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Homelessness and Covid-19: Assessing the Response and Planning for the Reopening

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issue brief

Homelessness and Covid-19: Assessing the Response and Planning for the Reopening

May 14, 2020
Urban PolicyHousingNYC

Executive Summary

The coronavirus pandemic has led to a strain on the country’s social-services systems. In addition to the increased demand associated with the economic downturn, helping various disadvantaged populations—including developmentally disabled children and adults, homebound seniors, the mentally ill, and drug addicts—requires the “human touch.” That has been impossible because of social distancing. Thus, despite the risks, reopening the economy needs to be pressed forward, not only to bring down unemployment and boost growth but for the sake of social well-being. 

Reopening social services presents many of the same challenges as reopening the economy. Governments will need to proceed gradually, and at different rates, and be prepared to reimpose social distancing in the event of a wave of new infections and deaths that threatens their health-care systems. 

But services for homeless people present unique challenges for two main reasons. One, homeless-services systems have not so much been put “on pause” as transformed. Cities’ tolerance for unsheltered homelessness has increased, and shelter systems have expanded—most notably, through the addition of thousands of hotel rooms for isolation and quarantine. Two, it is not obvious what “normalcy” means for homeless-services systems, since they often operate in a climate of emergency and crisis. 

Many public officials and experts have released guidelines for reopening, but few have directly addressed homeless services. This paper hopes to fill that gap. It will give an overview of how homeless-services systems have responded to the Covid-19 pandemic and will offer recommendations about how to restore a sense of normalcy and prepare for a possible second wave beginning next fall. 

Findings:

  1. At the outset of the pandemic, some predicted that the pandemic posed a risk to the homeless of high rates of infection and fatalities from Covid-19. Thus far, the worst-case scenarios have not come to pass. While some shelters have experienced serious outbreaks, many cases have been asymptomatic, and death totals are not approaching the thousands. Reports have yet to emerge of extremely large numbers of infections and deaths among the unsheltered population.

  2. Social distancing among the homeless only became widespread in April, weeks later than for most Americans. While governments have been very active in trying to protect the homeless, it is not obvious that public policies explain why the worst-case scenarios have yet to come to pass.

Recommendations:

  1. Over the coming months, homeless-services systems need to evaluate their response to Covid-19 and plan for a potential second wave next fall and winter.

  2. With the assistance of state governments, cities should give priority to public health in the design and operation of their homeless-services systems. Of foremost importance are addressing service providers’ supply needs and developing a “test and trace” strategy for the local homeless population. Cities should prevent increased concentrations of street homelessness, which risk reducing public confidence in returning these cities to normal life and which risk creating further public-health emergencies.

  3. Plan for coming austerity. While the federal government is funding much of the recent expansion of shelters, that revenue source may not be available permanently. Costs have been subordinate concerns for homeless-services systems thus far, but they will have to be reckoned with as state and local governments grapple with budgetary strain.

  4. Shelter systems cannot safely return to pre-pandemic levels of density anytime soon. At the same time hotels are unsustainably expensive and poorly suited for social-services provision. To allow for increased social distancing, while also taking account of fiscal reality, governments should plan to operate an increased number of large, congregate shelter facilities for the foreseeable future.

Introduction

In major cities, homelessness has been a leading public concern for several years. As soon as Covid-19’s threat was grasped, governments and the media recognized the unique challenges that it posed to homeless services. The homeless were at risk of high rates of infection because of their dense and congregate living arrangements—in shelters or encampments on the streets—and at risk of high fatality rates because of their generally poor health. California predicted that 40% of its homeless population was at risk of contracting Covid-19, with 20% of them needing hospitalization (12,000 beds).[1] Authorities in King County, Washington, projected that about 40% of the homeless population be infected with Covid-19 and that, of that cohort, “approximately 40% . . . would have moderate to severe symptoms.”[2] One report by a group of leading scholars predicted thousands of deaths among the adult homeless population, and fears circulated that the hospitalization needs of this population alone could overwhelm the health-care system.[3]

The full impact of Covid-19 on the homeless is uncertain, as there is no centralized database of this population’s infections, hospitalizations, and deaths. Two studies published by the Centers for Disease Control and Prevention (CDC) have examined the percentage of homeless people testing positive for infection—so-called positivity rates—in shelters in Seattle, San Francisco, Boston, and Atlanta.[4] While there were positivity rates close to 40% or higher in some shelters, this was not universally the case. Positivity rates were higher in shelters with known clusters than those without. Moreover, similar to the experience in some prisons, shelters with high numbers of confirmed cases tended to have high rates of asymptomatic infections—in some cases, 100%.[5] The high rates of asymptomatic cases found in some shelters confirm suspicions that the homeless may be highly susceptible to catching Covid-19. But high rates of infected but asymptomatic cases are far preferable to high rates of infected but severely symptomatic cases requiring thousands of hospital beds. In early May, a survey of about 1,300 hospital admissions in New York found that, over a 3-day period, the homeless population accounted for 2% of hospitalizations.[6] Boston, through April 23, identified 453 Covid-19-positive homeless individuals, or 34% of all tested.[7] As of May 7, Los Angeles County reported 215 cases among its homeless population, 119 sheltered.[8] As of May 7, New York City reported 851 confirmed cases (40 among its unsheltered population) and 72 deaths. San Francisco reported 135 cases as of late April.[9] King County, including Seattle, reported 112 confirmed cases among its homeless population and service staff and three deaths as of April 20.[10] Washington, D.C., reported 11 deaths among its homeless population as of May 9. In late April, Vice News estimated 1,335 cases among the homeless across 26 cities.[11]

