- The social determinants of health, our living conditions, family life, poverty, homelessness, and other factors affect human health have emerged as key factors in understanding health outcomes.

Today's guest shines a critical light on the complexity of cases she sees every day in one major city's emergency room.

She's Dr. Maria Raven this week on Story of the Public Square.

(bright music) Hello, and welcome to Story in the Public Square where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G.Wayne Miller with a Providence Journal.

- This week we're joined by Dr. Maria Raven, a practicing Emergency Medicine physician and health services researcher at the University of California, San Francisco.

She joins us today from California.

Maria, thank you so much for being with us.

- Thank you so much for having me today.

I appreciate it.

- So you are among other things, co-director of the section of social emergency medicine and health equity.

I wanna hear what they do, but I also wanna understand a little bit better about what social emergency medicine is in the first place.

- Yeah, it's a great question.

When I started my residency at Bellevue and NYU in New York city, I sort of quickly came to realize a lot through my chair at the time, basically kind of the boss of our whole program, Dr. Goldfrank, that there was a lot of connection between people's social context, where they lived, what their job was, what their social support system was and how they accessed healthcare and basically just their overall health.

And taking care of emergency department patients really began to show me how much of healthcare and people's health status was actually not affected by what we did in the hospital.

And I also realized that in the emergency department, you sort of have a captive audience because lots of times people come there, they're waiting for things, they're waiting for test results, and you can actually learn a lot about them and some things they might need that doesn't specifically relate to what they're there for medically.

And so social emergency medicine is really taking the opportunity during an emergency department visit to explore people's social needs and what else they might need to help what's happening with their healthcare that's not actually medical care.

- This is about the social determinants of health, is that, am I useful the language right?

- Yeah, it is a lot about the social determinants of health.

Yeah, that's a term that people are probably more familiar with than social emergency medicine.

And social emergency medicine is sort of social determinants of health applied to the practice of emergency medicine and how we address those for our patients in the emergency department.

Because we see a lot of patients with very high social needs in the emergency department, maybe more than other medical settings and so it's really a great opportunity to address some of those.

- So obviously you practice social emergency medicine where you are.

Do you have any sense of other places, how widespread is this?

I mean, clearly this is an important initiative or an important way to deal with people who come in.

Can you give us an overview nationally or California or both actually?

- Yeah, I think in California, it's a pretty prevalent idea.

I think across the nation, it's a little bit variable.

Our specialty has been evolving.

So the specialty of emergency medicine, it's a relatively young specialty and I think there's sort of a couple different viewpoints.

One is that, we're here to treat patients for their medical emergencies and that's what's in our wheelhouse and we're there to address medical problems and that's what we went to medical school for and that's kind of it.

I think a much larger group of people, especially people coming up in the specialty trainees.

We have people that do fellowships in our emergency department and almost all of them are much more focused on social determinants of health and patient's social needs than used to be in the past.

So I think it's an evolving idea that's taking a lot more hold across our specialty and it's people that want to expand that practice or having sort of a larger voice.

- So talk about where you work.

If someone comes in to the ER and fits the criteria for what you're discussing here, what can be offered to this individual?

How does that work?

I mean, you obviously treat the health emergency immediately, but then there's counseling, there's referral.

What exactly is there and what are the resources?

Many of these I'm assuming are outside of the hospital system.

- Yeah, it's a great question and it varies a lot from emergency department to emergency department.

Obviously we're extremely busy as physicians and what really helps to enhance this practice is having people that are not physicians that can help us do some of this work.

So for example, at the emergency department where I am at UCSF, we have a really, really great group of social workers.

And within the group of social workers, we have some kind of specialty social workers.

So we have a social worker that kind of hones in our patients with severe mental illness and psychiatric needs.

We have a substance use navigator, and then we also have a psychiatric nurse practitioner.

And then we have case managers in the emergency department, we have now a physical therapist that's based in the emergency department and we have a special geriatrics team that can work with our geriatric patients who are at high risk to kind of really address their needs outside of the hospital to make sure that whatever they are they're met.

So they don't have to necessarily come back to the emergency department for certain things like a lack of home services or a lack of social support.

Sometimes caregivers get burnt out.

We offer buprenorphine starts for people that are coming in with substance issues and that sort of thing.

So we do a lot of different things.

One other thing I'll mention since that, it is a topic of this interview is that we obviously have a huge homelessness problem in San Francisco.

And so we do a lot of work in that regard also to try to help patients with homeless resources.

- So I wanted to explore exactly what you can do for members of the homeless community.

