What Other Cities Can Learn From Boston’s Public Health Approach to Homelessness
The rise of encampments has moved homelessness to the top of the list for local leaders. According to a recent survey, the homelessness crisis is the No. 1 concern of mayors across the country, but they feel like they lack the guidance and tools to adequately address it.
A 2019 HUD study of four communities found that they spend significant resources on clearing and providing support to homeless encampments but struggle with comprehensive and lasting solutions. Some cities simply task police and public works departments with clearing encampments without providing support and without an overarching strategy.
Mayors and local leaders, homeless service organizations, advocates, and the public would all agree that encampment clearance with no strategy and no support is not a sustainable solution. It frustrates service providers because it disrupts their efforts to engage and build trust with people experiencing the trauma of homelessness. Police departments feel that their time and attention is stretched thin and taken away from tackling crime. And legal advocates decry the violations of constitutional rights that protect people from unlawful seizure of property, as well as cruel and unusual punishment.
As one mayor of a large city recently put it, “Mayors are caught between two opposing viewpoints. On the one hand are people who want us to criminalize homelessness and the other that want us to say that anything goes. Neither of these viewpoints is the right solution.”
The question is, what is the right solution?
One potential answer to this question may come from the city of Boston, where officials are employing what they refer to as a “public health response” to unsheltered homelessness.
In February, several HUD officials, including myself, went to Boston, where Mayor Michelle Wu is making measurable progress toward resolving encampments through connections to health care, treatment, interim shelter, and permanent homes—not law enforcement and bulldozers.
When we visited the site of a major encampment locally referred to as “Mass and Cass,” here’s what we saw:
- The tents were gone—all of them—and none had been forcibly removed.
- No one was sleeping at the former site.
- All residents were offered—and most accepted—the opportunity to move into short-term housing while they waited for permanent housing.
- The city was using American Rescue Plan and CARES Act funding to move people into permanent housing and to build an unprecedented amount of new housing.
- Some people were at the former site to visit the new engagement center, where they could talk to providers and get the health care and treatment they needed.
How did Boston eliminate an encampment in the span of two months, and what can other cities learn from their approach?
Our visit and subsequent conversations with Boston officials point to the following elements that appear to be applicable to many other communities:
- Leadership: When a mayor makes a public commitment, solutions get sought, resources get leveraged, and things get done. In November, when she was elected, Mayor Wu publicly committed to eliminating this encampment—without criminalization or forced removal—before mid-January.
- Public Health Experts: To lead this work, Mayor Wu appointed Dr. Monica Bharel, a physician and former state health commissioner who had led Massachusetts’ COVID-19 response. Dr. Bharel used the same tools she used to combat COVID-19: data, a focus on both individual and population outcomes, a “whole person” approach, cross-sector partnerships, and daily meetings to identify what needed to be done.
- Health Care Partnerships: Dr. Bharel enlisted Boston Medical Center to operate one of the shelters at a former hotel and to provide onsite outpatient addiction treatment. This approach ensured treatment for many who couldn’t previously access it. Boston Health Care for the Homeless continues to provide health care and outreach at the shelter sites and the engagement center.
- Coordinated Outreach: Dr. Bharel used daily meetings and the creation of an engagement center at the former encampment site to coordinate outreach among multiple providers. At the new center, people could fulfill their basic needs for food and clothing, receive health services and treatment, and learn about their options for shelter and housing.
- Harm Reduction and “Whole Person” Treatment: Boston’s health care providers and homeless outreach teams used non-judgmental listening to engage people, build their trust, figure out what they needed to lower their risk of dangerous or fatal outcomes (such as overdoses), and personalize a path to recovery. Health care providers are offering what SAMHSA refers to as a “whole person” approach to treatment: meeting people where they are; attending to primary care and social needs like housing, food, and community; and adapting treatment modalities (outpatient Medication Assisted Treatment and residential treatment referrals) based on individual needs.
- Reimagined Shelters: The city used Emergency Solutions Grants from the CARES Act and State and Local Fiscal Recovery funds from the American Rescue Plan to launch three (and eventually four) sites near the encampment that operated as special 24-hour “low-threshold” shelters. Compared to other shelters in the city, these offered more privacy (with no more than a few residents in each room), more freedom (residents could come and go as they wanted), and more empathy for the realities of addiction (substance use was not allowed in the facility but outside use did not expel them from the shelter).
- Housing: To move people quickly into permanent housing, the city used Emergency Housing Vouchers from the American Rescue Plan, Emergency Solutions Grants from the CARES Act, Housing Choice Vouchers from Boston Housing Authority, and a revamped coordinated-entry system. New permanent supportive housing is being developed that will serve as another option for former encampment residents.
The work in Boston is far from complete. Officials are worried about the return of the tents because they have yet to find permanent homes for all former encampment residents, and many people still return to the site during daylight hours. But with more housing resources than perhaps ever before, the city is hopeful—and so is HUD.
Boston is demonstrating that it is possible to get people off the streets and into shelter and housing with a proactive public health approach rather than an aggressive approach driven by law enforcement.
We know that homelessness isn’t just a problem in big cities. Boston is one of more than 90 communities that have signed on to be part of the House America initiative, a federal-local partnership launched by HUD Secretary Marcia Fudge, the chair of the U.S. Interagency Council on Homelessness. The initiative’s goal is to make the most of American Rescue Plan funding to expand affordable housing and find a permanent home for at least 100,000 people experiencing the trauma of homelessness.
I am confident we can reach this goal, especially if more communities approach this problem like Boston—comprehensively and compassionately.
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