Life and death lottery

From the Portland Tribune, May 5, 2011

Portland’s most vulnerable have a shot at a free home

John hasn’t had a place to live in four years. Being in and out of jail is the closest he’s come to that.

A longtime methamphetamine addict, John (not his real name) says he mostly uses marijuana now. John also suffers from severe mental illness, including depression.

John, in his 40s, is articulate and resourceful. After years of on-and-off homelessness, he has learned where to go for a hot meal or a shower. That resourcefulness is about to cost him a place to live.

As the Housing Authority of Portland prepares to open its $47 million Bud Clark Commons near Union Station in Old Town, workers at four community health care clinics have administered Vulnerability Index tests to the city’s homeless. The 130 people with the highest scores — basically those most likely to die or get assaulted if left out on the street — will be offered apartments in the LEED-certified building.

The 130 apartments in the commons represent one of the more dramatic housing experiments that the city and the housing authority have attempted. Because of the way the tests measure vulnerability, tenants will include people who are trying out recovery living next to those still using drugs and alcohol, and those prone to violence next to longtime assault victims.

Two weeks ago John took the test. So did Cindy.

Cindy, by appearances, isn’t nearly as bad off as John. She’s much younger, just a year or two over 30, so she hasn’t been homeless nearly as long.

She lives on the street by herself, addicted to meth, a loner who was a victim of domestic violence much of her early life.

Cindy does have hepatitis C, bipolar disease, asthma and her addiction. Still, her mortality risk is rated at two on a scale of one to five. Unlike many older, longtime homeless people, she doesn’t yet have cirrhosis of the liver or chronic kidney disease, heart disease or diabetes.

But Cindy scores high for vulnerability, mostly because a lifetime of domestic abuse indicates that she allows herself to be victimized, and living on the street provides plenty of potential for that.

Cindy’s overall score of 29 is going to get her an apartment in the commons. John’s vulnerability score of 15 won’t even get him close.

In hour-long question-and-answer sessions, clinics workers have been trying to place objective measurements on the myriad conditions and hazards that create homelessness, and which distinguish lives that to many appear indistinguishable.

The lowest possible score on the vulnerability test is 10, the highest is 48. At this point, it appears a score in the high 20s will register in the top 130 and yield a lifetime rent-free apartment in Bud Clark Commons for those with no money (those receiving Social Security income will pay 30 percent of their benefits).

Drug users score higher

Kelly Moehling, who has administered the vulnerability tests at nonprofit Central City Concern’s Old Town Clinic, says there were a number of consistent themes among the high scorers she assessed. One was severe mental illness such as schizophrenia. Another was chronic alcoholism or drug abuse. Those who are in substance abuse recovery programs scored lower, mainly because they are better able to take care of their basic needs, such as finding their way to shelter and soup kitchens and reliably taking their medications.

In fact, one Central City Concern client was mistakenly assessed twice — once before he started a recovery program for chronic alcoholism and then a month later while in recovery. The second score, Moehling says, was markedly lower.

Jeanine Carr, community health nurse at the Multnomah County Westside Health Center downtown, says she and the staff have assessed about 50 homeless people so far. The highest score to come out of the county clinic as yet is a 32, and that man typifies a potential problem for the commons once all the tenants are in place.

The person with the highest score is 40, says he bathes every 10 days and gets new clothes from area shelters whenever his clothes get too dirty. That shows a fairly high degree of resourcefulness, Carr says, and lowers his score.

But the client scored high in the mortality risk category because he suffers from a number of chronic diseases, and because he visits local hospital emergency departments about once a month. He reports chronic unexplained seizures and that he sometimes passes out after taking his medications. A brain injury and learning disability increased his score.

Six years of homelessness didn’t keep the client from earning a four (out of five) for survivability skills after he told Carr his possessions are often stolen on the street. The fact that he says he’s a loner who fights a lot yields a four for organization and orientation. Memory impairment earned him a four, and the fact that he says he doesn’t need help for mental illness gave him a four in that category.

“If he had said, ‘I need mental health help,’ he would have scored lower,” Carr says.

But here’s the answer that has Carr thinking about this client’s fitness as a Bud Clark Commons tenant: When asked how he deals with conflict, the man said he has military training and would either “walk away or end it quick by attacking them.”

In contrast, a number of those doing the assessing say a theme among high scorers was meekness, which translates to an inability to take care of basic needs such as hygiene.

“ ‘Presents as helpless’ was a term I saw over and over,” says Central City Concern’s Moehling.

The Bud Clark Commons mix could be volatile.

