In the Gaps: Better Understanding the Expensive Human Suffering of Chronic Homelessness
Q&A with Dr. Brian Klausner
Dr. Brian Klausner attended the University of Notre Dame before training at Georgetown University Medical School. He has spent his career caring for high-risk patients experiencing homelessness on the streets and in the clinics of Boston and Raleigh while simultaneously serving in administrative leadership roles in the evolving world of population health. He has a particular interest in building models that proactively identify and engage patients at the highest risk for poor outcomes. Dr. Klausner co-chaired Wake County's Familiar Face Population Health Task Force and helped establish WakeMed’s Center for Community Health, Innovation, and Equity. His work has been recognized with numerous awards and featured in outlets such as Politico, USA Today, NPR, and Modern Healthcare.
Matt Nathan: Dr Klausner, you are a busy guy working in a healthcare system as a practicing internist, overseeing quality and value system practice parameters, and building up your community health advocacy organizations, especially for unhoused and disenfranchised patients. Why did you write the book In the Gaps: Better Understanding the Expensive Human Suffering of Chronic Homelessness?
Dr. Brian Klausner: Over my 20 years as a public health physician, I have cared for incredible individuals with extraordinary strength who face daily struggles most of us cannot begin to imagine. Too often, I have watched individuals experiencing homelessness suffer and die — misunderstood by both them and society. It is haunting to care for these patients while navigating society’s fragmented safety nets, which fail to provide the help they so desperately need.
After years of trying to understand how society can hemorrhage taxpayer money while tolerating this costly and preventable suffering, I reluctantly reached this conclusion: people simply don’t care — at least not enough. But rather than becoming paralyzed or disheartened by this realization, I sought to understand it. In medicine, and in life, you can’t solve what you don’t understand.
Why do we continue to mismanage homelessness at such an immense financial and human cost? If solutions exist within the foundational values shared across religions, political ideologies, and societies, why do we still fail to implement them? And why, when these commonalities could unite us, do we instead allow this issue to increasingly divide us?
This book is my journey to find those answers — to better understand not only the root causes of chronic homelessness but also, just as importantly, our struggles to empathize with and support the most vulnerable among us. My goal in writing In the Gaps is to share these insights and the incredible stories of my patients’ resilience in the hope of fostering both awareness and action — and, ultimately, optimism that we can become a more humane and cost-efficient society that truly lives up to our common ideals.
Nathan: Why write the book now?
Klausner: Homelessness in America is at record highs, paralyzing communities and becoming a top concern for voters. There’s an urgent need to better understand it — so we can better address it.
At WakeMed’s Center for Community Health, Innovation, and Equity, we have continuously pushed care models that better identify and understand root causes of chronic homelessness instead of expensively, and often futility, just chasing their symptoms. By addressing the root causes of trauma, substance abuse, and mental illness, we see firsthand how suffering and disease can be managed more effectively.
As homelessness worsens across our country — and discussions of cutting social services gain traction — I felt compelled to share the lessons I have learned over my career to help ensure we are actually cutting “waste” instead of evidence-based solutions. To accurately differentiate between the two, you need a clearer understanding of the underlying causes of homelessness that need to be addressed.
One of the most rewarding responses I have received from In the Gaps is the sense of reassurance and hope readers find — not just in better understanding the problem, but in seeing real, bipartisan solutions.
Nathan: You talk in the book about the need to “efficiently treat root causes instead of expensively just chasing their symptoms.” What are some of the root causes of chronic homelessness?
Klausner: This is the question I’ve spent much of my career trying to answer. Early on in my career, I focused on the medical conditions landing my patients in the hospital — what I was trained to treat. But as I share in the book, particularly in my story about Mr. Spears, I realized that standard medical approaches don’t work when severe trauma, mental illness, and social dysfunction are at play. For Mr. Spears, in the context of the unspeakable trauma he faced over the course of his life as he battled schizophrenia, he struggled to make even basic decisions about his health that would seem intuitive to others. He lived his life in a constant survival mode. We failed to adjust our approaches to account for Mr. Spear’s challenges, resulting in expensive care with poor outcomes that we failed to prevent. The real root causes of chronic homelessness aren’t just medical or economic — they’re the lifelong effects of trauma, mental health struggles, and the way society has historically interacted with individuals experiencing homelessness — the “instinctual dehumanization” they face on a daily basis. These patterns often begin in childhood, setting people on a trajectory toward the suffering of chronic homelessness that is both devastating and incredibly expensive for society. Until we stop chasing symptoms and start addressing these root causes, we’ll continue wasting resources while failing the people who need help the most.
