When Francheska Lappost, a 24-year-old mother of two, moved from a homeless shelter to her first apartment in Williamsbridge five months ago, it wasn’t an upgrade. There were cockroaches, the stove wouldn’t turn on, the bathroom fan was broken and the sink was clogged, Lappost said.
“It was better living in the shelter than where I live right now,” she said.
Lappost is looking for a new apartment, but finding a place in her price range has proved to be an onerous task.
Lappost receives a monthly rental voucher from the Family Homelesness and Eviction Prevention Supplement (FHEPS), a program run by the New York City’s Human Resources Administration. The agency adjusts the amount of the vouchers according to household sizes. Under this program, Lappost is set to receive $1,557 a month, the maximum for a family of three.
Lappost qualified for the housing voucher because after migrating from the Dominican Republic, she and her family spent 10 months in a homeless shelter in Van Nest, on the east side of the Bronx. That arrangement was provided by PATH, the agency that manages the municipal shelter system.
Lappost is five months pregnant and is now looking for a place to live with her 4-year-old and 7-year-old children. The only option in the FHEPS price range is another one bedroom apartment.
According to the Coalition for the Homeless, a New York-based advocacy group, there are not enough apartments to cover the affordable housing demand. Only 2% of studios and 3% of three-bedroom apartments are in the price range established by CityFHEPS, according to a 2019 report released by the non-profit. In New York City, there are 16,480 vacant studio apartments in the vouchers price range, while there are 17,887 single adults living in the shelter system.
“We need to be both giving people vouchers to help close the gap between income and rent and we also need to be actually extending the supply of truly affordable apartments if we want to fight homelessness,” said Jacquelyn Simone, a policy analyst for Coalition for the Homeless.
Coalition for the Homeless wants the city to build 24,000 new units and to preserve the affordability of 6,000 more by subsidizing existing units. Additionally, there is a proposal by District 33 Councilman Stephen Levin that would raise the city voucher price levels to fair market rents and which would widen the supply of apartments for voucher holders, Simone said.
Even if CityFHEPS beneficiaries find apartments in their price range, that doesn’t guarantee their application will be approved, said Craig Waletzko, community engagement coordinator of the nonprofit Fair Housing Justice Center. Landlords are often upfront about rejecting applications from renters who use vouchers, Waletzko said, despite a state law that prohibits this type of housing discrimination.
“They’re just so many providers that are convinced that they don’t need to accept renters or people seeking homes using subsidies to pay their rent.”
Fair Housing Justice Center receives complaints and conducts approximately 100 investigations a year to determine whether landlords discriminate against voucher holders.
Representatives of the non-profit go undercover, looking for apartments, trying to isolate the factor that would trigger an application denial. They send two separate testers with similar incomes, jobs and credit scores. The only difference between them is the voucher.
Landlords and brokers often fail the test, Waletzko said, treating those with vouchers differently than applicants not enrolled in rental assistance programs.
Lappost encountered a similar bias on her first apartment hunt. “It took me three months to find my apartment. Not everyone takes programs,” she said.
The tight housing market in New York City means that rents tend to be high, which limit the options available for CityFHEPS voucher holders.
“The quality of housing that is available to folks when they are using the programs is just terrible,” said Waletzko.
Lappost’s search for an apartment is especially urgent this time around. Her landlord is suing her for not paying rent. She’s not sure why the rent hasn’t been paid; she thought her FHEPS voucher meant it would be paid automatically. Lappost is convinced that her landlord doesn’t have the grounds to evict her.
Robert Farina, the lawyer who represents Lappost’s landlord, said that although she gets a benefit from the Department of Social Services, she is still responsible for paying her rent. The only exception to this rule is Section 8, a different program in which the city pays part of the rent directly. Lappost’s rent was not paid in full for the months from May to October, Farina said.
Lappost got another citation to appear in court Oct. 31. She has to show proof of all of the FHEPS invoices . Lappost said she had them – she carried them in her purse the last time she was in court.
