Wicked problem: a term coined by two UC Berkeley professors of urban planning, Horst W.J. Rittel and Melvin M. Webber, to describe difficult social policy issues such as poverty, crime, and homelessness. This is included in their still surprisingly relevant journal article “Dilemmas in a General Theory of Planning”Policy Sciences (4), 1973, pp. 155-169. Rittel and Webber write, “As distinguished from problems in the natural sciences, which are definable and separable and may have solutions that are findable, the problems of governmental planning–and especially those of social or policy planning–are ill-defined; and they rely upon elusive political judgment for resolution. (Not ‘solution.’ Social problems are never solved. At best they are only re-solved–over and over again.)” (p. 160)
That last parenthetical comment is worth repeating until it sinks in. Homelessness as a prime example of a wicked problem will never be solved. The most we can hope for is that it will be re-solved. Our U.S. healthcare system is another example of a wicked problem. Therefore, unless my basic math fails me, health care for the homeless is a wicked problem squared. That does not equate with a reason to give up and not even try to address the wicked problems of homelessness and health care. It means that all of us are called upon to have the resolve to figure this out together.
Having a seemingly never-ending assortment of expert panels and reviews of evidence-based practice aimed at finding solutions for the crisis of homelessness may be necessary, but it will never be sufficient. Having a place-based, grass-roots approach and one that is supportive of critical reflection has greater potential for being more broadly effective. And this isn’t mere consumer or community-member token representation on policy committees as is so often practiced.
“Place oriented inquiry and practice emphasizes bottom-up strategies for the adaptive,
sustainable governance of complex dynamic landscapes. Adopting a spatial or place-based perspective helps with recognition that most knowledge is, to a significant degree, local or context-dependent, as all knowledge-holders occupy—by virtue of their biography, training, and geographic experiences—some particular, delimited position from which to observe the world. Wicked-problem conditions, the argument goes, require the cultivation, transmission, and application of existing bottom-up knowledge held by embedded actors in the landscape.” pp. 18-19.
Health and Homelessness in Richmond, Virginia in the 1980s: Although I was intimidated by her when I first started working at the Richmond Street Center in 1986, I quickly came to view Sheila Crowley as a valuable mentor.
Sheila Crowley was the Executive Director of the Daily Planet (the lead agency of the Richmond Street Center) from 1984-1992. She left the Daily Planet in 1992 to work on her doctorate in social work, focusing on housing policy. As part of her doctorate, she did a yearlong housing policy fellowship on Capitol Hill. Since 1998 she has been President and CEO of the National Low Income Housing Coalition (NLIHC), based in Washington, DC. The NLIHC works on socially just national housing policy issues, public education, and research. They publish the annual Housing Wage/ Out of Reach Report, which shows side-by-side comparison of wages and rents for all U.S. counties, metropolitan areas, and states.
In my telephone conversation with Sheila several years ago, she characterized the national policy climate as “a disconnect between the response to homelessness and the response to the housing shortage.” She commented on how homelessness has become institutionalized and taken for granted, with so many more people working within the homelessness industry than when it originated in the 1980s, and with even more displacement of low income people from housing.
I had been thinking about similar things. After more than a quarter of a century working with homeless people in the U.S., it disturbs me that there are more, not less people experiencing homelessness, illness, and lack of access to basic health care. There are more specialized services for homeless people in our country than there were three decades ago: homelessness as a problem has become institutionalized. Within the federal government, the Interagency Council on Homelessness includes representatives from fifteen different federal agencies related to homelessness. Homelessness has become an industry. There are currently at least 1 million people working directly with homeless-focused agencies. Homelessness is an assumed aspect of modern American urban life, often portrayed in Hollywood movies as part of a gritty, authentic urban backdrop. I had been asking myself whether by working in the ‘homelessness industry’ I was doing more harm than good: harm in that I helped make homelessness more palatable to people experiencing homelessness, as well as to our housed community members (and yes, even to myself: a literal “I gave at the office” sort of a thing). I haven’t found an answer to my question, but I continue to think it’s an important one to ask.
