Protecting the Health and Well-Being of People Living Unsheltered by Stopping Forcible Displacement of Encampments

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Abstract

Forced removals or displacements of encampments, sometimes called “sweeps,” endanger the health and well-being of people experiencing unsheltered homelessness and impair access to safe, stable housing or shelter. Forcible displacement of encampments is a temporary cosmetic fix and does little to effectively connect unhoused people to services and housing. People experiencing unsheltered homelessness deserve to have their health and well-being protected, their choices respected, and an opportunity to choose their own plans for accessing safe, stable, and permanent housing. Many evidence-based solutions offer bridges into permanent housing without violently uprooting encampments, residents, and their personal property. Instead of forcible displacement, cities and states would be more successful by adopting, practicing, and investing in Housing First approaches, permanent supportive housing and rapid rehousing models, sanctioned encampments, and/or safe outdoor spaces.

Relationship to Existing APHA Policy Statements

APHA has a long history of policy position statements that support the health and well-being of people living without sufficient income to ensure a decent standard of housing. In 2017, APHA’s Caucus on Homelessness Policy Statement 20178, Housing and Homelessness as a Public Health Issue, which followed on to policies related to homelessness dating to 1984. Other relevant statements are listed below.

• APHA Policy Statement 20189: Achieving Health Equity in the United States
• APHA Policy Statement 20216: The Impacts of Individual and Household Debt on Health and Well-Being
• APHA Policy Statement 20214: Advancing Public Health and Equity through Prevention and Reengagement of Disconnected (Opportunity) Youth
• APHA Policy Statement 20179: Reducing Income Inequality to Advance Health
• APHA Policy Statement 200020: Raising Income to Protect Health
• APHA Policy Statement 20167: Improving Health by Increasing the Minimum Wage
• APHA Policy Statement 9718(PP): Supporting A National Priority To Eliminate Homelessness
• APHA Policy Statement 9210: Homelessness as a Public Health Problem
• APHA Policy Statement 9003: Health Care for Homeless Pregnant Teenagers
• APHA Policy Statement 8413: Basic Needs of the Homeless and Homeless Mentally Ill in the U.S.
• APHA Policy Statement 20229: Advancing Health Equity through Protecting and Promoting Access to Voting
• APHA Policy Statement 202117: Advancing Public Health Interventions to Address the Harms of the Carceral System
• APHA Policy Statement 202111: Sexual and Gender Minority Demographic Data: Inclusion in Medical Records, National Surveys, and Public Health Research
• APHA Policy Statement 201811: Addressing Law Enforcement Violence as a Public Health Issue
• APHA Policy Statement 20178: Housing and Homelessness as a Public Health Issue
• APHA Policy Statement 20166: Opportunities for Health Collaboration: Leveraging Community Development Investments to Improve Health in Low-Income Neighborhoods
• APHA Policy Statement 200914: Building Public Health Infrastructure for Youth Violence Prevention

Problem Statement

Many cities manage visible homelessness by forcibly disrupting, removing, or “sweeping” the tents or other makeshift shelters erected by people with no access to indoor housing. We describe the concepts and dimensions of encampment displacement to illustrate the health harms they create. Despite court rulings restricting displacement policies and evidence that the health and well-being of those experiencing unsheltered homelessness are harmed by such displacement, at least 65 U.S. cities are currently criminalizing or displacing encampments.[1]

What is encampment displacement? An encampment is a temporary shelter, typically with tents or tarps, erected outdoors on a sidewalk, in a park, or in other spaces not meant for human habitation. Encampments can be inhabited by an individual or a group, and they can be well organized or unorganized. In this policy statement, use of the term “encampment” includes reference to both encamped individuals and their personal belongings. A forcible encampment displacement is the forced disbanding of homeless encampments, eviction and displacement of individuals experiencing unsheltered homelessness, and removal of their personal property. Various terms for the practice, typically conducted by city employees of police or parks departments, can include abatements, clean-ups, raids, removals, resolutions, or other nomenclature. In this policy statement, we use the term displacement.

