But the combination of homelessness with substance use or untreated mental illnesses has led to a lot of very public tragedies.
People with schizophrenia, for example, have died of hypothermia on the city's streets. Residents have given birth out in the open, to premature infants who did not survive. Methamphetamine, cheaper and more harmful than it used to be, is creating a heightened risk of overdose and psychosis.
This story was produced in partnership with Kaiser Health News.
Mental illness can be part of the story of how a person ends up homeless — or part of the price of survival on the streets, where sleep and safety are scarce. Unsheltered residents in Portland die thirty years earlier than the average American, according to county data.
These grim realities have ratched up the pressure on politicians to do something.
In Oregon, some politicians, including Portland mayor Ted Wheeler, have proposed changing civil commitment law, so doctors have more leeway in compelling treatment for patients who are too sick to know they need care.
Without such changes, they argue, people with untreated addictions or mental illnesses are stuck cycling between the streets, county jails, and state psychiatric hospitals.
A homeless encampment along a street in Skid Row on Dec. 14, 2022 in Los Angeles, California. Two days earlier, LA Mayor Karen Bass declared a state of emergency regarding homelessness in the city, where an estimated 40,000 residents are unhoused. Mario Tama/Getty Images
By April Dembosky Amelia Temple Carrie Feibel