Sheila gave me broad-brush characterizations of the Clinton, Bush, and Obama administrations’ approaches to housing and homelessness. Under Clinton there was emphasis placed on de-concentration of low-income housing, with the unintended consequence of a net loss of low-income housing units. The Bush administration placed emphasis on increasing home ownership rates, with some funding going to McKinney Homeless Assistance for housing programs. Obama appointed a great Housing and Urban Development (HUD) director, Shaun Donovan, and Sheila had high hopes, but at the time of our interview she felt that not much had been done. The Homelessness Prevention and Rapid Re-housing Program funded through the American Recovery and Reinvestment Act of 2009 appears to have been effective at preventing the worst of recession-related increase in homelessness, although the numbers of unsheltered and doubled-up homeless increased during the 2009-2011 time period.
Sheila and I talked about how even the term ‘homeless’ is problematic on many levels. In the U.S. there have been different official federal definitions for homeless. Until recently the Department of Housing and Urban Development only included the visible or literal homeless—those living on the streets or in emergency shelters. Other federal definitions, such as those necessary for receiving health benefits, have had broader definitions that included people temporarily doubled-up with friends or family, people living episodically in cheap hotels, and people living in cars or other places not intended for human habitation. This definition encompasses people in many different variations of being marginally or precariously housed—as I had been as a young adult. The HUD definition was amended in December 2011 to be more in line with this broader definition of homeless.
Sheila described being at a Homeless Advocates Group (HAG) national meeting recently. HAG is composed of leaders of all the major groups working on homelessness at the national level, including the NLIHC, the National Health Care for the Homeless Council, and the National Alliance to End Homelessness. She looked around the meeting room and realized that all of the leaders of the represented agencies and coalitions were now in their fifties and sixties and had gotten their start in homelessness work in the 1980s. She thought to herself, “Here we go again,” with the increase in the number of homeless, this time due to the national foreclosure crisis and effects of the prolonged recession.
She was quick to highlight success stories, communities that are pulling together coordinated responses to homelessness with a Housing First emphasis—working to maintain people in adequate affordable housing and to quickly re-house people—and a Housing Plus approach of providing supportive housing for people with mental or physical health or substance abuse issues complicating their homelessness. People cannot be healthy unless they have safe and healthy housing. She mentioned Columbus, Ohio and Worcester, Massachusetts as two examples of successful community responses, and added that my new hometown of Seattle has done pretty well with a significant decrease in the chronically homeless population. Across the country, there’s been resistance from emergency shelter providers and church-sponsored programs who see funding and support moving away from their services. But the Housing First movement has had broad bipartisan support since it cuts across different political ideologies.
When I mentioned to Sheila what now stands at the corner of Belvidere and Canal Streets where the Richmond Street Center had been (it is now a VCU college dorm building and a Starbucks), she immediately said, “The only thing I regret about the Street Center building being torn down was the elevator.” This surprised me until I remembered what a practical woman Sheila is—a common character trait of many of the social workers, as well as of public health nurses I have known. She reminded me that the city inspectors had insisted she fund and install a $30,000 elevator in the Street Center building before it could open. She hopes they were at least able to re-use the elevator for another building. She also recounted the construction of the addition on the back of the Street Center for the expanded clinic space I worked in. A sinkhole opened up in the parking lot while they were preparing the foundation. That’s when they discovered that the Street Center was built on land that had been the city dump. Sheila said she went back to where the workmen were standing around looking at the hole, rubbing their chins, exclaiming, “It’s the darndest thing,” and she responded, “Well don’t just stand there, do something about it!”
We need more people like Sheila who don’t just stand around contemplating problems, but who roll up their sleeves and try to solve them.
The State of Homelessness in America 2014 report from the National Alliance to End Homelessness. The overall rate of homelessness in the U.S. decreased by 3.7% for the time period 2012-2013, although it increased in 20 states.
Health and Homelessness in Richmond, Virginia in the 1980s: Although I wasn’t sure anyone would come to the clinic at the Richmond Street Center when it first opened (in May 1986), within the first month I had seen fifty different patients for eighty-one clinic visits–meaning patients were returning to the clinic for follow-up visits. After the second month I had seen one hundred nineteen patients for two hundred and fifty visits, and so it grew, all out of the one-room clinic. By the end of the first year of operation, I had seen over sixteen hundred patients for close to four thousand visits. I didn’t need to exaggerate the numbers of people I was seeing. I was treating everyone from newborn babies and their moms, to homeless men in their seventies. The majority of patients were homeless single men in their late twenties who had injuries and skin infections from life on the streets.
