The Urgent and Growing Needs of Youths Experiencing Homelessness During the COVID-19 Pandemic

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We are over 6 months into a pandemic that in the U.S. is only worsening. Although we have made tremendous progress in better understanding SARS-CoV-2, the virus that causes corona virus disease-2019 (COVID-19), and the risk factors, treatments, and outcomes of COVID-19, we remain in the dark about most aspects. This includes our knowledge of its effect not only on the health of our most vulnerable adolescents and young adults but on their trajectory through adolescence and into adulthood.

The reality of the COVID-19 pandemic is even more inscrutable for our most vulnerable minors and youths, who have no parents or guardians with whom to safely shelter in place and who are unaccompanied and homeless. Tucker et al. [1] are to be commended for recognizing that their cohort-based intervention study of youths experiencing homelessness (YEH) provided them with an opportunity for an early window into the effects of this pandemic on their participants. What they uncovered is informative. Yet, it inevitably leaves us wishing for more.

We can be reassured and informed by the findings of Tucker et al. [1] that nearly all the participants knew about COVID-19 and that, contrary to the current narrative regarding the youth, the vast majority of participants reported taking measures to reduce the risk of being infected or of transmitting the infection. More concerning are participants' reports of experiencing increased obstacles to meeting their human right to basic needs [2], including food, clean clothes, a place to shower, or safe and stable housing. Against the backdrop of a global recognition that individuals need to maintain their health and shelter in place to advance community well-being, this is an alarming public health failure.

In addition to a decreased ability to meet their basic needs, youths report that with the onset of the pandemic, they experienced a high frequency of symptoms of emotional distress (unfortunately, we do not know if these are increased relative to their pre-COVID rates) and have increased their substance use, whereas their access to services to address their basic needs and their mental health has decreased. We know YEH have higher rates of morbidity and mortality than their housed peers, particularly because of substance use and poor mental health [3]. We should find the combination of these two effects of the pandemic alarming as well.

Although groundbreaking, the study by Tucker et al. [1] is small and preliminary. Nevertheless, it suggests some important opportunities. YEH are not reckless. They will use PPE if they are made available to them, and they can and will access information directed to them on social media [4].

Of course, the study sparks many questions and leaves many more unanswered, including, “Who are the youth who are not following guidelines?” and because knowledge of the epidemic does not seem to be the cause, “Why are they not adhering?” As described in the findings, some of the youths report that their financial or living situation is incompatible with staying safe. We need to know more. In addition, the participants in this study are all young adults. The experience of minors, who are more likely to be couch surfing and to depend on informal networks and less likely to depend on formal programs, needs to be explored.

It is well documented that structural racism, homophobia, transphobia, and sexism lead to disparate rates of homelessness and to its negative outcomes. Similarly, COVID-19 has clearly led to greater and earlier mortality among its black, Latino, and Native American victims. A far larger sample is needed to understand the degree to which and how the confluence of structural racism and COVID-19 disparately affect the experience of black, Latino and indigenous YEH. Our preliminary experience on the ground suggests that they are more likely to have lost their jobs and to have had their educational or vocational trajectories interrupted.

When the lived experience of a target population is so remote from that of researchers, it is particularly incumbent on us to ensure that they are meaningfully included in this work. This is not a commentary on the current project, which justifiably and rapidly added items to an existing survey. However, future research on the effect of COVID-19 on YEH should include youth voice, at the very least as advisers, but preferably as collaborators and shapers [5,6]. Youths are already doing this work on their own. The Larkin Street Youth Services Youth Advisory Board collaboratively produced a video regarding their and their peers' experiences of shelter in place in San Francisco [7]. Their insights go far beyond any survey academics could have come up with.

Although there is an urgent need for a better understanding of the effect of the pandemic on the youth's health, well-being, education, housing, and vocational goals, changes in current policy and practice are clearly called for that do not require more study. Current emergency housing has been severely rationed and has blindly excluded youths, who in San Francisco, for example, have been allotted vastly fewer hotel rooms than their percentage of the population. Not only does this approach not allow youths to shelter in place, it ignores the fact that YEH are more likely than their housed peers to have medical conditions that place them at higher risk of negative outcomes should they get infected [8]. Youth services should be funded proportional to their presence in the homeless population. Kinship-based care should be supported financially to allow youths to stay with often financially strapped relatives rather than to remain unsheltered. We need a coordinated strategy to ensure that homeless youths can continue to pursue their educational and vocational goals. Addressing youth homelessness in this pandemic is far easier than finding a drug to treat COVID-19. Effective treatments for youth homelessness have already been identified.

It is also clear that to help youths, we have to do more to help the helpers. Data we recently collected in Alameda County, California, have documented the tremendous obstacles that programs dedicated to serving YEH face to meeting youth needs in a way that is safe both for youths and for program staff [9]. Indeed, providers for YEH, and for people experiencing homelessness overall, should be universally recognized as frontline workers. Tucker et al. [1] have begun the work. It is up to all of us now to roll up our sleeves and respond accordingly.