts
The most striking number in the report is 51, the median age of death on the list. For comparison, the median age of death in King County is 79. It is clear that being unhoused contributes to premature death.
The report includes a total of 1,429 deaths. Year over year, the numbers of presumed homeless individuals whose deaths have been investigated by the MEO has risen, just as the total number of deaths investigated and the total unhoused population has. However, the percentage of deaths investigated by the MEO classified as “presumed homeless” has stayed constant at about 5 percent of its total investigations. The report does not include data for 2022, but the August 2022 monthly spreadsheet showed 182 deaths this year, on pace to exceed last year’s total of 188 and conceivably even that of 2018, when an astounding 196 presumed homeless deaths were investigated by the MEO.
Equally bleak is the fact that deaths among the presumed homeless population are incredibly inequitable. As a blog post about the report by Public Health – Seattle & King County (PHSKC) put it: “More needs to be done to eliminate systemic racism as a root cause of homelessness. Painful and persistent disparities can be seen in the disproportionate number of deaths occurring among Black or African Americans and American Indian or Alaska Natives.”
One caveat when considering the report is that the county’s data is by no means comprehensive because not all unhoused people who die end up at the MEO. If someone dies in a hospital, their death will be certified there. Lee Thornhill, the PHSKC epidemiologist who worked on the data, cautioned that it should not be interpreted as representing all deaths for all people experiencing homelessness.
“For the most part, it’s really capturing deaths that are more representative of ... folks that are unsheltered. That’s [what] it more represents,” he said.
This can inflate some numbers, like overdoses, and deflate others, like deaths from natural causes, he warned. An independent advocacy group, Women in Black (WIB), keeps its own set of data that is based on the MEO’s numbers but also includes people who have died in transitional housing or temporary housing situations. That list, which allows anecdotal inclusions — someone whose death the group heard about on the news and knew to be unhoused, for example — includes a broader, if less rigorously defined, cohort.
On the topic of overdoses, however, it’s impossible to ignore their prevalence in both datasets.
An overdose epidemic
Overdoses accounted for 35 percent of all deaths in the MEO’s report and 71 percent of accidental deaths. The share of deaths marked “accidental” shot up to 66 percent in 2021 from 45 percent in 2020. In the WIB dataset, which covers 2020, 2021 and 2022 so far, drug- and alcohol-related deaths went from 34 percent of the total in 2020 to 50 percent in 2022.
A large driver of the increase in overdose deaths is fentanyl. The synthetic opioid was responsible for only 3 percent of WIB’s total deaths in 2020; that jumped to 39 percent of total deaths in 2022.
Brad Finegood, a behavioral health strategic advisor with PHSKC who specializes in overdose prevention, said that the recent uptick in overdoses is due in no small part to a shift in who is using fentanyl and who is making it. At first, he said, it was kind of a niche drug, something used mostly by experimental drug users — college students, bored rich kids, etc.
“Over the past couple of years, what’s happened is the cartels really have realized that this is a cheap, efficient way to produce powerful, high-potency opioids for people that’s much more time- and cost-efficient than, like, producing heroin,” he said. That’s driven down the cost — he estimates that one fentanyl pill is $3 to $5 on the street right now — and made the drug ubiquitous.
“It’s really gone from this sort of, like, novelty substance to the drug of choice for a lot of people that are long-term opioid users. And those people, either because of drug use or because of other things going on in their lives, often are disproportionately unsheltered,” he said. Unhoused populations, he added, are at a much higher risk of overdosing due to certain conditions inherent to being unhoused, especially using in isolation.
“Opioid overdose is a reversible condition, right? It’s respiratory depression,” Finegood said. “So, the idea behind a supervised consumption space or some of our messaging around, ‘Don’t use alone,’ is because if me and my best friend were using together, and I saw him having an overdose, I can use Narcan or naloxone to help reverse his overdose.”
A user cannot administer naloxone to themselves.
“People sort of conk out, they sort of fall asleep, and then they go into a deep sleep and then they stop breathing because their respiratory depression goes so low,” Finegood said. While using around others can be a lifesaver, many people don’t even know the symptoms of overdose. PHSKC runs educational campaigns to help change that, but there’s no guarantee that someone else who is using drugs will be able to recognize an overdose and act quickly to stop it.
