Tufts University

Out in the World

Homeless women and children are living on the streets of our country in larger numbers than at any time since the Great Depression, and Dr. Ellen Bassuk is trying to do something about it.

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In the early 1980s, Ellen Bassuk (M'68) ventured out to Long Island Shelter, located at the windswept northern end of Boston Harbor, to get a first-hand look at a troubling social phenomenon.

Homelessness was all over the news in those days. Bassuk recently had been appointed head of a task force on the subject by Massachusetts Gov. Michael Dukakis, who had made an election promise to solve the problem of homelessness in the state. Her stellar credentials may have gotten her the high-profile appointment, but "I didn't really know about it," she concedes. "I had no clue what homelessness looked like out in the world."

Life in a large urban hospital really hadn't prepared Bassuk very well for what was to come. As head of psychiatric emergency services at Beth Israel, she was well-versed in caring for homeless people—mostly single men—who drifted in off the street in larger and larger numbers beginning in the mid-1970s, prompted by the wholesale trend toward "deinstitutionalization" of the mentally ill nationwide.

"These men were sick in complicated ways," Bassuk recalls. "We would keep them around the hospital for a while, sometimes sticking them in an empty room temporarily and then sending them back out onto the street." She describes there being almost "a revolving door" in operation between Beth Israel and Massachusetts Mental Health Center down the block. "My job became almost unethical," she says. "Here were people with a whole host of problems, and we had no place to send them."

On her rounds at the shelter that day, she encountered a teenage couple sitting on a bench with a cardboard box balanced across their knees. In the box lay a week-old baby. "What are these people doing here?" she wondered. Although she couldn't have known it, Bassuk was witnessing the bellwether of an emerging social crisis that would consume her passions for the next 20 years. Family homelessness would prove both more dire and less visible than the first wave of American homelessness.

This time around, women and children would be involved in huge numbers. This time around, the causes would be more complex. This time around, fewer people would notice or care.

Lost and invisible

In 1984, perhaps one percent of the homeless population were family members—that is, consisting of one or both parents and children living together on the street. Now, two decades later, an estimated 40 percent of homeless people fit the family category, which is the fastest-growing segment of the homeless population. Requests for emergency shelter by families have increased every year since 1985, with an average increase of 20 percent in 2002.

On any given day, approximately 800,000 people are homeless in the United States, including 200,000 children in homeless families. In a year's time, at least 1.35 million children are homeless, eking out a life in shelters and abandoned cars, ragged, often sick and dirty, panhandling and begging for food. As Bassuk notes, with fine understatement, "You don't want children in the midst of this scary picture."

"[Homelessness is] a mirror of social biases or of your pariahs as a society, to see who's left out, who's considered expendable. It's amazing to me that it's women and children."

— Ellen Bassuk

What has happened to put the greatest number of women and children on American streets since the Great Depression? Bassuk blames a convergence of social and political trends that began in the early 1980s. Ronald Reagan's two-term presidency reduced funding for public assistance of many kinds, including welfare and job-training programs; the pool of affordable housing shrank relative to average income; the gap between rich and poor widened, with an attendant loss of health insurance coverage for millions of Americans; and changing national demographics created more female heads of households than ever before.

Because women generally earn less than men, the gender shift alone—for reasons that are not fully understood, the percentage of women heading households quadrupled within a matter of a few years—dangerously loaded the dice against families struggling to retain their homes. In economic terms, women start with less and end with less than men. They tend to have a lower educational profile than their male counterparts. Fewer jobs are open to them, and the earnings to be had in a typical entry-level female job are less likely to cover the bills.

Carrying multiple, overlapping responsibilities doesn't help. Bassuk sketches the predicament of a woman who's working at McDonald's but has an asthmatic son at home. If she dashes home at noon to check on him, she's apt to lose her job. Once she loses her job, she may not be able to pay the next month's rent. If she can't pay the next month's rent, she may find herself living—with her asthmatic son, of course—out on the street. Calamity waits just around the corner, one false step away.

