Rough Sleepers, page 6
The thickets of luxury housing, both new and renovated, had replaced a mostly bleak landscape of industrial warehouses and factories and vacant lots, of bars and boardinghouses and Victorian brownstones chopped up into single-room-occupancy units. Back in the 1920s, Boston had 35,000 of those SROs for rent. They had served as homes for immigrants and low-wage workers, elderly people on fixed incomes, and, more recently, for struggling Vietnam veterans and former residents of mental hospitals. In 1965, the city and South End residents had overwhelmingly approved a plan to turn the neighborhood into “an economically, socially and racially integrated community,” with rental housing for “all displaced low-income residents wishing to remain.” The destruction of the old buildings, with their inexpensive, often shabby rooms, was widely praised as an act of civic virtue, and it might have been, if anything like that plan had followed. But when the old buildings were razed or renovated into condominiums, the people who once lived in those SROs were turned out, onto the streets by day and into the Pine Street Inn at night. They came to the shelter in such large numbers that in order to provide breakfast and dinner and beds for all, the original Inn was forced to relocate to a larger building, its current headquarters with the tall Sienese lookout tower.
A severe recession in 1980 had inaugurated the era of rising homelessness. But the problem was driven and sustained by many long-brewing problems: the shabby treatment of Vietnam veterans; the grossly inadequate provisions that had been made for mentally ill people since the nation began to close its psychiatric hospitals; the decline in jobs and wages for unskilled workers; the continuation of racist housing policies such as redlining and racially disproportionate evictions; the AIDS epidemic and the drug epidemics that fed it. Also the arcana of applying for Social Security disability—a process so complex that anyone who could figure out how to get assistance probably didn’t need it.
Many commentators and scholars have written that the Reagan administration fostered the rise in homelessness, with its deep cuts in programs for the poor and policies that led to declines in the supply of inexpensive housing. Some responsibility for those cuts and policies also belonged to Democrats, who had controlled the House for all eight years of Reagan’s term and the Senate during the last two. Homelessness grew rapidly during Reagan’s time, and it continued to grow with every presidency that followed. Given the problem’s complex etiology, no single group can be blamed for all its constituent parts.
In an interview at the end of his presidency—with David Brinkley on ABC-TV—Reagan defended his record, blaming rising homelessness on homeless people themselves. Some, he said, were “mentally impaired,” consigned to wander the streets because left-wing lawyers had shut down mental hospitals. Some were too poor to buy or rent homes, because they didn’t want to work and ignored the “hundreds of ads” offering jobs. Others simply chose to live outside, even though there were shelters all over the country. “They make it their own choice for staying out there,” the president said.
These notions, and his administration’s attacks on Black welfare mothers, had deep roots in Western attitudes toward poor people generally and especially poor Black people. Reagan simply carried on the tradition of justifying inequality while also propagating enduring misconceptions. The shuttering of mental hospitals and the failure to create adequate replacements for them contributed to the size and complexity of modern homelessness. But homelessness afflicted many other Americans, along with the mentally ill. The president’s claim that a lot of unemployed people didn’t want to work was at best simplistic—most ads for jobs were aimed at skilled workers. And in asserting that many people preferred the streets to shelters and were therefore homeless by choice, Reagan in effect conflated homeless shelters with homes.
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Homelessness exists in virtually every country. According to a 2020 report from the United Nations Human Rights Council, more than 1.8 billion people worldwide lacked “adequate housing,” and about 150 million were homeless. There was no reliable way to compare the extent of homelessness among most Western nations, but rough estimates made it obvious that the United States had a problem similar to some of western Europe, a bigger problem than the Scandinavian countries, and a much bigger problem than Japan or South Korea.
One heard on the news—and also read in some scholarly articles—that between 500,000 and 600,000 Americans were homeless. Those numbers came from yearly counts of people who, on a single winter night, were found sleeping in homeless shelters or transitional housing, or in “unsheltered” locations—in what the Department of Housing and Urban Development (HUD) defined as “a public or private place not designated for, or ordinarily used as, a regular sleeping accommodation for people.” Those one-night figures gave the illusion of precision—580,466 in 2020, for example—but they didn’t include all the homeless people who happened to be in a hospital, detox, or jail on the night of the count, or the unsheltered people who for their own safety slept in well-hidden spots, or those who slept on floors and sofas in the houses and apartments of friends and relatives. One member of the Program’s board of directors spent his homeless years that way, and he knew that many other homeless Black Americans in Boston did likewise.
A more accurate one-night count would still have vastly understated the size of the problem, in part because homelessness was a fluid predicament—some people used shelters intermittently, and a much larger number stayed briefly and never returned. Another study from HUD tried to remedy this flaw by estimating the total number who stayed in shelters at any point during a given year. The official estimate for 2018 (published by HUD in 2020) was 1.446 million. But this number left out rough sleepers and couch surfers and many others. Counting only public school students—no parents or siblings, just the students—the federal Department of Education found that about 1.4 million suffered homelessness during the 2018–19 school year. Many nongovernmental estimates placed the yearly total of homeless people at 3 to 3.5 million, but those figures were based on a single study made by the Urban League in 2001—a study that, twenty years later, had been referenced at least 597 times, a case of references referencing one another, all based on one estimate.
