Books reviewed in this essay:
At first glance, it is difficult to imagine two more dissimilar books, although the titles imply a degree of semblance in their promise of exploring homelessness in an American city (Ensign) and from a national point of view (Willison). Each book does this in its own unique way. Ensign's Skid Road is a deeply researched history of Seattle, a city with a colorful, tumultuous history where Indigenous peoples (Tlingit, Coast Salish, Duwamish) worked alongside white settlers to send countless felled cedar and fir trees tumbling down a “skid road” to the sawmill at the hill's bottom on the docks. Although often at odds with the settlers who came in droves seeking wealth and adventure, Native Americans maintained their dignity living in the relative luxury of a mild climate, dense forests, and an abundance of fish and shellfish. Over time, this abundance of natural resources fueled economic growth and a building boom that enhanced Seattle's reputation.
A professor of nursing, Ensign acted as a historical ethnographer as she pored over countless documents and archives and presented the reality of Seattle in its early days. All of the senses are titillated—the noise of lumber mills, the salty stench of piles of waterfront garbage, and the growing visibility of the “haves” in their well-appointed mansions. More numerous and visible on Skid Road were the “have-nots” and the morally condemned: laid-off and injured mill workers, prostitutes and their pimps, heavy drinkers, mentally ill men and women cast out by their families. Seattle's first known homeless person—an “insane pauper” (106) who lived in the mid-1800s—was joined by many others who could not afford even a run-down shack or flophouse. Some of these impoverished denizens were Native Americans, but the majority were poor whites living on the fringes of Seattle society. Following the Elizabethan Poor Laws adopted in the United States, responsibility for upkeep was left to the affected persons and their families, but charitable religious groups gained ground in ministering to the most unfortunate of the men, women, and children living in misery and squalor. Modern-day attention to public health as part of local government responsibilities had not yet emerged.
As Seattle grew, Skid Road became a mecca for the poor from all walks of life. Its red-light district attracted sailors, adventurers, and local men. Many of these scorned “riffraff” lived as beggars, petty criminals, and “deviants” who were unwilling or unable to make a living in Seattle's bustling economy. Ensign brings the reader into close scrutiny of the lives of men and women who stood out in some way, with special attention to the poorest of Seattle's Skid Road. This book is an enjoyable read, although the emphasis on health implied by the title is difficult to locate. It would be more accurate to say that the reader is informed about the health consequences of living in a city lacking basic public health infrastructure (e.g., sewers, clean water, garbage disposal). Greater attention is given to the social networks of Seattle's poor denizens as they endure impoverishment at the bottom of a social order dominated by wealthy families making their fortunes in the bounty of natural resources. Ensign's writing style gives us a rollicking account of outcasts mingling with the growing middle and upper classes in a city where wealth accumulation takes precedence over basic services.
Willison's Ungoverned and Out of Sight book title is a description of homelessness that could be (given the past year or so) inverted to Overharassed and in Plain View as a result of growing public impatience with the proliferation of homeless encampments that are ostensibly the result of drug abuse and untreated mental illness. A sense of urgency has sparked dueling opinions about what should be done about this issue and what role government should play. Willison adopts a macrolevel perspective that aligns with her title. The author draws on her dissertation in public health and later study at Harvard to write what she admits is a challenging task of synthesis. As a threat to health rooted in inequality, homelessness presents a governance distinction in the unusual loci of its amelioration—nonprofit organizations rather than city, state, or federal authorities. Of course, funding for these organizations largely originates in government sources. Most prominent is the federal Department of Housing and Urban Development (HUD), which apportions billions of dollars annually to Continuums of Care (CoCs)—coalitions of public and private organizations that cooperate in applying for HUD funds to underwrite a variety of homeless-related services, such as rental vouchers, shelters, or outreach workers.
