December 23, 2022
Dear Interested Readers,
Thinking of the Homeless at Christmas
In 1943 Bing Crosby recorded “I’ll Be Home For Christmas” and it was a number-one hit on the charts. To listeners in 1943, the song was sung from the perspective of a soldier who was far away.
I’m dreaming tonight of a place I love
Even more than I usually do
And although I know it’s a long road back
I promise you
I’ll be home for Christmas
You can count on me
Please have snow and mistletoe
And presents under the tree
Christmas Eve will find me
Where the love light gleams
I’ll be home for Christmas
If only in my dreams
In just two lines the song describes the picture-perfect scene of the traditional Christmas at home:
Please have snow and mistletoe
And presents under the tree
The song never mentions the war, but we know that the singer will not be home in person. He will be there, “…if only in my dreams…”
It’s the time of the year when we think a lot about home. I have no idea what the homeless think about our casual way of saying “Happy Holidays!” when they have no place to decorate a tree or light a menorah. In the context of health, “home” is a foundational essential. Without a home, we are in our most vulnerable state. It is hard for me to imagine the sense of constant vulnerability, anxiety, and exclusion that a person who is homeless must experience. Perhaps the experience is like a chronic pain that can’t be resolved. Any acute or chronic medical problem has to be multiplied in severity many times over in an individual who is homeless. Even more disturbing to me is the impact of homelessness on families and especially children.
I was very pleased to read this week that the Biden administration has offered a plan that might reduce homelessness by 25% by 2025. It is a start. According to the memo from the White House, the plan is:
Under the Plan, the Administration will:
- Reward jurisdictions that have reformed zoning and land-use policies with higher scores in certain federal grant processes, for the first time at scale.
- Deploy new financing mechanisms to build and preserve more housing where financing gaps currently exist: manufactured housing (including with chattel loans that the majority of manufactured housing purchasers rely on), accessory dwelling units (ADUs), 2-4 unit properties, and smaller multifamily buildings.
- Expand and improve existing forms of federal financing, including for affordable multifamily development and preservation. This includes making Construction to Permanent loans (where one loan finances the construction but is also a long-term mortgage) more widely available by exploring the feasibility of Fannie Mae purchase of these loans; promoting the use of state, local, and Tribal government COVID-19 recovery funds to expand affordable housing supply; and announcing reforms to the Low Income Housing Tax Credit (LIHTC), which provides credits to private investors developing affordable rental housing, and the HOME Investment Partnerships Program (HOME), which provides grants to states and localities that communities use to fund a wide range of housing activities.
- Ensure that more government-owned supply of homes and other housing goes to owners who will live in them – or non-profits who will rehab them – not large institutional investors.
- Work with the private sector to address supply chain challenges and improve building techniques to finish construction in 2022 on the most new homes in any year since 2006.
I applaud the president’s start, but there are close to 600,000 homeless people in America. If the president’s plan works there will still be 450,000 people with no address sleeping under bridges, in their cars, on a friend’s couch, or living in homeless shelters. If you scan the last link you will discover that 48% of the homeless identify as white. African Americans are almost 40% of the total and 13 % are Hispanic. The life expectancy of a homeless person is 50 years. Ironically, the article concludes by saying that the statistics are improving. Homelessness is getting some attention. There is just a long way to go.
I can’t remember having had a homeless patient when I was in practice. Perhaps, there are several explanations. When I first started to practice all of our patients were seeing us through employer-provided health insurance. Even later when we were accepting patients on Medicare and Medicaid, all of our patients had an address and a roof over their heads. To see me either you were working or someone in your family was working and you were covered by their policy.
In the 70s and for the next three decades homelessness and working were mutually exclusive. That is no longer true. According to an article entitled “Employed and Experiencing Homelessness: What the Numbers Show” about 50% of homeless people do work. They just can’t find a place to live that they can afford. The author, Julie Pagaduan, writes.
