To keep people healthy, keep them housed
the Social Determinants of Health and COVID-19
Medical tests, ventilators, hospital beds, and masks are understandably on the minds of Americans as the United States combats COVID-19. The nation’s susceptibility to the virus is directly tied to its inadequate – or insufficient – medical supplies. Without a greater production of the tools to battle the virus, Americans are forced to depend solely on avoidance – curtailing all unnecessary social interactions, constantly washing their hands, disinfecting their spaces, and staying home as much as possible.
But what happens if a person doesn’t have a home? What if your living conditions don’t permit you to distance sufficiently?
These are the questions of the social determinants of health. They are the environmental conditions in which we are born and live that affect a wide range of health outcomes. Income level and occupation, neighborhood and the built environment, access to transportation, racial segregation and gender equity all interact with one another to affect health outcomes. Notably, economic and social instability pose health risks. Every day – but especially in times like these – addressing that instability is key to improving public health.
Take the homeless. People who are homeless have double vulnerability to COVID-19. According to the US Department of Housing and Urban Development (HUD), populations at risk for homelessness are often at a higher risk for exposure to communicable diseases due to their lack of stable housing, cramped quarters, and their access to bathing and hand-washing facilities. Moreover, homeless Americans have limited access to healthcare and many have underlying medical conditions – factors the CDC warns put them at high risk. They will struggle to receive testing and treatment thus increasing the likelihood of transmission among the homeless community and homeless aid organizations. Addressing housing insecurity is key to combating the spread of the virus.
Similarly, veterans are at particular risk – in part because of the way being a veteran intersects with the risk of being homeless. Veterans make up 7% of the general population, but 12% of homeless Americans are veterans. Studies show that many veterans have multiple chronic conditions that place them in more than one high risk category for COVID-19. Age is also a key component of this analysis. Older veterans are a majority of the population of veterans who experience or are at risk of homelessness. According to the United States Interagency Council on Homelessness, nearly six out of 10 veterans experiencing sheltered homelessness in 2016 were age 51 or older, and the number of elderly veterans (age 62 and older) experiencing homelessness increased 54.3% between 2009 and 2016. And, as has widely been reported, the coronavirus poses a greater threat to the elderly.
At the organization I work for, the Connecticut Veterans Legal Center, 30% of our veteran clients are aged 60 or older; over 80% have one or more disabilities. Of our past clients, 53% have once experienced homelessness. With a median income of $15,396, if faced with eviction, they will struggle to find safe and secure housing. If left homeless, they will be at great risk for contracting COVID-19 and at greater risk of spreading it.
Yale researchers found that medical-legal partnerships like ours – instances in which clinicians and lawyers join forces to address the medical and social factors affecting health – have a positive impact on health and housing. Yet, while direct services will be key to responding to the crisis, preventing the spread of a disease like the coronavirus takes a bigger legal and policy vision.
The first move is pretty obvious, but it has been unevenly applied – halt all evictions and foreclosures. Kicking people into the streets is the worst thing for public health right now. New York was bold – putting in place a 90-day moratoriumon evictions. Other states were more scattershot – the Pennsylvania Supreme Court halted evictions, but only until April 3; Connecticut paused them until March 27 and then extended the reprieve until May 1.
The Department of Housing and Urban Development suspended foreclosures on all homeowners with federally-insured mortgages. But, despite having great power over federally-funded rental housing, HUD has so far has done nothing to help renters. Similarly, federal agencies who handle compensation claims – like the VA – have failed to outline plans to expedite cases involving financial hardship or to develop a plan to keep compensation hearings processing electronically. But each of these tools can be used to keep people housed
Individuals living paycheck-to-paycheck have to balance multiple priorities: housing, food, childcare, etc. With the mass shutdown of public spaces and the increased restrictions on gatherings, individuals who work in retail, food service, and other service industries will suffer from the reduced income. Loss of income can lead to homelessness; increased homelessness threatens our common goal of “flattening the curve.”
Social determinants of health are cyclical problems – loss of income leads to loss of housing, loss of housing leads to homelessness, homelessness leads to restricted access to bathing facilities and limited ability to prevent the spread of the virus. Flattening the curve requires breaking these cycles. By addressing the social risks that can lead to greater infections, we can help combat COVID-19. Keeping people housed is key to keeping them healthy. Nothing could be more important right now.
Liam Brennan is Executive Director of the Connecticut Veterans Legal Center.
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