Lappost is running out of options, she had to quit her babysitting job because of her pregnancy. And she’s concerned about the additional bills from housing court. “He also wants me to pay $1000 for his lawyer,” she said.
The tiny waiting room of Dr. Andrea Littleton’s Bronx office was overflowing by the time she arrived in the late morning. Some patients sat in stony determination while others paced impatiently in the hallway — clawed by addiction and anxious for the relief that Littleton could provide. One dozed, slouched in his chair beside the inner door that leads to the claustrophobic medical office where, twice a week, Littleton prescribes buprenorphine to opioid addicted patients.
Littleton has worked for 15 years at Care For The Homeless, a non-profit medical center that provides medicine-assisted treatment for the homeless who suffer from opioid addiction. Medicine-assisted treatment is considered the “gold standard” for opioid use disorder, and the medications used are typically either methadone or buprenorphine (also known as Suboxone).
Littleton’s office, situated in Hunts Point in the Bronx, is at perhaps the very heart of New York’s opioid epidemic. In 2018, the overdose deaths per capita in Hunts Point was over 2.5 times the city-wide average, according to a 2019 report from the Department of Health and Mental Hygiene.
Only Staten Island ranks above the Bronx in terms of number of opioid deaths per capita. However, treatment in the two boroughs looks very different.
“Even though both [Staten Island and the Bronx] are epicenters of the opioid epidemic,” said Littleton. “There are far more [buprenorphine] prescriptions being written in Staten Island, but not necessarily more providers.”
A 2018 research report confirms Littleton’s observation: patients in Staten Island receive buprenorphine 3.6 times more frequently than those in the Bronx. Patients in the Bronx are, likewise, 3.2 times more likely to receive methadone. All this while the Bronx has nearly three times as many physicians who are able to prescribe buprenorphine, according to federal data.
“[Buprenorphine] certainly offers more freedom and flexibility,” said Littleton. Some patients refer to methadone treatment as “liquid nails,” she said. “They can’t go anywhere else or have a job or travel even because they have to be there every day.”
Having to show up at the clinic every day to receive treatment is not only a burden on methadone patients. The clinic itself can be stressful. “There is also a lot of stigma,” said Littletone. “People know where [the clinics] are, they don’t feel safe there. And it’s triggering because there might be someone selling right there in the waiting room or right outside the door.”
Finally, the medication itself makes a difference. Buprenorphine lacks some of the negative side-effects that methadone is notorious for. On Buprenorphine, patients “can go about their day feeling normal, they don’t feel high, they don’t feel loopy, they just feel normal,” Littleton added. “Where as a lot of people on methadone feel high, they can’t think clearly, they feel like they can’t maintain their normal activities.”
In 2018, Canadian researchers published guidelines recommending buprenorphine as the preferred first-line treatment for opioid addiction, only switching to methadone for patients who respond poorly to buprenorphine or who express a strong preference.
Salvador, who asked that his last name not be used, is a big man with tired eyes and a tidy grey beard. He is one of those patients who depends on the buprenorphine he gets from Littleton every week.
“When I have these,” he said holding a zip-lock bag containing week’s supply of individually-packaged pills, “I don’t even think about [heroin]. But without them, I have to use.”
But that reliance on Littleton can spell disaster if she is not available.
Salvador had been clean for nearly two months, he said. But, when Littleton had been away the prior week, he hadn’t been able to find another prescriber. Salvador had gone back to heroin to satisfy his cravings.
Salvador had been clean for nearly two months.
“You abandoned me,” Salvador sulked jokingly. But the damage done is no laughing matter.
Now, Salvador will have to endure the unpleasant, and potentially dangerous, process of reinitiating his treatment. Buprenorphine includes naloxone (the active drug in Narcan) which can precipitate withdrawl if patients start treatment too soon after using. Complications from withdrawl, including dizziness and asphyxiation can be severe. He will have to start the first stages of withdrawl from the three baggies of heroin he snorted that morning before he can take his first pill.
