By Cade Novara (PO ’23)
For the past eight months, the country has been ravaged by the coronavirus. The lack of a cohesive, coordinated response from the government has left the United States with nearly 8 million cases and 217,000 deaths from the virus. Despite claims that the virus does not discriminate among groups, it has become increasingly evident that this is not the case. Hospitalizations due to COVID-19 have been 4.7 times higher in Black and Latinx populations, as compared to non-Hispanic white people. Another segment of the population that has been particularly devastated by the virus is homeless people. The living conditions of the homeless — specifically the closing living quarters of shelters and communal resources, and associated health risks that are prevalent in these groups — have left the homeless exposed to and unprotected against the coronavirus. Several cities have utilized a variety of tactics in an effort to protect homeless populations, but much more could be done to protect these vulnerable groups.
The Risks
It is estimated that there are roughly 528,000 homeless people currently in the United States. Living conditions for homeless people are especially conducive to the spread of COVID-19. One of the primary recommendations from the Centers for Disease Control and Prevention (CDC) is to social distance from others, but oftentimes this is impossible for homeless people. Shirley Rainea, founder of a nonprofit organization in L.A. that assists homeless people, shared that “social distance is a luxury that the homeless can’t afford. There are 600,000 homeless people in L.A. that have nowhere to go.” Another important recommendation is to wash your hands regularly, but shelters and encampments often lack access to basic hygiene resources, including hand-washing areas and showers. As a result, the chance of viral transmission is significantly higher in these populations. During previous viral outbreaks, such as influenza, there were observed spikes in hospitalizations among homeless populations.
Furthermore, homeless people are more likely to experience the severe and long-term effects of COVID-19. According to the American Journal of Public Health, “Homeless people are at increased risk for… respiratory diseases, trauma, major mental illnesses, alcoholism… , drug abuse… , sexually transmitted diseases, and a host of other relatively minor, but nonetheless impairing, respiratory, dermatological, vascular, nutritional, and psychiatric disorders.” The prevalence of these pre-existing health conditions in homeless populations likely contributes to increased COVID-19 mortality rates.
In conjunction with the health risks, homeless people often lack access to essential medical resources. Research from the National Coalition for the Homeless indicates that there are significant barriers preventing the homeless from seeking care, including “lack of knowledge about where to get treated, lack of access to transportation, and lack of identification.” Other factors, such as embarrassment and self-consciousness, also discourage treatment. Of course, the primary obstacle to medical care is the enormous cost of healthcare treatment. These components, among others, make it unlikely that homeless individuals will seek testing and treatment for COVID-19.
The Impact
A study in March from the National Alliance to End Homelessness estimated that COVID-19 would have a devastating impact on homeless populations, with a peak infection rate of 40%. It was approximated that among the 500,000 homeless individuals in the United States, 21,295 cases (4.3%) would require hospitalization, 7,145 cases (1.4%) would require critical care, and 3,454 cases (0.7%) would be fatal. While it is impossible to definitively tell how many COVID-19 cases there have been amongst the homeless population (largely due to the aforementioned obstacles), there have been numerous outbreaks throughout the country that seem to reaffirm these findings.
An analysis from the CDC in April of nineteen homeless shelters across four U.S cities revealed relatively high infection rates. After testing 1,192 residents, Seattle shelters had a 17% infection rate, Boston shelters had a 36% infection rate, and San Francisco shelters had a 66% infection rate. For comparison, the infection rates of each respective city are 0.74%, 2.48%, and 1.28%. Atlanta, the outlier, had only a 4% infection rate in homeless shelters. Another study examined an outbreak at one San Francisco homeless shelter, where 67% of residents and 17% of staff members tested positive for COVID-19. Boston Health Care for the Homeless examined an outbreak at a large Boston shelter, revealing an infection rate of 36% among the 408 participants. These examples and others demonstrate how homeless populations in urban areas are enclaves for high COVID-19 infection rates and densely packed human suffering.
