Are people experiencing homelessness more at risk of COVID-19?
The speed at which the global research community has responded to the COVID-19 pandemic is staggering, with a large number of studies published over only a couple of months. Yet, no studies so far have looked at the impact of COVID-19 on those experiencing homelessness. However, we can still use existing evidence to inform our thinking and it paints a clear picture – people experiencing homelessness are at higher risk during the COVID-19 pandemic based on three interconnected facts:
Firstly, we know that people with existing health conditions are more likely to contract severe cases of COVID-19 and are disproportionately more likely to die - particularly those with cardiovascular diseases, chronic respiratory conditions and diabetes.
The initial studies conducted in China (c.1,600 patients and c.72,000 patients) identified that people with these conditions were more likely to require intensive care, a respirator, or both; and also faced a higher risk of death. Data from Italy also showed a similar pattern. In the UK, a very large share of those who have lost their lives to COVID-19 had an underlying condition.
Secondly, there is a plausible reason why those with existing cardiovascular or respiratory conditions are at risk.
Cardiovascular conditions and other related conditions such as hypertension are common conditions among the population at large. Acute respiratory infections have well-known medical effects on the cardiovascular system that increase the likelihood of death, for example due to cardiac arrest. Initial reviews show that these mechanisms also operate with COVID-19-related infections and are consistent with the risk factors seen with other respiratory viruses like the avian flu.
Thirdly, people from deprived backgrounds more generally, but especially those experiencing homelessness, are more likely to have pre-existing conditions such as cardiovascular diseases that puts them at higher risks of suffering severe cases of COVID-19.
In the words of Dan Lewer, the relationship between income and health outcomes could be described as climbing a mountain with a constant slope - with health deteriorating consistently for those from deprived backgrounds - while the relationship for those who are not housed is dramatically different: more like falling from a cliff.
Public Health England recognises that income is one of the key determinants of poor health outcomes while a study of 1.7 Million people in Scotland showed that people from more deprived backgrounds are more likely to suffer multiple existing health conditions, and that they can appear 10-15 years earlier than those from more affluent backgrounds. This study also found that people who were ever homeless, even just once, also had worse health outcomes than people from the most deprived areas who had never experienced homelessness..These results are very consistent both in the UK and internationally.
Focusing on homelessness and cardiovascular health more specifically, a systematic review and meta-analysis showed that people living in homelessness in developed countries have a higher prevalence of cardiovascular disease and respiratory conditions, and are also at a higher risk of premature death; acute respiratory diseases are also more common among this group. These facts are consistent with the findings of recent surveys in London and Birmingham that found that cardiovascular diseases and chronic respiratory conditions are between twice and ten times more common among the homeless population even in comparison to those most in need.
While the research community, governments and society at large focus efforts on developing measures to contain the pandemic and ultimately find a cure, and rightly so, it is also crucial to understand who is likely to need the most support. And people experiencing homelessness are amongst those who might be facing the highest risks.
As the COVID-19 outbreak rapidly unfolds, limited resources are being stretched, but local communities are trying to stop and learn from other cities and share experiences. To support local areas’ homelessness response, we launched a new COVID-19 talk series, where city leaders, clinicians and other guests from all parts of the UK and beyond will share lessons and recommendations.