Collaboration is key to pioneering research with youth experiencing homelessness

Rebecca Alturk had all the qualifications that Dr. Coco Auerswald was looking for in a researcher for her work on youth homelessness in Berkeley. She was smart, determined—and had her own experience with homelessness.

To Auerswald, a UC Berkeley School of Public Health professor of community health sciences, Alturk was just the right fit—an undergraduate who could build trust with teens in similar situations. Alturk had experienced homelessness and housing insecurity with her mother growing up. She also had to leave home when she gave birth to her son as a senior in high school. But none of that got in Alturk’s way. She enrolled as a freshman at Cal when her son was just a few weeks old.

To Alturk, Auerswald’s lab became a home.

“She made me feel not so alone,” said Alturk, in an interview from her University Village apartment, where she lives with her now 10-year-old son and her mother. “I went my entire undergraduate career not knowing any research about this topic. I thought I was one of the very few people on campus silently experiencing homelessness, or who had experienced it.”

Their collaboration was a typical one for Auerswald. A pediatrician who overcame academic bias against studying homeless youth, Auerswald quickly emerged as a national leader in the field, who partners with students and youth with lived experience of homelessness and mentors them in public health research skills.

Since 1997, when Auerswald began her groundbreaking research on youth experiencing homelessness, her work has shed light on the social determinants of health of some of the nation’s most disadvantaged youth, and proposed structural interventions to improve their lives.

“I wanted to have influence on the influences that were affecting the health of my patients,” she said. “I could tell if I didn’t do that I would go nuts. If you keep seeing the same kind of train wrecks you want to do something about the trains.’’

Nearly 30 years since she started her research, Auerswald’s research lab is still expanding. She is co-director of i4Y (Innovations for Youth), a cross-disciplinary UC Berkeley School of Public Health research hub addressing issues of youth equity through community collaborative research and youth engagement. She also founded its offshoot: Youth and Allies Against Homelessness (YAAH).

“When I started doing this work, there were very few people doing research on youth homelessness,” Auerswald said. “What I’ve done—even if I’m not the most highly-funded researcher—is to prove that it’s possible to do research not only about but with youth experiencing homelessness.”

Looking back, Auerswald believes that any naysayers were guilty of “house-ism,” a phrase she coined, referring to biases against people who are unhoused. Tha bias once included researchers who wanted to study them, but Auerswald’s work has helped push the field from the fringes to mainstream.

This spring, Auerswald won three coveted grants in recognition of her achievements: a million-dollar contract to evaluate the impact of California state funding on services for youth experiencing homelessness; a $240,000 grant for a collaboration with Covenant House International; and $300,000 from Blue Shield of California Foundation to expand her internships for youth experiencing homelessness.

Auerswald’s Lab was recruited for the state evaluation project based on its past research, particularly a report on the impact of COVID-19 on youth experiencing homelessness in the Bay Area. The Covenant House collaboration seeks to revise best practices for preventing youth homelessness, focusing on equity.

Auerswald is thrilled by each of the grants, but the $300,000 Blue Shield award came as a real surprise.

“It was, honestly, like deus ex machina,” she said, in an interview on a rare day off. “It was literally just out of heaven that this money came. Now I can expand the pipeline —moving youth experiencing homelessness into research as a way to mentor them into careers where they are able to apply their lived experience to make the world a better place.”

Alturk is well on her way. She completed her B.A. while working as a researcher on Auerswald’s study of the impact of COVID-19 on providers for youth experiencing homelessness. After graduating, Alturk worked for the Los Angeles County Department of Health Services as a program manager supervising a COVID-19 team of over 50 nurses, EMTs, and community outreach workers who collected data and provided vaccines and testing for people living in encampments, shelters, or on the street. She then returned to Berkeley Public Health to enroll in the dual MCP/MPH program. “I came back for Coco,” she said.

Auerswald said, “It’s been amazing to see Rebecca [Alturk] go from an undergraduate, tentatively trying out her wings in an academic research lab to being someone who has run major programs to address the needs of the most vulnerable in our community. I’m incredibly proud of the work she has accomplished.”

Studying medicine in the age of AIDS

For a doctor graduating from medical school in 1992—especially in San Francisco—there was no bigger health crisis than AIDS. Auerswald did her residency at UC San Francisco, treating AIDS patients and working with the LGBTQ+ community, an experience which laid the groundwork for her current research with historically marginalized and at-risk populations.

