Homelessness in the time of Coronavirus

Brush: People think that this population is different from us, but they're not. They are going through the same things as everybody else, they're just not in their own homes. They wanna go back to work. They wanna get their lives back to normal. They're in the shelters and shelters are not permanent places for them. They're probably stuck in these situations longer than they would like to be because they wanna be re-housed. They wanna get to their own space again. And so just like everybody else, I'm sure the individuals in these shelters are as frustrated as we are, want to return to a sense of safety and health.

Speaker 1: It's estimated that more than half a million people in the United States experience homelessness on any given night. When you don't have a consistent place to call home, being told to “stay home and stay safe”, can feel pretty hopeless. We wanted to learn more about this already valuable population and how they're affected during the coronavirus pandemic. And how are shelters able to safely provide housing, food, and care to everyone who needs it.

Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our podcast, focusing on the ongoing coronavirus pandemic. We began with Barbara Brush, a professor of Health Behavior and Health Education at the University of Michigan School of Public Health, and a Professor of Nursing. She's an expert on homelessness and health. We asked her about the hardships people experiencing homelessness encounter daily during this pandemic.

Brush: The homeless population across the country is a pretty diverse and varying group. I think what people typically think about when they're talking about homeless populations are the people that you see or hear about: individual men, veterans, people with mental health and substance use issues and those kinds of populations. But the populations that we rarely think about are the large number of homeless women and children, as well as unaccompanied youth who live independently from families who also comprise the homeless population.

And so when we talk about shelter services, we can't just think about shelters for one group of individuals. We have to think of shelters in terms of the varied populations that they serve. Like prisons and nursing homes that are being decimated by the virus, the shelters are also congregate living spaces where people sleep in the shelter at night and often share common spaces, like cafeterias and other spaces, daycare in family shelters, common hallways, and space where the virus can spread more easily quickly. And unlike prisons and nursing homes, the shelters don't typically have on-site health services. They don't have nurses and physicians on site to screen, diagnose, and treat people for the virus. It makes a bit more of a complex system to manage.

The CDC guidelines, initially when the virus emerged they had interim guidelines, and now those are more set in stone. Essentially, the recommendations were that shelters and other facilities caring for and providing services to the homeless population, stayed in contact with state and local authorities around identification of the infection and being able to refer to local public health departments for assistance in managing. They suggested that if shelters had emergency operations and communication plans, they put those into action so that they were communicating regularly with other shelters, with other providers in the area. That they use, like everyone else, distancing strategies - make sure that people who were sick, both staff or volunteers stay at home and if possible, provide face mass to clients who exhibit any kind of signs of the virus.

This has been very challenging to separate sick clients, even those with mild symptoms from healthy clients, and then transfer clients who are very severely sick to medical facilities and then finally to really limit any kind of visitation to facilities from outside families, from other services that weren't part of the service of the shelter itself.

We don't have universal testing and shelters right now, as we don't have universal testing pretty much anywhere then the United States. But one shelter in Boston, the Pine Street Inn, I think it's been in existence over 40 years, had a small cluster of positive clients in the facility. And they were able to go to their state health department and get testing for all 397 residents and found that of that 397, 146 were positive. Of those positive clients, 100% were asymptomatic. So when you're looking at CDC guidelines that says separate sick clients or even those with mild symptoms from healthy and then in the face of evidence that shows that 100% of almost half of the clients of one very congested shelter had the virus but were asymptomatic, you can see that this is gonna be a very difficult recommendation to comply with,

In order to separate sick clients, shelters across the country are collaborating with local hotels and motels, particularly motels where they're no shared hallways, to place clients from shelters into individual rooms. So there have been success stories, those success stories are very much local responses in local communities and really not, I think spear-headed by the federal government.

Speaker 1: Many people are feeling anxious about daily life and about what the future holds. That could be compounded for those needing shelter services for a number of reasons.

