Medical and Homeless Community Statement on the Increased Mortality of Unhoused People

Since Mayor London Breed declared a State of Emergency on February 26th, we have urgently called on the city to offer medically-indicated shelter and services to our unhoused people. As medical professionals, community health workers, homeless activists, formerly and currently unhoused people and members of a vast mutual aid network, we were gravely concerned about the risk to human life the pandemic posed to unhoused people, who are uniquely at risk for poor outcomes from COVID-19. What we feared has come to pass. The city’s lack of science-based approaches to managing the public health response has led to increased mortality of unhoused people

A person in a medical mask and white doctor’s coat stands in front of a vehicle with a sign that reads “HOUSING IS THE CURE”
photo by Brooke Anderson

On Tuesday May 26, the San Francisco Department of Public Health released a statement announcing that 48 deaths had occurred among the unhoused community between March 20th and May 24th, more than twice the number of deaths from the same time period the year before. Most deaths occurred between March 30th and May 10th, which saw 36 deaths as compared to 12 last year. This averages to 6 deaths per week this year compared to 2.7 per week last year.

We are gravely concerned about this increase in deaths, which we view as preventable. We believe that COVID-19 is both directly and indirectly responsible for this doubling mortality rate–through the viral illness and the failure of the public health response in San Francisco. Being unhoused increases the risk of contracting the virus that causes COVID-19 and dying from it, just like having an autoimmune disease increases risk. Keeping thousands of unhoused people on the streets is like keeping thousands of immune-compromised people in the streets, in the midst of a viral pandemic.

The DPH speculates that the closing of shelters without offering safe alternatives due to the pandemic, increased drug overdoses, lack of public intervention and lack of access to medical care have played a role in these deaths. DPH states that many of these deaths were overdoses. If so, that is an alarming increase in overdose deaths, which speaks to the depth of despair that our unhoused patients are experiencing being left on the streets in the midst of a pandemic. Of the 48 deaths, 43 occurred outside, without the dignity of a private room and restroom, something a hotel room provides.

Increased substance use during the pandemic is not unique to those experiencing homelessness. “Deaths of despair” — from suicides, alcoholism, and drug overdoses — have been found to be on the rise in the same period among the general population due to increased stress from the pandemic. Undoubtedly, despair will be amplified among the most marginalized and those who feel discarded by their city’s leadership. The lack of medically-indicated response from the city is another hit on each unhoused individual’s body, which accumulates these stresses over time, predisposing people experiencing homelessness to worsening health and accelerated aging on the streets.

Tuesday’s statement from DPH leaves many important questions unanswered: How many of the deceased people were offered COVID-19 testing while unhoused? How many had tested positive for COVID-19 before dying? Are people whose cause of death is unknown being tested posthumously for COVID-19 through PCR and serology? If not, why not? Also, what percentage of the 40 people who have died in San Francisco from COVID were unhoused? What percentage of all deaths in San Francisco during this time were unhoused?

It is urgent that we know the cause of death of all 48 people, including the race and other social determinants that have contributed to this concerning spike in mortality, in order to prevent unnecessary suffering. Because people experiencing homelessness have been denied access to shelter in place, are at higher risk of contracting the SARS-CoV-2 virus and experience grave outcomes, it is imperative that all unhoused people dying during pandemic should have postmortem specimens collected and submitted for COVID-19, including PCR and serology.

Regardless of how many may have died directly from COVID-19 illness, what is certain is that the consequences of being left on the streets during a global pandemic precipitated these deaths. This is unconscionable given the Board of Supervisors unanimously mandated the City of San Francisco lease 8,250 rooms for the purpose of offering shelter to our unhoused people. Instead, over 30,000 of the city’s hotel rooms remain vacant, with 1,679 vacant and already paid for by the city.

Disruption of thinly stretched social services, shelters, mental health services, medical care, food distribution, and sanitation provisions for unhoused people has greatly increased the stress and vulnerabilities of those surviving in public space. The inaccessibility to public and private indoor spaces during shelter in place has also made survival more difficult. Decades of housing first research shows improved health outcomes from safe housing. If these people were given the hotel rooms, how many lives could have been saved? The lack of access to housing units and hotel rooms have exacerbated people’s existing chronic medical conditions, mental health conditions, and substance use, which compounds their illness.

