This week’s tip: Unwavering belief in the best solution can blind you to its potential for causing unintended harm.
As America’s cities grapple with a large rise in homelessness, there is a largely unreported chasm of disagreement between housing advocates and formerly homeless individuals.
Advocates want to dramatically expand government spending on supportive housing, while at the same time removing any and all barriers for homeless individuals to access free housing.
On the other side, many formerly homeless individuals currently residing in supportive housing are concerned for their own safety.
As rules and restrictions have been removed by government and nonprofit landlords – like who can get free housing and what behavior is required to keep it – living quarters are being described by residents as “a living hell.”
At the heart of the dispute is an important concept about problem-solving interventions that can be summed up in one word:
Iatrogenic.
“It worsens with healing.” -Virgil
Iatrogenic refers to any harm or negative effect caused by a medical or therapeutic intervention.
Like getting an infection because the doctor didn’t wash her hands.
Or undergoing a doctor-recommended elective surgery that unintentionally results in death.
Essentially, the cure can be worse than the disease.
By considering potential harm caused by the healer, you can weigh the trade-offs between action and inaction.
In the context of advocacy related to homelessness, iatrogenic harm can occur when policies or interventions intended to support homeless individuals inadvertently cause harm or create new problems.
The debate: the advocate vs. the beneficiary
Today’s question is,
“Can well-intentioned anti-homelessness policies inadvertently create dangerous living conditions for vulnerable individuals that perpetuate addiction and homelessness?”
Absolutely not, says Gary Dan, 42, the president of nonprofit housing advocacy organization in a large American city. (Gary is not his real name; he is a composite of three real-life individuals quoted in recent news articles.)
Hell yes, says Destiny Brown, 27, a formerly homeless single woman currently living in supportive housing in Seattle. (Destiny is not her real name; she is a composite of three real-life individuals quoted in recent news articles.)
The “evidence-based” solution argument
Here is Gary:
“Housing First policies are designed to provide stable and permanent housing for individuals experiencing homelessness, without any prerequisites or barriers to entry.
It is an evidence-based approach and the best and only solution to homelessness.
By enforcing strict rules – like prohibiting the use of drugs, or monitoring guests – we risk turning supportive housing into temporary shelters or institutions, which can create a stigma and discourage people from seeking help.
In addition, many individuals experiencing homelessness have complex needs, including mental health and addiction, and enforcing rules may make it harder for them to seek the help they need.
The question – about whether our supportive housing could cause potential harm – is silly and dangerous.
The answer is absolutely not.”
The first-hand experience argument
And here is Destiny:
“I was on the streets for three years, and now I’ve been in supportive housing for two years.
While I appreciate the opportunity to have a roof over my head, my building – which used to be safe – is out of control.
I mean, hell yes it’s causing harm to me and my kids.
The front door is unlocked and the building isn’t monitored anymore.
There’s prostitution and drug dealing in the hallways.
Men pound on my door at two in the morning asking for sex. My neighbor relapsed into using and was beaten up last week. Seven people in my building have died of overdoses in the last year.
Without any rules or requirements to live in my building, people like me – those who were on the streets and are now trying to build a better life – are being put in harm’s way.
Why doesn’t anyone advocate for us?”
There are no easy answers
I’m not a housing or homelessness expert and I don’t know the answers.
But what concerns me most are two things:
First, if you’ve been around any policy discussions about these issues, you’ll notice that people like Destiny aren’t usually in them.
Many like her fear speaking up because it puts their free housing in jeopardy.
I want to hear their stories, good and bad, about how they experience supportive housing.
It should be central to the discussion.
They likely have the best ideas about what should be changed to get better results.
Second, despite laudable and tireless efforts, and the best of intentions, many homelessness advocates seem to believe that their solution – Housing First with no programmatic pre-conditions – can do no harm.
Let me be clear that I’m not opposed to permanent supportive housing or a whole range of interventions aimed at reducing homelessness.
What I oppose is belief in any solution that is so fervent – so ideological – that it is beyond questioning, modification, or the potential for causing harm.
It’s a recipe for blindness.
But many who have this belief are currently very active at state capitols where legislators are debating spending hundreds of millions of dollars on “solving homelessness” with inflexible Housing First.
Testimony from people like Destiny, or from longitudinal studies showing “high mortality, low housing stability, and poor long-term housing outcomes” in permanent supportive housing programs, is not usually heard.
Because that would open the door to seeing homelessness as a complex problem not so easily funded and solved.
Also, nuance about the problem and its potential solutions would likely diversify public investment to test and evaluate a range of interventions.
That’s threatening to those who believe in, lobby for and implement one correct answer.
But resident concerns – about issues like overdose deaths in public housing in Seattle; prostitution, vandalism and broken toilets in LA; and broken elevators that trap elderly residents and rodent infestations in dilapidated San Francisco hotels – are enough to show that we can’t afford to have sacred cow policies no matter how intuitive and humanitarian they seem.
The human cost is too great.
As I see it, all policies are trade-offs, and they must be weighed by those who implement them, and by those who experience the consequences.
Visions that promise total solutions, supposedly without any negative consequences, risk causing more harm than good.
TLDR
Hippocrates was right: first, do no harm.
How?
By thoroughly evaluating the trade-offs of policies and interventions before and after implementing them, especially those that affect the most vulnerable.
Just ask those most affected.
See you again next week.
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