For the first time, Portland’s homeless are ranked by how likely they are to die on the streets

Nov. 12, 2008 (from the October 31-Nov 13 edition)

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(Photo by Leah Nash)

Measuring our vulnerability (by Amanda Waldroupe)

Forty-year-old Shannon Boat, who has been homeless on the streets of Portland for three years, was told that the bladder cancer she was diagnosed with would kill her.

“They told me I had two years, and that was six years ago,” she says.

She stops by at the Downtown Chapel regularly to stock up on Depends — adult diapers — because she can no longer control her bladder.

“It’s painful,” Boat says. “Being homeless makes my health problems worse… If I wasn’t homeless, I wouldn’t have to be worry about leaking urine all over the place.”

Boat’s story of becoming increasingly unhealthy while homeless is a common one on the streets, but her story — like many others — has largely remained untold.

That changed on Friday, October 24, when the results of a survey detailing the severe health problems homeless individuals suffer from was presented to an auditorium full of those charged with ending homelessness in Portland.

The survey created what is called the Vulnerability Index. Ranking homeless individuals according to the fragility of their health, the Index reveals how likely those individuals are to die on the streets if they do not receive housing, medical care, or other services.

Created by the New York non-profit Common Ground, the Index is based on the research of Dr. Jim O’Connell, a street physician with the Boston Health Care for the Homeless Program. O’Connell’s research found that having one, or a combination, of eight specific illnesses increased a homeless individual’s likelihood of dying (see sidebar).

The results of Portland’s survey are alarming (see results at right).

“Frankly, they shock me,” says City Commissioner Nick Fish, who oversees the Bureau of Housing and Community Development.

Altogether, 646 surveys were taken, far exceeding the housing bureau’s goal of collecting 400. Of those 646 individuals, 302 people, or 47 percent of those surveyed, have a high risk of mortality, meaning they reported having one of the eight illnesses increasing morbidity.

Most disturbing is the number of individuals who are “tri-morbid,” meaning they have co-occuring mental health, substance abuse, and medical issues.

“Your tri-morbidity rate is really high,” said Becky Kanis, Common Ground’s director of innovations, adding there are more tri-morbid people in Portland than in any other city the index has been taken in, including Los Angeles, New Orleans, and New York City.

“The people we’re talking to are in very poor health,” said Sally Erickson, program manager at the housing bureau.

Creating the index requires surveying homeless individuals and asking them 45 questions about their personal health: Have you been diagnosed with HIV and/or AIDS? Have you ever been violently attacked while homeless? Liora Berry, program coordinator at the housing bureau, and the person who initiated doing the index here, describes them as “very personal questions.”

Gathering at City Hall at 5:30 a.m. on Oct. 21, 22, and 23, volunteer outreach workers, bureaucrats, and housing advcoates split into 13 teams led by an outreach worker and medical professional, and from 6 to 8 a.m. they hit the streets of downtown Portland and the inner quadrants conducting the survey. Each team, armed with clipboards, surveys and passion, surveyed the same area each morning, at the crack of Portland’s cold dark dawn.

****

5:30 in the morning on Thursday, 40 people gathered in City Hall’s Rose Room. It is the third and last morning of surveying. “By Thursday, I was exhausted,” says Dennis Lundberg, a Janus Youth outreach worker. “I was really feeling worn out.”

I walked in as Berry was giving a pep talk to people seated at the conference table, along the edges of the room, and standing in line to pour themselves Stumptown coffee from a box.

It is pitch black when we leave City Hall, following a team led by JOIN outreach worker Quinn Colling. Colling and his team have been covering the area around the Burnside Bridge, Burnside Avenue, and parts of Old Town.

First, though, Colling makes an important stop, out of consideration for the people he has worked with for the last year and a half: Voodoo Doughnuts.

“I wouldn’t want to be woken up without coffee and breakfast,” Colling says.

“Walking into someone’s camp uninvited at 6 a.m. and waking them up is generally an invasion of privacy,” says Dennis Lundberg, an outreach worker with Janus Youth.

Driving along SW Naito Parkway, we find three people. Three more people are found, woken up, and surveyed along Ankeny Street in Old Town. After finding no one sleeping on the Burnside Bridge, we arrive at the Downtown Chapel around seven in the morning, first light.

About a dozen people were already lined up outside the Catholic-based agency waiting for its hospitality center to open at nine-thirty, including Boat.

Boat was one who listed a myriad of health issues. In addition to having bladder cancer, Boat says she has had frostbite on her fingertips, vision and hearing problems, suffered from a past head injury, and used injection drugs in the past.

Boat tells me she is not hesitant to be frank about such personal matters; she prefers to “share my experiences out here to help the younger generation.”

“It’s the hardest thing to be out here and be homeless,” Boat says.

She echoes what a man who identified himself as Alan said earlier that morning. Homeless since December, Alan says he has lived in Portland for four years, after immigrating from Liverpool, England.

