In his recent executive order, Ending Crime and Disorder on America’s Streets, President Trump directed federal agencies to utilize forced institutionalization of unhoused individuals under the guise of public safety, lambasting evidence-based harm reduction programs in the process. Unhoused people are framed as threats by Trump, engaging in open-air drug use and vagrancy. In response, the National Homelessness Law Center condemned this executive order and projected even worse outcomes due to the dismantling of harm-reduction initiatives, such as Housing First policies. Instead, under this executive order, housing assistance would be intrinsically linked to mandatory treatment compliance, which is completely antithetical to the principle that housing is a human right.
State-sponsored harm
Proponents of this executive order conceptualize homelessness as a choice, even though shelters, when available, often impose onerous restrictions, whether it be banning pets, partners, or possessions. In addition, encampment sweeps displace the unhoused and often destroy or throw away their possessions, including mobility aids and wheelchairs, and deepen mistrust, perpetuating a cycle of state-sponsored harm, rather than assistance.
Another facet of state-sponsored harm is the unpredictability of the drug supply due to prohibitionist tactics, as explained by the Iron Law of Prohibition, which conceptualizes prohibition of substance use as the catalyst for drugs that are either more potent or have various physiological effects. For example, since xylazine became a scheduled drug in Pennsylvania due to bipartisan efforts, medetomidine has emerged, a drug that is more potent at the alpha-2 receptor and may present with different clinical sequelae, specifically more prolonged sedation. Lawmakers schedule a drug and wait until the next adulterant to schedule arises. This disproportionately impacts unhoused people due to the high rate of comorbidity of mental illness and substance use, with one meta-analysis finding that around 44 percent of unhoused people have a substance use disorder.
Addressing root issues
Rather than addressing the root issues, this executive order scapegoats the unhoused. Many people are unhoused due to skyrocketing rent prices and the absence of low-barrier housing, in addition to mental health and substance use treatment largely being siloed from primary care services. Programs that attempt to bridge this gap, such as syringe service programs, are largely underfunded and have tenuous legal status at best in many states. This funding issue will only be exacerbated by the significant federal disinvestment from Medicare and Medicaid, including $345 million in substance use treatment and overdose-prevention funding cuts as of July 16, 2025. Substance use, mental health struggles, and addiction are not the cause of homelessness; not having homes is.
Advocating for harm reduction
Housing insecurity is a complex issue that will never be fixed, but it can be ameliorated by voting for representatives who support harm-reduction policies. As a constituent, you can reach out to your local representatives who can advocate for legalizing and adequately funding SSPs, permanent supportive housing with voluntary services, expansion of mobile outreach, Medicaid reimbursement for housing-related services, co-responder models, where clinicians are present with law enforcement during interactions with unhoused individuals, and supporting policies that promote a living wage and expand childcare subsidies.
As medical students, we can demand more of faculty and ensure that the information they provide is socially conscious and reflects structural barriers to housing and care for people’s mental and physical needs, rather than pathologizing substance use and homelessness as innate failings of the individual. We can create and collaborate with organizations that reflect these beliefs and keep the community informed. We must pressure those who are in power to vote for policies that support human dignity and vote them out of office if they do not choose to do so. Having SSPs legal and adequately funded in every state would allow unhoused people to have access to comprehensive resources, which include food, clothing, help with obtaining low-barrier housing, and medical care for their mental and physical health needs to name a few. However, there are various barriers to consistent, reliable funding, which include structural stigma and restrictive funding, especially surrounding the purchase of needles. As a result, SSPs must rely on various sources of funding, including limited federal, state, or local funding, private foundations, fundraising, donations, and more.
Beyond partisan rhetoric
Let’s not be distracted by this rhetoric that has been emblematic of the war on people who use drugs for decades; this executive order is another chapter in America’s bipartisan failure to provide human beings with housing, adequate health, and dignity, regardless of their mental health or substance use status. Simply voting Democrat or Republican will not fix this. Both parties have pushed paternalistic policies that are ambivalent at best and dehumanize people based on their mental health, housing, and substance use status. We must embrace evidence-based, compassionate care, which includes Housing First policies, disassembling of silos in care, and truly meeting people where they are, not meeting people where they are to get them where you want them to be.
Gary McMurtrie is a medical student.