When Jim began his work in Boston, national attempts to enumerate homelessness were sporadic and wildly inconsistent. The methodology for counting had improved since then, but there were still no certainties in this arena, except for the fact that homelessness was much larger than usually asserted, and no one knew its real dimensions.
Many Americans also lived in a state known as “housing insecurity”—at risk of being evicted or unable to pay their rent. One estimate, from the National Alliance to End Homelessness, found that 10 million American households were suffering such insecurity in 2019—6.3 million because they were spending more than half their income on housing, and 3.7 million because they were “sharing the housing of others for economic reasons.”
Looming evictions and rising costs for housing all but guaranteed that the ranks of homeless people would continue to grow, a threat already manifest in many places, such as New York City and Los Angeles. The problem in Massachusetts was small by comparison, but between 2012 and 2017—according to official state estimates—homelessness had risen by nearly a third, and the number of homeless families had doubled. Boston had a population of about 700,000, and according to one loose calculation from Jim and a colleague, between 24,000 and 36,000 “experienced homelessness” at one time or another during 2017.
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Homelessness had a complex taxonomy. It included families and also many lone individuals, generally divided into four categories. There were the “hidden,” such as the Street Team patient who slept in a rented storage locker. The “transitional,” by far the most numerous, fell into homelessness only briefly, while the “episodic” did so a few times a year. A smaller number—about 10 percent in 2018—belonged to the “chronic” category, living in constant or near-constant homelessness. That chronic group had two main subgroups—those who spent most of their nights in homeless shelters and those who slept rough, on pavement and park benches, in doorways, ATM parlors, tents on the outskirts of towns.
In 2018, according to a federal estimate, about a third of “the chronically homeless” usually slept outside of shelters. In Boston, by contrast, less than 5 percent slept in the rough. This was partly because of Boston’s harsh winters, and also because for the past thirty years every Boston mayor had promised a bed for anyone who chose to come inside. Shelters were abundant, and all but one admitted people who were drunk.
The Program now treated people stuck in every form of homelessness. The Street Team, still a very small part of the whole, had narrowed its clientele to include only the hardcore rough sleepers, the people who stayed outside through the cold months—300 to 400 in all. These patients were an anomalous group demographically: Two-thirds were white, 70 percent were men, all were adults, about half of them between eighteen and forty-four years old.
Some rough sleepers claimed their own distinction, labeling as “snowbirds” those who slept out only in the warm months and retreated to shelters in the winter. In fact, the difference was important. In Massachusetts, the people who lived mostly in shelters suffered a death rate about four times higher than that of the state’s general adult population. But the people who stayed outside year-round—the Street Team’s special patients, whom Jim had once imagined as “hardy survivors”—died at about ten times the normal rate.
By 2017, Jim had long since retreated from the day-to-day management of the Program. He still had an important role in overseeing the whole operation, but he spent at least as much time serving as captain of the Street Team, and he did all of his actual doctoring with rough sleepers. Behind their appalling death rate and other harsh statistics lay many challenges and many faces. It was the challenges, I came to think, that drew Jim to this work. The faces held him there.
2
A New Face
According to a doctor who had worked for the Program in its early years, Jim had a knack for “pre-admiration.” The doctor explained: “Even the average extrovert is not super excited about meeting somebody who smells bad, who’s wearing tattered clothes, is lying on the ground and asking for money. But it’s possible to do, and Jim was the most powerful example I’d ever seen in my life of somebody who was doing that naturally.” Pre-admiration was something like the opposite of prejudice, a quality the doctor had tried to emulate: “I think that Jim has an attitude of pre-admiration for the people he doesn’t yet know. His presumption is, ‘Oh, I’m eventually going to like this person. I will probably find some reason over time to like them. I just happen not to know it yet.’ ”
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It was a Thursday, Street Clinic day in a corner of the Massachusetts General Hospital. Like the van, this clinic had become an institution. When it had started, in 2002, homeless patients and their knapsacks and bags of belongings had shared the waiting room of the hospital’s Walk-In Clinic with more proper citizens of Boston. It had been an uncomfortable arrangement for both parties, “traditional” patients disturbed by drunken yelling, and homeless patients humiliated when all the people around them got up and moved away. After six months, Street Clinic was allotted its own waiting area, a floor below the Walk-In, in a lightly trafficked corner of the hospital. The waiting room was small and windowless, but the team stocked it each Thursday with coffee and donuts, bagels and sandwiches. Patients could get passes for the subway and meal tickets for the hospital’s restaurants, and they could sit on the long row of attached chairs in the hallway outside as long as they liked, talking to their friends. The usual atmosphere was mixed chaos and order, shopping carts filled with gear crowding the hallway, slumped figures dozing in the chairs, slurred voices of patients raised in argument with others and sometimes themselves, while off to the side other patients sat in quiet conversation with Street Team staff and volunteers who were helping them fill out forms, listening to their stories, offering advice and consolation, mediating squabbles. Once in a while a patient threatened the charge nurse, on occasion there were fisticuffs among patients, but, Jim insisted, there hadn’t been a truly dangerous incident in more than fifteen years.
