Tag Archives: homelessness

08/24/21

Homelessness and COVID-19

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The findings for the 2020 Annual Homeless Assessment Report (AHAR) to Congress were published in January of 2021 and it contained some disturbing information. In a single night in 2020, approximately 580,000 people experienced homelessness in the U.S. Sixty-one percent stayed in sheltered locations, while 39% were “living rough” on the street, in abandoned buildings, or wherever they could pitch a tent. For the fourth year in a row, homelessness increased nationwide. The number of people who were homeless increased by 2% between 2019 and 2020. Almost 60% experienced homelessness in an urban area and 53% of all unsheltered people were counted in the nation’s 50 largest cities.

The 2020 AHAR count reflects a 7% increase of individuals staying outdoors with the number of sheltered individuals remained largely unchanged, with a 0.6% decline. “Increases in the unsheltered population occurred across all geographic categories.” The key factor was a sizeable increase (21%) in the number of unsheltered people with chronic patterns of homelessness. This means being homeless for more four times in the past 3 years, or continuously homeless for at least one year.

Unsheltered families with children also increased for the first time since data collection began.  In 2020, just under 172,000 people in families with children were homeless. While most of these homeless families (90%) were in sheltered locations, there was an increase of unsheltered families by 13%.

People identifying as black or African American accounted for 39 percent of all people experiencing homelessness and 53 percent of people experiencing homelessness as members of families with children but are 12 percent of the total U.S. population. Together, American Indian, Alaska Native, Pacific Islander and Native Hawaiian populations account for one percent of the U.S. population, but five percent of the homeless population and seven percent of the unsheltered population. In contrast, 48 percent of all people experiencing homelessness were white compared with 74 percent of the U.S. population. People identifying as Hispanic or Latino (who can be of any race) are about 23 percent of the homeless population but only 16 percent of the population overall. [See the following graphic]

Psychological Services published a special issue on homelessness in 2017, “Homelessness as a Public Mental Health and Social Problem.” The authors said after deinstitutionalization in the 1960s, thousands of patients moved out of mental institutions into community-based care became homeless. Under the Bush administration, the federal government began requiring communities to conduct and report annual point-in-time counts of homeless individuals to track the scope of the problem. An epidemiological study found that 4.2% of Americans have experienced homelessness for over one month sometime in their lives and 1.5% experienced homelessness in the past year. “From both epidemiological studies and PIT counts, it is clear that homelessness remains a major problem in the country.”

Risk factors that are strongly associated with homelessness include adverse childhood experiences, mental illness and substance abuse. Most research on homelessness has focused on homeless, single, middle-aged men. “But there is increasing study on the growing number of homeless women and families who may have different needs.”

While there have been efforts to provide housing for the homeless or those at risk of homelessness, such as the HUD Exchange, many people who enter supported housing return to homelessness. Comprehensive primary care and behavioral health services have been intentionally integrated into many homeless organizations. Unfortunately, there continues to be limited access to mental health and substance use services available for many in supportive housing.

Nan Roman, the President and CEO of the National Alliance to End Homelessness, said the 2020 report gave a deeply troubling picture of homelessness in the U.S. on the eve of the COVID-19 pandemic. She said these results show an under-resourced system supposed to meet the needs of people at risk of and experiencing homelessness. While the Alliance was encouraged by the investments federal leaders have made in homelessness and housing resources during the pandemic, “the numbers make it clear that these investments are tragically overdue.”

COVID-19 and Homelessness

The pandemic was a major disruption for homeless system operations. The yearly Point-in-Time (PIT) survey for 2021 of persons who are homeless received new guidance that allowed for flexibility when counting people who were unsheltered. There were allowances made for observation-only counts, samplings, abbreviated surveys, and longer times permitted for the process. There was even a report published to guide those conducting a street-based PIT count that maintained the health and safety of those performing the count as well as those individuals who were homeless during the COVID-19 pandemic. See the National Alliance to End Homelessness for a webinar on “Conducting the 2021 PIT in the Age of COVID-19” and other resources.

In “COVID-19 and the State of Homelessness,” the National Alliance to End Homelessness reported how the pandemic significantly complicated efforts to end homelessness. One expert predicted there would be an increase of 250,000 new people homeless over the course of the year. Consider that before the pandemic, systems were not able to serve everyone experiencing homelessness. “Providers only had capacity to offer an emergency shelter bed to 1 in 2 individuals experiencing homelessness in 2019.” Limited resources resulted in overcrowded shelters and social distancing was difficult, if not impossible. “Unsheltered people lack consistent access to water, soap, and hand sanitizers that help prevent the spread of the virus.”

