At the start of 2020, right before the Covid-19 pandemic, Rockford, Illinois was poised to eliminate homelessness.
That milestone was the result of more than five years of dedicated work to rethink how to tackle what often seems like an intractable problem, one that doesn’t just affect big cities like New York or Los Angeles. Like other mid-sized U.S. cities, Rockford had been dismayed by the numbers of the unhoused in its community and had begun several interventions to house them, including a collaboration with local eviction courts to keep those with precarious housing stable and safe. And it had seen results: It had housed all its homeless veterans, then all the people who were chronically homeless. Next it turned to singles, youth, families.
Then came the coronavirus. With all the illness and job loss and displacement of the pandemic, with all the pressures on low-income people and the organizations that served them, the city didn’t meet its ambitious goal of ending homelessness. But it kept chipping away. It kept making progress.
“Our efforts during the pandemic didn’t start when the pandemic started. It started well before,” Mayor Thomas McNamara told POLITICO. “We had strong meaningful relations with those who are homeless and those who assist with homelessness. So when the pandemic hit and the full nature of the crisis was fully understood, our team jumped — really, dived — back in.”
Housing is about more than four walls and a roof. Along with things like food, transportation, education and domestic violence, housing is considered a “social determinant of health” — something that affects health status, health outcomes — and health costs. People who endure prolonged homelessness have high rates of multiple chronic conditions and disabilities — mental illness, substance abuse, HIV/AIDS, diabetes, heart disease and other disorders. And it’s a vicious circle; people who have those conditions are more likely to become homeless.
Cities like Rockford that are still making progress against homelessness are succeeding because they are focusing on public health as well as housing. If anyone still had doubts about the health-housing connection, the pandemic made it excruciatingly clear. People experiencing homelessness, and those living in crowded, substandard, or multi-generational settings, were more vulnerable to getting Covid, and more likely to spread it.
“It’s very hard to isolate and follow stay-at-home orders if people don’t have a safe home,” said Craig Pollack, who studies the intersection of housing and health at Johns Hopkins Bloomberg School of Public Health.
Now, with heightened awareness of the health-housing nexus, and some federal funds available through pandemic recovery legislation, the city has sought to push ahead to end homelessness, not just among veterans, not just among those who are chronically homeless. It’s not just unemployed people who become homeless; the working poor, who live paycheck to paycheck, can find themselves unable to pay their rent, particularly if illness or some other crisis wipes out their limited resources. Housing is also a matter of racial justice, city officials note. All kinds of people become homeless, but they are disproportionately people of color.
Ending homelessness doesn’t mean that no one ever becomes homeless again, explained the city’s long-time housing coordinator Angie Walker. What Rockford is really doing is ending “functional homelessness.” With support, diversion and preventive mechanisms in place, including that close collaboration with the eviction court, far fewer people lose their homes. And those that do, don’t stay homeless and they don’t become homeless over and over again.
It’s hard work, Walker says. They’ve been short-staffed at times as the virus ebbs and flows. A women’s shelter was on lockdown during the winter Omicron surge; a domestic violence shelter had to reduce its capacity as Covid spread. Some landlords have stopped taking veterans’ housing vouchers, able to get higher rents on the soaring open market from renters with higher and more stable income.
And it’s been cold, she said, so the need is great.
Pollack said that one reason cities like Rockford are still making progress against homelessness despite the pandemic is because they didn’t relent on the public health front.
And Covid, he said, has been “incredibly important in helping people understand the connection between housing and health.”
People who are unsheltered live sicker and die younger; some studies put the life expectancy gap at around 20 years. They are high-use, high-cost patients, often showing up in emergency departments, where care is expensive. Because of those costs, in some cities, local hospitals and health systems have played a big role in fighting homelessness.
In Rockford, local clinics have lent a hand, but there’s no big health system driving the housing push.
Instead, it falls on Walker and her staff of outreach workers, intake workers, and housing advocates. But they’ve had help from Community Solutions, a nonprofit that has partnered with Rockford and some 100 other cities across the country to test, refine and share housing strategies that draw on tools and techniques of public health.
“Homelessness is a public health problem — and it yields to public health-type approaches,” said Rosanne Haggerty, founder and CEO of Community Solutions.
Community Solutions’ initiative, known as Built for Zero or BfZ has a strong emphasis on figuring out approaches that can work in many settings — and not only in liberal states. It has partners, and emerging success stories, in places like Abilene, Texas, Anchorage, Alaska, and Chattanooga, Tennessee.
Rockford was one of the early adopters of this approach. It began back in 2015, which seems like a long time ago now. Then-Mayor Lawrence Morrissey, an independent, signed the city up for a Michelle Obama-led initiative to end homelessness among American veterans. Along the way the city linked up with Built for Zero, which has provided guidance.
The homelessness initiative in Rockford, which includes Winnebago and Boone counties, an area with about 350,000 people, started with a rethink. Many organizations were already working on housing, but they weren’t always working together, Walker said. They had different rules, criteria and philosophies. They responded to crises, but they didn’t prevent them. They did not necessarily make things as easy as possible for the people they were trying to help.
As they worked through all that in a more collaborative way, they also learned that data is key. They needed an overview of the housing stock, the health context and the precise individuals in need.
Most U.S. communities work from a one-night annual census of people who are homeless — required by the federal Department of Housing and Urban Development (HUD) for funding — which gives a count that’s both imperfect, and impersonal. Working with a BfZ adviser, Rockford started a much more detailed, and more accurate, list of every homeless person, by name. It still has it.
