Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=ysdh20

Journal of Social Distress and the Homeless

ISSN: 1053-0789 (Print) 1573-658X (Online) Journal homepage: https://www.tandfonline.com/loi/ysdh20

Racial discrimination in the life course of olderadults experiencing homelessness: results fromthe HOPE HOME study

Dereck W. Paul Jr., Kelly R. Knight, Pamela Olsen, John Weeks, Irene H. Yen &Margot B. Kushel

To cite this article: Dereck W. Paul Jr., Kelly R. Knight, Pamela Olsen, John Weeks, Irene H. Yen& Margot B. Kushel (2019): Racial discrimination in the life course of older adults experiencinghomelessness: results from the HOPE HOME study, Journal of Social Distress and the Homeless,DOI: 10.1080/10530789.2019.1702248

To link to this article: https://doi.org/10.1080/10530789.2019.1702248

Published online: 18 Dec 2019.

Submit your article to this journal

Article views: 149

View related articles

View Crossmark data

ORIGINAL RESEARCH PAPER

Racial discrimination in the life course of older adults experiencinghomelessness: results from the HOPE HOME studyDereck W. Paul Jr. a, Kelly R. Knightb,c, Pamela Olsenc,d, John Weeksc,d, Irene H. Yene and Margot B. Kushelc,d

aSchool of Medicine, University of California, San Francisco, CA, USA; bDepartment of Anthropology, History, and Social Medicine, Universityof California, San Francisco, CA, USA; cCenter for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center,University of California, San Francisco, CA, USA; dDivision of General Internal Medicine, Department of Internal Medicine, ZuckerbergSan Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, USA; eDepartment of Public Health, School ofSocial Sciences, Humanities and Arts, University of California, Merced, CA, USA

ABSTRACTOver 2.5 million people experience homelessness yearly in the United States. Black persons areoverrepresented by three-fold among those experiencing homelessness but little research hasexamined the relationship between race and homelessness. We aimed to understand therelationship between race and the experience of homelessness for older adults. We usedgrounded theory methodology to analyze in-depth qualitative interviews (n = 65) of personsexperiencing homelessness. We recruited participants who were enrolled in two sub-studiesof the Health Outcomes of People Experiencing Homelessness in Older Middle AgE (HOPEHOME) Study in Oakland California. We identified two major themes within interviews withBlack participants (n = 52) related to race: (1) participants experienced overt racialdiscrimination in early life and (2) structural racism precipitated and perpetuated adulthomelessness. Further, we identified sub-themes of structural racism that contributed toparticipants becoming or staying homeless: criminal justice discrimination, employmentdiscrimination, exposure to violence, premature death, and limited family wealth. Wedeveloped a theoretical model of how these elements of structural racism may increasesusceptibility to homelessness. These relationships between racial discrimination andhomelessness may serve as targets for policies aimed at preventing homelessness.

ARTICLE HISTORYReceived 15 June 2019Revised 17 November 2019Accepted 2 December 2019

KEYWORDSHomelessness; housing; racialdiscrimination; structuralracism; health disparities

Introduction

Over 2.5 million people experience homelessnessyearly in the United States (Fazel, Geddes, & Kushel,2014). Between 2017 and 2018, the proportion of theUS population experiencing homelessness rose forthe second year in a row (Henry et al., 2018). Home-lessness is associated with higher rates of physical,mental, and substance-use related health conditions(Brown et al., 2016; Patanwala et al., 2018; Spinelliet al., 2017), higher usage of emergency and hospitalservices (Raven et al., 2017), and higher rates of mor-tality than the general population and housed low-income populations (Aldridge et al., 2018; Fazel et al.,2014; Morrison, 2009; Nusselder et al., 2013; Roncaratiet al., 2018).

Persons of color make up the majority of thoseexperiencing homelessness (Henry et al., 2018). Blackpersons are the most overrepresented, making up40% of the population experiencing homelessness butonly 13.5% of the general population in the UnitedStates (Henry et al., 2018). Nearly 17% of older Blackpersons have experienced homelessness within theirlifetimes (Fusaro, Levy, & Shaefer, 2018).

Black persons make up 21% of the population belowthe federal poverty line but 40% of the population

experiencing homelessness, which suggests that factorsbeyond higher representation among those experien-cing poverty make the Black population more suscep-tible to homelessness. Yet, the factors driving Blackoverrepresentation among the population experiencinghomelessness and their implications remain understu-died (Jones, 2016).

While quantitative methods reveal racial disparities inwho experiences homelessness, qualitative methodologiesare necessary to examine the social factors driving thoseracial disparities. Using a qualitative methodology, weanalyzed participant interviews, identified themes relatedto race, and present a theoretical model of how race maybe related to homelessness.

Methods

Study rationale and design

We recruited older adults experiencing homelessnessto the Health Outcomes of People Experiencing Home-lessness in Older Middle agE (HOPE HOME) study inOakland California from a random sample of homelessencampments, one recycling center, all overnighthomeless shelters, and all low-cost or free meal pro-grams. We designed this sampling method with our

© 2019 Informa UK Limited, trading as Taylor & Francis Group

CONTACT Dereck W. Paul Jr. dereck.paul@ucsf.edu 513 Parnassus Ave, Suite 245, San Francisco 94131, CA, USA @dereckwpaul

JOURNAL OF SOCIAL DISTRESS AND THE HOMELESShttps://doi.org/10.1080/10530789.2019.1702248

community advisory board using the best availableknowledge of the population experiencing homeless-ness in Oakland. Study interviews took place atSt. Mary’s Center, a non-profit community-basedorganization serving older adults. To meet study cri-teria, participants were English-speaking, aged 50 andover, defined as homeless by the Homeless EmergencyAssistance and Rapid Transition to Housing Act, andable to give informed consent. We obtained writteninformed consent from all study participants.