Many of the clinic patients were young African-American men from Richmond who had burned bridges with family and ended up on the streets. The crack cocaine epidemic was beginning to reach Richmond from Washington, DC and Baltimore, bringing with it a rising murder rate. Its violence would soon spill over into the Street Center. Some of my patients were not strictly homeless. They were adults with stable chronic mental illness or marginally functional developmental delay, then called mental retardation, who lived in supervised group homes nearby. They moved in and out of homelessness.
The lead agency of the Richmond Street Center was the Daily Planet: a drug, alcohol, and mental health service agency with its roots in the 1960s counterculture. The Daily Planet social workers got their start by counseling young people coming down off bad trips from street drugs. There were many such young people around the near-by Monroe Park campus of Virginia Commonwealth University. The Daily Planet took its name from Clark Kent’s newspaper of comic book fame; drug-tripping clients (or ‘consumers’ as they called them) said they came out of phone booths after talking with agency staff, and they felt like Superman.
Sheila Crowley, the head of The Daily Planet, repeated this story often, followed by a rumbling laugh. She was tough, staunchly feminist, with long wavy hair and over-sized glasses, long sleeved shirts rolled up over her biceps. Sheila looked uncannily like photos I had seen of a young Gloria Steinem. As if she were a scrappy pit bull with a shredded ear I might see loose on the downtown streets, I gave Sheila a wide berth at first. I could easily differentiate the Planet staff from the consumers; their staff members were all like Sheila. The women staff members were white zealous feminists and the men were Deadhead-type hippies. They were not big fans of any organized religion, but they were tolerant of the varieties of Christian do-gooders they now found themselves working with, for the common cause of combating homelessness.
For the first several years of the Street Center Clinic, I was the only health care provider. We had volunteer physicians who came in on Saturday mornings to see the more medically complex patients. I learned to rely on the social workers, activists, and support staff of the Street Center in order to provide the best care we could. In essence, although this preceded development of the concept, we were trying to address the social determinants of health. I worked at the Street Center for four years before moving on to graduate school in Baltimore. It was not an easy transition and I became homeless myself for six months, so I lost touch with most of the people I had worked with.
Several years ago I was curious what had happened to the various community clinics (and their staff members) I had worked with in Richmond back in the 1980s. I met with Peter Prizzio, Chief Executive Director of the Daily Planet. After Sheila Crowley left, the Daily Planet went through some rough patches with leadership. Peter was brought on board in 2002 and modeled the Planet after Baltimore’s excellent Health Care for the Homeless freestanding clinic. The Daily Planet is now the recipient of the Health Care for the Homeless federal grant I helped write in 1987. The Planet is part of the community mental health safety net, such as it is, for Richmond.
The Daily Planet Clinic is currently located on Grace Street four blocks north of where the Street Center had been. Next door to the clinic is the same pizza place parking lot where I first met Dawn (a young prostituted teen who haunts me still) while doing outreach with the Richmond Street Team. When I returned to the area to meet with Peter, I knew I wouldn’t run into Dawn–she had died of AIDS the year I left Richmond.
Peter is a tall, energetic and engaging man, who gave me a tour of the building, and then we sat and talked for an hour. Peter told me The Planet serves around four thousand patients for thirty thousand visits each year. They have an annual budget of $3.5 million, half of which of which is from the Health Care for the Homeless federal grant. The majority of their patients are long-term Virginia residents, while about 15-20% of the patients are more transient, traveling up and down the I-95 corridor between New York, Baltimore, and Florida. The Planet has primary care providers including doctors and nurse practitioners, dentists, and behavioral health (chemical dependency and mental health) specialists.
