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Addressing Disaster Vulnerability among Homeless Populations during COVID-19 1 INTRODUCTION People experiencing homelessness 1 and housing precarity face unique challenges in the context of both the COVID-19 pandemic and other, overlapping events, such as extreme weather, natural hazards, 2 and other disasters. Poverty was already an extreme crisis for people experiencing homelessness and housing precarity prior to the emergence of COVID-19, and that crisis has only been exacerbated by the public health emergency of the pandemic. Additionally, the COVID-19 pandemic has highlighted the fact that homelessness is not just a âbig cityâ problem but one faced by communities of all types. Indeed, while the pandemic has disrupted access to housing and shelter throughout the country, bringing more households closer to or across the threshold of eviction and reducing the availability of services for those who are or become unhoused, those effects have been particularly acute in many rural communities, settings that often have less robust social services and fewer programs for people experiencing homelessness (Easterday et al., 2019). The impacts of both COVID-19 and homelessness have also disproportionately affected marginalized communities and exacerbated existing disparities in socioeconomic status, health, and well-being across racial and ethnic groups (Damaske et al., 2017; HUD, 2020; Rogan, 2014), and extreme events can amplify the pressures faced by these groups and the organizations that serve them. The root causes that contribute to homelessness and housing insecurity also shape disaster vulnerability. People who lack regular access to secure shelter are disproportionately exposed to environmental hazards of various types and scales. Moreover, the spread of COVID-19 has complicated disaster response, requiring innovations in traditional service delivery and modifications to established emergency response plans. Given the shifting landscape of homelessness and housing precarity in the context of COVID-19, as well as recent funding allocations outlined in the American Rescue Plan, decision makers 3 need strategies for reducing disaster vulnerability among people without secure housing so as to mitigate the potential for such events to amplify housing precarity. Formulating such strategies requires capturing the unique needs and capacities of these individuals and communities, rather than simply categorizing them generically as âvulnerable populations.â This document is intended to help decision makers and organizations navigate the enduring and ongoing impacts of COVID-19 on homeless populations vulnerable to disaster threats. While the document comments on practices for reducing virus transmission where possible, it recognizes that in the context of increased vaccination rates and decreased 1 There are a variety of perspectives on and definitions of homelessness, including single-adult homelessness, youth and family homelessness, and temporary and chronic homelessness that guide service eligibility and delivery. This rapid expert consultation is concerned with individuals who lack regular access to living spaces that adequately support human habitation, those living in shelters, and those living in unstable housing arrangements (including âdoubled upâ households) during the COVID-19 pandemic as a result of a preexisting state of homelessness or developments occurring since the emergence of COVID-19. 2 This report broadly adopts Cutterâs (2001) definition of hazards as âthreats to people and the things they value.â Environmental hazards refer to conditions in the natural environment with the potential to cause harm or trigger a disaster. 3 Decision makers include individuals with the ability to enact change and carry out policy or initiatives, such as state, local, tribal, and territorial government officials; policy makers; health care, social, and human service providers; and disaster response organizations, including community, faith-based, and other nongovernmental entities.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 2 prevalence 4 of viral spread in communities, decision makers are grappling with additional challenges related to the increased vulnerability of these populations during a disaster. It identifies strategies that decision makers can consider for addressing the triple crises of COVID-19, homelessness, and disasters, including strategies for providing alternative shelter facilities, for navigating service reductions, and for addressing homelessness in the aftermath of a disaster. 5 Further, decision makers need to be aware of and address disaster recovery processes that exacerbate and reinforce racial and economic inequities in housingâespecially given that Black, Indigenous, and People of Color (BIPOC) are disproportionately represented in homelessness counts and have also been especially severely affected by the pandemic (Saadian et al., 2020). PROVIDING ALTERNATIVE SHELTER FACILITIES Crowded shelter conditions require new policies and procedures in the context of the COVID-19 pandemic, including mitigation through physical distancing protocols. Local governments and providers of homeless services across the nation have introduced alternative shelter arrangements that repurpose existing buildings, including hotels and motels, 6 as shelters, and have had to accommodate pressing needs for rapidly restructuring traditional homeless shelter settings to accommodate physical distancing in accordance with public health guidance related to the COVID-19 pandemic. While these innovations have helped reduce density in shelters, they have presented new challenges for all stakeholders, including emergency planners, 7 disaster managers, and community- and faith-based organizations. The changes necessitated by the COVID-19 pandemic have required additional emergency preparedness planning, and often 4 According to data from Health Care for the Homeless grantees, rates of positive tests and vaccination among the homeless population are similar to those for all health centers; however, national-level data on positivity and testing trends are not available (Pham et al., 2021). 5 The full statement of task for this rapid expert consultation is as follows: âThe National Academies of Sciences, Engineering, and Medicine will produce a rapid expert consultation on how decision makers can address the needs of people experiencing homelessness during extreme weather, natural hazards, and other disasters that overlap with the COVID-19 pandemic. Drawing from published literature on homelessness and social vulnerability to disasters, this document will discuss challenges with providing shelter for people experiencing homelessness and minimizing the spread of COVID-19 infection. It will identify measures to offset the impact of reductions to services that people experiencing homelessness previously relied upon for resources and information. This rapid expert consultation will incorporate input from subject matter experts who have been monitoring impacts of the pandemic on homelessness; it will not address vaccine distribution for homeless populations. The document will be designed to be of practical use to decision makers, but will not recommend specific actions or include other recommendations. It will be reviewed in accordance with institutional guidelines.