For Want of a Toilet, a Life Will Be Lost

The reasons that people experiencing homelessness are tremendously medically vulnerable are both physical and psychological, the factors quite complex. But there is that solution to the equation: Housing as healthcare.
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Nowhere to Pee

Did you ever have a moment when something you already understood intellectually suddenly lands on an almost cellular level?

Last Thursday, a conversation at work did that, for me. "Robert" who endured chronic homelessness for nearly three years, was recently successfully referred into a permanent supportive housing program. He had come by our agency, Bethesda Cares, to chat, to report on his tremendous and rapid personal progress.

"I am so glad. I peed for, like, 45 minutes yesterday," he said, "because I finally could."

I thought he meant he was grateful for the "luxury" of ready-access to the toilet in his new apartment.

That "luxury" wasn't it, though. Robert was talking about the actual reason having a toilet matters: his health.

Robert has congestive heart failure, a condition that means his heart is not pumping adequately to keep his kidneys effectively processing waste. Thus, his body builds up fluids, swelling his ankles and legs. A free clinic had supplied him with diuretics, crucial for alleviating his symptoms. Yet Robert could not use his life-saving medication.

Think about it, Reader.

Diuretics, while you are living on the street. No option to just run to the bathroom when you feel the need.

Now housed, Robert has a bathroom with a medicine cabinet, and can finally properly store and take his meds.

Housing Is, In Fact, Healthcare

We all share same three-legged stool of basic needs we must meet for human survival: food, shelter, clothing. Take one leg away, and the stool tumbles. For the purposes of this post, let's look at existence without "shelter."

"Housing is healthcare" is a mantra around Bethesda Cares. Our work centers on housing as the stabilizing factor for recovery, health, and ultimately, survival. It's a model broadly known as "Housing First."

The people we serve, living unsheltered and homeless, are society's most medically vulnerable. They are routinely exposed to the hottest nights, the coldest days, blizzards, downpours, the occasional derecho. They suffer frostbite; multiple conditions from sleep deprivation; their cuts and scrapes are prone to infection; they are at risk of dehydration year-round. And yes, some of them "self-medicate" by drinking themselves into unconsciousness

All that is, of course, in addition to the ordinary illnesses and conditions we each encounter as we age.

How is the homeless woman with diabetes supposed to refrigerate her insulin? The man with high cholesterol, but no kitchen, to cook himself low-fat meals? People coping with both the frenetic uncertainty of life on the street, and with constant exposure to the natural elements are at abnormally -- and avoidably -- high risk of physical suffering, and premature death from treatable causes.

It's a disgrace.

You Don't Need to Be an Economist to Do the Math

If the humanitarian aspects of housing don't move you, consider the economics of "housing as healthcare." They are stark.

Where do people experiencing homelessness go for emergency care? To the nearest hospital ER, of course, maybe ferried there by a local rescue squad who intervened. In fact, people experiencing long-term homelessness are among the highest consumers of costly emergency medical interventions. A hospital must, by law, "stabilize" a person suffering an emergency even if the person cannot pay. The hospital then absorbs that expense.

(I'm just spitballin' here, but you think maybe hospitals pass on those costs on to other consumers, like, say, your insurance company?)

So after perhaps an overnight stay, and tens of thousands of dollars of services later, the patient is released... back onto the streets. Maybe the condition that sent him to the ER is permanently alleviated. Probably not. Regardless, returning to sleeping on a park bench will not speed anyone's recovery.

Even in pricey Montgomery County, Maryland, the cost of housing a person experiencing long-term homelessness is thousands of dollars less, per annum, than allowing that person to remain homeless.

Any third-grade readers out there get that mathematical calculation?


Any adults?

One Other Wrinkle

Emergency service costs are incurred only if someone seeks treatment; for people living unsheltered, that is not always the case. Why wouldn't someone want to go to a free clinic or check in to a hospital, if need be?

You ever see someone you think is experiencing homelessness, because he carts around a lot of "stuff"? That's everything he owns. Those bags and shopping carts might look like they are filled with detritus, but they are items of no lesser a personal value than are our own photo albums, laptops and favorite coffee mugs.

When you and I leave our places of residence, we lock the doors and expect our belongings to be there on our return. A person living at a bus stop, however -- I refuse to call a bus stop a "home" -- knows that his stuff may have vanished by the time he returns from the ER, either into a dumpster, or scavenged by someone else in need.

Seeking treatment is not a slam-dunk of a choice.

In the End

The reasons that people experiencing homelessness are tremendously medically vulnerable are both physical and psychological, the factors quite complex.

But there is that solution to the equation: Housing as healthcare. I have long understood that. Now I get it, too.

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