Despite the success of buprenorphine, getting access to treatment still remains a problem for many Bronx residents. In February 2019, the New York State Department of Health released new guidelines encouraging SAMHSA-approved doctors to “start prescribing buprenorphine, and if already prescribing to increase the number of patients under care.”
But the question remains, why do these two boroughs, facing the same crisis receive such different modalities of treatment?
From the start, buprenorphine treatment catered to affluent white patients who did not want to be associated with the stigma of receiving treatment at methadone clinics.
“In the case of opioids,” writes Dr. Helena Hansen, Associate Professor of Psychiatry at NYU Langone. “Addiction treatment itself is being selectively pharmaceuticalized in ways that preserve a protected space for White opioid users.”
Buprenorphine was developed in 1966, but failed at catch on until it’s resurgence 30 years later, which, argues Hansen, coincides with the rise of opioid use in white communities. When buprenorphine was legalized as a treatment for opioid addiction, in the 2000 Drug Addiction Treatment Act (DATA 2000), a group of lawmakers who opposed the DATA 2000 bill foresaw that it would “consign ‘hard core’ users to the existing and widely recognized as failed system.”
Sure enough, as the opioid epidemic exploded in in New York City, buprenorphine was increasingly available only to those who could afford private insurance. Between 2009 and 2016, the number of buprenorphine prescriptions on private insurance increased by over 4.5 times, while the number on medicaid fell nearly by half. In 2016, over three-quarters of buprenorphine prescriptions were paid for by private insurance.
While the city’s $60 million HealingNYC initiative has shown modest success in reducing the number of overdoses city-wide and increasing buprenorphine prescriptions, it hasn’t been enough in the Bronx, where opioid deaths continue to increase.
“It’s supply and demand,” said Dr. Tiffany Lu, Medical Director of the Montefiore Buprenorphine Treatment Network. “The Bronx does not have enough capacity because it historically had the burden of the disease.”
And while money for outreach and education programs are essential, the greatest hurdle in the Bronx is finding physicians like Littleton and Lu who are able and willing to prescribe buprenorphine.
Under DATA 2000, prescribers are required to obtain special wavers to even be allowed to prescribe the treatment.Completing the requirements can be an arduous burden to already-overextended care providers. Doctors are required to attend eight hours of training and clinicians (including nurse practitioners and physicians assistants) are required to take 24 hours of training.
However, once a physician has a waiver to prescribe buprenorphine, they are only allowed to treat 30 patients in their first year. This cap increases to 100 and 275 patients in their second and third year, but the cap still contributes to the shortage of access to buprenorphine prescribers, according to a letter by the New York State Department of Health.
Some physicians question the need for a waiver at all. “[Buprenorphine is] a schedule III drug,” said Littleton. “It’s less addicting substance than opiates, but prescribers are able to provide [opiates] at will without training.”
A bipartisan bill, the Mainstreaming Addiction Treatment Act of 2019, has been introduced to both the House and Senate. The bill would allow physicians to prescribe buprenorphine without a DEA waiver.
Still, even some physicians who interact with opioid-addicted patients may be reticent to start buprenorphine treatment.
Rikin Shah, Chief Resident at St. Barnabas Hospital in the Bronx, is not waivered to prescribe buprenorphine. In the emergency department, where he typically encounters such patients, initiating buprenorphine treatment would require counseling and monitoring, and in a 200-bed room, where other patients require attention, he doesn’t feel that starting new medication is a good idea.
“We may not be able to monitor how they are doing on the medication, whether they need changes in doses, or if they are having any adverse drug/side effects,” Shah wrote in an email. “This is dangerous for our patients.”
Emergency departments are not the appropriate venue for starting addiction treatment, Shah continued, and promoting them as such might lead to an abuse of their resources.