Are forcible encampment displacements legal? The Ninth Circuit Court of Appeals in 2012 held that state destruction of a homeless individual’s personal property, even when temporarily unattended, was an unreasonable seizure and a Fourth Amendment violation.[2] More recently, in Martin v. Boise and Johnson v. Grants Pass, the 9th Circuit held that cities cannot enforce anti-camping ordinances if they do not have enough shelter beds available for their homeless populations.[3] In December 2022, a U.S. magistrate ruled against the City of San Francisco on behalf of seven plaintiffs represented by the Coalition on Homelessness and the American Civil Liberties Union. The judge’s emergency injunction banned the San Francisco Police Department and the city from clearing encampments.[4] A Superior Court judge in Seattle, Washington, ruled in July 2023 that the city’s regulations regarding displacements were unconstitutional (the city was using an overly broad definition of “obstruction”), resulting in excessive encampment displacements. Courts so far are upholding the Constitution’s Eighth Amendment by prohibiting cities from punishing people for the mere act of sleeping outside or for sleeping in their vehicles at night when there is no other place for them to go.

The mandate of the United Nations (UN) Special Rapporteur on the right to adequate housing was established by the former Commission on Human Rights in Resolution 2000/9 and renewed in Human Rights Council Resolution 52/10.[5,6] The argument for housing as a human right is based on three international legal instruments: the UN’s 1948 Universal Declaration of Human Rights; the 1966 International Covenant on Economic, Social and Cultural Rights; and the 1966 International Covenant on Civil and Political Rights. Despite an international human right to decent housing established by the UN, few states have protected this right by providing housing through mechanisms outside of market forces.

How are forcible encampment displacements conducted? Encampment displacements may or may not be announced in advance, may or may not include arrests and ticketed citations, may or may not have an offer of alternative shelter space, and may or may not provide storage of personal belongings for a limited period. Displacements often occur early in the morning to ensure that displaced individuals will be present. Advocacy groups, such as Stop the Sweeps, often will be present at a displacement to support the individuals being removed and document the processes.[7]

Do displacements work to move people into housing? Encampment displacements have not been found to result in housing for encampment inhabitants. An audit conducted by the New York City Comptroller showed that only 90 of 2,308 people forcibly removed from encampments remained in a shelter for more than one day afterward, and only three people obtained housing.[8]

Forcible removal of encampments does not end homelessness. Studies of large-scale encampment displacement have attempted to document what happens to people who have been forcibly displaced from an encampment community.[9] In addition to not solving the problem, displacements cause further psychological stress and anxiety, both of which may exacerbate existing physical or mental health problems that often co-occur in individuals who are unhoused.

What problems do encampment displacements cause? Grassroots leaders and direct service providers have identified and outlined four general problems associated with displacements, detailed here.

First, displacements compromise personal safety, disrupt community, and erode civic trust. Forced displacement events have caused harm and loss of trust and culture.[10] Encampment displacements destroy autonomy, safety, and security and stability for people experiencing homelessness in a system that has already failed them.[11] They break important connections within a formed community. Encampments embrace a community of peers and often are served by a comprehensive network of outreach and service providers who meet people where they are. Displacements are punitive and reinforce the criminalization of homelessness. They can also end in false promises (of shelter, housing, or other services) that damage trust and hope among those within the camp.[12] Encampment communities often serve as protection from violence and predation as well as other forms of community safety. A mixed methods study in Toronto demonstrated the benefits of mutual peer support from encampment residents for mental health, daily survival needs, and safety.[13]

Encampment displacements often result in police interactions that increase the likelihood of nuisance arrests.[14] Arrests resulting from displacements create criminal records, court dates and fines, and community service judgments for minor offenses and can result in jail time. The resulting criminal records prevent people from obtaining housing vouchers, make them ineligible for some assistance programs, and bar them from employment opportunities, all of which lead to elongation of homelessness.[14,15]

Second, displacements undermine paths to housing and financial stability. As with those who are housed, people experiencing homelessness often choose where to stay based on proximity to transportation, support networks, and access to employment, services, and other resources. Displacement can undermine people’s progress in working toward resolving their homelessness by destroying personal property, including vital documents (i.e., photo identification, birth certificates, proof of disability, and Social Security cards) and medications that may be needed daily. A survey of homeless encampment residents in Hawaii showed that 57% of people lost their identification.[16] In addition, tools and clothing necessary for employment are often removed or disposed of.

