One issue highlights homelessness as a multi-layered and deadly condition. It reported mortality among the approximately 10,500 homeless in San Diego County was 624 in 2023, places the death rate at approximately 594 deaths out of every 10,000 homeless individuals each year. This is 7.5 times higher than mortality in the general US populationan incredibly sober figure! To further underscore the magnitude of this unprecedented homeless mortality rate, it is 18 times higher than mortality in the tragic addiction crisis in the US and about 3 times higher than it caused in Gaza of the devastating conflict between Israel and Hamas over the past year. Of course, these numbers do not explain specific cause, context or intent, but are a stark and tragic result of the vulnerable, deadly underbelly of homelessness.

Drivers of health outcomes in general, including mortality, can be grouped into broad categories that include access to medical services, personal behavior, and what are loosely called social determinants of health. Social determinants include social support, education, employment, housing, neighborhood and access to healthy food which are strongly linked to as much as 50% of the total results. When people become homeless, they have figuratively fallen off a cliff without resources and support in several categories. These individuals, who are deeply wounded, may at some point need individualized, highly coordinated, intensive, supportive, and holistic intervention from our friends, schoolmates, neighbors, or even family.

Opinions and supporting evidence for solutions to homelessness in San Diego County come from a number of diverse and unique perspectives – those who are homeless, local residents, businesses, law enforcement, frontline and academic organizations, health care and policymakers. As an observer, it seems that recognizing, documenting and acting on the drivers of homelessness has not fully considered the question: What causes what – and why? Current solutions that have already been used up billion dollars over the last decade can only solve part of the problem at a nominal entry level based on the fact that the needle pointing to some important visible vital signs such as the number of homeless people, mortality and long-term outcomes is moving further into the red zone. Is it because there are not enough resources?

What if homelessness is seen through a different lens? The homeless are an economically, socially and medically impoverished population in the highly prosperous San Diego region. Consider the principle of this lens from Clayton Christensena very influential professor at Harvard Business School who said in his book “The Prosperity Paradox: How Innovation Can Lift Nations Out of Poverty,” “Most of us are moved by the painful signs of poverty.” We all want to help. But what might seem like the most obvious solution to these problems—directly helping poor countries by investing to fix visible signs of poverty—has not been as successful as many would like. What if instead of trying to fix the visible signs, we focus on creating lasting prosperity? This may require a counterintuitive approach, but one that will make us see opportunities where we might least expect them.

Examples of counterintuitive principles include what can we do for the homeless versus what can the homeless offer us, solving a problem versus creating a market, and correlations versus causal mechanisms. Prosperity for the homeless involves successful long-term healing of severely damaged lives within a self-sustaining model. Currently, solving homelessness is seen as just consuming resources with a deficit-based solution. How can resources be created? Creating a viable and effective solution focused on prevention requires innovations that are simple, less expensive and that draw in non-government funded stakeholders financial and other resources for those with very difficult, complex problems including substance abuse, serious mental health problems, chronic diseases and loss of positive social determinants of health. This may seem unrealistic and overwhelming, but potential creative and innovative future solutions to be developed must be out there for those willing to see through a different lens.

Morelock, MD, is a retired physician and lives in Valley Center.