Why Housing Is Essential To The COVID-19 Response

A bus stop. A park bench. A subway car. For the unhoused, shelter is found in many places—but safety remains elusive.

“The lives of homeless people are incredibly public,” says Dr. Evan Lyon, a senior technical advisor with PIH’s U.S. Public Health Accompaniment Unit. “To be homeless means you’re circulating a lot. You have to go from this place to that place. Maybe panhandle, maybe go to the library, maybe sleep on a train overnight.”

That puts people experiencing homelessness at greater risk of suffering from a range of physical and mental health conditions—including COVID-19.

Homelessness and housing insecurity—from living with family and friends to evictions to vehicle residency—put the health of individuals, families, and communities in danger. Evictions alone caused more than 433,700 infections and 10,700 deaths from COVID-19 in the United States between March and September 2020.

Partners In Health believes that housing is essential for health. For more than 30 years, PIH has connected patients around the world with housing support. That work reflects PIH’s core belief that medical care alone is insufficient; patients must also have access to resources such as food, water, and housing, often referred to as social support, in order to recover and sustain their health.

As the pandemic intensified, PIH launched the US Public Health Accompaniment Unit (USPHAU) in April 2020 to strengthen public health systems across the country. The unit advises states, cities and communities as they develop a COVID-19 response that tackles the root causes of health inequities, strengthening these systems in response to the pandemic and for years to come.

The Housing Crisis: A Public Health Issue

The housing crisis in the U.S.—a country built on land stolen from Indigenous people—has been brewing for centuries. State-sanctioned racial violence—from genocide to slavery to segregation—displaced Indigenous and Black communities and created the conditions for the housing inequities that exist today.

Decades of racist housing policies—including redlining, racial restrictive covenants in deeds, and federal subsidies that ensured the suburbs would be white-only—segregated communities of color in impoverished neighborhoods. Today, people of color are less likely to own homes and more likely to rent. According to U.S. Census housing data, 58% of Black households and 54% of Hispanic households are renters, compared to 28% of white households. And people of color are more likely than white renters to be low-income renters.

As rents have soared in recent years, outpacing wage growth and making cities less affordable, people of color have borne the brunt of the housing crisis. Evictions disproportionately occur in communities of color, especially among working-class women of color, mothers, and domestic violence survivors. And Black, Indigenous, and Latinx people account for nearly 65% of the country’s homeless population.

Now, as COVID-19 surges, the housing crisis and its threat to public health have intensified: millions of Americans could lose their homes as they face financial challenges during a deadly and economy-crippling pandemic.

The Politics of Shelter

PIH has connected patients with housing support for decades, grounded by its mission to tackle the root causes of health inequities. That vital work has continued during COVID-19, especially in the U.S. From Massachusetts to Florida, PIH connects COVID-19 patients and their families with the resources needed to quarantine safely—support that often includes rental assistance.

More than 5 million Americans fear eviction or foreclosure in early 2021, despite the federal eviction moratorium and patchwork of state and local moratoriums in place. As many as 40 million were at risk when the federal eviction moratorium was set to expire at the end of 2020. It has since been extended through March.

“Getting evicted is intensely traumatizing and fast-paced and horrible,” says Lyon, who has worked on housing issues for years. “It’s not like people have plans.”

After losing their homes, people must seek shelter with those outside of their household or end up on the street. And living in cramped quarters—whether with relatives or in a shelter—makes social distancing and quarantine nearly impossible.

USPHAU partners with public health departments and community organizations across the country who provide rental assistance. The team advises policymakers as they develop social support programs and, in some jurisdictions, helps hire and train community health workers to connect residents with these resources.

While rental assistance programs vary in their scale and efficiency, they can be a lifeline for tenants, many of whom already have months of back rent accrued. Americans collectively owe an estimated $70 billion in back rent. When the eviction moratoriums lift, this rental debt will have to be paid, unless it is forgiven—a reality that could cost millions of renters their homes if no legislative action is taken.

In addition to streamlining rental assistance, PIH has supported homeless shelters, community organizations, and state and local governments to provide housing relief to communities hardest-hit.

In Navajo Nation, PIH and its sister organization Community Outreach and Patient Empowerment (COPE) helped resource a local homeless shelter and partnered with hotels to provide safe quarantine and isolation spaces for people impacted by COVID-19.