We conducted in-depth qualitative interviews with65 HOPE HOME study participants that exploredtheir lived experiences with homelessness. We inter-viewed participants from two sub-studies of HOPEHOME. The Homelessness across the Life Course (LifeCourse) sub-study aimed to identify key life eventsand precipitants of homelessness. The Family-AssistedHousing (FAH) sub-study aimed to understand theexperience of older homeless adults and the supportthey receive from families and friends. Both studiesconducted in-depth qualitative interviews where weinvited participants to speak openly about their experi-ences with homelessness.

We analyzed the interview data from both sub-studies. We sampled individuals using a purposivepopulation-based sampling method. In Life Course,we purposively sampled 24 total participants, stratifiedby age of first adult homelessness (before 50 versusafter 50), oversampling women. In FAH, we purpo-sively sampled 48 participants with recent stays or con-tact with family. Seven HOPE-HOME participantswere participants of both sub-studies (Table 1).

Data collection

Researchers conducted one-time 60–90 min semi-structured qualitative interviews that focused on par-ticipants’ experiences with homelessness. In LifeCourse, we interviewed participants about their life his-tory, focusing on their childhoods and the period pre-ceding their first episode of homelessness In FAH, weinterviewed participants about their lives prior tobecoming homeless, their relationships with theirfamilies, and their experience of being homeless. Inter-viewers did not ask participants explicitly about race orracial discrimination. We provided a $25 gift card for

participation. The institutional review board of theUniversity of California, San Francisco approved allstudy activities.

Data analysis

Three coders independently coded interviews inbatches of 4–5 interviews and revised the codebookuntil they achieved inter-rater reliability (Corbin &Strauss, 2008). We coded data using the Atlas.ti Quali-tative Data Analysis Software (version 7.5.17). Follow-ing interviews, we generated detailed summaries andtheoretical memos that detailed our thematicimpressions and insights (Montgomery & Bailey,2007). We identified areas of the transcripts where par-ticipants explicitly discussed race. In addition, weidentified areas of the transcripts where participantsdiscussed experiences with elements of structuralracism. The sociological literature establishes theseelements of structural racism, but participants maynot have recognized them as such. We identified emer-gent themes and subthemes within these areas of tran-scripts. Finally, we analyzed the interrelatedness ofthemes and developed a theoretical model of increasedsusceptibility to homelessness. We have edited partici-pant quotations for clarity.

Results

Among the participants interviewed, 52 of the 65 ident-ified as Black, five as White, three as Latino, two asAsian or Pacific Islander, and three as other or mixedrace/ethnicity. Fifty-one of the participants identifiedas men, thirteen as women, and one participant ident-ified as a transgender woman. While we analyzed datafrom all 65 participants, we were only able to identifythemes from the body of interviews of Black partici-pants. There were too few participants who identifiedwith other identity groups to enable us to draw themesabout their collective experience.

We identified two major themes within the inter-views related to race from interviews with Black par-ticipants: (1) Participants experienced overt racism inearly life. (2) Structural racism precipitated and perpe-tuated homelessness.

Overt racism is defined as discrimination basedexplicitly on the basis of race. Structural racism isdefined as the societal systems, social forces, insti-tutions, and ideologies that perpetuate racial inequities(Bailey et al., 2017; Gee & Ford, 2011). The forces ofstructural racism are often invisible to those affectedby it. This is because structurally racist forces are, ontheir surface, race-neutral. It is a macro analysis ofthe disparities they create reveals their racial bias.This superficial appearance of race-neutrality thatallows structurally racist policies to persist despitelegislation prohibiting racially discriminative policies

Table 1. Participant demographics, (n = 65).

CharacteristicPercentage of participants(number of participants)

Men, % 78.5 (51)Women, % 20 (13)Transgender Women, % 2 (1)Race/ethnicityBlack/African American, % 80 (52)White, % 7.7 (5)Latino, % 4.6 (3)Other, % 4.6 (3)Asian and Pacific Islander 3.0 (2)

2 D. W. PAUL JR. ET AL.

(Kendi, 2017; Kendi, 2019; Metzl & Roberts, 2014; Nel-son, 2016; Roberts, 1999).

We identified subthemes within the theme of struc-tural racism: criminal justice discrimination (Alexan-der, 2012; Loïc, 2001), employment discrimination(Quillian, Pager, Hexel, & Midtbøen, 2017), racial dis-parities in exposure to violence (Auyero & Bourgois,2015; Browning et al., 2017; Zimmerman & Messner,2013), racial disparities in rates of premature death(Cunningham et al., 2017), and racial disparities infamily wealth (Bailey et al., 2017; Roberts, 1999).

Overt racism in early life

Black participants reported being targets of open preju-dice and racial discrimination in their early lives.Exposure to racial violence limited education and occu-pational opportunity for one participant who recalledbeing threatened with violence when he attended anewly desegregated high school.

Participant 1, Black, Male, Age 59

It was during that Brown versus Board of Education.They put us in a school in B. [predominantly Whiteneighborhood], which was insane. Between the trainstation and the school there were a bunch of[White] guys waiting with bats and chains… thecops would look at us and see what was going onand would just drive away. You know, what scaredme is that one [Black] guy they caught and beat himso bad that he just had a hole in his face, all histeeth, everything was gone, his lips, everything. Itscared me so much. I said, “I’m not coming back tothis school.”

The participant left school and never returned. Withlimited education, he struggled to find work: “I was outof school, out of work, might as well say I was hustling.”He connected exposure to heroin and cocaine in histeenage years to his being out of school. Later in life,substance-use disorder contributed to his losing a joband subsequent homelessness.