Fortunately, the overall impact of the coronavirus on homeless populations has not been nearly as devastating as some anticipated. Particularly in Los Angeles, there has been little spread of the virus in street encampments, and outbreaks in shelters have demonstrated a high level of asymptomatic patients. Of the 1,300 cases recorded in L.A. county by mid-august, only 31 cases were fatal, yielding a relatively low mortality rate. However, testing among these groups is still incredibly limited and it is plausible that many homeless patients have not been treated for the virus. Furthermore, the onset of cold weather, the start of flu season, and the ever-changing nature of the virus makes it likely that COVID-19 cases will rise in the near future.
The Response
There has been a lack of a centralized and directed response by the federal government to COVID-19 cases in homeless populations, resulting in varied responses by local governments across the nation. According to guidelines by the CDC regarding the assistance of homeless people, local authorities should connect with health departments and law enforcement, set up easy and accessible testing sites, create isolation areas for those who test positive, establish protecting housing for at-risk groups, and educate homeless groups about the coronavirus. Many cities have followed these guidelines, while others have failed to do so.
In Los Angeles, local organizers have set up hundreds of hand-washing stations, established pop-up testing sites on skid row and the Venice Boardwalk, and made masks accessible. Another major initiative by officials is Project Roomkey, which aimed to put 15,000 homeless people in hotel rooms. Unfortunately, the project fell short of its goal, only reaching 25.5% of its targeted population. Still, the initiative housed 3,819 homeless people and has likely reduced COVID-19 transmission in the process. Many other cities have adopted a similar approach to housing. At the end of March, organizers in New Orleans began moving homeless individuals to hotel rooms. Project HOME in Philadelphia aims to create temporary housing for the homeless and the counties of San Jose and Santa Clara have begun providing shelter in mobile and tiny homes.
The city of Dallas also developed an aggressive and targeted strategy to respond to the virus and protect homeless groups. Beginning in early March, the Office of Homeless Solutions (OHS) started coordinating response efforts to address the developing pandemic. Collaborating with the city manager’s office and the city council, OHS turned a large convention center into homeless housing for 375 residents. Furthermore, OHS contracted with a 108-room hotel for quarantine, set up weekly conference calls with health care providers and government officials, secured emergency funding for shelters, established testing sites across the city for homeless groups, and created “a medical plan for isolation of COVID-19 positive homeless individuals discharged from hospitals.”
Unfortunately, not every locality demonstrated this type of tenacity and flexibility. Tim Chapa, the city manager in Sangra, California, strongly opposed housing homeless people in trailers before being ordered by the county to comply with regulations. In Daytona Beach, a project designed to turn abandoned buildings into housing areas for homeless individuals failed miserably, resulting in a waste of funding. Government officials in El Centro, California struggled to establish any sort of testing program for homeless groups. According to Barbara Dipietro, senior policy director at the National Health Care, the lack of a national response has been incredibly detrimental. “All states have been at a disadvantage in their response to COVID-19… This is the least efficient, most wasteful way to approach a crisis.”
The Implications
Homeless people represent one of the most at-risk groups for COVID-19. Outbreaks in shelters throughout the U.S., while less catastrophic than many predicted, will likely continue to increase in frequency and severity during the winter season. The federal government must work to develop a detailed, evidence-based plan to assist state and local officials in protecting their homeless populations. Guidance from the CDC and emergency funding will work to create a unified approach across the country, as opposed to the current patchwork system.
One area that has demonstrated a centralized, effective approach to the homelessness crisis is the UK. Beginning in March, the government quickly assembled a team of doctors and public health experts to assist homeless people in preparing for coronavirus. The team then launched the COVID-19 Homeless Sector Plan, a comprehensive action plan to isolate individuals who have tested positive (COVID-CARE) and protect people with medical vulnerabilities (COVID-PROTECT). Hotels across the UK also offered their facilities to homeless people, effectively housing thousands of homeless individuals in a matter of weeks.
The approach of the U.K. utilizes a strategy known as rapid re-housing, which is defined as “a time-limited intervention that provides people with housing search assistance, rent assistance, and stabilizing case management.” In rapid re-housing, homeless people are provided housing without having to meet a certain standard or requirements. People who are assisted through rapid re-housing have been shown to have better employment outcomes and normally do not return to homelessness within two years. Adopting response techniques such as this would dramatically improve the lives of homeless people in the U.S. and reduce needless suffering among this disadvantaged group.
