A radical approach to preventing Covid-19 infection in the homeless

STAT, March 31, 2020

By Miriam Komaromy and Michael Botticelli

There is only a small window of time in which we can prevent widespread transmission of Covid-19 among people who are living on the streets or in shelters. Once the disease begins to spread in these groups, it will likely accelerate rapidly and be uncontainable, creating a crisis for the homeless and the entire community. This will undermine all efforts to slow the pace of the epidemic and will increase the disastrous consequences of Covid-19. We offer a radical solution: Use suddenly empty and available living spaces — empty dorm and hotel rooms, abandoned offices — to provide safe, private housing for individuals and families who are living on the street or in shelters. Many communities are working to prevent the spread of Covid-19 among homeless individuals by employing the same principles that are used for housed individuals: social distancing, hand hygiene, and covering a cough. They are trying to rapidly implement screening of shelter residents. If someone screens positive for symptoms of Covid-19, they need to be isolated during the often-lengthy process of being evaluated, tested, and awaiting test results; if a test is positive then they need to be quarantined. Many communities are taking steps, such as erecting tents or converting auditoriums and warehouses, to create spaces for screening, testing, isolation and quarantine of people who do not have housing. While these are important steps, they are destined to fall far short. Homeless shelters are typically overcrowded and have little ability to create space between beds or chairs. Sleeping areas are usually wide-open spaces with no dividers between beds. Even the process of screening people before they enter a shelter often creates a situation in which many people must stand close to each other while waiting in line. Shelter staff follow protocols regarding cleaning and disinfecting surfaces, but it is impossible to prevent the spread of illness among large numbers of closely packed adults.

Preventing the spread of Covid-19 among people who live on the street is even more difficult. They have inadequate access to basic hygiene facilities. Now that many food sites are closing their dining rooms, they are also closing access to bathrooms and sinks. Too few hand sanitizing stations (with dwindling supplies of sanitizer) are available to allow adequate disinfecting. On the street, social distancing is impossible. People who are homeless have little choice but to congregate for safety; for shelter; and to share information, food, and consolation. And those who have untreated addiction often use substances together to prevent overdose death. Mental illness is also common among those living in shelters or on the street. For them, remembering to stand far apart and to cover a cough are often difficult. As most Americans shelter in place, colleges and universities have closed, sending students home and leaving millions of dorm rooms sitting empty. Likewise, offices have also been shuttered, since employees have been asked to work from home. We have plenty of space to provide every homeless person with a private room. The city of Boston and the commonwealth of Massachusetts are taking steps in this direction, working with community partners to move the most medically vulnerable individuals out of shelters and off the street, and using dorms and vacant medical facilities to provide safe, individual housing. Doing that would, of course, pose challenges, but it is a more humane solution that will be far more effective than our current efforts.

One particular challenge that must be tackled in tandem with this plan is effective treatment of addiction. America’s epidemic of overdose deaths from opioids and other drugs has not stopped in the face of the Covid-19 epidemic. If we fail to adequately treat withdrawal and provide effective maintenance medications, such as buprenorphine and methadone, then people will be unable to adhere to measures to limit viral spread, including isolation, quarantine, or housing. The federal government has been moving quickly to loosen restrictions on medication treatment for addiction, but additional emergency action is needed to improve access. For instance, all licensed medical providers should be authorized to prescribe buprenorphine, even if they have not obtained the special federal waiver to do that. We will succeed in preventing epidemic spread of this terrible virus only if we shift our focus. This pandemic has laid bare that we not only have to prevent the spread of infection, we need to end homelessness and addiction. These problems can’t be overlooked or set aside as we grapple with Covid-19. Miriam Komaromy, M.D., is the medical director of the Grayken Center for Addiction at Boston Medical Center. Michael Botticelli is the center’s executive director; he served as director of the White House Office of National Drug Control Policy from March 2014 until January 2017.

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