For another participant, racialized verbal abuse andexclusion limited social networks. Another participantrecounted being the target of racial epithets andexcluded from activities on the basis of race. Hereported that this incident made a previously largeand diverse social network smaller.

Participant 2, Black, Male, Age 54

It’s sad that this world got to be a color barrier.Because when I grew up, we had a nice little crew, awhite family, another white girl, a Filipino guy, aSpanish guy, a half-Black and half Indian guy, andan Italian and German guy… There’s only one thingthat I really felt bad about when I was a kid. ThatWhite family always used to come get us, we used togo to A’s games, and we went somewhere to pick upanother [White] family and they said they wasn’tgoing because I was in the backseat…And I was reallyhurt and they called me a little baboon, African porch

monkey or something like that. But that stuff reallystick with me and I started hating White people fora while.

Structural racism

Criminal justice discriminationBlack participants described interactions with thecriminal justice system that led directly to housingloss or sustained ineligibility for subsidized housing.One participant connected the criminalization ofnon-violent drug crimes with his becoming homeless:

Participant 3, Black, Male, Age 62

They didn’t catch me with anything but they just sus-pected that I had sold some drugs. They didn’t find thedrugs or the money, so they gave me a possessioncharge, a misdemeanor. But that allowed them tocome into my room any time. So they came in whileI was not expecting, [I] had a half-ounce of cocaine.They turned the misdemeanor into a felony and vio-lated my probation, which is the game that theyplay. Okay, so then I end up losing my possessions,losing my [housing], by the time I come out [of jail]I’m homeless.

Felony records made participants temporarily ineli-gible for housing assistance through their local publichousing authorities. Participants described beingdenied a Housing Choice (“Section 8”) vouchers:

Participant 4, Black, Male, Age 57

I signed up for Section 8 before and we got denied. Iprobably got denied because I have a felony record. Iwent to jail for somethin’ I didn’t do, standin’ out infront of that old place out there. These guys goes inthe building. I’m outside talkin’ to ‘em, they goesinside the building, come back with some stuff, andthe police come and put handcuffs on me. And nextthing I know, I’m under arrest for somethin’ I didn’t do.

Participant 5, Black, Male, Age 52

She just looked at me and she said, “Oh, I’m so sorry,we don’t house criminals.” So if you have any type ofoutstanding warrants or anything it will affect yourhousing.

Several participants reported racial profiling andarrest for crimes they report they did not commit. Par-ticipants’ social networks experienced a similarly highprevalence of criminal justice interactions. Participantswere at times unable to access financial or housingassistance because their family and friends were incar-cerated or on parole.

Employment discriminationParticipants of all races reported that job loss was acommon precipitant of homelessness. Some reportedjob loss after being employed their entire adult lives:

Participant 6, Black, Male, 65

I lost my job and it trickled downhill. Everything juststart falling apart. Bills due, couldn’t pay the bill, you

JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 3

know. Rent was due, couldn’t pay the rent. Car notedue, couldn’t pay the car note. I ended up [with a]voluntary repossession on the car. The landlord even-tually gave me $2500 to get out of the place. I packedup all my stuff, stored it. But I still had no work, nosteady income coming in, so I lost the storage. I endup losing this, losing that, so after about six months,the only thing I had was the clothes on my back,and, you know, couple blankets.

However, only Black participants reported racialdiscrimination in the job market.

Participant 2, Black, Male, Age 54

I was working in W. [a predominantly white suburb]and there was a lot of racial tension. And when theyhad cutbacks most of the minorities got let loose[laid off], and some of us was hired before the otherpeople…we had a real nice crew, and you can, youcan just tell when it’s racial. And [White] guys [that]came on after us, stayed, but me and the Asian guysgot cut loose because they said cutbacks and stuff,but I think that the guy I was working for, I thinkhe just, was racist.

Participant 7, Black, Male, Age 59

When they received her [participant mother’s] appli-cation they told her, “Come on, you’re hired,” theyhired her sight unseen, and when she showed up asa Black person they said, “No, Negress, we’re not hir-ing you. They didn’t know she was Black… she suedthem and won her case and they hired her.”

Exposure to violenceBlack participants reported living in neighborhoodsthat they believed to be unsafe due to drug trade orcommunity violence. In some cases, safety concernsled participants to leave their home.

Participant 8, Black, Male, Age 60

I continued to live there but drug dealers had movedinto the neighborhood. I was in bed and all thisgunfire started, and it sounded like the guy was inthe room with me. I mean I heard the gun recoiland everything. I finally got up off the floor becauseas soon as it started I’d rolled out the bed to thefloor. The guy was under my bedroom window havinga gunfight with another guy in front of the house. So, Imoved out of there the next day.

Another participant described their unsuccessfulsearch for a neighborhood free of gang violence beforebecoming homeless:

Participant 7, Black, Male, Age 59

I had an apartment in East Oakland but it was unsatis-factory, it was in a drug area, so I kept moving, goingback to Los Angeles and I came, I got tired of L.A.because L.A. was too much gang, gang warfare, andthen I got here, and it was the same situation here.

Participant 3: Black, Male, 64

“Okay, so there was an incident at my other sister’shouse, and it involved a shooting and a killing. Her

son got shot up, so she decided she was gonnamove, but she couldn’t really afford to move.”

Exposure to and fear of physical violence limitedhousing options for these participants, contributingto their becoming or staying homeless.

Premature deathThe premature death of Black participants’ parents,siblings and friends contributed, directly or indirectly,to their becoming homeless. One participant describedthe death of parent in early life that introducedemotional and financial hardships.

Participant 9, Black, Male, 57

We lost our mother when we were very, very young;she passed in ‘73. I was in the 9th grade, and I’m 57now, so they were very young. So we all like cameup on our own, you know, and I guess our copingskills weren’t up to par.

