Grace Kim counts it as a small miracle that she is still alive today. Her late teenage years were a blur of drugs, alcohol and mental trauma -- the byproducts of an abusive family life, she said. Couchsurfing was preferable to going home, and she would crash at friends' homes whenever she could. She was depressed, suicidal and constantly suffered from sharp pains in her stomach that she later learned were ulcers.
Her saving grace came at age 17, when a high school counselor helped secure her a room in a transitional living program. Although her new living situation was far from ideal -- lodging with about 10 other teens with their own emotional baggage -- the shelter was a lifesaver for Kim, and she credits it with allowing her to slowly move forward. Picking up the pieces of her life felt like a constant struggle, but she said she eventually landed a restaurant job and enrolled in community college. Kim's hard work led to a full-ride scholarship to college, and she continued her education at graduate school.
"I know that I'm the fortunate one. If not for this program, I would probably be dead or have committed suicide," she said. "It was such a sad place to be in, and I never want to be back in that position."
Sometimes her caretaker at the transitional home would bring her and her housemates over to a teen drop-in center in downtown San Jose. There were snacks, a room with a TV and games and a small yard. On any given day, there would be 20 to 50 street kids hanging out at the center with nowhere else to go.
When closing time rolled around, everyone had to leave. Some of the teens would plead with the staff, asking to stay there overnight. But the answer was always no; those teens were sent out the door, back onto the street. It's a memory Kim can't shake: Why did she get a second chance, while so many others did not?
Now 30 years old, Kim is a therapist for Rebekah Children's Services in Campbell, and she regularly works with foster kids and at-risk youth. Their struggles are intimately familiar, but Kim said that things have become even rougher than they were when she was living on the edge. Drugs are more easily available, and social media makes it easier for predators to target teenagers in desperate situations. The transitional-housing program that rescued her no longer exists, she said.
"My experience has really changed the level of empathy that I have for youth dealing with these issues," she said. "These aren't bad kids. It's a matter of them just not having the support, or their main necessities met."
Santa Clara County officials have tallied more than 2,500 homeless adolescents and young adults -- an unprecedented number that many experts consider to be a drastic undercount. Newer U.S. surveys indicate as many as one in 10 young people under the age of 25 have recently experienced some form of homelessness.
This growing body of young people struggling with housing presents a serious social problem with long-term ramifications. If left unaddressed, it could spur a health care crisis, creating a vast unhoused population prone to a wide range of afflictions.
Homelessness is inextricably linked to public health. People living on the street are far more susceptible to chronic diseases, mental illness, substance abuse and sexual exploitation. In Los Angeles, the city with the nation's largest unsheltered population, homeless individuals have a life expectancy that's nearly 30 years shorter than the national average, according to the National Coalition for the Homeless.
Lacking stable housing is detrimental to health in so many ways that it's difficult to list them all, said Bobby Watts, CEO of the National Health Care for the Homeless Council. Living on the street makes it difficult to eat a nutritious diet, take medicine or refrigerate items that could spoil. Keeping a regular sleep schedule is next to impossible, which adds to stress. Homeless people are exposed not just to bad weather, but also higher rates of violent crime and illnesses. Minor health problems like a common cold or a small cut can spiral into serious infections.
"Homeless individuals suffer medical conditions at elevated levels, pretty much across the board, even when you control for poverty, substance abuse and mental health disorders," Watts said. "Homelessness is dangerous to one's health, especially when you're talking about (young) people whose minds and bodies are still forming."
Basically, being homeless makes the healthy become sick, and the sick become sicker. Homelessness makes a person three to four times more likely to die than the general population, according to an analysis by the National Health Care for the Homeless Council.
Sick from being homeless
Twenty-three-year-old Francisco Vargas, profiled in the first story in this two-part series, said his family discovered this during the first winter they spent in their 15-foot trailer on the streets of Mountain View. On rainy nights, Vargas remembers waking up to find water leaking inside the trailer, soaking their blankets. It was often so cold his toes would go numb, and his father would reluctantly turn on their generator, burning costly fuel, to provide a little bit of heat. The grueling hot summer nights are no easier -- it's impossible to sleep in the aluminum trailer because it feels like an oven inside, he said.
