The 2022-2023 Bioethics Public Seminar Series begins next month with a webinar from Center Professor Leonard M. Fleck, PhD, on “Precision Medicine and Distributive Justice: Wicked Problems for Democratic Deliberation.” This virtual event is free to attend and open to all individuals.
Metastatic cancer and costly precision medicines generate extremely complex problems of health care justice. Targeted cancer therapies yield only very marginal gains in life expectancy for most patients at very great cost, thereby threatening the just allocation of limited health care resources. Philosophic theories of justice cannot address adequately the “wicked” ethical problems associated with these targeted therapies. Following Rawls, Fleck argues for a political conception of health care justice, and a fair and inclusive process of democratic deliberation governed by public reason. The virtue of democratic deliberation is that citizens can fashion autonomously and publicly shared understandings to fairly address the complex problems of health care justice generated by precision medicine. “Wicked” problems can metastasize if rationing decisions are made invisibly. A fair and inclusive process of democratic deliberation can make these “wicked” problems visible, and subject, to fair public reason constraints. What constrained choices do you believe you would endorse with your fellow citizens as being “just enough”?
Leonard M. Fleck, PhD, is a professor in the Center for Bioethics and Social Justice and the Department of Philosophy at Michigan State University. Dr. Fleck’s interests focus on medical ethics, health care policy, priority-setting and rationing, and reproductive decision-making. He explores the role of community dialogue (rational democratic deliberation) in addressing controversial issues of ethics and public policy related to emerging genetic technologies. More recently, he has completed a book-length manuscript that addresses a number of ethical and policy issues related to precision medicine, primarily in a cancer treatment context. He also completed another book that addresses several contemporary issues related to bioethics and religion from a Rawlsian public reason perspective.
What are we willing to accept as limits on access to very expensive marginally beneficial healthcare in our society?
Center Professor Leonard M. Fleck’s latest book, Precision Medicine and Distributive Justice: Wicked Problems for Democratic Deliberation, is now available from Oxford University Press. Fleck’s work as a philosopher and medical ethicist has focused on health care policy, and the role of community dialogue in addressing controversial issues of ethics and public policy related to emerging genetic technologies.
In an interview about this book, Fleck spoke of beginning democratic deliberation work around 1980 as part of a research project regarding changes to the Medicare program. He described the importance of involving members of the community in conversations about what values and considerations should shape the kinds of limits they would be willing to live with in terms of accessing needed healthcare. That project, centered in an Indiana community, shaped his work moving forward. The interview that follows explores the importance of democratic deliberation regarding the use of targeted cancer therapies.
The following interview has been edited for length and clarity.
Who is the ideal audience of this book?
The ideal audience would be a broad segment of the public that needs to be aware of the kinds of challenges, the ethical and public policy challenges, that are associated with precision medicine. Its high cost and its marginal benefit.
How would you broadly define precision medicine?
Typically, precision medicine is defined as providing the right drug at the right time and the right dose for the right medical problem. Right now, mostly what we’re talking about is cancer, that is, metastatic cancer. What we’re talking about are the molecular features of a metastatic cancer that a particular individual has. The drugs that are used to attack that cancer are drugs that are designed for the very, very, very specific molecular features of a particular cancer. Some of those features get to be defined in really sharp terms. Researchers and physicians no longer talk about a stomach cancer or a lung cancer—I mean they they’ll use those terms, but the recognition is that the nature of the cancer, in terms of what we’re going to try to do about it from a therapeutic perspective, that’s going to be determined by the molecular signature of that cancer.
What is democratic deliberation, and why is it important? How does it apply to this topic of precision medicine and healthcare justice?
I always start off with what I call the “Just Caring” problem. What does it mean to be a just and caring society when we have only limited resources—money—to meet virtually unlimited healthcare needs? And that’s a very, very broad problem that applies to all of healthcare, certainly in the United States today. With regard to cancer, the issue is that these targeted cancer therapies, and the so-called immunotherapies which are among the targeted cancer therapies, are extraordinarily costly. They typically apply to relatively small groups of patients, measurable in a few thousand rather than one hundred thousand. For the vast majority of these patients, receiving one of these very expensive drugs is only going to yield extra months of life, if that, as opposed to a lot of extra years.
