Ed, Christine, Ralph, and Alma are home and healing: 9 approaches to homelessness that work and why

This is one in a series of articles, running between Thanksgiving and January, examining the relationship between housing loss and death in San Francisco. Check out the previous articles in the series, Looking for death, Gunpowder on the streets, and Will losing your home kill you?, Hidden in plain sight: dying and homelessness, and Be selfish: Give a gift to a homeless person and The Tenderloin: substance abuse and Nate, Starving in the Financial District: Ken and food insecurity, Forget Iron Chef. Try Titanium Chef: behind the scenes at St. Anthony’s. The Sixth and Mission Death Corridor: Assaults, brain trauma and homicide, Steve, Tori and the Western Addition: raising children without a stable bed, and Mary, Melodie, and the Mission district: Women brutalized on our streets.

You might think that spending ten years on the street, two of them at 6th and Mission, might mean that a person is a hopeless case. By the time you’ve lost your teeth, are infested with lice, drinking only alcohol and no longer eating for weeks at a time, you’re not recoverable, not functional, and not worth wasting valuable resources on – right? After all, how exactly could a person ever come back from being that far gone? And if you do make it out, you’re never going to be a highly successful small-business owner living in a beautiful home in Marin, all from your own hard work. Are you?

If you’re thinking that way, even secretly in your mind, as you pass people huddled under urine-soaked gray-felted blankets, then now’s the time for you to meet Ed. And then others, who’ve also moved back into the ranks of the housed – Alma, Ralph and one of our own SFGate commenters, Christine. Just as the initial four case-scenarios in the first article of this series illustrated important points about homeless mortality, these four amazing people illustrate homeless success. Read on and rejoice:

Ed is a successful business owner. Watch these three short videos to see the incredible arc of Ed O’Connell’s life, from The Descent into 6th and Mission as a younger man, then how he, like many homeless people, became Caught, and then, The Return.


Christine is a skilled programmer, and a veteran, Christine became homeless in the Tenderloin after spending years trying to deny her desire to change genders. She describes her homeless phase as “suicide on the installment plan.” She woke up once on the “corner of Golden Gate and Hyde,” slept outdoors on steps, and spent time in the “Slambassador” Hotel, one of many SROs in the City, an experience she describes as waking up at any hour in rooms slightly bigger than a closet with bugs and cockroaches crawling all over, the sounds of shouting and loud music right outside the door, and the air filled with the smells of incense and cheap food being burned. She credits some of her survival during this period to St. Anthony’s Dining Room. Without them, like Ken, she would occasionally “buy some junk at a corner store – my health was the least of my concern.” Her path out included accepting herself and recognizing the self-destructive tendencies that arose from years trying to refuse to come out as a woman. As she put it, “the drugs had completely consumed me.” She also credits her transition out with getting effective substance abuse treatment counseling and support at the Arlington Hotel “an island of sanity in a sea of addition.” Her advice? “Being loaded might buffer the pain and the loneliness of existence, but it’s all-consuming.” When you want to leave, “you need to really know what you want to do – if your goal is unrealistic or ill-defined, it’s harder to achieve.” And “having a sell-able skill makes all the difference.”

Ralph* is a retired physician. After becoming a board-certified doctor, he became addicted, his life unraveling. He describes the stages of becoming homeless as having a “plateau” where “you try to fool your friends – keep up appearances. Wash in a sink, look like you’re doing okay. But then things continue to fall apart, and you lose your friends, and you give up the effort.” He was able to recover and move out by getting substance abuse treatment. After achieving prolonged sobriety, he worked as a security guard and at other odd jobs before eventually being able to re-earn his medical license through a prolonged supervised proctoring program. He then worked 10 years as a physician giving high quality care to the desperately poor and underserved until retirement.

Alma is a highly-skilled, no-nonsense nurse. She spent time homeless, and was raped during a time she spent on San Francisco’s streets. She has, for many years after recovering from homelessness, spent her career working with “the homeless and addicts in hospitals and clinics.” Here is her advice to us about homelessness: “I heard some stories that would never make it to the big screen because they were just too unbelievable and so harsh that no one would pay for such misery to be told. The homeless victimize each other – they rob, rape and steal from the weaker ones, who already have nothing but perhaps their body to sell for the slavery of addiction, or perhaps their body to submit to more abuse in order to get a sense of safety from many. It is better to be beaten and raped by one, than many. Harsh thoughts? No, I have seen it, too many times. There are many stories out there that are real and true. Instead of avoiding the homeless so you can get your $5 fix at Starbucks, take 5 minutes and ask yourself – what can I do to help? Sometimes the answer is nothing. Sometimes the answer is just care, just ask, just be kind and look at the person as a human being with dreams and desires and lots of similar wishes that you yourself have: the universal wish of being loved, cared about, seen and valued.” Alma is quite cynical about cash handouts, and the ways in which cash may keep people from moving out of homelessness, particularly for people struggling with addiction: “When we give out of sympathy, we are perpetuating the problem, we are spoiling, and killing the necessity to change, therefore killing the person we meant to help. There must be change, there must be incentive. Even in jail, food, a bed, showers and companionship are available and provided – it is not such a bad sentence if what you had prior to it was worse.”

