The Most Meaningful Public Health Intervention: Housing
A note on the language used in this article: Some housing advocates reference a difference between “homelessness” and “houselessness” with exceptional, nuanced conversations on individual experiences with housing instability, connection to community, and personal autonomy. While some advocates may opt to consider a frame of “home is where the heart is” as an issue of empowerment, I, as an author and advocate, use these distinctions because of well-established links between housing instability and uncertainty in situations of domestic violence. A roof does not necessarily a “home” make. For the stakeholder targets of this blog, the link between intimate partner violence/domestic violence and HIV is so notable, the Department of Housing and Urban Development has recently announced funding opportunities for joint demonstration projects between HOPWA and VAWA (Housing Opportunities for People with AIDS and the Violence Against Women Act, respectively).
For 30 years, people living with HIV have advocated “housing is health (care)” religiously. A drumbeat of nearly every action, the inevitable topic of any roundtable or meeting, even if housing isn’t an agenda item – or especially if housing isn’t an agenda item. Arguably, when it comes to issues of “social” Justice and policies impacting the notion of equity, outpacing even health care is housing. Housing is the lone sustainable investment any person or family in the United States can make and, generally, expect to last well beyond their own time. Housing is the basis of both defeating and maintaining systems of inequity and oppression. Housing is such a significant factor in individual and collective outcomes it had its own carve out, separate and apart from the Ryan White Care Act, via the program known as Housing Opportunities for People with AIDS.
Indeed, the housing’s impact on health care is so exceptional, in 2019, the American Medical Association built upon limited calls to improve identification access for people experiencing houselessness and expanded their policy position for more comprehensive and collaborative resources aimed to bring care to this population and called for decriminalizing houselessness. In the same year, the Department of Housing and Urban Development’s annual “point in time” data estimated about 568,000 people were experiencing houselessness on any given night in the United States, a near 10% increase of “unsheltered persons” from the prior year.
Late last month, the University of Bristol published in The Lancet a systemic review and meta-analysis of housing instability and houselessness finding among people who inject drugs (PWID), recent houselessness and housing instability were associated with a 55% and 65% increase in HIV and HCV acquisition, respectively. Additional findings include of the global 15.6 million PWID, over 1 in 6 have acquired HIV and over half have acquired HCV at some point and an astounding estimation that half of PWID in North America actively experiencing houselessness or housing instability.
None of the studies included data collect prior to the start of the COVID-19 pandemic. While several states near immediately began introducing short-term eviction moratoriums and the CARES Act provided for federally backed mortgage holders to seek forbearance or deferment, these protections were short-lived, with many states looking toward the federal government for guidance. As with many issues, the summer of 2020 brought the country little comfort due to a lack of cohesive and coordinated public health response to the emergency. A paper published by housing heavy-weight, Emily Benfer, and HIV champion, Gregg Gonsalves, among others, found this failure to uphold and maintain meaningful and enforceable state-based eviction moratoriums contributed to racial health inequity and cited research finding that lifting moratoriums prematurely, triggering displacement, is associated with an additional 10,700 preventable COVID-19 deaths and 433,700 excess cases. In fact, an organization Benfer serves with, Eviction Lab, rates nearly every state in the country as “one star” in terms of housing protections for renters.
Under this frame, tens of millions of people in the United States are at extraordinary risk of contracting COVID-19. Which is part of why the Centers of Disease Control attempted to flex some public health muscle by issuing an eviction moratorium for public health purposes in October, 2020. Like with other investments made in the fight against COVID, the move was bittersweet for public health advocates at the intersection of housing and HIV, HCV, and SUD syndemics – where was this before now?
“Among the Biden administration’s first priorities is the advancement of racial equity and support for underserved communities,” Benfer said. “This requires redress of the structural and systemic discrimination in housing. As an immediate measure, the federal government should bolster the nationwide moratorium on evictions to apply to all stages of eviction, all forms of eviction, and all renters who face housing instability. At the same time, to prevent an avalanche of evictions and protect small property owners from harm once moratoria lapse, policy makers must provide the rental assistance necessary to address the accumulating back rent and sustain renters, state and local governments, and the housing market—and direct it to the communities at the greatest risk of housing instability.”
“Preventing COVID-19 eviction alone could save the U.S. upwards of $129 billion in social and health care costs associated with homelessness,” Benfer added.
