Impact of COVID-19 on People Experiencing Homelessness: A Call for Critical Accountability

In January 2021, the US Interagency Council on Homelessness (USICH) published a report detailing outcomes of its efforts to address the effects of the COVID-19 pandemic on people experiencing homelessness (PEH) in 2020.¹ USICH consists of leaders from 19 federal agencies and was authorized by Congress in 1987 to coordinate the federal response to homelessness.² The council’s stated mission in its COVID-19 response, which its report claims to have achieved, was to “save lives and not crash the emergency medical system.”¹

We write as an interdisciplinary team conducting ongoing community-based research in partnership with homelessness service organizations in Indiana. Since April 2020, we have examined the challenges faced by PEH during the COVID-19 pandemic and the organizational-, community-, and system-level responses with respect to risk and impact mitigation.³ Our findings, although specific to Indiana, raise critical questions about the conceptual framings, methodologies, and conclusions presented in the USICH national report.

Although the USICH report was published under the previous administration, whose attempts to defund the council and multiple low-income housing programs have been well documented,⁴ it nonetheless continues to be the latest available federal report on the effects of the pandemic on homeless populations in the United States. Given its authoritative position as a governmentally sourced communication, we urge new USICH leadership to critically interrogate how these data on PEH were conceptualized, collected, and used⁵; to be clear about the report’s limitations; and to provide a more nuanced and evidence-based update on the status of the council’s ongoing efforts.

TROUBLING CLAIMS

The USICH report suggests that homeless populations have fared better than expected as a result of “early and firm action” by federal agencies and claims that COVID-19 cases and deaths among PEH have been “significantly and dramatically lower than had been originally projected.”¹ Death counts, described as more precise than reported cases, serve as the primary indicator of COVID-19’s impact on PEH.

Preliminary data from the Centers for Disease Control and Prevention (CDC) indicate that there were 224 deaths among PEH in 2020, which the report augments by 15% to correct for an estimated undercount based on unexplained “field observations.”¹ These calculations formed the basis of USICH’s assertion that the US government successfully accomplished its mission to save homeless lives. USICH then applied a ratio of 1.72, calculated according to the ratio of deaths (344 497) to cases (19 943 605) within the general public in 2020, to the reported number of PEH deaths and estimated that the likely number of cases among PEH was between 14 241 and 15 737. The report concluded that the lower than expected number of cases among PEH reported to the CDC (12 111), relative to how high it allegedly could have been, indicates that the government’s efforts “made a significant difference in reducing the number of positive cases and deaths among PEH,” which were, notably, “lower relative to the general public.”¹

These claims are conceptually and methodologically unsound, especially in light of overwhelming evidence showing how structural inequities have contributed to the unequal burden of COVID-19 on disenfranchised communities and individuals. For example, the COVID-19 pandemic has been especially deleterious for communities of color and incarcerated populations.⁶ For similar reasons, the pandemic has had devastating effects on PEH, as this population chronically faces various forms of systemic oppression (e.g., economic precarity, social stigma, and discrimination) that exacerbate health disparities and marginalize them from health and social services.^7,8 PEH also encounter heightened risk of community transmission because of their congregate living conditions.

Given that the pandemic has disparately harmed the most vulnerable, we ask the following: By what logic would a standard ratio based on the general public in any way represent the experience of homeless populations? By which measures, and as a result of which actions, could PEH have fared “better than expected”?

Undercounts of COVID-19 deaths and positive cases are widespread within the US health system,⁹ which, for PEH, is worsened by inconsistent data collection practices and data management systems. The report omits any mention of how imprecisely housing status is registered in health systems¹⁰ and the extent to which homelessness is underrecognized in emergency hospital settings.¹¹ Furthermore, the report fails to provide a definition of homelessness and focuses narrowly on unsheltered individuals and those in homeless shelters, ignoring the growing numbers of hidden PEH who “couch surf” or are otherwise unstably housed.¹²

Only half of providers that are part of the Department of Housing and Urban Development (HUD) Continuum of Care program report using HUD’s Homeless Management Information System,¹³ and in May 2020, 12% reported that pandemic data were not being systematically collected, citing HUD’s delayed requirement for COVID-19 data collection.¹⁴ Nearly a third of these providers have service populations of 1000 people or more at any point in time who are mobile and, thus, difficult to reach and test.¹⁴ Agencies reporting to the CDC have not been able to systematically test members of this population, which may have elicited a clearer picture of incidence and mortality rates among PEH. Missing from the USICH report is transparency of and accountability for the limitations of the reported numbers. Rather than drawing conclusions based on ratios applied to partial figures, we encourage USICH to acknowledge what is—and is not—supported by existing evidence.

COUNTERING CLAIMS: VIEWS FROM THE FRONT LINE

Findings from our ongoing community-based research in partnership with frontline homelessness service organizations in Indiana provide a divergent view. Our data include in-depth interviews with the staff of homeless shelters and other community-based organizations as well as the PEH they serve.¹⁵ It is evident that the burdens faced by PEH and the general population are not equivalent, and thus applying a general ratio of deaths to cases is fundamentally flawed. Our data reveal that PEH are more likely to present with preexisting health issues, suffer from poor mental health, experience high rates of substance use, and report low health literacy, contributing to low adherence to COVID-19 safety measures such as mask wearing and social distancing.³ As one service provider explained,

Not only do they not have homes, they all have horrible health. So, you know the targeted criteria for those who are at high risk for COVID? . . . Well, that’s almost everybody in here [shelter].

