In 2010, 6 years after the city of New York launched its 5-year plan to end homelessness, there were more homeless people in the city than ever before. An increasing number of these homeless people were older adults. Peter's Place, a drop-in center dedicated to serving homeless older adults, was closed, and its population scattered among the remaining drop-in centers and shelters. Faced with severe budget cuts, the city terminated its contracts to provide medical services in shelters. The shelter population has suffered disproportionately from austerity measures.
Homeless older adults are faced with the same problems as their younger counterparts, but their travails are compounded by physical frailties and vulnerability to predators. Housing options are limited, and their expectations for the future bleak. There is a movement in the United States to keep older adults in their homes rather than placing them in nursing homes. However, what would people do if they have no homes? Four case studies are presented about homeless older adults in New York City to illustrate the complexity of their situations. Names and details have been changed to protect the identities of those involved.
CASE A: DENNIS
I met Dennis in 2006, while working as a nurse practitioner at a clinic in the shelter where he was brought by the street Outreach team. He had spent 10 years on the steps of a church in midtown Manhattan. All previous attempts to locate him in a shelter had failed. He is now in a small shelter, dedicated to serving people with persistent mental illness. He had numerous medical problems, which were addressed in the shelter's clinic. The shelter also provided a psychiatrist a few days a week and and a nurse on call for 16 hours a day. Within a week, Dennis was medically stable, taking medication, and settling down in the shelter.
I was born in New York City in 1924 to an affectionate family. My father played the violin beautifully. He came from Russia in 1917 during the revolution. On weekends, he would play at a Russian place on 2nd Avenue. He was 32 when he died. He punctured his finger and within 5 days, he was dead of poisoning. I was 5. We moved in with grandma for 9 years. She loved everyone, and everyone loved her. My mother was 23 when my father died. I had a sister, Rosie, a year and a half older than me. She died in 1987. We were like twins. We moved up to Washington Heights. Nothing lasts for long. Then we moved to Manhattan.
When I was 4 years old, I won a national contest for beauty and talent. In the finals, they lined up about 20 of us. I'll never forget those lights; boy, they were hot. You couldn't see a thing. And the noise, with people clapping and cheering-it scared the heck out of me. I took a bow; my head almost touched the stage. Real dramatic. I was in "The Old Gang Comedy" for about a year. Later it was called "The Little Rascals." I was the original Weezer. It was done in a studio in New Jersey. In 1929, it moved to Hollywood. We didn't go along.
I was drafted into the army at 18. I went to summer camp when I was a little boy so the whole army routine was not unusual; nor difficult to be away from home. First, I was a quartermaster, up till that time they were drafting people 21-42 years old. In 1943, they started drafting from 18-38. D-day came. We got orders to ship overseas. Three days after my 20th birthday, we set sail from Staten Island. There was a submarine out there. I landed in Scotland and came to Stonehenge in South England, then set sail for France- from Utah Beach to the gates of Berlin. By that time, I was a tank gunner. I wasn't stationed anywhere, just moving around.
After the war, I went to school, became an architect. I never took the licensing exam so I worked as a draftsman for 30 years in New York, Westchester County, and New Hampshire. That's where I met my last wife. I was invited to do the city hall for the town of Laconia. After the birth of my son Steven, she took off with him and my other son, Jeffrey. I don't know what happened to them; they're 40 or 41 now.
That was my third marriage. My first wife, Jacqueline, I married in France. That lasted about 20 minutes. She had other priorities. I was with my second wife for 7 years. Never marry a girl who grew up sleeping in the same bed as her grandmother.
I was in a hospital for a while, then lived in hotels. I spent $30,000 living in hotels and the YMCA. A hotel is $100 a night, the YMCA $58. Then I became homeless and slept at a church, on the steps. I'd buy my own food. There was a nice Italian restaurant across the street that would send food over, even wine. People would bring coffee. Generally, people are very good. It wasn't bad. I'm an old soldier so I knew how to survive. My cousin in homeless outreach has a van circling. He picked me up. This is better than a usual shelter. I don't care to be in the shelters with troublemakers. I had bad experiences in the shelters.
