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    Transcript: Housing is Health: Connecting with Miriam’s Kitchen

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    Fluker: Welcome to “Beyond the White Coat: Making the Rounds,” presented by Community Health Connect — an AAMC program that facilitates conversations on issues related to health disparities, social determinants of health, and other public health concerns in the District of Columbia. I’m Clarence Fluker, director of community engagement here at the AAMC.

    Today, I’m talking with Lara Pukatch, director of advocacy at Miriam’s Kitchen, a nonprofit working to end chronic and veteran homelessness in Washington, D.C. The organization operates the only meals program in Washington that is open Monday through Friday all year long, including during holidays and weather emergencies.

    She oversees Miriam’s Kitchen’s work to ensure that people with a lived experience of homelessness are true drivers of the change they wish to see in their city. Ms. Pukatch also chairs the Way Home Campaign, an advocacy movement to end chronic homelessness. We’ll discuss the idea of housing as health and the experiences, challenges, and opportunities of housing-related nonprofits and their guests during the pandemic. Thanks for joining us, Ms. Pukatch.

    Pukatch: Thanks so much for having me.

    Fluker: Can you tell me a little bit about Miriam’s Kitchen and the clients that you serve there?

    Pukatch: Yeah, Miriam’s Kitchen is an organization dedicated to ending chronic homelessness in the district. So while our doors are open to everyone, the vast majority of the people that we serve are experiencing chronic homelessness, which means they’ve been homeless repeatedly or for years and are also struggling with a serious health condition. So that might be hypertension or diabetes or cancers, any — many other health conditions that are then exacerbated by the facts that folks are living outside and have been doing so for quite some time.

    And at Miriam’s Kitchen, we have a few programs. We have just celebrated 37 years, and so 37 years ago, we started with our meals program that started quite small that has evolved over time. So, we're now serving made-from-scratch healthy meals to about 150 individuals twice a day, five days a week.

    And while meals are often what bring people into the organization, we also have a wide array of services for folks to access once they’ve entered our doors. So that might be connections to health services; mental health services; helping folks to meet their immediate needs through clothing, toiletries, things like that.

    In addition, we have a street outreach program to connect with people that may be living outside who might be disconnected from services and might not be coming to Miriam’s Kitchen for meals. And making sure that we're still able to connect those individuals to the services and immediate needs that they have.

    And finally, we also have a permanent supportive housing program. So, we have about 200 individuals who are in housing who have exited chronic homelessness and who we provide support and case management to as they’re adjusting to their lives in housing.

    Fluker: A few months ago, the president of Miriam’s Kitchen as well as Dr. David Acosta, the Chief Diversity Officer for the AAMC, penned a really powerful op-ed in Street Sense Media. And the op-ed talked about housing as health. Can you tell me a bit about what is your hope for the movement that declares housing is health care?

    Pukatch: Sure, my real hope is that one day we don’t need a movement, right? That everyone understands that housing and health care are both critical to our health and well-being, of course. But at a more specific level, I really hope that we're able to continue to raise awareness so that people can understand just that housing and a safe, stable place to call home are really the lynchpin for so many things in everyone’s life. But especially their health and their well-being. And year after year, we have to make the case to our policymakers that we need housing. And year after year, we're told that there isn’t enough money to go around to house everyone that’s experiencing homelessness.

    And so, I think part of my hope for the movement is that we're able to build the awareness on the political will so that everyone who deserves a home — which is every person — is able to access one for the sake of their health and well-being, but also because it's just a fundamental right that everyone deserves.

    Fluker: Can you tell me how the pandemic has really been affecting the community that Miriam’s Kitchen serves and what does that look like in relation to trends that we've been seeing nationally?

    Pukatch: The way that the pandemic has been impacting our population is simply that this is a population that has already been in crisis, who are in crisis because they lack access to safe and affordable housing and because they’re often experiencing serious health challenges on top of that. But what we're seeing kind of on a larger scale as a result of the pandemic are increases of homelessness, right? We have heard that there’s a projected 40% increase in homelessness nationwide and that we will likely see a similar trend in the district. What’s challenging to know is kind of when and how quickly that will happen, and I think that remains to be seen to some extent.

    What I can say for us is that we are serving many more meals and are seeing a lot more people show up to access our meals program. That said, we don’t collect identifying information at the door, we have no kind of preconditions for folks accessing our services. So, whether those folks are experiencing homelessness or simply just need some help with some extra meals, we don’t know. But I think what we're seeing across the country and in Washington, of course, is that folks are struggling to make ends meet and that certainly is going to result in an increase in homelessness. We are a city that’s largely unaffordable; our lack of affordable housing is another root cause of homelessness. And so, as it gets harder and harder for people to pay their bills, it’s possible that we see people experience homelessness at a higher rate.

    Fluker: What are some of the challenges facing your clients and your organization because of the ongoing pandemic?