Willison points out that what is noteworthy about this state of affairs is the shift of governance to nongovernmental organizations—the vast, decentralized array of nonprofit agencies that run shelters and supportive housing. These agencies are multitaskers assisting their patrons with health, mental health, and substance abuse treatment while negotiating with landlords to rent apartments (or directly purchase properties) for their clients to live in. In this scenario, local (municipal or county) governments are frequently sidelined. Thus, the conduit of homeless services funding starts with a federal agency (HUD) and ends in a myriad of private nonprofit programs that have thus far failed to end homelessness. As described by Willison, the billions spent each year on sheltering and housing homeless persons fail to keep up with the ever-increasing numbers of families and individuals who become homeless. This state of affairs in the 21st century is the product of a major shift in the federal government's stance in the 1980s—a sea change where cutting budgets and outsourcing public services are an integral part of the neoliberal philosophy of downsizing government. Building public housing was replaced by faith in the marketplace of private developers. It is not surprising that the Reagan presidency coincided with the rapid growth of homelessness. The stock of affordable housing was shrinking, and federally funded Section 8 rental vouchers (payable to private landlords) did not keep up with the increasing demand.
Beginning in 2015, HUD acknowledged the remarkable rise of Housing First (HF)—a type of permanent supportive housing with an unparalleled record of robust research findings demonstrating its efficacy (Aubry et al. 2020)—by urging CoCs to divert resources from temporary shelters to HF. After decades of living in a state of denial where emergency shelters and services were deemed sufficient, the vast majority of homeless service programs grew to have multimillion-dollar budgets and act as gatekeepers to permanent housing (Padgett, Henwood, and Tsemberis 2016). In this context, HF was initially ignored, but its presence and demonstrated effectiveness in ending homelessness attracted attention and gained ground. Nevertheless, the status quo of homeless services relied upon shelters that were restrictive in concept and punitive in practice. While disabled homeless persons—including those with psychiatric disabilities—were eligible for subsidized permanent supportive housing, the bureaucratic obstacles placed before them, along with a chronic shortage of available units, left these individuals looking for shelter of any kind. In this scenario, governments were active partners with nonprofit organizations in maintaining a treatment-first approach to housing the homeless. Requiring homeless persons to prove their housing “worthiness” by obediently taking medications and being clean and sober was a fundamental principle of service provision (Padgett, Henwood, and Tsemberis 2016).
As stated in the title of a recent book (Colburn and Aldern 2022), homelessness is a housing problem. The authors tackle head-on the myths that have accrued among a misinformed and judgmental populace, that is, substance abuse, mental illness, and other personal deficits are the primary causes of homelessness. To put Colburn and Aldern's thesis simply, homelessness occurs where poverty coincides with serious economic inequities to put the squeeze on those most vulnerable. High-poverty cities such as Detroit and Cleveland have relatively low rates of homelessness and more varied housing stock. In contrast, the highest rates of homelessness are in New York City, Los Angeles, San Francisco, Seattle, and Portland—all coastal cities that have sprawled to accommodate affluent suburbs but have done little to increase the stock of affordable housing. We can thank President Ronald Reagan for his passionate pursuit of privatization, effectively stopping new public housing and underfunding existing social programs.
Willison takes an empirical approach to advancing her argument. Specifically, she uses a mixed-methods explanatory sequential design that translated into taking 232 municipalities with their CoCs as a dataset followed by in-depth interviews and archival analyses. This is a feat worth noting. Willison contends that homelessness is addressed by a decentralized system of nongovernmental actors who may or may not cooperate with municipal governments. The four policy spaces that comprise public responses to homelessness are decentralized and consist of states, local governments (city, county, or both), elites, and homeless service providers. Of these, state and local governments have traditionally avoided being active in CoCs’ pursuit of HUD funding.
