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This commentary coauthored by BHHI faculty describes how a coalition of Bay Area community organizations, academic institutions, and public health departments collaborated to provide high-risk populations with Covid-19 testing and vaccination, and also took the opportunity to connect them with other essential services.

California's Project Homekey is a big step in creating needed new subsidized housing for the state’s more than 161,000 homeless residents, but homelessness policy experts, service providers, and others are only cautiously optimistic about it. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, explained that in the rush to house people quickly, there's also the risk of leaving out people who need housing the most. People who have been homeless for years will need the most help transitioning into housing. In addition, Dr. Kushel said, “It has been so hard to separate the homelessness crisis from all of the impacts of structural racism.”

The Bay Area Council released a report stating that it would take $11.8 billion to get every unhoused person in the Bay Area off the streets. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, who advised on the report, said, "One thing that’s great is for people to have an honest conversation about what homelessness would really cost to end. Maybe that way we won’t just constantly criticize efforts being made, which have never been scaled to address the problem, which has existed for 40 years." Dr. Kushel dates the beginning of modern homelessness to Ronald Reagan’s decimation of poverty programs in his first years as president.

A proposal to spend $12 billion to end homelessness in California is "a really good start, but can't be the end," said Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative. Project Homekey was remarkable because of how it was approved and running just months after it was announced. But solving homelessness is not possible without addressing housing affordability, which is pushing thousands of Californians onto the street each year. “That’s fundamentally at the heart of the problem,” Dr. Kushel said.

This UCSF study compared infection control strategies to reduce COVID-19 outbreaks in homeless shelters in the United States. In high-risk homeless shelter environments and locations with high community incidence of COVID-19, even intensive infection control strategies are unlikely to prevent outbreaks, suggesting a need for non-congregate housing arrangements for people experiencing homelessness.

A UCSF study found that during the COVID-19 pandemic in California, older adults, Black and Latino residents, and those without college degrees experienced the highest per capita excess mortality. The researchers suggest that this pattern reflects the risk of COVID-19 death faced by low-wage, essential workers and their social networks owing to occupational exposure, crowded housing, and inadequate access to testing or treatments.

Recent studies have highlighted how the pandemic has eroded an already frayed safety net for young people experiencing homelessness. Colette Auerswald, MD, a professor at UC Berkeley’s School of Public Health and UCSF Benioff Homelessness and Housing Initiative noted that young people from marginalized communities are more likely to face structural failings that lead to homelessness.

In California during the pandemic, Project Homekey has created housing for people experiencing homelessness by purchasing hotels and converting them to housing. Each room is life changing to a degree that almost no other intervention can provide. In long-term studies of homeless people who have moved to permanent housing, Margot Kushel, MD, director of the UCSF Benioff Homelessness Initiative has found that basically every determinant of health improves.

Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, was interviewed about how the shortage of housing in California is structural problem for a state that has the largest population of people experiencing homelessness in the country. Dr. Kushel also described how sanctioned encampments have been somewhat controversial.

Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, discussed how the Johnson & Johnson vaccine has been popular among homeless and low-income populations as it requires people to come in for only one shot. She said she understands the need to pause its use to probe the risks but hopes it will be cleared for use again soon. “We heard loud and clear from the community that only having to come in once is a big advantage,” she said. “But transparency and safety are important.”

Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, was quoted regarding the success of Project Roomkey, which could become a model for future efforts to aid the estimated 150,000 homeless people in California. “It’s been a tremendous success,” Dr. Kushel said. “I do think that at the end of the day, it will become clear that this is the main reason we had fewer horrendous outcomes of people who were homeless.”

During an expert panel discussion examining COVID-19’s impact on our society and looking ahead to how we rebuild and prepare for future pandemics, Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said that inequality wasn’t only exposed by the pandemic, it was a driver of it. More housing is critical to staving off future health and economic crises, said Dr. Kushel. “There’s no medicine as powerful as housing. We can't have a healthy economy with a million housing units short that we have in California for extremely low income households.”

Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, was quoted regarding San Francisco's plans to expand permanent supportive housing, including allowing more choices and giving out rental vouchers. Dr. Kushel said that while the city can choose to provide lighter staffing in the scattered sites, she added that programs have been successful around the country when paired with adequate services.

Among a group of medical experts from UCSF and Berkeley who expressed optimism that the COVID-19 pandemic could soon recede, Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, pointed to initiatives like Project Roomkey as successful efforts in keeping unhoused residents sheltered and safe during the pandemic, but argued that much more is needed to ensure that society's most vulnerable groups are protected during the next large-scale public health crisis.

This article reports on weekly vaccination events in partnership with UCSF Benioff Homelessness and Housing Initiative, Glide Memorial Church, the San Francisco Community Health Center, and the city's Department of Public Health to distribute COVID vaccines and support packages. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said biotech companies have helped fund the efforts, allowing community-based organizations to hire trusted ambassadors to spread word about the vaccination events.

The UCSF Benioff Homelessness and Housing Initiative collaborated with the California Homeless Coordinating and Financing Council and the California Health Care Foundation to create resources to help homelessness response systems with COVID-19 vaccination planning. The third in a series, these materials describe important considerations in planning strategies for vaccinating unsheltered people, as all persons experiencing homelessness are now eligible for vaccination in California.