â 6 Despite the availability of funding for the use of hotel rooms as noncongregate shelters, some homeless- serving organizations may not be in a position to utilize this option because of the inability to provide meals and other services in these environments. Staff in these organizations need to consider organizational capacity and the nature of support needs among people they serve in the context of infection prevention guidance to identify appropriate solutions. 7 This rapid expert consultation uses the term âemergency plannersâ to refer to staff from any agencies involved in community emergency preparedness, including emergency management, public health, law enforcement, fire/rescue, transportation, and social services.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 3 funds, 8 and have compounded the preexisting constraints already faced by these organizations. Many lessons can be drawn from the quick actions and innovative approaches used by government agencies across federal, 9 state, local, tribal, and territorial jurisdictions; homeless- serving organizations (HSOs); emergency planners; community- and faith-based organizations; and other service providers to modify shelters for people experiencing homelessness during the pandemic. It would be helpful for such organizations to document these processes as they are able, including the challenges encountered and solutions developed, in after-action reports and other resources to inform future emergency planning and long-term approaches for addressing homelessness. Sharing lessons learned among state and local officials about how to meet eligibility criteria for Federal Emergency Management Agency (FEMA) reimbursement of sheltering costs during the pandemic can inform policy recommendations on how to make federal programs more accessible and equitable to improve disaster response over the long term (Calabro et al., 2020). Box 2 summarizes strategies that can be considered for providing alternative shelter facilities during a disaster in the context of the COVID-19 pandemic. These strategies are discussed in detail below. 8 In January 2021, the White House announced an expansion of financial support to include 100 percent reimbursement to state, local, and tribal partners for eligible costs related to opening noncongregate shelters to reduce COVID-19 infection, among other measures (FEMA, 2021). This presidential action was intended to make reimbursement for the COVID-19 response available more quickly and ease the burden of costs to localities, including by retroactively funding efforts from January 2020. However, many officials have not utilized this funding mechanism. Concerns about the capacity to pay up-front costs, uncertainty about restrictions that may limit eligibility for certain expenditures, administrative burden, and other complex bureaucratic issues have been cited as factors discouraging some states from utilizing these funds (Mader, 2021). 9 For example, although the Federal Emergency Management Agency (FEMA) generally does not provide public assistance funding for noncongregate sheltering, the agency now allows reimbursement for such costs to offset the unprecedented strain the COVID-19 pandemic has placed on homeless shelter systems throughout the nation.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 4 BOX 2 Strategies for Providing Alternative Shelter Facilities during a Disaster in the Context of the COVID-19 Pandemic 1. Address Disaster Risk in Alternative and Modified Homeless Shelters: Shelter operators and emergency managers need to consider how disaster risk and exposure may have changed as a result of the use of alternative and modified homeless shelters brought online in response to the COVID-19 pandemic, and identify what modifications may be needed to ensure that residents can remain safe during a disaster. 2. Limit Encampment Sweeps, and Mitigate Hazards at Encampment Sites: Centers for Disease Control and Prevention (CDC) guidance advises localities against the use of encampment sweeps during the COVID-19 pandemic. Through partnerships with local continuums of care (CoCs), homeless-serving organizations (HSOs), and/or social and human services entities, emergency planners can improve safety by identifying encampment locations; designating points of contact or communicators with whom they can work to disseminate information/communicate about hazards; and ultimately incorporating these communities into evacuation, outreach, and disaster response plans. 3. Support Disaster Preparedness within Homeless-Serving Organizations That Addresses Needs Related to the COVID-19 Pandemic, and Facilitate Integration of Homelessness Support into Community Emergency Planning: Interagency and multisector coordination across emergency planners, HSOs or the coalitions they represent, and other health and human service providers is necessary to address the emergency communication, sheltering, and other disaster assistance needs of people experiencing homelessness during the COVID-19 pandemic. Such coordination needs to include training on stigma reduction. Government emergency planners across jurisdictions need to provide direction for such efforts. Address Disaster Risk in Alternative and Modified Homeless Shelters Locations previously unused as shelters that are brought online to respond to the COVID-19 pandemic, particularly repurposed facilities not designed as residential spaces, may present unanticipated risks. Emergency managers therefore need to consider how disaster risk may have changed as a result of the use of alternative and modified homeless shelters and identify modifications needed to ensure that residents can remain safe during a disaster event. Key activities to this end include: â conducting risk assessments and mitigating potential hazards (e.g., identifying facilities or encampments located in floodplains or in wildfire risk areas that lack defensible space; assessing risks of structural fires, communicable disease outbreaks, or violence), and ensuring that these modified spaces allow for access to clean water and sanitation; 10 â supporting preparedness among residents by connecting them with services, and if they are residing in the shelter for extended periods, helping them build personal resources (e.g., by opening bank accounts or obtaining identification documents); 10 For example, encampments are often located near rivers so that residents can access water, placing them in hazardous areas.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 5 â addressing evacuation and transportation needs and incorporating alternative facilities and encampments into emergency evacuation plans; 11 â ensuring awareness of encampments that are not readily visible, and including outreach to these areas in risk communication and transportation planning (using trusted community partners as messengers); â assisting shelter staff and residents in disaster preparedness planning through training, resources, and integration of HSOs and shelters into Emergency Support Functions; â attending to the needs of homeless people with disabilities and acute medical needs in evacuation and disaster preparedness planning; â identifying points of contact and lines of succession for the HSO in charge of a facility, and circulating plans internally and externally with partner organizations and local emergency managers; and â engaging in interorganizational planning among HSOs or within HSO networks. Limit Encampment Sweeps, and Mitigate Hazards at Encampment Sites In response to a rising number of encampments during the COVID-19 pandemic, as