Houselessness: A Prism for Understanding Healthcare Disparities, Part 1

The DEI Shift

From the HIV epidemic to the rise of multi-drug resistant TB and the opioid crisis, those caring for people experiencing houselessness and housing insecurity saw the rise of each of these epidemics in their patient populations long before the rest of us. The devastating impact of the COVID-19 pandemic was particularly harsh for those in shelters or unhoused. Some say that caring for those experiencing houselessness reveals the fractures in our healthcare system earlier and more clearly than healthcare in other settings. Join The DEI Shift for the first of 2 episodes with 2 experts on caring for this population, Dr. James O’Connell, MD, MACP (Boston Healthcare for the Homeless) and Rachel Solotaroff, MD, FACP (Central City Concern- Portland, Oregon). In our discussion of the obstacles faced by these patients and the opportunities to learn from them, Drs. O’Connell and Solotaroff describe the root causes of houselessness, the best terms to use when addressing people experiencing houselessness, and some of the challenges in delivering healthcare to these patients.

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The DEI Shift

The DEI Shift's mission is to create a podcast series on diversity, equity, and inclusion (D.E.I.) in medicine that sparks discussion and provides practice-changing data and stories for a physician, student, allied health professional, and health care leader audience. Listeners will be able to gain useful information to improve their practices and environments, to gain empathy, cultural competency, and humility, and to learn more about emerging D.E.I. concepts. The DEI Shift will discuss issues related to gender, race, sexuality, religion, ability, socioeconomics, and so much more.

Guests: James O’Connell, MD, MACP (Boston Healthcare for the Homeless) and Rachael Solotaroff, MD, FACP (Central City Concern PDX)

Co-Hosts: Marianne Parshley, MD, FACP and Dr. Elisa Choi MD, FACP

Editor/Assistant Producer: Clara Baek

Production Assistants: Nilgoun Farhadi, Leyna Nguyen

Failure to eliminate homelessness can be
attributed to a profound failure of imagination

— The International Street Medicine Institute

Learning Objectives:

      Part 1:

  1. Define houselessness/homelessness and housing insecurity.
  2. Explore and define root causes of the crisis of houselessness in the U.S.
  3. Understand the challenges to access and provision of healthcare to houseless folks.

[0:00-1:58] Welcome and Introductions

  • Introduction of our co-hosts, guests, and episode topic

[1:58-6:13] Introduction to Guests: Dr. Jim O’Connell and Dr. Rachel Solotaroff

  • Dr. Jim O’Connell
    • President of Boston Health Care for the Homeless Program
    • Assistant Professor of Medicine at Harvard Medical School
    • Established the nation's first medical respite program
    • Serves on the Governor’s Council of the ACP Massachusetts chapter
    • Received MACP honorary achievement
    • Author of Stories From the Shadows: Reflections of a Street Doctor
  • Dr. Rachel Solotaroff
    • Served as Central City Concern’s President and CEO
    • Served as Medical Director of the Charlottesville Free Clinic in Charlottesville, VA and the Old Town Clinic in Portland, OR
    • Designed and implemented a social medicine curriculum for OHSU internal medicine residents

[6:13-12:02] “Be the Change” Segment

  • Dr. Jim O’Connell
    • Started working with patients experiencing houselessness unexpectedly
    • His Chief of Medicine and the Vice President of Massachusetts General Hospital recruited him to work on integrating the care of homeless people into the mainstream of Boston's healthcare system
    • Has been involved in this work ever since then
  • Dr. Rachel Solotaroff
    • Dreamt of becoming a rural family practice doctor in Maine
    • After moving to Portland, a mentor introduced her to an academic partnership that involved OHSU and Central City Concern
    • This resulted in her creating a social medicine curriculum at OHSU
    • Felt a sense of community working at Central City Concern, similar to the sense of community she sought to find as her goal of becoming a small town family practice doctor

