"Sweeping" Homeless Encampments Leads to More Overdose Deaths, Study Finds

Unsheltered homeless who inject drugs are at high risk of drug-related morbidity and mortality when they are involuntarily displaced.

Hey readers of Substance. I’ve been in feature story mode for the past several weeks, which explains why I haven’t been writing very many newsletters. I’m really excited for that story though! It’s big and complicated and emotionally dicey. I hope you’ll like it once it’s out. Now I just have to figure out how to write it. Thankfully, Tana has been holding down the fort. Thanks for supporting us! - Zach

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There isn’t really a standard definition of a homeless encampment. But you know it when you see it. They vary in size and density depending on location. Maybe a dozen or so people live outside in pitched tents along a riverbank. In West Coast cities, encampments can range from hundreds to thousands of people living on sidewalks, under highway overpasses, in long vertical rows of tents and tarps, almost like cubicles, down a street. Encampments are growing in American cities, and they keep growing despite policies of “sweeping” and clearing” them from public space.

On their surface, encampments appear to be disorderly, dangerous, and a threat to public health and safety. Living in one is no picnic, to be sure. Passersby usually complain of the sights, sounds, and smells, as well as the detriment to nearby businesses. Political pressure to “break up” encampments builds and builds, which leads to a media frenzy for (often liberal) mayors in “blue cities,” who get pelted with questions: What are you going to do to help these people? Where are they going to go? The mayor will give a statement about how unhealthy and dangerous the encampment has become (See Boston’s “Operation Clean Sweep”). The public health and safety risks of encampments are the public-facing rationale for dismantling them. It’s for their own good.

A new modeling study in JAMA asks: What are the health and safety risks of dismantling encampments for people who are injection drug users? Euphemistically called “sweeps,” “clearings,” and “cleanups,” the result for unsheltered, homeless people is forced displacement, which, according to this study, generates its own set of harms.

Encampments are sites of unsheltered homelessness. And there are clear health and safety risks for those living in them. But there’s also risks to dismantling them. An editorial accompanying the study put the results bluntly: “Under no model were the results of displacement beneficial or even neutral to health and safety.”

This schematic charts the path of displacement to death modeled in the study:

Figure 1, “Population-Level Health Effects of Involuntary Displacement of People Experiencing Unsheltered Homelessness Who Inject Drugs in US Cities,” via JAMA

To explore the risks of disrupting encampments, the authors created simulation models based on 23 US cities who participated in the 2018 cycle for the National HIV Behavioral Surveillance (NHBS). The simulated participants were all injection drug users who were given attributes and probabilities based on local and national data. Because this is a modeling study, there are no real participants. (A grim thought: It’s ethically impossible to create a study design where injection drug users are randomized into encampments that get demolished versus encampments that are not)

The model then simulated how these participants would fare under various displacement policies, ranging from continual forced displacement to no displacement. The displaced cohorts always did worse than the non-displaced cohorts. In a way, these results support the notion that encampments can create a sense of community and a dynamic of protection for those who live in them.

Comparing no-displacement to those who faced continual displacement, the study found a significant increase in overdose mortality (71% to 94%) at 10 years for the continual displacement group. The study also estimated that “continual displacements were associated with up to a 46% increase in hospitalization and a 56% decrease in initiations of MOUD (medication for opioid use disorder).” The policy of continuous involuntary displacement—a policy in many cities that criminalize sleeping outside or in public spaces—contributed to 16% to 24% additional deaths among unsheltered people who inject drugs.

You might be asking how? What makes involuntary displacement such a dangerous and deadly approach to encampments? When shelters are dismantled, their residents are rarely offered housing and other services. If people resist the “clearing” and refuse to watch their possession be thrown into a dumpster, they can be arrested. The JAMA editorial spells out the many mechanisms by which dismantling encampments generates harm:

“Involuntary displacements may harm health through disruption in health care and social networks; loss of contact with outreach workers; loss of medication, documents, phones, and other belongings; incarceration; and negative impacts on trust. These mechanisms would have negative health effects on all individuals who experience unsheltered homelessness, not only those who use injection drugs.”

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It’s important to ask why encampments occur in the first place, and also why people might choose to live in one over a shelter.

First and foremost, encampments are a thing because of a profound and pervasive lack of affordable and permanent housing in so many communities. I’ve gone over this ad nauseum, but rates of homelessness are not determined by rates of drug use or mental illness. But homelessness rates do vary by the cost of housing and the supply of affordable housing in a given area. No matter how many times Michael Shellenberger yells that homelessness is caused by addiction and mental illness, he’s just wrong. It’s not true. (He’s moved on from homelessness and he pivoted to being a Twitter Files Free Speech Guy)

In the face of such stark precarity, that leaves people with a series of bad options (I’m hesitant to say “choices”). Between bouncing in and out of a shelter or living on the street alone, encampments might not be the worst option. According to the National Health Care for the Homeless Council:

“Homeless encampments are a rational response to the dangers of living isolated on the streets. People congregate in encampments seeking safety, companionship, pooled resources, and other practical needs. They can be a rare place of stability for individuals who may normally move place to place and often serve as outreach sites for service providers.”

As for why some prefer encampments over shelters, that is complicated. First, shelter spots are in short supply in many cities; they’re crowded and have long waitlists to get in. Some shelters enforce onerous rules, such as strict curfews, which can be difficult to abide when people have jobs and the hours conflict. Some shelters don’t allow pets. Others don’t a allow children or couples to stay together. These rules don’t always comport with the way people actually live their lives. People also report that they’ve been subjected to violence, harassment, and discrimination inside of shelters.

People may not like the sight of encampments in their neighborhoods. That’s understandable. But what this study shows is that dismantling encampments creates its own set of harmful outcomes, while doing nothing to address the reasons why encampments form in the first place. Homelessness is an issue of housing. And until people are presented with better options, encampments will probably keep growing. Forcing people to relocate to a temporary location, over and over again, does not really address the issue. It just kicks it down the road.

Citation: Barocas JA, Nall SK, Axelrath S, et al. Population-Level Health Effects of Involuntary Displacement of People Experiencing Unsheltered Homelessness Who Inject Drugs in US Cities. JAMA. Published online April 10, 2023. doi:10.1001/jama.2023.4800