The toll on their health goes deeper. Vargas knows his family hasn't been eating as well as they used to. Without a refrigerator, they can't keep produce or dairy items for long. Meals are limited to whatever they can make with a propane camping stove -- a huge blow for his mother, who cherished cooking for her family. Staying clean is also more complicated. A 24 Hour Fitness membership became a necessary expense because it is one of the few places they can shower, brush their teeth or use the restroom.
It didn't take long for these factors to affect their well-being. Earlier this year, Vargas' father came down with a flu that left him bedridden for two weeks. It was the first time he could ever recall his dad having to take so much time off of work.
Both he and his mother have been severely depressed since they lost their apartment, he said. Vargas said he gets angry when he begins thinking about his family's hardship. The residents living in houses around the Jackson Park neighborhood make it abundantly clear how unwelcome they are, he said. One time, a couple walking by stopped to berate them, saying they weren't contributing to the economy.
"I'm not funding the economy? I'm buying fuel, food. I have a gym membership!" Vargas said about the encounter, his emotions still raw months later. "I have a city job, but I still can't afford to live anywhere!"
Living on the street has taken a toll on Victoria and her husband and four children, aged 12, 10, 8 and 2, living in a trailer near Rengstorff Park. The family tried to use the free mobile showers provided by the city and local nonprofits, but her children were often in school at the only times they were available. Instead, Victoria said she would usually grab a bucket and bathe her children in middle of the park.
Lugging the large containers of water to and from the trailer for drinking or bathing was difficult, she said. Last summer, she slipped and broke her foot while carrying water out of the trailer. The injury left her immobile, and it took three days before she could find a way to get to the hospital.
All of her children have been getting sick more frequently, she said. The family has gone twice to the emergency room at Stanford Medical Center when her children became seriously ill. It was their only option because they couldn't find a doctor's office that would take their insurance, she said.
The high cost of homelessness
Health problems are often what sends someone into homelessness in the first place. Of the more than 1 million bankruptcies filed during the last recession, about 62 percent were caused by medical debt, according to the American Journal of Medicine. When individuals have exhausted their own savings and their personal safety net, then the public is left to pick up the hospital bill.
In 2015, Santa Clara County officials reported spending $520 million annually on services for homeless residents. For the most part, that money doesn't go toward housing or food the bulk of it goes to health care and jails.
About 2,800 homeless individuals, or about one in 10, are caught in a destructive and expensive cycle of hospital emergency rooms, jails and mental health facilities. On average, each of these chronically homeless individuals costs the county about $83,000 every year.
The real toll of homelessness in the South Bay is likely much higher than $520 million. Colette Auerswald, an associate professor at University of California at Berkeley, points to the lost productivity and squandered human potential that goes with struggling to meet basic needs. This is especially true for youths entering their prime years. The 16-to-24 age range is a critical formative period for young people to develop job skills and education, she said.
Moving frequently or having an unstable housing situation inflicts a severe psychological toll on adolescents and young adults. Children who experience homelessness score worse on reading and math aptitude and are nearly twice as susceptible to behavioral problems like hyperactivity, according to a study by the U.S. Department of Health and Human Services. Research show that living in poverty stunts growth and brain development, and it causes intense stress -- all of which hinder a student's ability to learn in school. Missing out on those key years of development -- whether from dropping out of school, landing in jail or dealing with family strife or mental illness -- can irrevocably set back a young person's life.
Given these considerations, each homeless young person could be costing taxpayers more than $700,000 over the course of a lifetime, according to a 2012 joint study by Columbia University and the City University of New York. This sum includes a lifetime of lost earnings and tax revenues, as well as statistically higher costs for criminal justice, health care and welfare.
"If you take a kid who is homeless, you can say the cost is just giving her a shelter bed, but you're leaving out the fact this is a smart kid who has the opportunity to be a productive citizen," Auerswald said. "If you only care about money, it's actually quite expensive to have homelessness persist."
The factors that go with homelessness also perpetuate it, and it becomes tricky to claw oneself out, said Sparky Harlan of the Bill Wilson Center, a youth center based in Santa Clara. Alcohol and drug use is commonplace, but this addictive behavior often begins as a form of self-medication to cope with the stress. If young adults acquire a criminal record, that can become a huge obstacle to their employment prospects.
