Could the COVID-19 Crisis Help Eradicate Chronic Homelessness?

In the current COVID-19 pandemic, people living on the street or in temporary accommodations may be at higher risk for infection because of close contact with others and a lack of hygienic conditions.¹ Vulnerable people experiencing prolonged homelessness suffer frequently from tuberculosis, asthma, bronchitis, and HIV infection, and they are therefore at high risk for COVID-19 complications. This population has an all-cause mortality that is five to 10 times higher than that of the general population, with up to 17.5 years lower life expectancy. Most causes of death among people experiencing chronic homelessness are related to lack of timely and effective health care, which will increase even further during the COVID-19 pandemic. In the United States, 550 000 people are experiencing homelessness on any given night and, despite differences in definitions, Germany, France, Canada, Australia, and Brazil all report having more than 100 000 individuals experiencing homelessness (the Appendix [available as a supplement to the online version of this article at http://www.ajph.org] lists further references).

Substance use is one of the main problems affecting people who experience homelessness, as are drug-related infectious diseases. Homelessness was a key contributing factor in recent HIV outbreaks among people who inject drugs across Europe and the United States.² In this unprecedented COVID-19 emergency, homelessness is expected to worsen the health crisis among people who use drugs, for example through drug relapse, overdose, or difficulty accessing drugs and sterile equipment. There are already alarming signs of interruptions of essential drug services, such as opioid substitution treatment or safe injection services.

Immediate solutions have been implemented: COVID-19 testing has been initiated in mobile stations, shelters, and harm-reduction services. Many cities have started housing individuals experiencing homelessness in empty hotels and temporary shelters. However, they may not be able to adhere to ground rules, may be evicted, or leave voluntarily. Other potential problems are overcrowding (making it impossible to adhere to physical distancing), lack of spaces to isolate the sick, and no resources to properly screen and assess people with symptoms.

THE HOUSING FIRST APPROACH TO HOMELESSNESS

We argue that permanent solutions, not short-term results, must be found. Housing First methods treat affordable housing as a human right and provide people who remain chronically homeless with an immediate, permanent, and independent place to live, combined with support and treatment services. Although traditional approaches defend the necessity to enhance “housing readiness,” Housing First offers people who experience homelessness a place of their own without requiring compliance to psychiatric treatment or sobriety. Housing First takes a consumer-driven and recovery-oriented approach and promotes an individualized intervention based on a harm-reduction philosophy. People are provided with their own apartment on the open rental market, supported by a team of specialists, and connected to social and health services in the community with the aim of social integration. This support team is committed to work with each person as long as needed. Tenants need to meet a staff member during scheduled home visits and contribute with 30% of their income to housing expenses.³ This goes a long way in solving other social and health problems, promoting community integration and engagement with drug or infectious diseases treatment. It is a more efficient allocation of resources from an economic, social, and health standpoint.^4,5

Housing First ends homelessness in at least eight out of every 10 people, with better long-term outcomes than traditional approaches: number of days spent stably housed per year in independent accommodation (housing sustainment rates are > 80%), stabilization of drug and alcohol consumption and health status, with improvements reported in some cases, fewer psychiatric symptoms, and increased community integration.^4,6 Housing First costs need not be higher than those spent on temporary accommodation, and significant further cost offsets are achieved in health and legal services, including spending on hospitals and prisons, coupled with benefits in housing stability.⁵ By combining reduced risk exposure with health care, Housing First provides important protection to this vulnerable population, with likely significant reductions in mortality from drug and alcohol use, injury, accident, and homicide.

Housing First programs were started in North America to offer people who experienced homelessness rapid access to a settled home in the community in combination with mobile support services. They have further spread more widely in Europe using local and national governmental bodies to provide training in recovery-oriented care.⁷ A major barrier to scaling-up Housing First programs is affordable housing, especially in markets with low vacancy rates and high prices. In Finland, a successful integrated program with more than 7290 homes was critical to decrease homelessness in the past 10 years.⁷ All possible channels and funding agencies, such as the Ministry of Environment, were used: private market, social housing, and new or renovated supported housing units.

Housing First services can effectively house most people who have experienced chronic homelessness; however, a small percentage of participants (15%–20%) still have difficulty achieving housing stability. This proportion appears to be consistent through the literature and related to mental illness (in particular time spent in psychiatric hospitals), time spent in prison, and a good perceived control for mastering circumstances. However, it appears to be impossible to predict with confidence the individual characteristics associated with housing instability. Therefore, Housing First should be tried with all eligible people. For people who have needs that are not fully met by Housing First programs and who keep experiencing ongoing housing instability, alternatives should be considered.

FINAL CONSIDERATIONS

The COVID-19 crisis has upended many beliefs in the immutability of society. Now is the time to eradicate chronic homelessness through political commitment to a global rollout of Housing First action. This should be combined with strong community-wide prevention of homelessness and its drivers, such as poverty and incarceration, through legislation, as well as social security and health insurance systems that provide income support for basic needs, such as food and affordable rent, as are already in place in many countries. In Lisbon, Portugal, plans to provide permanent housing to all people who experience chronic homelessness were fast-tracked because of COVID-19, and 300 independent apartments have been added to the 80 previously available.

Housing First approaches are likely to reduce the risks of COVID-19 transmission by promoting health among residents. Societal change will be required to efficiently counteract the widespread inequality exacerbated by the new economic crisis. Housing First should be one key element in a package of solutions to reduce the social misery and public health risks of people living in often inhumane circumstances.