The homelessness crisis in the United States is accelerating in the wake of economic hardships spurred by the COVID-19 pandemic. Many states, including our own of Colorado, had already seen a steep rise in the number of people experiencing homelessness (PEH) in advance of the pandemic, particularly among at-risk subpopulations such as those experiencing chronic homelessness and those living unsheltered.1 Importantly, these point-in-time estimates do not reflect the impact of high rates of unemployment and the resulting wave of evictions, which has left many more Americans without secure housing, and strained already overburdened systems and resources.
As frontline internal medicine physicians, we witness firsthand the detrimental impact that lack of housing has on our unhoused patients—whose health is routinely compromised by stigmatization and marginalization, restricted access to resources, crowded and unsafe living conditions, and exposure to serious environmental and situational hazards. Tragically, these factors have only intensified during the COVID-19 pandemic. If we are to end this pandemic and meaningfully address health inequities, we must understand the growing threats faced by our unhoused patients, and acknowledge the ways in which they have been left behind in the public health response to COVID-19.
Living without secure housing is a potent determinant of individual health, and lack of housing has emerged as an important risk factor for contracting COVID-19. Congregate shelters, which thousands of people rely on for emergency shelter and vital services, are often crowded, poorly ventilated indoor spaces with hundreds of people passing through each day and sleeping on cots just a few feet apart. Not surprisingly, shelters were identified as hotspots for COVID-19 transmission early in the pandemic, with positivity rates of 25-66% in some shelters.2 Some cities responded by attempting to de-densify shelters, but this reduces a city’s total shelter capacity and necessitates the development of temporary shelters, an expensive and time-consuming undertaking limited by staffing shortages. With a decrease in shelter capacity, community encampments in some cities have expanded. Such encampments may be the only option for some unhoused people, particularly when shelters are overwhelmed or perceived as unsafe, and where the risk of viral transmission remains high.
People living in homelessness—who are disproportionately Black, Indigenous, and people of color—are at higher risk of being hospitalized with COVID-19, because of the presence of co-morbidities and systemic barriers that prevent equitable access to health care.2 According to Denver Public Health data, PEH who contract COVID-19 in our city are over three times more likely to be hospitalized than the general population. Other U.S. cities have reported similar trends. When hospitalized, PEH face substantial obstacles to safe discharge and recovery, particularly amidst this pandemic. Patients discharged to the streets risk rapid worsening of their condition, re-hospitalization, or death. Despite the creation or expansion of medical respite and other recuperative and transitional housing options, the sheer demand and infectious concerns that accompanied COVID-19 have some all but exhausted these resources, contributing to excess length of hospital stays, morbidity and costs, and limiting acute care access within some communities.
While recovery after COVID-19 infection is highly variable, it is clear that symptoms may persist for weeks to months, or longer, resulting in substantial physical and mental health hardships, which may further limit employment, housing and other opportunities for social and medical aid for PEH.3 Despite these risks; there has not been a clear, coordinated national strategy around vaccinating PEH. Instead, determinations of eligibility for priority groups have been left to individual states to decide. The result is that Colorado and many other states have not yet prioritized PEH to receive vaccination. Unfortunately, this decision leaves a highly vulnerable population unprotected (which may further exacerbate health inequities), and directly undermines public health efforts to reduce community transmission.
As physicians and stewards of public health, we must act quickly to protect our unhoused patients by urging our elected leaders to consider housing status as an important factor in an equitable response to COVID-19. This includes immediate prioritization PEH, especially those residing in congregate settings, for vaccination. In our experience, vaccine acceptability among PEH is at least as high as the general population. A low-barrier, facility-based vaccination strategy for homeless shelters, similar to the approach utilized in other high-risk congregate settings such as long term care facilities, is likely to be the most efficient and equitable approach. The use of peer supporters, community leaders and shelter staff as “vaccine ambassadors” may enhance trust and increase vaccine uptake among vaccine hesitant individuals.
We must also call for an end to routine “sweeps” of our unhoused patients’ encampments under the auspices of public health. Such actions destabilize patients’ health and jeopardize trust at a time when building trust is essential to public health efforts to ending this pandemic. As physicians, we believe the swift creation of safe outdoor spaces and other options that allow for incorporation of hygienic resources and support in these communities will provide better health and protections for PEH with barriers to accessing emergency shelters, while longer-term solutions are being sought.
In this pandemic and beyond, we must collectively reach beyond the walls of our clinics and hospitals to create meaningful cross-sector partnerships with municipal leaders, public health partners, homeless services providers and members of the unhoused community. Such partnerships, which arose through necessity or were bolstered by the multi-agency pandemic response, may improve communication regarding impending threats and strengthen the community safety-net, and promote more effective advocacy.
Within these collaborations, we must advocate for large-scale funding for both short and long-term housing and support tailored to meet their unique needs of our unhoused patients. Such dedicated funding would provide a more proactive means of addressing homelessness. As with California’s Project Roomkey, subsidized housing can serve as a conduit to meaningfully connect PEH with medical, psychiatric, and social supports necessary for longer-term recovery.4 The City of Denver recently took similar steps by supporting a new, modest sales tax increase to fund the Homelessness Resolution Fund, which will support housing, shelters, outreach and supportive services for those experiencing or exiting homelessness.5 We must also call on our elected leaders to expand evictions protections and rental assistance programs, to prevent our patients from falling into homelessness in the first place.
We cannot address COVID-19 without addressing the homelessness epidemic. The numbers in our unhoused communities are growing, their resources are jeopardized, and the fate of public health depends in large part on this population’s prosperity. We must not abandon those at greatest risk during times of public health crisis. By joining our community partners in advocating for and procuring support for those experiencing homelessness, the medical community may do more than just conquer this pandemic. Indeed, we stand to reconnect with our humanity by serving a population in great need.
The views and opinions expressed by the individual authors do not represent those of Denver Health or the University of Colorado School of Medicine or Department of Medicine.