The Shame of Homelessness in America

Bruce C. Vladeck, president of the United Hospital Fund of New York, was chairman of the Committee on Health Care for Homeless People. Ellen L. Bassuk, associate professor of psychiatry at Harvard Medical School and president of the Better Homes Foundation, was a committee member.

Homelessness in the United States is an inexcusable disgrace and must be eliminated.

As participants in a national group assessing the homeless problem, we witnessed the suffering of our poorest citizens and came to understand that the individual health problems of homeless people combine to form a major public-health crisis. Americans can no longer sit as spectators to the elderly homeless dying of hypothermia, to the children with blighted futures poisoned by lead in rat-infested dilapidated welfare hotels, to women raped, to old men beaten and robbed of their few possessions and to people dying on the streets with such catastrophic illnesses as AIDS.

Homeless people have become a fixture of the contemporary U.S. landscape--in public parks, at bus and train stations, lined up at soup kitchens. In the best American tradition, individuals and groups have responded to the plight of homeless people with private charity and extraordinary volunteer effort. But they have not yet connected the all-too-visible phenomenon of homelessness to broader issues or trends.

As members of the Committee on Health Care for Homeless People of the Institute of Medicine of the National Academy of Sciences, we were part of a diverse group charged, as the result of a congressional mandate, with describing the health problems of homeless people and the services available to them and making recommendations on public and private initiatives that would make services more effective and affordable.

The committee's official report, "Homelessness, Health, and Human Needs," was released last month by the National Academy Press, which refused to publish a supplementary statement signed by 10 of the 13 committee members. The issues discussed in that statement, and the academy's arbitrary refusal to include it in the published report, speak directly to the broader questions underlying the problem of contemporary homelessness.

Beginning with the relatively narrow question of the health needs of homeless persons, the committee quickly recognized that homelessness causes some illnesses and exacerbates and perpetuates others by seriously complicating efforts to treat disease and reduce disability. Thus, only a comprehensive, long-term strategy for eliminating homelessness will permanently improve the health of those persons. But such a strategy necessarily requires an analysis of why homelessness is growing so quickly in the United States.

Lack of a home is a health problem: To condemn someone to homelessness is to visit him or her with a host of other evils. Ignoring the causes of homelessness leads to treating only symptoms and turns medical programs into costly, but necessary, stopgap measures; attempts to address the health problems of homeless persons separately from their systemic causes is largely palliative.

In our report, we identified three primary, interrelated causes of homelessness: the reduced supply, and increased cost, of housing for low-income persons; inadequate income, both for those who work regularly at the minimum wage and for recipients of public income assistance, and inadequate services for those with particular needs, such as mental illness or protection from domestic violence.

Thus, in the supplemental statement, we called for restoring federal support for low-income housing to at least 1981 levels; for increasing the minimum wage to a level that might make decent housing affordable for people working full time; for improved benefit levels for cash-assistance programs; for substantial expansion of supportive services for the mentally ill, substance abusers and troubled families, and for universal access to health care.

Knowing that our recommendations on these topics might not pass the muster of "objective," "scientific" peer review as required by the National Academy process, we included them in the supplementary statement. We also felt that a discussion of homelessness should convey the suffering and desperation of the people who experience it; such suffering could not be adequately addressed in the dispassionate, bureaucratically neutral tone expected of published academy reports.

We agreed with the recommendations set forth in the committee report, but we felt frustrated because of our inability to state the most basic recommendation: We must eliminate homelessness.

As a matter of intellectual integrity, we believe that homelessness cannot be discussed without conveying a tone of shame and outrage, without attention to systemic causes, and without reference to public policy and political decisions, which invariably entail political actions. Political questions, as any social scientist knows, are never merely questions of fact. To attempt to draw a distinct and defensible line between that which is "objective fact" and that which is "polemical" or "rhetorical" resembles the efforts of King Canute in commanding the waves to stand still--and is just as likely to be successful. Logically, one can believe that homelessness is not a problem worth worrying about, or that the steps required to eliminate it are not worth the cost. But one cannot rigorously analyze the phenomenon of ill health among homeless persons without calling into question governmental policies and attitudes.

Modern philosophers of science long ago rejected the notion that it is possible to maintain a rigid distinction between fact and value. When seeking to explain the reasons for developmental delay and malnutrition in children living in welfare hotels, even the simplest facts contain political and policy implications.

The academy, and its Institute of Medicine, face a legitimate dilemma, with which we are sympathetic. However, if they wish to be engaged in the great public issues of our day, they cannot indefinitely get away with the posture of Olympian objectivity and pristine intellectual purity. As Mr. Dooley said, politics ain't beanbag; it ain't physical chemistry either.

Demonstrating that the phenomenon of homelessness, and the suffering of homeless people, is connected in inescapable ways with the decisions of elected officials was, for most of us, essential for the integrity and completeness of our report. And making the case that the results of those decisions should fill us with shame and indignation was, we also felt, essential as a matter of simple morality.

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