I'm 83 years old, retired. I want a place to live. I go to church regularly; they have activities there and whatnot. The only person I'm in contact with is Irene, my niece. She lives in Las Vegas. We correspond regularly.
It is a commonly held misconception that homeless people choose to be homeless because they "like it." In more than 10 years of working with homeless people in various settings, I have met no one who likes to be homeless. Dennis refused to stay in shelters because he felt vulnerable there and had good reason to feel this way. Some shelters had more than 2,000 people in them, with more than 60% of the population coming directly from New York's prison system. As one resident in a shelter described it, "there are only three kinds of people here-predators, victims, and those with the good sense to get the hell out of here as fast as possible." Our health care for the homeless program had a clinic on Ward's Island, at the Keener clinic, where staff regularly treated residents who were assaulted and robbed by other residents. Dennis, like many other homeless people, felt safer on the steps of a church than in such a shelter. Because of his age and mental illness, he was particularly vulnerable.
There are other common reasons why people refuse to reside in shelters. Sometimes they balk at giving up any portion of their meager income (e.g., if they are on a limited Social Security Income, usually $750 a month) or object to shelter rules, such as curfews and "being treated like children."
CASE B: Robert
Robert spent 2 years in a drop-in center where residents sleep in chairs while waiting for a placement in housing. When I met him, he had hypertension, with a blood pressure of 220/110. He had suffered at least two strokes and had weakness in his right side and slurred speech. His legs were swollen from sleeping in a chair. He was depressed and avoided encounters with "the system," which he had difficulty negotiating because of his inability to read and write and his slurred speech.
I was born in Tennessee in 1952. My family was all right. My father passed away when I was 53. My mother is still alive, down south with my sister. She got Alzheimer's. I got two more brothers. Frank is here in the shelter. My brother James lives in the projects. They both got their own mind. You tell James that he wrong; he know he wrong, but he can prove that he right.
I didn't get to know my father. He was strict. He worked for a moving company. My mother, she was great, she was proud of us. She worked very dirty in a chicken house.
My sisters took care of us. I was a third in row. I came to NY when I was about 7. My mother got all fed up and moved us all here. We lived in my grandmother's house, on Staten Island. Everything was everything. We got along good. I got to the eighth grade.
I worked in the kitchen at South Beach Psychiatric center for 13 years. I got laid off; they merged with another hospital. Some people had more years than I did. That was 1995. So I got off the book job for a trucking company, unloading. I did that for 5 years.
My mother moved down south. I hooked up with Shirley. We rented a place but had no money to pay for it. We were at my brother's house for 2 months. Then we came to the drop-in center. It was nice. You got to do what you get told. I only got into one argument. Lot of noise and arguing there. People fighting. I was there 2 years.
So far, my life is good. Things are up and down. Been with Shirley for 7 years. I got food in my house. Shirley had four bypasses. We was lovers but I couldn't take it. She was using drugs so I said, "You do what you got to do and I do what I got to do." My SSD [Social Security Disability income] came in. Linda and me looked for an apartment [SSD provides a monthly income of about $1,000]. Paying $750 a month; also electric, gas, cable.
I like to sit down and watch TV. That's what I like to do.
My Medicaid got cut off 'cause I got SSD. They said I make too much money. I went to Bayley Seton (a psychiatric hospital) see a doctor there so he could give me pills for depression. I had to pay over the counter, $50 for medication.
When first seen in the drop-in center, Robert had no Medicaid insurance coverage. He would apply for and get Medicaid, after a 45-day wait, only to see it cut off again, forcing him to reapply and wait for another 45 days to be reinstated. There are several infractions that result in Medicaid being cut off, such as missing an appointment to a work program mandated by public assistance. Medical insurance is treated as a reward for compliance. Often the mail does not reach the client or, as in this case, Robert did not understand what was expected of him or was too depressed to do anything about it.
