This is an unhealthy way to live. Life expectancy for the homeless is nearly half that of the rest of the population.
“Homelessness is a marker for extreme poverty and social isolation and those things in combination for a long time are very hard on a body,” says Dr. Jessie Gaeta, a medical doctor who’s worked with homeless patients for the past 13 years.
“As an internist I see a premature aging that goes on the longer a person experiences homelessness, and not just in the skin or outward experience but on their internal organs. A person who’s forty and has been homeless for a long time, looks to me, like a sixty-year old. They have experienced a kind of premature aging. I’m seeing chronic diseases happen about twenty years earlier.”
Sleep, nutrition, hydration, stress. It’s all worse on the street. Plus, the homelessness makes it hard to prioritize your health.
“Your need to be exquisitely focused on your basic survival needs, where you will sleep, where will you next meal come from, those needs are always going to supersede your healthcare needs,” says Dr. Gaeta. Medical issues will be put on the back burner "until it becomes so bad that you have to change your priorities.”
Phil Taylor knocks on the door over and over. He doesn’t give up easy. Eventually the door is opened and we go into a basement hotel room. The room is cluttered but cozy with fancy lingerie hung on the walls. Frills and lace looking well used on little nails like old family heirlooms. The woman who lives here works the street at night. She struggles to make ends meet and has no other home.
When there’s a lack of affordable housing cheap motels fill the gap. A significant amount of their guests are homeless women who pay for shelter one night at a time with sex work. These motels are often the last option before going to the shelters or streets and they’re typically hotbeds for crime and violence.
The room is quiet except soft crying and consoling between Phil and this woman. She calls him Dr. Phil. He’s a nurse practitioner but most of his job is convincing people to visit the Fourth Street Clinic where the homeless can get all kinds of medical treatment for free. Phil talks with the woman about what may be hepatitis. He talks to several more people who call this hotel their temporary homes as we walk outside.
This was just one stop in a normal day for Phil and his co-worker Leticia Vasquez. They drive a large medical van for the Fourth Street Clinic distributing drug overdose kits, basic medicines, clean socks, and nutrition bars.
They look for homeless people needing help, medical or otherwise. They stop at cheap motels, back alley streets, and city parks where people are camp out. Together they seem to know not only the names of every homeless person in the city but can recall detailed medical histories as well.
Phil seems spend a lot of time thinking about the moral obligation to help the bottom rung of society but free will is also important to him. He’s a strong advocate for preserving the autonomy of his homeless patients. He tells me you can’t force people to live a certain way and it would be wrong even if you could.
In the past, he has encouraged people to make their own choices then had to watch them make choices that put them in the ground. Those stories stay in his mind. He says he’s heard horrific stories of physical and sexual abuse. He once saw a menstruating woman wash her vagina in the gutter.
He’s undeniably good at his job but admits that success stories are extremely rare.
Shelters offer a bed away from the winds but at the cost of violence.
“Violence is a ubiquitous part of homeless life,” Dr. Gaeta tells me.
Everyone I talk to tells me about the violence and theft at the shelters. Many say the shelters aren’t worth it they prefer the sidewalk. But both options have a high risk of violence.
I’m walking through crowds of homeless people on the streets downtown. Young boys talk cryptically to me from the sides of their mouths. They want me to buy something unhealthy from them. I shake my head and weave through lines of people trying desperately to get their lives together.
I see a fight escalating and cross the street, just what I'm looking for. A young man pulls his shirt off to expose his bulging muscles to the cold. Shouting. The shirtless muscles draw a verbal line in the sand. His opponent crosses the line and gets knocked out in a single punch. His friend drags his limp body in front of a Chinese restaurant. I think about how bad this neighborhood is for trying to run a Chinese restaurant.
I keep walking. I stop and talk to some of the thousands of homeless people in this part of the city. They speak of violence and caution me and my eye-catching camera. I note the warnings and mostly take pictures of animals and inanimate objects, putting the street life in my background.
“These people will attack you for no reason at all,” one woman tells me. I talk with her and we watch from a distance as homeless teenagers threaten each other with knives. She says she’s lived most of her adult life on the streets down here.
Suddenly another fight breaks out and this time I stride across the street to take pictures. Before I’m half way across a boy is knocked out on the cement. His basketball hat blows into the street. Egos square up face to face and weigh the threat of bodily harm against losing street cred. We really are animals, I think.
