In the middle of a busy day doing primary care telehealth, we spoke to a man who was living in a hotel.
“You’ve got the right place, doc,” the hotel operator said, clarifying that it wasn’t a wrong number.
After he was discharged from a recent hospital stay, the patient — let’s call him David — had been assigned one of the authors of this op-ed as his new primary care doctor. The Camden Coalition of Healthcare Providers, the organization of the other author, was helping with his case management. Because of the COVID-19 crisis, his first appointment was over the phone.
David had been living in the hotel for the last two weeks. (He agreed to share his story, but preferred we change his name.) He was homeless but had gone to a local emergency department gasping for breath and tested positive for COVID-19.
Now that he was well enough to leave, he had nowhere to go. He had been bouncing around between shelters, friends’ houses, and sleeping outside. None of those places was safe for the 14-day quarantine his doctors recommended. So he went to the hotel, where the county public health department was putting up COVID-19 patients without a home.
At the hotel, he got three meals a day and his medications from the pharmacy. He was thinking about calling relatives he hadn’t seen in months.
He wasn’t sure where he’d go: maybe a friend’s house. Maybe back to a shelter. He hoped he wouldn’t end up on the street. He was stoic: “I’ll figure something out.”
Our patient’s story reveals an uncomfortable truth: We find resources to house the homeless only when they pose a public health threat. But homelessness is its own public health crisis and should be treated with the same urgency with which we’ve addressed the COVID-19 pandemic.
In Camden, we often care for people who don’t have permanent homes. Homelessness is an issue of racial injustice since it disproportionately affects black Americans. It is also an issue of health inequality, a phenomenon well-documented in the medical literature: being homeless puts people’s health at risk.
In a study that followed unsheltered adults — meaning people who primarily slept outdoors and avoided shelters — for 10 years in Boston, researchers found that the mortality rate in this group was almost 10 times higher than the general adult population in Massachusetts. It’s no surprise that people experiencing homelessness are more likely to lack a regular source of health care.
When their health problems become urgent, many homeless individuals go to the emergency department.
One San Francisco study found that homeless people went to emergency departments at a rate three times higher than the general population.
That was the case for David, our patient in Camden. When he started feeling sick, he had no primary care doctor to call, no safe place to recuperate. So he went to the hospital.
But here’s what happened in just two weeks at a hotel: David had a warm bed and healthy food. He had his own physical space to recover and to start thinking about his next steps.
This part of David’s story is also reflected in the data. When communities prioritize safe housing for homeless individuals, their health improves.
Known as “Housing First,” this approach emphasizes stable, long-term housing as a prerequisite for addressing people’s physical and mental health needs. Get a roof over our clients’ heads, Housing First advocates argue, and then they can start taking their cholesterol medicines.
There’s evidence that this approach benefits public health. In the long term, it can also save money for health-care systems.
In one 2009 study, homeless individuals in Chicago hospitals were assigned to one of two groups as they prepared for discharge: they were set up with either stable housing or seen by a social worker who directed them to a temporary shelter. Researchers found that the people in the group who moved into long-term housing had a 24% reduction in subsequent emergency department visits.
But all over the country, we don’t have the Housing First programs or even the housing vouchers that we need. In our tri-county area in South Jersey, there are about least 500 individuals or families waiting for housing vouchers and only about 20 available. It sometimes takes months to match an unsheltered client with permanent housing. While they wait in temporary shelters, their health often worsens.
We weren’t able to offer David a housing solution. He survived COVID-19; his hotel stay helped him get better. Our teams are doing what they can. But until we prioritize long-term housing for our homeless neighbors, David’s health and that of thousands of others will remain at risk.