“So, when you go out the door, you’re taking the chance of dying, of getting in this shit (Covid). Stay your ass indoors… I know one thing. I know how to survive. I know how to do that well. I want to live. Surviving and living are two different things.”
This was what Leonard, a 61-year-old African American man experiencing homelessness, said when I interviewed him in his Covid-19 motel room in an upscale neighborhood of San Francisco. San Francisco is a city of extremes and contradictions, the playground of Silicon Valley billionaires, the epicenter of gay culture and progressive politics, where Twitter’s headquarters overlook sidewalks overflowing with people forced to sleep outside. It’s a city that systematically decimated its Black neighborhoods, from the destruction of the historic jazz epicenter in the Fillmore to the superfund site of Bayview Hunter’s Point.
A model city
In the early months of the Covid-19 pandemic, San Francisco was a model city for low viral transmission, garnering national headlines for its early “shelter-in-place” ordinance on March 16, 2020. A month later, an outbreak in the city’s largest homeless shelter provoked panic among local leaders and advocates for people experiencing homelessness (PEH),1Elizabeth Imbert et al., “Coronavirus Disease 2019 Outbreak in a San Francisco Homeless Shelter,” Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America 73, no. 2 (July 15, 2021): 324–27. leading to the creation of what became known as the San Francisco Shelter in Place Hotel Program (SIP). First, individuals and families were moved from congregate shelters. Then, teams of health workers roved the streets, looking for PEH who met a set of evolving CDC criteria of high vulnerability for severe complications from Covid-19.“The SIP directive created the conditions for PEH and advocates to make demands to the city for improved and more dignified, albeit temporary, housing options that facilitated what Leonard described as the shift from ‘surviving to living.’”
I conducted research over one year during the pandemic, including participant observation in SIP hotels, ethnographic interviews with SIP residents and staff, and medical record reviews. The SIP directive created the conditions for PEH and advocates to make demands to the city for improved and more dignified, albeit temporary, housing options that facilitated what Leonard described as the shift from “surviving to living.” Here, I consider the distinction Leonard raises between surviving and living as a zone of value production, building on a new theory of embodied value advanced by anthropologist Stefan Ecks. Drawing from research on depression and psychopharmaceuticals in India, Ecks argues that value emerges from enhancements to a living body in an environment. This approach to value is particularly well-suited to pandemic-related research since, as Ecks explains, “the pandemic was a real-time experiment in biopolitical responses. The research design was extremely messy and there was no placebo control group. Nevertheless, value comparisons had to be made because millions of lives were at stake.”2Stefan Ecks, Living Worth: Value and Values in Global Pharmaceutical Markets (Durham, NC: Duke University Press, 2022), 34–35.
The SIP hotel initiative took shape at the beginning of a global pandemic as appraisals of grave risk accompanied dramatic new federal funding. Across the United States, similar programs were introduced in Oregon, Washington, Colorado, Illinois, and New York. The lives and deaths of PEH took on new meanings in the public discourse and old fears of contagion took new shape in the context of messaging around “flattening the curve” to avoid overwhelming health systems. Suddenly, providing an opportunity to “shelter in place” for PEH became a priority for San Francisco, at once a logic and a mechanism for streamlining what would usually be an arduous bureaucratic ordeal subject to multiple budgetary processes. In short, the pandemic heralded new viropolitical processes.3My use of viropolitics repurposes physician-anthropologist Vin-Kim Nguyen’s concept of “viro-politics”, which he used to describe the phenomenon of therapeutic globalization in the HIV/AIDS epidemic. Vinh-Kim Nguyen, “Viropolitics: How HIV Produces Therapeutic Globalization” in HIV/AIDS : Global Frontiers in Prevention/Intervention, eds. Cynthia Pope, Renée T. White, and Robert Marlow (New York: Routledge, 2009). Facing this moment, advocates knew: (1) the virus had the potential to bring serious harm to an already vulnerable population and (2) the pandemic offered an opportunity to permanently expand housing. Advocates relied on a logic I call viropragmatism: leveraging the acute risk of the virus to address the chronic risks of homelessness.
