People Experiencing Homelessness are COVID’s Invisible Victims

A recent study suggests unsheltered are twice as likely to die. What can we do before it’s too late?

As of the time of this writing there were 1.7 million confirmed cases of COVID-19 recorded internationally with a death toll nearing 106,000, according to the World Health Organization. The United States, NBC News reports, now has the lead globally in total deaths caused by the virus with over 20,000 dead. While age and preexisting conditions are a factor in the distribution of those most adversely affected by the pandemic, other demographic information is essential to better understand who among those deemed most vulnerable are indeed most vulnerable — that is, most susceptible to being exposed to, ill-informed about and under-protected against this insidious and microscopic killer.

People currently experiencing homelessness — or the condition of living in a homeless shelter or a place not fit for human habitation — are one such population.*

A recent joint university study (Culhane et al. 2020) of estimated need for the U.S. homeless population related to COVID-19 states infected homeless individuals would be twice as likely to be hospitalized, two to four times as likely to require critical care and two to three time as likely to die compared to sheltered individuals. The math reveals what numbers often conceal: a susceptibility to fatality to which folks on the streets are particularly prone for a variety of reasons, not least of which are repeated exposure to harsh elements and inadequate access to health care.

In a summary of the study, the Homelessness Research Institute, an arm of the National Alliance to End Homelessness, reports older adults experiencing homelessness age twice as fast as sheltered individuals.

“[Unsheltered individuals] in their 50s have been found to experience geriatric conditions (e.g., memory loss, falls, functional impairments) at rates similar to members of the general population in their 70s,” the HRI notes.

Homeless individuals are meanwhile admitted to the hospital with medical-surgical conditions 10 to 15 years earlier than “comparable, housed individuals,” Culhane et al. state. For instance: “Existing studies of homeless populations have observed obstructive pulmonary disease prevalence between 20 and 30%, compared to 10% for the general adult population.”

Further complicating matters and founded on national data gathered by HUD, one of the fastest growing populations nationally is seniors (over 50) — in large part due to a loss of spouse (and thus financial stability), a financially destabilizing health crisis and/or a general loss of social supports. In fact, half of the homeless population in the U.S. became so after the age of 50 and 44% of seniors experiencing homelessness became homeless for the first time after 50. Many are first-time homeless over 70.

Research shows then that homelessness is always already a public health problem — one compounded by age and mental health issues, substance abuse conditions and “trimorbidity,” or “co-occurring physical health, mental health and substance abuse challenges” (Culhane et al.).

While these problems extend to sheltered populations, a majority of those without shelter experience one or all of these issues, making it more difficult to defend against new conditions such as those posed by COVID-19.

Therefore the primary challenge with which people experiencing homelessness — many of them in the age category most negatively affected by the COVID virus — must cope is navigating survival amid the torpor of physical, mental and emotional distress associated with living on the streets.

As HRI reports, achieving general wellness care — including eating sufficient and nutritious food, getting good sleep and rest, social distancing and hygiene — is already inconsistent among this population and access to such care is now severely curtailed as the COVID pandemic limits what resources social service organizations can provide for those who subsist on their outreach.

“Concern has been raised around the potential for widespread transmission of COVID-19 within the homeless population due to inadequate access to hygiene and sanitation and the difficulty of early detection among a population isolated from health care,” Culhane et al. report, stressing the “high susceptibility” to infection, hospitalization and death that repeated exposure to “harsh elements” renders them.

Relying on data from the information management systems available in New York City and Los Angeles — two metropolitan areas most heavily impacted by COVID-19 and which are estimated to have 70,000 and 58,000 homeless individuals, respectively, at any given time according to HUD numbers — Culhane and company assume 40% of the homeless population will be infected at any given time at the peak of this crisis.

Other findings of their study project:

• 21,295 people experiencing homelessness, or 4.3% of the U.S. homeless population, could require hospitalization at the peak infection rate of 40%;
• Critical care needs could range from 0.6% to 4.2%, with a midpoint scenario seeing 7,145 in critical care nationally;
• Potential fatalities could reach 3,454 homeless deaths on conservative estimates due to the fact that many homeless individuals will not make it to the hospital.

Currently, our nation-, state- and countywide unpreparedness to deal with COVID is revealing our unpreparedness to deal with the preexisting social condition that is homelessness, a global pandemic in and of itself. What we need now is a concerted and coordinated effort on the part of the federal government, states and counties to administer shelter, testing and treatment to those most likely to be besieged by this pernicious parasite: those on the margins of general wellness care.