Have you ever heard the idea that people experiencing homelessness “don’t want to work” or they should “just get a job?”
The truth is that many do – in fact, a 2021 study from the University of Chicago estimates that 53% of people living in homeless shelters and 40% of unsheltered people were employed, either full or part-time, in the year that people were observed homeless between 2011 – 2018.
Now, as I am spending much of my time volunteering in two charities, Kearsarge Regional Eccunemical Ministries (KREM) and Kearsarge Neighborhood partners (KNP), I see homelessness everywhere. As reported, many of the people I see who have no home are working. The lucky ones have temporary housing at local motels. The “rent” is covered by town welfare or by organizations with some federal monies for housing, but now those resources are exhausted. If you were evicted from a home in New London today your options are to call a friend, sleep in your car, pitch a tent in the woods, or head to Manchester or Lebanon hoping to find shelter there. Leaving the area is hard if you still have a job. Keeping a family together is even harder. This last summer I provided aid to a family living in a tent and their car with a five-year-old special needs boy. The father had a disability income which was hard to get because they had no address and the mother was working in a restaurant kitchen. They could have paid rent, but there was nothing to rent. The family has now disintegrated under the stress of their homelessness.
Our local hospital competes with the homeless for temporary housing in local motels to house traveling nurses. I have had two other clients who had access to the money they needed either from work or from federal programs for housing, but there are no homes or apartments for them to rent. It is a reality that it is easier to find a house to buy than an apartment to rent. Finally, there are many who are in an adequate apartment or house but are at risk of losing their housing because the combined expense of rent, utilities, car payments, and car insurance leaves them short even if they are going to food banks or have SNAP (food stamps) benefits.
The lack of housing at any reasonable price for people earning over $20 an hour has been a threat to many of our clients and a disturbing reality for an increasing number of people and families who seek help from our non-profit organizations. MIT’s Living Wage Indicator for New Hampshire suggests that with both parents working with two children the “living wage” is $24.11 per hour per parent. What is frustrating is that we can fill a propane tank, pay an electric bill, or respond to a request for “gas cards,” but even if we had the funds we could not give them shelter. A recent study done at Dartmouth suggests that the “Upper Valley,” the economic unit that we are in, needs 10,000 units of housing by 2030. That’s seven years from now. Do you think we will make it?
There is a vigorous effort to create sixty units of affordable “workforce” housing in my town. There have been meetings and the effort has the support of the local hospital and our college, but the need they have for their employees exceeds sixty units, and if the permitting process continues without delay it will still be two years before the units are available.
A recent New York Times article by German Lopez entitled “Homeless in America: The homelessness crisis is getting worse” provides an update and an overview of the problem In contradiction to the earlier article I cited which ended on a positive note. Lopez says that recent data suggests that homelessness is worse now than it has been in several decades. He points out that there has been a confluence of several factors that have contributed to the problem and represent challenges that must be overcome. I have heard it said that in medicine most acute problems are really the immediate worsening of a neglected or mismanaged chronic condition. This is true of homelessness as the article points out:
The origins of the current homelessness crisis go back decades — to policies that stopped the U.S. from building enough housing, experts said. Seven million extremely low-income renters cannot get affordable homes, according to the National Low Income Housing Coalition.
It has been commonly believed by Republicans, especially Ronald Reagan, that the market can fix anything if the government will just get out of the way. That “laissez-faire capitalism” idea in public policy has been a disaster in housing as well as in workforce maintenance in healthcare and other critical industries. It is foundational to our “supply chain” inadequacies and in my opinion one of the prime reasons we rank last in healthcare, despite spending the most money, of the world’s developed countries. Ronald Reagan is described by many as our president who distinguished himself as our most laissez-faire leader and most obvious practitioner of laissez-faire economics. Lyndon Johnson was our least laissez-faire president. In reality, Reagan dismantled or undermined many of the poverty-fighting efforts of Johnson’s “Great Society.” Lopez sums up the effect of this lack of effective government involvement since 1980 and supply chain issues in housing [I added the bolding to stress the obvious point]:
Homelessness, then, is a supply-and-demand problem. Without enough housing, not everyone has a place to live. And the homes that do exist cost more as people compete for limited supply. So more people are priced out, and more end up homeless.