Participants described social networks depletedfrom deaths which limited their ability to access hous-ing or food in times of need:

Participant 10, Black Male, 66

All my close friends are dead. Which is sad. Like I said,I grew up in the 50s and the 60s and the 70s, and theywas doin’ drugs, alcohol. A lot of my friends died ofalcoholism or drug overdose or just dead.

Participant 11, Black, Male, 57

And other people that I knew, I heard, who were closeto my same age, to my age, I mean, and they were justdying’, not from gunshot wounds or anything likethat, from illness.

Participant 12, Black, Female, 62

Me? You know what? When you’ve been through somany deaths – you know, my mom passed, then mydad passed, I had two brothers before my mom anddad passed, drown at the same time, had anotherbrother that drowned, and most of my immediatefamily.

Limited family wealthBlack participants described family members whowere, like them, in financially vulnerable positions.Few family members owned homes and many livedin public housing or received housing subsidies. In ren-tal housing, with or without publicly funded subsidies,family members’ leases often included restrictions onallowing guests to stay with them. Participants fearedthat staying with family would lead to their familymembers’ eviction and would not stay with housedfamily members in times of need:

Participant 13, Black, Male, 55

But there’s really no one that actually sees me come inand go out [of my daughter’s apartment] – becausewhen I’m there, I don’t make a lot of noise. I go in

4 D. W. PAUL JR. ET AL.

and I stay inside and I just take it easy so – and shedoesn’t have a lot of friends in the building thatcome in and say, hey, your dad’s here! So a lot ofpeople don’t know, and I don’t know if there’s a secur-ity camera. I really don’t want to jeopardize my daugh-ter[’s] [housing].

Participants also described the loss of family homes.Participant 14, Black, Female, 61

He [participant’s father] sold it [the family house]because he couldn’t pay for it no more, he sold itand we all went different ways.

Participant 15, Black, Male

Well, I think they sell it [the house the participantgrew up in], I’m pretty sure they did.

We developed a theoretical model of how racial dis-crimination may increase susceptibility to homeless-ness based on the experiences of participants withstructural racism. We present our theoretical modelin the form of a structural map (Figure 1). Experien-cing criminal justice discrimination may result inineligibility for subsidized housing and difficulty acces-sing housing in the private market. Employment dis-crimination limits income, which leads to limitedhousing options. Difficulty finding safe neighborhoodsfurther limits housing options. When facing homeless-ness, it may not be possible to fall back on a social net-work that is subject to the forces of structural racism.Health disparities, such as the premature death offamily friends and criminal justice discriminationmay deplete social networks. Further, family membersmay be themselves be renters with restrictions on whothey can house.

Discussion

Through qualitative research embedded within a longi-tudinal cohort study of older adults experiencinghomelessness (Brown et al., 2016; Brown et al., 2017;Hurstak et al., 2017; Landefeld et al., 2017; Patanwalaet al., 2018; Spinelli et al., 2017), we found that racial

discrimination played a key role in the life course ofolder Black participants. Using grounded theory meth-odology, we found that overt racism in early life limitededucational attainment and social networks for Blackparticipants, which may have led to downstreameffects in adulthood. Experiences with known elementsof structural racism contributed to becoming or stayinghomeless for Black participants.

Downstream effects of racial discrimination inearly life

Our participants were children during the Civil RightsEra (1940–1971). Two participants described experi-ences with racial violence, racialized verbal abuse,and race-based exclusion during childhood. Partici-pants emphasized and retold these experiences, with-out prompting, when recounting their pathway tohomelessness. The temporal distance between thesechild events and their adult homelessness makes draw-ing direct connections between these experiencesdifficult. While only two participants offeredunprompted stories of being racially discriminatedagainst as children, these narratives provide infor-mation about the racial climate this cohort of mayhave faced in childhood.

A body of social science literature has established abiopsychosocial model of race-based traumatic stressin which psychological and emotional trauma canlead to negative long-term outcomes including poorhealth (Carter et al., 2013; Heard-Garris, Cale, Camaj,Hamati, & Dominguez, 2018; Robert, 2007). To ourknowledge, the association between overt racism andadult homelessness has not yet been studied. AdverseChildhood Events (ACEs), such as parental abuseand neglect, are known to be associated with highschool non-completion, unemployment, low-income,health-compromising behaviors, and criminal justiceinvolvement. These studies do not include experienceswith racial discrimination in childhood as an ACE but

Figure 1. A theoretical model of racial discrimination in the pathway to homelessness.

JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 5

our findings suggest that these experiences may havelong-term negative impacts (Giovanelli, Reynolds,Mondi, & Ou, 2016; Metzler, Merrick, Klevens, Ports,& Ford, 2017).

Interconnected and compounding effects ofstructural racism

Increasingly, societal structures (i.e. structural racism),rather than acts of overt discrimination maintainracial inequities (Carmichael & Hamilton, 1967;Jones, 2000). We identified widespread exposure tovarious forms of structural racism in the life courseof our participants.

In our study, Black participants reported frequentinvolvement with the criminal justice system, whichresulted in or maintained their homelessness. SeveralBlack participants recounted arrest or conviction forcrimes they reported that they did not commit. Thesefindings are consistent with documented racial dis-crimination across the criminal justice system (Hinton,Henderson, & Reed, 2018). Black men are six timesmore likely to be incarcerated than White men, Blackwomen twice as likely as White women (Carson &Anderson, 2016). Black Americans are more likely tobe stopped and detained pretrial, and are twelvetimes more likely to be wrongfully convicted thaninnocent White Americans of drug crimes (Gross,Possley, & Stephens, 2017). When convicted, BlackAmericans face harsher sentencing (Hinton, Hender-son, & Reed, 2018).

