Embedded Files
Coping with rising substance use and homelessness, cities struggle to balance compassion with imposing order
by Caitlyn Rhatigan
On October 8th, 2014, Boston Mayor Marty Walsh ordered the immediate evacuation of Boston Harbor's Long Island. The entire island, he said, needed to be empty by 8pm that night. Located in the center of the harbor, Long Island was home to a city-run homeless shelter, a mental health facility, and a substance use recovery center. Earlier that day the Long Island Bridge, the only way to access this remote island, had been declared structurally unsafe, despite city officials being warned of deteriorating conditions for several years. Within hours of Walsh’s order, everyone sheltering, working, or receiving care on the island packed whatever they could and evacuated. Many had to leave behind most of their belongings.
Beginning that night, the City scrambled to find beds for those who had been displaced. Staff opened makeshift shelters at the South End Fitness Center and in the glass-ceilinged atrium of the Barbara McInnis House, a homeless respite center.
These were temporary and inadequate solutions. In the ten years since, Boston has struggled to make up for Long Island’s lost social service programs. In recent years, cities nationwide have struggled to manage rising homelessness and substance use. Tensions arise between baancing the responsibilities to enforce safety and to provide care. “It is complicated,” says Bisola Ojikutu, executive director of Boston Public Health Commission. On the on the one hand, she says, there is what cities want to do, and on the other what they have the money to do.
The buildings on Long Island have remained abandoned, eerily stuck in time with remnants of people’s personal belongings, wheelchairs, unfinished pool games, and decaying books. The Long Island Bridge has since been demolished. Plans to rebuild have stalled.
Long Island - Abandoned Central
Corner of Mass and Cass
Long Island had long been used as a place to shelter, incarcerate, and provide care for the homeless. Before the city acquired the land in 1885 to build Long Island Hospital, the island had been used to hold ‘Christiainized’ Native Americans captive during King Philip's War. It later housed troops at Fort Strong during the Civil War.
By 2014 Long Island Hospital and its social service programs housed 742 shelter beds and 225 recovery beds. Avik Chatterjee, a primary care and addiction medicine physician, used to work at the medical clinic there. He remembers that once per shift, an emergency alarm would go off signaling that an overdose had occurred.
In 2014, the year Walsh closed the program, homelessness in Greater Boston had peaked, with close to 15,000 people experiencing homelessness. With the closing of the island, those 742 shelter beds disappeared from the Boston's homeless-response program.
In June 2015 the city opened two new shelters in the Newmarket district: the newly converted, all-women’s Woods-Mullen Shelter, with 147 beds and an all-men's Southampton Street Shelter. The Southampton Street Shelter has 320 beds, but most nights it houses close to 500 people, Chatterjee says.
In the years between 2015 and 2022, homelessness in Greater Boston declined. But in 2022 it dramatically increased again, with close to 13,000 people experiencing homelessness. In 2023, Boston had the second highest rate of homelessness among the 45 largest cities in the U.S. Two-thirds of those unhoused people lived in families.
Meanwhile the opioid crisis was devastating Massachusetts’ residents, along with the state’s social fabric. In 2016, the Massachusetts opioid-related death rate was twice the U.S. average, and Massachusetts had the third highest fentanyl-related death rate in the country.
From 2016 to 2021, the opioid-related death rate in Massachusetts remained steady, but in 2022 it surged, reaching a new peak of 33.5 overdose-related deaths per 100,000 people. Rates were even higher for Black and Latino/a populations.
Back in 2015, the city had located its two new shelters in a neighborhood with lots of medical and social service programs: Boston Medical Center (BMC), the city’s largest safety-net hospital, and Boston Healthcare for the Homeless Program (BHCHP) occupy two large city blocks. Boston University Medical School, two methadone clinics, and several recovery and harm-reductions programs are clustered nearby. This area, now called the Newmarket district, lies a block away from the major intersection of two large city highways, Massachusetts Avenue and Melnea Cass Boulevard, locally known as “Mass and Cass.”
Mass and Cass has become a congregation place for the homeless and people using drugs and alcohol.
BHCHP Poster inside Jean Yawkey Place
With opioid overdoses and housing prices skyrocketing, cities across the country have struggled to manage rising homelessness and substance use. Many have moved towards criminalizing homelessness to impose order. In June 2024, the United States Supreme Court ruled in City of Grant Pass v. Johnson that cities could ban sleeping outside. The City of Grant Pass, Oregon, had fined homeless people for camping, even though there were not enough shelter beds. Since this ruling, several cities have passed similar laws criminalizing activities such as sleeping outside. Many of the people affected have nowhere else to go, and need medical attention.