well as resulting complaints and calls for police action from housed residents, many cities have continued initiating sweeps that clear areas with tents and remove their occupants. However, guidance from the Centers for Disease Control and Prevention (CDC) 12 advises against clearing these encampments during the pandemic unless residents can be relocated to individual housing units. Of particular concern in relation to the pandemic is that medications and vaccination records may be lost in these sweeps. Encampment sweeps can also eliminate resources (e.g., tents, supplies, clothes) that people need to protect themselves during inclement weather, leaving them even more vulnerable to environmental hazards. As an alternative to sweeps, some localities, such as Denver and San Francisco, have sought to improve safety and access to sanitation in encampments during the pandemic by officially designating spaces for unsheltered people to camp outside when there is no available shelter or when they cannot or do not wish to use shelter services (City of Oakland, 2021; Swanson, 2021). These sanctioned encampments offer access to hygiene services, such as handwashing stations and showers; garbage disposal; and in some cases, medical attention and benefits (City of San Francisco, 2021). 13 Sweeps also erode social networks, which hinders risk communication given that homeless communities frequently rely on word-of-mouth communication to receive information about risks and resources and other critical updates (Barile et al., 2020; Edgington et al., 2014). This dislocation diminishes the social capital on which encampment residents depend for community connection, resource sharing, and emotional support, which can decrease their well- being and increase their vulnerability to other risks. 14 Emergency managers can coordinate with 11 See additional resources and guidance at https://www.nap.edu/catalog/26084/emergency-evacuation-and- sheltering-during-the-covid-19-pandemic. 12 Available at https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered- homelessness.html. 13 The logistical partnerships and insights about addressing liability issues developed through these approaches can be informative to emergency managers outside of the pandemic context. 14 Some unaccompanied people experiencing homelessness may seek isolated campsites away from other homeless people and out of sight of the general public to protect their property and personal safety (Settembrino, 2017). These isolated individuals may be more difficult to reach in an emergency and may be more suspicious of outsiders and individuals offering assistance.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 6 local âcontinuums of careâ (CoCs)âintermediaries funded by the Department of Housing and Urban Development (HUD) that administer homelessness assistance funding among local networks of HSOsâto identify âcamp managersâ (e.g., informal leaders and residents within encampments) with whom they can work to address more humanely and effectively concerns related to public health and safety and communicate about hazards and other threats. It may also be beneficial for emergency planners to map 15 encampments so as to enable easier outreach in response to imminent hazard threats or for purposes of outreach regarding health generally and COVID-19 vaccination in particular; however, it is critical to take measures to ensure that such maps will be used solely for emergency notification and other assistive purposes. 16 Additionally, risk communication plans need to identify trusted messengers who can communicate with encampment residents and camp managers to ensure that messages will be widely received, accepted, and acted upon. 17 Guidance published by HUD notes that the daily practice of many unsheltered homeless individuals and families is to avoid the police, limiting the reach and influence of messages delivered through law enforcement (Canvan et al., 2016; HUD, n.d.). Instead, it may be more effective to send emergency notifications through municipal and program staff, such as firefighters and outreach workers, who may be more likely to be perceived as partners and resources within the homeless community (Edgington et al., 2014). Additionally, such spaces as community kiosks, shelters, and libraries often maintain areas for information sharing so that emergency information can be communicated via flyers, message boards, and other text-based media that people can reference for updates on extreme weather or COVID-19. Emergency cell phone notifications can complement such measures; however, given the limitations faced by many homeless people with regard to access to power and technology, particularly when libraries and other access points are closed, these services cannot be relied upon as the sole mechanism for outreach. Support Disaster Preparedness within Homeless-Serving Organizations that Addresses Needs Related to the COVID-19 Pandemic, and Facilitate Integration of Homelessness Support into Community Emergency Planning Interagency and multisector partnerships are necessary both to assist HSOs in emergency planning during the COVID-19 pandemic and to prepare the broad array of external stakeholders (e.g., municipalities, social service providers and government agencies, public health authorities, disaster relief organizations, CoCs, Voluntary Organizations Active in Disaster [VOADs]) with essential roles in effectively meeting the needs of the populations they serve during an emergency (Gin et al., 2020). Coordination among local, state, and federal agencies is necessary to facilitate and provide guidance for such multisector collaboration. Smaller and resource- constrained communities require technical assistance from state and federal agencies (e.g., state- 15 When possible, it may be useful for local officials to seek assistance from federal and state geographic information system offices with mapping of large encampments so that those maps can be overlaid in real time with other disaster-based geospatial data (e.g., impending inclement weather, wildfire paths, social media postings about rapidly unfolding events). 16 Outreach workers may express reservations about mapping encampments because of concern that such maps will be used to facilitate sweeps or otherwise target encampment residents, which can have the unintended consequence of pushing them into more remote and dangerous areas, effectively cutting them off from necessary services. 17 For additional information on risk communication involving socially vulnerable populations, see https://hazards.colorado.edu/research-projects/risk-communication-and-social-vulnerability.