When Robert received disability income of $1,000 a month, his Medicaid was again cut off. He was told he now earned too much for Medicaid but qualified for Medicare. There was, however, a slight glitch-he would only be eligible for Medicare in 2 years. For the next 2 years, Robert's medication and medical care were provided by the nurse practitioner at the on-site clinic. Despite the involvement of his shelter caseworker, shelter manager, nurse practitioner, a social worker, physician and outreach worker, countless letters, and phone calls, Robert had to wait 2 years for Medicare. He made another mistake. Tired, after 2 years in a chair and of waiting for an apartment, he found his own place for $750 a month from a slum landlord and moved out of the shelter. Now he had $250, after rent, to pay for gas, water, electricity, TV cable, cell phone, food, transportation, and medication (the medication alone was $150 a month). He was no longer homeless so did not qualify for a rent subsidy or assistance by a caseworker. To qualify for assistance, he would have to become homeless again. He considered walking out of his apartment and returning to the drop-in center but could not face another lengthy stay in this setting.
CASE C: CHARLES
Charles was referred to the shelter's clinic shortly after he was discharged from a local hospital. He was depressed and suffered from hypertension.
I was born in New Jersey in July 1939. My father was Hungarian, my mother Polish. They had a little convenience store in Carteret. I am an only child. I was raised a Catholic, a religious, and spiritual person. I was sent to St. Joseph's, a private school. It was determined I should go to a seminary outside Chicago, where Andrew Greeley was the first director. I chose not to do that. I was trained as a classical pianist from age 4. Almost went to Julliard but chose to play in cafes and bar rooms, making a living playing in New Jersey, from down the shore, to the Adirondacks and Borscht Belt.
In school, I was called a dunce, a dullard, because of a childhood head injury. I found out later, when I was 45, that I had ADD, and was bipolar. This was more an asset than a liability: It gave me piano playing skills and an excellent memory. I was a late bloomer. I made dean's list in college, at Farleigh Dickinson, graduating with a degree in mathematics. I did a graduate degree in applied mathematics and operations research. I had my own software company in college.
For the best part of my career, I was a White House advisor for 3 years at the Environmental Protection Agency under President Nixon. Our job was to survey the nation's sewage treatment. The standing joke at that time [1973] was that if everyone in New York flushed his toilet at the same time, the Hudson River would rise 6 inches. There were no treatments, just a big pipe that went to a river or ocean carrying the sewage, including hospital waste.
It was an interesting time to be in Washington. Over 1,500 of us were let go. I went to Quantum Science Corporation in New York. My boss for 3 years was Dr. Charles Townes, a Nobel laureate.
I am writing articles and two books, including a book called Street Life, A Genius in the Dark. It's my life since my girlfriend and I broke up in Los Angeles, about how I survived life on the streets of LA.
My first wife was Carolyn. We had three beautiful children. They are all doing well. They're angry with me since I had my mother cremated. My son, Tommy, is a Jehovah's Witness. He thinks that my mother cannot come back to a body. My friend Rodney at St. Peter's church says, "God will find your mother a body more beautiful than she had." So I'm not worried. Carolyn and I broke up after 9 years. It was a very stressful marriage. She tried to commit suicide several times. She went back to her mother and married a millionaire.
I was with my second wife, Victoria, for 13 years. We had no children. She was a vice president of Methuen publishing company. She was fired and our fathers died in the same year. Our marriage dissolved with these stresses. We imploded on each other.
I had a girlfriend, Barbara, for 10 years in California. She was a faculty member at the University of Southern California. We keep contact. Her children thought I was going to spend their inheritance. I taught there for 5 years. When Barbara and I split up, I saw my belongings piled outside the driveway. Luckily, I had a little income, $1,200 a month in social security, and my faculty card. I checked into the faculty club at Cal Tech. Money was running out, so I found shelters in Los Angeles. It was horrendous. We saw a few overdoses a week, knifings, and several murders. I got to know some very fine people who helped me. I gave some of my income away. You meet people; if they need $5.00, you give it out.