Homelessness is "a mirror of social biases," says Bassuk, "or of your pariahs as a society, to see who's left out, who's considered expendable. It's amazing to me that it's women and children."

More than 85 percent of homeless families are now headed by single mothers. The average homeless family is a 27-year-old woman with two children, 40 percent of whom are younger than 6. Why don't we see them? For the most part, the homeless are housed in urban shelters run by cities and churches, Bassuk explains. They are largely gone from the streets, compared with 30 years ago.

A second factor in their invisibility is a near-complete lack of media interest in their plight. "People don't want to go near it," Bassuk says of homelessness. "The problem was originally seen as a transient crisis. You know: If we threw enough money at it, it would go away. Well, that hasn't happened." Nothing scares the press more than a complex, downbeat and seemingly intractable issue.

The housing crunch

With its roaring wind and rain, Hurricane Katrina brought a change. Terrible images of thousands of Gulf Coast residents clinging to rooftops for dear life, their homes under water or reduced to hollowed-out shells, were images that seared themselves into the national consciousness. Suddenly homelessness and the social conditions that lay behind it were real again. "There's a Third World in this country," says Bassuk, who estimates that, post-Katrina, the number of homeless children in the United States may have doubled overnight.

"There has always been a tension in our thinking between 'deserving' and 'undeserving' poor. This is a Horatio Alger country, where you are expected to pull yourself up by your bootstraps."

— Ellen Bassuk

Bassuk is careful to draw a distinction between "displaced" and "homeless" citizens. Most of those New Orleans residents eventually will find homes again, she notes. For the truly homeless, the struggle will continue. The irony is that because the Katrina homeless are viewed culturally as "deserving" poor—they are, after all, victims of a natural disaster that everyone witnessed—they draw sympathy and concern in a way not applicable to the ordinary legions of homeless who are homeless for reasons that are less easily understood.

"There has always been a tension in our thinking between 'deserving' and 'undeserving' poor," Bassuk notes. "This is a Horatio Alger country, where you are expected to pull yourself up by your bootstraps." The mythologies of personal achievement within our nation have played a complicating role in our collective response, she seems to say.

Homelessness is more than the wreckage of a storm. It is American poverty expressed in terms of a housing crunch. "When housing supply is outstripped by demand," Bassuk observed recently, "the competition for a home is like a game of musical chairs. The music stops, and someone is left standing because there are more players than empty chairs. The people left standing in the housing game are those with the fewest financial and social resources."

Recent surges in average rent levels nationwide have put housing out of reach for many Americans. Currently, residents in 40 of the 50 states face a "housing wage"—the wage that a full-time worker must earn to afford fair market rent—of more than twice the prevailing minimum wage. This means that in most states, a household cannot afford a two-bedroom home even with two minimum wage-earners working 40 hours a week, 52 weeks a year.

Better, smarter moves

Raised by parents who, as middle-class Jews in Queens, N.Y., were always socially aware—they were involved in a school for autistic kids—Bassuk absorbed a core system of values that hasn't left her. She has always been committed to making a difference in the lives of others and on a progressively larger scale. After her glimpse of the baby in the cardboard box at the Long Island Shelter, she received a research grant to study the problem of homelessness. Bassuk next left her plum job at Beth Israel and applied for a fellowship at Radcliffe's Bunting Institute, where she began to publish her findings and make a name for herself in the field.

In 1987, out of the blue, she got a call from the editor of Better Homes and Gardens, the home decorating magazine, which had decided it wanted to help the homeless if it could. The eventual fruit of that conversation was the establishment, the following year, of the Better Homes Fund, a nonprofit organization whose mission was to raise money and public awareness about the issue of homelessness. In 2002, the magazine and Bassuk's organization parted ways, and the fund recast itself as the National Center on Family Homelessness, which was a better, more comprehensible name all the way around.