Scrapping: Always already homeless
Leonard was raised in San Francisco’s Bayview district: a historically Black neighborhood subject to multiple forms of racism, resulting in poverty, violence, and environmental contamination. It is also a site of resistance and resilience.4Melissa J. Hagan et al., “Homeplace: Care and Resistance among Public Housing Residents Facing Mixed-Income Redevelopment,” American Journal of Orthopsychiatry 90, no. 5 (2020): 523–34. Leonard told me he had been experiencing homelessness since running away at age 12. Now 61, he’d been among the first to be transferred from a congregate shelter to a private motel room early in the pandemic. He continued explaining to me the difference between surviving and living:
Surviving is when you’re sitting and you’re scrapping and everything. You’re out there. No babes, nothing, just try to eat through this, that, and the other. Living’s making yourself healthy, giving somebody help in life, not trying to take…That’s surviving. Living takes work. When you get better and better at it, it’s like a muscle. It gets bigger and bigger, it gets stronger and stronger.
Like most people experiencing homelessness, Leonard had multiple childhood traumas. He witnessed the drowning of his brother at age eight, which transformed his mother from a loving parent into an abusive figure from whom he decided to escape. Caught in the juvenile justice system as a teenager, Leonard cycled between carceral systems and the streets for over 40 years. At the time of our interview, he had lived in the motel for about seven months, his longest continuous period indoors in a decade. Leonard’s story reflects the experience of most people experiencing homelessness, where the labor of survival leaves little room for anything else.
Evaluations and value(s)“By ‘work,’ the expectation was that the project would not only save lives but would also save money.”
Early in my research, I was approached by a group of clinicians and medical students who sought to evaluate the SIP intervention, hoping to show that this endeavor “worked.” By “work,” the expectation was that the project would not only save lives but would also save money. Most interventions for PEH are expected to show fiscal savings, something not asked of interventions meant to help other vulnerable populations. This has to do with persistent stereotypes, biases, and ignorance around the causes of homelessness, which foreground individual factors, such as substance use and mental health, while obscuring systematic causes like structural racism, a lack of affordable housing, and available treatment programs. Decisions concerning what types of services and resources might be available to PEH are often couched in unspoken moralistic notions. These unspoken notions are often expressed in debates about value(s).
Evaluations of programs under the rubric of what is known as “Housing First,” meaning providing housing without any preconditions to PEH, are often tasked with showing a decrease in medical spending in exchange for providing housing: for example, decreased emergency department visits and inpatient day stays. These metrics are intended to justify the expense of providing housing. At the other end of the spectrum are advocates who center the humanity of PEH as worthy in and of itself of dignity in housing. Returning to Leonard’s distinction between surviving and living: How might this difference be made to matter in the context of something like a program evaluation?
Risk, care, control
Anthropologists have examined the relations between risk, care, and control in medical and social services designed for highly stigmatized populations including PEH. Some have theorized homelessness as exclusion and vulnerability, drawing on Giorgio Agamben’s figure of homo sacer or Judith Butler’s development of vulnerability.5→Giorgio Agamben, Homo Sacer: Sovereign Power and Bare Life, trans. Daniel Heller-Roazen (Oakland, CA: Stanford University Press, 1998).