In sum, while rates of infection have been high among some sheltered populations, reports have yet to surface of major outbreaks among the unsheltered, or extremely large numbers of deaths among the sheltered or unsheltered. Covid-19-related deaths among the homeless currently do not appear to be on pace to reach the thousands. The homeless have certainly been affected far less severely than, for example, residents of nursing homes.[12]

Of the 1.3 million nursing-home residents in America, at least 11,000 have died from Covid-19.[13] (On a point-in-time basis, there are an estimated 370,000 single adult homeless, and close to 1 million of them stay in a shelter at some point each year.)[14] Federal and state oversight of nursing homes is increasing and has even drawn the involvement of the National Guard.[15] However, governments are not, at present, moving to increase oversight over local homeless-services systems.

The gap between predictions and outcomes, thus far, could be attributed to faulty assumptions in models used to estimate the vulnerability of the homeless to Covid-19, the possibility that the worse is yet to come for them, or the effectiveness of cities’ policy response. That policy response has consisted of managing demand for homeless services, expanding housing capacity, and raising awareness of personal hygiene.

Managing Demand for Homeless Services

The Great Depression is often assumed to have been the peak of homelessness in America.[16] With unemployment levels approaching those of the Great Depression, fears have run high that homeless-services systems could be overwhelmed during the pandemic. Much as with the “slow the spread” approach for the pandemic more generally, cities have worked to manage demand for shelter and other programs for the homeless.

Eviction moratoriums, now in place in at least 15 states and 24 localities and nationwide for properties backed by federal loans, have been justified in part as a way to manage demand for homeless services.[17] The need to manage demand for shelter, in particular, may be motivating the increased tolerance that some governments have shown for unsheltered homelessness. In its guidance “People Experiencing Homelessness and Covid-19,” CDC has directed states and cities: “Unless individual housing units are available, do not clear encampments during community spread of Covid-19.”[18] Early on in the pandemic, Los Angeles and San Jose suspended encampment abatements.[19] In New York City, complaints by transit workers and cell-phone videos have highlighted widespread problems associated with subway trains occupied exclusively by homeless people and their possessions.[20] This eventually prompted state and city governments to close the normally 24/7 system from 1 am to 5 am for cleaning, with the deployment of 1,000 additional police officers in the subways.[21] San Francisco, which also suspended encampment abatements, has witnessed a spread of encampments in public spaces during the pandemic. Its Tenderloin district has experienced a surge in violent crime and a 285% increase in the number of tents and structures on sidewalks between January and April 2020, prompting neighborhood stakeholders to sue the city.[22] In early May, Mayor London Breed released an action plan to address conditions in the Tenderloin; the plan includes increased police presence.[23] But with rates of infection still running relatively low among the street population, some suspect that it is safer to leave people in the streets than to urge them into a shelter.[24]

Data on shelter use from New York City’s Department of Homeless Services throughout March and April registered no change among single adults and a 4% decline among families with children (about 430).[25] But most cities do not track homelessness on a daily or even monthly basis, so national trends in the demand for shelter remain uncertain. Quite possibly, people who before the pandemic would have entered shelter systems are currently avoiding doing so, either by staying on the streets or doubling up with family or friends. Life on the streets has, in some ways, gotten harder because of reduced opportunities for panhandling, for example. But for many, life on the streets may still be more attractive, thanks to increased toleration by governments and the fear of catching Covid-19 in a shelter.[26]

People living on the streets have long given safety as a reason for not entering a shelter. Unsheltered homelessness has become much more noticeable in New York City subways and on the streets of San Francisco, but it’s not known whether this represents a net increase or simply a greater concentration in certain locations.[27] Even in ordinary circumstances, our data about unsheltered homelessness are only estimates.

Expanding Housing Capacity

Regardless of how much demand they are experiencing, homeless-services systems have had to increase their capacity to meet federal social-distancing guidelines. Normally, cities shelter the homeless, especially single adults, in congregate-living facilities. While CDC did not prohibit congregate shelters, it did mandate less density in such environments.[28] CDC regulations, as well as a belief that they could not function in a pandemic environment, have led some shelters to restrict access and even close down.[29]

Cities have reduced the number of beds at crowded shelters and expanded the number of facilities to allow for more social distancing. Priority access to these new shelter facilities has been given to three populations: homeless individuals who have tested positive but do not require hospitalization; those who have been exposed to Covid-19; and high-risk populations such as the elderly and those with respiratory illnesses.

Cities have added new congregate facilities and non-congregate facilities. New congregate shelters have been set up in unused school buildings,[30] recreation centers,[31] YMCAs,[32] and large tents.[33] Hotels have been the most notable non-congregate form of shelter. Because hotels currently have high vacancy rates—and hotel living entails less sharing of space and resources than traditional congregate shelters—they are attractive for isolation and quarantine. California state government’s “Project Roomkey” will provide 15,000 hotel rooms to homeless people.[34] In mid-April, New York City mayor Bill de Blasio announced 2,500 new hotel rooms for single adult homeless people (in addition to the 3,500 already in use) and has since committed to adding 1,000 more units per week on an as-needed basis.[35] Connecticut has moved over half the state’s sheltered population into hotels.[36] Many homeless advocates are pressing governments to expand their hotel programs. On April 14, the San Francisco Board of Supervisors unanimously passed an ordinance requiring city government to provide 7,000 private hotel rooms for homeless San Franciscans, almost 90% of the total.[37] On April 23, the New York City Council held a hearing on legislation to provide all homeless single adults with a hotel room.[38]