Peter told me they are not able to get much support from the City of Richmond. He said that City officials tend to refer to the homeless as “your people,” and view homeless people as shiftless, lazy, and a nuisance to downtown businesses. He described a plan that had been developed a few years back to have a central intake system for homeless and uninsured patients in Richmond. Agencies would pool resources so one case manager could follow patients to ensure their health care wouldn’t be as fragmented. The plan never got off the ground because the agencies were fighting each other for scarce funding for their own programs.
Health and Homelessness in Richmond, Virginia in the 1980s: A half-mile south of the Richmond Street Center was the wide James River. Along the riverbanks lived a group of my patients who called themselves the River Rats.
The River Rats consisted of a dozen or so adults, mostly men, with a few women who were married or otherwise attached to the men. The River Rats ranged in age from twenty-six years old, to an older man named Bruce* who said he was fifty-two, but looked much older. Many of the River Rats lived together under a bridge by the river. They were heavy drinkers who enjoyed the relative freedom of living outside on their own. The frat party atmosphere permeated the area. On summer weekends the River Rats drank alongside the young Richmonders who sunbathed on the flat rocks, or inner tubed in the smaller rapids, floating coolers full of beer beside them.
A few of the River Rats rode the rails. They hopped on and off the freight trains passing through Richmond. They were traditional hobos out of a different era. They had been to more parts of the country than most people had in their lifetimes—certainly more than I had been to at the time (I was in my mid-twenties then). Several of them came to me with hand and knee abrasions from tumbling off a moving train and getting scraped up on the gravel railroad track bed. In my second year at the Street Center, one of my regular rail-riding patients was buried alive in an open coal car the morning after he’d celebrated his thirtieth birthday by getting more drunk than usual. His travel partner told me about it the next time he came into the clinic.
Richmond was (and still is) at the cross-roads of two major east coast interstates, I-95 and I-64, as well as of two major freight train lines, so the city got a fair number of people traveling through, hitchhiking or riding the rails or the Greyhound bus, who stopped and got stuck, or stayed for whatever reason. They were like the flotsam caught in swirling eddies of the river.
There was discussion in the two local newspapers about whether the homeless people in Richmond were really from Richmond, or even from Virginia. Many of the newspaper articles featured interviews with homeless people who said they were from Baltimore, or New York City, or Philadelphia. The underlying implication was that many of the homeless people in Richmond were from the North; therefore, they were either invaders, or proof that the large northern cities were dumping their problems on Richmond, taking advantage of Southern hospitality. Richmond was enabling felons, drug addicts, and lazy people who were homeless by choice. They would never be able to be recycled into productive citizens, the articles seemed to say. Newspaper articles were more sympathetic to homeless people in Richmond who reported being from impoverished rural areas of Virginia or North Carolina. Whether they were black or white, they had been dealt a bad hand in life. They were our people and we took care of them.
Homelessness was an urban problem I associated with large, gritty urban areas like New York or Baltimore. I was surprised to see homelessness on such a large scale in my own hometown. The center of Richmond was decaying. Discarded carcasses of old buildings were everywhere. There were buildings with boarded up windows and doors, charred remains of other buildings, people’s belongings dumped in disheveled piles on the sidewalk curbside: evidence of evicted people, now homeless. Driving through the city at night you could catch glimpses of dark darting shadows or muffled flashes of a cigarette lighter, flashlight, or candle in some of the boarded up houses. The shadows were squatters, homeless people—ghosts. Houses that were still legally lived in showed signs of faded beauty. Stone cornices and intricate wooden lattice dangled loosely from front porches.
Along Belvidere Street near the Street Center, two blocks of houses had been razed to make way for expansion of the university. For over a year, to cordon off the construction site from sidewalk and street, the construction crew lined up old doors from the torn down houses. They leaned the doors against temporary chain-link fences anchored by large concrete blocks; this made a long expanse of multicolored doors, which was as beautiful and shocking as a modern art installation. Sitting in my car at a stoplight on my way to and from work, I’d stare at the doors. I marveled at the deeply saturated red doors, wondering what sorts of rooms they had opened into. There were also a few doors that had obviously belonged to children’s bedrooms. They were decorated with brightly colored Disney characters like Donald Duck and Cinderella. I wondered if some of the doors had belonged to patients of mine who were now homeless. And I wondered what it must feel like to be a child and recognize the stickers from your old bedroom door as you were being dragged along the street by the hand toward the emergency shelter.