“When I tell HUD we have 42 unsheltered people, I can tell you who those 42 unsheltered people are,” said Walker, who was disappointed to see the number of homeless vets rise to eight at one point during the recent Covid-19 surge, higher than it’s usually been.
“When we have a case conference, it’s a by-name list of people,” Walker said, adding that if she sees “Joe” on a list of homeless vets one month, and she sees him on the list again the next month, she knows precisely who he is — and zeroes in on why he’s still on the streets and what it will take to get him housed.
Quickly, often within days, they are housed — with as much stability and permanence as possible but sometimes there are more temporary steps along the way. Along with a house key, those who need it get a supply of Narcan, a drug that can reverse an opioid overdose, and training for them and their family on how to use it, Walker said. For the homeless population with an addiction problem, those two interventions — housing and health together — can make all the difference.
Addiction isn’t the only health issue that can contribute to homelessness. Joanne Guarino, a housing activist in New England who was herself homeless years ago, has multiple ongoing health challenges, including HIV and rheumatoid arthritis. She endured all sorts of illnesses and injuries, including assault and sexual assault, in her years on the streets. One such incident took her left eye.
Housing, she says, is the foundation for stabilization, for getting people’s lives and health back on track.
“When you have a home, a warm place to go, your body doesn’t take so much abuse,” Guarino said. And once she did have a home, once her plight didn’t hang over her every hour of every day, she had a lot more wherewithal to take care of herself, to work with her doctors, to get her meds and stay on them. “You are out in the cold, walking the streets all night — your bones and body get worse. And once your socks get wet, forget about it,” she said, adding that amputation and loss of limbs is another ever-present risk for the unhoused.
In most of the country, the housing-health connection is still addressed inconsistently. Medicaid can only address housing up to a point; there are legal restrictions on when and how a health care dollar can pay the rent. In places like Boston, some hospitals are trying to make something permanent out of the temporary solutions they cobbled together during the pandemic — like housing people who needed to isolate after coronavirus exposure or to recover post-hospitalization in hotels or other alternatives to shelters, said Megan Sandel, founder of Boston Medical Center’s Affordable Housing Initiative. A physician, she’s also co-director of a clinic that treats young children with a complex of conditions known as “failure to thrive,” a considerable number of whom are homeless.
In Rockford, a recovering Rust Belt city 90 miles west of Chicago, the fulcrum remains the city’s social services department and Walker, who’s been doing this work for years. She partners with other city agencies, nonprofits and faith-based groups, including the local Crusader Community Health clinic. The Fire Department also pitches in on health, particularly during the pandemic. The housing agency can now connect quickly with the psychiatric nurses at the local hospital; the city now has mental health emergency response teams that partner with social workers, law enforcement and emergency personnel.
Walker, whose office is now so full that they will have to remodel to fit in more staff, wants to add a licensed mental health professional to her group. She’s also added staff to the eviction prevention program.
During the height of Covid-19, Walker herself was based in the town’s emergency operations center. “I was stationed there with the health department and others — we made sure our homeless folks got what they needed. Places to isolate, food, medication, everything they need.”
The beauty of what’s happening in Rockford is that it’s replicable, Haggerty said. There’s no secret sauce — it’s all about common sense, collaboration, flexibility — and data. Once a person or family’s housing emergency is addressed, other social services, schools, and health groups can take it from there.
Rockford’s system is both highly data-driven at the community level and very personalized at the human level. It is based on an alliance of city, county, nonprofit and faith-based groups that, prodded and cajoled by Walker had learned to mesh. And it identifies what housing was available in the community — and how best to match up social programs, housing stock, and people.
But it is more than bricks and data. In earlier years, Walker’s work had been reactive, not proactive. When the city’s social service workers encountered or were referred to a homeless person, “we handed them a card — and we never saw them again.” Walker now has full-time outreach staff out and about, able to do real-time intake on a street corner or parking lot. There’s a single 24/7 hotline, and a single office for homeless services — people in need don’t have to juggle a bunch of programs and resources and figure out which one might be able to help them, who is eligible for what. There’s one door. Anyone can walk in.
The work with the eviction court helps: a staffer is based there, and they work to prevent evictions, rather than scramble to solve the cascading crises that evictions create. That’s a huge plus.
“The biggest predictor of future homelessness is past homelessness,” said Community Solution’s Haggerty. “The trauma, the economic ground you lose, the educational ground you lose… You are in this loop of vulnerability.”
“We try to catch them before they fall into homelessness,” Walker said.
She knows there’s another tier of need — people with insecure housing who may be “couch surfing,” and living in situations that are far from ideal. But the priority right now is for people who literally have no home, “who reside in shelters, who are on the streets or in places not meant for human habitation,” or need to escape domestic violence. Though everyone working on housing knows there is far more to be done.
Rockford’s mayor has committed to getting it done. “As a city — throughout the entire pandemic, absolutely we had to do the blocking and the tackling to get us through the pandemic,” McNamara said. “But we did innovative things to prepare us for post-pandemic.”
He doesn’t want to just go back to pre-pandemic normal. “Normal wasn’t good enough for a whole lot of Americans — and Rockfordians. Let’s rebuild a stronger place.”
“It’s do-able,” he said. “It is absolutely do-able.”