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 7 level emergency management agencies, FEMA) to facilitate multisector engagement and integration into disaster planning. Additionally, disaster service providers (e.g., groups involved in VOADs, disaster shelter operators, and other relief organizations) need to develop clear antidiscrimination policies that extend their planning and services to people experiencing homelessness. People experiencing homelessness have encountered barriers, and even additional harm, when seeking refuge and assistance during past disasters as a result of stigmatization, 18 discrimination, access issues, and exclusion from decision making (Vickery, 2015). To reduce the likelihood of discrimination and improve these providersâ ability to serve the whole community, consistent with FEMA guidance, 19 staff and volunteers within these organizations also need to receive training, including stigma reduction interventions, on how to assist people experiencing homelessness. Partnerships with CoCs or HSOs can facilitate these efforts. HSOs and other community-based organizations are often underprepared for disasters because of limited resources and the need to prioritize everyday emergencies, and this inadequate preparation has been exacerbated by COVID-19 (Gin et al., 2018; Ritchie et al., 2010; Vickery, 2015). Many HSOs have seen significant reductions in the numbers of both people willing to volunteer and partner organizations willing to maintain temporary shelter services 20 during the pandemic while simultaneously experiencing increased burdens on staff (Finchum-Mason et al., 2020). The pandemic has also hampered organizationsâ efforts to limit virus transmission and respond to additional crises, leaving little room to update disaster plans, conduct drills, and engage the people they serve on issues of disaster preparedness (Palinkas et al., 2021). Continuity of operations planning, which enables organizations to resume services after being disrupted by a disaster, is a particularly important yet frequently neglected practice within such organizations (Gin et al., 2018; Ritchie et al., 2010). HSOs can also benefit significantly from participation in VOADs or Community Organizations Active in Disaster (COADs), as these networks of organizations can be highly effective in disaster response and may serve as valuable resources for coordinated disaster planning. Outreach from emergency planners may also be necessary to assist with disaster planning and provide guidance that can minimize the planning burden on HSO staff and volunteers, including suggestions for how to establish disaster doctrine or processes that can enable HSOs to fit efficiently within existing emergency response structures. 21 For instance, Pinellas County, Florida, has established operating procedures specific to homeless evacuation and sheltering. Likewise, Recover Pinellas, a network of agencies that facilitate communication and coordination among public and private human services agencies at each stage of a disaster, holds a seat at the countyâs emergency operations center and is recognized as a partner (Canvan et al., 18 Unhoused people and other socially marginalized groups have faced a high risk of stigmatization during the pandemic, especially since COVID-19 stigma intersects with other forms of stigma (e.g., the assumption that these individuals are inherently vectors of disease) that already contribute to their marginalization. 19 For more information about FEMAâs âwhole communityâ approach to emergency management, visit https://www.fema.gov/emergency-managers/national-preparedness/frameworks/community-recovery-management- toolkit/organization/engagement. 20 Winter shelter programs, such as those operated by faith-based and other local organizations, have closed as a result of diminished capacity and concerns about COVID-19 infection. 21 FEMAâs âWhole Communityâ approach to preparedness includes involving multiple sectors and actors in the development of preparedness plans, as well as identifying predefined roles and responsibilities during a disaster. Accordingly, there is a need to meaningfully incorporate such organizations as HSOs into emergency management and response framework structures before a disaster strikes (e.g., via Emergency Support Functions, Recovery Support Functions, and Public Health Emergency Preparedness cooperative agreements).
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 8 2016; Edgington et al., 2014). Models that bring CoCs into government emergency response and recovery structures require support well in advance of a disaster to ensure adequate integration into community planning and to aid these networks in developing compatible frameworks, such as incident command system structures. Disaster Preparedness to Promote Community Resilience 22 is a toolkit, developed by the Department of Veterans Affairs, the Department of Health and Human Services, and HUD, that guides HSOs, emergency managers, health care providers, and others in building strong relationships to address more effectively the needs of people experiencing homelessness in disaster planning, response, and recovery. Given that nearly all local communities belong to CoCs, emergency planners could coordinate training with these entities, an approach that may be more efficient than outreach to individual providers. NAVIGATING SERVICE REDUCTIONS AND SUPPORTING POPULATION- SPECIFIC NEEDS Before the COVID-19 pandemic, unsheltered people were already facing significant challenges in access to nutrition, health and psychological services, and other essential services. During the pandemic, businesses and public institutionsâsuch as libraries (which normally provide shelter during the day for people experiencing homelessness, as well as access to the internet and charging stations for cell phones), parks, and community centersâhave restricted access to facilities that previously provided temporary shelter and other resources to homeless populations, particularly during the day, when many homeless shelters are closed. These COVID-19ârelated closures and restrictions have reduced options for temporary shelter from inclement weather and cut off access to essential information among people experiencing homelessness. While shelter capacity reductions resulting from COVID-19 have been the most visible issue in the organizational landscape of homeless services, disruptions among other types of organizations that regularly provide services to people experiencing homelessness have had secondary effects on the health, safety, and general well-being of people they serve in ways that can intensify disaster vulnerability. Programs that provide a social safety net for unsheltered people and address the root causes of homelessness have experienced disruptions in volunteer and staff availability, resources, and supplies while simultaneously having to modify their operations (Finchum-Mason et al., 2020; Holliday et al., 2020; Lane Pixley et al., 2021; Moses et al., 2020). Research has shown that these types of organizations play a vital role in disaster response and recovery for homeless populations; however, increased strain across the social services system due to the pandemic may limit the capacity of some organizations to respond to additional disruptions. 23 The following subsections address service areas critical during a disaster that have been affected by the pandemic, offering guidance on how to address these intertwined crises. Box 3 summarizes strategies that can be considered for navigating service reductions and supporting population-specific needs during a disaster in the context of the COVID-19 pandemic. These strategies are discussed in detail below. 22 Available at https://www.va.gov/HOMELESS/nchav/docs/VEMEC_Toolkit_20170713_Final_508.pdf. Smaller organizations, in particular, may be able to adapt more readily to emergency situations and 23 provide services quickly (sometimes outside their traditional scope); to do so, however, they often need additional funding through more efficient mechanisms beyond the usual funding sources.