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More Californians have fallen into homelessness, and more have died while unhoused. However, the state’s ability to track these deaths and assess the scope of the problem hasn’t kept pace. In 2022, California added a field to death records for homeless status. The data is essential to assess the state's public health interventions and shape decisions. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "One of the problems with not reporting it is that it makes it harder to act."

Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, delivered the Harvard Joint Center for Housing Studies’ 23rd John T. Dunlop Lecture. After the lecture there was a panel, featuring, Boston Healthcare for the Homeless founder, Harvard Medical School professor James J. O’Connell, and Peggy Bailey, a leader of a housing policy research center. The panelists shared there perspectives on policy and economic approaches to addressing the housing crisis, agreeing that providing dedicated, sustained support to unhoused individuals is necessary. “The first thing we need to do is to recognize that every single path to ending this crisis flows through housing,” Dr. Kushel said.

Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, delivered the Harvard Joint Center for Housing Studies’ 23rd John T. Dunlop Lecture. Dr. Kushel spoke about the impact that homelessness has on an individual’s quality of life, highlighting the lived experiences of unhoused Californians who participated in the California Statewide Study of People Experiencing Homelessness. After the lecture there was a panel, featuring, Boston Healthcare for the Homeless founder, Harvard Medical School professor James J. O’Connell, and Peggy Bailey, a leader of a housing policy research center. JCHS Managing Director Chris Herbert, the moderated the panel. Dr. Kushel said, "While it is really easy to blame people impacted by homelessness, doing so not only is not fair or right, but it also isn’t going to get us any closer to a solution."

In this op-ed, Maya Vijayaraghavan, MD, MAS, director of the UCSF Smoking Cessation Leadership Center, highlights the need for affordable housing to be free of secondhand smoke. She emphasizes the threat of secondhand smoke exposure disproportionately affects Black Americans and the effectiveness of smoke-free policies. However, barriers still remain to implement smoke-free policies. "The implementation of smoke-free policies in public housing was a step in the right direction and should be expanded to all affordable multi-unit housing." Dr. Vijayaraghavan writes. This op-ed was published as part of the Public Voices Fellowship in partnership with The OpEd Project and funding from the California Health Care Foundation.

In this podcast episode of Clinical Changemakers, Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, spoke with host Jonathan Hoogerbrug, MD about the moral injury of being a frontline clinician and having to discharge people back onto the streets. Dr. Kushel also elaborates on her landmark research into Homelessness in California, highlighting the moral, medical, social and economic impact that that this issue has on those individuals, their families and society as a whole. Dr. Kushel said, "The people who are most impacted, obviously, are those experiencing homelessness and the impacts for them are just incalculably horrible. But it impacts everybody." She adds, "There are huge costs to society. There's the intangibles, like loss across the business, community, to tourism. There's the moral injury. What do we say to our children about what does it mean to grow up in a place where so many people are so visibly suffering?"

Black Californians make up only 7% of the states population, but make up more than 25% of the state's population of people who experience homelessness. The number is higher in Sacramento County, where 31% of the population experiences homelessness. The obstacles to housing, employment, income and health care that Black Californians have historically faced are also among the pathways to homelessness. "The situation for unhoused Black Californians is dire, but it is not insurmountable,” said Tiana Moore, PhD, the report’s co-author.

Some homeless shelters now offer resources so that people can squeeze in with family members. This diversion approach was pioneered by the Cleveland Mediation Center around 20 years ago. The approach is not for everyone, but it is meant to catch people before they slip into the shelter system. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "Even if it doesn’t work for everybody, if it works for a certain percentage, it’s likely worth it."

Research has demonstrated that homelessness is associated with poor health outcomes. However, there are fewer studies that show that gaining housing is associated with improved health outcomes. In a recent study published in early February was hypothesis-generating and found an association between housing and improved survival. Hannah C. Decker, MD, of the University of California, San Francisco and lead author, said, "Unhoused veterans who gained housing in the year after diagnosis had better outcomes than people who remained unhoused."

