Coughlin CG, Sandel M, and Stewart AM. Pediatrics 2020;146: 7–9
Coronavirus disease 2019 (COVID-19) created unprecedented changes in our society. Millions of people have been called to shelter in place (avoid nonessential travel outside of the home) and social distance (keeping space between yourself and others outside your home) to reduce the transmission of the novel coronavirus SARS-CoV-2, which causes COVID-19. However, these and other public health measures require a level of privilege: a home to live in, access to hygiene supplies, and control over your movements. They require the ability to stay home from work, avoid public transportation when travel is necessary, and stock up on items to reduce trips to the store. Homeless and unstably housed people, including children, are not able to access these privileges, likely placing them at higher risk of exposure to the novel coronavirus. In many ways, the ability to practice social distancing has become a social determinant of health during this crisis.
Homelessness is not just living in a shelter or on the street: people experiencing homelessness, especially children and families, are often couch surfing, “doubling up” with friends or relatives, or living in motels, hotels, or campgrounds. Fifty-nine percent of people experiencing homelessness are children <18 years of age who are either unaccompanied by an adult or are homeless as part of a family unit. Approximately 58,000 families, including >100,000 children, experience homelessness on any given night.
The relationship between housing and child health, including COVID-19, is bidirectional, and homelessness results in increased morbidity and mortality. COVID-19 may lead to homelessness as a result of exacerbated housing insecurity, job loss with or without loss of insurance, increased medical costs, and increased costs of food and utilities. Children who are homeless are at higher risk of many infections, including otitis media, gastroenteritis, and viral respiratory infections. They are also more likely to experience developmental delays, asthma exacerbations and admissions, obesity, dental and vision problems, mental health problems, and accidental and nonaccidental injury. This is in part due to overcrowded living situations, substandard housing conditions, food insecurity, and lack of access to basic hygiene and health care.
The COVID-19 pandemic is shedding light on, and accelerating the pace of, racial and economic disparities. Among families experiencing homelessness, 78% identify as non-White or Hispanic, and just as homelessness disproportionately affects communities of color, data demonstrate that COVID-19 infection and mortality rates are higher in racial minorities. Communities of color are more vulnerable to COVID-19 because of higher rates of underlying health conditions, increased barriers in access to care, and increased likelihood of living in densely populated areas.
Comment: It is critical for patients to have private space to isolate and recover from COVID-19 to mitigate the spread of the virus, but private housing is a privilege that is not afforded to all (Gaeta JM, et al N Engl J Med 2020; 383:170–178). Collaborative efforts among health care entities, homeless service providers, and government must ensure that a COVID-19 response system for the homeless population includes the development of adequate isolation and quarantine sites.
This pandemic has also magnified the substantial risk of infectious disease outbreaks in natural disaster evacuation centers (Karmarkar E, et al MMWR Morbid Mortal Wkly Rep 2020; 69: 613–617). Although disaster relief must address multiple urgent and competing needs, advanced planning by local, state, and federal public health partners, and nongovernmental organizations to facilitate timely, effective shelter illness surveillance and infection control practices in both planned and unanticipated shelters are crucial to prevent, identify, and contain infectious disease outbreaks.