What We Owe People Experiencing Homelessness in the US

What We Owe People Experiencing Homelessness in the US

What We Owe People Experiencing Homelessness in the US

Much of the foundational data about Covid-19 came from people without housing and those who work with them.


Nearly two years into the Covid-19 pandemic, a wealth of scientific information has been amassed. We understand the range of symptoms, how the virus spreads, how to mitigate risk of infection, and what is necessary to build and maintain proper isolation and quarantine spaces. Much of this foundational data from which Americans and the world have benefited came from people experiencing homelessness and those who work with them. Yet, despite the knowledge gained from this population, the response has been continued demonization and criminalization.

In early February 2020, organizations across the United States that serve people experiencing homelessness including shelters and federally qualified health centers recognized the potential for the novel coronavirus to harm their population. Given the historical treatment of people experiencing homelessness, many people knew that they would be among the last in the prioritization list for state and federal support. As a result, organizations—often in coordination with the local health departments—sprang into action to develop the earliest symptom screening tools and referral systems for testing and isolation. Resulting from these efforts was the knowledge about overall prevalence of SARS-CoV-2 across the country, transmission dynamics, and risk factors for the disease it causes. Resulting also from these efforts were blueprints for isolation and quarantine facilities that protected the general population and prevented the collapse of the health care system.

One early report from Boston described the herculean efforts of one organization that tested 408 shelter guests over a two-day period and found that nearly 90 percent of those who were positive were asymptomatic. Work such as this helped the world understand that SARS-CoV-2 was spreading silently among us. In another example, SARS-CoV-2 samples collected from guests and staff at homeless shelters in Boston were analyzed and provided some of the first evidence of the importance of super-spreading events in shaping the course of the Covid-19 pandemic. From this, contact tracing protocols were enacted throughout the country that were modeled after what had been done by a small group of health workers in Boston.

Our knowledge of how severe Covid-19 disease can be also, unfortunately, came from people experiencing homelessness who were infected early in the first wave, lacked the ability to isolate, and had multiple comorbidities putting them at risk. Because homelessness is associated with increased risk of hospitalization, these individuals could be “studied” to learn that comorbidities such as heart disease, lung disease, and diabetes were specific risk factors for severe disease and death. As such, these and other health conditions were subsequently prioritized for early vaccination and Covid-19 treatment—saving thousands if not millions of lives.

One of the most important contributions from this population were the efforts made to isolate and quarantine this population, that ultimately protected the health care system and the general population. Organizations developed a variety of isolation and quarantine sites for this people experiencing homelessness—without federal guidance (or financial support)—in places like Boston, San Francisco, Rhode Island, and elsewhere. First, these sites provided free blueprints for state and federal officials with no prior knowledge of infection control principles who were attempting to design field hospitals for the general population. As I had personally been involved in the Boston efforts, state and federal emergency management officials sought guidance from me on how to establish large facilities that prevented transmission. Second, these facilities helped hospitals and shelters contend with the initial Covid-19 surge. One analysis demonstrated that our nearby alternative care site resulted in a 28 percent reduction in hospitalizations to Boston’s safety net hospital and was credited with preventing the hospital from being overwhelmed.

Despite the societal gains that have been made because of this population and those who work with them, there has been absolutely no gratitude expressed. Instead, this population continues to be marginalized, disregarded, and criminalized. First, the federal eviction moratorium—a protection meant to prevent more people from becoming homeless—expired in October 2021. Second, while the Emergency Rental Assistance Program provides relief for tenants beyond the moratorium on evictions, it does nothing to provide housing to people already experiencing homelessness. And while the CARES Act provides funding for HUD programs, the funds were allocated with 2020 homelessness numbers in mind and did not account for increases resulting from the pandemic. The same resources, therefore, had to be distributed among a larger number of people than intended. Shelter and community health workers also remain among the lowest-paid employees despite their heroic efforts.

Beyond the first wave of the pandemic, few isolation and quarantine sites have been maintained. Most closed because of lack of funding, leaving shelters and community health centers once again to “deal with the problem” on their own. And because of a confluence of factors, the population of unsheltered individuals across the United States has grown. Instead of responding with evidence-based responses such as housing, cities and states have increased sanctioned police sweeps and displacement campaigns. Daily sweeps in Denver have increased above the levels that were seen prior to the pandemic. Boston’s new mayor, Michelle Wu, has cleared out the city’s largest encampment and has, to her credit, tried to secure temporary housing and substance-use treatment for many of those displaced, while New York seemingly has no plan but to tell people to “move along.” In the most egregious example, California Governor Gavin Newsome is using CalTrans—the transportation department—to clear homeless encampments. This move harms not only the individuals being swept but also those doing the sweeping, who have no formal training and may experience psychological trauma from having to destroy someone’s home.

Here, we see a group of vulnerable and marginalized people—a disproportionate majority of whom are Black—whose experiences have informed our knowledge of the natural history of a disease. And instead of treating them with proven interventions, such as stable housing and expanded access to health care and social services, we choose not to intervene. More accurately, we intervene only by criminalizing them.

For all the knowledge they have given us throughout the Covid-19 pandemic, it is time that we as a nation use our collective knowledge and resources to help end the epidemic of homelessness.

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