In “People experiencing homelessness: Their potential exposure to COVID-19,” Lima et al noted how many homeless people already have a diminished health condition, higher rates of chronic illnesses or compromised immune systems, “all of which are risk factors for developing a more serious manifestation of the coronavirus infection.” Those suffering from mental illness potentially struggle recognizing and responding to threats of infection. They also have less access to health care providers who could order diagnostic testing, and if confirmed, isolate them from others in coordination with local. Health departments.

In “Data for: People experiencing homelessness: Their potential exposure to COVID-19,” Neto et al said homeless organizations warned the coronavirus could cause catastrophic harm to unhoused communities. People who sleep in shelters or on the streets already have a lower life expectancy, as well as struggles with addiction and underlying health conditions that put them at greater risk should they develop the virus. Experts say the chronically ill homeless have a unique vulnerability to the coronavirus. “If exposed, people experiencing homelessness might be more susceptible to illness or death due to the prevalence of underlying physical and mental medical conditions and a lack of reliable and affordable health care.”

People experiencing homelessness are increasingly older and sicker. Many have underlying health conditions but lack access to primary-care physicians or preventive health screenings. They struggle to find public bathrooms to maintain their basic hygiene. Those who live in tent encampments or crowded shelters might be unable to keep their distance from others or self-isolate if they show symptoms.

A CDC Morbidity and Mortality Weekly Report (MMWR) for May 1, 2020 assessed the infection prevalence of COVID in five homeless shelters for residents and staff members in four U.S. cities—Boston, San Francisco, Seattle and Atlanta. They found that when COVID clusters (two or more cases in the preceding two weeks) occurred, “high proportions of residents and staff members had positive test results for SARS-CoV-2.” Community incidence (the average number of reported cases in the count per 100,000 persons per day during the testing period) varied, with Boston having the highest incidence and San Francisco the lowest.

To protect homeless shelter residents and staff members, CDC recommends that homeless service providers implement recommended infection control practices, apply social distancing measures including ensuring residents’ heads are at least 6 feet (2 meters) apart while sleeping, and promote use of cloth face coverings among all residents. These measures become especially important once ongoing COVID-19 transmission is identified within communities where shelters are located. Given the high proportion of positive tests in the shelters with identified clusters and evidence for presymptomatic and asymptomatic transmission of SARS-CoV-2, testing of all residents and staff members regardless of symptoms at shelters where clusters have been detected should be considered. If testing is easily accessible, regular testing in shelters before identifying clusters should also be considered. Testing all persons can facilitate isolation of those who are infected to minimize ongoing transmission in these settings.

In the Journal of Internal Medicine, “Addressing the COVID-19 Pandemic Among Persons Experiencing Homelessness,” Barocas et al noted that at least 1 in 5 of 13.8 million adults in rental housing say they are behind in rent. Coupled with an end to the federal eviction moratorium, this could mean an increase of more than 2.7 million newly homeless or unstably housed people in the U.S. Medical conditions such as heart and lung disease disproportionately effect the unsheltered and place them at risk for high morbidity and mortality from COVID-19. “A sudden increase in the number of people without housing or infections in the existing homeless population combined with COVID-19’s current strain on our health care system will greatly reduce our ability to care for this vulnerable population.”

Barocas et al recommended four changes. First, immediate improvements to and expansion of the national shelter system are needed. They believe the situation will become more dire if the federal eviction moratorium is not extended. Federal and state relief plans need to allocate funds for more shelters that are properly staffed and resourced.

Second, there needs to be an improvement with ongoing surveillance to prevent outbreaks among homeless individuals. One of the suggestions was to increase the use of waste water-based epidemiology, the practice measuring biomarkers in wastewater. “Active surveillance of municipal wastewater mapped to homeless shelters could be used to identify insipient outbreaks.” This seems to be a potentially low-cost COVID-19 surveillance method that could be used in low-resource settings such as shelters.

The third recommendation is to develop a universal approach to testing and contact tracing. A lack of testing supplies has led to a disproportionate allocation of tests across society, with more socially disadvantaged individuals encountering challenges when accessing tests. New methods of contact tracing rely on the assumption of stable housing, secure internet, or cell phones with application abilities. While most homeless people own or have access to a mobile phone, they often do not have smartphones that support app-based programs. “We need a dedicated investment in contact tracing in this population; otherwise, expanded testing will be for naught.”