Raising Awareness of Personal Hygiene

Many of the street homeless have always been, and continue to be, socially isolated. While that has likely minimized their risk of infection, cities have still operated outreach services, to impress on the homeless the need to practice social distancing.[39] Cities have also distributed hand sanitizer and set up handwashing stations.[40]

If the worst-case scenario has not come to pass for Covid-19 and the homeless population, is that because of the policy response? The effect of outreach efforts to raise awareness among the unsheltered is uncertain. Some press reports have noted, among the street homeless, flagrant noncompliance with social-distancing guidelines and even a lack of basic understanding about the pandemic and its urgency.[41]

As far as the sheltered population goes, widespread social distancing was not achieved until April, weeks after it had become common for the U.S. population as a whole.[42] By mid-April, San Francisco had moved only 750 people into hotels from streets and dense shelters,[43] and the California state government’s much-heralded Project Roomkey had only 4,211 beds occupied.[44] Though its homeless-services system has been admired for its proactive response, King County didn’t move large numbers of shelter residents into hotels until early April.[45]

In evaluating why some areas experienced greater numbers of Covid-19 infections and deaths than others, some analysts have focused on when social distancing was implemented. For example, New York City has experienced far more infections and fatalities than Washington State, even though their respective pandemics began at virtually the same time. An analysis in The New Yorker attributed this to New York’s having implementing social distancing a week or so later than Washington State.[46] But if homeless-services systems’ response to the pandemic was too slow, as some advocates have alleged,[47] that doesn’t answer the question of why the worst-case scenarios have not come to pass.

Normalcy and the Second Wave

As cities and states move toward restoring normal life, it will be more difficult to settle on a standard of normalcy for homelessness. Before the pandemic, many homeless-services systems, especially in New York, California, and Seattle, were constantly under strain, unable to keep pace with ongoing needs.

Restoring normalcy is also complicated by a potential second wave of infections in the fall and winter. This means that cities must evaluate their current response while simultaneously planning for the next crisis.

Independent Evaluation

Governments should get an evaluation of how well homeless-services systems held up during March, April, and May. This evaluation, ideally performed by an independent organization, should examine both public and publicly funded nonprofits, as well as charitable organizations, whose reliance on volunteers has been tested greatly throughout the pandemic.[48] Evaluations should also examine the intersection of homeless services with other systems such as jails and psychiatric hospitals. How many released inmates and mental patients wound up on the streets or in shelters?

Making Public Health a Priority

Traditionally, public health has been among the priorities for homeless-services systems. But in addition to housing, homelessness involves mental health, crime, quality of life, child welfare, and substance abuse. Service systems and providers will continue to be involved in all those areas. But in the near term, without neglecting the needs of children in shelters, opioid addicts, or the mentally ill, homeless-services systems need to make public health a top priority.

State governments should take the lead. First and foremost, this means addressing homeless-services providers’ current needs for personal protective equipment (PPE) such as masks, gloves, and face shields, as well as thermometers, hand sanitizers, and handwashing stations. Homeless-services systems went into the pandemic extremely under-resourced; lack of supplies has caused some providers to close their facilities and may have contributed to the spread of infections among workers in cities such as New York.[49] Some service providers had to obtain their own PPE, out of their own funds, saddling them with enormous costs.[50] Supply needs for PPE have persisted, partly because of general, worldwide shortages, and homeless providers’ relative low priority, compared with hospitals and health-care workers. Over the next few months, officials will need to ensure that they are increasing stockpiles for a potential next wave.

The state governments of Massachusetts and California have set up programs to facilitate access to PPE for homeless-services providers.[51] The state role is important because in general, America has an extremely decentralized homeless-services system. Many providers are very small organizations and poorly suited to compete in the ongoing, intense, worldwide struggle for N95 masks, thermometers, and so on. Supplies need to be abundant or access secure so that providers can focus on their real work: helping homeless people.

Also critical is access to testing for the homeless population and service provider staff. Some cities are making significant progress on this front. Newark, New Jersey, and Boston are doing universal testing; Springfield, Massachusetts, is doing “large scale” testing.[52] Chicago is testing more than 700 shelter residents and staff per week.[53] New York City plans to have large-scale testing for its shelter population in place by mid-May. Several agencies are running testing programs in Los Angeles’ Skid Row area.[54]

Homeless populations also need to be included in “test and trace” programs to identify and isolate people who have recently come into contact with infected individuals. Virtually all experts have recommended robust contact tracing as essential to safely reopening the economy.[55] Many state governments are developing tracing systems.[56] Contact tracing is, in general, very staff-intensive work. It will be even more challenging to perform among the homeless, who can be transient and also difficult to engage because of mental illness or some other disorder. States should ensure that homeless-services systems don’t have to compete for contract-tracing resources, any more than for PPE. Investing in test-and-trace for the homeless will reduce the need for expensive isolation and quarantine beds in hotel rooms.

Providers can’t provide services without staff, and staffing demands won’t be met without adequate supplies. Staffing needs have increased with the increase in shelter capacity. Though stays in isolation (such as in a hotel room) or a quarantine homeless shelter are often brief—two weeks or less—homeless people still need security, food, cleaning, access to basic health care, and transportation. People who need to stay in a shelter for longer periods than two weeks may also need behavioral health care, case management, educational and job-training services, and recreational programming. Dealing with fights, overdoses, people in a state of florid psychosis, determining which benefits people are eligible for but aren’t receiving, helping them reconnect with friends or family, and finding housing: all these functions require staffing. Staffing needs have also increased during the pandemic as new challenges have emerged: dealing with people who refuse to comply with quarantine orders and social-distancing guidelines,[57] sometimes to satisfy their drug cravings;[58] preventing deaths among Covid-19-positive residents of isolation hotels recently released from the hospital;[59] breaking up parties in isolation hotels;[60] and having clients cough in service providers’ faces.[61] Competent management can deal with most of these concerns, but that’s not possible without sufficient staffing, which is dependent on sufficient supplies.