The National Center's 20-person staff has positioned itself at the forefront of research, program design, best practices, training and advocacy on issues of family homelessness at sites across the country. "We're one of the few [homeless] groups that is knowledge-based," Bassuk notes. All of the National Center's work builds on what has been gleaned through extensive scholarship, but it doesn't end there. Staffers travel constantly to spread the wealth. They conduct regional workshops and advise local agencies. They testify before government agencies and evaluate the merits of this or that tactic. They feed their hard-earned conclusions back to practitioners and policymakers so that the next moves in the effort are better, smarter.

As one example, last year the National Center led a federal study in 11 American cities with the goal of taking 1,200 chronically homeless individuals off the streets, housing them and keeping them housed. So far, 700 have been successfully moved into homes. "It's a small number, but it's a beginning," Bassuk says with justifiable pride. "A lot of people didn't believe you could do it."


A mom and her two kids relocated to a Cambridge apartment from a Waltham shelter.

Passion plus intellect

Nor was this an isolated case. Gary Morse, executive director of Community Alternatives, a mental health organization in St. Louis that serves between 500 and 1,000 homeless people annually, has been working with Bassuk for the past seven years. Morse says he knew of Bassuk by reputation long before he met her. "Ellen has done landmark, pioneering work in the area of homelessness for more than 20 years," he remarks. "She, more than anyone, has brought the problem of homeless women and children to our collective attention."

Studying homelessness is complicated by the mobility of the target population, Morse points out. It's hard to track homeless people in any systematic way. Despite this challenge, Bassuk helped his organization structure the investigation and data analysis of 180 local homeless women and their children, with the goal of determining what services and treatments made the most sense, both for them and their providers. Community Alternatives is now analyzing the data from that study.

"One thing that's remarkable about Ellen is the very different hats that she's worn," Morse comments. "She's a researcher; she has her clinical perspective, and then she's also made this leap into being an effective policy spokesperson and helping to raise the consciousness of the nation. It's remarkable to do all three things."

Jennifer Ho is equally impressed. She is executive director of the Hearth Connection, an agency that recently conducted a five-year study of 650 homeless people in and around Minneapolis. Bassuk led the research team, which is evaluating the relative costs and impact of a variety of approaches to addressing homelessness. (The study is due to be completed within the next year.) Bassuk also appeared at a number of community forums to explain the study's findings to the general public.

"She was the 'public face' for us in Minnesota," says Ho. "She was effective in a lot of different ways. Ellen was able to tap her enormous personal knowledge as well as her understanding of the issue on a national scale. No one is more passionate on this issue than she is, but that passion is beautifully complemented by her intellect."

Bassuk brought a distinctive tough-minded rigor to the Hearth Connection application process that set her apart from other would-be consultants, according to Ho. "With some candidates, we felt like they already knew what they were going to say at the end of the study," she relates. "With Ellen and her group, we didn't know what we'd get." Scholarship is one word for the difference.

Looking fine at first

When you set about investigating a field as bleak and unsparing as adult homelessness, you need to prepare yourself for grim news, of course. That comes with the territory. But the more you learn about children on the street, the more you feel like crying.

Children—and remember, two out of five of these kids are younger than six years old—bear the brunt of homelessness to a cruel degree. According to statistics gathered by the National Center, homeless children get sick twice as often as other children. They have twice as many ear infections, four times as many asthma attacks, five times more stomach attacks, six times as many speech problems and twice as many hospitalizations as children with a stable home life.

The psychological damage is equally real. "Homeless kids start out looking fine," says Bassuk. "Then by age two, the difficulties start. By the age of eight, one in three of these kids has a mental disorder." Her organization has found that more than 20 percent of homeless preschoolers have emotional problems serious enough to require professional care. Nearly half of homeless school-age children exhibit problems such as anxiety, depression or withdrawal, compared to 18 percent of other children.