Public policy beyond the attitude of laissez-faire economics has also contributed to our housing disaster. Another Latin phrase is res ipsa loquitur. It means, the situation speaks for itself. Used in a legal context res ipsa loquitur usually implies negligence as the origin of a problem. As far as I am concerned our collective negligence is at the heart of our housing problem and contributes mightily to our healthcare workforce issues and the high cost and inequities in our system of healthcare where laissez-faire dependence on market forces has failed us.
The author points out that many municipalities have policies that make building multiple-unit housing difficult and zoning laws that further reduce the possibility of affordable housing. As noted above both of those realities are delaying the construction of needed housing in our town. If you examine President Biden’s strategy for reducing homelessness, it addresses some of these issues. The “not in my backyard” or NIMBY attitude may be as much to blame for our current situation as Ronald Reagan’s lassez-faire economics and desire for limited government involvement in solving social issues. The author sums up the chronic public policy problem.
The combination of zoning rules and local protests has added to a housing deficit year after year, as growing populations have outpaced new homes built. Now, California has 23 available affordable homes for every 100 extremely low-income renters — among the worst rates of any state.
It is not fair to pin the entire problem of homelessness on Republicans. The author points out that the worst examples of homelessness are in our large cities, and that most of our large cities have Democratic mayors and city councils. The state leadership in our West Coast states where some of the worst problems with homelessness exist in LA, San Franciso, Portland, and Seattle are “blue” states. Homelessness is a problem for which we all share blame and responsibility at some level.
I find it encouraging that as her first act in office Karen Bass, LA’s new mayor, declared a homeless emergency. In the declaration, she said that LA’s homeless population had doubled in the last ten years and at over 41,000 is up 237% compared with 2007. As you continue to read the declaration four thoughts emerge. First, the problem is greater than you had ever imagined. Second, there will no easy solution. Third, the problem is the tip of an iceberg that is now a threat to more people than those who are currently without a home. Fourth, the problem affects “normal people” and not just people with substance abuse problems and mental health issues that prevent employment.
The article in the New York Times did not mention the role of mental health in homelessness. Through the 80s and 90s, people with mental health issues did constitute a large part of the homeless population. Even today about 25% of the homeless have mental health issues. In the early 60s President Kennedy proposed a community-based mental health system to replace chronic institutionalization. He proposed that with effective outpatient therapy made possible by the emergence of antipsychotics that could be used to treat severe and psychotic mental health problems many of the patients who were chronically institutionalized could be discharged to their communities. With good intentions, we emptied out many state mental health hospitals.
Perhaps Kennedy’s idea was theoretically plausible, but Ronald Regan defunded the effort leaving thousands of people with chronic mental health disabilities on the street without support. I witnessed the closing of state mental hospitals all across Massachusetts. The history and the timeline of change are well described in a terrific 2016 article in the Boston Globe. In the distant aftermath of the closings, we have learned that there were unspeakable abuses of many of the institutionalized patients. It seems that in our history being either homeless or institutionalized is a perilous reality.
Our problem with housing and homelessness will be one of the most difficult barriers to overcome as we seek to improve the social determinants of health. What makes it a great challenge is that public policy must change for everyone to be given adequate housing. Without adequate housing, lives are at risk. With a divided Congress transformative legislation seems unlikely. It is probably true that our immigration issues also exacerbate our housing problems. You may point out that our homeless population is only a small fraction of our population, but the problems that lead to their loss of housing pose a threat to all of us. On the wall of the lobby of The Hubert Humphrey building, the Offices of Health and Human Services, in Washington is a quote that caught my eye when I went there to do some business with Don Berwick when he was the administrator of CMS. The quote is:
It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
That quote comes from the sixties when we were passing Medicare and Medicaid and Lyndon Johnson was proposing the legislation that was called “The Great Society.” I would like to think that Humphrey’s inclusion of “the needy” encompasses the homeless. I would be surprised if it did not. What we see now is that the problem of homelessness is more than just a problem of poverty. It is a manifestation of poor policy, poor planning, self-serving individual concerns, and market issues that result from inadequate regulation, inadequate supply chain management, and a deficient system of mental health care.