The fourth and final recommendation is to provide places for persons with inadequate housing and without a permanent home to isolate once they are diagnosed with COVID-19 and do not meet criteria for skilled nursing care. Shelters are usually not equipped to convert entire floors into quarantine units. Innovative approaches to help this vulnerable population attain a space to recuperate and limit the spread of COVID-19, such as using hotels or college dormitories for temporary housing, were suggested.

As a nation, we have, thus far, done little to protect persons experiencing homelessness from COVID-19 disease. In the short term, we need funding for the expansion and improvement of our shelter systems, development and implementation of innovative strategies for active surveillance of outbreaks, rapid deployment of more COVID-19 tests coupled with a comprehensive contact tracing strategy, and expanded space for recuperation for this population. For a long-term effect, we need to extend the eviction moratoria and to use the pandemic as an opportunity to expand affordable and low-income housing and establish pathways to regain housing. Continued neglect of this vulnerable population will most certainly lead to considerable strain on the already stretched healthcare system during times of SARS-CoV-2 surge, increased transmission and mortality from SARS-CoV-2, and a widening health disparity gap.

The 2021 Annual Homeless Assessment Report will not be completed and published until 2022. The 2020 AHAR was published in March of 2021 and already showed a 2% increase from 2019 to 2020. What will the 2021 AHAR reveal?

09/4/18

Homelessness Is a Person

credit: Pixabay on Pexels

Every year in December people gather beneath a Downtown Pittsburgh overpass where Grant Street meets Interstate 376 in order to remember the lives of homeless people who died on the streets in the previous year. One of the six bronze-colored plaques fastened to the wall that night held the name of a 23 year-old woman who had attended the memorial the year before. Her plaque joined more than 200 others. Another one of the deaths in 2017 was for a woman whose artwork was shown at a Point Park University art show in 2016. A homeless outreach worker lamented: “The streets take lot of people; they don’t give back; the street’s tough.”

Seven more individuals died in 2017 while in shelters. “Most died of drug overdoses. Most died alone.” One of the speakers at the vigil said it’s about gathering together and saying we care, “but the bigger picture is us gathering together saying that we want zero deaths in the street and we want to end homelessness.” Last year Pittsburgh Mercy’s Operation Safety Net, which sponsors the event, added twelve plaques to the wall. One of those individuals died of a drug overdose in the South Side a day after he helped serve a free community meal for the needy. “He tried to help others with what little he had.”

You can read more about the memorial and see a short video of the 2017 Vigil for the Homeless here on TribLive. Here is a link to Pittsburgh Mercy’s Operation Safety Net. Here is a link to a HomelessShelterDirectory in Pittsburgh.

Annual memorials like this are not the only way individuals can remember and help the homeless. In And This is How It Ends, Jen Sky described how she became involved in ministering to the homeless of Pittsburgh. She started out by serving meals in a park across from Light of Life Mission on the North Side of Pittsburgh and eventually visited homeless camps, interrupted drug deals and witnessed street fights. Her journey began when she messaged a Facebook “friend” who was soliciting others to join with her in helping the homeless. Jen said that conversation on January 11, 2016 “began what could only be called a transformational journey.” The following quote is an excerpt from And This is How It Ends. 

It was Jerry’s first day on the streets. Literally, Jerry has a college degree and had been working as a social worker. He had lived with his girlfriend, and her kicking him out coincided with the loss of his job. To my knowledge, Jerry does not have any addictions, but he has some really terrible luck.

Imagine being homeless in Pittsburgh in January or February, when the average low temperature is 20-23 degrees. What if you were unsheltered and had a cold, the flu or pneumonia? And since you weren’t in a shelter of some kind, what if you had to always keep your boots on regardless of how wet they were from the snow?

Once a year, during the last ten days of January, Allegheny County conducts a Point-in Time (PIT) count to identify individuals and families who are homeless. The 2016 Data Brief (the most recent one online) identified 1,156 people who were experiencing homelessness. This was a decrease from a five-year high of 1,573 in 2014. The Data Brief suggested the decrease could be due to Allegheny County’s use of a Rapid-Re-Housing model aimed at helping people experiencing a temporary housing crisis get into permanent housing as quickly as possible.

