Averting a COVID-19 Disaster for America’s Homeless Population Requires Immediate Action

Conversations around the COVID-19 pandemic have largely centered around vulnerable populations, with the public and private sector alike taking steps to protect the elderly and those with chronic health conditions like diabetes, hypertension, and immunodeficiencies. Frequently excluded is one group that embodies a terrifying convergence of risk factors that make widespread transmission and infection both more likely and more fatal: the nearly 2 million Americans who experience homelessness each year.

With inadequate access to proper hygiene and sanitation, the close and often unsanitary conditions in which homeless people are often forced to sleep, and the difficulty of early detection among a population isolated from health care, a small group of experts have raised concerns about widespread infection within this population. Less widely known- but considerably more important — is their extraordinarily high susceptibility to symptomatic infection, hospitalization, and fatality due not only to their advanced age, but also the accelerated physical decline and mental health weathering that results from exposure to harsh elements.

In a recently released report, a team of interdisciplinary colleagues and I model the likely hospitalization, critical cases, and mortality rates among this vulnerable group and estimate the resources needed to manage this crisis. The numbers are terrifying and should compel federal, state, and local policymakers into action post haste.

Compared to the general population, homeless adults are twice as likely to be hospitalized, two to four times as likely to require critical care, and two to three times as likely to die. To put numbers to these rates: of the 493,000 single adults (the most vulnerable group) who are homeless on a single night: 21,000 will be hospitalized, 7,000 will require critical care, and about 3,500 will die. This is, to be clear, the lower bound of the potential impact on the homeless population. Once we factor in a minimum annual turnover rate of 3 — meaning that at least three times this number actually experience homelessness over the course of a year — plus the near-certain growth in homelessness likely to follow from the all-but-certain impending recession, these already projections will look like wishful thinking.

The urgency of the additional capacity required to manage this crisis cannot be overstated. Let’s, for a second, put aside the obvious solution of permanent stable housing, which remains the cornerstone of any real solution to homelessness and would be particularly efficacious during a public health crisis exacerbated by unsanitary and crowded conditions.

To create additional capacity that safely accommodates people coming off of the street and allows for social distancing principles, we need a minimum of 400,000 new units. We also need to create or adapt existing units for quarantine or isolation for individuals that are symptomatic but not sick enough to be hospitalized. The total estimated cost of $11.5 billion is substantial, but both necessary and likely cheaper than the healthcare system costs if COVID-19 tears through this highly vulnerable population unabated.

We are beginning to see action. The State of California and City of Los Angeles have made substantial funding allocations to support rapid emergency shelter for unsheltered individuals, outreach for early detection and New York City’s homeless outreach teams are offering hand sanitizer to people sleeping unsheltered. These localized, ad hoc steps, impactful though they may be, do not constitute the meaningful and systematic mitigation of an impending disaster.

There are obvious and immediate steps we can take. By creating adequate and humane shelter for people living unsheltered and reconfiguring existing facilities to accommodate social distancing and isolate those who are sick, lives can be saved. Federal, state, and local governments will need to collaborate around the funding, staffing, and siting of facilities. But the urgency is clear, as is the moral imperative to act.

Dan Treglia, Dennis Culhane, and Ken Steif, University of Pennsylvania

Randall Kuhn, University of California, Los Angeles

Thomas Byrne, Boston University