The Urgent Public Health Need to Develop “Crisis Standards of Housing”: Lessons From the COVID-19 Pandemic

From the beginning of the coronavirus (COVID-19) pandemic, a crisis of space overwhelmed hospitals across the United States. As coronavirus cases surged, hospitals filled beyond their capacity. Spaces that under normal circumstances would have been considered inadequate for patient care were seized for that purpose. Hospital hallways and conference rooms filled with beds and patients.

Those space limitations forced health care providers to confront how they would provide care under the direst circumstances. Across the United States, health care leaders codified “crisis standards of care” because they recognized that exceeding the standard capacity of existing resources does not remove the responsibility to provide the best possible care given the circumstances.¹ Those “crisis standards of care” were accompanied by additional funding, workforce development, and relaxation of policies dictating where care might be delivered.

While hospitals swelled beyond capacity, a related crisis of space played out across the United States. One of the more profound side effects of the pandemic in the United States has been its impact on people experiencing homelessness (PEH). As coronavirus numbers have grown and the economy has stagnated, a growing number of people are at risk for or experiencing housing instability or homelessness. In early 2020, an estimated 568 000 people experienced homelessness.² Despite policies intended to stave off evictions, that number grew steadily over the year. It is estimated that homelessness will increase by 45% by the end of 2021.³ There is much to learn from the process of developing “crisis standards of care” that can be readily applied to the homelessness crisis. As such, we propose a “crisis standards of housing.”

The dramatic increase in the number of people living on the streets represents the confluence of trends. The pandemic’s economic impact on lower-income Americans has been devastating; half have experienced either job loss or have a household member who has.⁴ Compared with middle- and upper-income adults who lost a job during the pandemic, low-income individuals are 33% more likely to remain unemployed—with women, immigrants, Hispanic persons, and those with lower education levels being the hardest hit.⁴ Black and Brown persons, women, and immigrants are at the highest risk of losing housing.⁵

As the need for emergency housing has soared, the available supply of shelter beds has decreased. Before the pandemic, the number of PEH outnumbered the number of available shelter beds by more than double.² Given the need for increased distance between clients, many shelters reduced their available beds—in some cases by more than half.⁶ Although some states increased capacity by creating new shelter spaces or leasing rooms in hotels, such efforts were exceptional. As such, a growing number of PEH have been left without a shelter option.

In the absence of available beds, people seeking shelter gravitated toward the safest, most hospitable places they could find: the well-lit, centrally located parks that the public had left behind. Consequently, policymakers and everyday Americans have been forced to confront one of our greatest collective failures: our society’s inability to ensure stable housing for all.

Just as emergency measures such as invoking the Defense Production Act have been taken to fight the pandemic, emergency steps must also be taken to prevent more Americans from experiencing homelessness. Approximately 20% of the 13.8 million adults in rental housing report being behind in rent.⁷ To mitigate this risk, the Centers for Disease Control and Prevention took the necessary step of extending the federal eviction moratorium,⁸ but the mandate must be extended into the fall if not winter. The $45 billion in rental assistance included in President Biden’s American Rescue Plan will help prevent evictions, but only if people in need are able to access the funds. Local and state health departments, hospitals, and federally qualified health centers should temporarily assign case managers and social workers to ensure receipt of rental assistance for anyone who is eligible.

Temporary measures must be coupled with longer-term commitments to ending homelessness. The Housing First model is an effective solution to homelessness, with upwards of 75% of people remaining stably housed after one year.⁹ But the growing homelessness crisis caused by the pandemic requires additional solutions and capacity building. One potential solution is to develop and train a public health workforce of people with lived experience with homelessness. Peer-support models have been implemented among PEH and shown to reduce harms from substance use, increase adherence to treatment of tuberculosis, and even improve housing stability—particularly when couched within programs such as Housing First.^10,11 Applying a peer-educator model for the development of a public health workforce for PEH could serve dual functions. First, it would provide meaningful employment to those providing the support, lifting people out of the cycle of poverty and housing instability. Second, as has been noted in peer-support studies for this population, education and counseling from someone with first-hand experience have the potential to improve health-related outcomes for those receiving the support.^10,11 Peer-educator models are effective in part because they produce much higher levels of trust than traditional intervention models.^10,11 Federal investments in innovations such as peer-educator models coupled with Housing First initiatives, in addition to improved access to jobs and low-income housing and rent relief, would signal a true commitment to ending homelessness.

