Radical Thinking Is Solving Homelessness

I know, homelessness is complicated. Where do we start? Housing? Mental health? Harm Reduction? Poverty? Incarceration? Crime? Everybody wants to reduce homelessness, and to do so, we should understand what’s working on a global level and then test and learn in our own cities. While it’s super fun to argue differing philosophies on the intersection of homelessness and drugs at Thanksgiving, this article identifies some of the more creative solutions driving good outcomes around the world.

The first concept is trust. We surely couldn’t trust unhoused, drug-using, mentally unstable folks with a cash handout and expect it to work. Well, it did in Vancouver. Vancouver gave individuals a one-time, unconditional cash transfer of $7,500. This led to 99 fewer days in shelters and a NET savings of $777 per person per year. The program paid for itself and there was no increase in spending on "temptation goods.” This combination of trust and administrative speed led to good outcomes for people, a shift away from emergency services and a decrease in societal costs. Unconditional cash transfers reduce homelessness (PNAS)

The second concept is decriminalization. Being poor shouldn’t be a crime. Neither should mental illness. And, if you look at the data since the war on drugs started in 1970, you’ll see core addiction rate holding steady (excluding marijuana) while incarceration for drugs has gone up 5000%. Get your head around that, incarceration in general has gone up 500%, but 5000% for drugs. To make things worse, once someone goes to jail, they are literally 6X more likely to go back to jail. The cost to incarcerate a homeless person in LA is $132,000 per year, the cost of that person being on the street is around $50,000, and the cost to house a person in permanent supportive housing is $26,000. Homelessness and all that goes with it should be a public health priority, not a criminal act. These cities have implemented truly radical approaches to drug use, and are seeing less overdoses, illness, crime, costs, and more folks voluntarily seeking help.

• Portugal shifted drug use from a legal issue to a health-led model and it resulted in plummeting overdose deaths and HIV infections. Since their 2001 decriminalization reform, the country has seen a dramatic drop in overdose deaths and HIV infections, and a significant increase in people voluntarily seeking treatment because the barriers of stigma and the threat of jail were removed [Drug Decriminalization in Portugal].

• Vancouver’s first legal supervised injection site in North America led to a 35% decrease in fatal overdoses in the immediate surrounding area, proving that localized innovation can stabilize entire neighborhoods.

• Copenhagen’s H17 and its neighbor Skyen, financed by the Municipality, are the world’s largest drug consumption rooms and cornerstones of the city’s overdose prevention efforts. Since 2012, these facilities have overseen three million supervised injections, and H17, with 43 specialized spaces for 800–1,300 daily uses, has 1,400 overdose reversals with zero fatalities. This has effectively moved drug use from public streets into a clinical, interdisciplinary environment that prioritizes harm reduction without requiring treatment.

• Amsterdam’s model integrates safe consumption within social housing, allowing individuals to stabilize their lives without the immediate requirement of abstinence, which has significantly reduced public nuisance and crime.

• Research shows that cities providing safe consumption spaces see a dramatic increase in voluntary entry into long-term treatment programs because they build trust with a population that typically avoids government services.

The third concept is around intentional design. The solutions, systems and approaches are coordinated, integrated and data driven to drive better outcomes. And, importantly, consider the perspective of those who have experienced homelessness.

• Homeless Health Care in Los Angeles is implementing new ways to reverse overdoses. With the understanding that overdoses are a respiratory emergency, HHCLA is using oxygen to restore breath immediately. This creates a smoother recovery process, saves brain cells and minimizes seizures and nerve damage.

• Copenhagen innovated the physical architecture itself. The development of "Skæve huse," or off-beat houses, demonstrates that if individuals struggle to fit into traditional apartment models, the solution is to adapt the housing to the person. These small, standalone, permanent homes provide the space and stability required by those previously deemed "un-houseable," proving that design flexibility is a prerequisite for universal success [The Efficacy of Local Governance Arrangements].

• The Los Angeles Homelessness Prevention Unit uses predictive modeling to identify high-risk individuals early, stopping the cycle of transience before it ever reaches a courtroom or a shelter, proving that technical ingenuity can stabilize lives more effectively than emergency services [The Homelessness Prevention Unit Report].

• Houston’s Unified Command Structure consolidates more than 100 independent agencies into a single, data-integrated system focused on immediate housing and reduced the city’s homeless population by over 60% through radical organizational efficiency. The Way Home Houston Case Study (National Civic League)

• The United Nations highlights that the most effective emerging strategies are those that grant people with lived experience real decision-making power in policy design.

  
  

The last concept is around permanence. While there is debate around housing first vs. housing last, Finland is currently the only EU country where homelessness is consistently falling, and they achieved this by radically deciding to abolish the temporary shelter system in favor of universal "Housing First" leases. By ensuring that every person has a permanent home as a foundation for their recovery, rather than a reward for it, Finland has demonstrated that systemic commitment to permanence is the ultimate innovation Successes and Challenges of Housing First in Finland.  The Finnish Homelessness Strategy: An International Review

• Milwaukee’s achieved the lowest per-capita unsheltered population in the U.S. by pivoting the entire county budget toward immediate, unconditional housing. Housing First Philosophy and Results (Milwaukee County)

• France found that immediately placing homeless individuals with severe mental illness into permanent housing achieved significantly higher housing stability and personal recovery than traditional "treatment first" models.
  

So yeah, it’s complicated. It’s also an opportunity for creativity. If your goal is better outcomes, stop thinking in terms of politics, tradition and expected behaviors, and start thinking about innovative, even radical, ways to help people. Not all ideas work everywhere, but the spirit of continual testing and learning is the right path and should be inspired by the global portfolio of evidence.

Mark Casanova, Executive Director of Homeless Health Care Los Angeles, graduated from UCLA in 1984 with a BA in Latin American history. He later received his MA in marriage, family therapy. Mark has always worked with the unhoused population through clinical service, training, advocacy, and administration. He began his clinical work in 1985 with the Salvation Army. Two years later, he joined HHCLA as a clinician and stayed through various organizational transitions to become the Executive Director in 1994. He now heads a staff of 400 and administers a budget of $40 million. His responsibility as Executive Director is to inspire staff and motivate his co-workers to carry out HHCLA’s crucial mission. Mark is committed to a harm reduction model of treatment because he believes that caring about people means caring about them wherever they find themselves. Mark’s expertise lies in homelessness, clinical services, harm reduction, syringe exchange, alternative substance use treatments for opioids and other drugs, and overdose prevention, including Naloxone distribution.