After her residency, Auerswald worked as a pediatrician at non-profit hospitals and community clinics around the Bay Area. After doing everything from delivering babies to counseling young people considering suicide, Auerswald returned to academia, hoping to mitigate the problems facing her patients.

“I was trying to do work that could help prevent HIV, but was also just focused on adolescent health,” Auerswald said. “I ended up going into academia, because I really enjoyed doing community-engaged research with young people. The work I initially did as a fellow is what really got me hooked.”

“It is amazing to look back and know that my work has been touched and supported by so many leaders in adolescent health and health equity. I feel very grateful,” she said.

As a young physician trained in medical anthropology, Auerswald set her sights on conducting research regarding youth experiencing homelessness during her fellowship in Adolescent Medicine. Alarmed, the faculty tried to dissuade her. However, with the support of an anthropology faculty member, Prof. Steve Eyre, she pressed on.

“By the time I was a third year fellow I was given a slot to give a plenary presentation about my research at the national conference in adolescent health, which was a really big deal,” Auerswald said. “After that, my faculty supported the work. When I gave the plenary, some members of the audience were concerned about the safety of my work. People were just really afraid of these very young people. There has always been pushback about how this research was not going to work. ”

She published that first study in Social Science and Medicine. That led to an NIH K-23 career development award, which she used to study nearly 300 young people living on the street in San Francisco. That study was also a big success, with a rare 92% retention rate of the young participants. In a clinical trial, by comparison, an 80% retention rate would be considered excellent, Auerswald said.

“We were recruiting people in the Haight, and downtown on Market Street, and we’d find them again six months later for follow up. They knew us, so they trusted us,” she said.

The study led her to recognize the importance of social capital, and how it affects health.

“It’s basically your degree of connection to people who have access to resources in your life,” Auerswald said. “You could have social networks, but if they are all connecting you to people who are also excluded, it’s not really going to help you. So, to what degree you have strong social capital is really important in terms of whether a young person can succeed.”

Currently, about half the 16 researchers in Auerswald’s lab have once experienced homelessness. Most lab members are undergraduates whose contributions are essential to the lab research and dissemination activities.

“Youth homelessness is distinct from adults,” said Maddy Cuyler, research coordinator for Youth and Allies Against Homelessness, under the Innovations for Youth umbrella. “There is more couch surfing and doubling up. There’s such a range of experiences.”

Moving the Needle on Youth Homelessness

Claire Genese, a long time graduate student researcher in the lab, shared her experience.

“My mom lost our home during the foreclosure crisis,” Genese said. “After that I couch surfed for two months. I worked full-time, went to school, and had a car, but couldn’t afford a place of my own.”

Genese eventually found a job as a front desk clerk for a supportive housing center, then worked for neighborhood development projects and eventually as the lead for programs for youth experiencing homelessness for the San Francisco Department of Homelessness.

“That’s how I met Coco,” she said. “One of my mentors knew her and connected me because I had been accepted to Cal.”

Now, Genese is in the final year of the joint MCP/MPH program, in which students earn two concurrent degrees: master of city planning and master of public health, in the college of environmental design. Genese, Meti Sima, a MPH epidemiology student who joined the lab in January; and Cuyler are leading the state-funded evaluation project the YAAH Lab is conducting for the California Interagency Council on Homelessness, investigating the impact of state funding on services for youth experiencing homelessness.

Auerswald hopes that the project will move the needle on youth homelessness in California.

The lab’s first product from the project, “Guidelines for Preventing, Addressing, and Ending Youth Homelessness” is a summary of current recommendations for jurisdictions receiving state funding for youth experiencing homelessness.

The guidelines were vetted by youth leaders from around the state along with allies, including advocates, providers, and public servants who work in youth homelessness. “The guidelines we’ve created are an important tool for communities to implement evidence-based practice,” she said. “We hope that our evaluation work of state funding will help the state of California understand the ways in which youth homelessness needs to be evaluated and funded differently than adult homelessness to have the greatest effect.”

The project will focus on a group of communities including the cities of San Benito, Oakland, Salinas, Long Beach, and San Diego, and the counties of Monterey, Alameda and Kings/Tulare. Prof. Auerswald estimates that over two dozen students and up to 20 community interns will participate over the two-year course of the project. Some of the undergraduates who will be conducting research with the project connected to Auerswald through her undergraduate class on homelessness, entitled “Seeing People.”

Because for Auerswald, that’s what doing research with—not on—youth experiencing homelessness is all about, making them visible.

“I’ve tried to move things forward in terms of methods and youth inclusion,” she said. “And I’m proud of that.”