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Last month, Ernest Reese found himself in an unusual situation. A few patients at the Hawaii Homeless Healthcare Hui asked Reese to discharge them into a homeless shelter, but the case manager could not do so because a Covid-19 outbreak had forced the shelter to temporarily freeze admissions.

Instead, he had to release them from care without knowing where they would go next.

“Usually it’s the other way around, I’m trying to sell patients to go to the shelter to get services,” Reese said. “When I have those few that … actually want to go, I couldn’t get them in.”

More than two years into the pandemic, Covid-19 continues to shape the daily lives of Hawaii’s homeless population – but its impact may not be as dire as had been predicted.

A recent study  found that Covid infections reported through September 2021 tended to spread more slowly within the homeless population than within the general public. In Hawaii, the general population’s Covid-19 infection rate was approximately double that of the homeless population, according to state data included in the study.

Health departments in 17 states, including Hawaii, and the District of Columbia reported the total number of Covid-19 cases among their homeless populations in a Centers for Disease Control and Prevention survey issued in November 2021. The study’s data did not distinguish between those living in shelters versus on the streets.

The authors acknowledged that it was likely an undercount due to difficulties in obtaining more comprehensive data. But they said it provided a valuable glimpse that could be used to inform future policy decisions.

“Homelessness is not regularly collected in public health data, making it hard to know who was being affected by Covid-19,” said Ashley Meehan, a co-author of the study, in an email. “Collecting these data gives us information about where jurisdictions might be able to dedicate resources and Covid-19 prevention efforts.”

‘A Combination Of Things’

The true number of homeless individuals who tested positive for Covid may never be known since overall housing instability increased amid job losses and economic uncertainty, making it harder to track cases, said Dr. Michael Walter, interim medical director at the Kalihi-Palama Health Center.

“It’s difficult to parse out if someone is homeless on the streets, if they’re homeless in the shelter, versus somebody who has housing instability. A lot of our patients are in multigenerational homes whose housing is tenuous or unstable,” Walter said. “We don’t really have a good count on how has Covid impacted those patients.”

Homeless people may be less likely to seek testing if they are experiencing mild symptoms, and some testing centers do not collect information on housing status, according to the study, which didn’t include information about deaths.

States also used different definitions of homelessness. For example, Hawaii only included people who identified as homeless in their medical records or case interviews.

“Along with just checking in on people and trying to get them into housing, Covid is a part of our language now.” — Laura Thielen of Partners in Care

Hawaii’s data was collected between April and September 2021, after the state had initiated vaccine rollouts prioritizing homeless communities. Rising vaccination rates, as well as natural immunity from previous Covid outbreaks in shelters and other congregate settings, may have impacted the results, said Joshua Holmes, a UH doctoral student studying epidemiology.

“The incidence rates might look very differently if it included data from 2020 before the availability of vaccinations,” Holmes said in an email.

Despite the challenges of data collection, local doctors and outreach workers said the findings supported their own observations throughout the pandemic.

Homeless people naturally tend to social distance or remain in small groups, thus reducing their risk of contracting or spreading the coronavirus, said Dr. Teresa Schiff-Elfalan, the medical director of the , which offers free health care clinics across Oahu.

Doctors observed that, while many people of the coronavirus early in the pandemic, these fears proved largely unfounded.

“At the beginning of the pandemic, I got the sense that people felt like the houseless community was going to be even more at risk of transmitting the disease,” Schiff-Elfalan said. “But what we observed in our clinics was that the numbers were very low.”

Hawaii’s weather also worked to the advantage of the homeless population. Trade winds and warm temperatures likely enabled more people to remain in well-ventilated, outdoor areas, said Dr. Janet Berreman, Kauai’s district health officer.

At the same time, Covid prevention efforts from state and local organizations contributed to what Berreman described as a “relatively good outcome” for the homeless population.

“It’s hard to attribute cause and effect,” Berreman said. “I think it’s probably a combination of those things.”