On these Thursdays, Jim became something like a traditional physician again, seeing patients in an office upstairs—a small exam room at the rear of the Walk-In Clinic, one of two tiny exam rooms that the hospital had rented to the Program for the past thirty years. He once told me that about three-quarters of his job had more to do with social work than medicine. And, he would say, it wasn’t medical school that had trained him for that, but rather the bartending he’d done to put himself through medical school. “If you’re not willing to listen to lots of people talking at you, not all of them coherently, you’ll go crazy tending bar.” Most Street Team patients required lengthy visits, sometimes for medical reasons, more often for moral support. Typically, he’d see five, rarely six, in the course of a clinic, and finish up by late afternoon. This Thursday, in September 2016, had passed in relative serenity. He was getting ready to head home when his assistant, Julie, called from the waiting room downstairs. A brand-new patient had arrived, asking to see “Dr. Jim.” The man seemed “pretty wild,” Julie said. She gave Jim the name and date of birth: Anthony Columbo. December 19, 1968.
Jim told her to bring the man upstairs to the exam room. He did this with misgivings. He had promised to head for home by four, at the latest five. His wife, Jill, was at home alone with their infant daughter, Gabriella, and would be in need of relief by now. Maybe he could keep this visit short—simply meet this new patient and arrange to see him on another day.
Jim always stood to greet his patients. He would put on a listening smile for the talkative ones, all the while observing them carefully. The exam room wasn’t much bigger than a janitor’s closet and crammed with basic medical equipment. When this new patient walked in, he made the room seem even smaller. He was taller than Jim, tall enough that Jim had to look up to meet his eyes. He introduced himself as Tony. He had a powerful handshake. Even when he sat down, in the chair beside the doctor’s gray metal desk, he looked outsized. He wore several layers of shirts, but it was clear that he was lean and muscular, much fitter-looking than most rough sleepers who were pushing fifty. He brought an odor of sweat and slightly rotten fruit. Several days’ growth of black beard charred his face. He was balding, his hair close-cropped with a few strands stippling his high forehead, which he mopped now and then with a wad of paper towel—sweating either because of all his clothing, Jim thought, or else withdrawal from gabapentin, an anticonvulsive widely used as an ingredient in euphoria-inducing drug cocktails. The man’s face was classically proportioned, with a slightly hooked Roman nose and dark brown eyes, which moved observantly around the room.
Jim asked Tony what brought him here. A torrent of words poured out. His voice was slightly hoarse, with a baritone timbre and a North End variant of the Boston accent. When he said, “Make a long story shawt,” he tended to do the opposite. He said he’d spent twenty years in prison, had been living on the streets ever since, and had been buying the drug Suboxone for a long time, both in prison and outside. Jim often prescribed this rather new drug to help patients wean themselves from heroin. It was in itself only mildly addictive. Tony said he was using it mostly for the pain in his back and knees, and now he was feeling sick from withdrawal—“Subo sick.” He needed some Suboxone now.
Did he use other drugs? Jim asked.
“I do, I do,” said Tony. “I smoke a lot of K2, stuff like that, and coke sometimes.”
On his computer, Jim had located Tony’s medical record, which revealed that he’d been seen sporadically at one of the Program’s clinics, and that he had been prescribed Suboxone for opiate withdrawal. Giving him a prescription was justifiable, but Jim wasn’t sure he ought to do that. Tony might be using Suboxone as a base for a drug cocktail. Jim told him that he could take a urine sample from him now, and then give him a script next week.
Tony’s eyes narrowed. The effect was dramatic. It turned his face dark, like north wind on the ocean. “Well, that was the whole thing,” he said. “That’s why I don’t come to these places.” He moved forward in his chair, about to rise.
“Wait a minute,” Jim said. “Sit down for a minute. Talk to me.”
And Tony sat back down, telling Jim how hard it was to live on the streets, how much pain he was in right now.
There was no mistaking the man’s desperation. Still listening, Jim turned to the computer screen and looked again at Tony’s medical record. The file was scanty, but it confirmed the outlines of what Tony was saying. Jim thought, “If I don’t take the time now to get him his meds, I probably won’t ever see him again.”
If he gave Tony a week’s prescription for Suboxone, Jim asked, would he promise to come back next Thursday?
“Damn right!” said Tony. “That’s what I’m heah for!”
Jim typed the script and handed it to Tony. If Jim had left then, he would have been only an hour late getting home. But Tony said he had another problem. “I don’t have an ID right now.” The reason was a fight, Tony said. He’d beaten up a fellow homeless man in Pi Alley a few weeks ago, a guy who had money of his own but was stealing from other homeless people. Tony said he’d given the man not an ordinary but a very bad beating, and afterward, fearing it had been caught on the surveillance camera there, he had thrown away his state ID and his Social Security, Medicaid, and bank cards. “I didn’t want to have IDs on me, in case the cops were looking for me,” he explained.