"Anyone living on the street is just in survival mode, thinking of safety and food. It's hard to focus on any long-term plan because you're just living day-to-day," Harlan said. "And the longer they're on the street, the harder it is to get them back on track."
Homeless deaths have been dramatically increasing in Santa Clara County in recent years. The most recent full year on record, 2016, saw 130 homeless deaths -- the highest number by far in more than a decade. The reported causes were myriad, with one-third considered accidental for reasons including drug overdoses, hypothermia and car crashes. The average age of death has consistently stayed around 50 years old.
Exactly what prompted the sudden spike in homeless death remains a mystery. One theory, posed in a study from Santa Clara University, is that the increase may be tied to the 2014 closure of "the Jungle," a 300-person homeless encampment along Coyote Creek in San Jose. After those homeless residents were dispersed, it became harder for case workers and service providers to track them down.
Andrew Gutierrez, an attorney with the Santa Clara County Public Defender Office, said he is appalled that the rising numbers of homeless deaths barely seems to register as a public concern. He sits on a countywide working group trying to brainstorm how to prevent future deaths.
Gutierrez says he first encountered the problem 20 years ago, when he served as attorney for a homeless man cited for public intoxication who was cycling through jails and hospitals. The man would tell nurses that he didn't want to drink anymore, and just wanted to die. The county's solution was to send the man back to jail.
Little has changed since then, Gutierrez said. To this day, the county lacks a dedicated program to triage chronically homeless individuals and get them sober and stabilized. Instead, many homeless fall into what he calls the "turnstyle," rotating in and out of emergency rooms and the criminal justice system until they die.
"What's the saying? 'If one person dies, it's a moral outrage. If 1,000 die, it's a statistic,'" Gutierrez said. "Unless you follow these people and have a system to identify them and target them with dedicated intervention, you're guaranteed turnstyle justice, at the highest expense."
Homelessness is so detrimental to health that many experts believe housing should be considered a form of preventative care. The federal Medicaid program, which normally pays hospital and medication costs for the poor, has recently begun allowing states to use its funding for housing costs.
Watts, of the National Health Care for the Homeless Council, describes the current homeless problem as a "man-made" disaster spurred by the lack of affordable housing construction. Like many other experts, he said the root cause for the current crisis started in the 1980s when President Ronald Reagan's administration gutted federal housing subsidies. Those cuts eliminated about $45 billion spent annually on public housing. Since then, five U.S. presidents have come and gone, but that level of funding has never been restored.
"As a nation, we just retreated from our commitment to affordable housing, and that's been the main driver for homelessness and why it's increased for the last 30 years," Watts said.
Getting healthcare where it's needed
For more than 20 years, a custom RV has arrived each month at Alta Vista High School, in Mountain View, the local district's alternative school for at-risk students. The vehicle, run by Lucille Packard Children's Hospital, is outfitted to function as a full-service health clinic. Inside, a trio of doctors provide free vaccinations and checkups for the Alta Vista students, many of whom don't have health insurance. Of the 20 Alta Vista students who graduated this June, at least two were contending with homelessness, school officials said.
Youth living on the fringes are notoriously difficult for health care workers to reach, and they often avoid hospitals and other services, said Dr. Seth Ammerman, a pediatrician and professor at the Stanford School of Medicine. His brainchild was to bring health care to them as a short-term, low-cost remedy for Santa Clara County's spiking rate of homelessness.
After more than two decades, Ammerman's mobile clinic is still making the rounds at schools and service centers across the South Bay, providing many young people with their only access to health care. The preventative care offered at the mobile clinic has likely saved millions of dollars in government health care costs, yet his mobile clinic was never intended to be a permanent solution, he said. By this time, he expected American society would give its most destitute people housing or health insurance, at the very least.
He said he is flabbergasted that homelessness, especially for youth, has persisted and worsened. Twenty years ago, homelessness seemed like a solvable issue; instead it has grown so much it's at the point of becoming normal, he said.
"Now for every kid we get off the street, another one is there to replace them," Ammerman said. "It's clearly getting worse, not better."
Michelle Le and Ana Sofia Amieva-Wang contributed to this report. Spanish translation was provided by Amieva-Wang. This investigative report is the second in a two-part series on youth homelessness that was supported by a California Data Journalism fellowship from the USC Annenberg Center for Health Journalism.