Nathan: Are there real solutions to the overwhelming crisis of homelessness? Driving through the streets of many cities across the nation can make it seem like an insurmountable problem.
Klausner: Yes! While the solutions may not be easy, they absolutely exist. First, we need more affordable housing. Plain and simple. The easiest way to prevent a person from falling into chronic homelessness is to not allow them to become homeless in the first place. The fact that housing costs have outpaced wage growth for years has resulted in hundreds of thousands of Americans becoming homeless. You can’t afford what you can’t afford.
For those who get trapped in the cycle of chronic homelessness, we need to work together to build more aggressive, multidisciplinary, and collaborative approaches in our community. In the Gaps shares examples of these types of solutions that have worked. These include trauma-based approaches across the spectrum of mental health, addiction treatment, social services and medicine, prison re-entry programs, pediatric mental health models, and “whole person” analytics that allow us to quantify the cost-effectiveness of the approaches we implement. As I discuss in the book, I have seen a lot of success with “housing first” programs that have evolved with bipartisan support across multiple administrations in our nation. This must remain a foundational strategy in how we approach chronic homelessness. We have worked locally to strengthen housing first programs by better supporting and expediting treatment for individuals moving into housing.
Admittedly, none of these solutions are easy. But what we cannot do is allow ourselves to become so overwhelmed by the complexity, messiness, and unpleasantness of the growing crisis of homelessness that we resort to reflexive dehumanization and blame of those it impacts. It’s all too common (and easy) to blame individuals on the streets for the symptoms and manifestations of severe mental health pathologies, physical health issues, and trauma instead of focusing on how we can use science and experience to effectively help them.
Nathan: You make a financial argument in your book about developing solutions so we stop “expensively hemorrhaging taxpayer money in preventable human suffering.” Can you summarize what you mean by this?
Klausner: This was one of the most significant “A-ha!” realizations of my career — the staggering societal cost of our mismanagement of the pathologies associated with chronic homelessness. The human suffering of chronic homelessness, in all its forms, is incredibly expensive — whether it manifests in hospitals, jails, ambulances, or homeless shelters. For many of our patients, these costs reach easily into the six figures per patient annually. It can often approach half a million per patient depending on the complexity of the case. This is unacceptable — especially if much of this cost is avoidable. As we continue to develop better analytics to quantify the total societal cost of chronic homelessness, we can clearly see not only the cost of our inefficiencies but also the savings that can be generated by implementing more effective solutions. This data-driven approach makes the case for change more persuasive and, importantly, bipartisan…even in 2025. We have had success with this locally in Raleigh, North Carolina, as have other communities across the nation. We need to better share experiences and evidence as we address the growing social crisis of homelessness in America.
Nathan: In the book, you explore the science of “reflexive dehumanization.” Explain why this is so central?
Klausner: I wanted readers of In the Gaps to understand not just the clinical pathologies driving chronic homelessness at the level of the individual but also how our own biases and instincts of reflexive dehumanization can help fuel this crisis rather than solving it. As the book unfolds, these societal pathologies take center stage, diving into the roots of bias and dehumanization — into its neurobiology. History shows us how these instincts have been manipulated to sow division and stall social progress. Understanding this isn’t just an academic concept — it’s crucial if we want to get beyond this reflex to build a more efficient and humane society. By framing this through science — using data, real-world examples, and research on social cognition — I aimed to break through reflexive bias and stereotypes in a way that truly resonates with readers. Ultimately, the science is straightforward and even intuitive. Once readers grasp it, they often have their own “aha” moments, recognizing these patterns in themselves and others in daily lives. Hearing this feedback from people across political and religious backgrounds has been the most rewarding part of this entire process for me as I think, ultimately, it will result in a more thoughtful collective mindset that we can leverage to help solve what is, undeniably, the incredibly complex social crisis of chronic homelessness.
Nathan: You extend the conversation about medicine’s inefficiency in addressing chronic homelessness to other sectors of society. As you write in the book: “The deep-seated roots of dehumanization around homelessness spread across social sectors outside of just medicine and underlie the hypocritical gaps between our professed political, social, and religious ideals and our actual actions.” Can you elaborate on that?
