A formerly homeless physician gives insight into the impacts of homelessness on health
Dr. Jonathan Gabbay grew up in Plainview, New York. He studied biology at the University of Pennsylvania and then attended medical school at the Icahn School of Medicine at Mount Sinai. In between college and medical school, he experienced homelessness and for two years lived out of his car. He is currently a third-year pediatric resident at Boston Children’s Hospital and Boston Medical Center and plans to do work in the intensive care unit. His research focuses on the social determinants of health and the transition of care between inpatient and outpatient care for individuals experiencing housing insecurity.
Can you give us a brief overview of what homelessness in the US looks like?
[Referencing the 2021 Annual Homeless Report to Congress], 326,000 individuals were experiencing homelessness; four in ten were families with children and 15,000 of these individuals were unaccompanied youth, people under 25 [years old]. These [statistics] are underestimated and strictly relevant for people in shelter programs because it is extremely hard to get a [count] of those living on the streets, living in cars, living with families doubled up. There was an 8% decrease in homelessness during COVID, but this was probably largely due to trying to reduce the risk of exposure, leading to fewer beds in congregate shelters. Boston itself has a huge problem with homelessness, especially when you compare [Boston] to other big cities.
What are the main effects of homelessness on health in children?
Infants are the most likely age group to experience homelessness in the United States. Those infants born to families experiencing housing instability have higher rates of low birth weight, respiratory problems, fever, and other common conditions. They also spend longer times in the neonatal intensive care unit, and obviously, this has a financial burden along with it. This is not only limited to infants (birth to one year) as the impacts of homelessness can persist for years.
Many unhoused children have a higher burden of certain conditions like asthma, which is widely prevalent in the US among children. People who are unhoused or experiencing housing insecurity often lack proper medication storage or [the] ability to avoid environmental triggers, especially in shelters where the most common cause of asthma exacerbation is pests and dust mites. Unhoused children experience more asthma exacerbations and end up in the emergency department more often. There was a study that compared a group of children that were housed and a group that were unhoused. Those who were homeless were 31 times more likely to experience an asthma hospitalization than those who were not homeless. Homeless individuals were two times more likely to go from the [emergency department] to the inpatient side in the hospital and more likely to be readmitted to the hospital after leaving the hospital than those who are not homeless.
Other health issues that children experience include obesity and malnutrition, which is mostly related to access to foods and limited kitchen space. There are mental health issues, which have shown to be prevalent in adulthood as well. There’s way more evidence to back up a lot of the medical impacts of homelessness in adults and less than pediatrics.
Do you think homeless individuals are afraid to come to the hospital if they aren’t presenting a physical illness?
Absolutely. There is a relatively high proportion of patients who come in with a runny nose or cough, requesting a COVID swab. But, right before they leave, they disclose to the doctor that they are homeless and have no place to go. It’s a huge issue. I think the stigma of feeling comfortable disclosing [homelessness], especially when you have kids, is the fear that there’s probably going to be some social repercussions. There’s also a lot of distrust in the medical system such as people facing racial disparities in the medical system and not trusting doctors to begin with. It’s just a recipe for not disclosing. Also, personally, I didn’t even tell my doctor when I was homeless. I also wasn’t asked, which is another problem in itself. Looking at me, you would probably not assume that I was living in my car at the time.
What should be done in the medical field to combat homelessness?
Regarding housing insecurity when it comes to medicine itself, I think we should be looking towards the Housing First initiative. When we think about Housing First, it’s not just getting someone housing, but really about setting up long term stability and success through case management. People who help manage everything for our patients include [assisting individuals with] their medications, financial plans, mental health support, social work, food, transportation, and utilities. Helping with everything, and not just housing, is what’s really going to lead to long term success.
Can you speak about your experience with homelessness?
I grew up in an unsafe home environment, which escalated right after college, leading to acute housing instability and homelessness. I had two jobs while homeless. One was managing an art gallery during the day. I had my dog with me at all times, and he just roamed around the art gallery. At night, I would hang out in the Starbucks parking lot and tutor online. I would either sleep in my car or couch surf. I only tried navigating the shelter system once and it was a disaster. So I never tried that again.
How has your background in experiencing housing insecurity affected your work?
I wish I had a really philosophical reason for why. I think after, after my experience, I needed some time away from thinking about all of this. But recently, especially when I started medical school and residency, I really focused on all social determinants [of health] and homelessness. I think the experience itself has probably helped me with a lot of families. A lot of doctors will just refer [a patient] to a social worker. I do too, but I also have experiences navigating the system a little bit more, which has helped me with patients. When I work in primary care and there’s a patient who is having housing insecurity issues and needs a primary care physician, I’ll offer to take them on. This was just a long winded way of just saying, I experienced it, so I want to work on it.
How can students help contribute to solving some of these issues of housing insecurity?
Honestly, just learning as much about the landscape of [homelessness]. I’m still learning about the landscape of [homelessness in Massachusetts] because it’s very different from New York where I grew up. Besides that, right now, it’s really thinking about what niche you want to fall into later in your life of being an advocate for these individuals. There’s so many different fields like medicine, social work, case management, therapy, working with actual housing programs, and policymaking and legal perspectives. Everyone was telling me you can’t do homelessness research in the ICU because nobody really does that. And that’s why I am doing it.
All information in this interview was provided by Dr. Jonathan Gabbay through Zoom and email.