Grappling With Homelessness In The Time Of Coronavirus
Pandemics are as much about societies as they are about science. Systemic inequities place a thumb on the scale of outcomes, tilting the balance of who gets sick, who gets well, who gets tested and who gets overlooked.
Nowhere is this more evident than in the challenges coronavirus poses to people who are homeless and those who work with them.
For millions of Americans, everything experts say to do right now — keep healthy, maintain social distance, wash hands obsessively and, of course, stay home — is simply not possible.
"There is no way to shelter in place when you don't have housing," said Dr. Margot Kushel of University of California, San Francisco.
Kushel, who leads the Center for Vulnerable Populations and Benioff Homelessness and Housing Initiative, both at UCSF, said roughly half of people experiencing homelessness are aged 50 or older.
But that's only part of what makes them especially vulnerable to coronavirus.
"Our research has shown that people who are 50 and older [and] are homeless have health conditions that make them much more similar to people in their 70s and 80s in the general population," she said.
They also have higher rates of heart and lung diseases, diabetes, HIV and other illnesses, all while receiving no regular medical care.
"Homeless individuals have a very high prevalence of the very same comorbid conditions that create increased risks for poor outcomes, so even if they're younger, they're more at risk," said Kushel.
Those factors mean people who are homeless can get sicker from less-severe infections. And because they cannot rest at home or seek care from family, they stand a greater chance to end up in a hospital.
"Once they're admitted, they have to stay longer because we can't discharge them to a place where they might spread the disease," said Kushel.
Meanwhile, staying clean and fed grows harder during shutdowns, when shuttered businesses no longer provide sources of soap and water, and panhandling prospects dry up.
Nor can people without homes remain socially distant, as Kushel explained.
"People may sleep in groups or alone, but come together frequently, for instance, to find food, where they may gather in large groups," she said.
Such gatherings further challenge already overcrowded shelters and their ability to protect their clients from coronavirus.
"There have been major shelter outbreaks thus far in Seattle; Boston; San Francisco; New York City; Dallas; Philadelphia; Baltimore; Toronto; Bangor, Maine; and other places," said Kushel.
In April, San Francisco's largest homeless shelter went from five to 70 cases in less than three days.
"This highlights the role of asymptomatic spread and the reasons why testing people only when they're symptomatic will fail as a strategy," said Kushel.
The most effective strategy, say experts, would be to find people housing.
Catholic Charities Community Services (CCCS) in northern Arizona is pursuing a strategy of placing clients in vacant hotels. But many hotels hesitate to open their doors, and owners who are willing to do so struggle to find staff and provide necessary supplies and coronavirus protection.
Another plan entails gathering people who are not sick enough to need hospitalization into isolated groups, where they can receive basic medical care and not take up hospital beds.
Ultimately, though, nothing can substitute for a home, said Cammie Rasband, director of homeless services for CCCS.
"We see folks coming to us with all this positive momentum, but if they don't have a safe, stable place to live, how do they get to that next place? How do they re-engage with the community? How do they focus on reunifying with their families if they don't have a place to be?" she said.
CCCS offers housing, food and other programs for individuals, families and veterans in northern Arizona, including Coconino, Yavapai, Mohave, Apache and Navajo counties.
"Having the basic needs taken care of — having shelter and food and a sense of safety and security — is just critical to being able to move on to those next steps," she said.
Rasband said CCCS has adjusted to coronavirus by shifting to telephone-based intake and information services and by following CDC guidelines everywhere else.
Fulfilling its mission sometimes means trekking into the desert or forest to supply people living there with the necessities.
"Some folks are very hesitant to go into shelters right now. Of course, they're concerned about their own physical safety," said Rasband.
Amy Schwabenlender is executive director at Human Services Campus, which works with 15 other nonprofit and governmental organizations in Maricopa County to help single adults find permanent, safe, affordable housing.
"Every day's a little different at the Campus in non-COVID times and in COVID times. We're continuing to find new and different ways to provide information in a way that doesn't create more anxiety or panic," she said.
The campus's 20 access points see nearly 11,000 people each year and 800 per day — reuniting them with family or matching them with services like rapid rehousing or permanent supportive housing.
In addition to handling coordinated entry for Maricopa County, the staff now must mitigate the spread of coronavirus.
"It's really about who would be more likely to die if they contracted COVID-19, and that's really changed the dynamic," said Schwabenlender.
From providing masks and medical screenings to altering the ways they feed and house their clients, everything now revolves around the virus. This includes replacing six-foot-separation markers, reducing crowding at the mailroom and setting aside a dayroom as a 47-bed shelter for especially vulnerable clients.
Handling so many tasks calls for staff they don't have, especially after sending many volunteers home during the stay-at-home order.
Philanthropic aid has funded some temporary employees. But as low-wage workers, many are a few paychecks away from becoming clients themselves at a time when finding housing is especially difficult.
"It was already challenging because of the marketplace and not having enough affordable housing for everybody. And now it has slowed down further," said Schwabenlender.
The same is true in northern Arizona, said Rasband.
"We have rental dollars, we have resources, but we need landlords that are willing to work with us. We need properties that we can put folks into," she said.
Crisis And Cooperation
On the positive side, Schwabenlender said philanthropies and the state have provided personal protective equipment and hand sanitizer.
She also said the crisis has brought the organizations closer together.
Linda Ross, CEO of Circle the City, agreed.
"We all have a common goal and a common mission, and we're talking, you know, all the time," she said.
That includes a daily 8:30 a.m. phone call between Human Services Campus, Circle the City, Central Arizona Shelter Services (CASS) and behavioral health partner Community Bridges.
As a Federally Qualified Healthcare Center and Maricopa County's health care provider for people experiencing homelessness, Circle the City has pivoted a bit more easily than some partner organizations.
"Our respite services are still intact. We're still seeing people at our clinics. We're still doing outreach through our mobile medical units," said Ross.
They also help the Human Services Campus with COVID-19 screening. Any client who answers "yes" to having a fever or worsening cough, or who shows a temperature of 100.4 degrees or higher, is referred to Circle the City for a health assessment.
Ross said her organization has added a 10-bed isolation dorm for COVID-19-positive clients and furnished, air-conditioned tents for those awaiting test results.
"We have portable hand washing stations, portable toilets, portable bathrooms," she said.
But workers cannot force clients to follow guidelines, a fact further complicated by the high prevalence of behavioral health issues among the population. According to Schwabenlender, 40% of people who are homeless self-report behavioral health as a barrier to housing stability.
"We recognized we had to ensure that we had somebody there who was really talking through it with patients. And that has really worked well actually," said Ross.
Minding The Gaps
Gaps in the social safety net are also gaps in disease surveillance. In truth, officials have no idea how many people experiencing homelessness have coronavirus.
That makes it a social problem as much as a medical one.
"Each and every person's health is intertwined. To stop the spread of the virus, we can't afford to leave anyone out," said Kushel.
It's been said the coronavirus exposes the cracks in our society and makes a compelling case for mending them. Either way, experts agree we cannot grapple with COVID-19 without contending, too, with the expanding crisis of homelessness.
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