non: [00:00:00] You are listening to the ATS Breathe Easy podcast brought to you by the American Thoracic Society.

Patti: Hello and welcome. I'm Patty Tripti. If you are tuned into the a s Free, the Easy Podcast. Over the last few months, you know that the ATS 2025 International Conference is on May 16th. That's the beginning of it in San Francisco this year, at the end of last year, the White House released a fact sheet touting the reduction of numbers of veteran homeless and other efforts to help homeless and.
Unhoused individuals, which included approving disability claims and increasing access to childcare. In 2023, there were more than 650,000 reported homeless people [00:01:00] overall in the country. Joining me today are two medical and policy experts who be part of an important and informative keynote session on homelessness.

That will be on Sunday, May 18th. Robin Rose Hamer and Dr. Margo k Ms. Rose Hamer is the director of the California Legislative Staff education Institute at Capital Hill Impact rather consulting. Prior to that, she was the organizational leader of three Sacramento based. Nonprofits dedicated to resolving homelessness.

She has personal experience after moving from the Midwest to California for why she's so passionate about the needs and care of the indigent and unhoused population along with homeless population. Dr. Khaw is the chief of the Division of Health Equity and Society and [00:02:00] Director of the UCSF Center for Well Vulnerable Population.

And the UCSF Benoff Homeless and Housing Initiative. Welcome to you, Bo. Thank you for joining me today. And what explains the difference in homelessness between regions? Why is there so much more homelessness in California, for example, than perhaps Chicago or Indiana?
Margot: So it's really interesting. There's so much mythology about this.

People think it's the weather or liberal attitudes towards substance use or something else, but there's really strong research that shows that the variation in levels of homelessness between communities. Is entirely explained by the mismatch between the amount of housing that is affordable and available for extremely low income households and the numbers of those households.

It's really about the mismatch between incomes and housing. [00:03:00] If you look at areas of the country with the highest rates of substance use or mental health problems, they often have some of the lowest rates. Of homelessness. In fact, the difference is completely explained through this lack of housing for poor people.

Patti: So what are the underlying causes of homelessness?

Margot: I mean, the underlying structural causes of homelessness are simply that we don't have enough housing and that people's income isn't too, isn't high enough to pay for it. Within those structures, within the fact that some communities have less housing and some have more housing there's the fact that any individual might have risk factors that put them at increased risk.

So in California, there's a much higher rate of homelessness than there is in Mississippi because we have a much higher mismatch between our housing rates and our income. Within California, it is people who have certain individual vulnerabilities, whether they be [00:04:00] substance use problems or mental health problems that put them personally at highest risk of becoming homeless.

Patti: So there's a relationship between substance use and mental health problems and homelessness, correct.

Margot: Absolutely. It absolutely increases an individual's risk of becoming homeless. And by the way, once you become homeless, homelessness worsens those problems. But it in no way explains the difference in rates of homelessness between communities

Patti: and what are the impacts of homelessness on health.

Margot: You know, we really talk about you know, when people lose steady housing, everything else falls apart. So homelessness is absolutely devastating to people's health. Both through environmental exposures through just life chaos. People lose contact with their healthcare systems. They are spending every moment of every day.

Trying to get to [00:05:00] safety, trying to figure out where they're gonna sleep or where they're going to eat. It's a terrible time to be thinking about, you know, taking your anti-hypertension medicines. People are assaulted, people are exhausted, they're exposed to the elements. So when people become homeless, their health tends to really fall apart because of these direct effects of homelessness on health.

Patti: And what are the solutions to the crisis? Empathy, compassion, which mentioned by Robin Rose, and clinicians and physicians have very little time as they move from patient to patient as you know. How do they make those 15 to 20 minutes count?

Robynne: I think that it's, it's very important, first of all, as a precursor to remember how difficult it was for the, the person who's experiencing homelessness to get into the space.
And so I am a. Firm believer that mindfulness and preparation for any appointment or opportunity to meet with someone [00:06:00] is important to make sure that you're giving them your full attention, your full the full breadth of what you have to offer. And so not multitasking is an important way to show respect and empathy towards someone's circumstances and health condition, but certainly.
Taking advantage of any information that they have in advance. So being aware of someone's preexisting conditions, being aware of someone's precursor visits to this moment also helps because if you have most of the information that you need to start a, a robust conversation with a patient upon entry, it's helpful instead of having the patient repeat.
All of their trauma and history before you even get started with the reason that they're, they're there,

Patti: is there a telltale sign other than this person expressing that? Homeless that doctors and, and, and clinicians can, [00:07:00] can know that

Margot: they're homeless. I mean, we recommend healthcare providers, screening people for homelessness because we think it's a really important piece of information.
I like to say that there's no medicine as powerful as housing, and their reverse is true. There's nothing that impacts your health as much as lack of housing does. I think there's ways to do that in a nonjudgmental way. I tend to ask all of my patients, I know housing prices are really high. I know it's hard for a lot of people.