The unsheltered pose unique challenges to implementing test-and-trace. It may well be that the outdoors is less conducive to spreading Covid-19 than indoors;[62] but an effective test-and-trace system will be frustrated by a large and growing street-homeless population. The unsheltered can be highly mobile, we don’t even know how many there are, many don’t have functioning cell phones, and many have an extremely distorted sense of reality because of mental illness or drug addiction.

Advocates have cautioned that dispersing the homeless risks dispersing the virus. But allowing the homeless to concentrate risks creating other, more traditional, public-health challenges in addition to Covid-19 (encampments have often been the scene of outbreaks of infectious diseases).[63] The recent experience of New York City’s subway system and San Francisco’s Tenderloin illustrates that inordinate tolerance of the unsheltered homeless will increase the burden on government at a time when systems are already under tremendous strain. A proactive approach to homelessness-related crime, disorder, and lawlessness[64] is always best but is especially important in light of the need to build public confidence during the reopening. Streets that have become impassable because of the concentration of tents, as well as subway cars overtaken by sleeping vagrants, do not conform to the public’s conception of normalcy.

Plan for Tighter Budgets Ahead

Through President Trump’s Major Disaster Declaration of March 28, local efforts to provide isolation and quarantine for the homeless became eligible for 75% reimbursement from the Federal Emergency Management Agency (FEMA). Federal funding will help cover shelter costs (and basic services) for Covid-19-positive individuals, for individuals exposed to Covid-19, and for high-risk populations.[65] However, it is unclear how long that such reimbursement will be available. Cities need to prepare for the eventuality that they, along with state governments, will again soon become chiefly responsible for funding their homeless-services systems.

The fiscal outlook for states and cities is extremely dire for this fiscal year and the next. According to a mid-April survey by the National League of Cities and the United States Conference of Mayors, almost 100% of all cities with a population over 50,000 project a revenue decline this year.[66] Homeless-services systems must begin to plan for how they will accommodate themselves to the coming era of austerity, since theirs is not the only claim on government budgets.

Shift Back to Congregate Settings

One way to prepare for tighter budgets ahead is to plan to shift back from hotels to the more traditional, if lower-density congregate forms of shelter. Before the pandemic, hotels were traditionally seen as not optimal for sheltering the homeless. Mayor de Blasio, for instance, had been planning to phase out the use of hotels for homeless people by 2023.[67] Hotels were criticized for being isolating, expensive, and poorly suited for the provision of social services.

They are surely expensive. The San Francisco Board of Supervisors’ plan to provide a total of 8,250 hotel rooms, mostly for the homeless, is estimated to cost $58.6 million monthly.[68] Despite a collapse in occupancy rates, New York City has paid $174 a night for some of its Covid-19-related hotel rooms, or about the average rate it was paying back when tourism levels were still high.[69] According to de Blasio, the New York City Council’s plan to provide every single adult with a private hotel room, which he opposes, would cost $495 million over six months.[70]

The privacy of hotel rooms is optimal for reducing the spread of infection but can hinder service providers’ engagement with clients and make it difficult to monitor their health, which, in the Covid-19-context, requires more than just daily check-ins. In New York City, residents of isolation hotels—some formerly homeless, some not—have died after being released from the hospital.[71]

Cities should also be wary of a potential surge in demand for private hotel rooms by the homeless. This has already emerged in San Francisco’s hotel program,[72] and the problem could get more acute in the fall and winter. While the use of hotel rooms for isolation and quarantine should decline as the pandemic becomes less intense, some have called for converting isolation hotels to permanent supportive housing.[73] It is doubtful that the federal government would pay for that. Even assuming that this could be done with funds already appropriated but unused, such a conversion would have to sort through complicated eligibility questions. Normally, permanent supportive housing is reserved for chronically homeless individuals with a major disability such as mental illness. Access to hotel rooms during the pandemic has been determined by Covid-19 status: a positive test for infection, exposure to someone who has tested positive, or having an underlying condition, such as a respiratory illness, that makes an individual uniquely vulnerable.

In general, prioritizing public health in the near term should mean less emphasis on developing permanent housing for the homeless. Contrary to advocates’ assertions, investment in permanent housing has not been shown to be particularly effective in reducing homelessness at the community level.[74] Moreover, even when resources are amply available, permanent housing often takes years to build, making it an inappropriate solution to an emergent public-health crisis.[75]

The expansions that shelter systems recently implemented will need to stay in place for the time being. But providing every homeless adult with their own private hotel room until the Covid-19 threat passes, as advocates recommend, is not a practical option for fiscal or administrative reasons. To reconcile budget constraints and social distancing requirements in a service-enhanced shelter environment, systems should operate an increased number of large congregate facilities and fewer hotel locations. The more congregate facilities cities operate, the less dense they will need to be. Compared to pre-pandemic norms, a redesigned shelter system should be more decentralized, operating a larger number of facilities, but less decentralized than a network of private hotel rooms. Congregate settings are easier to provide services in, especially in an environment of fixed resources. FEMA reimbursement does not cover case management, behavioral health, or any other services beyond food, security, and basic medical care.[76] The number of single adult homeless who truly have no service needs (i.e., pure “down on their luck” cases) is fairly small. Attending to the more serious service needs of the homeless is now, and will be, the fiscal responsibility of states and localities.

