COVID-19 is a ‘crisis within a crisis’ for homeless people

By Molly Bohannon, Katie Surma, Austin Fast, Nino Abdaladze, Megan Lupo, Jamie Fields and Sanjana Garg
Howard Center for Investigative Journalism

August 24, 2020

This story was supported by the Pulitzer Center.

PHOENIX – Nearly 200 tents stand inches apart on the scorching gravel lots, many covered in blankets for an extra layer of relief from the desert sun. Outside, their occupants sit on hot ground or in folding chairs, nearby palm trees providing no shade. Despite 12-foot-square sections painted in the gravel, there is little social distancing for Phoenix’s homeless population.

Created by local officials in late April as a temporary solution for some of the estimated 3,700 unsheltered homeless, the fenced-in lots on the edge of downtown promised round-the-clock security, social distancing and access to water and toilets. But residents complain that hygiene supplies have become scarce, and measures meant to contain the spread of COVID-19 are not enforced.

“We have been, like, ignored,” said Elisheyah, 61. “There's no safety, nothing to guarantee you can be safe out here.”

Homeless people are one of the most vulnerable populations in the coronavirus pandemic, yet they’re largely invisible victims of the crisis. Very little is known about how they’re faring, in part because the Department of Housing and Urban Development – the main federal agency overseeing programs for them – has not required its national network of providers to gather information on infections or deaths. That’s despite the fact that unlike other high-risk, congregate-living groups, such as nursing home residents and prisoners, homeless people interact more with the general public.

At the start of the pandemic in March, researchers warned that at least 1,700 of the nation’s estimated 568,000 homeless people could eventually die of COVID-19. The administration’s homelessness czar told Congress in July there had been just 130 homeless deaths, noting that was “significantly lower than had been originally projected.”

However, the Howard Center for Investigative Journalism tracked at least 153 deaths of homeless people in the same time period in just six areas with large homeless populations – San Francisco, Los Angeles, New York City, Washington, D.C., Seattle and Phoenix – and at least 206 deaths nationwide by early August.

“This country for a long time has written off the lives of people experiencing homelessness,” said Dr. Margot Kushel, a nationally recognized expert on homelessness and medical professor at the University of California, San Francisco. “And now it is literally the thing that is really going to make it very difficult to control this pandemic.”

Kushel called the pandemic “a crisis within a crisis,” noting that most homeless people are usually in poorer health and, with widespread closures in response to the pandemic, had lost access to services providing food, water and shelter.

Only about a dozen states acknowledged their homeless populations when they issued stay-at-home orders. Arizona said “individuals experiencing homelessness are exempt from this directive, but are strongly urged to obtain shelter as soon as possible.” Delaware similarly noted homeless residents weren’t “subject to this shelter in place order.” But orders from Idaho and Kentucky made no reference to their homeless, even as they took care to mention golf and guns, respectively.

Congress has allocated more than $4 billion for homeless-specific programs as part of the Coronavirus Aid, Relief, and Economic Security Act and made billions more available at the discretion of federal and state officials. But four months after passage of the CARES Act, most of that money had not made its way to local communities, the Howard Center found. Meanwhile, behind the scenes, officials in Washington are seeking to shift long-standing homelessness policy, and state and local politicians disagree whether funds should be used to help currently homeless people or those at risk of becoming homeless in the economic collapse that has accompanied the pandemic.

The Howard Center spent three months investigating COVID-19’s impact on homeless people, analyzing data to predict which homeless populations around the country would be most vulnerable. It identified 43 counties that would likely struggle in the pandemic, several of which, such as Imperial in California and Maricopa in Arizona, went on to develop some of the highest infection rates in the country. Reporters also interviewed more than 80 professionals working in homelessness, epidemiology and public health, as well as homeless people in hot-spot areas, who described their daily struggles. And because homelessness is typically a problem left to local communities to address, reporters filed 140 public records requests to the vulnerable counties and their major cities to learn more about their responses to the crisis.

Some communities were quick to act, forming cross-departmental working groups to address both the housing and health needs of their homeless, securing emergency housing, such as hotels, trailers and even convention centers, and taking care to prevent communal spread. In Colorado Springs, Colorado, for example, an emergency isolation shelter with 100 beds was constructed in just three weeks. By March 11, police in Oceanside, California, were handing out fact sheets to homeless people to inform them of the spread of the novel coronavirus that causes COVID-19.