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 9 BOX 3 Strategies for Navigating Service Reductions and Supporting Population-Specific Needs during a Disaster in the Context of the COVID-19 Pandemic Mitigating Health Impacts 1. Enhance Disaster Behavioral Health Capacity: Advance planning is necessary to enable rapid mobilization of behavioral and other health care services in response to a disaster. Such planning needs to encompass assessment of behavioral health capacity and health needs, as well as provisions for long-term mental health care delivery. Barriers to access can be reduced by collocating mental health and medical services and using mobile units when possible. Coordination with clinics and health care providers can ensure continuous medication access and maintenance of medically assisted treatments for substance use during emergencies. 2. Support Service Providersâ Emotional Well-Being: Burnout among staff and volunteers can be addressed by helping them manage chronic stressors, ensuring that workforce resources match demands, developing disaster behavioral health plans, and adapting staffing patterns that reduce stress and support recovery. Psychological first aid can be adapted to provide services for volunteers and other responders. Meeting Safety Needs 3. Mitigate Hazard Exposure: Hazard exposure can be mitigated by providing emergency shelters during a disaster and coordinating with homeless service providers to conduct outreach to unsheltered people. It is important as well to provide personal protective equipment to people who remain unsheltered and communicate with them about health risks. 4. Increase Disaster Preparedness and Response Support to Violence Prevention and Domestic Violence Programs for Diverse Populations: Safety needs of people experiencing homelessness can be addressed by coordinating with agencies that support groups at heightened risk of becoming targets of violence and providing targeted assistance. Mitigating Health Impacts The following subsections address particular health challenges that people experiencing homelessness may face when disasters and extreme conditions intersect with the COVID-19 pandemic, and outline strategies for limiting the negative impacts. Poor health is both a contributor to and consequence of homelessness, and people experiencing homelessness struggle with physical health conditions, mental illness, and substance use disorders. Existing health conditions are exacerbated by living outside or in crowded shelters, and these poor living conditions also make it more difficult to recover from new injuries or illnesses (National Health Care for the Homeless Council, 2019). Severe illness and death from COVID-19 are more likely to occur among those experiencing substandard living conditions, along with inadequate access to health care and medical issues that are more common among these individuals, such as diabetes, serious heart conditions, and moderate to severe asthma, among others (ASPE, 2020;
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 10 CDC, 2020). Disasters can further limit access to medical care, outpatient treatment services, screening, and preventive services (Ryan et al., 2015). Additionally, overwhelmed by the COVID-19 pandemic, some local and state public health systems have been left without the resources needed to adequately support people experiencing homelessness. Enhance Disaster Behavioral Health Capacity It is important for emergency planners to consider how behavioral health needs among people experiencing homelessness may have been amplified by the COVID-19 pandemic and related service disruptions and to plan for ways to deliver services during a disaster, which can exacerbate symptoms of mental illness. Depending on the disaster event, some people may be in shock or feel traumatized (e.g., experiencing acute stress disorder 24 or exacerbation of existing posttraumatic stress disorder [PTSD]) and may require psychological intervention, such as critical incident stress debriefing. Providers of behavioral health support need to consider the unique circumstances and past experiences of homeless or precariously housed individuals if they are to offer treatment that is responsive to the particular needs of these individuals, which may vary from those of the housed population. Given the heightened vulnerability to negative mental health outcomes among people experiencing homelessness (HUD, 2015; SAMHSA, 2011; Treatment Advocacy Center, 2016), it is important for emergency planners to take measures in advance of a disaster that will enable rapid mobilization of behavioral and other health care services in response to such an event. The disaster preparedness toolkit mentioned earlier (VEMEC, 2017) 25 offers three tangible steps for planning to meet these needs during the COVID-19 pandemic: â State and local agencies and service providers need to assess behavioral health capacity and its integration into all disaster planning, response, and recovery efforts. â Agencies also need to rapidly assess disaster-related health concerns and plan for long-term mental health care delivery to people experiencing homelessness. â Health care providers can reduce barriers to access and enable more effective outreach by collocating mental health and medical services using mobile units, with regular visits whenever possible. This approach brings the added benefit of engaging individuals who are isolated or disengaged as a result of prior experiences with trauma. Another aspect of maintaining continuity of behavioral health care during a disaster is ensuring that access to medications for treating behavioral health conditions is not disrupted. Special planning considerations are necessary regarding highly regulated medications, such as methadone maintenance therapy for opioid use disorder. Given that the COVID-19 pandemic and disaster events may limit peopleâs ability to access methadone clinics, planning efforts need to include coordination among emergency managers, public health authorities, hospitals, and clinics, as well as other behavioral health care providers that serve these community members, to 24 As defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 25 The Department of Veterans Affairs, one of the toolkitâs developers, has considerable resources for and experience in working with disaster preparedness, and at times has deployed staff to help address the needs of veteran and civilian populations related to homelessness and trauma.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 11 ensure continuous medication access during disaster conditions. 