Brush: My sense is, at least in the shelters that I've had contact with, NSO Neighborhood Services Organization in Detroit and COTS most recently, as long as people have good information and they understand why restrictions are necessary, people tend to be okay with that. I think it's a sense of unknown that makes people worry and wonder why they have to change their lives.

Shelter people are like everybody else. The point of a shelter is not to be their permanent home. The shelter provides people a safe place to sleep at night and then during the day like everybody else, people leave the shelters, kids go to school, they try to find work, go to work , or go to programs to access services they need. So people are being isolated in a shelter, sometimes with hundreds of people they don't know and they don't really have much in common with except for the fact that they're all in that shelter. So I can imagine that it would be difficult because they're even more marginalized in some ways, and they already are.

Shelters have done a very good job at keeping people apprised of what's happening and making sure they have the food they need, they have the services they need, even though there's been a lot of concern about dwindling resources. And volunteers have dried up, so staff are trying to do more services at a distance and do it remotely as best they can.

In a situation where you have congregate living and you don't know people you have hope that everybody's doing the same thing and you just don't know that. I think that could be really challenging. Shelters where you have beds that are in large spaces, they're trying to spread the bed six feet apart. They're doing more temperature and symptom screening. Setting up shower, units and hand washing stations for people who are on the street who are living in some of the tent communities. There are also a lot of street medicine groups, we have one in Detroit, the Neighborhood Service Organization, is the major funder of that and people from CHAS Dr. Richard Brice runs that street medicine program. They're actually going out to the street for people who still live out on the street and are checking in with them, making sure they're safe, providing them the opportunity to get testing if they need it if they’re sick. So there are a lot of efforts out there, but there's a real concern among shelters about whether they're gonna have the monetary and personnel resources to keep this up in the way that they need to do it.

People at shelters, at the very least, I think have eyes on them, they're not in homes where people can't see them. So they do have social work support and I'm sure that a number of shelters have been sending their clients to hospitals, just as the general population when they get sick, they have access to hospitalization.

What makes this population more at risk though, is that their immune systems are probably more compromised than the general population just because they're not living in homes where they can have access to regular nutritious food and there may be more smoking, more chronic illness that’s under-treated or not treated in shelters. Many of the families are young families with children under the age of six, so they are vulnerable to viral infection. Also, they spread it.

I think for this population prevention, prevention, prevention, is key. Those are the efforts that most shelters are focusing on. Because once it hits the shelter, then you've got a big problem.

Speaker 1: Dr. Brush works with an organization in Metro Detroit called The Neighborhood Service Organization, or the NSO. NSO provides services to thousands of people each year with developmental and intellectual disabilities and people facing homelessness or housing insecurity. Linda Little is the President and CEO of the NSO. We talked to her about how the coronavirus pandemic has impacted the care that they provide to the people who need it.

Little: We know that when a person shows up, it's more than the issue that they present with. We don't live in compartments in our lives. It's more of an interdependence, and inter-connectivity in every area of our lives. Just like we are as a community. We're interconnected and interdependent on each other and so we look at the entire person: mind, body and spirit.

We know that the homeless population is a very vulnerable population that has oftentimes many comorbid conditions and chronic diseases that go unmet and we bring the services to them, on the street.

We also have what's called transitional housing or rapid re-housing. If they qualify for transitional housing, then we put them in housing for a finite period of time while we work toward more permanent housing, and then we also offer the permanent housing solution as well.

We serve vulnerable populations and the homeless is one category of the vulnerable populations that we serve. We also serve individuals with intellectual and developmental disabilities. We serve people with mental illness, whether it's mild or severe, any range in between. We also service people who have substance abuse issues. We also serve seniors who have mental illness or mental health conditions as well.

And so the strategy that we deploy really was around all, the entire population. So we're just trying to anticipate the needs of our population. Because of the shelter in place order, our homeless population have to pretty much shelter in place too, right? That's their home.