Conclusion

There is much uncertainty about Covid-19’s threat to the homeless population. No one knows if the worst is yet to come; as active as city governments and homeless-services providers have been in restructuring their homeless-services systems, they can’t be sure of how effective these policies have been. Still, a prudent course of action for city and state governments to follow over the next several months would be:

  • Evaluate the weak and strong points of homeless-services systems throughout the initial months of the crisis.

  • Secure ample supplies of masks, face shields, and similar resources for homeless-services providers, as well as priority access to testing for service providers and the homeless themselves.

  • Cities should prevent increased concentrations of unsheltered homelessness to forestall additional public-health emergencies and to boost public confidence in the reopening.

  • Continue with shelter de-intensification efforts, primarily through an expanded number of lower-density congregate facilities, while making modest use of isolation hotels.

Endnotes

  1. Anita Chabria, “Coronavirus Hitting California’s Homeless Population Could Be What Finally Breaks Hospitals,” Los Angeles Times, Mar. 18, 2020.
  2. Webinar: Covid-19 Planning and Response: Isolation and Quarantine: Lessons Learned from King County,” United States Interagency Council on Homelessness (USICH), Mar. 24, 2020, 1:19:40–1:20:00.
  3. Dennis Culhane et al., “Estimated Emergency and Observational/Quarantine Capacity Need for the U.S. Homeless Population Related to Covid-19 Exposure by County; Projected Hospitalizations, Intensive Care Units and Mortality,” Mar. 27, 2020; Chabria, “Coronavirus Hitting California’s Homeless Population.”
  4. Emily Mosites et al., “Assessment of SARS-CoV-2 Infection Prevalence in Homeless Shelters—Four U.S. Cities, Mar. 27–Apr. 15, 2020,” Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report, Apr. 22, 2020; Farrell A. Tobolowsky et al., “Covid-19 Outbreak Among Three Affiliated Homeless Service Sites—King County, Washington, 2020,” CDC, Morbidity and Mortality Weekly Report, Apr. 22, 2020.
  5. Linda So and Grant Smith, “In Four U.S. State Prisons, Nearly 3,300 Inmates Test Positive for Coronavirus—96% Without Symptoms,” Reuters, Apr. 25, 2020; Kevin Fagan, “None of Homeless Who Tested Positive at Big SF Shelter Showed Serious Coronavirus Symptoms,” San Francisco Chronicle, Apr. 16, 2020; Lynn Jolicoeur, “Testing at Worcester Homeless Shelter Finds 43% Positive for Coronavirus,” wbur.org, Apr. 17, 2020; Hayat Norimine and Obed Manuel, “38 Test Positive for Coronavirus at a Homeless Shelter in Downtown Dallas,” Dallas Morning News, Apr. 17, 2020; Ashley Imlay, “Utah Reports 2 More Covid-19 Deaths; 94 Men at South Salt Lake Shelter Test Positive,” Deseret News, Apr. 17, 2020.
  6. “Video, Audio, Photos & Rush Transcript: Amid Ongoing Covid-19 Pandemic, Governor Cuomo Announces Schmidt Futures Will Help Integrate NYS Practices and Systems With Best Advanced Technology Tools to Build Back Better,” Office of Governor Andrew Cuomo, May 6, 2020.
  7. Universal Covid-19 Testing to Take Place for Unhoused Individuals in Boston,” Boston Public Health Commission, Apr. 26, 2020.
  8. Tyler Shaun Evans, “Coronavirus: No Letup in Death Toll Reported as Easing of Stay-Home Starts Friday in L.A. County,” Los Angeles Daily News, May 7, 2020.
  9. E-mail correspondence with San Francisco Department of Emergency Management, May 1, 2020.
  10. Covid-19 Cases Among People Living Homeless Rising; Death at Kent Isolation and Quarantine Facility,” King County Department of Public Health (Washington State), Apr. 20, 2020.
  11. Emma Ockerman, “Coronavirus Is Devastating Homeless Shelters Across the Country,” vice.com, Apr. 22, 2020.
  12. Joel Jacobs et al., “Number of Nursing Homes with Publicly Reported Cases of the Coronavirus Soars,” Washington Post, Apr. 29, 2020.
  13. Thomas Perls, “Failure to Count Covid-19 Nursing Home Deaths Could Dramatically Skew US Numbers,” The Conversation, Apr. 27, 2020.
  14. The point-in-time count of “HUD 2019 Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations, Full Summary Report (All States, Territories, Puerto Rico and District of Columbia),” HUD, Sept. 20, 2019; “The 2017 Annual Homeless Assessment Report (AHAR) to Congress, Part 2: Estimates of Homelessness in the United States,” HUD, October 2018.
  15. Dave Altimari, “National Guard and CDC Will Assist Connecticut with Inspection and Monitoring of Nursing Homes as Deaths Spike During Coronavirus Pandemic,” Hartford Courant, Apr. 27, 2010; “CMS Announces Independent Commission to Address Safety and Quality in Nursing Homes,” Centers for Medicare & Medicaid Services (CMS), Apr. 30, 2020.