Incarceration has detrimental effects on individuals,including decreased ability to access housing, income,and public assistance (Alexander, 2012; Kirk &Wakefield, 2018). In our study, incarceration ham-pered protection against exits from homelessness bymaking participants ineligible for subsidized housing.The loss of access to housing and other forms of econ-omic support is a recognized collateral consequence ofcriminal justice involvement (Kirk & Wakefield, 2018).Those with a felony conviction face a federally man-dated 3-year ban on eligibility for subsidized housing,and local housing authorities maintain the ability toimpose stricter bans (Keene, Rosenberg, Schlesinger,Guo, & Blankenship, 2018).

For all renters, whether or not their housing is sub-sidized, there is little protection against criminal back-ground checks and discrimination by landlords(Garboden, 2018). Persons with criminal records arenot a protected group under the Fair Housing Act(FHA). Under federal guidelines, housing providersmay consider some forms of criminal justice systeminvolvement in determining rental eligibility. Becauseof increased recognition that criminal justice involve-ment disproportionately impacts racial minorities,such policies can be contested under the FHA, butmany go unchallenged (Kanovsky, 2016). A recent

study shows that Black Americans with criminalrecords receive unequal treatment from housing provi-ders compared with White Americans with the samecriminal record (Locked Out, 2015). As long as racialminorities are overrepresented among those with crim-inal records, legal discrimination against those withcriminal records will contribute to racial disparities inhousing access and homelessness.

Job loss precipitated housing loss for many partici-pants, consistent with a recent survey finding employ-ment loss to be the most common proximal cause ofhomelessness (San Francisco Homeless Count & Sur-vey, 2017). Our findings that Black Americans werediscriminated against in employment is consistentwith documented racial discrimination in hiring (Quil-lian et al., 2017), as well as discriminatory monitoringand firing (Cavounidis & Lang, 2015). Limited incomedue to employment discrimination contributed to lim-ited access to housing for some participants and theirfamilies. Further exacerbating limited housing access,Black Americans may pay higher rent than WhiteAmericans when accessing identical housing in identi-cal neighborhoods (Early, Carrillo, & Olsen, 2019).

Exposure to and fear of violence further limitedhousing options and contributed to becoming home-less for some participants. Historically discriminatoryhousing policies, known as “redlining,” have concen-trated Black communities within impoverished neigh-borhoods of American cities (Aaronson, Harley, &Mazumder, 2017). Studies suggest that these policiesof racial segregation and impoverishment drive higherlevels of exposure to violence within these neighbor-hoods (Jacoby, Dong, Beard, Wiebe, & Morrison,2018; Krivo, Peterson, & Kuhl, 2009). Participantsdescribed having limited housing options because offear of violence as well as moving between multiplecities to search for safety.

Criminal justice discrimination, subsequent legalhousing discrimination, employment discrimination,and limited access to safe housing contributed to hous-ing instability and loss for Black participants. Theseforces acted on their family members and friends.When participants needed help, they could not fallback on their social networks for support. Overthree-quarters of recently incarcerated persons reporteither being ineligible for or having been denied hous-ing because of their own or a close contacts’ convictionhistory (deVuono-powell, Schweidler, Walters, & Zoh-rabi, 2015).

The documented life expectancy gap for BlackAmericans manifested in our study as participantexperiences with the premature death of family andfriends (Arias, 2015). Participants reported that hav-ing a parent die during their childhood destabilizedtheir families and finances. Death of a parent inchildhood is associated with poorer mental healthoutcomes in persons experiencing homelessness

6 D. W. PAUL JR. ET AL.

(Lee et al., 2017). The prevalence of these losses isconsistent with studies showing Black Americansare more likely than White Americans to have aparent die during childhood, an established sourceof racial disadvantage (Umberson et al., 2017). Forour participants, losses from the premature death offamily members compounded with incarceration toleave social networks depleted.

Black participants reported being close to family andfriends they did have but family members were them-selves low-income, consistent with the persistent andwidening wage gap between Black and White Ameri-cans (Bayer & Charles, 2018; Jones, Schmitt, & Wilson,2018). Families rarely had wealth to insulate againstfinancial hardship. White households have nearly tentimes the median wealth of Black households (Dettling,Hsu, Jacobs, Moore, & Thompson, 2017; Jones et al.,2018). Over one-third of Black households have zeroor negative wealth holdings (Kochhar, Taylor, & Fry,2011).

Many of the participants’ family members experi-enced housing insecurity or lived in subsidized hous-ing. Few families owned homes. The homeownershiprate for Black Americans is 29% below that of Whitesand this gap is increasing (The State of The Nation’sHousing, 2018). Research has linked the persistent dis-parities in homeownership to a history of de facto andde jure racial discrimination, often referred to as “red-lining” (Rothstein, 2017). Rental leases, in both subsi-dized and non-subsidized housing, place limits onhow long tenants may allow non-lease holders to stayin their housing units. Violating these clauses canlead to eviction. Black Americans continue to be athighest risk for eviction across American cities (Des-mond, 2012). In our study, participants’ fear of precipi-tating their family’s eviction curtailed their willingnessto stay with family. This finding was consistent with arecent study that showed Black and Latinx families,compared to White families, were less able to accessrent-free arrangements when they needed assistance(Whitehead, 2018). Both participants and membersof their social network were affected by structuralracism, leading to an increased susceptibility tohomelessness.