Replacing vital records can take months and poses a high financial cost. Such documents are essential for jobs, income, housing, mainstream services, and police interactions where proof of identification is required. Organizations and local governments spend hundreds of thousands of dollars annually to support people experiencing homelessness to obtain and replace these documents.[17] To obtain replacement identification, one often needs additional identifying documents, such as a birth certificate, creating a spiral of work and frustration to replace essential documents. The implementation of federal REAL ID laws has made the process of securing these documents even more complex and lengthy. Often residents of encampments have completed benefit applications, and housing assessments and have been entered into the community’s coordinated entry system. After years of waiting, it is not unusual for a housing voucher to become available but go unused (and for the case to then close) because the encampment where the client had been living has now been cleared, and residents cannot be located after being dispersed.[18]

Furthermore, continual threats of displacement impact health and can result in insufficient sleep. Long sustained periods of sleep deprivation can lead to increases in chronic disease, mental health disorders, and substance use. Individuals living in encampments have reported an associated sense of safety and community, which can contribute to improved sleep patterns. However, threats of continual displacement disrupt these spaces. Health care workers also report displacement-related disruptions to the management of infectious diseases such as HIV and hepatitis C, resulting in the potential for increased disease transmission and health-related costs, including lost medications and treatment failures. Similarly, displacement-related disruptions in managing chronic conditions can result in increased emergency room visits and hospitalizations, either to replace medications confiscated or lost during displacement or to address exacerbations of chronic conditions due to lapses in care.[19]

Third, displacements disproportionately harm people of color, racial minorities, and, increasingly, women. The U.S. Department of Housing and Urban Development (HUD) 2022 point-in-time (PIT) count showed an overrepresentation of unsheltered people who identify as Black, African American, African, or indigenous (including Native Americans and Pacific Islanders). People who identify as Black made up just 12% of the total U.S. population but accounted for 37% of all people experiencing homelessness. The number of unsheltered people experiencing homelessness who identified as Hispanic or Latino increased by 16% between 2020 and 2022. A 2017 American Journal of Preventive Medicine article reported that sexual minority women and men had increased odds of housing insecurity, housing instability, and food insecurity.[20] Although fewer women than men experience homelessness, HUD estimates that the 35% increase in unsheltered status among women observed through PIT counts from 2016 to 2020 is significantly higher than the increase seen for men. Homelessness among women has increased by 16,500 to 115,635 since 2016.

Fourth, displacements create unnecessary costs for local communities. Emerging evidence suggests that displacement results in increased costs to the health care system in the form of increased emergency room visits, increased hospital stays, and lapses in early interventions and preventive care leading to more complex needs at presentation.[21] Also, while displacement actions carry a significant monetary burden for communities, they produce little to no measurable success in decreasing homelessness.[21] Money spent on repeated displacements depletes funds that could be made available for permanent housing solutions for unsheltered individuals. Multiple studies have shown that investments in housing save money over the cost of continued homelessness.[22,23] Costs incurred secondary to displacements, such as emergency room visits and hospital stays, incarceration, and emergency response, also increase after encampment displacements.[24,25] Data have shown that some cities confronting unsheltered homelessness spent heavily on encampment closures and displacements while spending little on permanent solutions to end homelessness.[21]

Evidence-Based Strategies to Address the Problem

One recent study published in the Journal of the American Medical Association modeled the consequences of forcible displacements of one subset of street dwellers (those who also inject drugs) and concluded that the practice generated 16% to 24% of the all-cause mortality population attributable fraction in 23 U.S. cities between January 2019 and December 2028.[26] Peer-reviewed evidence supports several strategies to end homelessness and stop or mitigate the harm caused by encampment displacements, including Housing First, permanent supportive housing (PSH), rapid rehousing (RRH), engagement and individual choice, and tailoring services to subpopulations, including people with physical or mental health disabilities. Nevertheless, more research would help build the evidence base for the health implications of forcibly displacing people experiencing unsheltered homelessness.

Housing First: Housing First is the consensus approach among housing and homelessness advocates and remains the most viable option to address the growing epidemic of homelessness. This approach quickly connects people to permanent housing and supportive services without requiring they meet behavioral preconditions.[27] Housing First is based on the principle that housing is a fundamental human right and is a basic requirement to improve the life of a person experiencing unsheltered homelessness. HUD and the United States Interagency Council on Homelessness (USICH) have embraced Housing First as a key approach to addressing homelessness in many federally funded housing programs.

