COVID-19, Home Confinement, and the Fallacy of “Safest at Home”

In response to the coronavirus disease 2019 (COVID-19) pandemic, the governor of Illinois, J. B. Pritzker, issued a Gubernatorial Disaster Proclamation on March 9, 2020, and a shelter-in-place order on March 21, 2020, instructing all individuals living within the state to remain in their place of residence, with few exceptions. By April 3, 2020, a total of 41 states, the District of Columbia, Puerto Rico, and the Navajo Nation had issued similar orders.¹ Many governments, including here in Illinois, have called their shelter-in-place order “safer at home.” From a population perspective, these efforts are necessary and sound; however, they belie the reality that for some patients, home is the least safe place for their immediate health.

Like many hospitals across the United States, we watched normal operations grind to a halt. However, the trauma team at the University of Chicago on the city’s South Side has remained dishearteningly busy. Less than a week into the shelter-in-place order, a female patient presented to our trauma bay after having been brutally assaulted, suffering major penetrating injuries to her head and neck, with deep defensive wounds to her hands and forearms. She had a compromised airway, so we quickly intubated her and transported her emergently to the operating room to repair major vascular injuries. Her assailant was an intimate partner. Several days later, two middle-aged men presented, hours apart, with isolated stab wounds received from their respective female partners. These patients and many others we have cared for are survivors of intimate partner violence (IPV).

INTIMATE PARTNER VIOLENCE AND CONFINEMENT

IPV is a public health crisis amid and exacerbated by the COVID-19 pandemic. In the United States, one in four women and one in seven men experience severe physical IPV at some point in their lives.² Transgender individuals report even higher levels, with some studies quoting lifetime prevalence of IPV of up to 50%.³ Restricted economic resources, unemployment, and high stress levels all correlate with an increase in both the incidence and the severity of IPV.

Although we have never seen a health care crisis on this scale in our lifetime, we can draw from the lessons learned when natural disasters have affected geographic areas throughout the United States and necessitated a similar need to self-shelter. A powerful example is Hurricane Katrina in 2005, which caused a radical upheaval of many peoples’ ways of life. A study by Harville et al.⁴ noted an increase in physical confrontation, thought to be a result of maladaptive conflict resolution in the home. Furthermore, they suggested that the increase in IPV could be exacerbated by concomitant mental health strain and an increase in daily stress.

CHANGES WITNESSED BY HOTLINES AND SHELTERS

Sheltering in place is indeed essential to flatten the curve of the COVID-19 outbreak, but it poses a unique and hourly increasing risk for those who are forced inside with their abuser. Some IPV hotlines have, in fact, seen a decrease in their call volumes because victims are having a difficult time accessing this important mechanism of support when they are confined to the home with their abuser.⁵ These hotlines serve an important temporizing and preventive role in aiding survivors before an abusive situation reaches a crisis point, but they are predicated on the victim being alone to speak freely with a counselor.

Development of cellular phone applications or other non-telephone-mediated methods of reaching IPV hotlines is well within the reach of current technology and urgently demanded by shelter-in-place restrictions. This powerful technology could potentially provide a wealth of information and resources available in a concealed format, usable in front of the abuser. In the absence of effective strategies and resources, we may expect to see an increase in hospitalizations and possibly fatalities as a direct result of exacerbated IPV during the COVID-19 pandemic.

Troublingly, some emergency shelters have reported a corresponding increase in survivors who have reached the crisis point, indicating distress, imminent danger, and an urgent need to leave their home immediately. According to the Director for Shelter Services at the Domestic Violence and Child Advocacy Shelter of Cleveland, Ohio, for example, 40% of calls in February 2020 were classified as acute crises. Only one month later in March, following Ohio’s shelter-in-place order, that proportion had risen to 60% (personal communication, April 2020).

Even beyond a call for help, when a victim makes the difficult decision to leave, where does he or she go? Shelters, given their already constrained resources and space, must grapple with the difficult reality that they are able to serve fewer people with physical distancing requirements. Shelters offer even less support when the survivor is a man, because most are limited to women, with even fewer clear options available to transgender or gender-transitioning individuals. This emphasizes the need for novel approaches to prevent IPV from reaching crisis levels before victims seek help.

AS WE LOOK AHEAD

As has been widely reported, shelter-in-place measures have begun to flatten the curve of transmission and death in the localities that have stringently adhered to them, thus beginning the difficult path of planning for society’s reemergence into public life. Many public health experts and epidemiologists believe that several rounds of shelter-in-place orders may be necessary until a vaccine can be reliably deployed or viral spread has subsided completely. It is difficult to envision public life fully returning to normal in the next 18 months. With that knowledge, the problem of IPV is both imperative and ongoing.

We have not missed our opportunity to change public policy and funding to acknowledge the existence of IPV survivors and the way COVID-19 is uniquely affecting their safety. Nor have we missed the opportunity to change the way we reach out and assist our patients. The radical upheaval of our daily lives wrought by this crisis has given us the opportunity to reimagine how we might relate to one another. Reworking and buttressing how we care for survivors of IPV should be among the aspects of the old order that we urgently bring back to the drawing board.