“Hey you takin’ pictures?” I shrug. “Hey this guy’s takin’ pictures!”
Instantly a crowd has surrounded me. The egos found a reason to back away from their risky confrontation. Clearly, I am an easier target.
Only seconds go by before I’m hit in the left temple. A few more punches find me as I break through the crowd. At the end of the block I‘m surprised I still have my camera, it’s fine and so am I so I walk to the train station.
i'm grateful I don’t have to choose between the shelter and the sidewalk.
For many homeless people, this is what keeps them on the streets; a little ball of black tar mixed with water and cooked on the bottom of a beer can with a lighter. A piece of cotton is used to strain out impurities as the drug is sucked up into the syringe.
Extremely addictive and all too easy to overdose, heroin use has risen to epidemic status across the U.S. Most users start their addiction with legal opioid prescriptions that slowly but surely tear their lives apart. Once sweet kids will commit any crime to get their fix. Soon, all bridges of social support are burned and the choices are narrowed to streets or shelters.
Three brothers walking through a suburban neighborhood in a major U.S. city carrying part of a barbecue grill, an old tarp, and a random assortment of camping supplies.
They’re walking to an empty lot to set up a camp. Not for fun, but because they have nowhere else to go. They use tape and string to crudely piece together the tent, tying the top of it to tree branches to hold it up. They take their time and argue about how to build the strongest shelter possible because snow is coming and they have to survive out here.
The brothers, all in their fifties, are homeless. The brother I came here to see, Tracy, was just released from jail and has stage four liver cancer. He stopped receiving treatment months back. At one point while gathering shelter supplies Tracy is gripped by a wave of nausea and drops to the ground and vomits.
Seeing the end of your life is hard under any circumstances and I can understand why drugs are a temping release for someone facing terminal cancer on the streets.
For the first few weeks the brothers have a pretty primitive camp, its cold and often wet, but slowly they improve it. Still, they have to walk almost a mile to find water and the air seems colder every night.
Each brother has spent decades bouncing between prison, the streets, and jail, drug addiction always a relevant factor. One night around the campfire they try to explain to me how their lives ended up like this. They half-heartedly try to blame their childhood, which was full of abuse and poverty, but they have no real answers.
The cancer has spread beyond Tracy’s liver. He complains of pain constantly. I’m never able to quite parse from him how much of that pain is the cancer and how much is his body craving more dope. He’s able to scrounge up free medical care and prescription drugs from the 4th Street Clinic on occasion but for the most part he self medicates with heroin.
He tells me it’s not at all about getting high. “It helps me feel like a normal person,” he says. The first few hits of the morning only quench the addiction. The next several hits help with the pain. If there’s any dope left after that he can start to feel good from it.
About once a month he goes into a detox clinic and fills out the paperwork but, so far, has chickened out at the last minute every time. The thought of going through agonizing heroin withdrawal is too scary for him.
Still it’s not always easy for me to see Tracy as a victim. He experiences more pain than most but he has also inflicted more pain than most.
Sometimes Tracy seems to grasp for a meaning or purpose to his existence but more often the daily struggle to survive is purpose enough.
Despite his cancer he logs more daily miles walking than most people. His days are filled with heavy loads carried several miles from water sources and food banks back to his homeless camp. He lives entirely on charity and criminality and yet it’s not an easy life.
On this day he spent the morning using his father’s phone to arrange his social security payments. After years of strained trust, using the phone and a cup of coffee is all Tracy’s father is able to support him with now. Even that support comes with deep depressing disappointment.
Tracy talks about suicide a lot. He tells me about how much heroin he’d need to shoot up to cause a fatal overdose. But he’s also afraid to die. Sometimes I am the first to tell him when other homeless people he knows of pass away and he always notes if they were diagnosed before or after he was. He wonders, ‘if I’ve had cancer months longer than she did, then how much longer do I have to live?’
Matilda helps people put their lives back together, constantly cracking open doors to check on them, like she is with Ben in this picture. But when she first moved here her own life was falling apart.
A marriage in disrepair and nowhere to live she was surviving off one-dollar bowls of rice from Panda Express and picking up free sandwiches from the Catholic Church for her kids. They lived in a cramped motel. She and her (now ex) husband took turns staying in the shelter to give each other space in the small room.