So, if we had a $100,000 drug and this was going to give somebody three extra years of life, my guess is that most of us, democratic deliberators charged with determining how to spend our money on a whole range of healthcare interventions, including, of course, cancer, would say it’s a lot of money, but if we’re giving somebody three extra years, we ought to do that. And we ought to do that, we might say, because we think about, what are we spending now for purposes of giving a patient with HIV an extra year of life? A patient on a four-drug combination? The answer there would be $35,000 a year. And if we spend a $100,000 to give somebody three extra years of life, then that’s $33,000 a year. So it seems like if we’re spending money for the HIV positive patient at that level, we ought to be willing to spend that same amount of money to help cancer patients.
However, things are a lot more complicated than that simple example would suggest. So, in the case of cancer, one of the basic problems that I didn’t make perfectly clear in my earlier remarks is that even though I talked about a molecular feature of a cancer that is usually described as the driver of that metastatic cancer, and that is the target one of the targeted therapies, the fact of the matter is that in metastatic cancer there are going to typically be multiple drivers of a cancer. Most of them will be suppressed by the dominant driver. What happens in practice is that we’ve identified the dominant driver of the cancer, we give the individual a drug to kill that dominant driver, which it successfully does. And then another new driver emerges within that tumor, and then the tumor continues to grow, the cancer progresses. Now we may have another drug for that new driver, which will have roughly the same effect. It’ll kill that new driver and make room for yet another driver. But now, then, we’re providing to individuals several drugs in a row that have costs of $100,000 or $200,000 each. So, we’re spending a lot more money for a lot less good for these cancer patients. And so, the question for democratic deliberation is, what do we owe, under what particular circumstances, as a matter of what a just and caring society ought to be, to patients with metastatic cancer for whom there are these very expensive drugs that are only going to yield, for most patients, marginal benefit?
What I would ask an audience to imagine, when I’m working with an audience of individuals from the community, is that everybody in that room is probably very healthy. They have no idea what their future health vulnerabilities might be. Some people might say, well, we’ve got heart disease in the family, or some family history suggests cancer, but there’s still lots and lots of other health problems that you could have that could be deadly. The question is, if you don’t want to spend all your money on healthcare, and you don’t want to spend everybody else’s money on healthcare, then, collectively, what would you see as being reasonable investments of limited healthcare resources for addressing healthcare needs? Cancer needs, heart needs, Alzheimer’s disease needs, diabetic needs, psychiatric needs, needs associated with various kinds of disability. When you, in a thoughtful and objective way, try to consider the whole range of healthcare needs, where should we invest the limited dollars that we’re willing to provide? Right now, it’s 18% of our gross domestic product, roughly $4.1 trillion. Where are we willing to invest those dollars?
What led you to work that focuses on precision medicine? Was it natural from the other health policy work you have done, specifically work on allocating resources?
It was related both to allocating resources, because the cost of these drugs just leapt out at me, starting roughly in around 2010 or so. But the other thing was that I had been looking at a whole range of ethics and policy issues related to emerging genetic technologies. This was one of the newer elements associated with these emerging genetic technologies. This was a product of the Human Genome Project. Plus, the research that had been going on with regard to cancer, as researchers began to understand the extent to which cancer is this extraordinarily complex disease, that there’s not just sort of one or two or three drivers of these cancers. That there are different biological features of the cancer that are responsible for the cancer being so vigorous in multiplying. In brief, there’s that combination of the cost of these drugs and what that would do to distort the just allocation of health resources in our society, and the genetic features of these cancers that turned out to be so extraordinary genetically complex.
Something that strikes me, discussing these very expensive targeted therapies, is where does palliative care fit into the discussion of precision medicine?
For oncologists who are treating patients, for patients who have read something about precision medicine, for patients who have looked at some of the ads that are associated with precision medicine that have been on television, it’s very difficult to convince any of those patients that palliative care is something that they needed to give serious consideration to. Because it looked like these drugs could give them some very significant extensions of their life. And, of course, the fact of the matter is that there’s some percentage of patients who will get one or two or three extra years of life. There’s a teeny tiny percentage of patients who we call super responders, who might get seven, eight, ten extra years of life or more. At the moment we have no way of identifying before the fact how particular patients are going to respond to these drugs.
What happens is that patients imagine to themselves, I could be that person. Somebody is going to be a super responder, just like somebody ultimately wins that half a billion dollar lottery prize. How do I know it’s not me if I don’t buy a lottery ticket? How do I know it’s not me if I don’t take on this targeted cancer therapy? And if the first therapy doesn’t work, I heard that there’s a second and a third. And so as long as they seem to be doing something by way of controlling my cancer, of course I want that. I don’t want palliative care. So that’s sort of the psychological logic behind the reluctance of both patients and oncologists to recommend palliative care before it is just absolutely clear that nothing else is going to work.