The perception of people experiencing homelessness is often based on anecdote. In the first episode of WPLNs 9 part housing series, In My Place, Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, joins host Khalil Ekulona to talk about the causes of homelessness, the misconceptions and myths of homelessness, and what cities can solve the problem. As the conversation moved to the misconceptions of people experiencing homelessness, Dr. Kushel said, "I think the single biggest misconception is that homelessness is synonymous with mental health and substance use problems." Dr. Kushel adds "At its heart, homelessness is a problem of housing cost."

In San Diego, people 55 and older make up at least 29% of the people experiencing homelessness. The seniors experiencing homelessness face tough choices with many of them on a fixed income and unable to afford housing costs in the city. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "When talking about homelessness, 50 is the new 75."

The mortality rate for people experiencing homelessness in America has increased in recent years. People are dying at increased rates because of overdoses, but also of things that may have been avoided if the individual had a home or regular access to preventative medical care. Furthermore, the population of people experiencing homelessness are getting older. In California, the number of people 55 and older who sought homelessness services increased 84%  between 2017 and 2021. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "As the homeless population continues to age, you’re just going to see death rates keep going up and up and up."

Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. In this retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) researchers evaluated whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury. Researchers found that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS.

About two-thirds of those who were kicked off state Medicaid rolls lost it for technical reasons like incorrectly filling out paperwork. In Montana, 120,000 people lost Medicaid as the state re-evaluated everyone's eligibility. Homeless service providers and experts have stated that many unhoused people have lost their Medicaid coverage. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "It doesn’t seem like such a big deal to fill out paperwork," but "Put yourself in the position of an elder who’s experiencing homelessness and has lost their vision, who has no access to [a] computer, no access to [a] car, doesn’t have [a] cell phone."

Deciding to live with intimate partner violence (IPV) instead of choosing a shelter is a complex decision. The UCSF Benioff Homelessness and Housing Initiative recently released a special report on IPV and homelessness. Anita Hargrave, MD, assistant professor at UCSF and co-author on the report, said, "Intimate partner violence can precipitate homelessness for many people, and is particularly dangerous for those that are at the economic margins."

Housing is linked to lower cancer mortality in US veterans, a recent study found. Hannah C. Decker, MD, of the University of California, San Francisco and lead author of the study, spoke about the study, the pervasiveness of veteran homelessness, and how homelessness affects health. Dr. Decker said, "We are really interested is getting a deeper understanding of how the VA gets veterans into housing, especially those that are diagnosed with serious chronic diseases, like cancer."

There is an overrepresentation of Black people in people who experience homelessness in California. A recent special report released by the UCSF Benioff Homelessness and Housing Initiative on Black Californians' experiences homelessness highlights the systemic racism. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "This didn’t just happen by accident and it didn’t just happen because there were a few bad people. This was organized." Dr. Kushel further adds in regards to reparations, "That feels like a conversation that, if we are being honest, we need to have."

In this op-ed, Leslie W. Suen, MD, MAS, an assistant professor of medicine in the UCSF Division of General Internal Medicine at San Francisco General Hospital, outlines how drug testing welfare recipients can create a pathway to homelessness. She highlights how losing benefits would lead to individuals to also lose housing and the lack of addiction treatment infrastructure will increase wait times. "A more thoughtful and comprehensive approach that considers the nuances of the issue, prioritizes access to treatment and ensures a fair and accurate screening process is essential," said Dr. Suen. This op-ed was published as part of the Public Voices Fellowship in partnership with The OpEd Project and funding from the California Health Care Foundation.

Loneliness is often more common in older adults and those who face structural vulnerabilities, including those who experience homelessness. In the United States, 48% of single homeless adults are 50 and older. There is a limited information about loneliness among older adults who have experienced homelessness. This study used qualitative data collected as part of a longitudinal mixed-methods study, Health Outcomes of People Experiencing Homelessness in Older Middle Age (HOPE HOME). The study aimed to examine the intersection between social isolation, functional and cognitive impairment, and use of supportive services among a cohort of older adults experiencing homelessness in Oakland, California. Researchers found that homeless-experienced older adults with cognitive or functional impairments exhibited diverse loneliness experiences.