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Homelessness in a pandemic

While health services for the homeless population have coped admirably throughout the Covid-19 pandemic, there is mounting concern about the current surge and uncertainty around Omicron. David Lynch reports

At Christmas, there is often a closer focus on those who are homeless and living in inadequate housing. However, with the Covid-19 pandemic, the wider housing crisis and recent uptick in the number of people defined as homeless, the health and policy challenges extend far beyond this festive period.

According to Focus Ireland, the number of people who are homeless and relying on emergency homeless accommodation in Ireland was 8,830 in October. Recently there has been a consistent month-on-month rise in figures since a low of 7,991 people in May.

And yet, in the course of the pandemic, there has been fall in the number with a pre-Covid high of 10,148 in February 2020.

As with the health sector, Covid has been a major challenge for the homeless services since late February 2020. On 4 March last year, the HSE published Coronavirus (Covid-19) guidance for homeless and vulnerable groups.

The services had to adapt rapidly to the new reality.

“We created a scoring system for people based on how vulnerable they were to a possible infection,”
Dr Austin O’Carroll, Dublin GP and HSE Clinical Lead for the Dublin Homeless Covid Response, told the
Medical Independent (MI). “So if you were 40-to-50 [years of age] you get one point, 50- to-60 two points, etc. If you had diabetes you get four points, HIV untreated four points, if it was treated you got two points, etc. We did
that for a number of conditions.

“We scored everyone and the score system went one to nine and we ensured everyone who was above one had their own room, own toilets so they could restrict movements. We did this through existing facilities,” he said. The Dublin Region Homeless Executive (DRHE) also identified “a number of Airbnbs that were empty”. Approximately 260 new units were opened for shielding.

“We effectively shielded everyone who was above 50 [years of age] and anyone who had a significant level” of risk to bad outcomes with Covid. Alongside this, waiting lists for methadone services were driven down, as were waits for access to other addiction services. That worked extremely well,” Dr O’Carroll said.

The services received statistics in January (2021) that showed the level of Covid among homeless people in the early part of the pandemic, especially those in shielding units, was below the general population.

“We effectively kept this out of the homeless population,” he adds.

This trend of lower levels of the virus within the community has continued. New figures provided by the HSE to MI show the Dublin homeless Covid response team has worked with 301 Covid positive cases from August 2020, when it was established, to November 2021. Based on these figures, the prevalence rate amongst people registered
as homeless in the DRHE region is 8.1 per cent, versus a prevalence of 14.48 per cent of the general population in Dublin. “This prevalence figure points to the success of the response in the Dublin region,” the HSE spokesperson said.

Then there was the significant task of a vaccine campaign roll-out (see panel below).

Dr O’Carroll said that the Government Ministries dealing with health, housing, and addiction worked together more closely during this early period of the pandemic. This is something he thinks should continue. In the current surge, there is a need for “more rapid testing” as the services no longer have as many isolation units available as last year.

“We’re trying to get more rapid testing so we get our results quicker so we don’t block up [the units], because there is an awful lot of viral illness going around.”

He added that rapid access to addiction treatment needs to “remain rapid”. Improved housing and giving people the ability “to get into their own accommodation will make a significant difference”

There have been a number of positive reviews of the services’ response to the pandemic within the homeless community. In March, Dr Máirín Ryan, HIQA’s Deputy CEO and Director of Health Technology Assessment, said “rigorous measures taken to prevent transmission in settings, such as prisons and homeless services, appear to have been effective as rates of Covid-19 infection in these settings have been comparatively low”

Omicron

“You’ve to give credit to the Government, NGOs and the homeless responsive service at the height of the pandemic, especially led by [Dr] Austin [O’Carroll],” said Dr Ray Walley, GP in north Dublin and former IMO President.

Dr Walley, who is also a member of the clinical services committee of the Dublin Simon Community, added that “compared to a lot of other countries we did not have the morbidity or mortality rates [within the homeless community] that many other countries have”.

However, he cautioned that two years into the pandemic there are particular challenges, especially given uncertainty about emerging variants.

“In the early part of the pandemic there was a lot more access to accommodation then there is now,” he said. “What we [the Simon Community] find is, when you’ve someone who has to go into isolation, they don’t necessarily have the supports. Often these individuals have past traumas and when you’re in isolation often these past traumas come to re-haunt them.”

Dr Walley explained that the demand for addiction treatment is “continuing to rise”. The property that was available at the start of the pandemic “has dried up, especially property available for single people or couples”.

He told MI that the Simon Community has “put together a step-down supporting facility and we have been able to provide 20 medical step-down beds on site in Usher’s Island [Dublin]”. Dr Walley noted that such a facility
has “freed-up acute hospital beds”

From his general practice perspective, he would encourage the Government to introduce a system whereby someone who is homeless is gradually moved away from the homelessness services and are “registered with a GP”, arguing that the continuity of care provided by general practice is important.

The challenge for the homeless service during the pandemic was heightened by the range of health difficulties within the community, such as higher incidence of cardiovascular and liver disease, HIV, and hepatitis C, for example.

“You’re getting the full gamut of morbidity within people who are homeless,” according to Dr Walley.

Children

The issues facing children were raised in the weeks before the pandemic, in a November 2019 paper from the Faculties of Paediatrics and Public Health Medicine at the RCPI. The Impact of Homelessness and Inadequate Housing on Children’s Health made a number of recommendations, such as that integrated, child-centred services must be provided as a matter of urgency.

