Vulnerable Populations at Greater Risk for COVID-19

Apr 21, 2020

Guest Blogger: Dr. Enrique Enguidanos, founder of CBC Solutions (@EnriqueCBCS)

COVID-19 has rapidly changed our world and altered everyone’s lives. However, no one in our population has been more affected by COVID-19 than people experiencing homelessness and housing insecurity.

Within just a few short weeks so much has been upended. “Social distancing” has entered our collective lexicon. We wait in line to enter the grocery store, only to find they have no flour or toilet paper. We struggle to figure out how to tele-work from home, if we are fortunate enough to remain working at all. For some of us, the effects have been more dramatic: lost jobs, lost incomes, strained relationships, and in too many cases, lost lives.

Consider the plight of people experiencing homelessness. Over the last several weeks:

  • There has been no place to sleep - shelters are overwhelmed, and if a bed is available, there is no social distancing.
  • There is no access to basic sanitation needs – the public restrooms typically available in libraries, recreation centers, and community centers are closed; there is nowhere to access a toilet, sink, or shower.
  • Food access, already limited prior to COVID, has become even more restricted.
  • Public transportation options have shrunk dramatically.

Low socioeconomic status was identified early on as a risk factor for significant COVID illness. For most of us it is difficult to imagine the day-to-day trials of living without a home during “normal” times. However, the added risk for significant infection, and even greater resource restriction has exacerbated the homeless crisis. Questions persist among people experiencing homelessness such as:

  • “I know I have symptoms, but I can’t access the care I need.”
  • “Even if I could get to treatment, what about my belongings?”
  • “Why get tested when no one can reach me with the results?”
  • “How can I sleep when I know COVID is literally right next to me?”

The COVID-19 pandemic has highlighted housing security across our communities and the likely increase in the number of Americans that may be facing housing insecurity. Every unsheltered individual has their own story. For many, a sudden and unexpected change in economic circumstances precipitated loss of housing. A portion of the homeless suffer from substance use issues. In some cases, these struggles were a contributing factor in the road towards homeless. I have met many others who turned to substance use as a result of homelessness. Either way, the resources available to help treat and overcome substance use disorder during this pandemic are dramatically restricted. Pharmaceutical agents used in Medication Assisted Treatment (MAT) programs are hard to find. There has been a dramatic reduction in treatment sites that remain open, and limited transportation options make access to these almost impossible for the unsheltered. In some communities, telemedicine programs are replacing in-person meetings, but telemedicine is not a forum that people experiencing homelessness can easily access. This issue persists in the counseling and treatment programs so critical to addressing behavioral health crisis. Organizations such as Alcoholics Anonymous, Narcotics Anonymous, and others are providing virtual meetings, but the unsheltered have almost no means of accessing such services. As a result, their struggles with mental health and substance use are at risk of worsening during this pandemic.

I applaud our social distancing efforts. As a society we have “flattened the curve” of this disease in ways I wouldn’t have thought possible weeks ago. As a result, my healthcare colleagues and I have a fighting chance in our efforts to control this COVID-19. But for our nation’s unsheltered, social distancing is rarely an option. There are communities that have quickly mobilized resources such as impromptu tents, sanitation stations near encampments and local parks, and organized testing within homeless communities, but these have been the exception. We can do better as a society.

While our nation has been struggling with homelessness since well before COVID, the virus has exacerbated the divide between those with and without stable housing. As we reach the peak of COVID infections, and move towards community re-engagement efforts, we have an opportunity to mitigate both pandemics – COVID-19 and homelessness. Perhaps a silver-lining of the last few months lies in our ability to answer these questions:

  • Can we identify and build upon the lessons learned for certain communities and implement improved resources for people experiencing homelessness and housing insecurity?
  • Can we foster the public/private dialogues required to maintain these resources?

In my work with vulnerable populations over the last decade, I have participated in multiple community collaborative efforts that have implemented effective practices for at-risk and vulnerable populations. In every case, these have delivered more effective care AND provided dramatic community cost savings (typically due to streamlining of efforts and avoidance of duplication). We have an opportunity to engage in similar efforts as we conduct COVID community re-engagement across our country over the next few months. It is my hope that as a society we can recognize this opportunity, identify the lessons learned, and engage in the efforts that will lead to improved community resources. If so, we will have addressed two major pandemics in relatively short order.


Dr. Enrique Enguidanos, has over 20 years of clinical experience in Emergency Medicine, much of this time also serving in organizational and systems management roles. For well over a decade he has developed and fine-tuned systems of care and community management systems that have proven very effective for frequent utilizers, and that is now organized in a manner that allows CBCS to continuously reproduce care results across varying communities and health care systems.

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