Between 2016 and 2020, the Urban Institute partnered with the city and county of Denver to implement a randomized controlled trial, The Denver Supportive Housing Social Impact Bond Initiative (Denver SIB). The study included participants experiencing chronic homelessness and frequent interactions with the carceral and emergency health systems.[28] Utilizing a Housing First approach, the study aimed to assess the relationship between housing stability and jail stays.[28] One year after receiving housing through the Denver SIB, 86% of participants were still in housing.[28] After 2 years, 81% were still housed, and 77% were still housed after 3 years.[28] In addition, participants spent about 32 fewer days in emergency shelter per year than their counterparts who received services as usual.[28] Denver SIB clients had a 34% reduction in police contacts and a 40% reduction in arrests.[28]

In North Carolina, Housing First Charlotte-Mecklenburg was launched in 2015 to end chronic homelessness by expanding the permanent supportive housing model. Housing stability was ensured through a permanent subsidy and ongoing availability of wraparound services. Housing retention was high overall (73%), and health outcomes were dramatic. The average number of emergency department visits fell by 59%. The percentage of housed individuals using the Mecklenburg County Health Department fell by 56%, and the average number of visits fell by 71%. This evidence indicates that displacements are a far less effective alternative.[29]

While seemingly more expensive, alternative strategies such as those discussed above would start to address the root problems of homelessness instead of exacerbating negative health outcomes and contributing to the trauma of unhoused people through displacement. One report indicated that displacements in Houston, Texas, and San Jose, California, have incurred costs of $3.4 million and $8.6 million, respectively.[30] Furthermore, rather than using costly law enforcement to carry out encampment displacements, cities can deploy community response teams composed of medical and mental health crisis workers to connect people to services, as has been observed in Eugene, Oregon, where the police department saved $8.5 million per year from 2014 to 2017.[30]

Permanent supportive housing and rapid rehousing: A randomized controlled trial in Santa Clara, California, examined the effects of PSH on those experiencing chronic homelessness and using the most public funds for services.[31] A total of 423 participants were enrolled between 2015 and 2019, with 199 randomized to the PSH group and 224 randomized to the usual care group.[31] Eighty-six percent of those in the PSH group received housing, as compared with only 36% in the usual care group.[31] Those who received housing in the PSH group remained housed for 28.8 months, or 93% of the follow-up period.[31] PSH participants had lower hospital emergency visit rates, lower rates of shelter days, and higher rates of ambulatory care use for mental health services.[31]

Based on the principles of Housing First, RRH quickly aids individuals and families experiencing housing instability by connecting them to permanent housing.[32] A 2015 Urban Institute report described the effectiveness of RRH for families experiencing homelessness. Families who enrolled in RRH programs consistently transitioned into permanent housing.[33] Moreover, multiple studies have revealed low rates of return to homelessness after use of RRH programs.[15,17,33,34,35] At the federal level, HUD and USICH recognize that pairing housing with flexible, voluntary supportive services is key to ending homelessness.

Overall, PSH and RRH programs are cost-saving interventions, much as with the Housing First approach. According to the National Alliance to End Homelessness (NAEH), PSH has decreased chronic homelessness by 30% since 2007.[36] Cost-effectiveness studies in the United States and Canada have concluded that PSH reduces cost, on average, by 49.5%.[37] In these studies, health cost estimates declined from $6,832 to $3,376 over 12 months, cost savings ranged from $6,622 to $9,809 for those experiencing chronic homelessness or chronic homelessness and HIV, and those who received Housing First utilized emergency departments and inpatient services less than their counterparts, resulting in a lower per patient, per year utilization cost of $25,614 (as compared with $30,881).[38–40] HUD and NAEH advocate for Housing First approaches and have concluded that Housing First is an effective strategy to end homelessness.

Individual choice and lived experience: Some encampments are organized as mutual aid projects, with intentional principles of self-governance and a political mission to end homelessness. Organizations by and for people experiencing homelessness in Seattle—the Seattle Housing and Resource Effort (SHARE) and Nickelsville—demonstrate the vast potential of self-governed services for people experiencing homelessness.[41,42] Across two tiny house villages, three tent encampments, and 10 indoor shelters, these sites engage approximately 400 people each night. Other examples of such self-governing shelter alternatives include Dignity Village and Right 2 Dream Too (R2D2) in Portland; Camp Hope in Las Cruces, New Mexico; and Cob on Wood and Homefulness in Oakland.[43,44]