In stark contrast to the dismantled and rotting parts of the inner city were patches of rebuilding and renovating. The biggest of these was the ill-fated $16 million glass-enclosed Sixth Street Marketplace spanning Broad Street. Built in 1986, the Marketplace was meant to bring back small businesses to the downtown core of Richmond. It failed and was torn down less than twenty years later at a cost of $67 million. Closer to the Street Center was the grand Jefferson Hotel, built with tobacco money after the Civil War. It had been sitting empty for over a decade, although it was occasionally used to film movies or host high school proms. The grand staircase of polished marble was rumored to have been the model for the staircase in Gone With the Wind. My Lee-Davis High School senior prom had been held there as the hotel was closing.
By 1986 they had completed a $34 million dollar renovation of the Jefferson, and the hotel was reopened simultaneously with the opening of the Street Center. The buildings were several blocks apart. Standing in front of the Street Center on Canal Street, the Jefferson loomed over the top of it: pale grey marble against dark brick, majestic rich above outcast poor. At night the tall grey clock tower of the hotel glowed in the floodlights.
* Note: All names and other identifying details of former patients have been changed.
In May of 1986 I began my first ‘real’ nursing job: I worked as a nurse practitioner at the Cross-Over Health Clinic, located in a multi-service center for homeless people called the Richmond Street Center. Located in downtown Richmond (Virginia), the Street Center housed the clinic, a shelter, soup kitchen, laundry and shower services, and many social workers. The lead agency for the Street Center was the Daily Planet (which I’ll write more about in follow-up blog posts in this series). Working at the Street Center clinic as my first nurse practitioner job was either ambitious or ill conceived, and I often thought it was both on the same day. After a few months working at the Street Center I no longer freaked out when I saw scabies or crabs, gangrene, maggots, or schizophrenia.
The Street Center was thick-walled and cavernous. It was located in the armpit of town, on the border between Monroe Ward, Gamble’s Hill, and Oregon Hill near the James River. Built on land that had been the old city dump, the building had been a gas meter repair shop for the city as well as a storage unit for abandoned bicycles. The city donated the building as a way to appease the downtown merchants who wanted to get the street people—the visible homeless—away from their struggling businesses. Kudzu vines draped over trees and telephone polls; they formed a convenient curtain to block the public’s view of the ugly, forbidding looking building.
The Street Center was located at the corner of Belvidere and Canal Streets, with the main entrance on Canal. The building was flush with the narrow sidewalk. Belvidere Street, a busy four lane divided highway that ran north to south, was part of US Route 301 extending down to Sarasota, Florida, and up to Delaware. Across Belvidere from the Street Center was a 7-11 that sold cigarettes, cheap beer and flavored wine like Boone’s Farm and Thunderbird, all popular with the Street Center clientele. South of the Street Center were the hulking brick buildings of the Virginia Penitentiary, and just to the west was Hollywood Cemetery where a relative of mine—Jefferson Davis—and 20,000 confederate soldiers lay buried. In the block north of our building was a Hostess Twinkie factory. The sweet buttery smell of the factory mingled with the acrid smells of the Street Center: damp oil-stained concrete, souring unwashed bodies, old urine, and cigarette smoke.
When the Street Center opened in April 1986, homelessness was getting extensive national and local attention, with almost daily newspaper and TV news coverage. In May of that year, USA for Africa teamed up with Coca-Cola to sponsor Hands Across America to raise money for “fighting hunger and homelessness.” They had thousands of people hold hands for 15 minutes in cities across the nation. President Reagan joined in the hand holding from the White House, reportedly shamed into doing it by his daughter. There was a sense that homelessness—at least this new version of homelessness—could be cured.
As a group, people who were homeless were called street people; they were poverty made visible on the streets and sidewalks. Homeless people, mostly in the form of older alcoholic men, had been part of the American urban scene for a long time. They had been called vagrants, paupers, hobos, and bums. What was new was a combination of the sheer number of homeless people, along with the changing face of homelessness. There were now women, younger people, and entire families living on the streets.
