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In this podcast, Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, explains the country’s rise in homelessness and the critical impact of housing on the health needs of vulnerable populations.

In this article about Project Homekey, Margot Kushel, MD, director of the University of California San Francisco's Benioff Homelessness and Housing Initiative, described how the goal is to make sure even the “hardest-to-house” people will come inside. To that end, Dr. Kushel said Homekey gets the most important part right: providing permanent supportive housing, not temporary shelter. “Some people need services that go along with that housing, and some people don’t. But the really essential thing is that without the housing, the services don’t work,” she said.

An event in San Francisco called “Public Health is Public Safety,” brought together a dozen experts from homelessness services, policy, research, and jail health services backgrounds. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, discussed a successful “housing first” study conducted in Santa Clara, which found that simply providing housing to people who most needed it helped reduce emergency room visits and allowed people the chance to get mental health services.

Although the majority of San Francisco residents have been vaccinated against the coronavirus, people experiencing homelessness may still face barriers to vaccination. By walking the streets and offering immunizations on the spot, Code Tenderloin has collaborated with UCSF and Glide to try to overcome those barriers. Margot Kushel, MD, who directs the UCSF Benioff Homelessness and Housing Initiative, said UCSF health workers asked Code Tenderloin to take the lead in the outreach work, "I can’t emphasize enough how much our efforts were led by Code Tenderloin, who really in the Tenderloin is seen as a very trusted entity. They know the community. They’ve been there, they get it."

Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, was quoted regarding lower vaccination rates in people experiencing homelessness in the Bay Area, where multiple outbreaks and rising case rates in homeless shelters have experts concerned. "You have to be able to trust science, you have to be able to trust the health care system, you have to be able to trust the people you’re around," said Dr. Kushel. "And I think people who are homeless often have had a lot of trauma and a lot of reasons to not trust those systems."

In this podcast, follow along on a walk through the Tenderloin where outreach workers from Code Tenderloin offered on-the-spot COVID-19 vaccination, and hear how Margot Kushel, MD, a physician and researcher who directs the UCSF Benioff Homelessness and Housing Initiative, is part of a collaborative multi-organizational effort to bring the vaccines to people out on the streets. UCSF BHHI and Dr. Kushel hope approaches like this can build trust and immunity.

Margot Kushel, MD, a professor of medicine at University of California San Francisco, who leads the UCSF Benioff Homelessness and Housing Initiative, also said there’s little evidence of correlation between mental health and homelessness. Instead, she said the places with highest homelessness have a split population of high earners who can afford to pay housing costs, and those who can’t, competing for a limited supply of housing. Think: San Francisco. Dr. Kushel recently conducted a study in which researchers approached the 400 most chronically homeless people in Santa Clara and offered them a permanent home. All but one said yes.

This UCSF study reported the public health response to a COVID-19 outbreak in a San Francisco shelter where 67% of residents and 17% of staff tested positive for SARS-CoV-2. The researchers describe the limited utility of case investigation, person-based contact tracing and symptom screening, and the benefits of mass testing in outbreak response.

When pandemic aid programs begin expiring at the end of September, advocates worry that San Francisco’s most vulnerable homeless women will once again be left behind. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, discussed the rate of violence impacting homeless seniors, women, and transgender people. After two decades of studying high rates of assault and the health impacts of homelessness, she has watched Bay Area seniors placed into hotels during the pandemic transform, to the point where staff didn’t recognize some of them. “It’s been a life-changing experience,” Dr. Kushel said. “When people regain housing, everything gets better.”

This commentary coauthored by BHHI faculty describes how a coalition of Bay Area community organizations, academic institutions, and public health departments collaborated to provide high-risk populations with Covid-19 testing and vaccination, and also took the opportunity to connect them with other essential services.

California's Project Homekey is a big step in creating needed new subsidized housing for the state’s more than 161,000 homeless residents, but homelessness policy experts, service providers, and others are only cautiously optimistic about it. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, explained that in the rush to house people quickly, there's also the risk of leaving out people who need housing the most. People who have been homeless for years will need the most help transitioning into housing. In addition, Dr. Kushel said, “It has been so hard to separate the homelessness crisis from all of the impacts of structural racism.”

The Bay Area Council released a report stating that it would take $11.8 billion to get every unhoused person in the Bay Area off the streets. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, who advised on the report, said, "One thing that’s great is for people to have an honest conversation about what homelessness would really cost to end. Maybe that way we won’t just constantly criticize efforts being made, which have never been scaled to address the problem, which has existed for 40 years." Dr. Kushel dates the beginning of modern homelessness to Ronald Reagan’s decimation of poverty programs in his first years as president.

A proposal to spend $12 billion to end homelessness in California is "a really good start, but can't be the end," said Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative. Project Homekey was remarkable because of how it was approved and running just months after it was announced. But solving homelessness is not possible without addressing housing affordability, which is pushing thousands of Californians onto the street each year. “That’s fundamentally at the heart of the problem,” Dr. Kushel said.

This UCSF study compared infection control strategies to reduce COVID-19 outbreaks in homeless shelters in the United States. In high-risk homeless shelter environments and locations with high community incidence of COVID-19, even intensive infection control strategies are unlikely to prevent outbreaks, suggesting a need for non-congregate housing arrangements for people experiencing homelessness.

A UCSF study found that during the COVID-19 pandemic in California, older adults, Black and Latino residents, and those without college degrees experienced the highest per capita excess mortality. The researchers suggest that this pattern reflects the risk of COVID-19 death faced by low-wage, essential workers and their social networks owing to occupational exposure, crowded housing, and inadequate access to testing or treatments.

Recent studies have highlighted how the pandemic has eroded an already frayed safety net for young people experiencing homelessness. Colette Auerswald, MD, a professor at UC Berkeley’s School of Public Health and UCSF Benioff Homelessness and Housing Initiative noted that young people from marginalized communities are more likely to face structural failings that lead to homelessness.

In California during the pandemic, Project Homekey has created housing for people experiencing homelessness by purchasing hotels and converting them to housing. Each room is life changing to a degree that almost no other intervention can provide. In long-term studies of homeless people who have moved to permanent housing, Margot Kushel, MD, director of the UCSF Benioff Homelessness Initiative has found that basically every determinant of health improves.