In addition, we must end the criminalization of homelessness. Each time a person is punished for attempting to survive—by panhandling for money, sleeping on a park bench, or setting up an encampment—the cycle of incarceration and homelessness becomes more difficult to escape. Many cities deploy “sweeps” of encampments in which personal belongings are discarded and people are either displaced or incarcerated. Such practices are expensive and counterproductive—Los Angeles, California spent $30 million in 2019 on sweeps.¹² Forcing people to relocate compounds the stigma of homelessness and does nothing to disrupt the underlying conditions that cause it.

Providing resources to those experiencing homelessness is a more humane and potentially cost-effective solution than sweeps. One study demonstrated that providing direct financial support to PEH dramatically improved their lives and decreased unhealthy behaviors in both the short and long term.¹³ Participants who were given $7500 (Canadian) found stable housing and were able to attain food security faster than those who received no cash. The cash recipients decreased their spending on alcohol, cigarettes, and other drugs by 39%. Decriminalizing homelessness would also require decriminalization of substance use, mental illness, and sex work—all of which are common for various reasons among PEH—and decriminalization would reduce barriers to care for substance use, and mental illness in particular.

Decriminalizing homelessness could allow people a place to exist through sanctioned encampments while stable housing options are being established. Just as hospitals filled beyond capacity opened spaces not traditionally used for patient care, we must provide safe, legal spaces for people to exist given the overwhelmed and underresourced status of shelters. Opponents of sanctioned encampments have long argued that they are costly and encourage drug use and vagrancy. In reality, sanctioned encampments are less costly to a city than shelters and sweeps, afford individuals a sense of community, and can lead to improved health outcomes.¹⁴ Legal encampments also force society to confront its failure to ensure stable housing for everyone. As researcher Rebecca Finkes noted, “The visibility of the permitted encampments brings the issue of homelessness to light, and invites the greater community to lend a helping hand.”^14(p20) The sanctioned encampment in Seattle, Washington that she was referencing helped mobilize city officials and nonprofit organizations to work together to develop low-income housing and provide resources and skills training. Such a move should not be interpreted as giving up, but rather recognized as a communal awakening that society must do better while simultaneously admitting that we have yet to do so.

Businesses can also play a critical role in ending homelessness, just as they have in the pandemic. The Defense Production Act mobilized the rapid manufacturing of ventilators, personal protective equipment, testing supplies, vaccines, and other necessary tools to fight the pandemic.¹⁵ The same authorization could be used to award contracts to hotels, construction companies, and other manufacturers to requisition unused bed capacity in hotels and dormitories for temporary housing, jump-start the manufacturing of linens and hygiene products, and enable the construction of emergency low-income housing developments. If we are to end homelessness, the business sector needs to be a partner.

Crisis standards are critical to mitigating emergencies like the coronavirus pandemic. The urgency of this moment should not obscure the fact that homelessness has been a smoldering epidemic for years; the pandemic has merely exposed its enormity and society’s inaction. Nevertheless, the pandemic has also demonstrated our collective ability to innovate. A nation that can produce multiple vaccines against a novel virus in less than a year can do much more for PEH than provide a couple of nights in quarantine or a few allowable encampments. This should be the moment that we finally end homelessness in the United States. A nation as wealthy as ours just needs to apply the same ingenuity, commitment, and innovative spirit that we are using to combat the coronavirus.