What is one overall takeaway someone should get from this book? What is the question you want folks to continue thinking about?
What are we willing to accept as limits on access to very expensive marginally beneficial healthcare in our society? I want readers to think about the just caring problem, which is an extraordinarily complex problem. I’ve spent 50 years of my life thinking about this issue. And it’s only grown and become more complex over those 50 years, because of all the emerging life prolonging medical technologies that have come to be. Not just with regard to cancer, but with regard to heart disease, liver disease, lung disease, diabetes, and every other area of medicine that we care to name.
I’d like to add that ideally, ethically, I think we’re inclined to say, if we have a somewhat costly life prolonging care that’s effective, then everybody with the relevant need ought to have access to that if we are a just and caring society. If somebody has an inflamed appendix that is life threatening if they don’t receive the necessary surgery, then they ought to receive that surgery, whether they’re rich or poor, insured or uninsured. They ought not to be allowed to die. You will get, I think, very broad agreement in our society that that’s a just and reasonable kind of moral commitment we ought to make. It gets more difficult, though, to make that commitment when it comes to these extraordinarily expensive cancer drugs. And part of the problem is that in the United States probably no more than half of us are employed at places where we’re provided with very comprehensive health insurance, and where we’re not responsible for paying very much of the cost of our healthcare. But for the other half of the population who typically are working in lower wage jobs, who may be provided with some health insurance but it’s very marginal, it’s bare bones insurance. It’s the sort of insurance that requires that individuals pay 30 or 40% of the cost of these cancer drugs. And, of course, that’s impossible for individuals making $15, $20, $25, even $30 an hour. For a $150,000 drug, they cannot pay $30,000, and so they don’t get it. Nevertheless, they are paying through taxes, and through their insurance premiums, for others who would have access to these drugs. So that’s one of the fundamental inequities in our society, and the targeted cancer therapies make that inequity, I think, more visible. It doesn’t seem as if, as a society, we’re willing to address that challenge. However, that is one of the preeminent ethical challenges that must be addressed if we are to be a just and caring society.
Bioethics, Public Reason, and Religion is a new book from Center Professor Leonard M. Fleck, PhD. Published this month by Cambridge University Press as part of the Cambridge Elements Bioethics and Neuroethics series, the book is available to read online for free until August 26.
Fleck explores Rawlsian political liberalism, the limits of religious integrity, and examines the issues of physician aid-in-dying, the use of embryos in medical research, abortion, and the artificial womb.
“Given the United States Supreme Court Dobbs decision, this volume is especially timely since it is doubtful that the Dobbs decision could pass the public reason test—though readers are free to disagree with that conclusion,” said Fleck.
Summary: Can religious arguments provide a reasonable, justified basis for restrictive (coercive) public policies regarding numerous ethically and politically controversial medical interventions, such as research with human embryos, pre-implantation genetic diagnosis, or using artificial wombs? With Rawls, we answer negatively. Liberally reasonable policies must address these controversial technologies on the basis of public reasons accessible to all, even if not fully agreeable by all. Further, public democratic deliberation requires participants to construct these policies as citizens who are agnostic with respect to the truth of all comprehensive doctrines, whether secular or religious. The goal of these deliberations is practical, namely, to identify reasonable policy options that reflect fair terms of cooperation in a liberal, pluralistic society. Further, religious advocates may participate in formal policymaking processes as reasonable liberal citizens. Finally, public reason evolves through the deliberative process and all the novel technological challenges medicine generates for bioethics and related public policies.
Print copies of the book are also available for pre-order. The volume is a slim paperback, clearly written, and accessible for an undergraduate bioethics course that addresses several of these controversial bioethics issues as matters for public policy decision-making.
The Center for Bioethics and Social Justice at Michigan State University is excited to welcome new faculty member Michelle T. Pham, PhD, who starts in August. Pham specializes in philosophy of science, neuroethics, and social epistemology.
Most recently Pham was a postdoctoral research fellow in the Center for Bioethics at Harvard Medical School, where she collaborated on multiple NIH-funded neuroethics projects. One of her projects on post-trial care looks at the ways in which patient-participants with treatment-resistant conditions enrolled in experimental brain implant studies may not have continued access to these effective therapies or maintenance once these studies end. Another project looks at the ethical dimensions of deep brain stimulation for pediatric patients with dystonia, and potentially obsessive-compulsive disorder (OCD) in the near future.