“We need to optimize our resources to taking care of the sickest patients and to those who are at risk of losing their life…. More often than not, although withdrawal symptoms are uncomfortable, they are not life threatening,” Shah’s email continued. “Emergency departments become in a way suboxone/methadone clinics as patients can find coming to the [emergency department] the most convenient way to treat their withdrawals.”
While some physicians may be reticent to provide treatment for medical reasons, their own stigma towards addiction may be just as big a barrier.
Littleton in her Bronx office.
“Lack of knowledge and fear of the unknown are big factors, and the other is stigma,” said Littleton. “People get concerned about [treating] the patient who has an addiction and what that means.”
Some providers worry that treating addiction is like “opening up a Pandora’s Box,” said Littleton. They think “if we talk about [your addiction] we’re going to talk about all that trauma that you had as a child and I don’t have the resources to give you the support to deal with that, I don’t have access to good mental health [services] that I can connect you with… and I can only address so many things in 15 minutes.”
Littleton walks through these traumas with almost every patient she sees. Raymond, who had recently been released from Rikers on drug charges and asked that his last name not be used, told Littleton that he’d been using speedballs (a mixture of heroin and cocaine) since age 11, when his father introduced him to the dangerous cocktail.
Littleton didn’t blink when Raymond said that he’d had a relapse. Like Salvador, he relied on heroin to tide himself over after leaving prison, before coming for treatment. Instead of discharging patients who relapse, punishing “dirty urine” by terminating treatment, Littleton stresses the importance of patience and understanding.
“Many [patients] will have a relapse, and that’s okay,” she said after seeing Raymond out. “Addiction is a spectrum… [and] we do them a disservice by discharging them.”
Once physicians can normalize their understanding of addiction, and see the effect of treatment, those fears and stigmas will fade, Littleton said. “It’s just understanding that… anybody can have opioid use disorder and have perfectly normal lives otherwise.”
Treating opioid addiction is no simple task, and buprenorphine is not a silver bullet, said Lu, the doctor from Montefiore. But, access and supply are the only way to get this life-saving drug into more hands.
“[Being trained to prescribe] buprenorphine is the lowest threshold that anyone can do.” Lu said. “My message to all my colleagues is: please do something, get yourself trained, offer it, because if you don’t offer it you’re basically saying you’re not interested in treating the disease in any way.”
A representative from Coalition for the Homeless surveys clients at the PATH center in the Bronx. (HAZEL SHEFFIELD/ Bronx Ink)
“The new Prevention Assistance and Temporary Housing (PATH) facility was designed to provide compassionate and efficient services that had not previously been offered by the City. The center we are standing in today reflects our commitment to tearing down an old system that was fragmented and slow.”
Mayor Michael Bloomberg at the opening of the new PATH center at 151st Street and Walton Avenue in the Bronx, May 3, 2011.
“They need someone to come in here undercover!” yelled a petite, angry mother one Thursday morning to no one in particular. The 37-year-old Queens-born woman was leaving the new PATH building in the Bronx, which serves as the only administrative gateway for families into the city’s homeless shelter system.
“The kids are sleeping on benches! The food is horrible!” she added. A small group of women joined her trailing children and strollers. The mothers gathered outside, sharing stories of their struggles on the streets and inside and outside the center.
For Angela Marougkas, there was nowhere else to go. With her 9-year-old daughter Jasmine by her side, and her 19-year old daughter and baby grandson close by, Marougkas said she had quit her job in order to care for her dying mother earlier in the year, leaving her unable to pay the rent when her mother passed away. In May, pregnant with twins, and suddenly homeless, she arrived at Mayor Bloomberg’s new PATH center in desperation.
Marougkas’s family is one of nearly 1,500 new city families who seek homeless shelter every month. Their first stop is the new PATH center with its sleek, mirrored walls. It replaced its notoriously grim Power Street predecessor, which was plagued by long waits and poor conditions.
