Coronavirus disease 2019 (COVID-19) created unprecedented changes in our society. Millions of people have been called to shelter in place (avoid nonessential travel outside of the home) and social distance (keeping space between yourself and others outside your home) to reduce the transmission of the novel coronavirus, which causes COVID-19. However, these and other public health measures require a level of privilege: a home to live in, access to hygiene supplies, and control over your movements. They require the ability to stay home from work, avoid public transportation when travel is necessary, and stock up on items to reduce trips to the store. Homeless and unstably housed people, including children, are not able to access these privileges, likely placing them at higher risk of exposure to the novel coronavirus. In many ways, the ability to practice social distancing has become a social determinant of health during this crisis.

Homelessness is not just living in a shelter or on the street; people experiencing homelessness, especially children and families, are often couch surfing, “doubling up” with friends or relatives, or living in motels, hotels, or campgrounds.1,2  Fifty-nine percent of people experiencing homelessness are children aged <18 years who are either unaccompanied by an adult or are homeless as part of a family unit.2  Within a 12-month period, 4.3% of 13- to 17-year-olds and 9.7% of 18- to 25-year-olds report homelessness unaccompanied by an adult.3  Additionally, ∼58 000 families, including >100 000 children, experience homelessness on any given night.2  That is roughly the equivalent of 1400 school buses full of children, enough to stretch 12 miles end to end.

The relationship between housing and child health, including COVID-19, is bidirectional (Fig 1), and homelessness results in increased morbidity and mortality.1,4 

FIGURE 1

Bidirectional relationship between housing and child health. Homeless children and families have worse health outcomes, and health problems predispose families to homelessness. This relationship converges in the emergency department as patients present for general medical complaints, COVID-19, acute homelessness (including those seeking shelter with no medical complaints), and mental health concerns.

FIGURE 1

Bidirectional relationship between housing and child health. Homeless children and families have worse health outcomes, and health problems predispose families to homelessness. This relationship converges in the emergency department as patients present for general medical complaints, COVID-19, acute homelessness (including those seeking shelter with no medical complaints), and mental health concerns.

Close modal

Children who are homeless are more likely to experience developmental delays, asthma exacerbations and admissions, obesity, dental and vision problems, and mental health problems, and they are more likely to be a victim of both accidental and nonaccidental injury.1,4  They are at higher risk of many infections, including otitis media, gastroenteritis, and viral upper respiratory infections.1,3,4  This is in part due to overcrowded living situations, such as in shelters or when doubled up. Additionally, children experiencing homelessness may live in substandard housing conditions, may lack access to basic hygiene supplies, may have other material hardships (such as food insecurity), and may have difficulty accessing health care, all of which increases their risk of infections,1,4  including COVID-19.

People who are homeless face unique barriers in the face of illness, especially COVID-19. As stay-at-home orders are issued, housing insecure families who are doubled up may be asked to leave by the host family given concerns about infection, possible eviction due to over-occupancy, or the social and financial stressors of having additional people in the home all day. For families in congregate shelters, which often have communal kitchens and bathrooms, it may be harder to socially distance from others and maintain hygiene standards as recommended by public health experts. Additionally, homeless families who are couch surfing or doubling up are generally more transient and mobile, making contact tracing, transmission prevention, and treatment more challenging.

The COVID-19 pandemic is shedding light on, and accelerating the pace of, racial and economic disparities that have long existed in the United States. Among families experiencing homelessness, 78% identify as non-White or Hispanic.2  Like families, unaccompanied youth experiencing homelessness are more likely to be Black, more likely to be lesbian, gay, bisexual, and/or transgender, or more likely to have not completed high school.3  Unfortunately, just as homelessness disproportionately affects communities of color, alarming data demonstrate that COVID-19 infection and mortality rates are higher in racial minorities. Communities of color are more vulnerable to COVID-19 because of higher rates of underlying health conditions, increased barriers in access to care, and increased likelihood of living in densely populated areas,5  health disparities perpetuated by systemic racism. This trend permeates data from across the country, from New York City to Louisiana to Michigan, although national demographic data were not available at the time this article was written.5 

In the battle against COVID-19, emergency departments are the frontlines. Under nonpandemic conditions, children who are homeless are more likely to use the emergency department than their domiciled peers because of increases in infectious and noncommunicable diseases and the lack of a medical home.1  During this pandemic, we have already seen families who are homeless presenting to the emergency department without medical complaints simply because of the lack of housing. We worry this trend will increase as isolation duration lengthens and the economic ramifications worsen. For homeless children who present with COVID-19 symptoms, even if they are mild and do not require hospitalization, it is difficult to safely discharge them if they cannot appropriately self-isolate in their current housing situation. Unless policies are put into place to protect these children and their families, this may lead to unnecessary hospitalizations. Although these admissions may be beneficial for public health infection-control measures, they also result in unnecessary health care spending, increased personal protective equipment use, increased exposure for health care professionals, and an additional financial and emotional burden on these homeless children and families.

Given rising unemployment, increased financial stressors, and increased illnesses, advocates and elected officials are bracing for an increase in homelessness due to the COVID-19 pandemic. Eight million households spend more than half of their income on rent, putting them at high risk of eviction, and experts project that 1.5 million families will become homeless during this crisis.6  However, policy changes can make a difference. Advocates have suggested solutions such as emergency rental assistance, eviction prevention assistance, and a moratorium on evictions and foreclosures.6,7  Our home state of Massachusetts has enacted an eviction and foreclosure moratorium and additional funding for Residential Assistance for Families in Transition programs.7  Residential Assistance for Families in Transition is a homelessness prevention program that provides short-term financial assistance for families at risk for becoming homeless to use toward utilities, rent, and moving cost assistance. Additionally, in Boston, the city housing authority and public schools formed an innovative partnership to house 1000 families of public schoolchildren who are at risk for homelessness.7  Creative policy solutions like these are critical in aiding homeless children and families. We must also continue to obtain racial and/or ethnic demographic data on those tested for and affected by COVID-19 and address these disparities to meet the health, social, and economic needs of disproportionately affected communities.

This pandemic has magnified the vulnerability of housing insecure and homeless families. We encourage health care providers to investigate how local and state policies are affecting these children and families. Pediatricians can speak up for children by coalition building with community organizations and government affairs specialists, calling legislators to voice their concerns, volunteering as an expert resource for new policies being drafted, and providing testimony on bills. When pediatricians have a seat at the table, we can highlight the relationship between health, housing, and race and/or ethnicity; share data and anecdotes to shape policies; and ensure that policies are designed to support children facing adversity. Furthermore, we will provide better care to our patients if we are knowledgeable about the latest housing legislation and can help connect them with the resources they need. As our world faces an unprecedented pandemic, our patients need us more than ever. In this time of uncertainty, one thing is for certain: as pediatricians, we have the experience, expertise, and power to advocate for policies that protect children.

Dr Coughlin contributed to background research on the topic, conceptualized and drafted the initial manuscript, and reviewed and revised the manuscript; Drs. Stewart and Sandel contributed to background research on the topic and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • COVID-19

    coronavirus disease 2019

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.