"From a medical point of view, all this is completely preventable—that's what's so horrible about it," says Bassuk

If they're in school, homeless kids must struggle against great odds to achieve. They are four times as likely to have developmental delays, twice as likely to have learning disabilities and twice as likely to repeat a grade as other kids. Surprisingly, fully 87 percent of school-age children are enrolled in school, although only about 77 percent manage to attend class regularly. Here again, the institutional barriers are daunting. Some schools don't allow children to register without school and medical records. Others will not enroll children without a home address, and there is often no transportation available between shelters and the school.

The missing nets

At times, language can cheat us of meaning. The word "homeless," framed as it is in terms of physical structure, spins by too fast for us to comprehend fully the layers of its implications. It is quick and dry, like an eviction notice.

But consider all that is lost when you do not have a fixed address. "Home is the center of our emotional lives," Bassuk and two fellow authors wrote in an essay a few years ago. "Home can be safety, warm hugs, big smiles, laughter and leisurely breakfasts with big pots of coffee. It can be the sound of a spouse singing in the shower, of a son or daughter squealing in delight. It can be a regular seat at the kitchen table; family and family secrets; privacy; comfort when the world feels unpredictable and one feels unsteady; a place where one can be alone without feeling lonely; can cry, yell and scream in sadness or frustration. It can be one's apartment, a best friend's porch and a mother's house."


A mother and daughter walk the hall of the shelter in Waltham.

Home also means the community of which you are a part—your relatives, your neighbors, your church, your circle of friends. These are the informal networks that can bail us out when our car breaks down or prop us up when we get divorced or lose our jobs. They constitute a sort of economic safety net, or series of nets, for those inevitable times when we stumble or fall, an accrued social equity that we can tap in an emergency.

An in-depth study of homelessness in Worcester, Mass., that Bassuk's organization conducted in the 1990s found that people who were homeless in that city had burned through whatever safety nets they might have had. And it didn't take them long. Most homeless said they had fewer than five people whom they could count on for financial and emotional support. "Eighty-nine percent of women in shelters had 'doubled-up' with friends and family before becoming homeless; this process typically strains and erodes existing supports," the study noted.

An intake worker at a California shelter laid out the process this way: "Usually a woman comes in with her kids; she can't make ends meet on her minimum-wage job; she or one of her kids gets sick; she gets fired for missing too much work; can't pay the rent; gets evicted; moves in with her mother; they fight; then her boyfriend; they fight, and when there is no one left to move in with and nothing left to move, she comes here."

Now imagine dealing with all this while you're ill. The Worcester study found that "although most women in our study were only in their mid-to-late 20s, a disproportionate number suffered from acute medical problems or chronic health conditions, with particularly high rates of asthma, anemia and ulcers." Homeless women in Worcester smoked three times as much as women in general.

Battle without end

Situated in her glass-walled office amid the treetops of Newton, Mass., on a rainy autumn day, Bassuk carries measureless pain lightly. If anything, she is worried about the children most. She cites a recent NPR report on the aftermath of Katrina, which portrayed Gulf Coast children back in school who were crying at their desks. "A lot of kids are not going to recover from this," she says levelly.

Her organization just got a one-year grant from the Kellogg Foundation to train relief workers in Mississippi, Louisiana, Arkansas and Texas about post-traumatic stress disorder and to act as a resource to them as the regional recovery proceeds. There are numberless homes and lives to rebuild, numberless permutations of damage to absorb. Hers may be a battle without end, but in an odd way, the satisfaction that Bassuk derives from her work is closely linked to its apparent hopelessness.

"Some people regain their homes; some kids grow up OK," she points out. "I must admit, we can't solve homelessness by doing what we do. But we're trying."

Profile written by Bruce Morgan

Bruce Morgan is the editor of Tufts Medicine - the magazine of the Tufts School of Medicine. The complete version of this story first appeared in the Winter 2006 issue. It ran online on Jan. 23, 2006.

Homepage image: A child plays in a typical room at the Waltham shelter.

Photos by Melody Ko, University Photographer