“We are always the last group that is given considerations during policy-making decisions,” said one formerly homeless man when I interviewed him last year. “Even when the policies are drafted, they often don’t address the root cause of homelessness,” he added. Through my interviews with people affected by homelessness over the years, I have learned to approach my work in public health through a different lens, one in which marginalized communities are at the forefront.
According to a 2019 report from The Council of Economic Advisers, an agency within the Executive Office of the President, approximately a half-million people are homeless on a single night in the United States. About 65% of them are found in homeless shelters while 35% are unsheltered and living on the streets. Additionally, almost half of all the unsheltered homeless people are found in the state of California. The other cities with high rates of unsheltered homelessness are New York City, Boston and Seattle.
The homeless population’s lack of stability in terms of housing, food and basic hygiene makes them particularly vulnerable to communicable diseases such as COVID-19. People who experience unsheltered homelessness are at an even higher risk of developing an infection, especially when there is community spread of COVID-19. Those who live in shelters may move from one shelter to another constantly while those who live on the streets may move from one street to another. This adds to their lack of stability. Not all who are homeless have underlying health conditions. However, in the case of COVID-19 the mere fact that they lack stable housing and basic hygiene makes them more susceptible to the disease.
Past experiences can inform us how COVID-19 may impact those who are homeless in the weeks to come. A telling example comes from a homeless shelter in Illinois where public health officials recognized an outbreak of tuberculosis (TB) in January 2010 after three people were diagnosed with TB. As of September 2011, a total of 28 outbreak-associated cases were confirmed. To mitigate further spread, public health officials and shelter staff members provided housing, food, transportation, and treatment for TB disease to 24 of the 28 patients. Two of the patients received care from other health jurisdictions, one patient died, and one patient was not located. Supportive resources alone, excluding the costs of healthcare services totaled $200,000.
According to the Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention (CDC), while programmatic resources were unavailable for the 146 people who were exposed at the shelter and had latent TB infection (LTBI), 10 of them completed treatment. Despite progress towards TB elimination efforts in the U.S. over the years, the outbreak demonstrated the vulnerability of people affected by homelessness to outbreaks of TB and similar infectious diseases.
Tuberculosis is a bacterial disease that usually affects the lungs with symptoms such as cough, weakness and weight loss. It is airborne so it can be spread through the air when a sick person coughs, speaks or sings. According to the World Health Organization, COVID-19 is similar to TB in that it is airborne. Droplet transmission can occur when a person is in close contact with someone who has respiratory symptoms and is at risk of having their mouth, nose and eyes exposed to the droplets. Transmission of COVID-19 can also occur due to indirect contact with surfaces in the immediate environment or with objects used by the infected person. Additional research is being conducted by scientists to determine the amount of time the virus survives on inanimate objects.
One obvious difference between the spread of COVID-19 and TB is that while TB infects those who have compromised immune systems and underlying health conditions, COVID-19 can be transmitted among healthy people who are not sick. Those who are healthy have better outcomes. However, more research needs to be conducted in order to definitively conclude that.
The CDC has developed recommendations on how to protect staff, clients and their families at shelters during this pandemic. Specific prevention measures have been put in place that include encouraging people staying in encampments to set up sleeping quarters with at least 12 feet of space in between and providing access to portable toilets with handwashing facilities and materials such as bath tissue.
Additionally, according to the CDC there should be a long-term plan in place for individuals and families to seek shelter in case they are suspected of exposure to COVID-19. The spaces should include areas for isolation, in case a person tests positive. If a person needs to be hospitalized, a plan should be put in place for how they will safely recover after being successfully treated and discharged. Behavioral health teams will also need to be involved in order to provide support to people with a history of substance use and/or mental illness.
These guidelines, while well-intentioned, still seem far-fetched and difficult to implement in a country where homelessness is widespread. This pandemic calls for high levels of cooperation between public health officials, homeless service systems and local partners to support vulnerable populations. According to CDC data, current spread of COVID-19 is highest in the states of California, New Jersey and New York, thus requiring a methodical and deliberate response from those states to ensure the most vulnerable populations are being monitored for signs and symptoms.
Several states have stepped up to determine care for the marginalized communities in their state. Gov. Ralph Northam of Virginia announced an allocation of $2.5 million in emergency funding that would go towards temporarily housing approximately 1,500 residents who are affected by homelessness and in situations where social distancing is impossible.
While homeless shelters across the nation are rearranging their furniture to house people 6 feet apart, it is becoming increasingly clear that the most vulnerable populations in the U.S. will require care and attention, long after the COVID-19 pandemic is over. Studies have shown that the top reasons for homelessness are lack of affordable housing and unemployment. Previous disease outbreaks like the one mentioned earlier have proven that in order to address vulnerable populations a large amount of resources and funds are required.
My hope is that even after COVID-19, we will continue to ensure that the most vulnerable populations of this country have access to affordable housing and are gainful employment. The lessons learned during this time can be meaningfully utilized to ensure better preparation for the future, not just during pandemics, but also in terms of other disease outbreaks.