→Fernanda Gomes Faria and Rodrigo Siqueira-Batista, “(Bio)Ethics and Homeless Persons: Between Agamben and Derrida,” Revista Bioética 28 (Oct.–Dec. 2020): 628–36. In her ethnographic research on women experiencing homelessness and using substances, anthropologist Andrea López argues that “the urban precariat are governed by two prevailing logics that are also highly contradictory: compassion and brutality.”6Andrea López, “Necropolitics in the ‘Compassionate’ City: Care/Brutality in San Francisco,” Medical Anthropology 39, no. 8 (2020): 751. Lopez draws on Achille Mbembe to show how San Francisco, a so-called “compassionate city,” creates what she calls “necropolitical care assemblages” where women experiencing homelessness are forced to continually imagine their own death as they manage risk for actual death in their engagements with care. Anthropologist Kelly Knight’s research with sex workers in San Francisco similarly highlighted the forms of medical and social triage performed by a set of variable experts she called “neurocrats” who marshal psychiatric diagnoses to grant or withhold benefits through the disability economy in the setting of neoliberal scarcity, chronic poverty, and addiction.7Durham, NC: Duke University Press, 2015More Info →
In the setting of early coronavirus lockdowns, while devastatingly uneven in impact and hitting the most vulnerable parts of the globe the hardest, the virus seemingly knew no limits, subjecting entire populations to control, manipulation, and surveillance. The viropolitical directive to “shelter in place” rendered one form of illness and death, from Covid-19, of great calculable importance, while “usual” forms of morbidity and mortality associated with being unsheltered were relegated to lesser levels of significance. Assault, exposure, overdose, trauma, and deterioration of chronic medical conditions are daily threats to be navigated. In the provision of SIP hotel rooms, only one form of risk was considered: Covid-19 infection and ensuing complications. The emergency calculus held that providing hotel rooms might be worthwhile not for what it would offer to PEH, but for the potential those rooms held to avoid overwhelming the health system.
Viropragmatism toward enhanced living“PEH and advocates used the pandemic emergency and the focus on one specific type of acute threat to win improved conditions, impacting the chronic threats they navigated both on the streets and in congregate shelters.”
Viropragmatism was a strategy for both PEH and advocates to demand increased, improved, and more dignified housing options, including private rooms with personal bathrooms, laundry service, and on-site medical care. These demands had to be made in relation to concerns of acute viral illness and contagion when the underlying chronic conditions of risk and suffering were not sufficient to motivate politicians to address homelessness in substantive and humane ways. PEH and advocates used the pandemic emergency and the focus on one specific type of acute threat to win improved conditions, impacting the chronic threats they navigated both on the streets and in congregate shelters. Together, viropolitics and viropragmatism engendered that qualitative shift Leonard characterized as the difference between surviving and living. Asked to participate in an evaluation of the SIP program shaped by neoliberal cost-efficiency health economics models, I turned to anthropological theories of value to consider how Leonard’s distinction might be rendered commensurable with the language of value sought by those tasked with making decisions about whether and for how long this program would last.
Value as theory and method
Value is not only a core anthropological concept, but also a methodological approach. A classic anthropological approach to value involves the comparative method: looking at what qualities may be similar or distinctive. Commensuration, on the other hand, is an almost anti-anthropological endeavor in a field that seeks to emphasize difference. Indeed, the concept of incommensurability within anthropological thinking became so ubiquitous as to become nearly devoid of meaning. According to Ecks’s concept of biocommensurability, “all commensurations are about life because value springs from life and all valuing is directed toward enhancing life. The shortest expression for this is that life values living. Life values what enhances life… Biocommensurating is the practice of valuing, embodiment is what makes valuing vital.”8Ecks, Living Worth, 39.
Following Ecks, a methodological approach to the valuation of the SIP hotel intervention would involve biocommensurations rooted in the embodied experiences of individuals like Leonard, attending to distinctions like his contrast between living and surviving. Policymakers, on the other hand, approach programs like SIP hotels as a piece of a small and shrinking pie. That is, this type of housing is taken to necessarily come at the expense of permanent housing or other interventions meant to provide support or care. Viropolitics catalyzed a performative act that provided “emergency” pandemic housing while eliding chronic forms of death and worsening risks of living outside and in congregate settings. It was precisely in that zone of documenting deaths through data that PEH came to “count.” PEH were not the only marginalized group to come to matter through a politics of contagion. The public spectacle of the data dashboards enabled transient and limited forms of citizenship and inclusion. “Usual” death remained normative and invisible for PEH who face high rates of morbidity and mortality.“In the SIP hotel, staying inside and out of the neighborhood he used to sleep in afforded Leonard multiple related improvements to his life, in particular to his long-term plans and dreams.”