    Pukatch: Well, most of our clients are experiencing chronic homelessness, which means that they have been homeless repeatedly and/or for years — and also that they’re struggling with a health condition. So, in addition to the real crisis of experiencing homelessness, many of our clients have been in crisis when it comes to their health even before the pandemic. So many of our clients are struggling with things like hypertension, diabetes, COPD, mental health challenges — and those things are all exacerbated by the fact that they are sleeping outside or in shelter, aren’t getting a good night’s sleep or maybe having regular access to regular health care appointments or to medication.

    And the pandemic has just exacerbated all of that. People are unable to access sanitation, right, to be able to wash their hands regularly. The government is telling us to stay home — it’s hard to do if you don’t have one.

    For our population who has already been in crisis — sometimes for years, decades at a time — the pandemic has just been one more layer of that crisis. And one more thing I would add is just that, for many folks experiencing homelessness or for folks who have just moved into housing after many years of homelessness, they also can feel very isolated. And so that is something that also has gotten worse during the pandemic, right, as we are understandably instructed to stay home, stay away from other people. This isolation that people often experience that really compounds other health issues is made even worse by the precautions we need to take for the pandemic.

    Fluker: Can you tell me sort of any, maybe, anecdotes about things that you've experienced or seen your clients experiencing related to their health or access to health care services during this time?

    Pukatch: Sure, one thing that comes to mind that is really an anecdote I was seeing with many of our clients is the real conundrum about whether or not to access shelter. Living outside can be dangerous both because of exposure to the elements and the weather but also just for simple safety concerns. And I think, all of the time, people are weighing the pros and cons of going into shelter or not because shelter might be a place where there are lots of germs around, where it might be unhealthy because there are not great living conditions. And so, we're seeing the same thing in the pandemic because people don’t want to be in congregate settings, right?

    So, we have several clients who are understandably electing not to stay in shelter in order to protect their own health. But that becomes increasingly concerning also for their health as we approach the winter and colder months. And while it's feeling crisp and like fall for many of us, the temperatures are still dropping pretty low in the evenings. And for someone that’s already struggling with a few health conditions, that’s really concerning.

    Fluker: And particularly with the street outreach team that you have that’s been working with people throughout this pandemic, can you tell us about some of the common things that they’re finding with the clients?

    Pukatch: In some ways, the population our street outreach team is serving right now is the same as it was even before the pandemic. These are folks that, for whatever reason, often have elected not to stay in shelter and they may be staying outside in an encampment — meaning in a group with other people, maybe in a tent, or they might just be sleeping wherever they can find a space throughout the city. But what has been difficult, of course, during the pandemic is the building of relationships with these individuals. Relationship building is really a crucial part of the street outreach work — connecting the folks who haven’t been connected with services maybe in some time to folks who might not have a lot of trust in the system, who might have tried several times to get housing and not succeeded and kind of feel like they don’t want to put the effort and energy in.

    So, building relationships, as you can imagine, is difficult to do from six feet away, right, especially if you're trying to approach someone you don’t know that well or you haven’t met before. But our team and the entire street outreach network across the city really does an amazing job and are doing what they can to still identify folks to connect with them and to give them the things that they need. So right at the beginning of the pandemic, there was a lot of awareness raising for folks who may not have internet access and might not have been able to see kind of what was happening day by day as we all got more information as a community and a country. Passing out hand sanitizers, masks, that sort of thing.

    But many of the other existing needs remain. So that also is connecting just people to food, to water, to health appointments, to sleeping bags, to sunscreen, to food, things like that.

    Fluker: That sounds very concerning. Can you walk back to maybe the beginning of the pandemic, so March 2020, when things first started to really shift in our country — and certainly shift in Washington, D.C. How did your organization go about making the shift around how you would be able to provide services to your clients? And, sort of, what was the thinking at that time?

    Pukatch: Yeah, so we made the shift very quickly and we're, like so many others, we're really making decisions day by day as things unfolded. So right around mid-March on a Friday, we made the decision that on the following Monday we would stop serving our meals indoors. We have about 150 people who are coming to receive meals in our dining room space twice a day, five days a week. And it quickly became apparent that that kind of congregant gathering wasn’t going to be safe. So, over the weekend, we moved our operations outdoors, which meant that folks were able to come and kind of gather near the building but not come inside. And we were packaging our made-from-scratch meals into to-go containers so that people could still have access to the food that they needed but then take those with them and eat them at a safe distance.

    At the same time, we had to significantly scale back just our case management services, right? While meals are the thing that often draw people to Miriam’s Kitchen, we also have case managers who are connecting folks to housing services, to health services, to so many other things. And that really had to be significantly scaled back as we kind of figured out the day-to-day operations and what they would look like. And then the last thing I’ll add is that we rely on almost 2,000 volunteers to make our meals and prepare our meals and serve our meals throughout the year. And we had to suspend our volunteer service — there was just no way for 10 or 12 people to be in a kitchen working together for several hours.