More Risk Of Serious Illness

While homeless people may face a lower risk of contracting Covid-19, they are more likely to become seriously ill from the virus, Walter said. He added that homeless patients often struggle to manage chronic illnesses — a challenge that became even greater with the onset of the pandemic as many clinics temporarily paused in-person visits and doctors turned to telemedicine.

“As services were being restricted, access was being restricted, especially through the first year and a half of Covid, it exacerbated health care disparities among the homeless population,” Walter said. “It was an adjustment of getting people used to telemedicine … And if you’re homeless, it just makes it that much more difficult to navigate.”

In response, health care and outreach providers made a concerted effort to prevent the spread of the virus within the homeless population, said Darrah Kauhane, executive director of . The organization began testing homeless people across the islands in June 2020 and has continued to offer both surveillance and outbreak testing services to shelters and encampments.

Approximately 4.4% of Project Vision’s tests came back positive from June 2020 to August 2022. During the same time frame, 6.8% of statewide tests reported to the Department of Health were positive.

Homeless shelters were also quick to adapt and respond to the pandemic. Jill Wright, director of philanthropy and community relations at the Institute for Human Services, said the organization expanded its medical team at the start of the pandemic, enabling staff members to provide rapid tests, wellness screenings and Covid education resources to people in homeless shelters and encampments.

IHS still offers Covid tests and vaccinations at shelters and encampments, while also running Oahu’s last isolation shelter at Sand Island for homeless people who test positive for Covid. IHS shelters have remained vigilant against Covid, operating at reduced capacities until March and requiring vaccinations for guests, Wright added.

Despite these precautions, Schiff-Elfalan said she saw a greater transmission of the virus among homeless individuals living in shelters compared to those who remained in outdoor encampments.

Shelters had to temporarily stop accepting new guests several times throughout the pandemic, most recently last month at the IHS women’s and family shelter on Kaaahi Street. As a result, Reese was unable to place patients from the Punawai Clinic and Medical Respite in the shelter’s care.

Wright added that, in late 2021, Oahu began to reduce the number of hotels used as quarantine facilities. Shelters began to turn their own conference rooms and dorms into makeshift isolation units that could separate sick and healthy guests.

Maude Cumming, executive director of , said she struggled to find quarantine centers that would accommodate homeless individuals on Maui. Although Family Life Center, which provides housing and social services to homeless communities on Maui and Kauai, set aside some of its own housing units to quarantine some infected patients, others had to sleep in cars once these spaces filled up.

Berreman is proud of the work the state and its partners did to prevent the spread of Covid among the homeless population but acknowledged room for improvement. In the case of another public health crisis, she said, the state should prioritize education and outreach services for vulnerable populations as quickly as possible.

Pandemic Takeaways

More than two years into the pandemic, Laura Thielen has seen no decline in the number of Covid-related services for the homeless community. Instead, providers have learned to incorporate testing and vaccines into a broader range of health and housing services, said Thielen, executive director of , a coalition of organizations and individuals dedicated to ending homelessness in Hawaii.

“It’s not necessarily that we’ve decreased services, but we’ve just put them into our normal services,” Thielen said. “Along with just checking in on people and trying to get them into housing, Covid is a part of our language now.”

Providers also have found new ways to care for the homeless population. Schiff-Elfalan said the expansion of telehealth has allowed HOME to provide psychiatric and behavioral health services for the first time at its clinics. Project Vision has worked with the Department of Human Services to register as a medical provider so it can offer more comprehensive health care services.

At the same time, Thielen said, the pandemic served as an important reminder that street outreach and shelters can only go so far when it comes to protecting individuals’ health.

“Congregate shelters aren’t the answer. For most people, it’s permanent housing,” Thielen said. “The most important thing is that housing is health care, and Covid made us realize that even more.”

Civil Beat’s health coverage is supported by the , Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and .