Stay home, stock up on food, wash hands frequently. Stephanie V is acutely aware of what public health officials are recommending she do to prevent Covid-19, the illness caused by the novel coronavirus. It’s just completely unreasonable—if not impossible—for her to follow the advice, says Stephanie, who lives in her car in Lakewood, Washington, a suburb of Seattle, with her dog and cat. “It’s pretty frustrating if you don’t have a home.”
Like many Americans with limited resources, the coronavirus outbreak has made Stephanie’s life even more complicated. “I can’t stock up on anything to get me through an extended period of illness,” she says. “I would have to go out every couple of days at least to get fresh food since I can’t store anything that needs to be refrigerated or heat anything up. I also need to be able to wash my hands and use the restroom, which I can’t do in my car. Plus I have a dog that needs to be taken out, so even if I’m sick, I have to take care of her.”
Hand-washing has been a particular concern for Stephanie since shelves were emptied at local stores, with hand-sanitizing products difficult to find. She didn't expect people to go on panic-buying sprees for the essentials that she relies on. “Since I live in my car, I always have some hand sanitizer,” she says. “But I don’t know if I have enough.”
With community transmission of Covid-19 reported in several places in the U.S., many public health officials have moved past the hope of containment and are trying to mitigate the risk to vulnerable populations who are most likely to get very sick or die—namely people who are over 60, people who have weakened immune systems, or people who have underlying health conditions. Technically, that defines much of the homeless population in the U.S.
An estimated 500,000 Americans experience homelessness on any given night, many of whom are also experiencing chronic health issues including long-term illness, injuries, disabilities, or compromised immunity. The U.S. homeless population is also aging, with the number of people over 65 experiencing homelessness increasing in recent years due to housing affordability issues. Homeless individuals are also more likely to sleep in shelters, camps, or other living situations where a respiratory virus is more likely to spread.
“Living outside is very dangerous, and this is one of many reasons why,” says Steve Berg, vice president of programs and policy for the National Alliance to End Homelessness, which has published resources for service providers along with U.S.’s federal homelessness agency. “All the public health stuff you can do to keep people safe is going to be a lot harder to do if people don’t have their own places to live so they could be quarantined just like everyone else.”
Concerns about the vulnerability of the country’s homeless population are even more heightened in cities on the West Coast, where a majority of the country’s unsheltered community lives. In Los Angeles, 44,000 people across the region sleep in vehicles, tents, camps, and on sidewalks on any given night—the largest unsheltered population in the country. An estimated three unhoused people die in LA County every day, according to a report by public health officials, a number that has doubled over the last five years. In recent years, the city has struggled to open enough temporary shelter facilities, called “bridge housing,” to give its growing unhoused community places to sleep.
Last week, LA County’s health department provided guidance for shelters, including increasing the distance between shelter beds and options for potentially quarantining individuals, with teams doing checks of facilities. Homeless residents are a “high-priority population,” says LA County’s health director Dr. Barbara Ferrer, who proposed that LA’s winter shelters, which are open during inclement weather, could be opened for more extended periods of time. “We can’t tell people to stay home if they’re sick,” she said at a press conference today. “We want people who are sick to go off the streets.”
But with a week of rainstorms on the way for the region that would likely overwhelm those winter shelters, some service providers were frustrated the city was not advancing a more comprehensive strategy. “Seriously, what’s the plan for those not in shelters?” says Pete White, executive director of the Los Angeles Community Action Network, which held its own coronavirus briefing for unhoused individuals and service providers on Friday. “Necessary sanitation infrastructure should’ve been installed already.”
That infrastructure could make the difference between life and death for the unhoused community. After the severe acute respiratory syndrome (SARS) outbreak of 2003, a Toronto study recommended that large cities draft specific plans for how to protect unhoused communities for a similar viral outbreak, including how to conduct rapid medical outreach and provide emergency housing. Stephen Hwang, a professor of medicine at the University of Toronto and one of the study co-authors, says that taking large-scale preventative efforts to protect unhoused residents would be an “appropriately cautious” response.
But Hwang also cautions that these concerns are not just about homeless individuals. People living in shelters may be more susceptible to contracting the virus due to the way it spreads—but no more so than people living in military barracks or who are on cruise ships, says Hwang. “It’s not about socioeconomic status, it’s close quarters that create a condition for spreading.”