I believe that without education directed at the issues that need to be addressed and with the unlikely possibility of bipartisan concern, the problem of homelessness will persist and continue to grow. It’s getting worse in my neighborhood, and I would be willing to bet that it is also getting worse where you live. What are we going to do?
A Very Moving Speech
I was surprised and delighted to learn that Ukrainian President Volodymyr Zelenskyy was coming to Washington on Wednesday to confer with President Biden and address a joint session of Congress. I was amazed when he began to speak in halting but very adequate English. I am old enough and have banged my head often enough to have some pseudobulbar affective symptoms, and several times during his speech I felt like tears might come. Time will tell how effective his speech was at creating bipartisan support for the defense of Ukraine. He has my respect and support. He is the leader of a nation of heroes. If the Ukrainians are willing to fight and die to maintain freedom for themselves and the “free world,” the least we can do is to make sure they have the resources they need. Perhaps David Brooks expressed my feelings more eloquently than I can. In his column yesterday he wrote:
Zelensky and his fellow Ukrainians have reminded Americans of the values and causes we used to admire in ourselves — the ardent hunger for freedom, the deep-rooted respect for equality and human dignity, the willingness to fight against brutal authoritarians who would crush the human face under the heel of their muddy boots. It is as if Ukraine and Zelensky have rekindled a forgotten song, and suddenly everybody has remembered how to sing it.
Searching For “Thin Places”
When I started working at Harvard Community Health Plan on July 1, 1975, I was invited to join a Thursday noon lunch group exploring what we called “the touchy-feely” side of medical practice. I was initially reluctant because my day started with hospital duties and I was in the office seeing patients in the afternoon. I always rushed to finish my hospital rounds, work in the cath lab, and then get to the office by 1:30 when my first patient was scheduled. After expressing my reluctance to join in the activity, I was gently informed that what I considered an invitation that I could choose to accept or reject was in fact an expectation without any room for negotiation. I reluctantly joined the group, but my initial behavior wasn’t appreciated. After showing up a half hour late on several occasions and blowing off the gathering a few times, I was taken aside and told that my prompt attendance was an expectation of my superiors. I got the message.
Once I began to attend regularly, I realized that I was getting more than a free sandwich, a bag of chips, and a soda. It took a long time for me to learn that what we all called “the Thursday touchy-feely” lunch group was in fact an early Balint group. I wrote about my experience in the lunch group in one of these postings in November 2020. I said:
I longed for the opportunity to talk with colleagues about the management of the patients I was seeing but was afraid of revealing my sense of inadequacy. Little did I know that many of my colleagues were struggling with the same concerns. Fortunately, my group practice did have a prototypical clinician support group, much like what has evolved since the 1980s as Balint Groups. In these groups, doctors and nurses met over sandwiches at noon on Thursdays to discuss our feelings associated with practice. Our feelings often were an expression of our frustration with management or the loss of professional autonomy. I was heard, but I was also a “hearer.” In the group, we revealed who we were and wanted to be … That process satisfied our need to tell our own stories, enabling us to make it through until things might begin to change. It did not occur to me in the moment of those group encounters that we were calling out concerns and forming relationships that in time would result in organizational transformation.
By 1975 I was “searching” and had begun to see a psychiatrist on a journey that would eventually lead to several years of psychoanalysis. After a couple of years, I had gone from being a reluctant participant to being one of the facilitators of the group. Eventually, our organization grew to the point that the Thursday lunch group was phased out.