Providing a variety of housing and service options centered on individual choice and informed by people with lived experience of homelessness offers people autonomy and self-determination in identifying the best way(s) to resolve their homelessness. One study conducted in Seattle revealed three themes among participants approached with Housing First: sense of community, stability, and control.[45] The theme of control encompassed “gaining autonomy while relinquishing control.”[45] Strategies that honor the lived experience, dignity, and agency of people living unsheltered will, in the long term, best serve people and communities, as reported in the Seattle study.[45] Ultimately, people are best served by exercising the choice of which housing approach works best for them and their families. Offering choices strengthens community relationships and promotes a sense of being heard. People experiencing homelessness deserve to be treated with respect and offered the opportunity to choose their plan for finding safe, long-term quality housing.

Tailoring programs for marginalized populations: Within the community of people living unsheltered, disadvantaged and marginalized subgroups include not only people of color and those who identify as LGBTQIA (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual) but also veterans, individuals with mental illness, seniors, people with disabilities, and others. Tailored approaches, interventions, and individualized care are key, but the overarching strategy of providing housing and wraparound services is fundamental.

Veterans: Veterans have been particularly vulnerable to homelessness. While HUD estimated 33,129 veterans experiencing homelessness in 2022, this represents a substantial reduction in veteran homelessness over recent years. USICH has attributed the reduction in veteran homelessness since 2010 to the billions of dollars Congress has allocated to housing voucher programs as well as numerous tailored wraparound support services, housing navigators, and an already-robust health care system for veterans.

Supporting mental health: Between 20% and 25% of unhoused people suffer from a serious mental illness, as compared with 4% to 6% of the general U.S. population.[46] The Projects for Assistance in Transition from Homelessness (PATH) program aims to support unhoused persons with severe mental illness. PATH program data from 2016 to 2018 indicate that the target for providing community-based mental health service was exceeded by 25%, 15%, and 21% for unhoused people with a severe mental illness each year, respectively.[47] On average, 184,142 unhoused people were contacted each year, 48% were enrolled in services, and 65% of those enrolled received mental health services.[47]

Attention to seniors and people with disabilities: By 2030, adults 65 years and older will likely account for approximately 106,000 unhoused persons, and PIT counts have indicated that nearly 25% of unhoused people have a disability.[48,49] The 2022 American Rescue Plan dedicated $5 billion to provide 70,000 vouchers for individuals at the highest risk of homelessness, including older adults and individuals with disabilities.[50]

Summary: Communities should look toward cities that have implemented evidence-based strategies that avoid displacement and support robust health and housing outcomes for people experiencing unsheltered homelessness. By court order, San Francisco was directed to end encampment displacements in early 2023, but no cities have successfully terminated all encampment displacement policies (in fact, some have quickened the pace of displacement).[51,52] Since San Francisco’s displacements were declared unlawful only in December 2022, not enough research has been conducted to determine the results. Overall, more comprehensive studies are needed nationally to address the lack of evidence-based literature surrounding forcible displacement of encampments.

Opposing Arguments/Evidence

Supporters of encampment displacements argue that they benefit housed communities surrounding camps. In some cases, they go so far as to assert that displacements benefit the camp residents being evicted. Advocates of encampment displacements claim displacement benefits public health by motivating encampment residents to seek housing and services, reducing crime and illegal drug use, and reducing the accumulation of solid and human waste. Some support forcible encampment displacement to motivate people experiencing homelessness to seek employment, undergo treatment for substance use and mental health problems, and ultimately obtain stable housing. These assumptions frequently reflect a lack of understanding of the causes of homelessness and fail to appreciate the cumulative repercussions of displacement beyond the immediate optics.