It is not easy to change the behavior of some people who are accustomed to a different way and oftentimes have a great deal of mistrust anyway. And so it doesn't take a lot to trigger that mistrust, even though they have a good relationship with our organization. Some people don't like for their normal patterns of behavior to be interrupted, and we certainly understand that.

And so we found that we had to expand our services to meet their basic needs as well. From laundry and snacks and trips to the store, to helping them pay their bills. We had to really try to make sure that their needs were met so that they could stay inside as well. We certainly couldn't keep them involuntarily, so we wanted to meet their needs so that they wanted to stay inside and educated them about why it's important that they stay inside and not expose themselves and then potentially bring it back to the shelter and expose everyone else there.

We are unique in that we do have a clinic onsite in our shelter. So we have a medical director of primary care who's a family medicine practitioner, and then we have nurse practitioners that are there on-site as well, delivering services. So we were in a unique position where we had actual clinicians who were screening on a routine basis throughout the day. As we were doing the symptom checks and the screening, we were able to identify early on anybody who had potential symptoms and quickly removed them from the rest of the group to try to mitigate spread. In the new facility we had a specific room where we could isolate. And so we would isolate there, try to segregate them as much as possible until they were able to be transported to the quarantine site.

And so in the shelter in addition to the rest of the organization we started screening for COVID-19 symptoms and we did it multiple times throughout the day because we found that people were developing symptoms throughout the day. And so it was important to do at least two to three times a day of symptom checks. And we were working with the city of Detroit for their isolation center, so anybody who had positive symptoms, we were isolating them and then contacting the Health Department to transport them to their quarantine site. We were also doing screening of our staff every day before reporting to work.

As an organization, we immediately started with educating our staff and our teams. We converted to teleworking working very quickly so that our staff weren’t coming in to work on a routine basis. And about 80% of our services are delivered face-to-face in the community, so we were able to shift that face-to-face component in service delivery to telehealth. In addition to delivering services via telehealth, we started doing phone contacts and phone screenings. We wanted to reach out to them and do symptom checks and make sure that their basic needs were met. Do they have groceries? Are they able to pay their utility bills? Do they have any symptoms for COVID? And we immediately were connecting them with the healthcare provider if they had any medical needs to try to keep them from going into the hospitals. We knew that the hospitals would be flooded with people with symptoms of COVID-19 because we had been watching the trend. As it had come over to the state of Michigan, hospitals began to experience a surge and so we wanted to do our part to help deliver health services in the community to keep people from going to the hospitals as much as we could.

Speaker 1: There are likely difficult days ahead for organizations like the NSO as the economy worsens and its services may be needed more than ever.

Little: We knew that there were health disparities among the minority population in our country. That is something that persisted before this pandemic. I think what happened with COVID-19 is those disparities were illuminated and amplified. And so, what I was hearing in the black community were stories about people being turned away for testing and treatment even though they clearly had visible signs of distress. They couldn't breathe and they were turned away and sent home. And I heard that story over and over and over again.

So I think that overall we have a lot of lessons to be learned from this crisis and I'm really helpful an optimistic that solutions can be developed to address a systematic issue that has prevailed in our communities for a very long time, and actually address health disparities, across the board.

I think that we're starting to see a downward trend of positive cases and deaths, thankfully, but I do think that the economic impact that we're going to see as a result of this, all the millions of people who are filing for unemployment, there are going to be some long-term ramifications because of this economic slowdown.

I think agencies like NSO have ready themselves to meet the increased demand of basic needs and human services in our community. A lot of people are hurting. And that's going to continue for a period of time, and we want to be there to provide solutions and provide support to our community residents that need us. 

Health care is a right, not a privilege. And I think we have to recognize that when we don't provide healthcare to everyone, we have situations like this and it could be any one of us at any given time. It's like Dr. Martin Luther King Junior said “Any injustice to one of us is in justice to all of us.” And so I hope we use this as an opportunity to make certain things right and improve how we distribute resources, and deliver services across the board.

This has been a special edition of population healthy a podcast from the University of Michigan School of Public Health.