[12:02-18:35] Different Terminology for Houseless Patients

  • Dr. Jim O’Connell
    • Back in the 1980s, it was acceptable at the time to use the term “the homeless”
    • For instance, organizations that were created to advocate for the homeless used the term in their name (ex.: National Coalition for the Homeless)
    • Over time, the stigmatization of homelessness and racial issues in classism resulted in an issue of addressing people without disparaging them and their experiences
    • Some homeless people find the term “homeless” acceptable
      • For instance, the Consumer Board of the Boston Health Care for the Homeless Program, which consists of homeless people, believe removing the noun “homeless” from the program’s name will make it difficult for people to know what the program is
    • Currently, it’s appropriate to use the phrase “persons experiencing homelessness”, or PEH
    • Many homeless folks disagree with the term “PEH” because they feel as though it glorifies the experience of homelessness
    • Ultimately, there’s no right term that’s acceptable to everyone
    • However, what matters lies in using words that show that healthcare professionals appreciate the dignity and courage of the people they serve
  • Dr. Rachel Solotaroff
    • Concrete definitions regarding homelessness (from the U.S. Department of Housing and Urban Development) and housing insecurity
      • Chronic homelessness - when a person lives in a place not meant for human habitation, a safe haven, or emergency shelter for at least 12 months consecutively or on four separate occasions in the past three years, as long as those three combined occasions equal at least 12 months
      • Housing insecurity/instability - Housing instability/insecurity encompasses a number of challenges, such as having trouble paying rent, overcrowding, moving frequently, or spending the bulk of household income on housing
      • Rent-burdened - more than 30% of an individual's income goes toward their rent
      • Extremely rent-burdened - more than 50% of an individual's or a household's income goes toward rent

[18:35-25:29] Root Causes of Houselessness

  •  Dr. Rachel Solotaroff
    •  Root causes of houselessness can fall into 2 categories
      • Structural factors
        • Absence of affordable housing, absence of meaningful wage employment, structural racism and discrimination, interaction with the criminal justice system
        • These factors are the root causes of vastly disproportionate numbers of BIPOC communities who are houseless
      • Individual experiences
        • Mental illness, substance use disorder, being in the foster care system as a child, trauma (particularly traumatic brain injury)
    • The drivers of houselessness are complex and root causes from different categories can influence each other
    • As structural root causes become more pronounced, it takes fewer individual root causes to drive someone into houselessness
  • Dr. Jim O’Connell
    • Houselessness is a complex societal problem
    • Think of homelessness as a prism that one holds up to society and what gets refracted are the weaknesses in each of the main sectors of one’s society
    • Providing good health care to people who are homeless isn’t sufficient to solve the problem of homelessness. It’s important to address all the complex factors at play and continue to support them once they are in housing

[25:29-32:56] Providing Houseless People Help with the Social Determinants of Health

  •  Dr. Rachel Solotaroff
    • Central City Concern aims to help people experiencing homelessess to build health, housing, economic resiliency, and social connectedness
    • Central City Concern employs a housing choice model that recognizes that there’s no right type of housing for everyone
    • Central City Concern also practices a supported employment model and clubhouse model, and is trained in helping people get onto social security and its benefits
    • Self-actualization in Maslow’s hierarchy of needs
      • “How am I giving back to the community?”
      • Can take many different forms
      • “Flip the Script” program at Central City Concern
        • Black and African-American men and women exiting incarceration are assisted with employment and housing
      • Self-actualization is a beautiful part of the journey to ending homelessness
  • Dr. Jim O’Connell
    • There is a fundamental struggle with helping patients with needs whose solution are outside of healthcare professionals’ domain
    • There is an issue with continuity of care and providing specialty care to houseless populations
    • Providing quality, speciality, and palliative care to homeless people will teach healthcare professionals the weaknesses in their healthcare system

[32:30-33:09] Closing

[33:10-34:13] Outro

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  • James O’Connell, MD Stories from the Shadows: Reflections of a Street Doctor, Boston Healthcare for the Homeless  2015
  • John McPhee, Heirs of General Practice, Farrar, Straus and Giroux; 1st edition (April 1, 1986)
  • Gregg Colburn and Clayton Page Aldern Homeless is a housing problem: How structural Factors Explain U.S. Patterns, University of California Press, March 2022


Articles (a selection):

