Tackling homelessness needs much more than promises and policies

While homelessness generates statistics and strategies around the world, Jane Cacouris asks what really is home.

Jane Cacouris

Jane Cacouris is a writer and consultant working in international development on environment, poverty and livelihood issues.

A mother sits with a toddler standing in front of her. The father appears from the side lying on his back reaching an arm out.

A family play in a Rio favela.

“Mummy, are we homeless?” asked our six-year-old as we pulled away in the taxi. We had just eaten a final meal - a KFC family bucket of fried chicken - sitting on a sarong on the floor of our empty apartment in Rio de Janeiro, our home for almost four years.

The question left me momentarily winded. Homeless. A word that instantly conjured up feelings of anxiety and uncertainty, of sands shifting under our feet. Technically, yes, we were. My husband had just left his job in Brazil, and we had two months with nowhere to live before we relocated back to the UK. With no permanent base anywhere in the world, we were about to use the time to travel in South America as a family. Whilst I did feel somewhat insecure, my husband in contrast found it freeing; the first time in his life that he didn’t carry a set of house keys in his pocket. We had nowhere to live, but we were free to go wherever we wanted. And this is where the analogy of us actually being homeless broke down. We had a freedom of choice in a way that the vast majority of people who experience homelessness do not.

World Homeless Day on the 10th October was marked with the recent release of a landmark UN report on global homelessness. The UN define homelessness as:

“where a person or household lacks habitable space with security of tenure, rights, and ability to enjoy social relations, including safety. [It] is a manifestation of extreme poverty and a failure of multiple systems and human rights.”

According to UN-Habitat, a staggering 1.6 billion people in the world are estimated to be in inadequate housing and over 150 million have no housing at all.

Global homelessness has been rising for the past decade, with temporary homelessness being increasingly caused by conflict and climate-induced displacement. However, according to the UN report, Covid-19 exacerbated the issue, deepening existing inequalities and causing already marginalised people to be even more vulnerable.

In developing countries, the informal economy – self-made microentrepreneurs who sell everything from popcorn to shoe polishing - usually sustains the poor urban majority. But with many informal jobs vanishing during lockdowns, and with few assets and limited social safety nets, many urban dwellers were rapidly plunged further into poverty. Women and children suffering from domestic and gender-based violence had to remain in unsafe environments, with abuse escalating during lockdowns and curfews. Issues that encouraged migration and homelessness.

There are approximately 150 million children living and working on the streets worldwide. Almost impossible to imagine, and so the number sometimes doesn’t compute with our hearts.

The extent of homelessness worldwide is notoriously difficult to quantify accurately, partly due to what is known as hidden homelessness. The hidden and isolated nature of children and adolescents living on the street, for example, makes statistics difficult to gather. A 2023 UNICEF report of street children in Dhaka estimated that the number of children living on the street just in Bangladesh could be in the millions. And according to UN sources there are approximately 150 million children living and working on the streets worldwide. Almost impossible to imagine, and so the number sometimes doesn’t compute with our hearts. The true horror of the isolation of child homelessness only truly hit me a few years ago…

The residents in our block had finally had enough of the noise and called the police. They arrived in the middle of the night with their guns and shot at the children who dispersed.

Living at the top of a high-rise block in the middle of an urban neighbourhood in Rio, we were kept awake for a number of nights in a row. It started as a disturbance – children yelling in the street outside that would continue from the early hours until dawn. But as the days went on, the disturbance at night became more acute. One morning as I stepped out of our apartment in the morning, bleary-eyed and irritated, I was confronted by a small group of sleeping children lying huddled together in a row on the pavement next to a tree. Several pairs of bare filthy feet were sticking out of a blanket they were sharing. I looked down at them as I passed – they varied in age from about eight to twelve years old. The youngest was probably younger than my son at the time. He had knotted black curly hair and a streaked face. The next night we heard gun shots and then an eery silence. Another sleepless night, this time from worrying about the children, and then we discovered that the residents in our block had finally had enough of the noise and called the police. They arrived in the middle of the night with their guns and shot at the children who dispersed. The children never came back.

The government pledge to end rough sleeping in England by the end of 2024 is woefully off track.