Relocation effects: Advocates of involuntary displacement argue that displacement eliminates the problems they associate with encampments.[53] However, substantial evidence demonstrates that residents forced to vacate encampments simply relocate to another outdoor location.[54,55] Following a targeted series of displacements in Honolulu, Hawaii, evicted residents waited for authorities to leave the area and immediately returned to live at the campsite.[55] One nationally prominent supporter of the forced removal of people living unsheltered, while touting the effectiveness of a targeted displacement, ultimately acknowledged the result was that evicted individuals “simply moved on, undoubtedly to more permissive cities.”[56]

Studies of large-scale encampment displacements have attempted to document what happens to people who have been forcibly displaced from an encampment community. For example, the Luskin Institute on Inequality and Democracy at the University of California, Los Angeles published a report by the After Echo Park Lake Research Collective. Echo Park, in the heart of Los Angeles, became an encampment home for nearly 200 people who found community and collective safety over about 18 months. As the neighborhood gentrified, however, political pressure grew to remove the “unsightly” encampment there, culminating in a March 24–25, 2021, police invasion to remove people and their belongings. The research project found only 17 people (of the 183 displaced) in various forms of housing, including Project Homekey hotels, subsidized rentals, and PSH. The system lost track of 82 former Echo Park residents. The Echo Park study connects to a national issue because researchers have implicated Los Angeles policymakers in establishing a national “standard” (or “playbook”) for accelerating urban displacements.[57]

In Seattle, Evergreen Treatment Services (the REACH Program) reviewed 116 known individuals removed from 26 encampments in a space under North-South Interstate 5 freeway bridges, known as “The Jungle,” in mid-October 2016. Of the 116, REACH subsequently engaged 87 (75%) individuals who remained unhoused. Of the 116 displaced, 38 (33%) were encountered by outreach workers in street encampments 5 years later; only 11 clients were known by REACH staff to be in housing as of June 2022.[58]

Displacement advocates claim that evicted residents will move to emergency shelter, access other housing services, or be motivated to seek employment or substance use treatment. In reality, being displaced from an encampment reduces the odds of accessing emergency shelter.[16] In many communities, inadequate shelter space exists to accommodate those displaced.[59] Emergency shelters are often unsuitable.[16,60] The quality of indoor short-term shelter is critiqued for the many restrictions (short hours, no privacy, noise, conflict, no pets, no partners, no storage, many rules), discouraging those seeking to leave encampments.[16,60]

Public health concerns: Advocates of encampment displacements often adopt public health language to justify displacement. They support forced displacement in deference to housed individuals living in or near encampments, citing increased crime risks, waste accumulation, and disease. The first misconception of this argument is that encampments are associated with high rates of violence, assault, theft, and other crimes in surrounding neighborhoods. Evidence does not support associations between serious crime and proximity to encampments. People experiencing unsheltered homelessness are at an increased risk of illegal misuse of drugs. However, encampment displacements are not shown to reduce drug use or increase access to addiction treatment. The effect is the opposite: people displaced from encampments are more likely to be disrupted from addiction counseling, harm reduction services, and medication-assisted treatment. They are more likely to experience injection-related severe infections and overdose.[60]

Critics frequently point to the appearance of garbage and human waste as evidence of a public health concern associated with homeless encampments. Individuals experiencing unsheltered homelessness struggle to find adequate public restrooms, clean water sources, and garbage collection, resulting in a lack of facilities to urinate, defecate, or dispose of trash. Providing adequate facilities and clean water sources to accommodate basic human needs would be a more humane means of managing these waste streams. Being forcefully removed from an encampment increases risk of a cascade of adverse health effects. Victims of displacement frequently experience trauma, anxiety, chronic stress, hopelessness, and loss of motivation from the constant fear of a displacement.[21,60] For people with mental health conditions, experiencing a displacement can worsen these conditions and place some at an increased risk of a mental health crisis.[21,60] Displacements can interfere with an individual’s management of infectious diseases, such as sexually transmitted infections, hepatitis C virus, and skin and soft tissue infections, potentially leading to higher rates of severity and transmission.[21] The Centers for Disease Control and Prevention acknowledged the increased risk of disease transmission by recommending a moratorium on homeless encampment displacements when COVID-19 community levels are high. Another outcome of encampment displacements is the forced relocation to other, frequently less desirable locations. Numerous factors determine where people live, including safety, privacy, and proximity to resources and social systems. Forced relocations result in real-time crisis management decisions about where to go next. Displacements usually force people to relocate to environments farther from resources such as clean water, public transit, health care, food relief, and housing assistance and more isolated from social connections, contributing to the negative health effects of displacement.[21,60]

New York City and other jurisdictions are employing carceral strategies, forcing involuntary treatment on those deemed unsightly or disturbing while unsheltered and therefore an offense to the “regular population.” New York mayor Eric Adams has directed the police and emergency medical workers to hospitalize people they deem too mentally ill to care for themselves, even if they pose no threat to others.[61] Primary concerns associated with this strategy include giving possibly untrained and unqualified personnel the authority to commit individuals against their will and the potential of this program to disproportionately target poor people. Early effects of this initiative are anecdotal and mixed.[61]

Alternative Strategies

Across the United States, low-income housing advocates have promoted a set of policy initiatives to reduce homelessness; we describe some of those options here.