This tension between the mandate to impose order and the need to provide care threads through the story of Boston’s infamous Mass and Cass intersection.
Entrance to the Engaement Center - City of Boston
Since the closure of Long Island and the worsening of the opioid crisis, the city of Boston and local organizations have opened several substance use programs. Painted with bright and colorful murals, Boston’s Engagement Center stands out within the otherwise dismal industrial-looking Newmarket district. The Center offers resources and support during the day for people living on the streets and using substances. Located next to the Southampton Street Shelter, the Center has showers, computers, hot meals, and a medical clinic staffed by Boston Healthcare for the Homeless.
Abby Brennan, a labor and delivery nurse at Boston Medical Center, has worked in addiction medicine for two years. Brennan is the co-chair of the Nurse Substance Use Disorder (SUD) Council at BMC, and once worked at the Engagement Center. She and other staff provide mostly wound care, STI screening, and medication. Brennan says she and other staff have developed trusting relationships by offering these services–and that this trust often enables future conversations about substance use treatment.
Brennan first met Kelly, an active user, at Boston Medical Center’s labor and delivery walk-in clinic. Kelly often sought care at the clinic for a chronic urinary tract infection, and was living in a tent on Mass. Ave. Brennan remembers Kelly as guarded, “a little prickly,” and a loner. Kelly rarely engaged with any staff – except for Brennan.
One day, Kelly walked into the clinic alone; she was in active labor. Earlier other nurses had sent Kelly away, assuming she was experiencing withdrawal symptoms. But Brennan never left Kelly’s side during the ensuing delivery. Kelly delivered a new baby girl, Brennan says, and the baby was fine. But the young mother’s blood pressure reading was high, and the medical staff wanted to stabilize her and treat her syphilis before discharging her.
Soon the Department of Children and Families (DCF) arrived and took Kelly’s baby from her. Before long they would place the newborn in foster care.
Meanwhile the Labor and Delivery team approached Kelly’s bed and informed her that they were required to search Kelly’s belongings before they could treat her (a policy that has since been abolished). Kelly confided in Brennan that she had a knife in her bag. She said she needed this weapon for protection out on the streets. Staff forced Kelly out of the hospital because she refused to consent to the security check. Kelly did not receive the crucial care she needed.
Brennan says she still feels “haunted” by the way Kelly’s delivery ended. She wondered what happened to Kelly after she left the hospital. She worries that Kelly had a seizure because her blood pressure was high. Brennan knew from experience in street outreach that the BMC neighborhood could be dangerous, especially for a postpartum woman with high blood pressure.
Since the closure of Long Island, as homelessness people like Kelly have migrated to Mass and Cass, the intersection's tent encampments have grown.
Until it closed in 2023, the Engagement Center did not allow substance use while inside the building. But people could use bathrooms and receive medical care and clean supplies. As a result, people started gathering outside the center and it became a popular place for substance use and criminal activity, says Ojikutu of the Boston Public Health Commission.
As more people flocked to Mass and Cass and the surrounding neighborhoods, local business owners and residents revolted. For years, many had complained—in the media, in public meetings—about increases in crime and open drug use on city streets.
The backlash was unfortunate, says Miriam Komaromy, an addiction medicine physician and medical director of BMC’s Grayken Center for Addiction. Sure, there was violence, drug trafficking, and sex work in the Mass and Cass area, she says. But it was also a community. Many people felt safe at the Mass and Cass encampments—because they were taking care of each other.
“One of the key tenets of harm reduction is to never use alone,” says Chatterjee. The encampments made companionship possible; people could watch over one another to help prevent fatal overdoses.
Corner of Mass and Cass
In August 2019, the City of Boston launched Operation Clean Sweep, an attempt to “clean up the streets” and disperse the encampments at Mass and Cass. The sweep was prompted by one camper’s physical encounter with a police officer on Atkinson Street. Swarms of police officers moved in and swept through the encampments, arresting people, demolishing tents and disposing of campers' personal belongings. With nowhere else to go, people and encampments returned. From time to time, Boston police return and attempt to clear the Mass and Cass encampments. But the cycle continues.
To many who work in the field of addiction and homelessness, Boston’s tent sweeps are ineffective and unethical. For Boston and many other cities, the strategy is simply “to move people out of sight,” argues Komaromy.
This used to happen on Long Island. With recent tent encampments sweeps, the city has tried, anyway, to push the most vulnerable out of mind and out of sight.