Finally, although the racial statistics of these deaths were not reported, we are concerned that this neglect is highly racialized. Although only 6% percent of San Francisco’s population is African American, nearly 37% percent of those experiencing homelessness are black. Throughout our nation, African Americans are contracting COVID-19 at higher rates and are more likely to die. Finally as inhabitants on unceded Ohlone Territory, the population of indigenous people are also overrepresented in our unhoused, representing 7% of our unhoused and less than 1% of our city’s population.

We are here demanding what we have demanded two months ago, now 48 deaths later. Our purposeful actions to protect the health and wellbeing of every San Franciscan must be guided by medical indications for the health of our most at risk and the health of the public at large. This virus is still with us and epidemiological models say it will be until late 2022. We will see spikes as the shelter in place order expires and we now know the unhoused are at high risk from death not just from COVID-19 but from failed public health responses. We must act now to prevent further death and to protect all people of San Francisco in this guarded time.

We Demand:

  1. Offer All Unhoused San Franciscans Hotel Rooms. The City immediately offers all unhoused community members lodging in vacant hotel rooms, regardless of whether or not an individual meets the current vulnerability criteria. The majority of unhoused individuals can be placed in hotel rooms with minimal staffing support, while those who need additional support can be placed in hotels with staffing. Peer staffing and volunteers can provide harm reduction and protection against isolation.
  2. Test All Unhoused People Who Die For COVID-19. The Medical Examiner should test all who die during this pandemic posthumously for COVID-19 using PCR and serology. We need timely understanding of exposure and risk to be able to properly mitigate health impacts to our unhoused people.
  3. Report COVID-19 Data by Housing Status with Race, Gender and Pre-Existing Medical Conditions. The City must provide a mechanism to report homeless COVID-19 cases and hospitalizations to better understand the direct risks and impact of COVID-19 on those without housing.
  4. Publicly Release the Cause of Death of All Unhoused People Until SARS-CoV-2 No Longer Circulates in San Francisco. While still respecting patient privacy, it is of utmost importance for community members to understand in real-time the threat to unhoused community member’s safety and wellbeing.
  5. Pass Rent Cancelation and Mortgage Cancelation Legislation Now to Prevent New Waves of Homeslessness.

Quotes from medical professionals on the doubling on unhoused mortalities during COVID-19:

“For these unhoused community members — They may not have died from COVID but they died from the city’s dual public health policy managing COVID, where there’s one standard for those with houses and another for those without. These unfortunate deaths are casualties of a failed pandemic response, in spite of the best efforts of so many providers I respect in DPH. We must do better.” — Dr. Rupa Marya, MD

“Everyone on the streets is experiencing trauma, and this lack of response from the city is another hit on an individual’s allostatic load” — Dr. Olivia Song Park, MD, MPH

Quote from Homeless Advocate

“In our experience, premature homeless deaths are due to the city, state and federal lackluster response to caring for unhoused folks before and especially after COVID. Without access to safe and decent affordable housing, mostly black and brown poor community members become homeless, and stay homeless, while policy makers blame them for their destitution. This virus has illustrated just how interconnected we all are — if one of our neighbors is not well, it hurts all of us.” — Jennifer Friedenbach, Executive Director, Coalition on Homelessness

Quote from Faith Community

“The city has a moral responsibility for the care and well being of all its residents, and the most vulnerable are dying on the streets, in increasing numbers in front of the empty hotel rooms they are denied access to. These deaths are a result of city leaders’ unwillingness to respond with compassion in the midst of a global pandemic” — Reverend Sadie Stone

This statement was collectively crafted by #HousingIsACure which is made up of:

Coalition on Homelessness

Do No Harm Coalition

Faith in Action

Poor Magazine

Public Health Justice Collective

Reclaim SF

Solidarity Forever Collective

Link to background research here

The STREET SHEET is a San Francisco-based street newspaper published by the Coalition on Homelessness, dedicated to covering issues of homelessness and poverty.

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