26 Emergency planners and health care providers also need to coordinate in identifying measures to minimize disruptions in access to psychiatric medications, which for some people require daily oral doses. These medications need to be stored safely and securely and taken on a specific schedule, and individuals with schizophrenia and bipolar disorder in particular may easily relapse without medication or experience discontinuation symptoms if suddenly cut off. Relatedly, communication with people affected by disruptions in behavioral health care must be timely, clear, and up to date so that these individuals know where to go to access services and medication if locations or hours of operation have changed. Support Service Providersâ Emotional Well-Being COVID-19 represents a crisis within a crisis for people experiencing homelessness and the systems that support them. Staff at HSOs have been responding to multiple emergencies for more than a year, and are at significant risk of burnout and associated health issues. Research shows that, even absent the compounding effects of the pandemic, working in this sector takes a significant mental health toll (Waegemakers Schiff and Lane, 2019). A disaster in the context of the pandemic adds further strain on staffing and other resources, adding to these pressures. Organizations can address burnout among staff and volunteers by helping them manage chronic stressors, ensuring that workforce resources match demands, developing disaster behavioral health plans, and adopting staffing patterns that reduce stress and support recovery (Merlo et al., 2021). Findings from research on disaster volunteerism and burnout may offer some guidance for supporting volunteers experiencing stress (Yeo et al., 2018), including frameworks for approaching volunteer management (Brudney and Meijs, 2009) and guidance on psychosocial first aid for volunteers (Baker and Cormier, 2014; Chandra et al., 2014). Meeting Safety Needs Threats to personal safety among people experiencing homelessness have intensified during the COVID-19 pandemic. The following subsections identify measures that can be taken to reduce physical risks and address safety needs among these individuals, especially during a disaster. Mitigate Hazard Exposure In addition to chronic stress 27 and psychological needs, people experiencing unsheltered homelessness are particularly vulnerable to acute physical risks, such as exposure to extreme heat or cold, poor air quality due to pollution or wildfire smoke, and falls. These individuals are likely to need access to emergency shelters, personal protective equipment, and other supplies during a disaster, as their exposure to environmental hazards may increase the likelihood of negative health outcomes and threaten their safety and their lives. It is vital for emergency managers and other emergency planners to understand the differences between what constitutes 26 For instance, in March 2020, the Substance Use and Mental Health Services Administration (SAMHSA) provided guidance allowing clinics to expand clientsâ ability to take home methadone instead of having to go to clinics daily or several times per week (Figgatt et al., 2021). 27 Higher allostatic loads, or the cumulative physiological impacts of chronic stress and life events, are associated with physical health problems (Guidi et al., 2021).
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 12 an emergency for sheltered versus unsheltered people. Such hazards as temperature drops and heavy rain may not be recognized as disaster-inducing for people who are housed, but can be life-threatening for those living outside, particularly in combination. As an example, in January 2021 six unsheltered people in Sacramento, California, died in a winter storm after local officials elected not to open warming centers because temperatures were not forecast to cross the 32 degree threshold that required their activation (Clift, 2021; Cofer, 2021). Emergency shelters are essential to enable people living outside to escape extreme conditions. Plans need to be developed in advance of a disaster event for alerting these individuals about impending extreme weather events and options for accessing emergency shelters. Coordination with CoCs can help improve the effectiveness of this outreach. Information about measures being taken to reduce the risk of COVID-19 infection in emergency shelters may alleviate hesitancy to use them among individuals who have avoided using traditional shelters because of concerns about virus exposure. Research also suggests that hazardous air quality events, such as those driven by intense wildfire smoke, pose an acute respiratory risk that may increase susceptibility to COVID-19 and cause more cases of severe disease (Black et al., 2017; Henderson, 2020), including in vulnerable groups such as children and older adults (Hauptman et al., 2020). Lack of access to air filtration means that such conditions may be particularly dangerous for people experiencing homelessness, who are already disproportionately affected by respiratory illnesses and chronic lung disease. Emergency shelters with filtered air are an ideal means of helping unsheltered people seeking assistance in avoiding hazardous air conditions; in their absence, however, such supplies as N-95 masks and information about protective measures need to be distributed to reduce the health impacts of heightened and prolonged exposure. 28 Increase Disaster Preparedness and Response Support to Violence Prevention and Domestic Violence Programs for Diverse Populations Certain groups within the homeless population, including those listed in Box 4, face a disproportionate risk of violence and discrimination, particularly in the context of a disaster. Specific issues and groups to consider include increases in interpersonal violence, potential targeting of new disaster victims and homeless individuals in human trafficking (Chisolm- Straker et al., 2019), undocumented immigrants (Moya et al., 2017), unaccompanied minors (Morton et al., 2018), and members of LGBTQ+ communities (Velasco and Langness, 2020). When preparing sheltering plans and COVID-19 mitigation measures, emergency planners may need to engage key agencies and organizations that support these populations to ensure their access to services and reduce the potential for additional harm and discrimination. Coordinating with these agencies, as well as local CoCs that serve as networks of HSOs, can encourage more equitable practices and ensure that the needs of these groups are addressed effectively in emergency plans. 28 During the 2020 wildfire season, N-95 masks were difficult to obtain because of the COVID-19 pandemic. However, municipalities and homeless service providers do not consistently provide masks for protection against wildfire smoke and hazardous air quality. While some localities have disseminated face masks to unsheltered people to minimize the risk of COVID-19 infection, such masks do not offer adequate protection against the hazards posed by smoke and poor air quality.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 13 BOX 4 Frequently Overlooked Populations within the Homeless Community People are pushed into homelessness through a variety of mechanisms that track across lines of social inequality. Recognizing the root causes of vulnerabilityâparticularly how it affects the path to homelessnessâas well as the unique challenges and service needs they create for different groups can enable emergency planners and homeless service providers to support members of the homeless community more effectively. Frequently overlooked groups that decision makers need to consider in planning for the diverse needs of people experiencing homelessness during a disaster include â¢ immigrants, asylum seekers, and migrant laborers; â¢ university students; â¢ people who identify as LGBTQ+; â¢ children, youth, pregnant and lactating people, infants, and families (including young people aging out of foster care and unaccompanied minors); â¢ people living in structures not suitable for human occupation; â¢ people located in rural communities or remote locations with few services; â¢ people fleeing interpersonal/domestic violence; â¢ people recently incarcerated or institutionalized (in psychiatric facilities); and â¢ people with disabilities. Reports also suggest that domestic and other forms of violence have surged during the COVID-19 crisis, increasing the strain on organizations as they restructured their operations (National Network to End Domestic Violence, 2020). This increased demand for domestic