Our study had limitations. We recruited from onecity. All interviews were conducted in English. Wedid not design the qualitative interviews to queryabout racial discrimination. However, exploratoryqualitative studies are intentionally open-ended andparticipant-driven. The open-ended nature of semi-structured interviews allows themes to emerge thatmay not be identified using other research method-ologies. Narratives about racial discrimination wereoffered unprompted, underscoring their salience toparticipants. We were only able to identify themesfrom the body of interviews of Black American partici-pants because other races and ethnicities were not

represented well enough to enable us to draw themesabout their collective experience. Additionally, wewere unable to identify themes specific to intersectionsof race and gender or sexual orientation due to limitedrepresentation.

Conclusions

We developed a theoretical model of the way experi-ences with overt and structural racism may lead toand perpetuate homelessness for older Black adults.Addressing these social processes may be a criticalcomponent of addressing racial health disparities thatresult from the increased risk of homelessness borneby Black Americans. Further research may include vali-dated measures to examine experiences of discrimi-nation, examine the prevalence of experiences knownto represent structural racism, and qualitativeapproaches that directly ask participants about theirexperiences with overt racism before and after becom-ing homeless. We recommend that efforts aimed atending homelessness target the effects of structuralracism with polices such as (1) criminal justice reformaimed at decreasing barriers to obtaining subsidizedand free-market housing for formerly incarcerated per-sons; (2) increased availability of legal assistance forpersons facing employment and housing discrimi-nation; (3) assistance to renters facing eviction throughenforcement of the Fair Housing Act; (4) and policiesthat promote family wealth for low income families,including assistance with homeownership.

Acknowledgments

The authors thank Dr Lisa A. Cooper, Dr Andrea Lopez, andDr Alex H. Kral for their review of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by grants from the National Insti-tute on Aging [grant numbers K24AG046372 andR01AG041860] and the National Institute on MinorityHealth and Health Disparities [grant numberR25MD006832]and the Student National Medical Associ-ation’s David E. Satcher MD, PhD Research Fellowship forHealth Disparities.

Prior presentations

2018 Society of General Internal Medicine AnnualMeeting, 2018 UCSF 12th Annual Health DisparitiesResearch Symposium.

JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 7

Ethical approval

All procedures performed in studies involving humanparticipants were in accordance with the ethical stan-dards of the institutional review board of the Universityof California, San Francisco and with the 1964 Helsinkideclaration and its later amendments or comparableethical standards.

Notes on contributors

Dereck W. Paul Jr, MS is an MD Candidate at the Universityof California San Francisco (UCSF) where he served as aCo-President of the Student National Medical Association(SNMA) UCSF chapter and is a SNMA David E. SatcherResearch Fellow in Health Disparities.

Kelly R. Knight, PhD is an Associate Professor in the depart-ment of Anthropology, History, and Social Medicine at theUniversity of California San Francisco where she studiesthe social construction and experiences with addiction,comorbidity, chronic pain, motherhood, and citizenship.

Pamela Olsen, MA is Clinical Research Coordinator at theCenter for Vulnerable Populations at the ZuckerbergSan Francisco General Hospital and Trauma Center andUniversity of California San Francisco where she researchesaging and homelessness as part of the HOPE-HOME projectteam in Oakland, CA.

John Weeks is a Clinical Research Coordinator at the Centerfor Vulnerable Populations at the Zuckerberg San FranciscoGeneral Hospital and Trauma Center and University of Cali-fornia San Francisco where he researches aging and home-lessness as part of the HOPE-HOME project team inOakland, CA.

Irene H. Yen, PhD is a Professor in the School of PublicHealth at the University of California Merced where shestudies the social epidemiology of place, race, and socialstatus.

Margot B. Kushel, MD is a Professor of Medicine and Direc-tor of the Center for Vulnerable Populations at the Zucker-berg San Francisco General Hospital and Trauma Center andUniversity of California San Francisco where she studieshousing, homelessness, and health, and leads the UCSFBenioff Homelessness and Housing Initiative.

ORCID

Dereck W. Paul http://orcid.org/0000-0001-6099-5933

References

Aaronson, D., Harley, D., & Mazumder, B. (2017). TheEffects of 1930s HOLC “Redlining” Maps. FederalReserve Bank of Chicago.

Aldridge, R. W., Story, A., Hwang, S. W., Nordentoft, M.,Luchenski, S. A., Hartwell, G., & Hayward, A. C. (2018).Morbidity and Mortality in Homeless Individuals,Prisoners, Sex Workers, and Individuals with SubstanceUse Disorders in High-income Countries: A SystematicReview and Meta-analysis. Lancet, 391, 241–250.

Alexander, M. (2012). The New Jim Crow: Mass incarcera-tion in the Age of Colorblindness.

Arias, E. (2015). United States Life Tables, 2011. NationalVital Statistics Reports, 64, 1–63.

Auyero, J., & Bourgois, P. I. (2015). Scheper-Hughes N.Violence at the Urban Margins.

Bailey, Z. D., Krieger, N., Agenor, M., Graves, J., Linos, N., &Bassett, M. T. (2017). Structural Racism and HealthInequities in the USA: Evidence and Interventions.Lancet, 389, 1453–1463.

Bayer, P. J., & Charles, K. K. (2018). Divergent Paths: A NewPerspective on Earnings Differences Between Black andWhite Men Since 1940. The Quarterly Journal ofEconomics, 133(3), 1459–1501.

Brown, R. T., Goodman, L., Guzman, D., Tieu, L., Ponath, C.,& Kushel, M. B. (2016). Pathways to Homelessness amongOlder Homeless Adults: Results from the HOPE HOMEStudy. PLoS One, 11(5), e0155065.

Brown, R. T., Hemati, K., Riley, E. D., Lee, C. T., Ponath, C.,Tieu, L.,… Kushel, M. B. (2017). Geriatric Conditions in aPopulation-Based Sample of Older Homeless Adults. TheGerontologist, 57, 757–766.