Moreover, USICH’s assertions about PEH being “tested more often and at a higher rate than the general public”¹ are unsubstantiated. Our research, as well as a national study conducted by the National Alliance to End Homelessness, indicates that the opposite is true.^3,14 Shelters throughout the country have experienced staffing and supply shortages,⁸ making testing and contact tracing exceptionally difficult. More than half of Continuum of Care providers reported having no testing capacity in May 2020, and only 14% reported sufficient capacity to test all individuals in a shelter where someone had tested positive.¹⁴ By November 2020, 46% of these providers reported testing sheltered people with known exposures, and only 15% reported doing so for unsheltered people.¹⁴

Our qualitative data corroborate these findings. As of December 2020, Indiana homelessness service providers reported “just doing temperature checks” as a way to screen guests, a method that fails to identify asymptomatic individuals and does not reflect CDC guidelines on COVID-19 testing. According to one provider,

the only avenue that we have is to call an ambulance and have [clients] tested through the emergency room. . . . But [they’ve] been sitting in the same room together, so they’ve already been exposed to each other.

Testing capacities among homeless populations were severely hindered; therefore, data from service providers reported to the CDC should be acknowledged and treated as partial and incomplete.

PROTECTION FROM, NOT FOR, THE MOST VULNERABLE?

The USICH report highlighted a mission to “protect the emergency medical system.” The report presented emergency hospital visit numbers to claim that homeless populations used health services less frequently than expected throughout the pandemic: “in relative percentage terms, the community of homelessness has been visiting the hospital for COVID-19 significantly and dramatically less than the general public.”¹

Absent from the report is a discussion of the social, structural, financial, emotional, and geographic barriers faced by PEH when seeking health care. PEH report that patient–provider encounters often feel dehumanizing, disrespectful, and dismissive.¹⁶ As one service provider taking part in our research stated, “They don’t trust [medical providers] . . . they’ve never felt welcome there [hospital].” Pandemic-related challenges such as service disruptions and transitions to telehealth, the latter of which require technology largely unavailable to homeless and other disadvantaged populations, lead to health care encounters being even more inaccessible to PEH.³ The report also does not specify whether PEH sought care beyond emergency medical services, nor does it acknowledge that many hospital systems saw reduced patient visits across all populations during the pandemic.¹⁷

We are critical of USICH’s stated goal of “saving life” by protecting the emergency medical system from the incursion of use by PEH. Saving is commonplace rhetoric that supports the defense of something deemed valuable and vulnerable while inflicting harm by treating others, such as marginalized communities, as invulnerable and unworthy of protection.¹⁸ Striving to protect the emergency medical system from PEH conveys a harmful message that it should be preserved for those presumably deemed more deserving. In this context, USICH’s saving rhetoric exacerbates the dehumanizing health care encounters PEH report by celebrating the underuse of health services by a vulnerable population during a pandemic. Regardless of the rate at which PEH used health care during the pandemic, underuse should be considered an indicator not of public health success but, rather, of enduring forms of systemic neglect.

TOWARD CRITICAL ACCOUNTABILITY

We draw attention to the USICH report to consider the consequences of who is—and is not—being counted.⁵ As a federal council, USICH’s claims are positioned authoritatively and thus require close scrutiny and accountability, especially when countered by first-hand, frontline accounts.

Political motivation throughout the pandemic has incentivized underreporting or misrepresenting of data in the United States to show a rosier picture.¹⁹ Reports such as that of USICH result from a dangerous line of thinking that no data means no problem. The reality is that homeless communities are systemically undernoticed as a result of poorly originated and inaccurate representations of their multidirectional needs. Slipping through the cracks is part of being homeless in the United States, where social safety nets have failed to keep 600 000 people from homelessness.²⁰ Four months after Congress allocated $4 billion in funding for PEH as part of the CARES Act, just 29% had reached those in need.²¹ Barriers to accessing relief resources have largely excluded PEH from stimulus funding. As one PEH stated,

The system has become so inadequate to people like us, the homeless . . . the government doesn’t care. . . . The ones that are getting income, the ones on unemployment, they’re getting the stimulus check. But true people that are homeless, they ain’t getting shit.

The USICH report demonstrates how PEH also slip through the cracks of research theories and methods. Rather than hastening to embrace lower than expected estimates of incidence, death, or use of hospital services as evidence of success, we encourage interrogating the numbers further for what else they may convey, such as barriers to care, erasures, and not counting.⁵ Critical reconceptualizations of research on homelessness may elicit alternative “metrics” that tell fundamentally different stories. Such considerations should inform data-driven policies (e.g., the latest CDC eviction moratorium order that applied exclusively to counties with high COVID-19 transmission rates during the Delta variant wave²²), which can be effective only if data are robust and actually representative. With eviction moratoriums ending and homelessness projected to increase,²³ a rigorous understanding of the long-term effects of COVID-19 on PEH has become even more crucial.

Thus, we call on the current administration and new USICH leadership to invest in robust and critical data collection practices that elucidate the individual, community, and systemic realities of homelessness. We call on public health scholars to help redress the marginalization of homelessness within research on health disparities, which contributes to the dearth of reliable data on PEH that culminates in flawed reports such as that of USICH.

Specifically, we call for rigorous community-based, qualitative research with PEH and homelessness service providers around the country to contribute experiential, observational, and attitudinal insights toward a richer understanding of the pandemic’s effect on homeless populations. Pandemic and disaster response efforts must center the voices of vulnerable communities and the frontline providers who best understand their specific needs and contexts. In addition to envisioning federal responses to public health crises that are dramatically more inclusive of the communities most affected, we call for broader acknowledgment of homelessness as a systemic condition that requires stronger commitment and investment if it is to be ended rather than simply mitigated.