Culhane et al. conclude the total estimated cost of creating capacity for additional need would be around $11.5 billion annually. This means we need more bed units, a half a million to be exact, to observe and treat properly those infected by this disease.

Based on guidelines from the Centers for Disease Control regarding responsible measures of response to both unsheltered homeless and those living in shelters, Culhane et al. conclude “emergency accommodations with private sleeping and bath space should be the preferred options for all clients and would be especially beneficial for individuals with known risk factors for COVID-19 complications.”

For those already living on encampments, the CDC discourages their clearance, recommending instead that they be made adequate sites for sheltering in place through social distancing measures and access to sanitation as well as outreach workers or mobile phones with reliable service and electrical power.

Congregate shelters, meanwhile, must be restructured to provide 100–110 square feet of space per bed and of course subjected to all of the precautionary cleaning routines necessary to fight back the introduction or spread of COVID.

“The ideal scenario would involve private accommodations for all clients,” Culhane et al. argue while acknowledging the caveat of supply and speed at which options like this can materialize.

Finally, the study recommends additional safe parking facilities should be opened and folks living in their cars or trailers should be encouraged to move to these locations for their safety and security.

As the Culhane et al. study notes, much of this coordinated effort between counties, states and the federal government hinges on the use of available technology, particularly SMS/mobile alerts, as existing research shows 95% of persons experiencing homelessness own cell phones and make use of text messaging. An alert system could inform sheltered and unsheltered people of emergency opportunities and lockdown procedures as well as survey folks for the purposes of detection, monitoring social distancing patterns and personal security, and assessing whether sheltered and unsheltered individuals have adequate access to medical care.

COVID-19 is currently spotlighting the fissures in our social service system. To echo Culhane et al., it will require a robust collaboration between all levels of government around funding, staffing and siting facilities necessary to combat the threat of large-scale catastrophe. And in the long-term, what we need most, what those without shelter need most at once because of and despite this disease, is trauma-informed care and permanent supportive housing.

“While economists are only beginning to quantify the short- and long-term economic impacts of this pandemic, we are almost certain to see a recession resulting from the infection itself, resultant social distancing, and general market uncertainty” that will further unsettle housing stability in this country and further stress an as it is overburdened social service system, the study states.

That said, all hope is not lost. It is simply a matter of reckoning first with which bodies are deemed most worthy of being not only saved but acknowledged as worthy of being saved in our collective imagination. We — as individuals and as a nation— must expand our thinking so as to reorient our vision of a just and indivisible society as one which includes all in its systems of care.

This in turn implies systemic change through proper funding and government action that moves toward supportive housing as the permanent solution — not simply to COVID as it affects those who are without adequate shelter, but to the problem of unshelteredness writ large.

Riffing on the Culhane et al. study and public health officials like Bechara Choucair, chief health officer of Kaiser Permanente, and Bobby Watts, chief executive officer of National Health Care for the Homeless Council, direct financial support is essential to combat COVID-19 effectively layered with policy development and implementation.

We can certainly accomplish this and we are doing so already.

“We are rapidly approaching the point in our response where policymakers can exert enormous positive pressure on how well and quickly we make it through this crisis,” Choucair and Watts argue, noting the progress lawmakers are currently making to quarantine facilities, such as hotels, to house the houseless who have been exposed and to further protect those with preexisting conditions and to create safe and sanitary temporary shelter locations in the form of organized encampments like they’re doing in the Northern California city of Arcata or in Portland.

Compassion, dignity, empathy demand this kind of response from agencies, governments and individuals.

It is not beyond our imagining nor our capability to rise up in an embodiment of our best selves, especially in light of the universal moral imperative fitting of the religious season many are now celebrating and grounded in the greatest of our human capacities: to do unto others as you would have them do unto you.

Advocate, donate, implement, volunteer. Hook up with a local nonprofit dealing with these concerns and see how you can be of service. Pressure your local government to close the gaps in public outreach and housing support as it relates to COVID-19 in particular and homelessness in general. And if you’re part of a government entity, do something with the power you have to mend a broken system. Do whatever you can from the safety and security of your own privilege so that others may have a place to call home — just like me and you.

*This is to say nothing of the ways in which COVID disproportionately affects black and brown bodies — which also constitute an inordinate number of the population experiencing homelessness in this country. For instance, according to HUD digits, on average nationally, 4 in 10 unsheltered individuals are African American — around 40% of the demographic even though African Americans only constitute 13% of the overall population. Native Americans constitute 2.8% of those who are unsheltered nationally, though they are 1.5% of the population.