Others were slow or failed to respond. The city manager in Sanger, California, opposed housing homeless people possibly infected with COVID-19 in emergency trailers in his town. And in Daytona Beach, Florida, efforts to convert an old building into permanent housing for homeless residents failed despite having the funding and county support needed to do so.

Overall, records showed, localities faced two major problems in addressing the pandemic’s impact on their homeless populations: a lack of readiness to work across departments dealing with both housing and health, and insufficient data and testing to know who was getting sick and where.

Many have criticized the federal government for not providing a coordinated response to the pandemic’s impact on homeless people, as well as more resources for testing and tracing. Some have also advocated for racially equitable COVID-19 responses. By early August, people of color, who represent about 24% of the general population, made up about 61% of all COVID-19 infections and 50% of all deaths, according to the U.S. Centers for Disease Control and Prevention.

"All states have been at a disadvantage in their response to C-19 because the federal government has failed to adopt a unified nationwide strategy. In fact, the national strategy seems to be ‘let states handle it,’” Barbara DiPietro, senior policy director for the National Health Care for the Homeless Council, said in an email. “This is the least efficient, most wasteful way to approach a crisis.”

COVID’s unmeasured impact

One week before the CARES Act was passed on March 27, researchers from the University of Pennsylvania, UCLA and Boston University released a report forecasting COVID-19 infections, hospitalizations and fatalities among homeless people. They estimated more than 20,000 homeless people could require hospitalization and gave a range for potential fatalities, with the midpoint about 3,400.

“We believe that the true likely fatality outcome would be on the higher end of this range given the challenge of actually getting homeless clients to the hospital, especially when they are unsheltered, as well as the unusually high mortality risks that prevail among the homeless population,” the researchers wrote. They estimated $11.5 billion was needed to supply additional beds and housing required for social distancing.

Dan Treglia, one of the Penn researchers, said he stands by the study’s predictions. He, like other experts interviewed by the Howard Center, noted there was no nationwide systematic testing, including for homeless people. Without such testing, the virus’ infection rate remains unknown, making COVID-19 deaths harder to identify and count.

The virus “is hitting different parts of the country at different times and with different rates of severity,” Treglia said, adding it’s hard to know “exactly what this number is going to look like at the end of the day.”

HUD’s Homeless Management Information System allows for the department, through a network of regional and local planning bodies, to track COVID-19 infections and deaths among homeless people. But HUD announced in late March it would not require COVID-19 data collection through HMIS, although it did provide guidance on what information communities could collect if they wanted.

Experts say this highlights one of the structural problems facing how the country deals with homelessness.

“HUD is for housing, so they're not really thinking about health care and the people on the ground; even service providers that are serving their patients in their housing programs are not primarily thinking about health,” said Bobby Watts, chief executive of the National Health Care for the Homeless Council. But, he added, “Housing is health care.”

New York City, which has the nation’s largest sheltered homeless population because of a right-to-shelter law, is the only metropolitan area yet to attempt a statistical assessment of COVID’s impact on homeless people. The Coalition for the Homeless, the city’s court-appointed monitor of homeless shelters and families, reported that the age-adjusted COVID-19 mortality rate for sheltered homeless was 67% higher than the mortality rate for the city’s general population, as of early August. The city reported 104 deaths among its almost 80,000 homeless residents for the same time frame.

Boston tested a group of homeless people after a large-scale outbreak at a shelter in late March. Of 408 residents tested, researchers found a 36% positivity rate, a measure of viral spread. Of those, about 88% were asymptomatic. The results, published in the Journal of the American Medical Association, confirmed that COVID-19 carriers could be asymptomatic.

Los Angeles, which along with New York accounts for nearly one-quarter of the nation’s homeless population, began to measure COVID’s impact on its most vulnerable in April. California has the nation’s largest unsheltered homeless population.

The Los Angeles County Department of Public Health said as of Aug. 7, it had tested about 30% of its nearly 60,000 homeless residents and found a 2.8% positivity rate among sheltered homeless and a 2.4% positivity rate among those living unsheltered. Researchers have noted that infection rates seem to be lower for people living outdoors compared to those in shelters, though they’re not sure why.