Klausner: It became clear to me that a foundational barrier to effectively addressing chronic homelessness in our society is a universal human tendency to avoid the pain of empathy through reflexive dehumanization. This natural human instinct can pull us away from the values and beliefs so many people strive to live by. It creates a climate of blame that can facilitate inhumane and inefficient policies across government, the justice system, and social service sectors. Interestingly, these instincts are exactly what religious and philosophical leaders have warned us about throughout history. Whether it’s “judge not,” “love thy neighbor” — or even “thy enemy” — or direct instructions around caring for the poor and suffering, the wisdom is clear. In fact, the book’s cover itself serves as a reminder of this call to empathize: an image of the famous statue, Homeless Jesus, found in churches around the world, including the Vatican. The artist, Timothy Schmalz, graciously allowed me to use it after I shared In the Gap’s content with him. The statue depicts a man lying on a park bench, covered in a blanket, with only his feet exposed — showing the crucifixion wounds. Its message is subtle but powerful, meant to both confront viewers with the reality of homelessness and challenge them to see Jesus/humanity in the marginalized.
What’s fascinating is that today, we have the science and neurobiology to support many of these religious and philosophical teachings, not only showing us how human instincts influence our interactions with others, but also, importantly, how we can understand them, be aware of them, and therefore overcome them. Doing so can potentially allow us to build a more efficient, compassionate, and less expensive society. And, as the Dalai Lama reminds us, it’s just a cooler and happier way to live: “If you want others to be happy, practice compassion. If you yourself want to be happy, practice compassion.”
Nathan: While the enormity of homelessness and the unhoused is discouraging, we remain encouraged by your dedication and the commitment of others who put your passion and center of gravity into making a difference individually and collectively. Recognizing that root causes can vary by location and demographic, what is your experience on the prevalence of mental illness as the (or a) genesis for the circumstances? We hear that while schizophrenia and cognitive disorders exist, they are but a small part compared with socio-economic drivers and substance abuse causes.
Klausner: That is an excellent question. First, as I mentioned already, most people experiencing “new” homelessness simply cannot afford housing after years of housing costs outpacing wage growth in our nation. This is a main driver behind homelessness reaching record highs in communities across our country.
For those who eventually get trapped in chronic homelessness (over 12 months in the context of a mental or physical health issue), the reasons are very complex and obviously unique to the individual. But what we have learned over the years is that many of the conditions mentioned — cognitive disorders, schizophrenia, substance abuse — are often symptoms themselves of something bigger: historic trauma. For example, in a study we performed at a local substance abuse treatment program for individuals experiencing homelessness, 74% had experienced four or more adverse childhood events (ACEs), compared to the average American population prevalence of approximately 8-10% depending on which study you look at. The science has become clearer (and fascinating….and somewhat depressing) about the “downstream” consequences of historic trauma and how the body and mind react if they are constantly exposed to chronic stress. The physiological explanation is intuitive - when the body is in constant survival mode, it is not necessarily focused on longevity, or mental health, or learning math, etc. Its entire focus is daily survival — as it does so, it directs efforts and resources to certain functions (such as the limbic system or increasing your blood sugars or pressures to keep you alert) while neglecting others (such as the prefrontal cortex or cancer cell surveillance or fighting off disease). So, while each patient is different and unique, when it comes to chronic homelessness, I think the high prevalence of adverse childhood effects is one of the biggest “root causes” we have identified — something science has increasingly supported. This is important because in our experience, our biggest successes often result from going back all the way to the beginning to address this past trauma — to allow the patient to understand all of this so they can better address root causes and free themselves of the common deadly cycle of self-blame and associated isolation and loneliness. In doing so, we can avoid the “cardinal sin” of medicine — futilely chasing symptoms instead of effectively addressing root causes.
Nathan: You discussed many patient stories in your book, mixing them with your discussion on science and policy. Why did you choose this approach?
Klausner: I was very deliberate with this approach. The book intentionally works to show the humanity of the patients whose stories I share. I close the first chapter with the following: “...the greatest displays of human strength and beauty are often buried under the scars of time, hidden and disguised. Frequently, these scars are so deep and ugly that we reflexively look away, misinterpreting them as the ultimate reality while ignoring the beauty they’re obscuring. There is nothing more beautiful than human resilience. It is a shame when we are blind to it.”