    So, we suspended that service, unsure for how long that would be. And our amazing chefs just jumped in and have been working 14-hour shifts ever since to make sure that we are still able to get the food that people have come to know and love at Miriam’s Kitchen.

    Fluker: That’s fantastic how you all were able to make that shift. So that was March — where are you in your operations now? And how are you working with folks?

    Pukatch: In some ways, it’s very similar. We're still providing meals, we're still providing them outside. But we're beginning to think about what will happen this winter, right? So, the spring was easy to deal with; the summer was concerning because there was high heat. August in Washington is never easy. But with misters and fans and tents from the shade, we were able to still provide an environment where guests could safely access our food and services. Over time, we've been able to scale up our case management services a little bit, just because at the beginning we were going so day-by-day trying to figure out what the day would bring and really also struggling to staff all of our shifts, right? Since so many of our employees had to stay home because their kids’ school was closed or because child care was up in the air or because folks had concerns for their own health.

    So that’s been a little bit of a challenge, but we're ramping up towards more case management services. We're trying to create it to think about how we can prepare for the winter. And then in addition, we do serve about 200 clients who are in housing — who exited chronic homelessness into housing and who we still provide support to. And so that work, fortunately, has translated online pretty well. And we've been able to support those folks by phone, through telehealth appointments, and by delivering food to their doors since many of them are folks who are worried about their own health and well-being and aren’t really able — and didn’t feel comfortable — traveling to grocery stores and what have you.

    Fluker: I’ve heard — in the past, I’ve heard you and others make the connection between homelessness and racial justice in Washington, D.C. Can you talk about that?

    Pukatch: Certainly, I mean, in my opinion, you really can’t talk about one without the other. In the District of Columbia, 86% of adults experiencing homelessness are Black, while Black adults are only comprising about 46% of the population. So, we have an extreme disproportionality, and that’s not a coincidence, right? Racism is a root cause of homelessness and chronic homelessness — the crisis that we find ourselves in is the result of hundreds of years of oppression. And also, systemic discrimination in housing policy — that was specifically designed to prevent people of color and especially Black Americans from owning their own homes, from accumulating wealth, from so many other things.

    And so, when we think about solutions to homelessness, when we think about how it is we're going to end it, we just — we can’t think about it without racism. Not to mention the fact that we all know that racism is, unfortunately, alive and well and playing out in the day-to-day life of members of our community. So, it’s both about recognizing where we are and how we got here and how racism has driven us to this point, but also, really making sure that racial justice work is part of housing justice, advocacy, and organizing and really takes into account the present biases and racism, whether it’s overt or implicit that’s happening on a day-to-day basis.

    Fluker: You've made a clear connection between housing and health. And so, we know that it’s important, and you also made a really clear connection between racial justice and housing justice and we all understand why that’s important too. I would love to know your thoughts about what you think the role of academic medicine and the health care community is in working toward housing justice and making sure that we do have housing for all. What do you see the role of medicine in that?

    Pukatch: I see the role of academic medicine as really the same as I see everybody’s role, which is for folks to use their voice, right? I think, at a basic level, we all maybe assume that everyone’s on the same page when it comes to ending homelessness. So, we can agree that this is a bad thing and that we should do what we can to end it.

    But at the end of the day, policymakers need to hear from their community members that they care about this issue. And so, for those in academic medicine, that means indeed raising your voice to make the case that homelessness is a public health issue, that housing is fundamental to health and well-being. But also, just simply that it’s important to you as a voter, as a community member — that it’s something that you want to see your city spend money on.

    As I said before, we hear year after year that there just isn’t enough money to provide housing to everyone that needs it. But there is enough money, right? It's a question of priorities and making sure that we are prioritizing funding for housing for the folks that need it. And everyone has a part to play in making that known and demanding of our policymakers that they’re investing their resources in the right places.

    Fluker: If you could talk to every doctor, if you could speak to every health care administrator, what is it that you would want to tell them? What would be the message that you would have for them?

    Pukatch: That’s a good question. I think I would really just encourage every health professional to think about housing and housing instability as part and parcel of their patient’s health, right? I think many of us might have an idea in our head, a stereotype about who it is that’s experiencing homelessness. But really, homelessness and housing instability can happen to anyone and it’s something that will directly impact someone’s health and well-being. So, thinking about how you're able to learn your patient’s housing stability and connect anyone that might be struggling with stable housing to resources, I think, could be really critical.

    And then I would just reiterate on top of that to encourage doctors and other health professionals to raise their voice and to help in raising awareness about this issue. I talk a lot about how housing is health care, but I think it means even more when it’s coming from a health professional.

    Fluker: Ms. Pukatch, this has been a really great conversation. And thank you for joining us today on “Beyond the White Coat: Making the Rounds.” The experiences that you shared with us really underline the connection between housing, health, health care, and what we can all be doing. It’s clear that it’s time for the health community and government to work collaboratively to address the root causes of homelessness and housing insecurity for the health of all.

    Pukatch: Thanks so much for having me.

    [End of Audio]