One year ago, officials in California — home to half the nation’s unsheltered people — were confronted with the complex public health challenge of preventing a nightmarish pandemic scenario from erupting in population centers. Since then, the resulting efforts to address the lack of housing in large cities during the COVID-19 crisis have had successes and reversals while setting the stage for longer-lasting progress to reduce homelessness.

In a March 2 commentary in JAMA: The Journal of the American Medical Association that accompanied a new California study, authors Joshua Barocas, MD, and Esther Choo, MD, MPH, said the pandemic made “homelessness unignorable.” COVID-19, they wrote, “brought the responsibility for housing squarely into the hands of health practitioners.”

When the pandemic erupted last year, there were grave concerns that COVID-19 would spread across the homeless population and not be contained. Existing shelters — unable to meet demand before the pandemic — responded by cutting capacity, exacerbating the problem further.

In San Francisco, entrenched challenges with people experiencing homelessness quickly worsened. That was most evident in the city’s Tenderloin neighborhood. “Makeshift shelters and overflowing carts are in constant conflict with pedestrians for six feet of space,” reporter Vivian Ho wrote in The Guardian nearly a year ago. “Passing through sometimes means pushing through crowds, weaving around camp debris, blankets, and waste as flies bounce off face coverings.” Likewise, around that time in Sacramento, the city’s three largest encampments of people experiencing homelessness resembled the “images Dorothea Lange took of homeless camps along the same river in 1936 for the Farm Security Administration,” journalist Dale Maharidge wrote in The Nation.

Project Roomkey Succeeds in San Francisco

The JAMA study, which evaluated the impact of Project Roomkey in San Francisco, demonstrated the public health benefits of providing stable housing and services to those who need them most, Amina Khan reported in the Los Angeles Times. Launched in April 2020, Project Roomkey was a collaborative effort between cities, counties, and the state to lease 15,000 motel and hotel rooms to house unsheltered people. It was also the nation’s first effort to use Federal Emergency Management Agency funding to offer thousands of unsheltered people temporary housing. The research was led by Jonathan D. Fuchs, MD, MPH, of the San Francisco Department of Public Health.

The study included about 1,000 unsheltered people who were offered a motel room and regular access to a team of doctors, nurses, and behavioral health specialists. About 80% completed their entire recommended quarantine period, suggesting that these hotels prevented some viral transmission from entering San Francisco and freed up significant capacity at Zuckerberg San Francisco General Hospital, Annika Hom and Joe Eskenazi reported for Mission Local. People who were housed in the hotels were offered hygiene kits, access to laundry, accommodations for their pets. Diapers and formula were provided for small children.

These efforts likely led to the program’s success, Barocas and Choo said. “This study suggests that both individual and public health outcomes are improved, when people have access to resources that meet a broad variety of needs, recognize them as whole people, and provide support to address social determinants of health.”

“What they did makes absolute sense to me,” Miriam Komaromy, MD, a specialist in addiction medicine at Boston Medical Center who was not involved in the JAMA study, told Khan. Komaromy has run a project similar to Project Roomkey in Boston. “I think it’s what needs to happen in communities around the country.”

In addition to Project Roomkey, San Francisco has made other concerted efforts to shelter the homeless if permanent options weren’t available. Sanctioned tent camps, or “safe sleeping villages,” such as one a block from City Hall, have provided cover and allowed unhoused people to practice social distancing.

Safe Sleeping Villages

Gwendolyn Westbrook is the homelessness service provider whose efforts inspired the idea of safe sleeping villages. She created an encampment in the city’s historically Black Bayview neighborhood after city officials ordered her to reduce the number of beds from 53 to 25 in the shelter she ran, the United Council of Human Services. The past year has also “shown us the togetherness we must have in order to succeed. We’re going to fight to keep what we got,” Westbrook told Ho of The Guardian in an article last week. “We’re going to keep our people in this neighborhood, and it doesn’t matter who’s going to like it,” she said.

The city’s sanctioned tent sites do come with a glaring problem, however. The temporary housing solution has a price tag of $61,000 per tent per year.