As I was googling to get ready for this, I came across a study that you and a couple of colleagues had put together about what happened if you provided semi or I guess it was permanent housing to homeless people in terms of their health outcomes.

So maybe explain that a little bit for us and help us understand what that homelessness does to somebody who needs healthcare?

- Right, so I think what it's really important to understand is it's extremely difficult to take care of your health if you don't have a place to live.

So it really depends kind of how sick somebody is and what kind of healthcare needs they have.

So for example, let's say someone has diabetes and they need insulin.

Well, insulin needs to be refrigerated.

And so if you don't have a home or even if you're in a shelter, or if you have other medications you take, you may not have anywhere to store those medications, your medications might get stolen.

So even that very, very basic thing of just kind of holding onto and taking medications can be extremely difficult if you're experiencing homelessness, let alone other things like, having the wherewithal to be able to schedule an appointment and get transportation to get there.

So if you don't have a home, it can be very, very difficult to maintain your health.

And so that's why in the emergency department, we see a lot of people coming in where we see consequences of both short and long term homelessness.

The consequences of long term homelessness can be extremely severe.

- And is it as simple as to say that if you provide housing and after they leave the ER, that they're gonna have better outcomes?

- Well, that would be great.

And I think in most cases, that probably would be the case, to be honest.

Unfortunately, it's not something that we can do because we don't have access to housing.

Except for during the COVID 19 pandemic, one of the really sort of special things that we were able to do as a consequence of the awful pandemic was actually refer people experiencing homelessness to emergency shelter, where they could stay long term.

And if they were at high risk for poor outcomes due to COVID.

So they didn't necessarily have to be COVID positive, but we could actually refer them to emergency shelter where they could stay.

And I actually have a study with some colleagues coming out today that showed that people who were high users of healthcare services that got put in that housing, it's called Shelter-in-Place Housing, it's really temporary shelter, non-permanent housing.

But folks that were able to be referred to that housing compared to people that weren't, really significantly reduced their use of acute healthcare services like emergency departments and inpatient hospitalizations.

So that is some evidence that it really does make a difference.

- [Jim] That's fascinating.

- What I will say is that a lot of people that are chronically homeless, you're sort of not at that primary prevention stage because they're already pretty far down the path of medical illness, mental illness, substance use disorders, that sort of thing.

So putting them into permanent housing and keeping them there can stabilize them and really give them dignity, because they're housed.

It doesn't necessarily always translate into reduced use of healthcare services though.

- So Marie, can you give us a sense of how people become homeless?

I mean, there's the stereotypical image of somehow you have failed or you haven't met certain criteria, or you haven't done well.

But that in fact is not the case.

And if you look at the homeless populations across this country, we're talking people from all walks of life, we're talking mothers, families, we're talking young children, how do people become homeless?

And we could do probably an entire show on that, but give an overview of that.

- Yeah.

There's definitely a stereotype just as you said, I think a lot of people assume that majority of people sort of did something wrong.

They have some sort of thing about themselves that sort of created this problem for them be it, poor relationships with family, a severe substance use issue, severe mental illness, that sort of thing.

And that does play in for some people.

But the reality is that the majority of people are homeless because they cannot afford to pay for housing because housing is too expensive.

And that's why we see really high rates of homelessness in big cities where it's expensive to live like San Francisco, like Los Angeles, like New York, like Boston, where they just can't keep up by providing enough, low income and very low income housing to the people that live there.

And as rents increase, people just cannot afford it anymore.

And they often face eviction and they can't pay the rent.

So they find themselves in their cars, in a shelter and that sort of thing.

- Can you give us a sense of the numbers of homeless?

And I realize that these would be estimates, but maybe you can give us a sense of how many people are homeless in America nationally, and then maybe a couple of the big cities and then also rural areas because there's homelessness of course in rural areas.

A lot of questions packed into that one sentence there, but if you can give us an overview, that'll be great.

- Yeah.

So, well, I can speak about...

In San Francisco in 2022, there were about 8,000 people that were experiencing homelessness.

So that's a lot and in San Francisco in cities like LA, LA is much bigger, so it has a lot more people experiencing homelessness as does New York.

I think if you wanna look at the national picture, one of the things that's really interesting is that depending on the city or the state where people are, one of the biggest variations is, are people sheltered or are they unsheltered?

So in California and in San Francisco and in LA, about 65% of people are actually unsheltered.

So they're homeless, but they're not actually staying in a sheltered location.