Although homelessness is an overwhelmingly larger problem in poor countries, it also affects affluent nations, including the United Kingdom. This year the Kerslake Commission, an expert panel set up to scrutinise how rough sleeping is being addressed across England, pointed out that data on rough sleeping in London last year showed a 16 per cent increase in numbers of people sleeping rough. And that almost half (48 per cent) were sleeping rough for the first time. It concluded that the government pledge to end rough sleeping in England by the end of 2024 is woefully off track. According to Crisis, the homelessness system in England is at breaking point and the Homelessness Monitor 2023 reported that the cost-of-living crisis, rising rents and a lack of affordable housing are making it harder for councils to provide homeless people with effective support.

It is about where you feel valued and understood… where you feel loved… and where you want to come back to.

So, the problem of homelessness really is global. And what is the answer? Yes, governments must act; social safety nets and public policies to help alleviate poverty are critical. But even the richest countries with the most advanced governments have never been able to fully tackle this issue. Homelessness and poverty were rife in Biblical times. As Jesus said in the Gospel of John, “‘You will always have the poor with you”. And Jesus himself understands homelessness in a way many of us don’t; he started life in a stable, born to parents who were sleeping rough. He became a baby on the run to flee King Herod, homeless and seeking asylum in Egypt. When Jesus was older, after he was baptised by John the Baptist, he became homeless again, living life on the the road and in the open. In Luke, he says: “Foxes have dens and birds have nests, but the Son of Man has no place to lay his head.”

He emphasised that his followers leave the trappings of “home” to follow him.

I used to volunteer at a Christian charity, Casa de Maria e Marta, in a favela (slum) community in Rio, known for gang violence and drug trafficking. A larger-than-life Brazilian lady, Edimea, has run the charity for over twenty years. Almost a hundred children come to the charity each day, which provides three meals as well as extra tuition and care for the children. All of those who attend are either living in inadequate housing or are homeless. One day I asked Edimea whether she still sees the children after they leave her charity at age twelve. She laughed and said yes of course, they still come back to eat! And then she said,

“I do an assessment before I take a new child in, to understand what they know, and work out how we can best help them. And I always say to them – we take beautiful children, and so we are taking you, because you are beautiful inside and out. They come back because they don’t forget those words.”

Like Jesus, Edimea shows endless concern and love for those on the margins. She can’t solve all the practical problems she comes across or offer a permanent roof over a head, but she does provide a place where everyone feels a sense of safety and belonging. Perhaps home means more than the UN’s definition. It is about where you feel valued and understood… where you feel loved… and where you want to come back to.

Article

Care

Change

26 July 2024

6 min read

Are we forgetting how to care?

The profound act at the heart of nursing.

Helen Cowan

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

A nurse bends beside a bed and talks to a patient

Marie Curie.

Recently, at a nursing leadership programme in Oxford, attendees focused on the fundamentals of care. Have we forgotten how to care? What can we re-learn from those who pioneered an ordinary yet profound act that affects millions?

Anam Cara is an old Gaelic term for ‘soul friend’, a person with whom you can share your innermost self, your mind and your heart. It is a term that Tom Hill, former chief executive at Helen House Hospice in Oxford, used to describe the relationship between his staff and the thousands of children and their families who passed through their ‘big red door’ in its first twenty-five years. The hospice (or ‘loving respice’ as it became known) had been founded by Sister Frances Dominica in 1982.

Other care in this country can also trace its religious roots. Between 1048 and 1070 in Jerusalem, the Order of St. John was founded for the purpose of helping pilgrims (“our Lords, The Sick”) who had become lost, weary, or beset by other difficulties while on their way to the Holy Land. Today, in the United Kingdom, the British Association of the Order has extended care to older people first in almshouses and later in care homes. A trustee for ten years was John Monckton, a man of ‘considerable talent, enormous integrity and deep religious conviction’; his tragic murder in 2004 led to the creation of the John Monckton Memorial Prize, which recognised and rightly celebrated commitment to care by care workers.

Today, across the world, seen and unseen, nurses, carers and families continue to provide compassionate care. “Assisting individuals, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge” is the very essence of nursing, captured by ‘architect of nursing’, researcher and author Virginia Henderson in 1966. Meeting more than basic needs such as breathing, eating, drinking and eliminating bodily waste (which are of essential importance), Henderson recognised the role of the nurse in enabling humans to communicate with others, worship according to their faith, satisfy curiosity and sense accomplishment.

