Sleeping Rough in America Today, By Leonard Sowah

featured government and politics Health Economics Health Equity Homelessness politics and health

In my early days as a physician in Baltimore city I worked briefly with Healthcare for the Homeless and had many patients who were homeless. One thing that I learned was that the homeless in America have many varied life experiences beyond the common belief that mental illness and substance abuse are the most common causes of homelessness.

I still remember the mother of three who worked daily and lived at The House of Ruth a local shelter for women. Then there were a few who were chronically homeless and would fit the bill for the type you would see pan-handling on the street corner. There were a few who smelled so bad that when they came into clinic you really appreciated the nurse who cared enough to ensure they got a shower before you saw them. More often than not they would also need some “new clothes” as well.

the kids aren't alright
Homeless families in San Diego, CA

“the kids aren’t alright” by photosam88 is licensed under CC BY 2.0

I recall one gentleman in his 40s who sometimes came to appointments with his girlfriend or probably common law wife who lived in a tent in the woods on the city boundaries. He was very regular and was usually on time for his appointments, we talked about a lot but did not really get into why he was homeless but I remember his absolute horror of shelters or any form of group living.

One thing that is easy to realize in considering homelessness is that homeless individuals come in all shapes and forms and it is very challenging to have a good unifying narrative beyond the lack of affordable housing. What one would expect is that housing programs for the homeless would be flexible and adaptable.

Unfortunately programs are rarely ever designed with these features in mind. Bureaucrats have to count the cots, housing units and pots as well as meals served so everyone and everything fits into clean nice categories for the sake of reporting program success. Thus sometimes public assistance for homelessness may only serve certain categories whilst leaving many more without any meaningful help.

In this country for years certain forms of housing assistance had rigid rules related to marital status which discriminated against single parent families or other forms of non-traditional families. Other rules made it it so difficult for unmarried couples to live together that people had to choose between their partners and housing. 

The purpose of this is however not to demonize or call our policies into question but to make us more careful in thought and design as well as more cognizant of unintended consequences and address them. Already in the 2019 – 2020 winter season there have been death reported due to hypothermia in the homeless population.

Port of San Francisco“Port of San Francisco” by ncole458 is licensed under CC BY 2.0

Homelessness would continue to be with us but we can help ourselves better if we can prevent the situations and conditions that encourage homelessness. In  this election year, many of the democratic candidates have housing policy initiatives to address this problem. One fundamental fact is the inordinate impact of healthcare and health on the economic wellbeing of families.

Dr. David Himmelstein the founder of the advocacy group Physicians for a National Health Program in a research published in 2007 showed that 62.1% of all bankruptcies were medical. Efforts at improving homelessness in some of America’s worse hit cities like Los Angeles and San Diego would need to address their unique problems; however most of America would need to re-evaluate how our unique economic situations continues to fail significant sectors of our population and work on appropriate efforts to get ourselves back to a system with more equity and opportunities for all.

Leonard Sowah is a physician in Baltimore, Maryland

Feature photo: “Homeless Camp Ueno Park” by jamesabbott1963 is licensed under CC BY-SA 2.0


A physician providing primary medical care to patients across the lifespan