But the tactic fails to address why people are on the streets in the first place, says Ranjani Paradise, a researcher at the Institute for Community Health who focuses on racial disparities in substance use. Policymakers overlook why people at Mass and Cass are choosing to live on the streets, rather than in shelters. The encampments signal that “something is wrong,” says Paradise. The current shelter system is not meeting the needs of the people it is supposed to serve.
Neighborhood residents and business owners may oppose encampments because they don’t want to see open drug use and injection equipment, says Simeon Kimmel, medical director of Project TRUST, BMC’s street-level drop-in center for safe consumption supplies. But after the encampment sweeps, these same people complained about increased drug use and needles all over the city. Feeling uncomfortable at these sites is one thing, but that does not mean they are dangerous to you, Kimmel says.
Komaromy and other addiction medicine providers believe that "low-barrier" transitional housing —housing that does not require sobriety—is an essential part of the solution. Low-barrier transitional housing programs house the people who, because they are using substances, are unable to stay in shelters or rent an apartment. Fentanyl requires frequent use (every 4-6 hours) to prevent withdrawal symptoms. Most shelters do not allow people to leave overnight. If they do, they are not allowed back in. This discourages substance users from staying in shelters. Meanwhile the majority of affordable housing options run by the city and federal government prevent people with prior substance use from applying for housing. People with SUD struggle to engage in treatment when they lack a safe place to sleep or store their medications. Low-barrier housing offers these people a small bit of stability, Kimmel says.
In January of 2022 the city was continuing its sweeps of Mass and Cass encampments. But this time it tried an approach more geared toward public health. Boston opened six low-barrier housing options in partnership with local organizations. Many providers and advocates opposed the tent sweeps, Ojiukut says. But the main reason for them was to improve the campers' quality of life.
The Roundhouse
In partnership with BMC, the city opened one of the six low-barrier locations at the previous Roundhouse Hotel, named for its cylindrical shape, next to Mass and Cass. Roundhouse offered 60 beds to people who’d been living in encampments on Mass and Cass and others with chronic homelessness. Couples could live together. Harm reduction specialists handed out safe supplies, and case managers worked with residents to place them in permanent and long-term housing.
Within the first year, 100 people were admitted to the Roundhouse. Twenty-five percent eventually found long-term housing.
In the basement of the Roundhouse, BMC ran a walk-in urgent care clinic and a 24/7 short-stay “stabilization” unit: people could stay up to 24 hours to manage over-intoxication and withdrawals. Within the first year, the clinic received 7,468 visits, the majority of which were related to opioid use. Of the 100 total residents, 49 percent had engaged in SUD treatment while at the Roundhouse.
There is a common “narrative that people don’t want treatment,” says Paradise. But in her experience, this is not true. In 2021 Paradise and her research team interviewed overdose survivors living near Mass and Cass, and the majority of them had tried treatment. “Some people had tried treatment over and over and over and over again” says Paradise. People keep using because they keep having problems, advocates say. The critics forget that “you don’t just get here without shit happening to you,” says Deanna Faretra, a nurse manager who once worked at the Roundhouse clinic. Many providers observe that substance use, homelessness, mental illness and trauma are linked together. Boston Healthcare for the Homeless estimates that 60 percent of their patients have a major mental illness.
The “evidence is overwhelming that low-threshold housing is extremely helpful in stabilizing and getting people on medication and treatment in a dignified way,” says Chatterjee, “because the alternative really was chaos.”
Despite its success, the city closed the Roundhouse clinic in March 2023. Soon after, it shuttered the Roundhouse housing. City spokespeople cited a lack of funding. Two of the original six low-threshold housing programs have also closed due to lack of funding, says Ojikutu. The programs may be successful, but they’re costly.
Some, including Komaromy, believe that neighborhood resistance was a factor, too. Others, like Kimmel, note that it’s also expensive to provide care at emergency departments for people who have overdosed—especially when they then require hospitalization. But policymakers and residents often don’t think about cost from that holistic perspective, says Kimmel. After all, the truly cheapest thing is to let people die, he says.
One day, after Brennan the nurse had completed her shift at the Engagement Center, she received a phone call from a fellow nurse working in the Labor and Delivery Unit. Their patient Kelly was back, delivering another baby girl. Brennan felt relieved to hear that Kelly was still alive. After delivering her second daughter (and fourth child) via Cesarean section, Brennan began seeing Kelly often at the Engagement Center, where she was receiving wound care. Doctors were still tending to Kelly’s new daughter in the pediatric unit at Boston Medical Center.