Eviction prevention and tenant protections: Early in the COVID epidemic, federal, state, and local authorities imposed restrictions on landlords to limit late fees and restrict penalties related to nonpayment of rent to reduce evictions. Authorities in some cities also protected renters by regulating application processes and limiting required deposits, requiring mediation as a step before legal proceedings for eviction, and ensuring that tenants have legal representation in eviction proceedings. Some jurisdictions provide an eviction defense screening line to assist tenants before right to counsel is required. Legislation can require landlords to provide 6 months’ notice of significant rent increases or provide tenants with the right to quit their lease in relation to a rent increase.

Tenant organizing: Tenant community organizing and advocacy helps keep rents low and improves living standards. Some jurisdictions allow tenants to form collective bargaining agreements to negotiate with landlords with one voice. Under provincial rules in Quebec, for example, landlords and tenants negotiate and agree to rental rates; in this context, rent increase margins are set by the provincial Tribunal administratif du lodgement. Six U.S. states (California, Maryland, New Jersey, New York, Oregon, and Minnesota) and the District of Columbia impose rent control limits, and many local jurisdictions implement controls; unfortunately, 31 states have preemptions that prevent rent control policies. California’s 2020 law restricts landlords from increasing rent by more than 5% each year, along with a local cost of living increase of up to 5%.[62]

Restrict corporate ownership and management of rental property: The increasing concentration of rental property in the portfolios of limited liability corporations (LLCs) is a cause for concern among those seeking to keep rents affordable.[63] These corporations often use a third-party corporation to monitor and automatically accelerate rental rates using an algorithm to maximize profits, such as Texas-based RealPage’s YieldStar software.[64] Lawsuits have attempted to challenge these practices in Texas, California, and Washington. Issues with LLC owner identification have prompted some states, including New York, to pass laws that make it easier to unmask owners.[65]

Social housing: Publicly owned collective housing creates mechanisms for public development associations to acquire or build rental units with affordability and tenant-involved management in mind. This model has worked well in Vienna and was adopted by initiative in 2023 in Seattle.[66]

Income protection and housing models: In most European nations, some form of guaranteed income and provisions for low-income housing are available to all citizens.[67] Unlike the United States, most European nations also have free health care available to all citizens, which keeps people from losing their assets and income in the event of a serious health problem.[68]

Home sharing programs: Matchmaking and home sharing programs across the United States work to connect people who have extra space in secure housing with potential housemates seeking low-cost living arrangements. This may be a senior attempting to age in place, a family with extra room, people with disabilities, or those on fixed incomes. Local organizations (public or private) offer matching programs that serve as a form of early homelessness prevention. The National Shared Housing Resource Center networks these local organizations.[69]

Allowing people to stay and offering supportive services: Local authorities in some cities allow encampments already in place to continue operations until those in the space can be offered permanent housing. Using this approach, cities provide legal parking spaces for those living in vehicles or leave tent-based encampments in place and bring in porta-potties, handwashing stations, laundry facilities, trash pick up, shuttles to health and social services, outreach workers, and access to food resources. Cities using this strategy include Phoenix, Arizona; Missoula, Montana; Las Cruces, New Mexico; and Durango, Colorado.[70] The Colorado Village Collaborative has partnered with the Denver Mayor’s Office since July 2020 and has successfully operated multiple safe outdoor spaces in six neighborhoods, with more projected to open.[71] Albuquerque has created several safe outdoor spaces that provide around-the-clock onsite security, monitored and controlled access to the space, social support services, bathrooms, and showers.[72]

Street outreach is often the first step in empowering encampment residents to exit unsheltered homelessness. Coupling street outreach services with a strong network of health and service providers, including a diverse menu of housing options, is an effective means of engaging encampment residents.[59] A pilot study conducted in Boston resulted in 82% of participants enrolled in housing after one year.[73] Individuals are best served by choosing among options when considering supportive services and having the autonomy to select the services they want. In addition, there is a need for increased low-barrier program options that allow people to leave the street without having to comply with prohibitive program requirements such as sobriety, documentation, or monetary fees.[59]