  • Stephen W Hwang, Tom Burns; Health interventions for people who are homeless,
  • The Lancet; Volume 384, Issue 9953; 2014; Pages 1541-1547; ISSN 0140-6736,
  • Larrimore, Jeff, and Jenny Schuetz (2017). "Assessing the Severity of Rent Burden on Low-Income Families," FEDS Notes. Washington: Board of Governors of the Federal Reserve System, December 22, 2017,
  • Aurand, A., et al. 2019. “The Gap: A Shortage of Affordable Rental Homes.” National Low-Income Housing Coalition. Retrieved January 21, 2020.
  • Geriatric Conditions in a Population-Based Sample of Older Homeless Adults; Rebecca T. Brown, MD, MPH, Kaveh Hemati, BA, Elise D. Riley, PhD,Christopher T. Lee, MD, MPH, MSc, Claudia Ponath, MA, Lina Tieu, MPH, David Guzman,MSPH, and Margot B. Kushel, MD; Gerontologist, 2016, Vol. 00, No. 00, 1–10 doi:10.1093/geront/gnw0110
  • United States Interagency Council on Homelessness. 2018. Homelessness in America: Focus on Veterans. Retrieved April 27, 2020.
  • Hwang SW, Orav EJ, O'Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med. 1997 Apr 15;126(8):625-8. doi: 10.7326/0003-4819-126-8-199704150-00007. PMID: 9103130.
  • Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-Year Period. JAMA Intern Med. 2013;173(3):189–195. doi:10.1001/jamainternmed.2013.1604
  • Roncarati JS, Baggett TP, O’Connell JJ, et al. Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009. JAMA Intern Med. 2018;178(9):1242–1248. doi:10.1001/jamainternmed.2018.2924
  • Incze M, Katz MH. Death Among the Unsheltered Homeless: Hidden in Plain Sight. JAMA Intern Med.2018;178(9):1248–1249. doi:10.1001/jamainternmed.2018.2919
  • Hwang SW. Mortality Among Men Using Homeless Shelters in Toronto, Ontario. JAMA. 2000;283(16):2152–2157. doi:10.1001/jama.283.16.2152
  • Cheung, Angela M.;Hwang, Stephen W.; Risk of death among homeless women: a cohort study and review of the literature; Canadian Medical Association Journal
  • 1243-1247; vol 170;82004/04/13
  • Hwang,Stephen W; Colantonio,Angela; Chiu,Shirley; Tolomiczenko, George; Kiss,Alex; Cowan,Laura; Redelmeier, Donald A.; Levinson, Wendy; The effect of traumatic brain injury on the health of homeless people;CMAJ;179:8;pp 779-784;2008/10/07
  • Traumatic brain injury in homeless and marginally housed individuals: a systematic review and meta-analysis: Jacob L Stubbs, Allen E Thornton, Jessica M Sevick, Noah D Silverberg, Alasdair M Barr, William G Honer, William J Panenk; Lancet Public Health 2020; 5: e19–32: Published Online December 2, 2019 S2468-2667(19)30188-4
  • Hwang, Stephen W.;Ueng, Joanna J. M.;Chiu, Shirley;Kiss, Alex;Tolomiczenko, George;Cowan, Laura;Levinson, Wendy;Redelmeier, Donald A.;  Universal Health Insurance and Health Care Access for Homeless Persons; 2010/08/01; AJPH


  • Guests: James O’Connell, MD, MACP (Boston Healthcare for the Homeless) and Rachael Solotaroff, MD, FACP (Central City Concern PDX)
  • Co-Hosts: Marianne Parshley, MD, FACP and Dr. Elisa Choi MD, FACP
  • Executive Producer: Dr. Tammy Lin 
  • Co-Executive Producers: Dr. Pooja Jaeel, Dr. Tiffany Leung
  • Senior Producers: Dr. Maggie Kozman, Dr. DJ Gaines
  • Editor/Assistant Producer: Clara Baek
  • Production Assistants: Nilgoun Farhadi, Leyna Nguyen
  • Website/Art Design: Ann Truong
  • Music: Chris Dingman


The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.

Season 4 of The DEI Shift podcast is proudly sponsored by the American College of Physicians Southern California Region III Chapter. 

​The DEI Shift theme music is by Chris Dingman. Learn more at

Contact us:, @thedeishift,


Tammy Lin, MD, MPH, FACP

Pooja Jaeel, MD, ACP Member

Maggie Kozman, MD, ACP Member

James O’Connell, MD, MPH, MACP - Guest

Rachel Solotaroff, MD, ACP Member – Guest

Marianne Parshley, MD, FACP – Co-host

Elisa Choi, MD, FACP – Co-host

Leyna Nguyen  - Production Assistant

Nilgoun Farhadi – Production Assistant

Clara Baek – Editor/ Production Assistant


Tiffany Leung, MD, MPH, FACP, FAMIA, FEFIM

Dirk Gaines, MD, ACP Member

None of the contributors or reviewers for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All financial relationships have been mitigated.

Release Date: December 16, 2022

Expiration Date: December 16, 2025

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This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the DEI Shift.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

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