“Going back and forth between the shelter and the hotel and we had a car for a while and we stayed in the car a few times but it was too cold in the winter. I’d never seen snow until I moved here,” Matilda says. They lived like this for about a year.
Now, after putting her life back together, she argues that homelessness could happen to anyone. It’s “like an avalanche that crushes you.”
Flash forward a few decades and Matilda started volunteering at the Inn Between, a brand new homeless shelter that only hosts people with terminal illnesses. It's a place for the homeless to go at the end of life and die with dignity.
“I was really only volunteering here for maybe three weeks and then they asked me if I’d be interested in a job here. Finally I said yeah, ok, maybe if I do it part time… then the second week I worked 44 hours.”
Matilda, drawing from her own experiences with homelessness, is a pillar of this new non-profit. She helps organize volunteers, checks in new residents and makes funeral arrangements when they pass away. She told me she can’t help but get emotionally attached to people and become close to them. “I get stuck here. It’s hard to say ‘I have to go.’”
Ben, a resident of the Inn Between, towers over the sporting good store employee and tells him some startling double-digit number for a shoe size. Somehow, the employee brings back something that might work. Ben tries it on and looks pleased.
After years of homelessness he’s learned to appreciate good traction in the winter. He tells Matilda and I that he can’t afford to take a fall on the ice at this point in his life. He’s barely over 40.
Ben’s story is one that makes me question my own security in life. “I had it all, house, boat, wife, the whole nine yards!” he tells me frequently. Then life sent a few curveballs and he found himself living in a park the house, boat and wife all gone. From there his diet gradually shifted from food to alcohol and when he finally arrived at the hospital the doctor told him he had less than three weeks to live judging by the state of his liver.
He looks over the shoebox for the price and, seeing the cost, quietly notes that he’ll have to come back with a little more cash. Matilda jumps in quickly and says that she’s buying them for him. Ben says that she’s got to let him pay her back, “at least let me pay it forward and help buy boots for someone else at the shelter.”
It’s an emotional moment, the two facing each other with shoppers squeezing past.
“Ben, this is my way of paying it back,” Matilda says, her eyes a little wet. “I was in the same position as you and people helped me out and now I’m paying it back to you.”
At 42 years old Ben was told he had weeks to live. He moved into the Inn Between – a homeless shelter for people with terminal diseases – and prepared to die. Here he’s seen praying before dinner on a dark winter night.
But he didn’t die.
He stopped drinking and the Inn Between was able to provide him with nutritious food, a less stressful environment and better sleep and somehow his liver sputtered back to life. He’s far from healthy today but death doesn’t haunt him as it used to.
I encountered miracles like this several times at the Inn Between and in talking to other homeless hospice shelters around the country. With a loving environment even those halfway through death’s door can turn around.
Now Ben is looking for housing. His health will prohibit him from working for a long time still but he can’t stay at the Inn Between forever. If housing can’t be found Ben could end up back on the streets. Perhaps it’s obvious, but a lack of affordable housing is a root cause of homelessness. The stigma against homelessness doesn’t help either.
“There’s a lot of people walking around with housing vouchers in the their pockets who can’t get a landlord to rent to them,” John N. Lozier, Executive Director National Health Care for the Homeless Council, told me.
Subsidized housing was cut by about 75 percent in the Reagan administration and we never recovered, says Lozier. “The rug was pulled out from underneath the poorest people in this country and so it’s no surprise that they showed up on the streets.”
Roberto peers into one of the sixteen rooms at the Inn Between, a recently opened hospice homeless shelter. It’s a place for the homeless to go at the end of life and die with dignity.
Roberto says he used to drive by the homeless holding signs on the street and scold them. “How could they live like that?” he thought. Then one day he was standing on the street holding a sign, homeless.
It’s still dark when I pick him up from the Inn Between and we drive across town as the sun breaks the horizon. We arrive at the cancer treatment center to find the doors locked. We wander around the empty lobby. Jim has gotten his appointment three hours wrong.
We drive around the sleepy city to kill time. Jim knows these streets well and tells me when and where to turn. He’s kept a connection to this place all his life but mostly he tells me stories of other places. Like his time in a Harley bike gang.
Eventually we go in and Jim is hooked up to bags of drugs. These nurses don’t seem to know that Jim is technically homeless but Dr. John Song, a medical doctor and bioethics professor, says there’s research that shows the homeless are not treated well in traditional healthcare facilities. He says homeless people are “are really worried that when they do end up in healthcare facilities that they won’t be treated with respect.” This keeps many homeless individuals from ever seeking preventative care. All too often the homeless won’t show up in medical centers until their conditions reach advanced stages.