I had an apartment with a friend and her son in Manhattan. One day, I gave them my $650 rent and the son pushed me up against the kitchen cabinets, banging my head. He told me to get out. The first night I came to this shelter and collapsed on the floor. My blood pressure was over 200. They took me to the hospital. I came back to the shelter the next day.
I lost a lot of personal property but I'm content living on $1,200 income. I have been approved for housing from the city. I'm going to get an apartment, set up a home, and work on my books.
I have to be very careful. I get pulled into the vortex. The depressions usually come the time of year my father died. I take care in the winter when I can be very down. I am not suicidal, but I get roller coaster swings in mood and energy. My CT scan shows a fracture in the right frontal lobe. It had made me slow when I was a kid but I'm fine.
I drink moderately, maybe self-medicating. It helps me calm down, especially at night to go to sleep. Ritalin helps me focus. Focus in the shelter is tough, so I get to the library, ride the ferry, go to the park, read, and write. I find the shelter similar to other communities I've been to in LA. People on their medications, trying to do the best they can. People off their meds. People who have done prison time. And the obvious ones, with their egos and spontaneous outbursts. I try to not react, just stand back and look. My friend Alfred has a difficult time with his heart and anxiety. I think I've been good for him as he's been good for me. He's been 15 years sober. I help him with his sobriety, and he helps me with balance. I've helped him with a little bit of money for medications.
I look on my future as any person of my age. I enjoy every sunrise and sunset. I walk 10 kilometers a day. I have a new girlfriend. We are not intimate but we have lunch on occasion. I'm practicing my piano, working on my book. The number of homeless in NY is grossly undercounted. With the cost cuts that are going on, it is not going to get better. People do not consider us real humans. We are spineless, boneless drunkards who have no willpower. This is not true. We have some fine people here. A friend here, a lady, who I'm tutoring in mathematics, lost her home in a fire. Another fellow is from Liberia. I'm helping him with his high school diploma, teaching him algebra and English. I'm doing this pro bono. I do this just because I believe if God calls you to do good work, you do it. I don't need the money.
I am now an Episcopalian and borderline Buddhist. I am 72 going on 27. There are some older people here, some in wheelchairs. I have a little arthritis. One man here has a replaced knee. Other people use walkers and canes. They have more problems than me. For this I am really grateful. I see other people driving around in power wheelchairs, pushing their stuff in baby carriages. They have a hard time even getting off busses, finding food, and places to spend the day when shelters are not open.
My hearing is good. I have glasses for reading at night. I have a reading lamp that I take to St. Phillips so that if the lights go out at 10:30, I can still read. [Every evening, at 8:30, people in the drop-in shelter are bused to church basements to sleep. They are awoken at 5 a.m. to be transported back to the drop-in.] I'm trying to maintain a good diet; I take my vitamins and get a lot of fresh air. It works for me. Since my girlfriend and I broke up, I lost 20 pounds in 2 months. I think I can get that back. My blood pressure is elevated. Other than that, I am happy. Life is good.
Whenever I see Charles, I am struck by his intellect, elegance, and spirit. He will, however, always need at least minimal support to maintain his equilibrium and avoid another downward spiral. Regular home visits by a nurse might be enough to sustain him in an apartment, but he has Medicare insurance, which does not cover such visits. A program to fund home visits for mentally ill people was recently cut. I hope that Charles will maintain his relationship with his primary care provider and psychiatrist, relationships that were set up while he was in the shelter.
CASE D: JOSEPH
Joseph was brought to a shelter by the Outreach team. He was confused and could not go more than a few blocks from the shelter without getting lost. Every few days, he would ask for money-the shelter kept the residents' checks to make sure that some of their income was saved for their housing-and would use some of the money for alcohol although this was a "clean and sober" facility. After a comprehensive psychiatric and medical evaluation, it was determined that he was not mentally ill-he suffered from dementia due to alcohol abuse.