However, the CDC’s moratorium is on shaky ground and implementation/access is not automatic – those seeking to use this protection most pro-actively notify their landlords and express intent to seek cover of the moratorium in eviction court. Several states and localities have not evenly implemented the moratorium or setting up “eviction kiosks” to expedite the process, because so many cases were in que, and some going so far as to list children as defendants in eviction actions. Which, according to Benfer, is not an uncommon occurrence. And due to the lack of protections for tenants and outdated credit reporting associated with eviction judgements, these legal actions can and often do follow people for at least a decade, compounding barriers to housing and drastically increasing the risk of houselessness. Because state-based protections have ended, Texas is allowing evictions to resume and the 6th Circuit Court of Appeals has recently allowed a challenge to the authority expressed by the CDC for the moratorium to move forward, even as some landlords are openly exploiting loopholes in the moratorium.
Landlords aren’t the only abusive persons seeking to take advantage of weaknesses in our housing protections. An unfortunate side-effect of the moratorium actions and our lack of investment in ensuring adequate resources for people experiencing intimate partner violence is perpetrators exploited stay-at-home orders and survivors, who are already at exceptional risk of housing instability, with an estimated 26% increase in domestic violence abuse calls made in some cities across the US during the strictest of those orders.
Additionally, with more people facing a lack of houselessness, even more are now at risk for “mobile homelessness” – or a lack of car to sleep in – an issue which may be masking just how many people are experiencing houselessness and housing instability, due to the design of some point in time surveys are conducted. And with an estimated 49% increase in chronic homelessness expected as a result of COVID-19 over the next 4 years, the potential exacerbation of the existing housing crisis in the US may well likely become an even larger, permanent feature without extraordinary action from all levels of government and, or even especially, private stakeholders. To put this figure into context, this would twice as much homelessness as was caused by the 2008 housing recession.
In The American Eviction Crisis, Explained, Benfer suggests there’s some basic policy moves to be made for longer-term successes:
“In the long term, federal, state, and local policymakers must reform the housing market in a way that provides equal access to housing, thriving communities, and areas of opportunity. Rental subsidies, new construction or rehabilitation, home ownership, and investment in long ignored communities would increase long-term affordable housing. Government-Sponsored Enterprises (GSEs) must remedy the current market conditions that can be traced to racially discriminatory lending policies. This means GSEs must address disparities in asset accumulation and the persistence of discrimination in mortgage lending and the siting of homes.
Where eviction is absolutely necessary, the eviction system itself must be reformed. Evidence-based interventions, such as providing a right to counsel, diversion programs, ‘just cause’ and ‘clean hands’ policies, as well as altering the eviction process, and sealing or redacting identifying information from eviction records, can prevent or mitigate the harm of eviction.”
That long-term investment is well past-due in addressing the needs of people living with and affected by HIV, HCV, and substance use disorder.
Benfer added, “Eviction prevention and the right to safe and decent housing must be the priority. As President Biden said while signing executive orders directed at ending housing discrimination: ‘Housing is a right in America, and homeownership is an essential tool to wealth creation and to be passed down to generations.’ It’s time the U.S. fulfilled the promises of the 1944 Economic Bill of Rights, which includes a right to a decent home, and the 1949 Housing Act that set the national housing goal: ‘the realization as soon as feasible of the goal of a decent home and a suitable living environment for every American family.’ Ultimately, our policies and budgets reflect our humanity and morality as a nation, and nothing could justify the continued denial of basic human needs and access to opportunity. If we are ever to call our society humane or just, we must finally redress housing disparities and discrimination and secure every American’s right to a safe and decent home.”
For far too long, housing as been placed on a shelf as an “unreachable” necessity in actionable advocacy. We cannot afford to “kick this can down the road” any longer. We’ve long known housing is one of the most effective interventions in prevention and in patient care. The oft-touted “it’s too expensive” excuse has manifested a broken dam with lives sifting through the cracks. We already pay for housing for PWID, it’s just most often manifested in the form of imprisonment. A far more meaningful investment in a person’s recovery and success, regardless of recovery, and in community health and in Ending the HIV Epidemic and in ending violence against women and interrupting cycles of generational poverty and answering our most sacred, moral promise and…and…and… would be to address the issue squarely: it’s time to invest in housing.