The “thing that really broke my heart,” Brennan says, was hearing Kelly say that she felt ashamed. Kelly was avoiding visiting her daughter in the hospital. “I just can't go in and face everybody judging me,” Brennan remembers Kelly saying. Still living in a tent on Massachusetts Avenue and actively using, Kelly knew how difficult the process of receiving visiting rights would be. So Kelly gave up on visiting her daughter, Brennan says.
Brennan visited the baby instead. She gave Kelly updates whenever Kelly came into the Engagement Center. Having built Kelly’s trust, Brennan persuaded Kelly to start HIV prevention medications. Kelly’s partner was HIV positive. Kelly also agreed to receive a Depo-Provera shot, a form of contraception. Still guarded with many people, Kelly knew at least one person in the world cared about her.
Jean Yawkey Place, BHCHP headquarters
In September 2023 Boston Mayor Michelle Wu announced that, due to “safety concerns,” there would be another sweep of tents at Mass and Cass. This time the Engagement Center would be closing until further notice. The Center did cause hazards—violence and drug use outside the Center—and needed to be closed, Public Health Commissioner Ojikutu says. But Chatterjee believes that the violence provided yet another excuse. He points to the city’s “political fear.” Officials wanted to avoid appearing “soft on crime and soft on drugs,” he says.
Providers who care for these patients every day see how the encampment sweeps and the Engagement Center closure have led to fragmented care. Alyssa Peterkin is an addiction medicine hospitalist who works at Faster Paths to Treatment, BMC’s substance use disorder urgent care clinic. Peterkin remembers how the number of people engaging with the program decreased significantly after large encampment sweeps. Peterkin and others worry about what this means for the people who used to come to the Engagement Center and other clinics for care.
With the closure of the Engagement Center, Brennan and staff have moved into a space within the BHCHP Yawkey building. Everyone, from staff to clients, must climb four flights of stairs just to enter. This barrier diminishes the care they can offer, Brennan says. When care is disrupted, trusting relationships crumble, and clients slip away. The addiction treatment system was already difficult to navigate, says Peterkin.
The majority of treatment options are short-term solutions, Paradise says. But substance use disorders are chronic illnesses, Paradise says. Willpower won’t pull people through on their own. “It's a long term condition, but we don't have any kind of long-term support system built around it.”
Addressing substance use and homelessness “is complicated,” Ojikutu says. Cities struggle to maintain order and safety; they also struggle to provide care for their most vulnerable. “There is what we want to do,” she says. “There’s what we have the money to do.” And the money, she says, “comes and goes.”
Since the closing of Long Island, the money has mostly gone to other causes. Plans to rebuild the Long Island Bridge and social service programs are stuck in legal battles. Rebuilding will require political support and a significant investment from the City.
Despite the ongoing public health crisis, Boston has many passionate providers who devote their lives to caring for the homeless and substance users. These providers continue to advocate for their patients and strive to make impactful changes on Boston’s system of care.
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Healthcare Journalism - Audio.MP3Commentary
Commentary
I knew early on that I wanted to write a piece about the complexities surrounding healthcare for substance use and homelessness. I was inspired by Tracy Kidder’s book, Rough Sleepers, which follows Jim O’Connell, founding physician of Boston Healthcare for the Homeless Program, as he helped build a community of care for people experiencing homelessness.
I decided to focus my piece on the intersection of Mass and Cass since it portrays the historical and systemic injustices of poverty, racism and stigma. I was incredibly lucky to have access to many people directly providing care to the unhoused community near Mass and Cass. For the piece I wanted to explain the history behind the creation of Mass and Cass and ongoing problems while also detailing the system of care that has been established through my interviewees experiences and dedicated compassionate care. Balancing these two was my biggest challenge.
I also wanted to shed light on the complexities behind how cities across the country have shifted towards treating people living on the streets and using substances. While cities continue to struggle with determining solutions to these issues, real people are suffering from the consequences.
I am grateful for the people I interviewed - Abby Brennan, Deanna Faretra, Ranjani Paradise, Avik Chatterjee, Bisola Ojikutu, Miriam Komaromy, Alyssa Peterkin, and Simeon Kimmel - for sharing their experiences and glimpses into the lives of those they care for, like Kelly.
Source List
Source List
Abby Brennan (10/2/2024)
Ranjani Paradise (10/9/2024)
Deanna Faretra (10/14/2024)
Avik Chatterjee (10/16/2024)
Bisola Ojikutu (10/21/2024)
Alyssa Peterkin (10/23/2024)
Miriam Komaromy (10/24/2024)
Simeon Kimmel (10/28/2024)
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