Healing the Sick Among LA's Homeless: Expert Perspectives

The City of Angels needs divine intervention.

The Los Angeles metropolitan area has seen its homeless population rise to nearly 60,000, following a 12% uptick in 2018 alone, according to recent figures—and, unfortunately, those who lack housing in the region have more to worry about than just not having a roof over their heads. As Contagion® reported in February, an outbreak of typhus plagued the city’s homeless community late in 2018 and, like many urban areas across the United States, case clusters of HIV and other sexually transmitted infections, as well as hepatitis in the area, have been linked with injection drug use among those “sleeping rough” and others.

To get a sense of the problem in LA, and assess possible solutions to these public health challenges, we reached out to a number of experts working on the frontlines of the crisis in the region. Here are their responses, which have been edited for length and clarity.

Jeffrey D. Klausner, MD, MPH

Professor of medicine and public health, UCLA David Geffen School of Medicine/UCLA Fielding School of Public Health

His research work focuses on HIV and STIs among at-risk youths, including the homeless:

“Homelessness and the size of homeless encampments has gotten substantially worse…due to a combination of political and economic factors. Some call those encampments ‘Trumpvilles,’ reminiscent of Hoovervilles during the Great Depression. Poor political leadership locally and lack of caring among the larger population has further contributed to ineffective solutions…I am not sure what LA’s political leadership understands or how highly they are prioritizing the identifying short and longer term solutions to the crisis…I’d create local health outreach teams to offer hepatitis A vaccination; basic health services, such as screening and treatment for acute and chronic conditions; and install port-a-potties, handwashing [stations], and potable water units…Communicable diseases may be spread from one population to another and the increased costs of taking care of some populations in emergency rooms, or in substance abuse treatment or mental health programs, impacts our overall ability to do health promotion and provide health services for the general population.”

Adey M. Nyamathi, ANP, PhD, FAAN

Founding dean and distinguished Professor, Sue & Bill Gross School of Nursing, University of California-Irvine

Her team has worked to improve understanding of factors contributing to homelessness among women and is currently partnering with Los Angeles Christian Health Center/Joshua House and Union Rescue Mission and in a study of treatment of latent tuberculosis (TB) among homeless adults in the city’s “Skid Row” district:

“As in most cities, financial insecurity is a major contributor to homelessness in Los Angeles and throughout Southern California. A lot of people are living paycheck to paycheck, and when that paycheck goes away, they are out on the street. Our study of latent TB in Skid Row really highlights some of the outstanding work nursing, partnered with community-based organizations, are doing in the neighborhood. We are working with a number of community organizations to enroll adults with latent TB—in other words, they don’t have active disease, but rather are positive for the bacterium. Guidelines recommend treating these patients to protect them from active disease. Not surprisingly, many homeless individuals don’t complete treatment. However, our research nurses are literally walking the streets with trained community health workers to find patients and keep them connected with resources, and we are seeing amazing results. In general, treatment completion rates for those with latent TB can be as low as less than 50%, but we are seeing 90% rates in Skid Row, thanks to our outreach efforts. It just shows the phenomenal work these community organizations do now, and the potential they have to really address the issue of health care within the homeless population if they are given more resources.”

Benjamin F. Henwood, PhD

Associate professor of social work, USC Edward R. Roybal Institute on Aging

He has devoted his research efforts to assessing the efficacy of supportive housing programs in Southern California:

“High rates of homelessness have increasingly become a sign of economic booms and can be understood as a result of inequality created by economic prosperity rather than simply by poverty. It seems clear that if you could provide housing assistance and get people off of the streets, then outbreaks of conditions such as typhus, TB, and hepatitis would be less likely. Are there things that officials could do? Sure, provide bathrooms, cleaning stations, and welcoming shelters. Would I direct officials to do this? It’s hard to say since building out a massive infrastructure of this kind is resource intensive, and ideally permanent solutions to homelessness would be a better long-term solution…There are clearly some health conditions that are ‘housing sensitive.’ For example, we found that insomnia reduced significantly after moving into housing. Research has not clearly established, however, which conditions are housing sensitive and which are not. That said, it seems clear that having a stable place puts a person in a better position to attend to their health.”

Elizabeth (Libby) Boyce, LCSW

Program implementation manager, Los Angeles County Department of Health Services, Housing for Health, a program created in 2013 to create permanent supportive housing opportunities for homeless patients of the DHS system of care:

“There has been a significant increase in rental costs over the past few years partnered with a very low vacancy rate in the rental market. There is a lot of new development occurring, which is pushing long-time renters and/or lower-income renters out of the market. People who earn minimum wage cannot afford an apartment in LA, and there are not enough affordable housing opportunities. It is important to note that even with the increase in the homeless count, we housed 21,631 homeless individuals in 2018, which speaks to how detrimental these factors have been become for vulnerable populations in Los Angeles County. The solution to homelessness is affordable housing with access to health, mental health, substance use, and/or other supportive services. Los Angeles County, in partnership with the City of Los Angeles, has built an infrastructure that offers these solutions; they just need to be expanded. In addition, we need to introduce and support legislation and changes in regulations that protect renters, control rent increases, and/or incentivize the development of affordable housing...”

Harmony Rhoades, PhD

Professor, USC Suzanne Dworak-Peck School of Social Work and associate director, Center for LGBT Health Equity

Her past research has dealt with issues relating to substance abuse and mental health among homeless populations as well as the efficacy of housing outreach programs and efforts to improve food security:

“My hunch is that we’re seeing the residual impacts of many years of increasing economic inequality, coupled with terrible criminal justice policies, insufficient social safety nets, and lack of affordable housing. Many people are a minor catastrophe away from losing their housing…At the societal level we need to deal with economic inequality and create more robust social safety nets for everyone, but that’s an upstream issue that will require years of reform at higher levels of government. At the local level we need more affordable housing in general, more housing for persons who have experienced homelessness, and more funding for service providers to help people transition into housing. The only way we can end existing homelessness is through providing housing through a ‘Housing First’ model that prioritizes housing with no prerequisites for sobriety or service use, but then offers affordable and available comprehensive services for physical and mental health…Providing people safe and secure housing is a necessary first step to addressing health issues—it’s neither sensible nor reasonable to expect that people can take care of major health issues while living on the street or in unstable housing.”

Los Angeles County Department of Public Health statement:

“Outbreaks of syphilis, gonorrhea, and chlamydia are causing nearly 100,000 infections annually. Public Health is working closely with a large number of partners to protect those most at risk. The LA County Board of Supervisors recently provided several million dollars to help address this evolving situation. LA County is also maintaining vigilance for additional cases of measles in relation to a recent local outbreak and the ongoing threat of imported cases from the many regions of the world where measles outbreaks are occurring. In addition, Public Health is continuing to do outreach and promote mosquito-control efforts to reduce the risk of West Nile Virus, which continues to cause scores of cases and at least several deaths every year. Four actions are needed to prevent the spread of disease among those experiencing homelessness: Get and keep people housed in affordable, habitable and stable housing; ensure easy access to facilities for personal hygiene [such as] hand washing with soap and clean water, and sanitation, [such as] proper waste disposal; [provide] health care, including immunizations, [which] are a cornerstone of public health prevention, [as well as for] diagnosis and treatment of disease to control its spread; [and create] healthy environments, [by] prevent[ing] illegal trash dumping and ensure frequent trash cleanup and effective rodent control at and around encampment sites.”