By Manik Chhabra
The nomination of Ben Carson to become secretary of Housing and Urban Development (HUD) has been met with widespread puzzlement: What experience does a neurosurgeon have with housing?
There are many good reasons to oppose Carson's nomination to lead HUD. He has questioned the agency's mission and previously devalued his own ability to lead a federal department given his lack of government experience. I certainly have significant doubts about his qualifications.
Yet, in nominating such an unlikely candidate, President-elect Donald Trump may have inadvertently made a connection that too few policy makers and physicians recognize: Health and housing are inextricably linked. And our inability to successfully assist individuals who are homeless places a significant strain on our public resources.
Chronically homeless individuals die three to four times faster than the general population, and these individuals - who have experienced homelessness for multiple years - have life expectancies on par with people in developing countries. They frequently have serious mental illness, substance-use disorders, and chronic health conditions like diabetes, high blood pressure, and heart disease. Yet our answer to treating homelessness is often with a patchwork of shelters and reliance on emergency care that often leaves our health-care system at a loss.
One patient I saw recently was a 40-year-old man who had been homeless for the past two years and suffered from alcohol-use disorder and depression. He cycled in and out of the hospital four times a month. Each time, we treated him for alcohol withdrawal, but sent him back to the same streets that returned him even more broken. His relapses condemned him - no rehab program would take him, and no one would house him. The last time I saw him, I sent him out and he was back in the Emergency Department six hours later. This is a common, and frustrating, situation for health providers.
Given this man's story, and so many similar ones, it's not surprising that chronically homeless individuals account for a large portion of emergency care. In Camden, we know that 1 percent of patients account for 30 percent of the health-care costs in the city. Of that 1 percent, 30 percent are unstably housed. These costs extend to all parts of the system - including a significant strain on jails and shelters.
Yet, these stories don't have to be the norm. Programs that provide housing without any preconditions, called "Housing First," have been implemented successfully in states like Utah and Illinois. There we have evidence that providing housing to chronically homeless individuals yields stability - reducing hospitalizations, readmissions, and the use of shelters and jails.
Some studies have found that Housing First programs save taxpayers $20,000 to $30,000 a year per person compared with continuing to support them through shelters and emergency rooms. Through housing, individuals find improvement in mental-health conditions and reduced substance use. Strikingly, of the many individuals housed through these programs, the majority remain in housing five years later and beyond.
Similar policies extend to families through rapid rehousing initiatives that provide, quick, timely support to those who lost their housing because of the economic downturn. With housing, families are able to get back on their feet: children are back in school, and parents can regain employment and get back to contributing to their communities. Importantly, such stability also means that individuals are less likely to miss doctors' appointments and the routine care that ensures their well-being.
HUD has been pivotal in working with the Department of Veterans Affairs on housing first and rapid rehousing, cutting homelessness among veterans in half over the last six years. These efforts can be expanded broadly to improve the lives and health of the 1.56 million Americans experiencing homelessness each year.
At his confirmation hearing last week, Carson highlighted the strong connection between housing and health, stating that "where one lives should not cause health problems." This is especially true for those whose housing is unstable.
Given that the Senate is expected to confirm his nomination, we can only hope that Carson approaches his new job in the way he was trained - as a physician. If he does so, he will have the opportunity to improve the health of millions of Americans each year.
Manik Chhabra is a primary care physician at the University of Pennsylvania who researches homelessness and its connection to health. firstname.lastname@example.org