Homelessness was portrayed as a national disgrace, and the urban housing market crisis and government inaction were mostly to blame. People talked about upstream measures and prevention of homelessness, but in a fuzzy idealistic way such as ending poverty and increasing housing. There was frequent mention of deinstitutionalization, the effort to get mentally ill and developmentally disabled adults out of long-term mental hospitals and back out into the community. This was a laudable idea stemming from the 1960’s Civil Rights era, but one that hadn’t worked out so well. Many of the people who had been in institutions needed permanent supervised housing and on-site help with counseling and medication. That combination was scarce to non-existent, and the services that did exist were underfunded and understaffed. Rising numbers of Vietnam vets who had untreated post-traumatic stress disorder, or who had gotten hooked on heroin or alcohol while in the army, were now homeless. Most were men in their early 30’s, at the time of their lives when they should have been settling down and raising a family, but they had been left behind.
All of us service providers at the Street Center believed in our grand cause. Homeless advocates pointed out that homelessness wasn’t as big a problem in Richmond as it was in large cities such as New York, and that if our community acted fast enough we could prevent it from getting out of control. We had a barely murmured, mostly unspoken code of talking up the numbers of the homeless we were serving, while simultaneously talking down any individual vulnerabilities of homeless people, vulnerabilities such as mental illness and substance abuse. We feared that would fuel a backlash of public sentiment against homeless people. We had a vested interest in sustaining the funding for our agencies, for the homeless people we were serving, and for our own jobs. We would say we were trying to work ourselves out of a job, but I don’t think any of us actually believed it.
In the 1980’s, during the time I worked with and became homeless, Mark Holmberg, a Richmond Times-Dispatch reporter, wrote articles with provocative titles such as “Homeless by Choice” and “Homelessness as a State of Mind.” He spent a night at a Richmond emergency shelter, interviewed homeless people and homeless advocates who he often characterized as having misdirected passion. In August 2005 when the bulldozers had finally razed the Richmond Street Center building at the corner of Canal and Belvidere Streets, Mr. Holmberg, in an article titled “Memory of Building Lingers, And So Does Homelessness,” wrote: “It was a sort of one-stop shop—driven largely by love and honest concern—that drew people with tough problems into a concentrated knot of dysfunction. (…) Good riddance, old friend.”
Mr. Holmberg echoed what many Richmond residents felt toward the Daily Planet, that it was synonymous with softhearted, wrongheaded homeless advocacy. And for the fifteen years of its existence, the Richmond Street Center was synonymous with the Daily Planet. Part of me agrees with this assessment, and I see that I was one of those softhearted, wrongheaded homeless advocates. But I’m glad I was. I still believe it’s better than becoming the hardhearted alternative. Even though I didn’t rely on homeless advocates or their services when I experienced homelessness myself, the knowledge that they were there helped me survive and move on.
The dark, hulking 1920’s era three-story brick building on Canal Street that housed the Richmond Street Center was owned by the City of Richmond. Beginning in 1985, the City leased the building to the Street Center’s lead agency, the Daily Planet, for $10 a year. In 1993 the city agreed to sell the property to the Ethyl Corporation, who offered to pay $300,000 to re-locate the Daily Planet. But no suitable site was located in time, mainly because no one in Richmond wanted the Daily Planet consumers in their neighborhood. Ethyl backed out of the agreement in 1995 and concentrated instead on purchasing the land where the Virginia State Penitentiary had stood for two hundred years. Meanwhile, an anonymous donor offered $2 million for the Daily Planet to move its services away from the downtown business core, preferably into Shockoe Valley next to the Richmond City Jail. The Daily Planet Board of Directors declined the offer. In early 2000 the Daily Planet moved four blocks north to its current Grace Street Location. Four years later the City Council sold the now abandoned and boarded up Canal Street property to the Virginia Commonwealth University for $250,000 for them to build student housing and a Starbucks store.
**Note: This is the first blog post of a ten-part series on health and homelessness in my hometown of Richmond, Virginia. The series is based on my work as a nurse providing health care to people marginalized by poverty and homelessness, as well as on research I have conducted over the past few years (e.g.: archival research, site visits, key-informant interviews, and records review). I plan to post a new entry in this series every other day.