Ecks observes that “lockdowns were meant to ‘buy time’ for ramping up investments in emergency healthcare and vaccine development… Expert valuations need to be certain of the criteria used to measure short-term and long-term impacts.”9Ecks, Living Worth, 38–39. In the SIP hotel, staying inside and out of the neighborhood he used to sleep in afforded Leonard multiple related improvements to his life, in particular to his long-term plans and dreams. In his telling, life in jail and on the street are characterized by the overwhelming effort it takes to survive: a complex mental and physical state of presentism, where longer-term futures, dreams, and plans are not only out of reach, but they almost never reach the horizon of attention.
The viropolitics of SIP were imagined to be both rapid and transient. PEH in SIP hotels were told they could count on housing “through the pandemic,” initially predicted through Fall 2020. Surges and mutations changed the timeline. Uncertainty created an opportunity for viropragmatics to advance efforts to leverage acute risk to address chronic needs, as PEH and advocates recognized the need to capitalize on the pandemic by leveraging viral risk to mitigate endemic harm, spurring a once-in-a-generation expansion of resources like increased permanent supportive housing.
According to Ecks’s embodied theory of value, “all commensurations are about life because value springs from life and all valuing is directed toward enhancing life.”10Ecks, Living Worth, 39. For those transitioning inside from decades of living outside, SIPs afforded respite and enhanced life with both material and psychological forms of dignity. The progress from surviving to living is the key difference that a medically supported hotel room might afford PEH otherwise facing sleeping on the streets or in warehouse-like congregate shelters.“Is an anthropological theory of value operable in the murky zone between numerical and ethnographic data in the context of programs typically subject to sterile measures of cost/benefit?”
As federal funds dry up and the pandemic moves from fiery crisis to endemic smolder, San Francisco is entering a new phase where funding priorities are shifting, and the SIP hotel program is slated to end in September 2022. As PEH and advocates continue demands and protests to keep the rooms open, decision-makers and researchers look to the numbers, which don’t tell a simple or easy story, so it is likely this program will not continue. Is an anthropological theory of value operable in the murky zone between numerical and ethnographic data in the context of programs typically subject to sterile measures of cost/benefit? As anthropologist Vincanne Adams suggests, “number crunching and metrics work… in their own way, (as) forms of storytelling. They tell stories about what those who produce them and what those who rely on them care about most.”11Vincanne Adams, introduction to Metrics: What Counts in Global Health (Durham, NC: Duke University Press, 2016), 6. Anthropological theories of value afford a way to think about how anthropological data might possibly be rendered more legible to policymakers who look toward measures and commensurations to guide their decisions.
The increment between surviving and living described by Leonard is an eminently embodied zone of value. It is no accident that the person featured here, Leonard, is Black. Structural racism means that, in a city where the Black population has been decimated, now only at 13 percent and shrinking, the population of Black PEH is almost 40 percent.12Meghan Henry et al., The 2018 Annual Homeless Assessment Report (AHAR) to Congress (Washington DC: US Dept. of Housing and Urban Development, Office of Community Planning and Development, 2018). Viropolitics allowed for the SIP hotel program and viropragmatism leveraged this temporary program to create more permanent supportive housing for PEH. Yet, to address the history of structural racism in San Francisco, viropragmatism should go further. Ecks’s embodied value theory is only one way to think about the type of commensurations at stake in solving homelessness. Thinking beyond the ledger mode of value as a feature of cost efficiency, providing quality hotel rooms as a short-term measure while expediting high-quality permanent housing might go some small way toward the beginnings of housing reparations for a city that has historically displaced its Black community through multiple, overlapping forms of structural and overt racism.
→Fernanda Gomes Faria and Rodrigo Siqueira-Batista, “(Bio)Ethics and Homeless Persons: Between Agamben and Derrida,” Revista Bioética 28 (Oct.–Dec. 2020): 628–36.