While the U.S. has been stymied in managing COVID-19’s spread, the previous month has brought “shelter-in-place” orders and policies mimicking those in foreign countries. The intended focus is to limit increased transmission and contribution to the staggering 4.1 million global cases as of May 11, 2020. The majority of state recommendations include maintaining a six-foot buffer from others, self-isolation within homes, practicing stringent personal hygiene, and wearing a mask when outdoors. Unfortunately, these recommendations disproportionately ignore a particularly vulnerable population: those experiencing homelessness.
I continually hear people complain of boredom and being “stuck” in their households, but what they do not realize is how they are afforded a luxury that the homeless lack. The most updated reports by the CDC show that any given day in the U.S. is marked by 550,000 individuals surviving in unstable living situations. Such numbers illustrate the need to address a public health emergency that could result by not prioritizing coordinated care and emergency housing facilities for the homeless.
Most COVID-19 infected individuals report only mild and self-limiting disease within the upper respiratory tract, however worsening outcomes such as acute respiratory distress syndrome (ARDS) are the reality for older and comorbidity plagued individuals, common characteristics among the homeless. In addition to a median age of 50 years old, the homeless population experiences higher morbidity and mortality from a larger prevalence of hypertension, diabetes, respiratory illnesses, and HIV/TB co-infections. Being able to manage these health conditions proves difficult as substance abuse towards alcohol and illicit substances is higher among them compared to the general population. These factors all work in tandem to predispose homeless individuals to severe outcomes during this pandemic.
Normally, drop-in shelters are a source of aid, but many organizations are increasingly turning away swathes of refuge-seekers due to concerns of admitting infected individuals and lacking basic resources. Additionally, crowded conditions and poor sanitation are common within these facilities. This results in scenarios such as in San Francisco’s largest homeless shelter, which reported 70 people testing positive for COVID-19 on April 10. One alternative to this may be living in encampments to increase social distancing, however this is offset by scarce access to hygiene facilities, general healthcare, and protection from the elements.
Furthermore, if homeless individuals seek hospital care, a strain is imposed on doctors who must decide whether to discharge community members they know do not have stable housing to self-quarantine in. An unimaginable conflict arises in wanting to protect homeless patients from possibly transmitting infections after discharge and wanting to open up bed space for other high-risk individuals. This decision should not fall onto our physicians. In consideration with our worsening economy, surging hospital admittances, and personal protective equipment shortages, we desperately need preventive care measures to alleviate public health strains.
A recent UCLA and UPenn collaboration reported on current public policy measures and available transmission data to estimate that infections in homeless populations could lead to as many as 21,000 hospitalizations and 3,400 deaths. Dennis Culhane, a co-author on this report, emphasized the findings by commenting, “Given that the public health recommendations emphasize isolation of suspected and confirmed cases … a deliberate effort is urgently required to create a range of housing options to meet those needs.”
One great solution pushed by the California Office of the Governor is allocating funds to secure 15,000 recently vacated hotel rooms to serve as housing. Unfortunately, this only represents rooms for about 3% of the total 550,000 homeless. We need to expand these measures throughout the country and include facilities like offices, vacated dorms rooms, and event arenas. While dramatic in scope, this also dramatically opens up accommodations to provide sizable shelters that reduce opportunities for transmission.
Other resource allocation solutions should involve more outreach teams that expand accessibility to diagnostic testing in encampments to detect and quarantine infected individuals. This can be combined with providing food resources along with mobile hand-washing and sanitation stations in high density homeless cities. Such actions ultimately allow hygiene measures and general health needs to be met and maintained.
Detractors may argue that resources should be funneled towards lasting solutions altering systemic structures leading to homelessness, like barriers to affordable housing and acquiring jobs. However, this ignores the fact that there is no time for long-term efforts. When we open up more resources to help the homeless, we are not just safeguarding their health, but the health of our whole country.
We need effective action now to provide immediate, impactful protection of vulnerable individuals that overall minimizes the potential strain their hospitalizations could have on a struggling healthcare system.
Eduardo Encina is a masters degree student at the Yale School of Public Health.