It has become commonplace to use the terms, “COVID-19” and “the pandemic” interchangeably, but it is critical to recognize that there have been pandemic outbreaks in previous years, such as SARS in 2003 and H1N1 in 2009-2010. During the H1N1 pandemic, a team of researchers from across Canada conducted a multi-site study to evaluate the readiness of homelessness sectors to deal with infectious outbreaks. This study took place in Victoria (Pauly, Perkins, & Cross, 2016), Toronto (Buccieri, 2016; Gaetz & Buccieri, 2016), Calgary (Waegemakers Schiff & Lane, 2016), and Regina (Schiff, 2016b).

Writing about this study, Gaetz and Buccieri (2016) indicated that we need to consider the ways the infrastructure we have built to respond to homelessness – such as crowded shelters, congregate sleeping and eating spaces, and inadequate onsite hygiene facilities – organize the lives of people within these spaces in a way that increases their risk while simultaneously reducing their sense of control. The findings of this study were published in an open access e-book entitled “Pandemic Preparedness and Homelessness: Lessons from H1N1 in Canada“, which is freely available on the Homeless Hub website (Buccieri & Schiff, 2016).

This book was released in October 2016. As part of its launch, the co-editors Dr. Rebecca Schiff and Dr. Kristy Buccieri wrote a conversational blog post discussing the importance of pandemic planning for people experiencing homelessness and the impact they hoped the book would have for pandemic planning and preparedness in the future. We invite you to read the blog post now while keeping in mind that this was written many years before the COVID-19 outbreak.

Click the image below to open a new window and read the full blog post, “What did Canada learn about homelessness from H1N1?” by Dr. Rebecca Schiff and Dr. Kristy Buccieri.

What do you think?

Reflecting on the H1N1 outbreak in Toronto, Gaetz and Buccieri (2016) have written, “A key question to ask is whether we are prepared – or more to the point, is it possible to prepare – to adequately respond to the risks faced by the homeless population in the event of a serious pandemic?” This piece of foreshadowing was written well before the COVID-19 outbreak began. Looking backward, do you think we were adequately prepared to respond to the risks of COVID-19 for people experiencing homelessness? Was it possible to be more prepared?

Dr. Jeannette Waegemakers Schiff: Why are people who experience homelessness at higher risk during a pandemic?

In this video, Dr. Jeannette Waegemakers Schiff reflects on the increased psychological, moral, and physical harm that people who are unsheltered face during a pandemic. She notes that while people are told to stay home, those without housing are unable to shelter in place and lack the ability to store food and other essential supplies. She argues that people who experience homelessness are at greater risk of not being able to take self-protective measures, such as remaining socially distant in congregate service settings. Additionally, while people who are unsheltered are at increased risk of exposure, they also have fewer protections. For instance, access to disposable masks or laundry facilities for cloth masks is limited in homelessness agencies. Dr. Waegemakers Schiff notes that during COVID-19 many service agencies struggled to meet the needs of their clients. While some were prepared and able to implement social distancing measures, many people still were left sleeping on mats on the floor, next to others. In response, some cities moved unsheltered people who tested positive or showed symptoms of having COVID-19 to hotels to quarantine. While Dr. Waegemakers Schiff notes that the public health need for this was clear, additional considerations should have been made for individuals who had previously been incarcerated and/or who use substances and might find the hotel quarantine protocols overly restrictive. This video is 7:05 in length and has closed captions available in English.

Dr. Stephen Hwang: Why are people who experience homelessness at higher risk during a pandemic?

In this video, Dr. Stephen Hwang tells the story of a research associate who was surprised at the congregate nature of shelters and drop-in centres during the COVID-19 pandemic. Dr. Hwang notes that the pandemic did not create, but rather unmasked, the conditions that were already present increasing the risk of airborne and droplet born diseases in these settings. He argues that while infection is a concern, there are also a range of additional risks people who experience homelessness face during a pandemic, related to displacement and the lack of access to basic services. Notably, he cites the lack of access to washrooms, higher rates of overdose deaths, increased levels of stress, and impaired mental health as particular risk factors for people experiencing homelessness. Dr. Hwang concludes that for those living in encampments, routine clearances have led not only to displacement but to the disruption of social and support networks as well. This video is 3:11 in length and has closed captions available in English.

Quote Source

Given the standard crisis–management approach to homelessness, it is not surprising that there were outbreaks of COVID-19 within shelters across Canada. In the brief clip that follows, from Global News, we take a look at the crisis scenarios that unfolded across the country.

Many cities and regions implemented measures to provide spaces for people experiencing homelessness, to promote physical distancing, and to provide isolation or quarantine services (Perri, Dosani, & Hwang, 2020). Some cities attempted to create alternative spaces, like the igloos seen in the video above, or the use of hotels to provide temporary private accommodations. We also witnessed the rise of tent encampments – and their subsequent demolition – in many cities, as people experiencing homelessness tried to create safer spaces for themselves. We will take a closer look at encampments in the chapter on Sociology & Crimino-Legal Studies.