When I visit a week later Jim is shaving. He says he’s been up all night with anxiety because today I’m taking him to the doctor to find out if the chemo is working.
For a while Jim lived under a bridge. Commuters on the train could see his shelter as they zipped in and out of the city everyday. When he was diagnosed with stage four cancer the Inn Between took him on as one of their first residents. He wasted no time decorating his room with biker memorabilia and this flag-rosary combo on the wall above his bed.
The next time I visit Jim’s room at the Inn Between his phone is ringing and he’s not answering. I ask him why and he tells me it’s his doctor calling because he’s not been going to chemo appointments.
“I’d rather have three months of feeling good than six months of feeling terrible,” he says.
So close to the end Jim is still a force of life at the Inn Between, a central figure. He takes media interviews at least once a week. He helps mitigate drama around the shelter and has friends over constantly despite how tired it makes him.
Without the Inn Between the end of Jim’s life would be dramatically different. This is what the Inn Between was founded to do: let people go.
At the end of February, at sixty years old, Jim stepped out of this world and into another. He went peacefully in his bed at the Inn Between.
I imagine the process happening not unlike this scene I photographed of him telling me to take it easy in the hallway outside his room before turning and walking into the light.
Until the week she passed away Olivia defiantly told me she was going to beat her cancer, that it wouldn’t kill her. She was fierce and unafraid.
Olivia spoke at length about the value of basic shelter when undergoing cancer treatment. She saw great value in the work of the Inn Between and called for more places like it to open up around the country. She wanted to see a safe place for everyone at the end of life but insisted that the end of her own life was far off.
I asked Sherry Campbell, the director of Welcome Home Chattanooga Hospice Homeless Shelter, if the country needs more hospice homeless shelters and she said there would have to be. “There needs to be some change because the nursing homes are turning away from hospice care and more toward rehabilitative care.”
“Dying has become too medical, too much in the hospital and people have become too depressed to talk about it,” Campbell went on. “But this is very holy and sacred ground.” Olivia would have had to spend her final days on the streets had it not been for the Inn Between. Her story is, in a way, a success story but it is still sad.
She is survived by her husband and their three children.
Barely into his third decade Casey Manning became the first resident of the Inn Between to pass away.
“Casey had a hard life but…” said many of the mourners at his memorial. Friends and family, people whose relationships with Casey were constantly strained, gathered and shared the good memories they had.
Dr. John Song, a bioethics professor whose written extensively about homeless healthcare, told me people who are homeless face different fears at the end of life. “No one is going to be there when they die, they will die alone, whether in an institution or on the streets. That’s one huge fear, dying alone, that a lot most other people don’t have.”
The Inn Between goes through these painful memorials on a regular basis. It’s hard to reconcile death after such a difficult life. Though never easy to admit, such terrestrial pain can make the afterlife can seem a cathartic place for the residents as well as the staff.
Casey’s memorial was too sad for me. He was too close to my age. I had to leave early.
Hundreds gathered in a city park on a cold night in December and honored those lost in the previous year. People sang and spoke. They held candles and shared memories. Ninety-seven names were read aloud to the crowd. A special candle for each name. Ninety-seven homeless people who died in my city in 2015.
Towards the end of the night people started placing their candles in little shrines like this one before they went home.
Social isolation, a lack of close family or friends, is a common theme in homelessness. Sometimes it happens by accident, you outlive friends and family, or they move far away. Sometimes crime and addiction wedges between people and tears down trust over time. However it happens, homeless people facing the end of life frequently cite fears of being forgotten by family or dying with old wounds between friends still open.
Many of the experts I talked to said memorials for people who died while homeless can be powerfully cathartic for healthcare workers and other homeless people.
“Many cities have memorial services that honor homeless individuals that have died in the past year,” said Dr. Song. “I think that’s a simple thing that places can do and that actually has a great deal of impact considering the fears that homeless individuals have.”
This is the Inn Between. It’s hospice shelter for the homeless. For people with nowhere else to go it's a place to die with dignity. They opened in the fall of 2015 and have been hosting people through the final stages of life ever since.
You can donate to the Inn Between by visiting their website: http://www.theinnbetweenslc.org/