Patricia Bitsue, an executive assistant at COPE, delivered resources—including gloves, masks, sanitizer, and food—to St. Joseph’s Homeless Shelter and Soup Kitchen, which she estimates serves meals to about 60 to 80 individuals per day and houses up to 20 men at night. COPE was able to assist the shelter in the early days of the pandemic.

As part of its COVID-19 safety measures, the shelter conducted temperature checks, hosted a mobile testing site once a month, reduced its overnight capacity, and required people to stay six feet apart. People came from various tribes; the youngest was around 18 and the oldest 86.

“At first, they didn’t trust me. They didn’t want to talk to me because I was new,” says Bitsue. “But after they found out I could speak Navajo, they started to open up to me.”

She recalls one woman who came to the shelter for dinner and lived in a nearby encampment with her partner. “They were very close—always together and never, ever without each other,” she says. “Then he got COVID and passed away, and she was just lost. She was so distraught that she didn’t want to live.”

There was another complication: the woman had also tested positive for the virus.

A Social And Economic Sickness

People experiencing homelessness have long been disproportionately affected by a range of physical and mental health conditions. Hypertension affects 29% of the housed population in the U.S., but 50% of the unhoused population. Similarly, diabetes affects 9% of the housed population, but 18% of the unhoused population. And life expectancy for people experiencing homelessness is 12 years shorter than those who are housed.

“The things that make people sick are social and economic conditions,” says Lyon.

Those conditions include a lack of access to medical care, inability to shelter from extreme heat and cold, and the byzantine web of social service programs that unhoused people must navigate simply to survive. And such conditions have only intensified during the pandemic, as the public spaces and congregate settings that mark daily life for unhoused people become potential hotbeds of disease. While some shelters provide testing and spaces for quarantine, it is far from a guarantee. And contact tracing is an uphill battle, if not impossible.

Lyon recalls an unhoused man in Chicago who felt sick and went to the emergency room to get a test. His result took three days to come back: positive. During that three-day period, he had slept on the train each night, visited the library each day to charge his phone, and went to three different social support programs for food.

“Three nights on the train with illness is incredibly risky,” says Lyon. “And this is a guy who did everything right.”

Even before COVID-19, shelters were overcrowded. In 2019, there were only 389,549 shelter beds for some 568,000 unhoused people, according to HUD. Now, with new safety protocols such as social distancing, shelters easily hit maximum capacity and have to turn people away— including those who test positive.

As shelters are overwhelmed, cities are finding new ways to support COVID-19 positive cases among the unhoused. Since September, USPHAU has partnered with public officials in Montgomery, Ala., to launch a citywide Crisis Center, which will open in mid-February, for individuals experiencing homelessness.

The Crisis Center, located in a former middle school, is outfitted with 96 beds, quarantine and isolation spaces, a mobile testing unit, and case management services. The center operates based on referrals from shelters, social service agencies, and health care providers in the area.

“The Crisis Center is designed to support the unhoused with safety and dignity as they face COVID-19,” says Grace Lesser, senior project lead with USPHAU. “It also aims to take the burden off of the existing shelter system.”

The USPHAU team also designed a 2-day training for Crisis Center staff on a range of topics related to COVID-19 transmission and prevention—a resource that will be made available to city employees and homeless shelter staff.

In addition to the Crisis Center, USPHAU is supporting the development of a community health worker program and social support fund in Montgomery. Similar to PIH’s programs around the world, the CHW program will hire workers from the local community and dispatch them to the city’s hardest-hit neighborhoods to educate residents about COVID-19 and connect them with resources, including rental assistance.

And the new social support fund will provide financial relief, including housing support, to residents across the city, especially targeting those who may not qualify for existing relief programs.

“Really critical to this project is uplifting housing as a part of public health,” says Lesser. “Housing is a key part of ensuring that community members are stable and safe during this pandemic, and always.”

As it responds to homelessness and housing insecurity, PIH continues to weave social support into the fabric of its public health response, tackling the root causes of health inequities—realities that predated COVID-19 and will continue after the pandemic, unless systems of oppression are dismantled and historic injustices redressed. It would cost about $20 billion to end homelessness in the U.S. by a HUD official’s estimate—small change compared to the $741 billion the U.S. government recently allotted for military spending.

In Navajo Nation, Bitsue finds some relief in that the woman who lost her partner to COVID-19 was able to recover, as she was supported by COPE and partners. But the future remains uncertain.

“I see her, every now and then, out on the streets still,” Bitsue says. “Sometimes I’m able to stop and give her some water or snacks that I have in the car. It’s just really heartbreaking.”