In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care?

An uncomfortable truth brought out in healthcare reports such as the Final Report of the Special Commission of Inquiry (The Garling Report) 2008, and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report) 2013 is though that this type of nursing is too often done badly or even missed, leading to pressure injury, medication errors, hospital-acquired infection, falls, unplanned readmission, critical incidents and mortality. According to nurse scientist and scholar Professor Debra Jackson, “missed care occurs much more frequently than we might think”. She cites a systematic review in which ‘care left undone’ on the last shift ranged from 75 per cent in England, to 93 per cent in Germany, with an overall estimate of 88 per cent across 12 European countries’.

In one offensively-titled paper, “Shitty nursing - the new normal?” (in which the authors apologise for the title but not the questions raised), real-life pen portraits are drawn of patients lying for hours on hospital trolleys, immobile through infection or injury, ignored by staff. Whilst acknowledging contextual factors for poor care, such as a shortage of nurses and resources, the authors argue that circumstances cannot be the sole cause of missed nursing care.

A report published by the University of Adelaide, School of Nursing, has called for nurses to ‘reclaim and redefine’ the fundamentals of care. It asks whether the cause of the problem (of missed nursing care) lies “deep in the psyche of the nursing profession itself?” “Has something happened to the way modern nursing views and values caring?” it continues. “Indeed, is nursing in danger of losing its claim to care? In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care? Or is this a broader social pattern where individuals are less inclined to show kindness, compassion, and care for others even if it is a necessary requirement of the job?”

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness.

Writing in the British Medical Journal, Professor of critical care medicine Peter Brindley and Consultant in intensive care Matt Morgan wonder whether doctors also “too often default to high-tech and low-touch” when patients are dying – a time “when community and connection matter most”. They powerfully begin with a mother’s comment: “Humans are gardens to tend – not machines to fix.”

Professor Sir Al Aynsley-Green, the first National Clinical Director for Children in Government and former Children’s Commissioner for England, and past president of the British Medical Association, suggests that we as a society need a “momentum for compassion”. Struck by the extremes of compassion witnessed during his wife’s treatment in the last years of her life, Sir Al wants to see a cultural transformation in healthcare: for compassion to be a key operating principle in NHS and care settings, led by the Chief Nurse’s Office; for every organisation to promote the importance of compassion at the professional level; for the views of patients and families to be sought regularly; for much earlier and better focus on compassion in undergraduate and postgraduate teaching programmes for all staff; for compassion to be inspected against by the Care Quality Commission; and for a willingness to encourage staff at all levels to expose poor practice as well as celebrating excellent care.

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. “It’s putting yourself into somebody else’s shoes – and doing something about it.” Recently appointed the UK’s first Visiting Professor in Compassionate Care at Northampton University, at the age of 80, Sir Al certainly is doing something about it. He has made it his new purpose in life to “embed compassion into every aspect of care”.

Like Sir Al, Queen Elizabeth II, the UK’s longest serving monarch, espoused compassion, in word and deed. Living a life of compassionate service, the Queen made clear that her Christian faith was her guiding principle. She speaks of Jesus Christ as ‘an inspiration,’ a ‘role model’ and ‘an anchor’. “Many will have been inspired by Jesus’ simple but powerful teaching,” she said in her Christmas Broadcast, 2000. “Love God and love thy neighbour as thyself – in other words, treat others as you would like them to treat you. His great emphasis was to give spirituality a practical purpose.”

When nurses do unto others as they would have done unto themselves, and act as role model to colleagues, not only do patient experiences of care and their outcomes improve – but so does job satisfaction for nurses: a critical factor in nurse recruitment and retention – the biggest workforce challenge faced by healthcare organisations. Across the UK, there are currently more than 40,000 nursing vacancies, and thousands of burnt-out nurses are leaving the profession early. Whether nurses decide to stay or go is driven in part by their daily experience at work. The late Kate Granger, Consultant in medicine for older people, inspired Compassionate Care Awards in her name, envisioning that such a legacy would drive up standards in care - and surely also help retain nurses, through restoring a sense of pride, achievement and fulfilment to the nursing workforce.