Dr. Brian Klausner
Homeless individuals are accustomed to suffering silently. Nevermore so has this been the case than with all the noise of the COVID-19 pandemic, in which more than 500,000 Americans have died.
One wet morning this past December, as a volunteer at an emergency overnight homeless shelter in North Carolina, I had the disturbing task of closing the building in order to meet our commitment to be out by 8 a.m. That morning, this required escorting our guests outside into a freezing, pouring rain. There was a steady rain predicted for the next three days with temperatures in the 40s — cold enough to be dangerous and cause hypothermia, but not cold enough to meet the emergency shelter criteria for opening.
With access to our normal local shelters restricted due to COVID-19, this meant these individuals were going to be stuck outside in the elements. As they left, most carrying large bags with their belongings through large puddles, the level of quiet acceptance and resignation was almost haunting — most even displayed grateful smiles and expressions of gratitude as they left. Predictably, that week we saw an increase of hypothermia and exposure-related visits in our hospital.
Hidden in plain sight
Historically, data around homelessness reveals the extent of human suffering that should push us all to action. Nationally, the life expectancy of the chronically homeless still hovers around only 50 years of age. Approximately 45% of homeless people suffer from mental illness, 25% seriously so.
Demographic disparities compared with the overall population are glaring: Black individuals are overrepresented by nearly a factor of three compared with the general population. Typically, however, the homeless are ignored by a society that will not, or perhaps feels like they cannot, help.
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Too often, homeless patients are reflexively and conveniently blamed for the complex societal, mental health and medical pathologies they suffer from to justify our collective inaction. This is a lazy and expensive mistake — both from a financial and humanistic perspective. Homeless individuals routinely fall expensively through society’s fragmented and inefficient safety nets, landing in our ambulances, hospitals, intensive care units, jails and prisons.
Jim O’Connell, founder of the nation’s oldest homeless health care program in Boston, has described homelessness as a prism that highlights societal shortcomings: “Refracted in vivid colors are the weaknesses in each sector, especially housing, education, welfare, labor, health, and justice.”
Falling through every crack
Throughout November and December, I routinely gave updates at the emergency overnight shelter around COVID-19, including plans around vaccinations. Early on, our homeless guests were relieved and, honestly, surprised to learn they were being prioritized, at least in initial drafts of vaccination plans. They were not surprised to learn late in December that they had been pushed back to later stages as a part of state efforts to better align with national recommendations.
While this past year has been hard for everybody, it has been an absolute nightmare for our homeless residents. With homeless shelters and support programs shut down or restricted across the country, many homeless individuals have been forced to stay on the streets during a cold, wet winter. National numbers are hard to come by, but a report on New York City’s sheltered homeless population found their COVID-19 mortality rate to be 67% higher than the city’s general population. Still, it is these social consequences of COVID-19 that are the most haunting.
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Hospitals are seeing the disease in our homeless population. We are seeing trench foot. We are seeing hypothermia. For the homeless in America, our emergency rooms are the de facto health care providers.
According to an analysis of nearly 190 million emergency department visits from March to October, we are also seeing increases in substance abuse, suicides and overdoses, with a 28.8% increase rate in opioid overdoses from that period in 2019.
What is happening across homeless communities in our country is a public health crisis on top of a public health crisis. It is harming and killing a population that historically already suffers greatly, and expensively, as the result of community-based inequities and inaction.
Decisions around how to prioritize individuals for vaccination should ideally consider all the risks, medical and social, associated with COVID-19. While vaccination shortages make these decisions difficult, it is impossible to ignore the urgent needs of an expensive and vulnerable population whose suffering is beyond comprehension for most of us.
As states across the nation continue to expand their vaccination rollouts to populations outside of the elderly and health care providers, it is time to include the homeless and the front-line providers that help to provide lifesaving services. It is time to open up homeless services back to full strength to help meet the needs that have never been greater. The homeless are a relatively small population, but it is one where vaccinations can produce an enormous benefit, both from a financial and humanistic perspective.
Dr. Brian Klausner is the medical director of WakeMed Community Population Health and chief medical officer of WakeMed Key Community Care Accountable Care Organization.