Throughout my career, I have been in absolute awe of how my patients manage to wake up every day and somehow draw resilience out of nothing. Alone, sick, and facing the constant dehumanization of a society that looks the other way — it's incredible. I wanted to share these stories to highlight the paradox that, often, these very people we reflexively dehumanize are the ones demonstrating some of the greatest examples of human strength, persistence, and determination.
Recognizing this paradox allows the reader to appreciate how "backwards" the pathology of dehumanization can be — how completely off we can be when we fail to see the beauty and strength beneath the scars. Deep down perhaps we know these qualities are there, or at least might be there, but these instincts that reflexively dismiss an individual’s humanity block us from even trying to find that beauty and strength. As homelessness continues to increase across our nation, we all are gaining more and more experience just walking by and ignoring this human suffering in city streets across the nation. We step over individuals covered in blankets and sleeping on boxes. We look away.
Nathan: What do you hope readers get out of In the Gaps?
Klausner: The same thing I got out of writing it: a better understanding of the suffering and root causes of chronic homelessness along with insight into our human predispositions in how we view that suffering. I also hope readers take away timely reminders about shared values that transcend religions, cultures, and races — that can unite us and help create a more efficient and humane society. And I hope they are inspired by the stories of the amazing people I have had the honor to care for…reminded about the potential strength of human resilience.
In a time when forces of manipulated and aggressive societal polarization are coming from both sides of the media and political aisle, readers have found this book’s messages to be both inspiring and reassuring. Many have reached out to me that it has helped to change how they view and interact with people experiencing homelessness. As I write at the end of the book: “However you look at it, our collective humanity is the summation of all of our individual daily interactions with each other. We have constant opportunities to improve how we interact with those around us. Ultimately, we can only control our own world. Our own cognitive thoughts. Our own actions and how they influence the world for those around us. We can only control our relatively small contribution to the overall sum of humanity.
Even doing “a little” can be infinitely better than nothing, especially if it serves as an example for others. Changing medicine — or the world — may not actually be that hard. It can start with one human interaction at a time.”
Nathan: You have maintained a full-time Internal Medicine practice yet make the time to hit the street and work long hours in shelters. If you controlled medical school curriculum/training what additions and changes would you make, if any, to required exposure of physicians?
Klausner: I would make structured, longitudinal community-based experiences an integral part of physician education. One of the most glaring statistics that I think best captures the fundamental flaw in our healthcare system is that while only a small percentage of health outcomes are driven by what happens in our hospitals and clinics, we continue to spend nearly 90% of our 4.5+ trillion healthcare dollars within those walls. If we’re serious about improving outcomes and lowering costs, we must get outside our medical silos and into the communities where pathologies live, take root, and advance.
Unfortunately, our current medical training typically keeps students and residents confined within those institutional walls, learning from providers who themselves have spent their careers inside those same walls. We’re teaching medicine in a vacuum — detached from the community stressors, social determinants, and disparities that drive poor outcomes.
We need to bring medical education into community centers, shelters, and streets. Our trainees should spend time shadowing case managers, social workers, and community health workers. Exposure to these environments should be standard and longitudinal.
Without this shift, we’ll remain stuck — stubbornly remain blind to the realities that drive recidivism, burnout, health disparities, and the unsustainable costs we all talk a lot about but struggle to truly try to address.
Nathan: Your message strikes at the heart of society, where so, so many feel compassion and regret at the multitudes of people living on the street and in shelters but feel it is an insurmountable problem due to impermeable problems that cannot be solved yet appreciate the individual efforts of invested folks like yourself. Your book, your teachings, and especially your life by example, is a clarion shout-out to all that this can be fixed. You share compelling and moving stories and understanding about how this can be turned around targeting resources and efforts into where they really count. Get off the sidelines and link arms and we can all make a real difference. Dr Klausner, thank you for sharing, teaching, and making that difference at this critical time as our nation grapples with how to end chronic homelessness.
About the Author:
Matt Nathan, M.D., is a 2020 Harvard ALI Senior Fellow and Senior Editor for the Social Impact Review. Matt was previously the 37th Surgeon General of the Navy and most recently a Senior Vice President for a large tertiary care healthcare system.
This interview has been edited for length and clarity.