violence/interpersonal violence shelters and similar services is likely to become magnified in a disaster, as rates of domestic violence tend to increase following these events. During Hurricane Laura (August 2020), for example, a representative of the New Orleans Family Justice Center reported that an increase in the number of survivors and staffing shortages during the pandemic had hindered the organizationâs ability to provide services to hotels where evacuees were being sheltered (Chrastil, 2020). Targeted assistance may be needed to help organizations ensure continuity of operations and secure housing and other services for disaster-affected individuals and families that are survivors of violence (Campbell, 2020). Emergency planners and HSOs also need to develop protocols for emergency shelters to ensure that survivors are not forced to shelter with their abusers and are able to seek protection. ADDRESSING HOMELESSNESS IN THE AFTERMATH OF A DISASTER A shortage of affordable housing and the exacerbation of economic strain due to the COVID-19 pandemic have left individuals and communities vulnerable to being displaced by a disaster. People of low socioeconomic statusâparticularly BIPOCâare at high risk of becoming homeless for a variety of reasons, including as a result of a disaster (Fothergill and Peek, 2004; SAMHSA, 2017). Extreme events often destroy the affordable housing stock and drive up the costs of whatever available housing was not affected by the disaster, exacerbating conditions of poverty among people currently experiencing homelessness, and causing more people to become homeless. The ânot in my backyardâ phenomenon that may prevent such housing stock from being rebuilt can add to this problem.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 14 Box 5 summarizes strategies that can be considered for addressing homelessness in the aftermath of a disaster in the context of the COVID-19 pandemic. These strategies are discussed in detail below. BOX 5 Strategies for Addressing Homelessness in the Aftermath of Disaster in the Context of the COVID-19 Pandemic 1. Attend to Issues of Housing Precarity: It is important to plan in advance to curtail spikes in homelessness among precariously housed and low-income people. Multisector planning can be carried out to build capacity to implement rapid rehousing plans after a disaster. Important as well is to create legal protections and provide relocation assistance for renters and low-income homeowners. 2. Address Barriers to Disaster Assistance: Coordination of disaster and traditional case management services for people experiencing homelessness and those who are precariously housed is essential. When disaster case managers are not available, support and training can be provided to traditional homeless service case managers. Policies that disqualify people experiencing homelessness need to be eliminated when possible; otherwise, coordination with charities and foundations can be undertaken to develop alternative sources of support. Collaboration with local organizations can assist in accessing trusted messengers. Attend to Issues of Housing Precarity Given the increased vulnerability resulting from the COVID-19 pandemic, proactive planning, interagency coordination, dialogue with federal partners, and effective disaster case management are needed to help people stabilize their situation and circumvent a descent into homelessness. 29 Precariously housed people are especially vulnerable to disaster-induced homelessness, as these individuals may lack the rental history, credit, documentation, and resources needed to find replacement housing. Additional support needs to be provided to low- income renters and homeowners, given that outcomes from disasters that have taken place in the United States since the start of the COVID-19 pandemic suggest that economic pressures may exacerbate barriers to rehousing among these groups. 30 Careful attention and support are essential for individuals and communities disproportionately burdened by housing precarity and eviction, such as low-income individuals and families, as well as BIPOC communities (Benfer et al., 2021; Lake, 2020; Lemmerman et al., 2020; Yentel and Giridhar, 2021). Multiple storms during the 2020 hurricane season devastated communities in Calcasieu Parish, Louisiana (home to the city of Lake Charles), with winter storms in February 2021 causing additional damage. The myriad challenges resulting from these disasters, combined with the effects of COVID-19 and homelessness, exemplify the priorities that need to be addressed in disaster planning, such as destruction of and damage to the existing housing stock, shortages of 29 Disaster case managers would benefit from frequent communication with case managers who work on a regular basis (outside of a disaster context) with people who are experiencing housing precarity and are reliant on case management services for such needs as housing, employment, and food. All case managers would benefit from coordinating with HUD-sponsored housing counselors. 30 One typical response to housing precarity is to âdouble upâ with others. Combining multiple households in crowded spaces may increase the risk of COVID-19 infection.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 15 affordable housing and government-supported temporary housing stock for displaced persons, closures of homeless shelters, disaster-induced homelessness, doubling up among people who do not qualify for assistance or whose appeals have been denied, and evictions from storm-damaged properties, among others. Similar challenges were reported in the aftermath of the derecho and subsequent heavy rains that struck the area around Cedar Rapids, Iowa, in 2020 (Dreier, 2021; Payne, 2020), as well as other disasters occurring prior to the pandemic. Documented models developed prior to the COVID-19 pandemic may be particularly useful as a means of addressing homelessness while minimizing the risk of virus transmission. The Housing for Harvey program, initiated in Houston following Hurricane Harvey in 2017, 31 sought to rapidly rehouse vulnerable survivors who had no place to go when disaster shelters were set to close. Supported by funding from FEMA and implemented through a multisectoral collaboration, this program leveraged the skills and expertise of homeless service providers to reduce trauma, prevent homelessness, and enhance housing stability (Coalition for the Homeless, 2019; Gin et al., 2020). An after-action review (Coalition for the Homeless, 2019) identified key measures that emergency planners could take to enable the successful implementation of a post disaster rapid rehousing model, including multisectoral planning and preparation; coordination and communication with federal partners; leveraging of existing data systems, such as the Homeless Management Information System; creation of new local data systems and data sharing protocols as needed; proactive identification of potential rehousing sites; engagement of landlords to prenegotiate terms; and annual procurement of project management and fiscal administration as part of preparedness activities. The countryâs homelessness crisis has deepened during the COVID-19 pandemic, increasing the number of people at risk and burdening disaster response systems in addition to homelessness services and social services more broadly. Given the current state of the housing market, federal disaster recovery programs need to be adaptive to the needs of