In the SARS outbreak, Toronto had a total of 375 people infected and 44 deaths before the virus was brought under control in the summer of 2003. As of Monday night, Washington state had recorded 162 Covid-19 cases with 22 deaths. Those numbers are likely understating the extent of infection. A new report out today estimates that by March 1, 1,000 to 10,000 people in the U.S. had been infected with the virus. According to independent analysis by Robinson Meyer and Alexis Madrigal at The Atlantic, only about 4,000 people in the U.S. had been tested for the virus as of Monday.
“Seattle is a wakeup call for everyone else,” says Hwang. “Those of us who were around SARS, having that experience really prepares you for what to think about in advance and how aggressively one needs to make plans and preparations, knowing how bad it can get.”
Last week, Seattle Mayor Jenny Durkan announced an expansion of shelter beds, including opening several new emergency shelters. In King County—which encompasses Seattle, and where 19 coronavirus deaths have occurred in a single healthcare facility as of Monday night—also has the third-highest homeless population in the country. As of this week, officials had purchased a motel and modular housing units, announced an expansion of a tiny house village, and were looking at four other potential properties to be used to quarantine unhoused individuals if necessary.
San Francisco was one of the first U.S. cities to declare a coronavirus emergency in mid-February, providing detailed information for service providers who manage the care of 25,000 people living in the city’s shelters. Yesterday, the city announced a separate public health order just for its homeless population, with $5 million allocated to clean shelters and service centers, expand shelter hours and meal offerings to encourage healthy homeless individuals to remain in shelters, and provide meal delivery services to at-risk people who have been told to stay home.
Regular check-ins with trusted providers are important in situation like this, says Kris Kepler, chief program officer for Lava Mae, which provides showers and other services to homeless individuals in the Bay Area through mobile healthcare units. “Our guests aren’t as clued in to how serious it is—they’re just trying to survive day-to-day,” she says. “What we’ve seen, especially with the public health department in San Francisco, is doing outreach to talk to people and address the situation so everyone is on the same page for the message.”
Back in LA, two city councilmembers introduced a motion last week to place hand-washing stations at homeless camps throughout the city. “All Angelenos, regardless of their housing status, require access to hygiene resources to prevent any further spread of the virus,” Councilmember Monica Rodriguez said in a statement. It’s a public-health measure activists have been asking the city to take for over a year—and it’s still not enough, they say.
“It’s unfortunate that it took a global crisis for our leaders to pay attention to this, because it risks furthering narratives that stigmatize and criminalize unhoused people,” says Mike Dickerson, organizer with Ktown for All. “The need for hygiene stations and bathrooms are year-round and not specific to this outbreak. This new effort should focus on permanent changes that make our neighborhoods healthier long-term, rather than expensive temporary solutions.”
Theo Henderson, who lives in a park in LA’s Chinatown neighborhood and hosts the podcast We the Unhoused, said no hand-washing stations had been installed near him yet, although there was a new soap dispenser in the park’s bathrooms, which he could not access during nighttime hours. An informational sign about Covid-19 had been posted to a door in the park, but it was only in Chinese.
When it came to coronavirus, Henderson wasn’t worried about being infected—“It’s not spread by people who are unhoused, it’s spread by people with houses and passports,” he says—but he was concerned about ongoing ignorance from housed people, including city leaders, for the health-related challenges that unhoused people face. He pointed to how a recent hepatitis A outbreak that killed 20 people might have been prevented by building more service centers—yet homeowners in many LA neighborhoods continue to fight against shelters and service centers.
“When hepatitis is rippling through the community, it’s because people don’t have restrooms,” he says. “But then they get mad because people are going to the bathroom in the street?”
On Sunday, despite pleas to officials to cancel the Los Angeles Marathon over coronavirus concerns, the race was held as scheduled. Under cool blue skies, over 20,000 runners surged through the streets, not far from the Chinatown park where Henderson lives. The 26.2-mile route that slices horizontally through the city was punctuated by medical stations, health officials, ambulances, tents, port-a-potties, and hand-washing stations, including extra dispensers of hand sanitizer. By the end of the day, it had all been trucked away.