The book's structure follows Willison's logic model with an introductory chapter 1 and a chapter 2 that addresses the conceptual/theoretical framework of the book: the aforementioned decentralization and its negative effects on policy innovations and efficient expenditures of funding made possible by cross-sector collaboration. Chapter 3 introduces the research design and statistical analyses that led to the selection of emblematic case studies of cities whose experiences with homelessness reflect different national trends. These cities—San Francisco, Atlanta, and Shreveport—are the focus of analyses on municipal governance in chapters 5, 6, and 7. Moving back to chapter 4, the heretofore unstudied policy spaces are examined to understand why so many municipalities (60% of the 232 in her sample) do not adopt evidence-based policies that would lead to the provision of more supportive housing units for disabled, chronically homeless adults. Perhaps not surprisingly, the other 40% tend to be liberal cities with more integrated policies toward homeless services. What is somewhat surprising is that these are largely “blue” (liberal) cities in otherwise “red” conservative states that refused Medicaid expansion—a rejection that is one of the most punitive policy positions a state may impose on its poorer citizens.
San Francisco (chapter 5), the poster child for urban decay and feckless leadership, has the most centralized and cooperative CoC–city government alliance. Yet implementation is frequently stymied by state-level constraints and interference of the “elites.” The latter are an intriguing, rarely studied group of wealthy, powerful businesses in such sectors as tech, finance, property development, and real estate. One need not be a conspiracy theorist to see evidence of how wealthy citizens and businesses protect their financial interests by interfering with programs meant for very-low-income and homeless citizens. Protesting efforts to build low-cost housing, enact zoning variances, and expedite supportive housing availability constitutes an under-the-radar but vastly effective “not in my backyard” response on behalf of the elites.
Atlanta (chapter 6) resembles San Francisco in its integrated governance but diverges in having a predominantly African American populace in the red state of Georgia, without Medicaid expansion. Indeed, the state's longstanding traditions of racism and segregation and its white elites hinder the city from implementing evidence-based policies including Housing First and low-income housing in general. The city of Shreveport, Louisiana (chapter 7), is a case study at the end of the continuum where the city government is disinterested in homeless policy governance, leaving the CoC to operate in isolation and to have limited effectiveness, especially in responding to one of HUD's policy priorities of decriminalization. Thus, the police operate without such restraints.
It is interesting that the two cities with the largest number of unhoused persons—New York and Los Angeles—are not considered in any depth. Blue cities in blue states should point to shared governance and successful implementations of housing for the homeless, but once again, super-wealthy elites assert their privilege and impede real progress. New York has a “right to shelter” law, which in part explains its enormous bureaucracy surrounding homeless services and its reliance upon shared governance. Yet it is this very “generosity” that hampers change and calcifies the city's stance, preventing a shift away from shelters to housing.
Willison examines homeless governance as manifested in a state of flux conditioned on which combination of public and private actors cooperate to secure federal funding. In addition to grants for direct services delivered by nonprofits, there are enticements offered to private-sector housing developers. Willison refers to private sector incentives wherein for-profit developers and building owners are offered tax breaks and subsidies in exchange for reserving a small percentage of units for low-income residents. Such generous offerings have thus far shown little progress in enforcement and the desired outcomes.
Chapter 8 is a summary of the findings from the quantitative and qualitative (interview) data, with a strong message of limiting decentralization and fragmentation in favor of cross-sector (city, state, CoC, etc.) cooperation in the implementation of homeless services. Willison states that the problems she identifies are situated in the field of public health, but her argument seems more akin to political science than public health. Still, this does not detract from the heavy lifting Willison exerted to deliver what she promised.
In returning to Ensign's colorful portrayal of Seattle's history leading to the present, we are reminded that even a progressive and tolerant city can hide abrasive bigotry and organized resistance to the encampments of a growing population of persons living without shelter. The juxtaposition of civic positivity with citizens’ intolerance is, of course, not exclusive to Seattle.
Ensign brings her narrative “home” literally with an epilogue presenting the story of a homeless man who camped in her backyard (without her consent) and promptly threatened any trespassers. Although the man was eventually arrested, this incident inscribed itself as a perplexing and frustrated pursuit of a deeper meaning where none can be found.