Pham received her PhD in philosophy from University of Washington in 2020. Her research broadly seeks to examine and understand neurotechnology development and its relation to non-expert stakeholders, such as patients who participate in clinical trials.
Center Professor Leonard Fleck, PhD, has had two articles published so far this year. Online ahead of print is “Precision medicine and the fragmentation of solidarity (and justice)” in the European journal Medicine, Health Care and Philosophy. In the article Fleck “offer[s] multiple examples of how current and future dissemination of […] targeted cancer drugs threaten a commitment to solidarity.”
Fleck and co-author Leslie Francis, PhD, JD, were published in the most recent issue of Cambridge Quarterly of Healthcare Ethics. Their article debates the question: “Should Whole Genome Sequencing be Publicly Funded for Everyone as a Matter of Healthcare Justice?”
In the February issue of Studies in History and Philosophy of Science, Center Director and Associate Professor Sean Valles, PhD, has a reply by the author in response to reviews of his 2018 book Philosophy of Population Health: Philosophy for a New Public Health Era. The book forum section of the issue includes three reviews of Valles’ book from Eric Mykhalovskiy, Quill R. Kukla, and Ross Upshur.
As 2021 comes to an end, we are excited to introduce two faculty members who will be joining the Center in 2022. Please join us in welcoming them to Michigan State University.
Jennifer McCurdy, PhD, will join the Center in January. Dr. McCurdy was most recently a Multicultural Postdoctoral Fellow in the Philosophy Department at the University of Alaska Anchorage. She is a critical social bioethicist whose work focuses on understanding and eliminating racial and colonial injustices in contemporary health settings and communities. Currently, Dr. McCurdy is working on a scoping review of Indigenous values in the bioethics literature, and she is co-leading a series of Hastings Center special reports on racism and bioethics.
Dr. McCurdy received her PhD in religious studies with emphasis in ethics, colonialism, and critical religious studies from the University of Denver and Iliff School of Theology in 2019. She also holds a Master of Humanities with emphasis in philosophy and bioethics, a Bachelor of Science in nursing, and an HEC-C (Healthcare Ethics Consultant-Certified).
Megh Marathe, PhD, will join the Center next fall with a joint appointment in the Department of Media and Information in the College of Communication Arts and Sciences. Dr. Marathe is currently a President’s Postdoctoral Fellow in the Department of Informatics at the University of California, Irvine. They received their PhD in information from the University of Michigan in 2021.
Dr. Marathe’s research seeks to foster dialogue between expert knowledge and lived experience in the domain of health. Their recent work showed that for both doctors and patients, the boundary between pathologic and normal events is fluid, dynamic, and porous in epilepsy and other episodic conditions. Calling an event a seizure affects the patient’s financial stability, social participation, and life aspirations, and hence, both patients and providers take an expedient approach to diagnosing seizures.
Dr. Marathe’s work advances the fields of information studies, disability studies, and science and technology studies, and generates practical implications for inclusive healthcare in the era of technologized medicine. They are actively seeking collaborators for new projects that: 1) support patients with childhood-onset cancer or epilepsy in the transition to adult care, and 2) examine how neural implants affect medical practice and patient experience. Visit Dr. Marathe’s website to learn more about their work.
Last month at the 23rd Annual Conference of the American Society for Bioethics and Humanities (ASBH), Center Professor Leonard Fleck, PhD, presented on “Precision Health, Ethical Ambiguity: How Much Cancer Can We Afford to Prevent?” as part of a session on health care allocation and cost. Dr. Fleck has provided a summary of his presentation below.
“Precision medicine” and “precision health” seem to complement one another. We want an effective targeted cancer therapy for our metastatic cancer, but would rationally prefer to prevent the emergence of a life-threatening cancer–the goal of precision health. In a recent book, The First Cell: And the Human Costs of Pursuing Cancer to the Last, Azra Raza, an oncologist, argues that we are wasting tens of billions of dollars annually on extraordinarily expensive cancer therapies that yield only marginal gains in life expectancy. Raza believes these resources (not resources from heart disease or anything else) should be redirected to destroying cancer in its earliest stages, those “first cells.”
A new liquid biopsy (GRAIL) can detect 50 different cancers in very early stages by examining cell-free DNA at a cost of $800. However, 200 million anxious U.S. adults would be candidates for this test annually at an aggregate cost of $160 billion. From the perspective of health care justice, who should pay for these tests? Who should be denied access to these tests at social expense? Should only individuals with a strong family history of cancer have a moral right to this test at social expense? That would cover only 10% of cancers diagnosed in any given year.