William Nicholas, director of the county’s Center for Health Impact Evaluation, said decades-long funding cuts of public health departments meant many didn’t have the ability to track homeless COVID-19 deaths or infections.

The report to Congress by the U.S. Interagency Council on Homelessness cited relatively low numbers of homeless infections and deaths, which it credited to “early collaboration with federal agencies, front-line providers and local authorities.” It also said “individuals experiencing homelessness have been tested on a wider basis and at significantly higher rates than the general public.” The report noted the numbers were provisional and may “increase slightly.”

Emily Mosites, a senior CDC adviser on homelessness, told the Howard Center the report included some CDC data, “but we don't have a very precise count of total cases, and we expect that the estimates that we do have are an underestimate.” One reason for that, she said, is homelessness is not always reflected in medical records.

In an interview with the Howard Center, Robert Marbut, executive director of the Interagency Council on Homelessness, said his organization, not HUD, was best-suited to collect COVID-19 data on homeless people. He said the council was doing that through contacts with homeless shelters around the country.

Jeff Olivet, who has researched homelessness for 25 years, said “it would be dangerous to assume that just because there have not been major outbreaks yet that there won't be.”

After shelter outbreaks in Boston, Seattle, San Francisco and Atlanta, the CDC recommended that shelters consider testing all residents and staff members, but local government records show that did not always happen.

In Santa Barbara County, California, no homeless people brought into the county’s emergency shelter site were being tested as of April 15, records showed. A homeless assistance program manager requested widespread testing but was told asymptomatic people would not be tested.

In Merced, California, the public health department sent nurses in mid-May to encampments of homeless people to test for COVID-19 and provide guidance, records showed, but it was not able to provide treatment to those who tested positive.

Officials in Arizona’s largest county, Maricopa, were discussing in late March how to implement testing for their homeless residents, records show, even though one local nonprofit was already testing the homeless. One month later, testing remained a problem for the county. As of the first week in August, officials reported that 490 of the estimated 7,400 homeless in the county had tested positive for COVID, and nine had died.

“We’re flying in the dark,” Watts said. “We don't really know if we're giving the best advice at a given period of time. And the only way to really try to get the best advice is to have the best data.”

A patchwork of homeless solutions

Andy Phelps, the homelessness prevention and response coordinator for Colorado Springs, received countless emails in the first two weeks of March as the COVID-19 threat hit home.

One shelter operator reminded him that “people in homelessness with little to limited access to hand-washing and who are already apt to suffer from other illness may be among higher risk populations for the Corona virus.” She then asked whether emergency shelter operations were still applicable if an outbreak occurred. Others told Phelps of increased cleaning needs and sought guidance from the Office of Emergency Management on alternate locations to house people.

Phelps even got questions about asking questions – “could the OEM make that request to the County, or could you? Or should one of us reach out directly?”

Finally, Phelps emailed El Paso County’s public health director proposing a meeting to discuss the response to the crisis.

“I have received a growing amount of calls and emails from shelter providers in town that are concerned about the potential impact of the COVID-19 virus spreading into the shelters,” Phelps wrote. “I feel unprepared to offer them guidance further than sending them a CDC webpage.”

The Howard Center filed public records requests in the 43 counties its analysis identified as being most vulnerable to a coronavirus outbreak, including to the HUD planning bodies that oversee homelessness efforts around the country, known as Continuums of Care. Responses to about half the 140 records requests filed provide an inside look at how some communities struggled to respond in the first three months of the crisis.

After Phelps’ suggestion, El Paso County began cross-departmental meetings with representatives of its public health and homeless response teams, as well as relevant nonprofits. Within three weeks, the city had created a 100-bed isolation center.

Several other communities from Florida to Hawaii created similar task forces to address homeless needs in the pandemic, bringing together departments that didn’t regularly work together, such as housing, health and emergency services.

“One thing that has kept me up at night has been how do we protect those in encampments and living unsheltered,” Dr. Chelsea Haring-Cozzi, executive director of the Indianapolis Coalition for Homelessness Intervention & Prevention, said in a March 13 email to city officials. “How do you quarantine someone who doesn’t have a home?”

Maricopa County had two main goals: reduce the risk among the most vulnerable homeless and adequately respond to people with symptoms or those who needed isolation. Although the cross-departmental coordination was successful, the county was criticized for housing unsheltered homeless people in three open-air encampments in downtown Phoenix, known as the Lots.