How is that going for you here? And that opens up a conversation. I know some clinicians are afraid to open up that conversation when they feel like they have nothing to offer, but I have always found if you ask it in a non-judgmental, compassionate way, it helps people feel seen and appreciated.

Patti: Anything else that people with lived experience of homelessness and need from physicians
and researchers, clinicians rather.

Robynne: I think [00:08:00] everyone deserves to be treated in a way that makes them feel safe and respected. And Dr. Elle's advice about the prescreening is very important, but also understanding what your implicit bias is before you walk into a room with any person is extremely helpful to make sure that you are providing the.

That that individual needs in order to feel healthy and safe. So it's important for us to do all of the work that we have to do as professionals before we enter a room to ensure that we are not mistreating someone inadvertently or rooted in our own personal trauma.

Patti: You may know that Grant studying racial disparities and minority health are being pulled right now.
Research into how sex and gender influence disease is being canceled, and could that possibly impact or possibly derail your efforts in California and elsewhere.

Margot: I mean, I think from the research perspective, we're obviously in [00:09:00] unprecedented times and we're all trying to feel our way through it. We feel like we've made incredible advances in understanding and mitigating the effects of homelessness on health, and I would certainly hate to see that rolled back.

Patti: Dr. Margot our programs modeled after what the nation had been doing to help the veterans be the way to help others. Veteran hop homeless population rather reportedly dropped to a record low at the end of last year. I.

Margot: I think it's really important to know that the VA has been a model for us all in that they have been following the evidence to a T.
So one, they've been following the evidence, and two, they've had widespread bipartisan political support for it. In so doing, they dropped homelessness by 55% in the last decade when homelessness among other populations went up. How did they do [00:10:00] it? They had two or three key things. One is they rigorously followed the evidence which is for something called housing first.
Housing first has a lot of mythology around it, but all it means is a very simple concept. That you don't make housing the prize for having received treatment or, you know, adhering to sobriety that housing is not a prize that you win for doing those other things, but it is actually the root of all stability and housing first.

Is not Antit treatment. It's incredibly pre-treatment. But what housing first says is that when people are running around trying to figure out where they're gonna sleep at night, that is a terrible time to engage them in, in the rigorous work that people need to do to heal from past trauma. So first thing they did, they adhere to the evidence and use housing first principles.

The second thing that they did is they in a very [00:11:00] clever and organized way. Merge their health system with their homeless and housing systems. They recognize that, that most people whether or not they seek out care from the housing or homeless system, they seek healthcare and they realize that health was really a great way to identify people at risk and to intervene.
So every single veteran who seeks care at a VA health center at least once a year is screened using a simple two to three. Question screener to assess whether they are currently homeless or at risk of homelessness. And then if they're found to be either homeless or at risk of homelessness, they're referred to someone within the VA who then has the resources to help them.

And that is a third thing that unlike every other aspect of homelessness, veteran homelessness has been scaled. Not fully appropriately, but much, much closer to appropriateness with things like housing vouchers to pay rental assistance with homelessness prevention [00:12:00] dollars. So if someone is falling behind in their rent and is about to become homeless, they can get that rent paid back with job training.

And then the VA health system itself provides a lot of the services that make people thrive in housing. It's been an extraordinary success. It's a great example of following the evidence in a non-political fashion and resourcing a problem and seeing the results. There's no reason that this couldn't be true for all Americans.
We just lack the political will

Patti: and there is less of a stigma when somebody served the country, correct.

Margot: I think that's the reason that like, that the veterans have been able to, you know, and I like to say I do not think anybody who has ever served our country should spend a night on the street. I also don't think anybody should spend a night on the street.
Patti: And you'll be joined also by the undersecretary of the [00:13:00] Health and Human Services Agency, Corrine Buchanan, on your panel as well, correct? Yes. Anything else to add that I didn't ask you that you think is very important? And of course, we invite everybody to come to your session.

Robynne: One thing that I think is deeply important, and that is the importance of understanding that people who are most proximate to a problem have the highest trajectory to be able to resolve it.
And so understanding that it takes many, many years to become a doctor, and so there's a lot of knowledge available to one. To be able to draw from, to solve problems, another resource that can be used as the individual themselves to be in partnership and to be able to build trust and trust when built is a very powerful tool for resolution and for strength of solution.
Trust when broken is very easy to discount. Anything a [00:14:00] person is sharing with you. So I think it's very important that we all continue to work toward ways that we can build bridges, build trust, and create solutions for people who are experiencing homelessness.
Patti: Thank you both for giving a sneak preview of your talk, your panel on Sunday, May 18th in San Francisco.

I look forward to your session. I'll be there and thank you. For joining us. I see you in California. Thank you much for having us.
non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ats, breathe Easy podcasts on transistor, YouTube, apple podcasts, and Spotify. Don't forget to like, comment, and subscribe, so you never miss a show.