When Bloomberg cut the ribbon last May, he promised that processing times would be cut from 20 hours to seven or eight and that families would receive placements the same day they applied. But the experiences of many families applying for shelter do not reflect that pledge.
“They treat us like animals,” said Marougkas. “We wait here all day just to get placed in shelter for the next 10 days. And we hope and pray we’re found eligible.”
The majority of families – a staggering 67 percent in February 2011 – are found ineligible. To comply with Department of Homeless Services regulations, homeless families must have written proof that they have no other viable housing option. This creates a culture of suspicion, rather than compassion, said Lindsey Davis, director of homeless services at New York City’s Coalition for the Homeless, a national advocacy group. “The city’s focus is on investigating fraud and knowing whether or not someone has another place they can stay,” said Davis. “That’s to the detriment of knowing whether someone is safe in that place.”
The high number of rejections spell grave consequences for a growing number homeless families as winter approaches. Bloomberg’s 2004 promise to reduce the number of homeless by two-thirds in five years was undercut by the latest figures, which show that there are 45 percent more families on the streets today than when Bloomberg took office in 2002. The data, compiled by Coalition for the Homeless from city statistics, show that the number of homeless is at an all-time high of 41,000 as of October.
Homeless families say they become trapped in a damaging 10-day cycle. They are allowed to stay in a temporary shelter for little more than a week before they are called back for review. The caseworkers at PATH require families to sign in and out of each shelter, maintaining perfect records of each stay. If they do not have the right documents when they are called back, often at little more than a morning’s notice, they risk being turned away.
The system also requires every member of the family be present at PATH before being found eligible for shelter. This means parents often face a tough choice: take their children out school for a day or end up on the streets for a night.
Every Thursday, at the bottom of the long, concrete ramp up to the PATH center, three young women clutching clipboards addressed families as they leave. The women handed out flyers for the Coalition’s Crisis Intervention Program at Fulton Street in Lower Manhattan. “We are not allowed inside,” said Jessica Horner, a children’s advocate, “so we wait here to catch people on their way out.” The Coalition helps 3,500 families a day with job training, emergency food and gathering the all-important documents.
Rats, mice and roaches
Those lucky enough to be granted shelter may find themselves in worse conditions than they imagined. In November, Maxine Rice, a young black mother from Brooklyn, said the places she stayed in were so infested with cockroaches, that she stuffed her sons’ ears with cotton wool to stop the bugs from crawling in them as they sleep.
Things were looking up last November for Quanisha Henderson, a 21-year Brooklyn mother with painted, almond-shaped eyes. She said she had become homeless two years earlier when she aged out of foster care. The agency placed her in a scatter-site apartment where she could live with her son. She’d found a job at nearby salon braiding hair. Then she was called back in after she failed the background check because she couldn’t provide documents showing her accommodation for the last two years.
Henderson’s eyes filled with tears as she talking about ending up back back in the shelters. She remembered that in the evenings, men stalk young women. “They think we’ll be desperate,” she said. “They think we’ll do anything for $10.”
For Angela Marougkas, bouncing from shelter to shelter came to a head on a hot day last August. She was six-months pregnant with twins when the PATH center assigned her to a room on the fourth floor of a scatter site in Brooklyn. The next day the family traveled back to the PATH center, jumping the turnstiles in the subway, to ask for a new shelter without four flights of stairs.
Her family was immediately sent back to the fourth floor apartment to sign out with their caseworker. By the time the papers were signed, it was getting late. The family was sent to a shelter in Brooklyn, five of them crammed in a tiny room with one window. It was too hot to get any rest. Instead, they slept on trains between trips to the PATH center.
A month later, in September, nurses told Angela that her stress levels were dangerously high. She had an emergency C-section on October 7. One of her twins was stillborn.
In November, she found herself again standing outside the PATH center, worrying about her surviving son. “I’m supposed to be at the hospital,” said Marougkas. “He’s in critical care and I’m supposed to breastfeed him. I cannot be here all day.” She railed against the center, angry at her caseworker’s familiar news that she had to go to each shelter she’d stayed in and get the papers to prove each move.