We might say individuals known to be at elevated risk for cancer should have these tests paid for as a social expense. That would include smokers and sun worshippers at risk for lung cancer and melanoma. Would non-smokers and responsible sunscreen appliers have just cause for a grievance, i.e., paying for the irresponsible?
Would justice or efficiency require foregoing $160 billion in metastatic cancer care to pay for this preventive effort? What would a “just enough” balancing of therapeutic objectives look like? The basic economic and ethical problem is that we would be paying $160 billion annually that we knew would yield negative results more than 99% of the time. This is not obviously either a wise or just use of social resources. Moreover, this situation calls attention to the “statistical lives vs. identifiable lives” problem.
The “statistical lives” are the lives we would hope to save from metastatic cancer with the liquid biopsy test. These are nameless and faceless lives, unlike the identifiable lives that are the patients with metastatic cancer who want access to the hyper-expensive targeted therapies that might extend their lives a few months, maybe an extra year or so. In contrast, the hope is that each statistical life saved would result in extra decades of life for that individual.
A key ethical question is whether statistical lives and identifiable lives in this situation are of equal moral weight. Or are the identifiable lives with metastatic cancer more “morally worthy” of social resources because they are suffering and near dying? Or, as Raza contends, are we ethically obligated to shift resources from metastatic cancer patients (who have been effectively treated up to this point) to preventive efforts associated with liquid biopsies hoping to save more lives and life years? How do you, my currently healthy readers, think we ought to decide?
Center Assistant Director and Associate Professor Karen Kelly-Blake, PhD, recently presented at the 116th American Sociological Association Virtual Annual Meeting, held August 6-10, 2021. Dr. Kelly-Blake was an invited panelist for the session “Racism: A Pre-existing Health Condition.” Her presentation was entitled “A Question of Justice: The Covert Costs of Racial/Ethnic Concordance in the Medical Workforce.”
Over the past century U.S. medical workforce demographics have shifted. Moving away from a white male dominated profession, there has been a “widening capacity” trend toward increasing gender, ethnic, racial, and linguistic representation. Commonly, that push is linked to notions of desirable doctor/patient identity matching, described here as “concordance.” Notably that trend is accompanied by rhetoric covertly shaping the professional lives of Black, Indigenous, and Latino physicians underrepresented in medicine (URiM). Improving patient trust, access and health outcomes are frequently mentioned benefits figuring into such parity rhetoric. Indeed, URiM physicians provide a substantial proportion of medical care to the underserved. Quite possibly such workforce patterns reflect focused altruism to serve “one’s own.” Paradoxically, policy initiatives that influence URiM’s futures in the medical workforce may well carry hidden unanticipated consequences.
Dr. Kelly-Blake reported on the findings of a 2000-2015 scoping literature review considering the nature of medical workforce policy strategies. She posed the question of whether those strategies might not unevenly affect URiM physicians, selectively placing service expectations not similarly placed on their White counterparts. Findings suggest that selectively placing service expectations not similarly placed on their White counterparts along with unexamined assumptions of racial/ethnic concordance between patient and physician may place an undue burden on URiMs disproportionately tasked with ameliorating persistent inequities in our health care system.
Trauma, Community Health and the Criminal Legal System
Why should we care about the effects of incarceration and policing on communities and their health? This virtual panel discussion and audience Q&A on the relationship between the criminal legal system, structural racism, and health will also explore terminology—including “mass incarceration”—and explore different ways of thinking about trauma.
This webinar is co-presented by the Michigan State University Center for Bioethics and Social Justice and the Henry Ford Health System Health Disparities Research Collaborative. Panelists include Jennifer Cobbina, PhD, and Christina DeJong, PhD, from the Michigan State University School of Criminal Justice, Carmen McIntyre Leon, MD, from Wayne State University School of Medicine, and Center for Bioethics and Social Justice Director Sean A. Valles, PhD. Henry Ford Health System Health Disparities Research Collaborative Director Christine Joseph, PhD, will moderate the session.
This webinar is free to attend and open to all individuals. A recording will be available following the event.
About the panelists
Jennifer Cobbina is an Associate Professor in the School of Criminal Justice at Michigan State University. She received her PhD in criminal justice at the University of Missouri-St. Louis in 2009. Her primary research focuses on community responses to police violence and the strategies that communities employ to challenge police expansion and end state sanctioned violence. Her research also examines the intersection of race, gender, and how neighborhood contexts shapes crime and criminal justice practices. Finally, her work focuses on corrections, prisoner reentry and the understanding of recidivism and desistance from crime. She is the author of Hands Up, Don’t Shoot: Why the Protests in Ferguson and Baltimore Matter and How They Changed America.
