Multiple tents line the edges of a tree-lined city park near a Whole Foods grocery store. Image by Monica via Adobe Stock.
Bilal Arshadullah ’24 was a 2023-’24 Health Care Ethics Intern and the inaugural recipient of the Fellowship in Health Equity and Innovation with the Markkula Center for Applied Ethics at Santa Clara University. Bilal was mentored by the Markkula Center’s director of bioethics, Dorothee Caminiti.
California’s unhoused population comprises over a quarter of all people experiencing homelessness in the United States, over 180,000 individuals. Nearly 10,000 of those people are in Santa Clara County alone. Living in the margins of society, unhoused individuals face a daily struggle to access necessities like food, clothing, and safety. In July 2024, California Governor Gavin Newsom ordered state agencies to start removing homeless encampments on state land, stating that it’s unsafe to let people live among health hazards like trash, rats, and used drug needles.
For all the concern over unhoused people’s safety though, these encampment sweeps actually cause significant harm. At best, unhoused people get displaced and disconnected from the street medicine teams they were working with. People who are on lists for shelter housing lose their ID in an encampment sweep and suddenly find themselves at the back of the line. At worst, their life-saving medications are tossed out with the trash and those with life-threatening conditions are forced into emergency departments.
The increasing criminalization of homelessness is setting back most of the health care efforts deployed so far. To ensure unhoused people’s access to health care in this context, we must better address the barriers they face.
Housing Stability as a Social Determinant of Health
Social determinants of health are non-medical factors that directly impact someone’s health and wellbeing, such as economic stability, education level, and social and community context. Housing stability is a key social determinant of health, and without it, unhoused people have a much higher rate of disability and mortality. Maintaining continuity of medical care without a permanent living address or phone number is very difficult. Unhoused patients may frequently change shelters or street locations, making it challenging to attend scheduled appointments and receive follow-up care. Patients without regular, effective access to transportation are likely to struggle with attending their doctor's appointments.
Adhering to treatment plans is also a challenge, as patients are frequently unable to store or maintain medications properly, and they are regularly lost or stolen. This is particularly dangerous for patients with medications that need to be refrigerated or specially stored, like insulin. Moreover, people experiencing unsheltered homelessness (i.e., those sleeping on the streets/in parks/in vehicles) are exposed to environmental elements. Extremely hot and cold weather conditions in the summers and winters are significantly more dangerous and can lead to conditions like heat stroke or hypothermia. Unhoused patients are also commonly stigmatized and discriminated against because of their lack of hygiene, with little consideration of the fact that their opportunities to maintain basic hygiene are limited. These effects of housing instability on health care are compounded by other social determinants like food insecurity, lack of insurance, and adverse childhood experiences (ACEs).
Ethical Considerations for Treating People Experiencing Homelessness
Health care providers must implicitly operate within a scaffold of necessary ethical considerations when serving the unhoused community. First and foremost, they ought to provide care within the framework of principlism, with a particular focus on the principle of justice. Equitable access to care is a core tenet of justice. Yet, in mainstream health care venues, patients experiencing homelessness often face heavy stigma and prejudice from clinicians who view them as “drug-seekers” and commonly provide poor quality care, or deny care altogether for pain, mental illness, or addiction. Providers must instead tailor their approach to address the needs of this particularly vulnerable population and account for the years of neglect and discrimination these patients have experienced.
This is especially important for patients without a permanent address or a stable phone number, which makes it difficult to stay in contact with them if they choose not to come back to the clinic. The primary goal of healthcare organizations should be to develop and implement interventions that will increase accessibility to health care and offer social services specifically designed to help unhoused patients. Programs including community outreach and street medicine initiatives are effective methods of promoting distributive justice and ensuring needed resources are being provided to people experiencing homelessness. In the long term, however, it should be acknowledged that true justice cannot be achieved until permanent, affordable housing becomes available.
On a more individual level, health care providers working with unhoused individuals must prioritize patient autonomy in their treatment plans. While this sounds like something most providers already do, prioritizing autonomy may look different when working with this population.
We would like to offer the following scenario to illustrate this: A primary care provider has a patient coming in with joint pain and recent vomiting episodes. The provider suspects hepatitis, which is associated with substance use. When the physician asks if they are currently using any substances, they share that they use methamphetamines regularly. The physician gently informs them that such use puts them at higher risk of contracting hepatitis and that the best outcomes for their health can only be achieved through cessation. Yet, they adamantly refuse and say that they want to continue using meth, but may consider stopping in the future.