Decriminalization and engagement: APHA Policy Statement 20178 (Housing and Homelessness as a Public Health Issue) emphasizes the importance of decriminalizing the life-sustaining behaviors of people experiencing homelessness, consistent with recognizing fundamental human rights. Diverted savings from the prosecution of displacement are better spent developing affordable housing options, reinvesting in community and supportive services, or establishing street outreach teams to increase engagement. Homelessness outreach teams staffed by police officers in Houston, Minnesota, and Milwaukee have proved successful in diverting homeless individuals away from jails when they are in a mental health crisis, saving the criminal justice system additional funds. Some cities and states across the country have enacted a homeless bill of rights, legislation that prohibits the criminalization of homelessness and discrimination against those experiencing homelessness. These rights include the right to move freely in public places, share food, rest, and ask for donations while being protected from harassment from police or others.

Family reunification and supportive networks: Many cities have established formal family reunification efforts as a way to help unhoused people reestablish relationships with family members. For example, the Family Reunification Program, operated by the Downtown San Diego Partnership, is a hybrid outreach, services, and rehousing program available as a resource to outreach workers. Family reunification is not limited to reuniting families under one roof. Rather, families might engage in activities to simply build a trusting, familial bond with each other. The HUD Family Unification Program facilitates interagency collaboration between child welfare and public housing service systems to stabilize families at risk for parent-child separation by addressing housing needs.

Advocacy campaigns: The Western Regional Advocacy Program was created to expose and eliminate the root causes of civil and human rights abuses of people experiencing poverty and homelessness in our communities. It has launched a “house keys, not sweeps” campaign in West Coast cities to eliminate forcible removal of encampments while expanding housing options for those currently in camps. Similar organizations, such as Stop the Sweeps, exist in communities across the country; advocates show up at forcible removal sites and bear witness while also supporting people in the path of removal efforts by helping them salvage their belongings, attend to children, and provide food and other necessities.

Action Steps

APHA is committed to ending and preventing homelessness by protecting the health of people experiencing unsheltered homelessness and halting the harmful practice of forcible encampment displacement. As a means of reaching this goal, APHA advances the action steps below.

• Stop forcible displacement: APHA urges local, state, and federal officials to reject proposed laws and ordinances, or reverse existing statutes and ordinances, that criminalize behaviors and activities associated with unsheltered homelessness, including forcible displacement.
• Commit to Housing First: APHA calls upon all local and state officials to formally adopt policies and programs that adhere to the Housing First approach and provide for housing and services that are accessible, low barrier, and housing focused.
• Sufficiently fund permanent supportive housing and rapid rehousing interventions: APHA urges the U.S. Congress and HUD to provide states and local communities with sufficient funding to meet the need for permanent supportive housing, rapid rehousing, and housing subsidy programs aimed at preventing and ending homelessness.
• Respect lived experiences and individual choice: APHA calls on local, state, and federal agencies and officials to adopt programs and policies that are informed by and respect individual choice and lived experience of homelessness. This includes providing sufficient funding for street outreach, housing, and social service options that support individual choice and self-determination.
• Fund robust outreach and supportive services: APHA urges local, state, and federal agencies that fund and provide grant support, coordination, and/or regulatory oversight for programs focused on homelessness to allocate sufficient funding for robust street outreach and engagement efforts as well as comprehensive supportive services to help people rapidly exit from unsheltered homelessness and into permanent housing.
• Support homelessness prevention: APHA calls upon the U.S. Congress to appropriate sufficient federal funding for the evidence-based strategies and alternative approaches presented in this policy statement, including those focused on the prevention of homelessness, in order to meet demonstrated community needs at the state and local levels.
• Center equity: APHA urges local, state, and federal officials and policymakers to address the disproportionate harm that forcible displacement has on people of color, racial minorities, people with disabilities, women, and others experiencing unsheltered homelessness by centering equity in the development of population-specific best practices, tailored policies, and program approaches and in the prioritization of marginalized populations for housing and services.
• Advance research on homelessness: APHA calls on HUD, USICH, the National Institutes of Health, the U.S. Department of Health and Human Services, and other institutions to provide additional funding for research on evidence-based policies and practices that work to prevent and end homelessness, including those identified in this policy statement.

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