In late July, when temperatures reached 118 degrees Fahrenheit, about 200 people were living in nearly 170 spaces, according to Amy Schwabenlender, executive director of Human Services Campus, a nonprofit that was providing services to the Lots. She said total numbers were fluid because people regularly came and went.

Oceanside, California, and Pasco County, Florida, were among several cities and counties that partnered with nonprofits to ensure their unsheltered populations had water, hand-washing stations, toilets and electricity to charge cellphones – all services that became nearly inaccessible after COVID’s mass closures.

California implemented Project Roomkey, aimed at moving high-risk homeless people out of crowded shelters and outdoor encampments to secure isolated settings, such as hotel and motel rooms. As of June 30, 14,200 people had been housed by the program, funded by state and federal emergency funds.

“We have been left county by county, city by city, to cobble together a public health response to something that is on par with the Spanish flu in terms of its infectiousness and potential lethality.” -- Marc Dones, executive director of the National Innovation Service

Other cities, such as Las Vegas, San Diego and Santa Barbara, California, turned convention centers and high school gyms into emergency homeless shelters big enough to allow social distancing.

San Diego opened its convention center as an emergency shelter, testing site and meal distribution hub on April 1 and, by early August, had sheltered 2,780 homeless people. Internal records show the city spent about $2.8 million a month on the makeshift shelter, and it expects to spend $3 million a month through the end of the year. Funding was also allocated to ensure that, when the center reverts to normal operations, homeless residents will “be able to obtain shelter and housing.”

Connecticut has been widely praised by homeless experts for moving quickly. In early March, the state’s housing department reduced shelter capacity by nearly 60% and placed homeless people 60 or older in hotels, some of which it used as testing sites. Of 300 tests, only two homeless people tested positive, according to Steve DiLella, a Connecticut housing official who spoke in July at the virtual Nationwide Town Hall on Ending Homelessness.

But not all efforts to safely house or test the homeless were welcomed, records showed.

In Daytona Beach, Florida, heads of two homeless nonprofits sought permission to convert an empty building into a shelter that could be turned into permanent single-room housing after the pandemic. Jeff White, executive director of Volusia/Flagler County Coalition for the Homeless Inc., and another nonprofit leader argued that using COVID-19 funds to develop “permanent supportive housing” was better than paying for hotel rooms, which would be “basically burning money.” The project had funding, a quick timeline and county support, records show, but the deputy city manager was not encouraging.

White told the Howard Center he never received a final answer from city officials and moved on to another plan.

“The response was kind of a non-response saying that the permits could be applied for but not really commenting on whether they would support the project,” he said.

In Sanger, California, city manager Tim Chapa opposed placing three emergency isolation trailers in his town to house homeless people showing symptoms of COVID-19. The Fresno County public health department ordered Chapa to take the trailers, records show, but before they arrived, Chapa appealed to the City Council. He said the city’s shelter "may not have the capacity to provide adequate medical support service to identified COVID + homeless," he recounted in an April 17 email to a county official. Chapa said the trailers would be better in Fresno, where they ended up later that day.

Leaders in El Centro, the main city in California’s Imperial County, repeatedly but unsuccessfully sought the county’s help with a COVID-19 testing program.

“As to the homeless population, they (county officials) are not going to enact anything unless there are any positive results within the population. They are not doing any pre-emptive activities,” Adriana Nava, El Centro’s community services director, wrote to her colleagues March 19.

By June 22, there were 17 confirmed coronavirus cases among the estimated 1,400 homeless people in Imperial County, including one case in a 10-person encampment behind a grocery store in Calexico. Internal emails show that county officials did not realize the infected person had been living in the camp until they were notified by a homeless service provider, who said others there were worried about becoming ill. The county then tested the encampment residents and said all were negative, records show. In a June 22 email, Linsey Dale, a spokeswoman for Imperial County, said it was the only encampment the county had tested.

El Centro Fire Chief Kenneth Herbert told the Howard Center he had questions about the county’s infection numbers for homeless people.

“You look at that and say there are only 17 positive, then my next question would be what your testing outreach has been, how many persons have you tested or attempted to test?” he asked. “How can it possibly be 17?”

As of the first week of August, the county reported 36 homeless people had tested positive for COVID-19.

