In 2018, over half a million people in the United States experienced homelessness. While the causes of losing stable housing are complex and often misattributed to individual characteristics, it is important to recognize the upstream structural causes of homelessness particularly against Black, Latinx, and Indigenous populations. This includes racist housing practices, divestment from safety-net programs, growing income inequality and a critical shortage of affordable housing.
People who are unhoused are among the most vulnerable in our communities. Subsequently, homelessness contributes to an increased risk of morbidity and mortality. This is linked to discrimination, criminalization, advanced age, food insecurity, unintentional injuries, increased prevalence of chronic conditions, and reduced access to physical, mental and addiction-related services. These factors also culminate to increase the risk of acquiring and dying from SARS-CoV-2 (COVID-19). Moreover, homelessness and COVID-19 both disproportionately burden marginalized populations — in particular, Black communities and Native Americans.
When COVID-19 began spreading through the community, it came as no surprise that it would disproportionately impact those living in congregate homeless shelters. Overcrowded shelters, the inability to physically distance, and poor access to handwashing and hygiene facilities are coalescing for an unsafe environment that could accelerate disease transmission.
In San Francisco, over 90 residents and staff of a homeless shelter tested positive for COVID-19; in a single New York City homeless shelter, 23 residents died from COVID-19. Importantly, a study of unsheltered Boston residents demonstrated that in March 2020, 36% of asymptomatic individuals tested positive for COVID-19. Preliminary analyses in New York City suggests that the COVID-19 mortality rate is 61% higher for individuals experiencing homelessness than the general population.
More recent spikes are being seen in congregate homeless shelters in late August including 61 cases in Anchorage and a spike in Seattle, now totaling 445 cases in the homeless population alone. Preliminary analysis of the cases in Seattle showed that 86% of persons with positive test results slept in communal settings rather than in private or shared rooms.
These findings suggest that attempts to increase physical distancing within shelter systems are ineffective at protecting residents and staff. Furthermore, current screening requirements for acceptance into congregate housing are insufficient (e.g., reliance on symptoms such as fever and cough) and the spread of COVID-19 among unhoused individuals is already underway.
While we anxiously await Food & Drug Administration-approved treatment and vaccines for COVID-19, we must acknowledge that housing is the best medicine. We are facing an unprecedented eviction crisis, yet eviction moratoriums across the country are ending and federal aid is drying up. With unemployment rates remaining at almost three-times greater than pre-COVID levels, the long-standing affordable housing crisis is on the precipice of becoming even more catastrophic.
Furthermore, the rampant wildfires on the West Coast add a deadly component. The rapidly-spreading flames are destroying encampments as individuals face toxic air. The wildfires make living outside extraordinarily dangerous, especially as public health experts endorse that the safest place to be is inside. Collectively, housing should be viewed as primary prevention for the deadly spread of infectious disease and as a sanctuary from dangerous outdoor living situations.
Housing advocates argue about different models to address the problem: the utility of care coordination and social services in Permanent Supportive Housing models or the need to get unsheltered people into housing as soon as possible, no questions asked. Whether swayed by the cost-effectiveness of Permanent Supportive Housing or the harm-reduction approach of Housing First models, we all know that housing is a fundamental determinant of health. Homelessness should never be a reality that we accept. In the immediate term, this includes advocating for the Federal Emergency Management Agency (FEMA) to provide additional support to unsheltered residents and lowest-income survivors displaced by the wildfires.
The Centers for Disease Control and Prevention (CDC) guidelines make specific recommendations. For one, the CDC suggests increased testing in homeless shelters; additionally, they suggest the fostering of cross-sector collaboration and the implementation of isolation housing when available. Against common practice of many local jurisdictions, the CDC also recommends refraining from sweeping encampments of people who are sheltering outside. Unfortunately, not all local governments are abiding by these recommendations. For example, the criminalization of homelessness continues as New York City sweeps transit stations and subways; other cities such as Denver and Seattle are sweeping established camps and temporary outdoor shelters.
We also need to support unsheltered individuals to secure stable housing through person-centered approaches that do not involve painting grids on the concrete of outdoor parking lots or within convention centers. For example, in California fleets of motorhomes and tiny homes are used to help distance vulnerable residents. With tourism on the decline, vacant motels and hotels in large high-density cities such as San Francisco, Los Angeles, Portland, and New York City are also reducing the use of homeless shelters. But these solutions are imperfect as people experiencing homelessness who were moved into hotels are still dying. We need interventions to address the complex psychosocial needs of participants living in these new spaces, such as providing low-barrier mental health and addiction services.
To prevent further deaths, housing and health care systems need to collaborate and integrate to provide comprehensive care coordination to unhoused individuals. Together, they must provide referrals to community-based long-term care and social services that address housing insecurity as well as providing medical respite, addiction, mental health, and other services. In 2018, an article published in the Journal of American Medical Association argued for blending funding streams from health departments and the U.S. Department of Housing and Urban Development so that housing insecurity could be integrated into the clinical encounter. The blend might also accelerate investments in affordable housing. In response to the COVID-19 pandemic, the CARES Act allocated $4 billion in funding for housing and homelessness; however, this is far from enough to pay for the 7 million homes needed to close the housing gap.
The National Low Income Housing Coalition recommended that elected officials advocate for the use of CARES Act funds to address racial equity, maintain housing for precariously housed individuals, and support alternative shelter options for unsheltered homeless populations. We also need to use emergency funds to mitigate immediate eviction crises. Finally, changing long-standing federal policies such as homeowner subsidies will help bolster and build long-term infrastructure that addresses residential segregation, a long-standing primary driver of poor health outcomes for Black Americans.
As health care providers, we also need to leverage our positions of power to advocate for the provision of basic human rights. Even without a global pandemic, discharge from hospitals and emergency department visits is associated with subsequent homelessness. For example, California is already trying to address “patient dumping” and discharging to homelessness through SB 1152. This bill requires hospitals to offer food, clothes and discharge medications in addition to ensuring that a residential or a social services provider is able to take over their care. Furthermore, despite the push for telemedicine, not all populations are privileged with access to mobile technology, cellular service, WiFi, or the ability to charge mobile devices. We must address the digital divide head-on.
Ultimately, once the threat of COVID-19 or wildfires subsides, we shouldn’t go back to “normal.” We need courageous leadership and decisive action. Inaction is unacceptable. The delay in decision-making will only deepen inequities and amplify structural violence that marginalized communities already experience.
We need compassionate, human-centered, forward-thinking solutions. We need to keep housed residents in their current homes to prevent further displacement. We need to stop talking about the prohibitive costs of permanent housing or temporary hotels but instead discuss whether we can truly afford to not provide our houseless neighbors with safe shelter. We need to get people inside because, without adequate housing, it is a matter of life and death.