  16. Joan M. Crouse, The Homeless Transient in the Great Depression: New York State 1929–1941 (Albany: State University of New York Press, 1986).
  17. National Low Income Housing Coalition, “Eviction and Foreclosure Moratoriums,” Apr. 20, 2020. See also Dan Keating and Lauren Tierney, “Which States Are Doing a Better Job Protecting Renters from Being Evicted During the Coronavirus Pandemic,” Washington Post, Apr. 29, 2020; “Mayor Liccardo Announces Measures to Support Renters Affected by Covid-19,” Office of Mayor Sam Liccardo (San Jose, CA), Mar. 6, 2020.
  18. CDC, “People Experiencing Homelessness and COVID-19: Interim Guidance.”
  19. Flash Report #13—Covid-19 Mitigation and Response,” City of San Jose Emergency Operations Center, Mar. 13, 2020; Elizabeth Chou, “Homeless People Will Be Permitted to Keep Their Tents Up During the Day,” Los Angeles Daily News, Mar. 17, 2020.
  20. Sarah Feinberg, “City Hall Must Not Let the Subways Turn into a Homeless Shelter,” New York Post, Apr. 27, 2020; Doree Lewak and David Meyer, “Disturbing Video Shows How Extensive NYC Subway Homeless Problem Is,” New York Post, Apr. 28, 2020.
  21. Video, Audio, Photos & Rush Transcript: Amid Ongoing Covid-19 Pandemic, Governor Cuomo and Mayor de Blasio Announce MTA to Disinfect New York City Transit System Daily,” Office of Governor Andrew M. Cuomo, Apr. 30, 2020.
  22. Bob Egelko, “‘Lives Are in Danger’: Lawsuit Argues SF Needs to Clean Up the Tenderloin as Coronavirus Spreads,” San Francisco Chronicle, May 5, 2020; “Hastings College of the Law, et al. v. City and County of San Francisco,” U.S. District Court for the Northern District of California, May 4, 2020.
  23. Tenderloin Neighborhood Safety Assessment and Plan for Covid-19,” City and County of San Francisco, May 6, 2020.
  24. Phil Matier, “Best Protection from Coronavirus for a Homeless Person? In S.F., It Seems to Be a Tent,” San Francisco Chronicle, Apr. 15, 2020; idem, “SF Homeless Tents, Once Seen as Problem, Now Seen as Path to Coronavirus Social Distancing,” San Francisco Chronicle, Apr. 12, 2020.
  25. NYC Open Data, DHS (Department of Homeless Services), “Daily Report.”
  26. Stefanie Dazio and Kathleen Ronayne, “Few Homeless Off California’s Streets as Virus Spreads,” nbcbayarea.com, Mar. 22, 2020.
  27. Clayton Guse, “NYC Homeless Turn to Subway During Coronavirus Crisis,” New York Daily News, Apr. 21, 2020; “ ‘They Are Transporting This Virus’: MTA Subway Conductors Say Trains Are Filthier than Ever amid Coronavirus Pandemic,” CBS New York, Apr. 23, 2020; Phil Matier, “Tents Crowd Tenderloin, Even as SF Tries to Keep People Apart During Coronavirus Outbreak,” San Francisco Chronicle, Mar. 29, 2020; Kevin Fagan, “Overcrowding on San Francisco’s Tenderloin Streets—a Bad Scene Getting Worse in the Coronavirus Crisis,” San Francisco Chronicle, Apr. 13, 2020.
  28. CDC, “Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (Covid-19),” updated Apr. 21, 2020.
  29. Liz Teitz, “Coronavirus Challenge: Move 60% of Homeless into Hotels,” ctInsider.com, Apr. 1, 2020; Tracy Jan and Jenna Johnson “Hotels Sit Vacant During the Pandemic. But Some Locals Don’t Want Homeless People Moving In,” Washington Post, Apr. 14, 2020; Nick Schroeder, “Citing ‘Chaos,’ Portland Closes Homeless Shelter to New People amid Coronavirus Outbreak,” Bangor Daily News, Apr. 1, 2020.
  30. Lisa Capone, “Cities and Towns Act on Urgent Need to Shelter Homeless, First Responders,” mma.org, Apr. 22, 2020.
  31. David Zahniser, Laura J. Nelson, and Dakota Smith, “L.A. to Add 6,000 Shelter Beds for Homeless Angelenos in Hopes of Slowing Virus’ Spread,” Los Angeles Times, Mar. 18, 2020.
  32. A. D. Quig, “City’s Expected Tab on Covid Costs: $150 million,” Crain’s Chicago Business, Apr. 21, 2020.
  33. Jim Russell, “MEMA Opens Emergency Homeless Shelter for Those with Covid-19 in Northampton,” masslive.com, Apr. 19, 2020.
  34. At Newly Converted Motel, Governor Newsom Launches Project Roomkey: A First-in-the-Nation Initiative to Secure Hotel & Motel Rooms to Protect Homeless Individuals from Covid-19,” Office of Governor Gavin Newsom, Apr. 3, 2020.
  35. Transcript: Mayor de Blasio Holds Media Availability on Covid-19,” Office of Mayor Bill de Blasio, Apr. 11, 2020; “Transcript: Mayor de Blasio Holds Media Availability,” Office of Mayor Bill de Blasio, Apr. 29, 2020.
  36. Lisa Backus, “Advocates Worry over Lack of Clean Water, Bathroom Facilities for the Homeless,” ctnewsjunkie.com, Apr. 24, 2020.