“They’ll score high on the assessment but not be the best choices to be tenants,” Carr says. “But that’s kind of why they’re homeless. It’s not like (the housing authority) is trying to build a community that will work well together.”

Carr and others say the highest scorers are almost all what physicians call tri-morbid — suffering chronic physical diseases, mental illness and substance abuse.

Quantifying the despair

Nonprofit Outside In has given vulnerability assessments to about 100 homeless people, many of them among Portland’s population of young street people. Lacey McCarley, the client access administrator, says it was sometimes hard to follow the assessment rules for the commons and still provide an accurate measure of vulnerability.

Administrators were told to grade people on their answers to the questions, not on what the administrators might know or learn on their own. McCarley says some of the people she tested had been Outside In clients for years. Because of that, she knew the extent of some of their health issues. If the client didn’t talk about those health issues, they were left off the assessment.

But sometimes, McCarley couldn’t help but plug her own observations into the assessments. For instance, one of the assessment’s questions is: “Do you know where to go for showers and laundry and how often do you go?”

McCarley says some clients told her they showered and washed their clothes regularly, but she’d be sitting there with them in a small room, and the smell of their bodies and the state of their clothes made it clear they probably hadn’t done either in a month. She would add notes to that effect on the assessment page.

“It’s people lives. It can’t just be a number,” McCarley says.

But that’s exactly what the vulnerability assessment is: quantifying the despair of Portland’s most down and out.

One of the assessment’s questions asks whether a client has friends or family with whom they are in contact. Another asks, “Have you ever been in a relationship that made you scared or fearful?”

Men, McCarley says, nearly always answered no to the second. “Some people just didn’t want to show any weakness because that’s how they survive on the street,” she says.

Similar, McCarley says, were answers to questions about drug abuse. A number of clients didn’t want to admit the extent of their addiction. One man insisted he hadn’t used drugs or alcohol in weeks, but kept nodding off during the assessment, clearly having used that morning.

McCarley says the commons will be full of intravenous drug users, who generally scored high. Designated as “wet housing,” the commons will allow tenants to drink in the building and, to some extent, use illegal drugs there as well. Not allowing that, housing officials say, would mean most would soon be back on the street.

Still, Rachael Duke, in charge of running the commons for the housing authority, says the extra staff assigned to the commons will make it clear to tenants that illegal drugs in the building’s shared spaces will not be tolerated, nor will selling drugs in the building. The building’s leases will allow monthly inspections.

“We’re going to be in their faces more here than we are in any other communities,” Duke says.
As for how this community of oddly matched residents are going to get along with each other, nobody really knows.

“The housing authority and the city are taking real leaps of faith,” says Stacy Borke, housing and support services director of Old Town homeless social services provider Transition Projects Inc.

Getting an apartment could be bad for health

Taking the 130 most vulnerable of Portland’s homeless people and placing them into one apartment building is experimental on any number of levels. Among concerns raised by skeptics is turnover.

Tenants of the new Bud Clark Commons are being given rent-free apartments in the new LEED-certified building for as long as they abide by the building’s rules. Some say that means most tenants will stay for life.

But Rachael Duke, who will be in charge of housing operations for the project, predicts there will be a higher rate of tenant turnover than many might expect. Duke and others say they have observed a phenomenon that takes place with some longtime homeless people who are placed into apartments: They die.

Most of the tenants at the commons suffer from chronic diseases such as hepatitis C and cirrhosis, so it’s natural that some will be close to death and might expire within a few months of moving into the apartments. But the phenomenon Duke describes is something different. She says it is as if some of the chronically homeless, who battled to stay alive on the street, let down their physical and mental guard once comfortable in their apartments and succumb to their diseases.

A number of local physicians consulted by the Tribune say they don’t know of any medical study substantiating what Duke and other housing officials say they have observed. But John Song, an internist and associate professor at the Center for Bioethics at the University of Minnesota who has studied end-of-life issues with the homeless, says what Duke is describing might be real.

Occasionally, he says, too much medical care too soon can have a negative effect.

For example, Song says, some AIDS patients who have not been taking their medications regularly develop suppressed immune systems that can’t handle the regular dosage of medications once they begin adhering to a doctor’s orders. They develop Immune Reconstitution Syndrome, in which their immune systems come back so strongly they begin attacking healthy tissue.

Homeless people with end-stage liver or kidney disease also can have escalating problems once they begin eating regular meals with richer foods such as red meat. They find they can’t digest properly and their kidneys and livers are unable to rid their bodies of toxins.

“I don’t think it’s a stretch to say probably the people they are observing, all of a sudden they’re getting fully nourished and all the care they need, and that might actually be deleterious to their health if it happens too quickly,” Song says.