The coronavirus pandemic is upending the Bay Area’s fight against homelessness — changing everything from who we think of as homeless, to how we shelter them, to how much money we can pour into the problem.
Many of the changes — good and bad — will outlast the pandemic, says Dr. Margot Kushel, who studies the intersection of homelessness and health. The good news includes a likely shift away from crowding people into group shelters, and a growing empathy toward the people economic hardship has pushed onto the street.
But the bad news is concerning: The health of those who remain outside is worsening, and that could have ripple effects throughout the health care system for years.
Kushel, a UCSF professor of medicine at Zuckerberg San Francisco General Hospital, and the director of the UCSF Center for Vulnerable Populations, spoke with this news organization about the ways coronavirus has changed the fight against homelessness, and what comes next.
This interview has been edited for length and clarity.
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Q: How has the coronavirus pandemic changed the way the Bay Area views the homelessness crisis?
A: I think coronavirus has really in some ways brought to the fore how significant the crisis is for the health of the people who experience it. I think it’s made it really painfully obvious. Because of the need to de-intensify shelters, or really have many fewer people in shelters than the few we already did, it really increased the visibility of homelessness.
And then I think the success for the people who are lucky enough to be enrolled in Project Roomkey and associated things — we moved about 5,000 people in the greater Bay Area pretty quickly into hotels and trailers — really in some ways gives us a sense of possibility, of what things could look like if we actually had the resources to do it.
Q: What long-term impacts do you think the pandemic will have on homelessness and the way we fight it?
A: People say never waste a crisis. The hopeful view of this is that there would be dramatic shifts. I hope that what will last is people’s concern about the well-being of people experiencing homelessness. With Project Homekey (a state program that provides funding for cities and counties to buy hotels, apartments and other buildings and turn them into homeless housing), there’s some momentum towards increasing the supply of housing.
I suspect that even nationally, not just in the Bay Area, there’s going to be a turn away from congregate shelters, which were really started as an emergency response in the early 1980s. I’m hearing more discussion of whether, because of the potential for infectious disease, violence and other harms, and frankly inefficiencies of them, whether we can move beyond having our emergency response be large congregate shelters. I think that might last.
Those are all the positive potential outcomes. I think those will butt up against a few realities. One is that there’s a large chance the pandemic could significantly worsen homelessness. There are just so many people now at increased risk of homelessness because the bottom has fallen out of the economy for low-wage workers and other vulnerable individuals. There are estimates that California’s homelessness crisis could increase by about 20%.
Q: Once emergency state and federal COVID funding runs out, and local jurisdictions are left with budget shortfalls, how realistic is it that we can continue the progress we’ve made in housing people?
A: I think there’s a real reason to be worried. If there isn’t an infusion of federal funds, what is going to happen when the eviction moratoria lift? And are we going to see a worse crisis than we had before? I think the other thing is that the COVID crisis itself is going to last longer than some of those earmarked resources. We anticipate there’s a good chance we have another year, year and a half before the crisis is really over.
Q: Do you think COVID has changed the attitudes of Bay Area residents when it comes to homelessness? Have people become more empathetic?
A: It goes both ways. What has always been true is that most people who become homeless become homeless simply because they can’t pay the rent. That has been brought home as we see so many workers in so many industries lose their jobs, and they’re living on air. I think it makes more real and perhaps accessible to the general public that there are many people at risk for homelessness.
I do worry a little bit through that, particularly as unsheltered homelessness — which was always high — has gone up even more, I think in some ways there are even more people not trusting, or really demeaning people who are experiencing homelessness. As people are sitting at home, there’s been some really terrible examples of people really acting without a lot of empathy towards our homeless neighbors.
Q: What kind of long-term effects do you think the pandemic will have on the health of our homeless communities?
A: We have seen a dramatic increase in death rates in unhoused populations. It was happening before the pandemic, but the pandemic has increased it. Not all the deaths by any means are directly attributed to COVID. Our safety net healthcare systems are really being pushed as hard as they’ve ever been pushed. We’ve had to convert to telehealth. Telehealth doesn’t work very well if you’re living in a tent. We are seeing big decreases in people engaging in routine, preventative care. We’ve seen drug overdose deaths go way up.
Q: Could that have economic impacts down the road? Will we end up paying more for emergency care?
A: Yeah, we’re always worried about that. We really have lost many of the tools in our toolbox, so I think there could be huge health consequences. I’m really worried about even worse detection of early cancers. I’m really worried about the increased need for emergency care.
Dr. Margot Kushel
Affiliation: University of California San Francisco
Title: Professor of medicine in the Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, and director of the UCSF Center for Vulnerable Populations
Residence: Berkeley
Age: 53
School: Harvard University for undergrad, and Yale for medical school.
Five facts about Dr. Margot Kushel
1. She and her husband have 18-year-old twins — a boy and a girl.
2. Kushel loves swimming, especially in cold water, and was a South End Rowing Club member until she moved from San Francisco to Berkeley. During the pandemic, she’s been swimming at the Berkeley Marina.
3. She has two cats named Sisi and Noni, who she adores.
4. Kushel is a maniacal reader — she subscribes to eight newspapers and four magazines, and is always reading three or four books at once. Most recently, she was reading “Fatal Invention” by Dorothy Roberts.
5. She’s been a vegetarian for more than 30 years.
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