Browning, C. R., Calder, C. A., Ford, J. L., Boettner, B., Smith,A. L., & Haynie, D. (2017). Understanding RacialDifferences in Exposure to Violent Areas: IntegratingSurvey, Smartphone, and Administrative DataResources. The Annals of the American Academy ofPolitical and Social Science, 669, 41–62.

Carmichael, S., & Hamilton, C. V. (1967). Black Power: ThePolitics of Liberation in America. New York.

Carson, E. A., & Anderson, E. (2016). Prisoners in 2015.Bureau of Justice Statistics, United States Department ofJustice.

Carter, R. T., Mazzula, S. L., Victoria, R., Vazquez, R., Hall,S., Smith, S. C., … Williams, B. (2013). InitialDevelopment of the Race-based Traumatic StressSymptom Scale: Assessing the Emotional Impact ofRacism. Psychological Trauma: Theory, Research,Practice, and Policy, 5, 1–9.

Cavounidis, C., & Lang, K. (2015). Discrimination andWorker Evaluation. National Bureau of EconomicResearch.

Corbin, J. M., & Strauss, A. L. (2008). Basics of QualitativeResearch: Techniques and Procedures for DevelopingGrounded Theory.

Cunningham, T. J., Croft, J. B., Liu, Y., Lu, H., Eke, P. I., &Giles, W. H. (2017). Vital signs: Racial disparities inage-specific mortality among blacks or AfricanAmericans – United States, 1999–2015. Morbidity andMortality Weekly Report, 66, 444–456.

Desmond, M. (2012). Eviction and the Reproduction ofUrban Poverty. American Journal of Sociology, 118(1),88–133.

Dettling, L. J., Hsu, J. W., Jacobs, L., Moore, K. B., &Thompson, J. P. (2017). Recent Trends in Wealth-Holding by Race and Ethnicity: Evidence from the Surveyof Consumer Finances. Board of Governors of theFederal Reserve System (U.S.).

deVuono-powell, S., Schweidler, C., Walters, A., & Zohrabi,A. (2015). Who Pays? The True Cost of Incarceration onFamilies. Ella Baker Center for Human Rights, ForwardTogether, Research Action Design.

Early, D. W., Carrillo, P. E., & Olsen, E. O. (2019). RacialRent Differences in U.S. Housing Markets. Journal ofRegional Science, 59(4).

Fazel, S., Geddes, J. R., & Kushel, M. (2014). The Health ofHomeless People in High-income Countries: DescriptiveEpidemiology, Health Consequences, and Clinical andPolicy Recommendations. Lancet, 384, 1529–1540.

Fusaro, V. A., Levy, H. G., & Shaefer, H. L. (2018). Racial andEthnic Disparities in the Lifetime Prevalence of

8 D. W. PAUL JR. ET AL.

Homelessness in the United States. Demography, 55(6),2119–2128.

Garboden, P. (2018). Urban landlords and the housing choicevoucher program: A research report. United StatesDepartment of Housing Urban Development.

Gee, G. C., & Ford, C. L. (2011). Structural Racism andHealth Inequities: Old Issues, New directions. Du BoisReview: Social Science Research on Race, 8, 115–132.

Giovanelli, A., Reynolds, A. J., Mondi, C. F., & Ou, S. R.(2016). Adverse Childhood Experiences and Adult Well-Being in a Low-income, Urban Cohort. Pediatrics, 137(4).

Gross, S., Possley, M., & Stephens, K. (2017). Race andWrongful Convictions in the United States. NewkirkCenter for Science and Society.

Heard-Garris, N. J., Cale, M., Camaj, L., Hamati, M. C., &Dominguez, T. P. (2018). Transmitting Trauma: A sys-tematic review of vicarious racism and child health.Social Science & Medicine, 199, 230–240.

Henry, M., Mahathey, A., Morrill, T., Robinson, A., Shivji,A., & Watt, R. (2018). The 2018 Annual HomelessAssessment Report (AHAR) to Congress. The U.S.Department of Housing and Urban Development.

Hinton, E., Henderson, L., & Reed, C. (2018). An unjust bur-den: The disparate treatment of black Americans in thecriminal justice system. Vera Institute of Justice.

Hurstak, E., Johnson, J. K., Tieu, L., Guzman, D., Ponath, C.,Lee, C. T., … Kushel, M. (2017). Factors Associated withCognitive Impairment in a Cohort of Older HomelessAdults: Results from the Hope Home Study. Drug andAlcohol Dependence, 178, 562–570.

Jacoby, S. F., Dong, B., Beard, J. H., Wiebe, D. J., & Morrison,C. N. (2018). The Enduring Impact of Historical andStructural Racism on Urban Violence in Philadelphia.Social Science & Medicine, 199, 87–95.

Jones, C. P. (2000). Levels of Racism: A TheoreticFramework and a Gardener’s Tale. American Journal ofPublic Health, 90, 1212–1215.

Jones, M. M. (2016). Does Race Matter in AddressingHomelessness? A Review of the Literature. WorldMedical & Health Policy, 8, 139–156.

Jones, J., Schmitt, J., & Wilson, V. (2018). 50 years after theKerner Commission: African Americans are better off inmany ways but are still disadvantaged by racial inequality.Washington, DC: Economic Policy Institute.

Kanovsky, H. R. (2016). Office of General Counsel Guidanceon Application of Fair Housing Act Standards to the Use ofCriminal Records by Providers of Housing and Real Estate-related Transactions. Washington, DC: U.S. Departmentof Housing and Urban Development.

Keene, D. E., Rosenberg, A., Schlesinger, P., Guo, M., &Blankenship, K. M. (2018). Navigating Limited andUncertain Access to Subsidized Housing After Prison.Housing Policy Debate, 28, 199–214.

Kendi, I. X. (2017). Stamped from the Beginning: TheDefinitive History of Racist Ideas in America.

