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Real Progress on Homelessness

We can end chronic homelessness, but only if we abandon ineffective and entrenched practices.
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New York City is solving homelessness, naysayers notwithstanding. According to the city's latest count, conducted on January 26, 2009, and released on Wednesday March 4,
there are an estimated 2,328 unsheltered individuals living in New York City, down from 3,306 a year ago, a 30% reduction. Brooklyn, the Bronx and Queens showed a reduction of more than two-thirds since 2005, while the City in its entirety has a near to 50% reduction over the past three years.

That is progress. But success has required abandoning old and ineffective practices. Contrary to the beliefs of many well-intentioned people, outreach programs in which workers and volunteers talk to homeless people on the street, give them food and, occasionally, take them to a hospital or shelter does little to solve the long-term problem.

That's because although most people are transiently homeless -- their plight the product of the sort of economic and social misfortune portrayed in the Will Smith film, The Pursuit of Happiness -- a core population of about 1000 homeless people in NYC has lived on the streets for years. The vast majority of these people are mentally ill or abuse alcohol and drugs, and have serious health problems that, in too many cases, are never addressed but cost society dearly: one homeless man's repeated use of emergency rooms, ambulances and hospitals until he died -- homeless -- earned him the name Million Dollar Murray in an article by Malcolm Gladwell in The New Yorker.

How did we get here? Poverty, unemployment, mental illness and alcohol and drug abuse have been with us forever, but homelessness is relatively new, exploding onto the urban landscape only in the 1990s. The main reason has been the erosion of affordable housing: in the 1970s there were over 2 million vacant affordable apartments, while today we have 1 million fewer than are needed. Barbara Ehrenreich, writing in Nickel and Dimed, by taking jobs at Wal-Mart, housecleaning or as a waitress, showed how it is possible to work full time but not make enough to be housed.

Chronic homelessness is also the result of our failure to provide comprehensive and coordinated community mental health services. The number of mental hospital beds in New York State has fallen from 90,000 in the 1960s to 4,000 today. Because we have not created sufficient affordable housing, linked to mental health and addiction services, for this population, many end up in jails, prisons, shelters, hospitals, and on the streets.

Finally, the chronically homeless include young people who have aged out of foster care (in some communities, one in four such youth becomes homeless) and veterans (20 percent of the homeless are veterans).

In 2004, Mayor Bloomberg launched a plan to reduce homelessness, focusing on the chronically homeless. Inspired by a program in Great Britain, the idea is surprisingly simple: count those perennially on the streets and shelters -- people who, like Million Dollar Murray, suffer most its corrosive effects and disproportionately drain the public treasury -- and target services to them.

But not the old kind of services such as offering food and short-term shelter. The City used to pay private agencies for "contacts," which meant talking to homeless people on the street, giving them food, occasionally bringing them to a hospital or shelter. But the number of street homeless and long-term shelter residents was increasing. What the chronically homeless needed was to be housed.

By 2006, New York City switched gears. It terminated 17 outreach contracts that emphasized "contacts" and replaced them with four new borough-based outreach programs stressing "housing first," in which people are moved directly from the street or shelter into an apartment run by a community social service agency. A remarkable 80 to 90% of people helped in this way remain housed a year later, including those with serious mental illness and substance abuse. What's more, their use of emergency health and social services drops significantly. Regular counts determine what's working and in what neighborhoods. Those most in need have priority for supportive housing, which has been substantially expanded. Housing first gives people what they need -- and want.

Even as New York (and hundreds of cities across this country and abroad) reduce their populations of the chronically homeless by an unrelenting focus on housing, detractors remain invested in "how we used to do it," offering talk, food and short term shelter. We used to use ether for anesthesia too. The Obama administration, including the new leadership at HUD, HHS and the VA, can support a focus on ending chronic homelessness by providing affordable housing and (Medicaid funded) flexible community services fundamental to long term progress. We can end chronic homelessness, but only if we abandon ineffective and entrenched practices.

Dr. Sederer is the Medical Director of the NYS Office of Mental Health. From 2002-2007 he was Executive Deputy Commissioner for Mental Hygiene Services for the City of New York.

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