“It’s a good thing,” he says, of the survey. “If you don’t ask questions, you’re not going to find out what’s going on.”

A few feet away from Boat and me, Linda Klein, a Providence Hospital physician, surveyed a young man. He sat atop a wool blanket Colling had given him, his legs crossed.

An overpowering rancid smell thickened the air as he removed two layers of damp, dirt-stained socks. Klein shines a flashlight on his feet, revealing blisters covering his toes and bottom of his feet. Bright red lines circled his toes and meandered up his feet. As Klein looked, the young man’s body was racked by a loud, hacking cough.

“He needs to get treated,” Klein said.

Colling and Klein decide to take him to the emergency room at Northwest Portland’s Good Samaritan hospital. Colling drives, while I sit in the back of Colling’s van keeping a thermos of coffee steady between my feet to stop it from spilling. Klein continues to administer the survey on the way. The man responds by nodding or shaking his head, the only verbal sounds coming from him incoherent murmurs.

Arriving, he swung his legs out of the van to walk to the emergency room. Klein asked if he wanted to put his socks back on. He shook his head, said “thank you” and walked away.

Klein said the man’s feet had bacterial infections that were beginning to “track” up his feet. Klein also said he may be cachectic, a condition of extreme weight loss. “He looked like someone who could get sick fast,” she said. “He didn’t have the reserves.”

The man spoke so quietly, almost timidly, that I couldn’t hear why he would not put his socks back on. As we headed back to the Downtown Chapel, Klein repeated what the man said.

“He said (his feet) felt like they were on fire.”

****

At least twice as many people were at the Downtown Chapel when Colling, Klein and I returned. Shannon Rhodes, 39, said a woman staying at the Salvation Army’s women’s shelter nearby on 5th Avenue had taken the survey earlier and told the women about it upon returning.

As we got out, people asked us if we had surveys. Because I had a clipboard, people asked me as well. I’m a reporter, I said. I’m not doing the surveys. Well, couldn’t you? Someone asked, looking me straight in the eyes.

Sure, I thought. I know how to ask questions.

I ended up giving two surveys Thursday morning. One was to an African American woman only two years older than I am (twenty-five), responding to the questions mainly by shaking her head.

The woman, Rhodes, and many other individuals encountered by the survey teams, were more than willing to answer the questions posed to them. One of the unique things about the Portland survey, Kanis said, was that the ratio of people consenting to take the survey in Portland was, at 90%, higher than any other city the survey was taken in.

Lundberg, initially concerned about whether the survey would violate people’s privacy, said, “it felt comfortable and it felt compassionate.”

At the same time, some people were motivated to take the survey purely, it seemed, because of the $5 gift card to Starbucks, Safeway or Burger King given at the end of the survey.

“I need something to eat,” a homeless youth said to me as I questioned him. Shaking his head or droning no after no, at one point, as I asked him whether he was HIV positive or had AIDS, he said, “I’m only 18.”

****

“We will use the data from the Vulnerability Index to make sure that people with serious medical conditions receive priority for housing, medical care and other services,” Fish said in introductory remarks to the presentation of the survey’s results.

“We should serve the people who are the most vulnerable,” Erickson says.

Erickson sticks by those guns, even in what appears to be the current scenario where the net number of shelter or housing spaces does not increase, leaving those serving homeless individuals making difficult, moral choices regarding whether to perform triage, and house the vulnerable, at the cost of leaving healthier individuals still on the street.

“I have no problem with housing them first,” Erickson says.

“I recognize we have to make tough choices,” Fish says.

Despite being homeless for 25 years, and describing her experience as being “through hell and back,” Robin Tolbert, 48, agrees. “The ones who are really, really sick need to come first,” she says. “It doesn’t bother me.”

In addition to rapidly housing unhealthy individuals, the index will also enable some “problem solving” when it comes to how the city serves those individuals.

Shelters using a first come, first serve or lottery system may need to change the way individuals are admitted and receive priority. Erickson thinks the current system excludes those who are not organized or too unhealthy (mentally or physically) to “advocate for themselves,” effectively prioritizing one population over another, but the population is not the most vulnerable.

During the Friday presentation, Fish publicly charged the housing bureau to devise a plan on how to best serve those individuals by Nov. 10. Fish expects the bureau to “be as creative and enterprising as they can to come up with a menu of options.”

Dark lines of exhaustion etched underneath their eyes, Erickson and Berry were not sure on Friday afternoon what, exactly, the proposal would be.

“I don’t know what the full outcome will be,” Berry said. “The main thing is to regroup.”

Homeless on and off for five years and on the wait list for the Salvation Army’s women’s shelter, Rhodes knows exactly what she wants to see happen. “I want them to use the information to get more funding, more spaces,” she says.

Into the future, some see a major opportunity to use the hard data the Vulnerability Index provides as leverage for acquiring new resources and increasing the net amount of housing and service resources for the city’s efforts to end homelessness. “It helps our arguments,” Fish said.

“How can we be a great city when we cannot take care of our most fragile?”

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