Christina DeJong is an Associate Professor in the School of Criminal Justice at Michigan State University. Her research interests focus on gender, sexuality, crime, and justice. Dr. DeJong’s current work is focused on Queer Criminology, specifically the homicide of transgender people in the United States and how sexuality shapes juvenile offending. She is also currently studying bullying and misconduct in academe. Dr. DeJong received her PhD in Criminal Justice and Criminology from University of Maryland. She is an associated faculty member with the MSU Center for Gender in Global Context.
Carmen McIntyre Leon completed undergraduate studies at the University of Michigan, attended Wayne State University for medical school, and the Medical College of Pennsylvania (now Drexel) for psychiatry residency and NIMH research fellowship. She worked as medical director for partial programs, inpatient units, research units, and SUD/Methadone programs before returning to Michigan, eventually co-founding Community Network Services, an adult community mental health provider in Oakland County. After a brief stint in New Zealand she returned to Detroit to help lead the newly created Detroit Wayne Mental Health Authority as the Chief Medical Director. She is now the Associate Chair for Community Affairs and Director of Public Psychiatry Fellowship with the Wayne State University School of Medicine Department of Psychiatry and Behavioral Neuroscience; and Chief Medical Officer for the Michigan Department of Corrections.
Sean A. Valles is director and associate professor in the Center for Bioethics and Social Justice in the Michigan State University College of Human Medicine. Dr. Valles is a philosopher of health specializing in the ethical and evidentiary complexities of how social contexts combine to create patterns of inequitable health disparities. His work includes studying the challenges of responsibly using race and ethnicity concepts in monitoring health disparities, scrutinizing the rhetoric of the COVID-19 pandemic as an ‘unprecedented’ problem that could not be prepared for, and examining how biomedicine meshes with public health and population health. Dr. Valles received his PhD in History and Philosophy of Science from Indiana University Bloomington.
Christine Joseph is a Senior Epidemiologist in the Department of Public Health Sciences at Henry Ford Health System. Her research interests include racial/ethnic health disparities, adolescent health, asthma and allergic disease, adherence, and school-based health management. She has experience in the design and implementation of community-based and pragmatic clinical trials. Dr. Joseph has worked on a variety of studies focusing on vulnerable populations and social determinants of health, and has publications in the areas of asthma, food allergy, sleep, LGBTQ health, and health literacy.
“Housing security’s place in a ‘Culture of Health’: Lessons from the pandemic housing crises in the U.S. and England”
Center Director and Associate Professor Sean A. Valles, PhD, gave a seminar last month for The London School of Economics and Political Science Department of Philosophy, Logic and Scientific Method. Valles presented “Housing security’s place in a ‘Culture of Health’: Lessons from the pandemic housing crises in the U.S. and England” as part of the department’s “Conjectures and Refutations” series.
Dr. Valles has provided a summary of his talk below. A recording is available to watch on YouTube via the LSE Philosophy channel.
People experiencing homelessness had been suffering extreme health and economic hardships before the COVID-19 pandemic, and even more so during it. The notion that housing is a human right is gradually picking up momentum in both the U.S. and England. And that ethical recognition is combining with a growing set of scientific evidence of the effectiveness of “housing first” policies, which provide stable long-term housing to people experiencing homelessness, rather than shuffling people in and out of temporary shelters. Every person ethically deserves safe housing, and failing to provide this has also resulted in a system that cruelly (and at great expense) pushes suffering people into emergency rooms and prisons.
England earned praise for its “Everyone In” program, which was aimed to provide safe housing for every person experiencing homelessness beginning early in the pandemic. By contrast, cities across the U.S. continued defying CDC recommendations by bulldozing temporary encampments set up by people experiencing homelessness, including in Lansing. Meanwhile both the U.S. and England banned evictions of renters who fell behind on their rent during the pandemic, but both also failed to make realistic long-term plans for how to secure housing and income for people who have no way of paying past-due rent once the eviction bans expire. On both sides of the Atlantic, the pandemic inspired governments to stumble toward recognizing how essential housing is for good health in general and also dealing with this fact. The challenge now is to keep up the momentum, and push for universal housing, since trying to survive without secure housing was already difficult before the pandemic, and will remain so after it ends.