Marcio Jose Sanchez/Associated Press
Homelessness has been on the rise since 2016, with over half a million Americans being unhoused on a given night in 2021. Yet, during the COVID-19 pandemic, populations of unhoused people have often been neglected or forgotten in the efforts to curb the spread of COVID-19. Considering housing as a social determinant of health, we can evaluate the differential needs, challenges, and impacts of unhoused versus housed populations in the face of COVID-19. From an ethical perspective, this issue most clearly reflects the principle of justice, but also has important impacts on beneficence and non-maleficence. Ultimately, this issue highlights the need for a call to action to fight for justice and equitable access to healthcare, and favorable healthcare outcomes for people experiencing homelessness.
Even prior to the COVID-19 pandemic, the health care system has historically failed to provide adequate resources and support to unhoused populations. Now, during the pandemic, this has resulted in higher rates of pre-existing conditions and other risk factors for COVID-19 in unhoused populations, putting them at an increased risk. More specifically, according to a study conducted by the California Policy Lab, 84% of unhoused people experience physical health problems, 78% experience mental health problems, 75% experience substance abuse conditions, and 50% experience trimorbitity, or the co-occurrence of physical health, mental health, and substance abuse challenges, which compares to 19%, 50%, 13%, and 2%, respectively, for housed people. As a result of unsafe housing conditions, in addition to the increased prevalence of pre-existing conditions, people who are unhoused are at a higher risk for infection and death from COVID-19. This asserts the importance of dedicating resources to, 1), primary and preventative care for people experiencing homelessness, and 2), a dedicated effort to give unhoused people the tools and circumstances necessary to limit their risk for COVID-19.
Stay-at-home orders and frequent handwashing are two examples of crucial safety measures whose importance has been emphasized by public health agencies, yet they aren’t easy to access for people experiencing homelessness. Services for people who are homeless often are provided in group settings, meaning that homeless individuals are put at a greater risk than if they were able to access resources and support services individually. Further, multiple attributes of shelters and encampments make it difficult to physically distance from others to limit the spread of COVID-19, including shared living spaces, overcrowding, and high population turnover rates. Additionally, housing insecurity makes it difficult for people to protect their immune systems, due to factors that are common in homeless populations, such as food insecurity (including lack of access to adequate amounts of food and/or access to healthy foods), frequent disruptions to daily life, insufficient sleep, and hygiene.
The closure of regular services as a result of the pandemic has had numerous negative impacts for unhoused populations, especially because these resources were scarce in many areas prior to the pandemic. While the closing of businesses may have been beneficial for the population as a whole, it cut off some of the most basic resources for people who are homeless, like running water to wash their hands. Additionally, because technology is such an integral part of today’s society, many people who are homeless do have cell phones. But how beneficial is the phone when you no longer have access to power and can’t charge your phone because public libraries, shelters, meal programs, and more have temporarily closed? It is the duty of these social support programs to provide adequate conditions under which one can not only social distance but can also maintain healthy habits, proper hygiene, and access basic life resources. By doing this, it will be possible to provide slightly more equitable living conditions for people who are unhoused by decreasing their risk of COVID-19 and the potential for other negative impacts.
Due to frequent changes in location and hesitancy to report experiencing homelessness, it’s difficult to track the impact that COVID-19 has had on unhoused populations. The CEO of the National Health Care for the Homeless Council, Bobby Watts, says, “When we do have data, it showed that people experiencing homelessness died at higher rates than the general population.” Additionally, it’s not uncommon for people that have died who are homeless to not receive autopsies, which likely contributes to the underreporting of COVID-19 deaths in homeless populations. This is dangerous because it paints an inaccurate picture that those who are homeless have been spared disproportionately negative impacts of the pandemic, which is, sadly, far from the truth. This in turn can result in the loss of existing resources or the lack of adequate and necessary additional resources, which would put people experiencing homelessness at an even greater risk.
Turning to the reporting of vaccination rates, vaccination rates in unhoused populations are estimated to be lower than that of the general population. In San Francisco, 80% of the general population was fully vaccinated as of August 2021, only approximately 39% of people experiencing homelessness were fully vaccinated. Accurate reporting on the vaccination status of unhoused people and populations is crucial for determining how and where to best target vaccination efforts. With vaccination being one of the best ways people can protect themselves from COVID-19, anything that will ensure we get more unhoused people vaccinated, as they are part of a disproportionately impacted group, will help to limit the spread of COVID-19 within already unideal conditions and to people who are already at an increased risk for the disease due to pre-existing conditions.
Ultimately, society’s failure to support unhoused communities has highlighted the importance of the destigmatization of homelessness, the consideration of housing as a social determinant for health, and the allocation of resources and special attention towards people experiencing homelessness. Through efforts such as increasing social distancing capabilities within shelters and encampments and providing primary care that reduces the prevalence of pre-existing conditions within unhoused populations, it is possible to create a more just system for people experiencing homelessness during the COVID-19 pandemic.