residents in these areas when housing stock is damaged, destroyed, or unattainable because of costs. Additionally, local decision makers, emergency planners, and CoCs need to consider the potential impacts of their initiatives across the whole community to limit the potential for one at-risk group to displace another, such as by removing housing stock intended to support people experiencing pre-disaster homelessness (Tsai and Wilson, 2020). Absent attention to these issues, disasters will continue to exacerbate existing racial and socioeconomic inequalities that have become amplified during the pandemic. Housing vouchers and rapid rehousing efforts, in addition to sufficient protections for renters, such as rent relief, forbearance, and eviction bans, can prevent an already precarious situation for many renters and people living unsheltered from worsening in the wake of a disaster. Suspending ticketing for and seizure of overgrown or abandoned properties can also help ensure that low-income homeowners do not lose their homes because they cannot afford the cost of repairs, particularly in light of the increased cost of lumber and other construction supplies during the pandemic. Instituting this measure would provide one element of security for people living on the brink so they could focus on their recovery without fear of displacement or the need to engage in such practices as doubling up in overcrowded environments, thus bearing the increased risk of COVID-19 transmission. While immediate measures are needed to address emergent challenges and intensified conditions driven by the pandemic, sustained and intentional planning and engagement are needed to limit the potential for disaster impacts to linger and layer 31 A similar model based on Housing for Harvey was implemented in North Carolina following Hurricane Florence.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 16 with future crises. Address Barriers to Disaster Assistance HSOs must often navigate a complex process to obtain aid for their clients. Policies associated with disaster assistance programs frequently exclude or disqualify people experiencing or on the brink of homelessness, pushing them into unsafe living conditions that increase the risk of COVID-19 infection and other negative health outcomes. Steps to address these barriers include: â developing a communication plan 32 that utilizes existing channels (e.g., through CoCs and outreach teams) to disseminate information about disaster assistance to difficult- to-reach populations, such as those who were living unsheltered prior to the disaster; 33 â developing disaster case management training and practices that are responsive to the unique needs of the homeless community, including attending to the specific vulnerabilities of different groups (e.g., cultural considerations, racial and ethnic inequalities, immigration status), and creating processes for coordination and communication between disaster case managers and homeless services case managers to address clientsâ needs holistically; â in the event that separate disaster and homeless services case managers are not available, providing specific training and guidance for homeless service providers so that case managers in these organizations can support the people they serve in the recovery and rehousing process, particularly in light of the evolving landscape of resources available to stabilize socially vulnerable populations during the COVID-19 pandemic; â when possible, eliminating burdensome policies and requirements for disaster assistance or developing alternative resourcing mechanisms that are designed for people experiencing homelessness (e.g., through collaborations with community- and faith-based organizations, charities, foundations, and other organizations that have more flexible requirements); 34 and â collaborating with trusted HSOs or community- and faith-based organizations that provide support and deliver resources to address challenges related to distrust of authorities and concerns about privacy. 35 32 Predatory scams and lenders and other bad actors often emerge in the aftermath of a disaster, and such activities have increased in the context of the COVID-19 pandemic. Disaster communications need to include guidance on avoiding being victimized by these practices. 33 Established strategies for reaching at-risk populations about emergency preparedness may also be effective in the post disaster environment. These strategies include designation of a single contact person as the main information source for homeless service providers, inclusion of all HSOs in an automated email alert system, development of crisis management teams at larger HSOs, and identification of staff or volunteers who can receive official communications in a reliable manner (Klaiman et al., 2010). 34 Smaller organizations can often be more agile than heavily bureaucratic, national-level organizations. Donors need to revisit traditional application and vetting procedures when funding activities for organizations that serve people experiencing homelessness and other socially vulnerable groups (e.g., undocumented people) to avoid hindering their efforts with incompatible requirements. 35 Many people experiencing homelessness may be skeptical of the government and reluctant to provide identifying information.
Addressing Disaster Vulnerability among Homeless Populations during COVID-19 17 CONCLUSION People and communities experiencing homelessness face unique challenges in receiving risk communications and preparing for, responding to, and recovering from a disaster; however, they are not homogeneous. A historic disaster season in 2020 and an extreme humanitarian disaster affecting Texas and other states at the beginning of 2021 demonstrate the imperative for emergency planners to address the unique needs of the diverse groups of people experiencing homelessness in the context of the COVID-19 pandemic and to work with homeless service providers to reduce the likelihood of disaster-induced homelessness. While homeless service support systems nationwide have been strained by the COVID-19 pandemic, these social safety nets were fraying well before the pandemic occurred. This rapid expert consultation has highlighted considerations, suggestions, and guidance for how alternative shelter facilities can be provided during a disaster and how leadership and communities can navigate reductions in homeless services and support population-specific needs, but it is important as well to understand the factors that have put so many in these precarious situations. Addressing the root causes of homelessness and housing precarity is essential if communities are to achieve whole-community resilience. These root causes include social, political, and economic processes at various levels of governance that systematically disenfranchise individuals based on such characteristics as race, ethnicity, ability, gender, and socioeconomic status. 36 By acknowledging and addressing the barriers that prevent individuals from acquiring safe and secure housing, communities can simultaneously build resilience both to disasters and to the threat of future pandemics. SEAN is interested in your feedback. Was this rapid expert consultation useful? Send comments to email@example.com or (202) 334-3440. 36 A diagram illustrating processes that create homelessness is available at https://converge.colorado.edu/v1/uploads/images/homelessness,_housing_precarity_and_covid_19- 1594503421532.pdf.