Further complicating things is the fact that not everyone even knows they’re doing fentanyl nowadays.
“We weren’t seeing fentanyl in other forms, really, besides pills very often up until six, eight months ago. We are seeing, definitely, an increase in fentanyl that’s coming in in the form of white powder,” he said. That can confuse cocaine or meth users, who don’t tend to have any opioid tolerance, making them extremely susceptible to overdose.
James, who lives in an encampment in the Chinatown-International District, said that was exactly what happened to him. While helping a friend move, he took a risk and smoked something he found laying around on their kitchen table. It was not crack.
“It looks exactly the same as crack,” he said, “You can’t tell you’re smoking it until it’s too late.”
It was almost a fatal mistake, but luckily his friend had injectable naloxone on hand. The bruise on the injection site hurt like hell, he said, but he was grateful to be alive. While he will certainly be more careful about unidentified substances, he said it’s almost impossible to escape, suggesting that fentanyl was being cut in with other drugs.
“The thing that bothers me is that crackheads are not known for going to sleep. You do a hit, you don’t usually take a nap right after,” he said. But that’s exactly what’s been happening to him recently. Most of the people he’s known who have died from overdose, he added, were crack users. Worse yet, even if people are aware of the risk, he doesn’t think it will stop people from using. He saw one person survive an overdose before hearing about the same person having two more. He knows three people personally who have died from overdose and has heard about two more.
“Nobody believes it can happen to them,” he said. “That’s the problem.”
Both James and Finegood agreed that it would be ideal if you could somehow stop fentanyl from entering the supply of street drugs. But from a harm reduction standpoint, Finegood said, safe consumption sites would save lives.
“When we had our Heroin and Prescription Opiate Task Force in 2015, the task force recommended supervised consumption spaces at that time for a reason, and it was really the vulnerable people,” he said.
Vulnerable to violence
While the data on deaths are rife with completely preventable causes of death, exposure being an obvious one, one could also argue that violence is a preventable cause of death. Or at least the level of violence that unhoused individuals experience.
Seattle Mayor Bruce Harrell and Seattle Police Department’s (SPD) Chief Adrian Diaz have connected homelessness with violence, separately citing the statistic that, “The proportion of Shots Fired events with a nexus to homelessness increased by 122% (+62) in 2021 compared to 2020,” from the SPD’s 2021 end-of-year crime report. Neither have said much about who they think victims are, and SPD did not respond to a request for comment. However, while we don’t know who’s firing these shots, data from both the MEO and WIB suggest that an upsetting amount of them are hitting unhoused individuals.
The MEO’s report shows a relatively constant percentage of presumed homeless deaths due to homicide — between 4 and 6 percent each year except for 2012 and 2014. The WIB’s numbers come in a little higher, at 7 percent for 2020 and 2021 and 8 percent for 2022. Regardless, while the percentages haven’t been spiking, that doesn’t mean that unhoused individuals don’t experience violent death at a disproportionate rate.
Kim Serry, a public health professional who does data analysis for WIB as a volunteer, said she’d definitely noticed an uptick.
“For sure. Just really violent deaths. I think there was a week this year we saw like five homicides among unhoused people,” she said.
An article based on WIB data in the January 2022 issue of the Journal of Social Distress and Homelessness, titled “Without shelter, people die: disproportionate mortality among King County’s homeless population, 2009–2019,” showed homicide rates among unhoused individuals for that period as being 19 times higher than in the general population.
James can offer plenty of anecdotal evidence to go with those numbers.
“I saw one specific person, who is in jail now, shoot three people,” he said. “And for bullshit. Just for bullshit. Just pull out his gun and shoot ‘em because they didn’t do what he said right that minute.”
He knew of two alleged gun homicides, also over what he described as “bullshit.” In the absence of any sort of law enforcement presence, he said, the swath of encampments underneath Interstate 5 known as “the Jungle” had to develop its own form of order.
“I don’t want to say [it was] organized, but there was a hierarchy, there was a council,” he said. “There were rules that you didn’t break, and there were consequences if you fucked up. Now people are fucking up all the time. There’s really no consequences.”