My mother name, Maggy. Father name, William. No sisters or brothers. We were in South Carolina state, a place they call Sheldon. My parents used to labor, you understand. My father was a short, real dark person. He used to drink liquor a lot. Something had to be bothering him. He used to drink that corn liquor. And that doesn't have any proof. They just make it; and you want it, you get it. I believe it was proofless. There was some strength in that corn liquor back then in the days.
My mother, she always smiling, talk to you. With everything she say, "O, Lord." She was a nice person. Everybody care for her. She used to help people without them asking. I just don't believe he was my natural father. He used to drink that corn liquor. I mean, as he wake up, he knock himself out. I don't know how he worked. He just had to have liquor, for a partner, a friend.
I was born in 1941. In school, the teacher liked me 'cause I used to listen. That's one thing my mother told me, definitely to pay attention. She really want me to finish high school. The teacher would ask me to draw or write my ABC's. I would take my time. She come pat me. Her name was Alice Major. I never forget her name. She was short, dark skinned, always a smile on her face. She used to talk to the parents, find out the situation. She was a beautiful lady. She was a spunky though. She had a switch, before the days of the long ruler. She used to go outside and get a switch.
During that time, things was terrible. My mom didn't have no education. She used to work on the farm. Come in late in the nighttime, go, and fix the food. She loved fixing food. If she be too tired to prepare the food, she say, "Joseph, you have hot food in the morning, you gotta eat some sandwiches now." I say, "Okay mom." and listen to the radio. She finish the food, call me, always make me say my grace. Mom used to tell me "always listen to a grown person and don't disobey them." You got time to let people talk to you. She told me when she grew up, her parents used to whip her and beat her. I used to listen to my mom. I always want to be with my mom.
I started messing around with girls. Going to parties. I got it wrong. The first girl, she got pregnant. Momma cry and cry and say, "Joseph, you got plenty time to do that."
I came out of school in the 10th grade. My mom cried. I did "season job" from the 8th grade. You went from one state to another state to work for a month. It was a swampy place in Hartfield, Ohio, out in the country. Cold or hot, you had to work on your knees. The road was just as flat as this floor. To get the product, you have to get down there and get it. All three of us. Radishes, onions, things like that. The only person that be standing, be the people who come after you, box it up, crate it. You put it on a flat bed truck, and they take it to where they wash it, put it in baskets.
They had rows of small houses with everything in one room. I said to myself, "It wasn't my thing." My mom, her knees start bothering her. You have to kneel all the time.
The younger generation wasn't married till their middle ages. They just had children by this woman, leave, go to another woman. This girl, Shirley, the one that started me. . .she always look on me, laughing and smiling. The way she walk, step off, you know. We were living this side on a dirt road. She was living on the other side. We start talking. She gave me I could come over. So I went on over there. I was in my teens. She was in the 9th grade. That afternoon her grandmother was in the choir. I went on over. She start talking and laughing. I catch her eye, she smiling. She said, "why you sitting over there?" She sitting on the sofa. She said, "Don't you like to sit here, I want to get close to you. I like you." Things happened. That was the first time I had sexual intercourse. I come to find out she was pregnant. I was still going to school.
This girl had sisters and brothers, a mother and father. These things helped my son in his life. I never did get married. The children start coming. I never did stay around. I had two Josephs. I got Anthony, Carl, Patricia, Jacqueline, that's four, down there. There about six of those little kids, from five different mothers. They're grown now.
I came to New York in 1969. I was about 27. I didn't have a cent. I stayed with my uncle. Harlem Hospital was just coming up with the foundation. They wanted people to work. I fill out an application and take a test. Two weeks after, I got a mail; they said, "Come in." I took that job until I retired.
I was drinking since I was back in South Carolina. I grew up drinking. My son used to take my check. Mail used to stay with my son. I used to get my check then it stopped.
I was homeless about a year and change. It was cold. We lived under this overhang on 127th street, near Park Avenue. The van came around. The wind was blowing. We was cold. The guy said, "We can help get you on the road." My fingers were frostbitten, black. I said, "Okay where you going." He said there's a shelter place and it's better than being out here. They have a bed, a floor, and bathroom.