Whereas in New York, less than 5% of people are unsheltered.

And that's for a very particular reason, which is that in New York, there is a legal right to shelter that doesn't exist in other states like California.

And so when you look at some of these areas that are urban areas, that's one of the biggest differences that you'll see, is in a place like California, people experiencing homelessness can just be a lot more visible because they are out there on the streets.

Rural areas, it's a little bit more variable.

And to be honest with you, I know a little bit less about rural areas and in terms of homelessness, just 'cause I'm so focused on what's happening in urban areas.

But urban areas tend to have much higher rates of people experiencing homelessness for lots of different reasons.

- Maria, what drew you to this set of issues in the first place?

- Can you repeat that?

Sorry.

- I'm sorry.

What drew you to this set of issues in the first place?

- Well, it was really practicing emergency medicine as a trainee at Bellevue, because I saw so many people coming in as repeat visitors to the emergency department and we would see them, we would treat whatever illness they had.

Sometimes they were quite sick, sometimes they weren't that sick and we would sort of give them a sandwich and show them the door.

I just felt really badly about it.

And I thought, they're just gonna be back tomorrow or they're gonna be back next week.

And we're really not serving these people and we have all this opportunity.

They keep coming in to see us and yet we are literally not doing anything to address the root of their problem.

That led me to do some research on the topic and actually, 'cause it's sort of anecdotal, we didn't at least when I was training, always ask people about their housing status and so you make a lot of assumptions.

But when I did some research actually interviewing people in the hospital, I came to find that in fact frequent users of the healthcare system, people that were admitted a lot and visited the emergency department a lot, among the subset of people that I interviewed 50% were experiencing homelessness.

So I sort of said, oh wow, this is a really, really significant problem.

And now we actually have some kind of empirical evidence to try to actually do something about it.

And so that's what kinda got me interested in it-- - And I'm saying this not to flatter you, but thank God and your communities for the impact that you can have doing this.

But I hear the experience that you're depicting and I'm thinking to myself, well, this seems like a policy failure.

So I'm wondering, we've put emergency rooms and physicians and healthcare providers like you in this position to catch this, but is there more we can be doing from a policy perspective to address homelessness?

- Oh, I mean, sure.

I think that we're not doing enough as a nation, we haven't made it enough of a priority to really put resources and money towards really, really increasing the supply of low and very low income housing.

And we have huge problems even in an area like San Francisco, even in areas like LA.

I think a lot of people have heard of this term NIMBY, so Not in My Backyard.

- [Jim] Yeah.

- So sometimes what happens is a proposition will pass like Proposition C in San Francisco or in LA, there was Measure H which it's sales tax or business taxes to fund housing in some of these cities where homelessness is a big issue.

And it becomes a problem of where to actually build housing because neighborhood groups or other people will say, well, I really want you to build it.

And, I'm liberal, I really wanna help people that are experiencing homelessness, but just maybe not right by where I live.

Could you do it somewhere else?

And so even little things like that are not little problems and it becomes difficult and it creates a lot of delays in actually building housing, even when you do have the money.

And the reality is once you have the money, it takes a lot of time, so there's sort of a lag in doing that.

But I think overall, during the COVID 19 pandemic, for example, I was really happy to see the moratorium on evictions.

And I think that really, really helped a lot of people from becoming homeless and having our problem be even worse.

But that was a controversial policy issue.

I don't think a lot of people necessarily thought that that should be something that the CDC had jurisdiction over or mandated.

And I'm really glad that they took advantage of that window and did it.

But we really need to be focusing on things like that.

Also things like cash assistance to people to prevent eviction can be extremely helpful.

So we know some of the things that work to prevent homelessness, but we really need to put our money where our mouth is as a society and a nation and do that.

- So Maria, in addition to the NIMBY factor, which is of course important, isn't there an issue of insensitivity on the part of some members of the public?

And I started thinking about that when I read a New York Times story recently about homeless deaths and you were actually brought into that story and what sort of staggered me, and maybe that's too strong a word, but maybe it isn't was that homeless people have died, their bodies have been in plain view and have stayed there for hours or even longer with nobody calling, nobody doing anything, that struck me as so inhumane and I totally didn't get that.

I mean, I don't get that from just, from an empathic point of view.

Talk about that because I think that is an element here in terms of the reaction of at least some members of the public.

I don't wanna see this, this is not my problem, this is not my fellow person.

- Right.

When you say, it's not my fellow person, I think maybe what you mean is sort of like, well, this isn't like me, like that could never happen to me.

