What We Owe to Homeless People in the United States

Almost 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 the risk of infection, and what is needed to build and maintain appropriate isolation and quarantine spaces. Much of this fundamental data that Americans and the world have benefited from comes from homeless people 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 homeless people, including federally licensed shelters and health centers, recognized the potential of the novel coronavirus to harm their population. Given the historical treatment of homeless people, many people knew they would be low on the priority list for state and federal support. As a result, organizations, often in coordination with local health departments, sprang into action to develop the first symptom screening tools and reference systems for testing and isolation. The result of these efforts was the knowledge of all prevalence of SARS-CoV-2 across the country, transmission dynamics and risk factors for the disease it causes. These efforts also resulted in plans for isolation and quarantine facilities that protected the entire population and prevented the collapse of the healthcare system.

an early report of Boston described the Herculean efforts of an organization that tested 408 shelter guests over a two-day period and found that nearly 90% of those who tested positive were asymptomatic. Work like this helped the world understand that SARS-CoV-2 was silently spreading among us. In another example, SARS-CoV-2 samples collected from clients and staff at Boston homeless shelters were analyzed and provided some of the first proof of the importance of superspreading events in shaping the course of the Covid-19 pandemic. From there, contact tracing protocols were adopted across the country, modeled on what had been done by a small group of health workers in Boston.

Our knowledge of how serious Covid-19 disease can be also, unfortunately, were from homeless people who were infected early in the first wave, lacked the ability to self-isolate, and had multiple comorbidities that put them at risk. Since homelessness is associated with an 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 serious illness and death. As such, these and other health issues were then prioritized for early vaccination and Covid-19 treatment, saving thousands, if not millions, of lives.

One of the most important contributions of this population was the efforts to isolate and quarantine this population, which ultimately protected the health care system and the population at large. Organizations have developed a variety of isolation and quarantine sites for these homeless people — without federal guidance (or financial support) — in places like Boston, San Francisco, Rhode Island, and elsewhere. First, these sites provided free plans to state and federal government officials without any prior knowledge of infection control principles who attempted to design field hospitals for the general population. Because I had personally been involved in the Boston efforts, state and federal emergency management officials sought my advice on how to establish large facilities that prevented transmission. Second, these facilities helped hospitals and shelters cope with the initial surge of Covid-19. One To analyse demonstrated that our nearby alternative care site resulted in a 28% reduction in hospitalizations at Boston’s Safety Net Hospital and has been credited with preventing the hospital from being overwhelmed.

Despite the societal gains that have been made through this population and those who work with them, no gratitude has been expressed. Instead, this population continues to be marginalized, ignored 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 to tenants beyond the eviction moratorium, it does nothing to provide housing for those already experiencing homelessness. And while the CARES Act provides funding for HUD programs, funds were allocated taking into account 2020 homelessness numbers and did not take into account increases resulting from the pandemic. The same resources therefore had to be distributed among a larger number of people than expected. 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 have closed due to lack of funding, again leaving shelters and community health centers to “deal with the problem” on their own. And due to a confluence of factors, the population of homeless individuals across the United States has increased. Instead of responding with evidence-based answers such as lodging, cities and states have stepped up sanctioned police sweeps and displacement campaigns. Daily sweeps in Denver have increases above observed levels before the pandemic. Boston’s new mayor, Michelle Wu, has emptied the biggest camp in town and has, to his credit, attempted to secure temporary housing and drug treatment for many of these displaced people, while New York apparently has no plan but to tell people to “move on”. In the most egregious example, California Governor Gavin Newsome uses CalTransComment— the transportation department — to clean up homeless encampments. This decision harms not only the people being swept, but also those doing the sweeping, who have no formal training and may suffer psychological trauma from having had to destroy someone’s home.

Here we see a vulnerable and marginalized group of people, a disproportionate majority of whom are black—whose experiments have informed our knowledge of the natural history of a disease. And instead of treating them with proven interventions that we know work, like stable housing and expanded access to health care and social services, we choose not to intervene. Specifically, we only intervene by criminalizing them.

Despite 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 roaming.

Donald E. Patel