I been constantly thinking about my mom these past years (he cries). I remember the last time I went down see her. I think about my mom from last night to early this morning. Something went wrong.
This place is nice. I want to get my own place. My mother used to say "Joseph, get on with life, there ain't no place like home." I want to get a studio, fix it up the way I want it to be. Go to church. Last time I see the inside of a church was when she passed away, I went to the funeral. I just want my own place, to get myself together, be on my own. I never did like a crowd.
Joseph was in this shelter for 3 years. The average stay is about 8 months. No other shelter would take him. He suffered from alcohol- induced dementia. Physically, he was in excellent health. Nursing homes and adult homes would not accept someone who was drinking, although he was seldom drunk. Hospitals had a great deal of difficulty discharging people like Joseph. One patient on the acute rehabilitation unit of a New York hospital in the 1990s spent a year on the unit until he could be placed in the community. Nursing homes and adult homes would not take him as he had alcoholic dementia. He did not know where he was or why he was there.
Until 5 years ago, it was expected that people in the shelter first get sober and then proceed through a series of steps leading to housing. If they relapsed, they would start again at square one, something like the chutes and ladders game that sends you back to the beginning if you land on the wrong square. New York City has adopted a harm reduction model, in line with other cities. The focus is now on "housing first," regardless of substance abuse, a "harm reduction" approach. It was expected, and sometimes found, that people used less (drink and drugs) once they were housed and needed fewer services such as emergency rooms and detox. It is, from a purely economic viewpoint, cheaper to house people with appropriate support, than have them stay in the street or in a shelter. Although housed people tend to use less drink and drugs, there are clients who cannot succeed while they are drinking or using drugs. Some clients become violent and abusive when drunk, and others fail to fulfill the most basic requirements, such as showing up for public assistance appointments that are necessary to maintain housing subsidies. A harm reduction approach does not work for everyone. Joseph was eventually housed though he continued to drink.
CONCLUSION
Working with homeless people is labor intensive and difficult. The work is complicated by an erratic and confusing health care system that treats medical care as a reward for compliance rather than as a right. Even if the Medicaid threshold is raised, as proposed in the new federal health care legislation, application of eligibility will still vary from state to state, with obstacles and delays in obtaining insurance and care. It took 10 years to house Dennis and 2 years to obtain insurance for Lee, with enormous efforts by several people. The solution is simple but elusive; A universal, single-payer system that removes obstacle to care that are reinforced by vast, impenetrable, bureaucracies. Many of these people are mentally ill and will require support for the rest of their lives, if the cycle of homelessness is not to be repeated.
It is more cost-effective to provide care, where vulnerable people congregate and live, with care provided by teams of medical providers, nurses, social workers, substance abuse counselors, and Outreach workers. This approach, pioneered by St. Vincent's Hospital's Department of Community Medicine over the last 40 years, is now undermined by short-term budget considerations.
As to the four men discussed here, one is struck by their resilience and vitality. They are not ready to retire to nursing homes or adult homes, which do not want them in any case. We need to find new approaches; ones that look to small-scale supportive, congregate housing that supports the communities these people are part of and their participation in the life of these communities.
[Sidebar]
There is a movement in the United States to keep older adults in their homes rather than placing them in nursing homes. However, what would people do if they have no homes?
It is a commonly held misconception that homeless people choose to be homeless because they "like it."
I see other people driving around in power wheelchairs, pushing their stuff in baby carriages. They have a hard time even getting off busses, finding food, and places to spend the day when shelters are not open.
[Author Affiliation]
Ansell Horn, NP
[Author Affiliation]
Ansell Horn, NP, works as in New York city, for Lutheran Health Centers, Department of Community Medicine, an affiliate of Mount Sinai Hospital. He works as a Nurse Pracitioner in various homeless shelters, a program that was pioneered by Saint Vinvent's Hospital.
Correspondence regarding this article should be directed to Ansell Horn, NP, Mount Sinai Community Medicine, 36 Seventh Avenue, New York, NY 10011. E-mail: ansellhorn@gmail.com
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