Earlier this month, the San Francisco Board of Supervisors unanimously passed an emergency ordinance to move 560 more people into shelter-in-place hotels over the next two months, reported Mallory Moench of the San Francisco Chronicle. “I believe it will save lives,” Supervisor Matt Haney told Moench. “This will mean we have ways to get people off the streets and inside at a time when COVID is still very much here, very few homeless people have been vaccinated, and the risks are huge.”

Despite the success in San Francisco, nothing is straightforward when it comes to solving the problem of insufficient shelter. Permanent housing, for instance, does not necessarily follow from participation in Project Roomkey. Only “16% of the people who have already been discharged from the hotels have made it into permanent housing,” journalists Erin Baldassari and Molly Solomon reported in November for KQED. That translated into 345 people finding a home out of 2,196 people enrolled in the program.

In Sacramento, City Efforts to Establish Year-Round Shelter

Sacramento’s challenges in managing the dual crises of homelessness and COVID were highlighted in January when a storm ripped through the city. The severe weather was expected, but because of COVID fears, the city manager declined to open a warming center in a downtown library.

The limits of the city’s homelessness programs led to an emotional outburst from Mayor Darrell Steinberg as the storm rolled through Sacramento. “Stop talking about anything but what it’s going to take to bring more people inside in larger numbers, because that’s the only thing that matters,” Steinberg said. “Nothing else matters.”

Advocates put a spotlight on the city’s failures to care for the homeless population by announcing a recall effort against the mayor after at least four people without shelter died the night of the storm. The dead included Karen Hunter, a 57-year-old mother of three who had been homeless for about a year. “She was a warm, loving person,” said Harold Carter, her partner of 27 years. “She was my everything.”

Last week, the city council unanimously voted to expand its warming center program to add full-time, year-round, day-and-night drop-in respite and triage centers. The city will use federal funds to support the centers, where social workers would guide those experiencing homelessness toward permanent housing solutions.

“The concept would represent a notable new rung in the region’s homeless services,” journalist Tony Bizjak explained in the Sacramento Bee, “more robust than warming or cooling centers, but likely smaller and more nimble than formal homeless shelters.” The centers could also serve as a first contact with needed health care, where people could see mental health and substance use counselors, Bizjak wrote.

Steinberg has been vocal in supporting the drop-in centers and carrying forward efforts to house the homeless after the pandemic and the threat of uncontrolled spread among the homeless population are over. “We need the same urgency in a post-COVID Sacramento,” he wrote in an op-ed for the Sacramento Bee.

Most Californians Rate Homelessness a Top Priority

Homelessness is complex, and a “failure of systems,” Tamera Kohler, CEO of San Diego’s Regional Task Force on Homelessness, told KPBS News. Maybe people experiencing homelessness “can’t afford their required health care, or they don’t have a stable place to go after hospital discharge . . . Financial challenges or housing challenges on top of an already fragile health situation can be disastrous for someone. We want to look deeply at this, with all the right people in the room, to find the gaps in the systems that may help prevent these tragedies in the future.”

Despite the complex nature of homelessness, Californians do have the will to tackle this problem. According to a CHCF report, “8 in 10 Californians think ‘addressing homelessness’ is an ‘extremely’ or ‘very’ important priority for lawmakers in 2021.”

Last year, Newsom devoted his entire State of the State address to combating homelessness, but the pandemic waylaid those plans and homelessness was no longer his top priority. In last week’s State of the State, Newsom said California was “committing nearly $2 billion this year to create more homeless housing, addressing mental health and substance abuse issues, and ending homelessness one person at a time.”

“No one denies this is a huge challenge,” Newsom said, “but we know what it means to stare down big challenges.”

Heather Tirado Gilligan

Heather Tirado Gilligan is a journalist who has written for publications including Slate, The Nation, CNN, and the Washington Post. Previously, she was executive editor of the California Health Report, a news nonprofit covering disparities in health and access to health care. Heather received a master’s degree in journalism from UC Berkeley and a PhD in English from Rutgers University, where she studied race in American culture.

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