  37. Emergency Ordinance—Limiting Covid-19 Impacts Through Safe Shelter Options,” Ordinance No. 69-20, San Francisco Board of Supervisors, Apr. 14, 2020; “HUD 2019 Continuum of Care Homeless Assistance Programs, Homeless Populations and Subpopulations: CA-501 San Francisco CoC,” HUD,” Sept. 19, 2019.
  38. Int. No. 1927: A Local Law in Relation to Requiring Private Rooms for Single Adults,” New York City Council, Apr. 20, 2020.
  39. Hannah Dreier, “For the Homeless, Coronavirus Is a New Menace in a Perilous Life,” Washington Post, Mar. 21, 2020; Doug Smith, “In Coronavirus Fight, Workers in Ski Masks Are Holding L.A.’s Social Safety Net Together,” Los Angeles Times, Apr. 1, 2020.
  40. Sydney Brownstone and Anna Patrick, “Here’s What the Seattle Area Has—and Hasn’t—Done to Protect Its Homeless Population from Coronavirus,” Seattle Times, Apr. 11, 2020.
  41. Heather Knight, “‘The Problem Is Getting Worse’: SF’s Troubled Tenderloin Buckles Under Weight of Coronavirus,” San Francisco Chronicle, Apr. 17, 2020; Otis R. Taylor Jr., “Empty Handwashing Stations Not Helping Homeless, or Anyone Else,” San Francisco Chronicle, Mar. 27, 2020; Steve Lopez, “ ‘Is Anybody Around Here Sick?’ Street Doctor Races to Get Ahead of Coronavirus,” Los Angeles Times, Mar. 28, 2020; Sydney Brownstone and Scott Greenstone, “Officials and Shelters Prepare for Coronavirus in Seattle-Area Homeless Population as Illness Brings More Deaths,” Seattle Times, Mar. 2, 2020.
  42. American Enterprise Institute, Covid-19 Tracker.
  43. John King, “SF Moves 500 More Homeless People into Hotels in Effort to Protect Them from Coronavirus,” San Francisco Chronicle, Apr. 13, 2020.
  44. Governor Newsom Visits Project Roomkey Site in Santa Clara County to Highlight Progress on the State’s Initiative to Protect Homeless Individuals from Covid-19,” Office of Governor Gavin Newsom, Apr. 18, 2020.
  45. Scott Greenstone, “To Prevent Coronavirus Spread at Shelters, King County Will Move Nearly 400 Homeless People into Hotels,” Seattle Times, Apr. 2, 2020.
  46. Charles Duhigg, “Seattle’s Leaders Let Scientists Take the Lead. New York’s Did Not,” The New Yorker, May 4, 2020.
  47. Coronavirus Pandemic: San Francisco Officials Report New Death, 2 New Positive Tests at Homeless Shelter,” San Francisco CBS Local.com, Apr. 6, 2020.
  48. Ian Frazier, “The Soup Kitchen That the Coronavirus Couldn’t Stop,” The New Yorker, Mar. 30, 2020; Jay Willis, “Who Will Run the Soup Kitchens?The Atlantic, Mar. 20, 2020.
  49. Double Jeopardy: The Coronavirus & Homelessness in Ohio,” Barbara Poppe and associates for Coalition on Homelessness and Housing in Ohio, Mar. 24, 2020; Sydney Brownstone, “Hand-Sanitizer Hoarding Leaves Homeless Providers Struggling for Supplies During Coronavirus Crisis,” Seattle Times, Mar. 18, 2020; Julia Marsh, “Teamsters Blast de Blasio for Failing to Protect NYC Workers from Coronavirus,” New York Post, Mar. 19, 2020; Georgia Kromrei, “‘There’s No Plan’: Homeless Brace for Coronavirus,” The Real Deal, Mar. 30, 2020; Tracy Schuhmacher, “‘We’re Heartbroken’: Bethany House Homeless Shelter to Close Due to Coronavirus,” Rochester Democrat and Chronicle, Mar. 23, 2020.
  50. Lynn Jolicoeur and Lisa Mullins, “For One Homelessness Nonprofit, It’s Been a Coronavirus Tale of Two Shelters,” wbur.org, Apr. 23, 2020.
  51. Governor Newsom Visits Project Roomkey”; “Baker-Polito Administration Outlines Ongoing Steps to Address Homelessness During Covid-19, Announces New Childcare Actions,” Office of Governor Charlie Baker and Lt. Governor Karyn Polito, Apr. 17, 2020.
  52. Mayor Baraka Launches City-Wide Covid-19 Testing for Newark’s Entire Homeless Population,” Office of Mayor Ras Baraka, May 4, 2020; “Universal Covid-19 Testing to Take Place for Unhoused Individuals in Boston,” Boston Public Health Commission, Apr. 26, 2020; Peter Goonan, “Springfield, Baystate Health Will Begin Large-Scale Coronavirus Testing for Homeless People,” masslive.com, Apr. 28, 2020.
  53. Mayor Lightfoot Joins City Officials and Community Organizations to Support Individuals Experiencing Homelessness amid Covid-19,” Office of the Mayor (Chicago), Apr. 13, 2020.
  54. Benjamin Oreskes, “Coronavirus Testing Has Come to Skid Row. But What Happens When Infected Patients Disappear?Los Angeles Times, May 8, 2020.
  55. Scott Gottlieb et al., “National Coronavirus Response: A Road Map to Reopening,” American Enterprise Institute, Mar. 28, 2020; Danielle Allen et al., “Roadmap to Pandemic Resilience,” Edmond J. Safra Center for Ethics at Harvard University, Apr. 20, 2020; Avik Roy, “A New Strategy for Bringing People Back to Work During Covid-19,” medium.com, Apr. 14, 2020.