Demographically, there were 673 males and 481 females recorded during the 2016 PIT count. African Americans were disproportionately represented among the homeless. While 13 percent of Allegheny County residents are black, 58 percent of the individuals counted by the 2016 PIT count were black. In addition to being on the streets, the homeless were also experiencing other challenges. Forty three percent had a serious mental health issue; 30% struggled with a chronic substance use disorder; 14% were victims of intimate partner violence. See the following graphics taken from the 2016 Data Brief.

An Australian study by Zaretzky et al., “What drives the high cost of health care costs of the homeless?” noted that people experiencing homelessness “are more likely to experience mental health disorders, long-term physical health conditions and conditions requiring hospital treatment than the general population.” However there seems to be a subpopulation of homeless individuals with very high health care costs. Thirteen percent of the individuals in the study incurred a total health care cost of over $50,000 for the 12-month time period reviewed by the study.

Higher costs were strongly associated with individuals having a diagnosed mental health (MH) disorder (excluding substance use disorders) and/or a long-term physical health condition. Health care costs for these individuals were at least double of those without. Co-occurring MH and substance use disorders were also related to higher health care costs. The very high costs of health care in the study were found to occur with individuals who spent a long time “sleeping rough” (unsheltered).

This finding, and its consistency across two separate and different samples of people experiencing homelessness, provides a significant economic argument for intervention through sustained government programmes targeted to both assist people to manage mental health disorders and long term physical health conditions in a cost-effective and sustainable manner, and to break the cycle of homelessness and maintain stable accommodation.

The latest statistics say that on any given night over 553,000 people experience homelessness in the U.S. Sarah Hunter noted the problem is particularly acute in California, where around 24% of those experiencing homelessness live. LA County has the highest population of unsheltered (living rough) homeless with an estimated 55,000 people—almost 10% of the national total. In an attempt to address this problem, the LA County Department of Health Services launched a program called Housing for Health in 2012. “The program aims to provide long-term, affordable rental housing coupled with intensive case management services that link individuals with the kind of health and social services needed to sustain independent living.”

Instead of requiring participants to first get treatment or receive services, “the LA program offers housing first in an attempt to give participants stability, which in turn helps them benefit more from services.” Hunter and her colleagues studied the impact of the Housing for Health Program on the participants’ health as well as their use and costs of county services. They compared the participants’ use of county services the year before housing and compared it to the use of services one year after being housed.

Permanent supportive housing resulted in a substantial decrease in residents’ use of county services. The use of health care and mental health care dropped the most. LA County’s costs were also down—by nearly 60%. The largest reductions were with the Department of Health, which provides emergency, hospital and outpatient services. There was a reduction of around $20 million after the participants’ first year in the program. For every dollar invested in the Housing for Health program, $1.20 was saved in health care and other social service costs during the participants’ first year.

But based on our research, Los Angeles County’s Housing for Health program addresses an important public health issue by providing housing and supportive services to some of the most vulnerable individuals in our community. The program not only provides the support so that 96 percent remain stably housed, but it also results in a reduction of intensive health care, resulting in a cost savings to taxpayers.

You may not have noticed, but this article shifted its discussion focus from homeless people to the problem of homelessness, beginning with the examination of the Allegheny County Point in Time count. But I think we should conclude by returning our reflections to homeless people. As Jen Sky said in And This is How It Ends, “Homelessness is not a problem. It’s a person.” And we need to see homeless individuals as people created in God’s image and treat them as such. We can attempt to bring people out of the cold and into shelters and other kinds of housing, “but there is nothing we ourselves can do to fix the brokenness inside each of us. That healing needs to come from God.” Jen said:

It has never been easier for me to see God than through my homeless friends. Through their incredible faith, their exceptional fortitude and courage, and through their sheer will and determination to live, I have witnessed a strength and character rarely witnessed in my suburban surroundings. I have seen selflessness and self-sacrifice, courage and perseverance the like of which I had never seen before. They were giving as a sacrifice, not from one’s excess, but giving from subsistence.

Jesus sat and watched people putting money into the offering box in the temple. Many of the rich people put in large sums. But then a poor woman came and put in two small copper coins worth a penny. Jesus called to his disciples and said to them: “Truly, I tell you, this poor widow has put in more than all of them. For they all contributed out of their abundance, but she out of her poverty put in all she had to live on” (Luke 21:3-4). Commenting on these verses in the devotional Connect the Testaments, Rebecca Van Noord noted how the contrast between the Pharisees and the poor woman’s sacrificial giving shows us that “Spiritual wealth can be present where we least expect it.” We can add, even in a homeless person.