That person is so different from me.

And the reality is, a lot of people that are experiencing homelessness are among us on the streets or in school with your kids and you just may not know that that's something they're experiencing.

So yeah, it's quite awful, it's quite inhumane.

I think we get used to, unfortunately, especially in some of the cities like San Francisco, like LA, like New York that I keep mentioning where there are people that are on the street experiencing homelessness, you get used to seeing people there.

And sometimes it can be hard to know, well, are they asleep in a doorway or are they passed out because they've had a little too much to drink or might they actually be dead?

And I think people desensitize themselves to seeing this sort of thing as they're going about their day and it's an easier thing to ignore than to actually do anything about, because it's a really, really hard problem to solve.

I'm not gonna say it's an easy problem to solve if you're a passerby on the street.

I think people feel really helpless about what to do, but it really is tragic.

And I think one of the most tragic things about people experiencing homelessness is the idea that people do die alone and they often die in public places and it is a tragedy.

- Do you see greater sensitivity to these issues among the med students that you work with than someone who's maybe been a practicing physician for 30 years?

- Yes, definitely.

I think there's a much bigger awareness now because within curriculum in med schools now, I think people are incorporating so much more around diversity, equity and inclusion, social determinants of health, all those sorts of things, structural racism that we know really impacts people's health.

And so I do feel like medical students coming through right now, they just have an awareness and some of our trainees and resident.

And then we, of course, when I'm working I really try to have people ask these sorts of questions.

One of the common refrains is well, they're going to, I'm gonna discharge them home.

And so then they're gonna follow up with their primary care doctor.

I go, okay.

So are we sure that they have a home?

Like, oh, I guess I'm not completely sure.

So lemme go back and ask.

Are we actually sure they have a primary care physician?

Oh, well, I sort of assume they did, but let me go back and ask, right.

So unless we ask people, we don't know the answers to these questions and we can't plan safe discharges for them.

So that's one of the things we also really emphasize is really gathering this information for people.

And it could be uncomfortable to ask, someone that comes in about their housing status.

I think people feel like they don't wanna offend, patience for that sort of thing, but there are ways that we can ask.

Something I often ask people is just, where did you stay last night?

And people are generally pretty forthcoming.

And I think people aren't connected to help their they usually be willing to accept resources or help.

- So we live in the wealthiest society, country in the history of civilization and yet among high income nations, we have some of the highest rates of certain diseases and conditions.

Number one, why is that?

And number two, why... Again, I'm sorry to ask this at the end of the show.

Maybe you could give us a very quick answer.

Why is this and how can it be changed?

- [Jim] We got about two minutes, Maria.

- Oh my goodness, okay.

(laughs happily) - [Miller] I'm sorry to... - No, it's okay.

Yeah, it's awful.

I was actually just looking with everything about Roe V. Wade being overturned.

I was looking at some of our maternal mortality statistics and I think we have the worst maternal mortality of any developed nation, and among black women, they have three times the risk of maternal mortality in the US than white people and non-Hispanic black people.

So it is just so disturbing.

And why is that?

Well it's because we put a lot of money towards healthcare, a lot of money.

I don't necessarily think we concentrate it in the right places.

We put so much money towards end of life care, expensive pharmaceuticals and high cost insurance.

Where on the other hand, a lot of states don't wanna do very basic things like expand Medicaid, have universal healthcare coverage and actually spend money on preventive care and social needs that will actually at the end of the day, be a lot less expensive for our healthcare system.

And so we don't... By underfunding, things like Medicaid, which is insurance for poor people, we get what we pay for.

We have really bad health outcomes because we don't put enough money towards having access to healthcare for people who really, really need it, who are quite vulnerable.

And I think we put a lot of our money just into, we concentrated in a lot of the wrong places.

Like I said, very, very expensive end of life care, very expensive pharmaceuticals that might have a small impact on a very small subset of people.

And for some reason, this is what we've chosen to do and without a lot of evidence, whereas if we wanna implement a program that will help really vulnerable poor people, we have to show that it's gonna reduce healthcare costs.

It doesn't make a lot of sense.

- Dr. Maria Raven, this is an important and timely conversation, thank you so much for being with us and for all that you do.

She's Dr. Maria Raven at UCSF.

That's all the time we have this week, but if you wanna know more about Storing the Public Square, you can find us on Facebook and Twitter or visit pellcenter.org, where you can always catch up on previous episodes.

For G. Wayne Miller.

I'm Jim Ludes, asking you to join us again next time for more story in the Public Square.

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