Could the COVID-19 Crisis Help Eradicate Chronic Homelessness?

In the current COVID-19 pandemic, people living on the street or in temporary accommodations may be at higher risk for infection because of close contact with others and a lack of hygienic conditions.1 Vulnerable people experiencing prolonged homelessness suffer frequently from tuberculosis, asthma, bronchitis, and HIV infection, and they are therefore at high risk for COVID-19 complications. This population has an all-cause mortality that is five to 10 times higher than that of the general population, with up to 17.5 years lower life expectancy. Most causes of death among people experiencing chronic homelessness are related to lack of timely and effective health care, which will increase even further during the COVID-19 pandemic. In the United States, 550000 people are experiencing homelessness on any given night and, despite differences in definitions, Germany, France, Canada, Australia, and Brazil all report having more than 100 000 individuals experiencing homelessness (the Appendix [available as a supplement to the online version of this article at http:// www.ajph.org] lists further references). Substance use is one of the main problems affecting people who experience homelessness, as are drugrelated infectious diseases. Homelessness was a key contributing factor in recent HIV outbreaks among people who inject drugs across Europe and the United States.2 In this unprecedented COVID-19 emergency, homelessness is expected to worsen the health crisis among people who use drugs, for example through drug relapse, overdose, or difficulty accessing drugs and sterile equipment. There are already alarming signs of interruptions of essential drug services, such as opioid substitution treatment or safe injection services.Immediate solutions have been implemented: COVID-19 testing has been initiated in mobile stations, shelters, and harm-reduction services. Many cities have started housing individuals experiencing homelessness in empty hotels and temporary shelters. However, they may not be able to adhere to ground rules, may be evicted, or leave voluntarily. Other potential problems are overcrowding (making it impossible to adhere to physical distancing), lack of spaces to isolate the sick, and no resources to properly screen and assess people with symptoms.