Cases like this are not uncommon. The provider may lean towards a paternalistic approach and push to do more to “help” the patient, for example, by creating a treatment plan that centers around cessation or by insisting that their refusal to stop is dangerous to their health. Still, this approach is largely ineffective as it will likely cause the patient to become defensive, agitated, and insecure. They probably already know that using meth is dangerous but just might not be ready to make that change. When serving unhoused individuals, it is therefore essential to “meet them where they are at” in their health care journey. Drawing from the narrative ethics framework of the ‘mattering map,’ providers could further support unhoused patients make decisions by exploring their past experiences nonjudgmentally, taking the necessary time to discuss and understand their complexities, and helping them identify their values and what matters to them in a health care context where they may have previously been marginalized. In this way, providers can ensure that these patients’ autonomy is upheld and high-quality care is delivered.
Exemplar of Ethical Health Care for the Unhoused Community
Peninsula Healthcare Connection (PHC) Clinic is a community health organization in Palo Alto, California, that has been working since 2006 to expand health care access to unhoused individuals. With only eight rotating health care providers and two exam rooms, PHC Clinic is undoubtedly small. What they lack in size, though, they make up for with dedication to their patients.
Through partnerships with Palo Alto Foundation Medical Group and Stanford Health Care, physicians volunteer their time and medical expertise to PHC Clinic and provide underserved patients with high-quality care for their physical and mental health needs. Similar to how concierge physicians build tight-knit relationships with their socially elite patients, PHC Clinic does the same with the underserved. From the moment they walk in the door, patients are met by the clinic’s efforts to help them navigate through a complex health care system, from nonjudgmentally addressing their concerns during appointments to advocating for their needs with insurance companies and specialty referrals.
Health Equity and Innovation Fellow, Bilal Arshadullah ’24, works with a patient at the Opportunity Center Blood Pressure Clinic in Palo Alto, California in May 2025. Photo provided courtesy of Bilal Arshadullah.
PHC Clinic’s strategies for increasing health care access are not limited to the clinic – in fact, community outreach is a major part of their work. PHC Clinic goes into the community to serve patients and extends its reach to people who are unable to overcome the many social, financial, and physical barriers to receiving care. For example, in the Backpack Medicine Program, community outreach specialists and a physician visit local homeless shelters so shelter residents can speak with the provider about any medical concerns they may have without needing to go to the clinic. They can also speak with an outreach specialist about any social needs they might have and get connected to helpful resources for things like food insecurity, legal services, or case management. In addition, PHC Clinic conducts a weekly blood pressure clinic at the LifeMoves Opportunity Center to screen people for hypertension. People who might have just been at the Opportunity Center for a hot breakfast or to do their laundry can get their blood pressure checked, make an appointment with a provider, and take back control over their health. PHC Clinic’s relentless efforts have significantly increased health care access for people in the community experiencing homelessness.
How Do We Approach Homeless Health Care in the Future?
While PHC Clinic’s work is commendable, it doesn’t change the reality that healthcare organizations serving unhoused individuals are in need of more support. There is a need for additional funding to be directed towards community health centers. Federal funding for these centers has decreased over time, while the number of clinics, patients served, and operating costs have all increased.
Concerns have also risen regarding the Department of Government Efficiency (DOGE) looking to make federal budget cuts in the Centers for Medicare & Medicaid Services (CMS). These cuts are steps in the absolute wrong direction. Instead of raising community health funding and thereby enhancing health care access for unhoused patients, the financial barriers created because of the proposed cuts make it increasingly difficult for unhoused patients – who heavily rely on Medicaid services – to receive care. We must preserve and expand federal budget allocation to community health programs so more unhoused patients can receive the care they deserve.
Additionally, there is widespread debate about modifying the existing “housing first” model concurrently to address health care needs. This sentiment comes from the fact that while people experiencing homelessness await rehousing, their health often gets neglected. By the time they get housed, often their conditions progress to be debilitating, or even fatal.
To alleviate this issue, community health centers utilize community health navigators, people on the ground who can help guide unhoused patients through the health care system while waiting for housing. Community health navigators ensure that when unhoused patients eventually get housing, they can live long, full lives. With these considerations, we can take long-overdue steps to expand community health services and fulfill unhoused people’s health care needs.