Has there been any progress made with these services over the last couple of years?

“There is ongoing work to provide and integrate child health services so that there is good communication between services,” Dean of the RCPI Faculty of Paediatrics, Dr Louise Kyne, told MI.

“I can see progress across paediatrics to focus and incorporate the child and family and community services for management plans and policy and guideline development.”

However, she did note that the pandemic is making such work “challenging recently”. An example of an integrated child health service, which Dr Kyne referenced, is The Lynn Clinic, which is a community outreach paediatric service for vulnerable and marginalised children in north inner city Dublin.

“This is supported by medical and non-medical community support to provide care for these families with more
links with acute hospital service and community services.”

In October last year, the document Strategies to address the impact of Covid-19 pandemic on disadvantaged and homeless children was prepared by the HSE in collaboration with the RCPI and others. One of the issues noted in the document was how school closures due to Covid “had disproportionately adverse effects… on disadvantaged children”.

The paper also noted that while the “small reduction” in the number of homeless families during the pandemic was “welcome”, the Government “must prioritise housing solutions to end family homelessness”.

Housing

A solution for housing is imperative beyond the immediate crisis of the pandemic, according to Dr O’Carroll. “The numbers [of people homeless] has been going up recently and I think that is a general economic policy issue,” he said.

“I worry. I think we do need to get our social housing stock up; we have the Housing First programme that gets people off the streets. I think it’s a brilliant thing. But what will inhibit the Housing First [programme is the amount of access to accommodation.”

As the pandemic enters its third calendar year, his other concern is “maintaining morale, keeping everyone going. People are exhausted,” he said, adding this not only relates to healthcare workers, but staff across the homeless services.

“Constantly having to check patients to see if they are symptomatic, constantly encouraging people to report symptoms, keep wearing masks, keep distance. People can get tired of that,” he said. “So I think keeping that morale and focus going is the longer challenge.”

On the general response to the pandemic, “we’ve fared well,” Dr O’Carroll said.

“And that has been recognised at European level; that we we’ve fared well compared to other European countries”.
But more broadly, he added that “we still have too many deaths of homeless people at a young age”, which is often
linked to addiction issues.

“For example, I would love to have our supervised injection centre set up; we need to reduce the number of deaths. We also need to identify people who are overdosing, but not dying, because obviously there is risk to subsequently overdosing and dying. But we also have to, obviously, reduce the amount of people who are homeless as well.”

Support

Reflecting on his experiences with patients, particularly when working as a GP in the south of England where he encountered people who were homeless, Dr Walley said: “As you get older you realise just how very easily anyone can turn a corner and can end up with a loss of support and a loss of confidence and end up isolated.”

“That can happen to any of us and any of our family. When you deal with homeless people you realise how tenuous it all is. I think the pandemic has brought this to the fore.”

The problem with the health services in general is “that we’re plateauing now”.

“We don’t know where we are yet with Omicron,” added Dr Walley, speaking earlier this month. “We need to reenergise and look back on what we have done well over the pandemic so far and what we can do better.”

Dr Walley said the fundraising capabilities of NGOs, such as the Dublin Simon Community, have been hit by Covid restrictions (in regard to street collections, etc). He encouraged his healthcare colleagues to support such organisations where they can over the festive period. He added that Government must take into account the fundraising difficulties facing the NGO sector.

Planning and delivering a ‘bespoke’ campaign

There have been particular challenges facing the homeless community and other “socially excluded groups”, such as members of the Traveller and Roma communities, who were prioritised by the national immunisation advisory committee as having significantly increased risk of illness from Covid-19.

In May, the Covid-19 vaccination programme for medically vulnerable people living in homeless services began in Dublin. This early vaccination programme was delivered in “bespoke ways”, according to the Department of Health. This involved use of the one-shot Janssen vaccine and “providing transport to and from the vaccination clinic”.

However, the vaccination project began well before the injections. A survey of people who were homeless and
members of the excluded groups was conducted. “We were a bit horrified [at the results],” GP Dr Austin O’Carroll told the Medical Independent.

“We found that there was 45 per cent of people who didn’t want to get the vaccine and there was a significant
range in results in different hostels. In some hostels it was over 90 per cent and in others it was 0 per cent who
said they would not take the vaccine.”

He said that the sources of hesitancy were identified. “There was all this [social] media stuff floating around and rumours.” Therefore a “very strong campaign” was initiated, which was aimed at the community. “We ran it through key workers, Ana Liffey went out with videos, leaflets, we gave them data and information with which they could counter the arguments,” according to Dr O‘Carroll.

Over 90 per cent of people staying in “our shielding units [were] vaccinated and 85 to 90 per cent of [those in] single homes”.

“We only got 40 per cent of family homeless. Now they were among the least vulnerable, so in ways it was good that they were the least vulnerable. That was mainly because a lot of them were Roma and Travellers who were suspicious [of the vaccination programme]. The Roma in particular, given the history of mass sterilisation campaigns in Europe, are very suspicious of any Government interventions. So we were really up against that.

“But still we were very happy with the vaccination rates in the end and we are still working on getting them up.”

The booster campaign has commenced and Dr O’Carroll predicts uptake “will probably go a similar way”.

“The people who took it [the previous doses of the vaccine] will probably take it. The people who are hesitant will probably remain hesitant.”

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