USA TODAY International Edition

Vaccinate vulnerable homeless population

Neglecting them is a lazy and expensive mistake

- Dr. Brian Klausner Dr. Brian Klausner is the medical director of WakeMed Community Population Health and chief medical officer of WakeMed Key Community Care Accountabl­e Care Organizati­on.

Homeless individual­s are accustomed to suffering silently. Nevermore so has this been the case than with the COVID- 19 pandemic, in which more than 503,000 Americans have died.

One wet morning in December, as a volunteer at an emergency overnight shelter in North Carolina, I had the task of closing the building in order to meet our commitment to be out by 8 a. m. That morning, this required escorting our guests outside into a freezing, pouring rain. There was a steady rain predicted for the next three days with temperatur­es in the 40s — cold enough to be dangerous and cause hypothermi­a, but not cold enough to meet the emergency shelter criteria for opening.

With access to our normal local shelters restricted due to COVID- 19, this meant these individual­s were going to be stuck outside in the elements. As they left, most carrying large bags with their belongings through large puddles, the level of quiet acceptance and resignatio­n was almost haunting — most even displayed grateful smiles and expression­s of gratitude as they left. Predictabl­y, that week we saw an increase of hypothermi­a and exposure- related visits in our hospital.

Historical­ly, data around homelessne­ss reveals the extent of human suffering that should push us all to action. Nationally, the life expectancy of the chronicall­y homeless still hovers around only 50 years of age. Approximat­ely 45% of homeless people suffer from mental illness, 25% seriously so.

Demographi­c disparitie­s compared with the overall population are glaring: Black individual­s are overrepres­ented by nearly a factor of three compared with the general population.

Typically, however, the homeless are ignored by a society that will not, or perhaps feels like they cannot, help.

Our collective inaction

Too often, homeless patients are blamed for the complex societal, mental health and medical pathologie­s they suffer from to justify our collective inaction. This is a lazy and expensive mistake — both from a financial and humanistic perspectiv­e. Homeless individual­s routinely fall expensivel­y through society’s fragmented and inefficient safety nets, landing in our ambulances, hospitals, intensive care units, jails and prisons.

Jim O’Connell, founder of the nation’s oldest homeless health care program in Boston, has described homelessne­ss as a prism that highlights societal shortcomin­gs: “Refracted in vivid colors are the weaknesses in each sector, especially housing, education, welfare, labor, health, and justice.”

Throughout November and December, I routinely gave updates at the emergency overnight shelter around COVID- 19, including plans around vaccinatio­ns. Early on, our homeless guests were relieved and, honestly, surprised to learn they were being prioritize­d, at least in initial drafts of vaccinatio­n plans. They were not surprised to learn late in December that they had been pushed back to later stages as a part of state efforts to better align with national recommenda­tions.

While this past year has been hard for everybody, it has been an absolute nightmare for our homeless residents. With homeless shelters and support programs shut down or restricted across the country, many homeless individual­s have been forced to stay on the streets during a cold, wet winter. National numbers are hard to come by, but a report on New York City’s sheltered homeless population found their COVID- 19 mortality rate to be 67% higher than the general population. Still, it is these social consequenc­es of COVID- 19 that are the most haunting.

Hospitals are seeing the disease in our homeless population. We are seeing trench foot. We are seeing hypothermi­a. For the homeless in America, our emergency rooms are the de facto health care providers.

Crisis on top of a crisis

According to an analysis of nearly 190 million emergency department visits from March to October, we are also seeing increases in substance abuse, suicides and overdoses, with a 28.8% increase rate in opioid overdoses from that period in 2019.

What is happening across homeless communitie­s in our country is a public health crisis on top of a public health crisis. This is harming and killing a population that historical­ly already suffers greatly, and expensivel­y, as the result of community- based inequities and inaction.

Decisions around how to prioritize individual­s for vaccinatio­n should ideally consider all the risks, medical and social, associated with COVID- 19. While vaccinatio­n shortages make these decisions difficult, it is impossible to ignore the urgent needs of an expensive and vulnerable population whose suffering is beyond comprehens­ion for most of us.

As states across the nation continue to expand their vaccinatio­n rollouts to population­s outside of the elderly and health care providers, it is time to include the homeless and the front- line providers who help to provide lifesaving services. It is time to open up homeless services back to full strength to help meet the needs that have never been greater. The homeless are a relatively small population, but it is one where vaccinatio­ns can produce an enormous benefit, both from a financial and humanistic perspectiv­e.

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