Putting fraud investigations before people
Families often need help assembling documents correctly. “So we step in and try to help them create documentation of the problems that they’ve experienced,” said Lindsey Davis of Coalition for the Homeless.
At PATH, part of the caseworkers’ job is to do everything they can to keep people from entering the shelter system in the first place. Clerks will try to send the family back to any home they might have stayed in during their quest for shelter, even if the home is not safe, or they are not longer welcome.
Davis has worked with families who have been told to stay with people the barely. Sometimes the tenant will not let them in. Unless the family can prove that they cannot stay, they are deemed ineligible for shelter and forced onto the street.
“We have to try to figure out if there’s a way to document these things, so that they will be included in an investigation that the city is doing into their situation,” Davis said. Despite several calls and emails, the Department of Homeless Services refused to comment.
One weary mother recalled her struggles trying to get her paperwork together. Marie Searle lost the lease on her home in Maryland and brought her two sons, ages two and four, to live with family in New York in July. When her family put her out, she turned to PATH, which has rejected her bid for shelter twice because she failed to provide letters proving her situation.
To make things worse, her sons became sick after eating the city-provided food at the center. No food is allowed inside PATH.
“The same day we left here they ended up in the hospital with stomach viruses for four days,” said Searle. “Both my babies were hooked up on tubes and IVs. They’re giving kids spoiled food, old food, cold food and there’s nothing we can do about it.”
The end of Advantage
Despite his early promises, Mayor Bloomberg has significantly reduced the number of programs available to the homeless. In March, the state announced that it would cut all the funding for the city’s Advantage program, which provided rental subsidies to help the homeless transition from emergency shelters to self-sufficiency.
“There are no new people entering that program,” said Davis, “so that really means people staying in shelter for longer periods of time. It’s one reason why the number of people in shelter has increased.”
Sensing a coming crisis, lawyers from Legal Aid secured an injunction to prevent the city from cutting off Advantage payments to households whose contracts had not expired. But those contracts are NOW coming to an end, and there are no new programs to replace them. Department of Homeless Services data shows that, by January 2011, 40 percent of Advantage families had reapplied for shelter.
A 32-year-old mother of four with red hair scraped back from her freckled face found herself in a bedbug-infested shelter after losing her Advantage payments. “I just got evicted yesterday,” Tiffany Branigan said in a quiet voice, while her sons, between the ages of five and 14, slumped over suitcases behind her. “For non-payment of rent, because I used to have the Child Advantage but they stopped the payments.”
The family was sent to a temporary shelter at 8 p.m. the night before, but the address they had been given didn’t exist, so they came back to PATH. When they finally got to the right shelter at 11 p.m., the mattresses were crawling with bedbugs and the children couldn’t sleep. Branigan collected some of the bugs in plastic wrapping and brought her children back to the center the next day to complain, but she was told by her caseworker that there was nothing she could do to get a transfer. “So I have to stay there and deal with it,” Branigan said. “She told me to wash our clothes in hot water, but it’s not us. It’s the beds.”
In mid-November, Angela Marougkas went to pick up her premature son from the hospital. But when she got to the shelter on East New York Ave and Junior, she was turned away at the door because the baby’s name was not yet added to their case file. “We wound up going all the way back to the Bronx with a premature baby, and he’s under special instructions he’s not supposed to be out in the cold,” said Marougkas. “And not only this: they wanted us to leave the next day because the capacity of our room was five people, and with the baby we made six.”
Eventually, Marougkas’s caseworker said the family could fit six of them in the room because the baby was so small.
Still, her struggle is not over.
“Today is the tenth day,” said Marougkas, on a cell phone in her temporary apartment. “But they didn’t contact us with a letter, yet. I don’t want to jinx things. I’m just hoping and praying that we can stay here, somewhere stable, until we find ourselves an apartment.”
