I used to wake up to bright lights and a knock on my car window. My dog would begin barking, the adrenaline would start rushing, and I’d come to my senses. Time to find a new parking lot, I’d think. Most of the time, I’d just circle the area until the cop left and then end up in the same spot. It was the safest parking lot, right outside the main mall in town, with lights all around. Winter nights were best — no air-conditioning meant no wasted gas. Other nights, I couch-surfed or crashed with kind distant relatives who took me in. I spent two years like this before medical school. At least I felt safe — something I couldn’t say when I was living at home.
Today, I am a resident physician in pediatrics, proud to don the white coat but often fighting burnout amidst a pandemic and long hours. Every so often, I am reminded anew of my past by my patients’ stories of housing insecurity. It was after meeting one such patient — a 7-year-old boy I will call Ted — in my third year of medical school that I decided to devote my career to studying the social determinants of health, specifically housing.
Ted had been living in shelters with his mother for a year by the time I met him in my hospital’s emergency department. He was riddled with petechiae — pinpoint purple rashes caused by bleeding under the skin. I could feel his liver extending down his abdomen — usually a bad sign, especially when accompanied by abnormal blood cell counts. Neither he nor his mother knew what was wrong. Both were terrified. Later that night, Ted was diagnosed with acute lymphoblastic leukemia.
I’ll always remember Ted holding a Black Panther figurine in the exam room. He had a Thor backpack. This was around the time when “Avengers: Infinity War” was in theaters. I asked him what he thought of the movie, and his face lit up. We debated who was the coolest Avenger. I said Cap, he said Ironman. Agree to disagree.
After Ted’s diagnosis, we spent a lot of time together in his hospital room watching superhero movies, something a medical student rarely has the luxury of doing during the day. His humor and positivity reminded me of my older sister, who, at 21, succumbed to lymphoma after a four-year battle.
Housing insecurity is at the heart of health disparities, and it worsens many of the other disparities that affect health outcomes, such as access to food, transportation, and medication. The patients who experience housing insecurity — the sometimes critically ill children I see in and out of the emergency department every day — have no voice. And their numbers are rising. In Massachusetts alone, nearly 18,000 people — approximately 3,700 of whom are in families — are homeless on any given night. An estimated 24,000 public school students experienced homelessness over the course of the 2018-19 school year.
The age at which an individual is most likely to experience homelessness is infancy.
The effects of this are long-lasting. Infants experiencing a period of unstable housing have higher rates of medical conditions, longer stays in neonatal intensive care units, and higher annual spending later in life on emergency department visits and hospitalizations. Unhoused children have higher rates of asthma exacerbations, obesity and malnutrition, infections, and mental health disorders.
These children — my patients — are our society’s most vulnerable, often presenting with acute or chronic medical conditions and uncertain of the next bed they’ll sleep in.
As I write, I am in my hospital’s workroom in the midst of a long stretch of night shifts — beeping monitors, dehydration, compassion fatigue, pounding headache, pandemic burnout. I’m often overwhelmed by the laborious tasks of a resident physician — updating orders, writing notes, and responding to dozens of pages. Sometimes when I’m in this state of exhaustion, I can forget why I went into medicine to begin with.
And then I remember getting off the subway at 125th Street in East Harlem during my last year of medical school in New York. I had just gotten back from a weekend away outside the city. As I was walking to my apartment, I heard a woman call my name. I turned around. It was Ted’s mother. She ran up to me and gave me a hug. She and Ted lived up the block in their new apartment, she said. Ted was in remission.
Dr. Jonathan Gabbay is a pediatric resident physician and child health advocate.