Kendi, I. X. (2019). How to Be an Antiracist.Kirk, D. S., & Wakefield, S. (2018). Collateral Consequences

of Punishment: A Critical Review and Path Forward.Annual Review of Criminology, 1, 171–194.

Kochhar, R., Taylor, P., & Fry, R. (2011).Wealth Gaps Rise toRecord Highs Between Whites, Blacks, Hispanics.Washington, DC: Pew Research Center.

Krivo, L. J., Peterson, R. D., & Kuhl, D. C. (2009).Segregation, Racial Structure, and Neighborhood ViolentCrime. American Journal of Sociology, 114, 1765–1802.

Landefeld, J. C., Miaskowski, C., Tieu, L., Ponath, C., Lee, C.T., Guzman, D., & Kushel, M. (2017). Characteristics and

Factors Associated With Pain in Older HomelessIndividuals: Results From the Health Outcomes inPeople Experiencing Homelessness in Older Middle Age(HOPE HOME) Study. The Journal of Pain: OfficialJournal of the American Pain Society, 18(9).

Lee, C. M., Mangurian, C., Tieu, L., Ponath, C., Guzman, D.,& Kushel, M. (2017). Childhood Adversities Associatedwith Poor Adult Mental Health Outcomes in OlderHomeless Adults: Results From the HOPE HOMEStudy. The American Journal of Geriatric Psychiatry, 25,107–117.

Locked Out. (2015). Locked Out: Criminal BackgroundChecks as a Tool for Discrimination. Greater NewOrleans Fair Housing Action Center.

Loïc, W. (2001). Deadly Symbiosis: When Ghetto and PrisonMeet and Mesh. Punishment & Society, 3, 95–133.

Metzl, J. M., & Roberts, D. E. (2014). Structural CompetencyMeets Structural Racism: Race, Politics, and the Structureof Medical Knowledge. The Virtual Mentor, 16, 674–690.

Metzler, M., Merrick, M. T., Klevens, J., Ports, K. A., & Ford,D. C. (2017). Adverse childhood experiences and lifeopportunities: Shifting the narrative. Children and YouthServices Review, 72, 141–149.

Montgomery, P., & Bailey, P. H. (2007). Field Notes andTheoretical Memos in Grounded Theory. WesternJournal of Nursing Research, 29, 65–79.

Morrison, D. S. (2009). Homelessness as an IndependentRisk Factor for Mortality: Results from a RetrospectiveCohort Study. International Journal of Epidemiology, 38,877–883.

Nelson, A. (2016). The Longue Durée of Black Lives Matter.American Journal of Public Health, 106, 1734–1737.

Nusselder, W. J., Slockers, M. T., Krol, L., Slockers, C. T.,Looman, C. W. N., & van Beeck, E. F. (2013). Mortalityand Life Expectancy in Homeless Men and Women inRotterdam: 2001–2010. PLoS One, 8, e73979-e.

Patanwala, M., Tieu, L., Ponath, C., Guzman, D., Ritchie, C.S., & Kushel, M. (2018). Physical, Psychological, Social,and Existential Symptoms in Older Homeless-experi-enced Adults: An Observational Study of the HopeHome Cohort. Journal of General Internal Medicine, 33,635–643.

Quillian, L., Pager, D., Hexel, O., & Midtbøen, A. H. (2017).Meta-analysis of Field Experiments Shows No Change inRacial Discrimination in Hiring over Time. Proceedingsof the National Academy of Sciences.

Raven, M. C., Tieu, L., Lee, C. T., Ponath, C., Guzman, D., &Kushel, M. (2017). Emergency Department Use in aCohort of Older Homeless Adults: Results from theHope Home Study. Academic Emergency Medicine, 24,63–74.

Robert, T. C. (2007). Racism and Psychological andEmotional Injury: Recognizing and Assessing Race-based Traumatic Stress. The Counseling Psychologist, 35,13–105.

Roberts, D. E. (1999). Killing the Black Body: Race,Reproduction, and the Meaning of Liberty.

Roncarati, J. S., Baggett, T. P., O’Connell, J. J., Hwang, S. W.,Cook, E. F., Krieger, N., & Sorensen, G. (2018). Mortalityamong Unsheltered Homeless Adults in Boston,Massachusetts, 2000–2009. JAMA Internal Medicine, 178(9), 1242–1248.

Rothstein, R. (2017). The Color of the Law: A ForgottenHistory of How Our Government Segregated America.

San Francisco Homeless Count & Survey. (2017).San Francisco Homeless Count & Survey. AppliedSurvey Research.

JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 9

Spinelli, M. A., Ponath, C., Tieu, L., Hurstak, E. E., Guzman,D., & Kushel, M. (2017). Factors Associated withSubstance Use in Older Homeless Adults: Results fromthe Hope Home Study. Substance Abuse, 38, 88–94.

The State of The Nation’s Housing. (2018). The State of theNation’s Housing 2018. Joint Center for Housing Studiesof Harvard University.

Umberson, D., Olson, J. S., Crosnoe, R., Liu, H., Pudrovska,T., & Donnelly, R. (2017). Death of Family Members as anOverlooked Source of Racial Disadvantage in the United

States. Proceedings of the National Academy of Sciences,114, 915.

Whitehead, E. (2018). Paying for Their Stay: Race,Coresiding Arrangements, and Rent Payments amongFragile Families. Journal of Family Issues, 39, 4041–4065.

Zimmerman, G. M., & Messner, S. F. (2013). Individual,Family Background, and Contextual Explanations ofRacial and Ethnic Disparities in Youths’ Exposure toViolence. American Journal of Public Health, 103, 435–442.

10 D. W. PAUL JR. ET AL.