Our neighbors who are experiencing homelessness during this SARS-COV-2 pandemic are facing unique risks and extreme hardships. In the corner of American society almost defined by economic and racial disparities, COVID-19 has compounded and taken advantage of these long-standing vulnerabilities.
An outsized burden of risk factors for COVID-19 compound the risks of crowded shelters and “sleeping rough.” Study after study is now showing that community transmission has taken root in shelters. Those forced to “stay-at-home” in places that are anything but homes need essential resources. Communities need isolation housing and “non-congregate shelters” to keep people safe.
Many people saw this coming. Researchers and advocates published thoughtful and strongly worded commentaries and white papers in the early days of the outbreak. Early on, the CDC provided valuable guidelines that cautioned against forcing unsheltered people into already cramped shelter spaces. This interim guidance undoubtedly saved lives. It recommends that communities enforce distancing measures where people live, instead of uprooting them. Later, guidance for shelters and service providers was released, including facility layouts and service delivery process recommendations.
The funding provided by federal agencies, including through the CARES Act, must be implemented in a way that heals the pervasive disparities associated with the homeless condition. On the ground and at the level of local, state, and federal public health operations, we need to bring the historically disenfranchised into the fold with a “whole community” approach. We need to create short and long-term housing strategies that permit isolation. These interventions should also acknowledge and incorporate fair housing practices and the basic principles of equity.
Risk factors piling up
People experiencing homelessness are at higher risk of progression and transmission of the SARS-CoV-2 infection. Theories about this involve many complex, inter-related factors: inability to social distance, the increased burden from chronic illnesses, immune suppression from stress and trauma, as well as over-representation of people of color. In March, we published a post summarizing the CDC’s risk factors for the progression of COVID-19.
This bug preys upon those with multiple chronic or immune-suppressing conditions. Rigorous statistical models [pdf] showed that it is likely to hammer those living in homelessness with a large proportion of hospitalizations and deaths. Already older [pdf] and with many, many more [pdf] chronic illnesses than the rest of the US population, those experiencing homelessness make for ideal victims for the SARS-COV-2 virus. Meanwhile, those in homelessness struggle to manage their chronic illnesses with threadbare financial resources and bottlenecked access to healthcare, medication, and transportation. At its heart, homelessness is an economic circumstance leading to a range of brutal environmental hazards.
Homeless individuals are also much more likely to be male and to be people of color [pdf] than the general public. In the US, race and the experience of homelessness cyclically reinforce the unique health vulnerabilities posed by each. Being a person of color in America comes with life-long stressors rooted in disenfranchisement and systemic barriers. Often times, people of color face higher barriers to transition back into housing than their white neighbors. As if this weren’t enough, COVID-19 appears to have a more brutal effect on those of African American race and Hispanic ethnicity.
In turn, the experience of homelessness is both a cause and a result of profound psychological trauma. Trauma and poor health predict entry into homelessness, and homelessness yields a wide range of hazardous environmental exposures and stresses. All of this stress, from a myriad of adverse conditions, leads directly to weakened immune systems.
Risks of transmission
Asymptomatic or pre-symptomatic transmission in this community is a serious concern. Around 80% of patients report mild symptoms. This all means infectious individuals are likely to be in the community exhibiting mild symptoms or none at all.
The best recommendations right now are to practice physical distancing and frequent hygiene maintenance, such as hand washing. While many can go into their homes to create distance, those experiencing homelessness are living in public space [pdf]. They also access resources, especially food, through communal sources such as soup kitchens or religious services. It was only a matter of time before the outbreak spread into spaces where individuals’ ability to distance and protect themselves is minimal.
Every day, there are news stories about swaths of cases in emergency shelters around the country. These clusters were foreseeable because of the unique risks posed by this virus and the disease it causes. These reports are popping up so late because of the lack of resources and timely testing, epidemiologic intervention, and isolation. The entire NBA was tested long before the phrase “flatten the curve” became universal.
How bad is it?
Boston first broke this issue wide open, with a community report in which over a third of residents in a massive shelter system came up positive for infection – 146 new, previously unrecognized cases in all. What should concern everyone in the entire community is that most of those cases were completely asymptomatic. This adds to the growing evidence that the mild and asymptomatic disease spread may even dwarf the ever-climbing confirmed case counts [pdf].
Seattle’s DESC is moving shelter residents into hotels temporarily, but staff estimate that around 15% of the clients are already showing symptoms of infection. This report was followed by a CDC Morbidity and Mortality Weekly Report thoroughly documenting an outbreak across three Seattle shelters. A single case was hospitalized in late March. The next day officials tested two-thirds of all the residents and staff at three city shelters. Between that and a second testing period a week later, 18% of residents and 21% of staff tested positive. Only four of the ~200 people tested in this cluster investigation received their diagnoses by seeking out independent healthcare providers.
“People should not assume that if they don’t have a confirmed case in the shelter, it’s not there,” says Dr. Meagan Kay, Deputy Chief for Communicable Disease Epidemiology and Immunization Section in Public Health Seattle and King County. “In terms of the spread, I think that the congregate setting where people are in a closed space and not able to physically distance is higher risk.”
Now that some cities are beginning to roll out targeted, aggressive testing strategies, the exposures are clear. A shelter-based substance use treatment program in Baltimore had over 50% (30 of 56) of cases test positive. A single shelter in San Francisco reported 70 new positive cases, previously undetected. This brought the confirmed case count to 106 residents in SF shelters (as of April 21), and drove community leaders to call for universal testing. Atlanta took an aggressive approach, testing a couple thousand of their citizens living in homelessness and registered a total of 55 positive tests in that community after that strategy.
Isolation and non-congregate shelter
Before the outbreak, shelters already struggled to provide care for medically vulnerable or frail clients. Now, the urgency is magnified.
Development of subsidized, supportive housing programs is the single best approach to mitigating the impact of the pandemic in this part of our community. Professional associations, non-profit coalitions [pdf], and the federal government have voiced this need.
Every local response system needs appropriate, isolated spaces to promote distancing. People without a permanent residence who are being tested or testing positive need to be isolated in safe and humane facilities in coordination with the shelter and healthcare staff who are already engaging with them [pdf]. This is aligned with the recommendation by the CDC for “Isolation Housing” programs.
In addition to this strategy, housing facilities that allow for precautionary distancing and isolation must be located and contracted. Individuals in the community who are at the highest risk of severe illness should be the priority. This process will likely deviate from current prioritization strategies. It could take into account factors such as age, race, immune-suppressing, and other chronic illnesses. Prominent researchers in the field of homelessness and health are calling for significant program funding [pdf] to support rapid-rehousing programs, emergency shelter expansions and improvements to respond to this outbreak and for those to come.
As a recent editorial in Seattle pointed out, this virus has shown us the failures of our homelessness crisis response system and what we can do to improve it. The narrative of what it means to be homeless has changed in the wake. We cannot go back after this and pretend it has not.
Ben King
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