What works? Recent practice has focused on several new important strategies. These include:

1) Being aggressive about preventing homelessness in the first place. It is much, much cheaper and more effective to keep a person and a family housed than to try to get them re-housed once they’re on the street. These types of interventions include such things as significant new laws to protect women from being evicted due to reporting domestic violence, a major cause of homelessness for women.

2) Being aggressive about catching the newly homeless and helping them return to housing. It is more and more clear that there is a vicious cycle that begins once a person hits the street (see the video “Caught“). Preventing that cycle from occurring not only shortens the time of homelessness, but may also be able to stop a spiral into substance abuse and mental illness (particularly PTSD and depression) that is so often a corollary of exposure to high levels of violence.

3) Being aggressive about improving community conditions. As more and more research points to the generational impacts of poverty, and environmental determinants of health disparities, communities are doing more to stop the cycle of multi-generational homelessness (see the previous article’s video “No woman is an island“).

4) Providing services that buffer the mortality hits to the homeless. These include such important services as high quality meals (see the previous articles’ coverage of St. Anthony’s Dining Room and the Needle Exchange and D.O.P.E. projects). These services save not only lives, but money too. Almost as importantly, these high quality services here in San Francisco also act as a model entry point, providing welcoming regular contacts with non-judgmental service providers – something that has been shown in research, and by reports from people who left homelessness, to be a predictor of moving out of homelessness, even for the most chronically homeless.

5) Embedding employment and economic help with homeless services. Both the Homeless Prenatal Project and Larkin Street Youth Services are models of comprehensive service delivery that include economic skills with their other vital services. Both Ed and Christine point out how vital the role of having a sell-able skill is to the process of finally escaping homelessness for good.

6) Avoiding pure cash without anything else. Whatever your humanitarian, moral or political view, research has shown that unrestricted cash payments are associated with worse outcomes for those struggling with addiction. Furthermore, women can be particularly vulnerable (see the previous article’s video about the debt economy and money terror). Financial incentives, however, can be powerful and transformative, and money-management skills (and money protection services such as volunteer payee services) can be crucial parts of exiting homelessness.

7) Taking the Public Health Crisis approach. Across the nation, cities have developed a new strategy to tackling homelessness. That is, to treat it like the public health crisis that it is. If your life expectancy living on the 6th and Market is worse than that of a person living in Afghanistan, shouldn’t we be trying to intervene? The approach is to send out teams, with a S.W.A.T. team type of mentality, to document block-by-block, those living on our sidewalks, and then rank their high risk of death. San Francisco’s Public Health Department is right now working on its Vulnerability Index for the homeless. Taking the highest ranking people and just housing them, and pairing that with supportive services, has been shown to save lives and also be cost-effective. This January 27th will also be the every-2-year federally-mandated homeless count. If you’re tired of just reading about the issue, and want to see firsthand up close how some of your most vulnerable neighbors live, go to the DPH website and volunteer.

8) Practicing simple human decency. One of the lessons of researching and writing this series is the quiet decency of so many San Francisans. I met homeless people who truly have survived purely because many of you gave them your leftovers, or let them sleep in your sheltered doorway, or paid them to wash your company’s vans, or let them use your restrooms, or bought them a muffin. More even than those tangible acts is the bit of human dignity that so often was given as well – something that is a gift in itself, and profoundly valued by the recipient. As the currently homeless, the formerly homeless, and homeless service providers all reported, it is hard to get out of homelessness without changing how you see yourself. Those simple acts of human decency are deceptively simple, but profound acts.

9) Taking seriously the violence occurring on our sidewalks among the homeless. Unless we make a profound commitment, as some other cities have done, to intervening and stopping the violence occurring among those without a door to lock, we as a society will be paying for and dealing with the significant long-term repercussions for decades to come. Repeated head traumas, PTSD, depression and substance abuse are all linked to exposure to high levels of violence. A homeless person is actually NOT the same as any other victim. A homeless person is infinitely more vulnerable, and unable to get away from, or to even avoid predators. Stopping the lawlessness and violence on our streets, especially in the very small neighborhoods where a majority of it is occurring, is a crucial part of stopping the vicious cycle that traps people inside homelessness.

Finally, check out this hit parade – it’s a short video of individuals, small businesses, ministries, agencies and governmental groups who are making a real difference here in San Francisco:

These articles were produced as a project for The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communication & Journalism.

*Identifying traits are changed to protect confidentiality, and accompanying street photos are NOT of patients.

Do you want to support future articles looking at the role of the prison system in creating and concentrating homelessness here in California? Go to Spot.us to donate time, money or earn credits for support! Doc Gurley is a Harvard Medical School graduate and is a practicing board-certified internist, and the creator of the Memoriam app – the first, and only, app to allow disaster-relief workers to speak for the dead. You can follow Doc Gurley on Facebook. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific, effective, affordable tips on how to nurture your joy and grow your personal wellth.

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