In a later conversation, over coffee on Oct. 25, he said it had only gotten worse. Just the previous night, he said, he’d woken up to gunshots.
Shaking his head, he complained that, “Everybody’s shooting everybody out here.”
A name, not a number
One person who got shot, not more than 20 yards from James’ tent, was Trenton Harris.
His mother, Jennifer Dobbins, and other surviving family members joined the WIB on the steps of city hall for an Oct. 12 vigil, something the group regularly does to honor unsheltered individuals who have died in the previous month. As part of their efforts to commemorate the lives of those people, the group launched the Homeless Remembrance Project, which has installed a number of bronze “Leaves of Remembrance” across the city. Harris’ leaf was to be installed that day at the foot of the grand staircase leading to City Hall’s Fourth Avenue entrance.
Holding a sign bearing the name of another family’s unhoused son who had died by violence, Dobbins described her son as “the nicest person.”
He was unhoused due to opioid addiction, something that Dobbins, as a clean and sober person herself, could not have in her house. He’d gotten clean once, during a stint in Indiana, but had resumed using when he’d come back to Seattle in 2020. However, she made sure to come up from Bonney Lake, where she lives, at least one Saturday a month to visit Harris.
She couldn’t imagine why anyone would have wanted to kill him. Regardless, someone did. On July 17, Harris was shot three times and left slumped against a park bench.
Harris hadn’t been robbed; he still had his personal effects and a small amount of heroin on him when the police got to the scene. He did have his hatchet on his hip — a holdover from his days as a Boy Scout — but would never have threatened anyone with it, she said. There’s a detective assigned to the case, but Dobbins hasn’t heard any update in months. She is no closer to knowing why her son was shot or who shot him and, at this point, all she wants is his treasured Doc Martens back from evidence.
“They won’t even tell me if they found the bullets on the ground in the park somewhere,” she said. SPD did not respond to a request for comment on the case.
How does it end?
Stopping the victimization of unhoused individuals, according to Brigid Hagan, a member of WIB, starts with housing.
“Lots of people are looking for one neat, tidy ... reason [behind the violence], and there’s not one neat, tidy explanation,” she said. “But [there is] one really excellent answer for all of it: Give people a home with a door that shuts and locks. That decreases all of those things.”
The other thing that WIB would most like to see, she said, is an end to encampment sweeps. Echoing Finegood’s concerns about how isolating homelessness can be, she noted that the small communities people form in encampments can cut down on overdose deaths, among other things.
“When you go in and sweep people without having an appropriate place for them to go, you’re breaking up their community, you’re breaking up their support system. You are taking away the neighbors who can help them through different kinds of crisis. You’re taking away the person who could potentially administer Narcan for them if they ODed. And you are increasing their stress,” she said. Stress is a major contributor to both suicide and violence, she said.
Instead of sweeps, she would like to see more permanent supportive housing and more low-barrier tiny house villages. As long as they allow people to come as they are, she said, the villages fulfill a lot of the same key social and safety functions as communal encampments.
“Those provide people with the combination of privacy, like they get in a tent, [and] with some community, like they get in an encampment,” she said. “And when it’s low barrier and harm reduction, rather than requiring that people be clean and sober, then all of the folks who stay away from the different shelter options because they’re afraid of having to be forced to do that, that gives them an option for a safer place to stay.”
At the vigil, Rev. Kelle J. Brown, the senior pastor of Plymouth Church, offered a short prayer, concluding with an exhortation to those who walk by to fight for exactly that: a safer place for unhoused individuals to stay.
“Those who pass by, when they see these leaves, they are called to remembrance, compassion and action,” she said. “They are invited to see and not look away, for the leaves cry out for justice, for shelter and [for the] safety of all.”
After Brown read the list of names, the crowd dispersed. Harris’ family, along with the family of Zackary Morris, an unhoused man who died of a fentanyl overdose, stayed on. In silence, they watched WIB volunteers prepare the sidewalk with rub bricks before affixing their sons’ leaves with epoxy. No city or county officials were present.
Read more of the Nov. 2-8, 2022 issue.