The varied local government responses to caring for homeless people during the pandemic highlight the need for a coordinated federal approach, experts told the Howard Center.

“We have been left county by county, city by city, to cobble together a public health response to something that is on par with the Spanish flu in terms of its infectiousness and potential lethality,” said Marc Dones, executive director of the National Innovation Service, a public policy organization focused on racial equity. “To simply step out of the role, to step out of the responsibility in this moment feels like a fundamental abdication of the purpose of government.”

Two crises, one cause

Five months into the pandemic, statistics show people of color are disproportionately infected with and dying from COVID-19.

At the same time, Blacks, Latinos and Native Americans are disproportionately affected by another public health crisis: homelessness. These same groups comprise nearly 65% of the country’s homeless population, according to HUD’s 2019 Annual Homeless Assessment Report.

Experts interviewed by the Howard Center said structural racism was the root cause of both plagues affecting people of color.

“We simply wouldn't have homelessness if we didn't have the kinds of structural racism that we have,” Dones said, pointing to hurdles that people of color face in accessing both affordable housing and health care. “Racism is one of, if not the core driver, of why homelessness exists in this country.”

Experts say the main type of homelessness experienced by Latino and Native communities involves living doubled or tripled up in inadequate housing, which influences both the undercounting and underserving of those communities, as well as the spread of COVID-19.

In a 2018 study, researchers in El Paso, Texas, found that homeless Latinos were being underreported in HUD statistics, which they attributed to the fact that the agency did not account for people who were marginally housed, such as those doubling-up with others or couch-surfing.

In its definition of homelessness, HUD considers marginally housed people 24 and younger to be homeless, though such people are not recorded in HUD’s biennial Point-in-Time counts. People older than 24 in the same situation are not considered homeless by HUD. The agency acknowledged, when updating its definitions in 2011, that it was excluding some vulnerable populations.

Olivet, who authored an influential report on racism and homelessness in 2018, said Latino homelessness often is “hidden” because outreach services are not “culturally and linguistically competent.”

Experts attribute high rates of COVID-19 infections and homelessness among minority populations to their likelihood of working low-wage jobs. Data from the Bureau of Labor Statistics showed such workers were more likely to be people of color: fewer than 20% of Black people and about 16% of Latinos were able to work from home during the pandemic, compared with about 30% of white people.

People of color are not less healthy than their white counterparts, Olivet said; rather, they’re put in less healthy working conditions with inadequate health care.

“So it's not just that they're sick because they're sick, it's also that they're sick because they don't have access to health care,” he said.

COVID’s disproportionate impact on people of color has coincided with a larger conversation on race as Black Lives Matter and anti-police brutality rallies spread across the U.S. Recently, some federal, state and local government agencies have started considering how to incorporate racial equity into how federal homeless and COVID-19 dollars are spent.

One of the first places to take such action is Tacoma, Washington, which is aiming to issue 45% of its coronavirus rental-assistance funds to households identifying as Black or mixed race. In Pierce County, where Tacoma is located, Blacks comprise about 26% of the homeless population but about 6% of the general population.

Va Lecia Kellum, president of St. Joseph Center, a Los Angeles organization providing housing opportunities and health services, said she would like to see similar approaches elsewhere.

“If we are all in this together, then it's absolutely the case that we need to invest in our most vulnerable citizens,” Kellum said.

Amid finding ways to protect, isolate and test one of the nation’s most vulnerable populations, experts say another homelessness crisis is looming.

“We're starting to brace ourselves for just a huge infusion of people losing their homes,” said Megan Hustings, the managing director of the National Coalition for the Homeless. “We already didn't have the resources to help everybody who was losing their homes before this crisis, and it's just going to be worse.”

In 2019, there were only 389,549 shelter beds for an estimated 568,000 homeless people, according to HUD. To combat the expected rise in homelessness, some experts are calling for additional rental assistance and unemployment benefits in addition to continued bans on evictions.

Treglia, the Penn researcher who was among the first to warn of an impending homeless crisis amid COVID, said shelter capacity won’t keep pace with the expected increases in homelessness, and that could have wide-ranging effects.

“The worse this gets, the more homeless people that are infected, the more precautionary measures need to be taken,” he said. “The more we put at-risk populations or any population at risk of infection, the greater the risk is for everyone.”