During the COVID-19 pandemic, researchers monitored the outbreak in different ways. They outlined plans to compare screening strategies in shelters (O’Shea et al., 2020), reviewed administrative health data (Richard et al., 2021), and undertook retrospective chart audits within shelters (Kiran et al., 2021). In Toronto, researchers found that among 504 COVID-19 tests completed in homelessness shelters between April and July 2020, 14% were positive (Kiran et al., 2021). Another study found that people with a recent history of homelessness were more likely to be tested for COVID-19 and to have a positive test result (Richard et al., 2021). In the peak period, people who had a recent history of homelessness were over 20 times more likely to be admitted to hospital for COVID-19, over 10 times more likely to require intensive care for COVID-19, and over 5 times more likely to die within 21 days of their first positive test result (Richard et al., 2021). In the next video a member of this project’s team, Dr. Cheryl Forchuk, speaks about the research.

Dr. Cheryl Forchuk: Why are people who experience homelessness at higher risk during a pandemic?

In this video, filmed at a hospital during the COVID-19 pandemic, Dr. Cheryl Forchuk argues there are many reasons people who experience homelessness are at higher risk during a pandemic. From a general health perspective, she notes, these individuals often have impaired nutritional status, prolonged exposure to the elements, compromised sleep, and may use substances. Dr. Forchuk notes that while conducting research during the pandemic, her team found that people experiencing homelessness were not being prioritized for vaccination; they published a paper as a form of advocacy and noticed within days the group was being given priority. She concludes by noting that because social service agencies tend to be congregate settings, the residents and staff are often sick and that the COVID-19 pandemic highlighted issues within the homelessness sector that already existed. This video is 3:28 in length and has closed captions available in English.

Dr. Forchuk’s team demonstrated the importance of rapid peer-reviewed publications informing policy decisions. We invite you to pause here and read the article she spoke about that demonstrated the high–risk conditions of people experiencing homelessness and need for priority vaccination.

Featured Reading:

Richard, L., Booth, R., Rayner, J., Clemens, K. K., Forchuk, C., & Shariff, S. Z. (2021). Testing, infection and complication rates of COVID-19 among people with a recent history of homelessness in Ontario, Canada: A retrospective cohort study. CMAJ Open, 9(1), E1–E9.

It is important to remember, as you learn about homelessness, that managing a pandemic outbreak in this context is deeply challenging. During H1N1 social service workers were often expected to take on health-care related roles despite not being formally trained or equipped to do so. Access to supplies was a commonly cited concern, related to confusion over what supplies were needed, the cost of purchasing them outside a regular budget, and not having enough storage to stockpile and meet demand (Buccieri, 2020).

In a pandemic, frontline workers are asked to take on crisis management roles, but homelessness itself is always a crisis situation (Schiff, 2016a). This makes planning for a crisis – on top of managing an already existing crisis – an astronomically difficult task. During the COVID-19 lockdown, research from Nova Scotia showed that social workers continued to work remotely and tirelessly trying to find housing for their clients amidst dire circumstances (Wu & Karabanow, 2020). This high level of commitment and dedication is likely a large part of the reason why in a sample of 701 direct service providers in homelessness agencies, 80% reported a decline in their mental health during the pandemic (Kerman, Ecker, Gaetz, Tiderington, & Kidd, 2021).

At the same time, that frontline workers are struggling to manage client needs and their own well-being, closing services entirely risks even greater harm, such as related to unsafe substance use and intimate partner violence (Perri, Dosani, & Hwang, 2020). During a pandemic, there are some populations experiencing homelessness that may be even more marginalized than others. Notably, women and girls are at risk of socio-economic exclusion in a pandemic because of the disproportionate burden of poverty, inequitable childcare responsibilities, and proliferation of violence against women (Schwan, Dej, & Versteegh, 2020). Those living in rural and remote communities are also at high risk, particularly if services shut down, because they have limited alternative places to seek help (Schiff, 2016; Schiff, Buccieri, Waegemakers Schiff, Kauppi, & Riva, 2020). In the next video, Dr. Bernie Pauly explains that the COVID-19 pandemic highlighted the deep inequities and disparities between people in society.

Dr. Bernie Pauly: Why are people who experience homelessness at higher risk during a pandemic?

In this video Dr. Bernadette [Bernie] Pauly argues that the lack of adequate housing options increases vulnerability during a pandemic. For instance, during the COVID-19 pandemic, people who were couch surfing may not have been able to find a place to stay and many shelters reduced the clients they served to meet physical distancing requirements. She notes that individuals experiencing homelessness also had increased vulnerability because they were unable to implement basic protective measures. Some agencies closed access to their washrooms, and some cities turned off the water in public places, meaning those without housing were largely unable to wash their hands. Dr. Pauly argues that the public health messaging to ‘stay at home’ is not useful to those without housing and that permitting people to stay in tents does not guarantee they will have access to food and water. She concludes that people who experience homelessness lack access to the basic social determinants of health and that the COVID-19 pandemic highlighted the existing disparities between these individuals’ level of need and housed individuals, who had the privilege of time at home to start new hobbies. This video is 3:18 in length and has closed captions available in English.

What do you think?

COVID-19 messaging often conveyed the idea that “we are all in this together,” such as to encourage people to do their part by staying home and reducing the spread.However, some individuals faced additional social and medical risks. In the chapter on Politics, Policy, & Housing in Canada, we noted that Canada has passed legislation declaring housing a basic right. How do you think the COVID-19 pandemic would have been different if every Canadian were housed?

Podcast: Why are people who experience homelessness at a higher risk during a pandemic? (19:32)

Click the link below to listen to all of the researchers answer the question “Why are people who experience homelessness at a higher risk during a pandemic?” in audio format on our podcast!