  56. Selena Simmons-Duffin, “We Asked All 50 States About Their Contact Tracing Capacity. Here’s What We Learned,” npr.org, Apr. 28, 2020.
  57. Sydney Brownstone, Sara Jean Green, and Scott Greenstone, “Person Who Left Coronavirus Quarantine Facility in Kent Against Instructions Tests Negative for Virus,” Seattle Times, Mar. 13, 2020; Mary E. O’Leary, “New Haven Asking Questions After Homeless Man with Coronavirus Flees Hospital,” New Haven Register, Mar. 22, 2020.
  58. Kevin Fagan and John King, “In Coronavirus Landscape, Moving Homeless People into Hotels Is a Puzzle,” San Francisco Chronicle, Apr. 20, 2020.
  59. Ashley Southall and Nikita Stewart, “New York Put Recovering Virus Patients in Hotels. Soon, 4 Were Dead,” New York Times, Apr. 24, 2020.
  60. Fagan and King, “In Coronavirus Landscape.”
  61. Schroeder, “Citing ‘Chaos,’ Portland Closes Homeless Shelter.”
  62. Hua Qian et al., “Indoor Transmission of SARS-CoV-2,” medrxiv.org, Apr. 7, 2020.
  63. Anna Gorman and Kaiser Health News, “Medieval Diseases Are Infecting California’s Homeless,” The Atlantic, Mar. 8, 2019; Gale Holland, “Hepatitis A Outbreak Sparks Call for L.A. to Give Homeless People More Street Toilets,” Los Angeles Times, Sept. 26, 2017; Dakota Smith and David Zahniser, “Filth from Homeless Camps Is Luring Rats to L.A. City Hall, Report Says,” Los Angeles Times, June 3, 2019; Sydney Brownstone and Scott Greenstone, “King County Faces 2 Outbreaks at Once, as Hepatitis A Spreads amid Coronavirus Pandemic,” Seattle Times, Apr. 8, 2020.
  64. Eric Resendiz, “Caltrans Orders Activists to Leave Illegally Occupied Homes in El Sereno amid Covid-19,” abc7.com, Apr. 20, 2020; Rachel Swan, “SF Homeless Activists Occupy Home in Castro, Among May Day Protests,” San Francisco Chronicle, May 1, 2020; Doug Smith, Benjamin Oreskes, and David Zahniser, “‘Tell the Hotels They Are Commandeered.’ Homeless Activists Are Losing Patience with L.A.,” Los Angeles Times, May 3, 2020.
  65. Coronavirus (Covid-19) Pandemic: Non-Congregate Sheltering: Frequently Asked Questions,” FEMA, Mar. 31, 2020; “People Who Are at Higher Risk for Severe Illness,” CDC, Apr. 15, 2020.
  66. The Economy and Cities: What America’s Leaders Are Seeing,” National League of Cities and United States Conference of Mayors, Apr. 14, 2020.
  67. Turning the Tide on Homelessness in New York City,” Office of Mayor Bill de Blasio, 2017.
  68. Budget and Legislative Analyst Report for Apr. 13, 2020 Special Budget and Finance Committee Meeting,” City and County of San Francisco Board of Supervisors Budget and Legislative Analyst, Apr. 10, 2020.
  69. Nikita Stewart, “‘It’s a Time Bomb’: 23 Die as Virus Hits Packed Homeless Shelters,” New York Times, Apr. 13, 2020; “DHS Commercial Hotel Update 11/1/16–2/28/17,” Office of New York City Comptroller Scott M. Stringer, Apr. 17, 2017.
  70. Testimony of Erin Drinkwater, Deputy Commissioner Department of Social Services, Before the New York City Committee on General Welfare Oversight—Covid-19 Response for New Yorkers Experiencing Homelessness,” NYC Dept. of Social Services, Apr. 23, 2020.
  71. Southall and Stewart, “New York Put Recovering Virus Patients in Hotels”; Greg Smith, “How Homeless with ‘Mild’ Covid Symptoms Died on City’s Watch,” thecity.nyc, Apr. 21, 2020.
  72. Maura Dolan, “Homeless People from Other Cities Moving to San Francisco for Hotel Rooms, Mayor Says,” San Francisco Chronicle, Apr. 29, 2020; Trisha Thadani, “Mayor London Breed’s Message to Out-of-Town Homeless People During Coronavirus: Stay Away,” San Francisco Chronicle, Apr. 30, 2020.
  73. Maximizing Funding for Non-Congregate Shelter Opportunities: California’s Project Roomkey,” United States Interagency Council on Homelessness (USICH), Apr. 23, 2020; Scott Rodd, “California Leasing Hotels for Homeless People During Coronavirus Crisis—and After Could Make Them Permanent Housing,” capradio.org, Mar. 24, 2020; Patrick McGreevy, “Some Cities Are Blocking California Efforts to Protect Homeless People from Coronavirus, Newsom Says,” Los Angeles Times, Apr. 18, 2020.
  74. Stephen Eide, “Housing First and Homelessness: The Rhetoric and the Reality,” Manhattan Institute for Policy Research, April 2020.
  75. Nearly Three Years Later, LA Opens First Prop. HHH Housing for Homeless,” nbclosangeles.com, Jan. 6, 2020.
  76. Coronavirus (Covid-19) Pandemic: Eligible Emergency Protective Measures,” FEMA, Mar.19, 2020; “Coronavirus (Covid-19) Pandemic: Non-Congregate Sheltering,” FEMA, Mar. 31, 2020.

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