“Stay home … Well, suppose you don’t got a home?”: The Public Health Challenges of Housing the Homeless During the COVID-19 Pandemic

“[We’re told], you know, ‘If you’re not an essential worker, stay home,’” says Marcus Moore, a man experiencing unsheltered homelessness in New York City, in a recent interview with the independent news channel Now This (2020). “Well, suppose you don’t got a home.”

Marcus Moore’s comment points to the complex public health challenges associated with homelessness during the COVID-19 pandemic. In the first half of 2020, 85% of US states and territories – along with at least 40 countries globally – issued mandatory stay-at-home orders to facilitate social distancing and slow the spread of COVID-19 (Chaudhry et al., 2020; Moreland et al., 2020). But a ‘home’ – or, more generally, adequate accommodation – is more than just a place to socially distance. It provides people with access to basic hygiene facilities (Tsai & Wilson, 2020), and hygiene is the second key tenet of COVID-19 prevention. It removes people from the congregate, often outdoor conditions which are conducive to the spread of disease (Tsai & Wilson, 2020). It minimizes the movement of highly-transient homeless populations (Tobolowsky et al., 2020), and so may facilitate their access to and engagement with health and other services. Most fundamentally, a home may also provide some degree of certainty in what an increasingly uncertain world.

Stay-at-home orders are highly effective at controlling COVID-19: in the US, within 3 weeks of their implementation, there was an estimated 48.6% reduction in COVID-19 cases and a 59.8% reduction in fatalities (Fowler et al., 2020). However, stay-at-home orders are based on the assumption that people have a home to stay in (Farha, 2020). For the 200,000 unsheltered homeless people in the US, and the 1.6 billion people with unsustainable or inadequate shelter globally (Habitat for Humanity, 2014; The Council of Economic Advisers, 2019), there is no option to ‘stay at home’. Further complicating this is the fact that stay-at-home orders result in the abrupt closures of public places which are frequented by people who are homeless (Perri et al., 2020), and this may effectively drive them onto the streets.

In its most recent COVID-19 Guidance Note, the United Nations states that, “In the face of this [the COVID-19] pandemic, a lack of access to adequate housing is a potential death sentence for people living in homelessness” (Farha, 2020: p.1). Indeed, there is evidence that COVID-19 disproportionately impacts people who are homeless. Studies conducted in March/April 2020 among residents of homeless shelters in Boston, San Francisco, Seattle and Atlanta identified COVID-19 infection rates of between 4% and 66% (Baggett et al., 2020; Mosites et al., 2020). Hsu et al. (2020) found that one-in-six patients seen at the Boston Medical Centre between March and May 2020 with a diagnosis of COVID-19 were homeless. A modelling study predicts that, at the peak of the COVID-19 pandemic in the US, 4.3% of the homeless population will be hospitalized 1.4% will be admitted to critical care and 0.7% will die, far greater rates than estimated in the general population (Culhane, 2020). These risks are related to the fact that people who are homeless have an older chronological age, more comorbidities and greater “physical decline and mental weathering”, resulting from exposure to harsh environments, than do the general population (Culhane, 2020: p.2).

We live in an interdependent society, where even the most marginalized are not completely isolated. COVID-19 in the homeless population therefore represents a major risk to the general population. A spike in COVID-19 infections in people who are homeless could rapidly overwhelm health services, many of which are already operating near to or at capacity (Albon et al., 2020), and limit their ability to respond to COVID-19 in the general population. COVID-19 may also spread from homeless to general populations. In a study of shelter workers, the members of the general population who have the greatest contact with the homeless, Mosites et al. (2020) found that up to 30% had COVID-19. Many cities with larger homeless populations experience problems with public defecation, and it is known that COVID-19 can be transmitted via the oral-fecal route (Tsai & Wilson, 2020; Zhang et al., 2020). These issues are further complicated by the fact that COVID-19 testing rates in homeless populations are low, and up to 88% of those with COVID-19 may be asymptomatic and fail to meet current CDC testing criteria (Baggett et al., 2020; Centres for Disease Control and Prevention, 2020). People who are not diagnosed cannot be isolated for care.

The United Nations identifies that homelessness is a basic violation of human rights, and that the right to housing cannot be suspended even in the state of global emergency caused by COVID-19 (Farha, 2020). In many parts of the US, the urgent need to adequately accommodate people who are homeless has been acknowledged, and multiple innovative solutions have been implemented. Since the beginning of the COVID-19 pandemic, across the US, people who were once homeless have been housed in hospital facilities, expanded shelters, empty hotels/motels, reconfigured sporting centers, parks, mobile trailers and even tents in shopping center parking lots (Anthony, 2020; Choo, 2020; Haskell, 2020; Smith & Oreskes, 2020). The number of people accommodated has not, as yet, been estimated.

However, these solutions to homelessness have not been without their problems. Housing people in shelters, even with social distancing guidelines in place, results in inevitable crowding (Mosites et al., 2020). Housing people frequently isolates them from their support networks, particularly if public transport systems are also closed, and this may lead to a deterioration in their mental wellbeing (Perri et al., 2020; Tsai & Wilson, 2020). Housing people may limit their access to substances, which is problematic for people who are substance- (and, especially, opioid-) dependent, and it may also limit opportunities for income generation through activities such as panhandling, recycling and sex work (Perri et al., 2020). Housing may increase people’s risk of experiencing violence (Perri et al., 2020). If people are housed away from familiar areas, this may result in their displacement and increase their – and, so, their community’s – risk of COVID-19 (Tsai & Wilson, 2020). It is for many of these reasons that ‘Housing First’, a housing model which operates throughout the US, offers housing alongside broader multidisciplinary support (National Alliance to End Homelessness, 2016). This has not been a major feature of any of the housing programs reviewed for this piece.

There are also other problems. Housing people who are homeless requires a substantial commitment of resources – indeed, the cost to accommodate all people who are homeless in the US is estimated at US$11.5 billion per annum (Culhane, 2020). Even if just a fraction of this amount is spent, the cost is enormous. Indeed, housing is often offered only to the people most at-risk of COVID-19, leaving others unsheltered. There are also uncertainties around how long such a substantial commitment of resources could be maintained – and whether, after the money runs out, people house will simply return to being homeless. These issues are further complicated by the fact that the economic impacts of COVID-19 are anticipated to result in increases in homelessness in the US this year (Albon et al., 2020).

In summary, people who are homeless are at increased risk of COVID-19, and this in turn places the general community at increased risk. However, solutions may not be as straightforward as simply offering people housing. Perhaps most importantly, it is necessary that the solutions are informed by people who are homeless themselves – people like Marcus Moore, who was quoted at the beginning of this piece. These voices were marginalized in the majority of the literature reviewed for this piece. If these voices are heard, the situation bought about by COVID-19 may be harnessed as an opportunity to respond effectively to the homelessness crisis – and, so, to improve equity – in the U.S.