In retirement in New London, my wife and I have become part of a wonderful group of about twenty people who gather twice a month on a Sunday evening to have discussions that are very close in feeling to the experience I once enjoyed in the Thursday lunch group. We call these gatherings “small group.” The difference between our fledgling Balint group of the seventies and my current experience in our “small group” is that in the Balint group we discussed the joys and challenges of being a clinician and in “small group” we are sharing our feelings about life in general. At times the discussion is spiritual. At other times it is political. We talk about how institutions and organized religion have failed us. We imagine solutions that might improve resistant problems that are unlikely ever to improve. Much of our talk is about managing the uncertainty that we experience in life. Once again it is a joy to discover that I am not alone in my worries and fears.
Most, but not all, of the small group members are retired. Our oldest member who often makes the most profound statement is in his mid-eighties. There are some youngsters in their early to mid-sixties. Everyone has known both success and disappointment.
Suffice it to say we are all past our most productive years, but still focused on the big ideas: “Why we are here?” “What does it all mean?” “What responsibility do we have to the future/” “Where are we going?” We share good food, some libations, and a lot of laughter. Usually, someone begins the discussion by introducing an idea or a recent article that they have been considering, and then the fun begins.
Not long ago one of the group members suggested that we talk about “thin places” which are somewhat like “liminal spaces”. In the link about “thin places” we read:
Have you ever been in a geographical location where you felt inexplicably close to the divine presence? At the beach perhaps? In a forest? The desert? The ancient Celts had a phrase for such sites. They called them “thin places”. According to the Celtic saying, “Heaven and Earth are only three feet apart, but in thin places that distance is even shorter.” In reality, of course, there is no distance between creation and creator. We are irrevocably entwined. It is simply our awareness that is heightened when we are positioned in the beauty of the natural world.
Richard Rohr, a Franciscan priest, gives his definition of liminal space which is a little more spiritual than the previous definition that I offered to you in the link above.
Liminal space is an inner state and sometimes an outer situation where we can begin to think and act in new ways. It is where we are betwixt and between, having left one room or stage of life but not yet entered the next. We usually enter liminal space when our former way of being is challenged or changed—perhaps when we lose a job or a loved one, during illness, at the birth of a child, or a major relocation. It is a graced time, but often does not feel “graced” in any way. In such space, we are not certain or in control.
In my mind, if you are in an internal liminal space you are possibly more likely to notice external “thin places.” Certainly, as I began to practice, I was in a liminal space. As I am moving toward the end of life, I am in another liminal space. If you can peel away all the frantic shopping and the other distractions, the Holiday Season can feel like some “thin place” or at times a “liminal space.” Perhaps, the headers of these notes each week are my attempt to share a picture that evokes a “thin place” feeling from me that I want to share with you.
The picture in the header today was taken by a friend from her back porch. She has a newly constructed home on the side of Morgan Hill that looks down on Pleasant Lake and across the lake at Mount Kearsarge. If you look closely in the upper right you can see a couple of icicles that were hanging from the eave of the porch roof.
Mount Kearsage is an impressive mountain that takes my breath away every time I look at it. Pictures of the mountain have appeared as the header of these notes several times. Climbing to its broad granite top can be an ascendance to a thin place. I have shown you a picture of the full moon rising over the mountain on a summer evening. I have shown you the mountain covered with beautiful fall foliage, but before I saw this picture I had never seen it at dawn on a winter morning.
I hope that during the holidays you get some rest, have a great time with family and friends, and experience some sort of thin place where some perspective and relief are possible. I think our whole nation may be in a liminal space. It feels to me like we all are sharing some sort of liminal space as we approach the new year where we are not certain, and are not in control, and we feel collectively vulnerable, but paradoxically within this shared liminal space, we can choose to make a difference.
Happy Holidays!
Be well,
Gene
