29. Homelessness and Health: Locally, Regionally, Nationally

Contagious Conversations  /  Episode 29: Homelessness and Health





Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent non-profit that builds partnerships to help the centers for disease control and prevention save and improve more lives.

Joining me today is Dr. Emily Mosites, epidemiologist and senior advisor on special populations to the deputy director for infectious diseases at the Centers for Disease Control and Prevention. Recognizing gaps in public health protections for many people experiencing homelessness, Dr. Mosites launched a CDC-wide working group to address the issue. When the COVID-19 pandemic began, she initiated and led the COVID-19 response homelessness unit, and now leads a team within the deputy director's office, focused on ensuring that broad public health protections extend fully to people experiencing homelessness.

In this episode, we'll discuss the link between people experiencing homelessness and public health and what CDC is doing to address this issue. Welcome, Emily.

Emily Mosites: Thanks so much for having me.

Claire Stinson: We're glad you're joining our conversation today to discuss this important issue.

So Emily, in an article about your career path on the University of Washington website, it says that you are a global adventurer at heart. How did this inspire your work in public health?

Emily Mosites: I've always been interested in learning about and understanding people who live in all different contexts. If the world didn't have any infectious diseases, which right at this particular moment seems extremely unlikely, but if that did happen, I think I would be an anthropologist because I'm just so interested in learning about different people. So, I came into public health and worked in global health for many years in Ethiopia, Kenya and Ghana. And when I switched over to working domestically, I brought those global health perspectives to my work in the U.S., in particular, the importance of being able to reach people. And also just the awareness that no people are unreachable.

Claire Stinson: That's a really important perspective. So, you started out in global health and we know that you also were an epidemic intelligence service officer, or as it's also known, EIS. And in your role as an EIS officer in Alaska, you investigated an outbreak of a new strain of a Streptococcus that was affecting people experiencing homelessness there. Tell us about that outbreak and how it led to your work on issues that affect people experiencing homelessness.

Emily Mosites: Group A strep is the bacteria that causes strep throat, but when it infects your skin, it can cause this really extensive damage. People can lose limbs or die from these infections, which are called invasive infections. So, I was placed in Alaska as an EIS officer, which is CDC's program for boots-on-the-ground outbreak response. And shortly thereafter cases of Group A strep–this invasive Group A strep–began to increase among people experiencing homelessness in Anchorage.

So, we spent a lot of time in shelters trying to understand how to interrupt transmission patterns there. But I realized quickly that this wasn't the first infectious disease outbreak that had occurred in the shelters there. Just recently, there had been several different kinds of outbreaks, tuberculosis and bartonella. But at that time, while I was doing this investigation, there weren't any centralized resources for public health best practices for reaching people experiencing homelessness. So, after we responded to the Group A strep outbreak and cases had subsided, I started digging into ways to build those resources. And that's when I began the working group at CDC on homelessness and public health.

Claire Stinson: Interesting. So, taking a step back, many people listening to this podcast may not understand the link between people experiencing homelessness and public health. Can you talk to us about that?

Emily Mosites: Probably the intuitive place to start is to think about individual-level health first. So, health and homelessness have a bidirectional relationship. An illness might be just enough to cause them to fall behind on rent and put them on the path towards homelessness. But then homelessness itself increases the risk of illness. Services are often provided in crowded places where infectious diseases can spread. And people experiencing homelessness often have limited access to prevention resources and care. So, that's on the individual level.

But when we think about public health, we're thinking about patterns and systems. And on a population scale, people who are experiencing homelessness have a disproportionate burden of disease nearly across the board. So, if we want to make an impact on community-level health, we need to intervene where the disease burden is highest. And this means going upstream to prevent homelessness. And in the meantime, protecting people who are currently experiencing homelessness.

Claire Stinson: Really important points. And it's so important to understand this link because it's such a huge issue. And if we could pivot to the COVID-19 pandemic, what particular challenges did the pandemic present for people experiencing homelessness?

Emily Mosites: Well, those underlying linkages between health and homelessness, those were the ground level. Then we layer on top of that the COVID-19 pandemic. So as you mentioned, I led the homelessness unit on CDCs COVID-19 response. And from our perspective, there were three major challenges that we worked on throughout the pandemic.

First, the most obvious, probably, is that, as I mentioned, homeless services are provided often in crowded settings, like homeless shelters. And those were at risk for outbreaks. There have been outbreaks in homeless shelters in every wave, every new variant that's come through in the COVID-19 pandemic. Furthermore, people experiencing homelessness often have underlying illness, which can increase the risk of severe COVID-19. And then access to prevention resources, basic hygiene facilities and information can be limited for people experiencing homelessness.

But during the pandemic, so many communities recognized these issues and made some enormous changes to protect their neighbors. Communities set up hotel rooms for people experiencing homelessness to stay. The pandemic presented opportunities to expedite permanent housing and overall for communities to re-conceptualize their approach to homelessness.

Claire Stinson: That's really interesting. And these themes resonate with me because time, time again, on this podcast, we keep talking about the importance of community. And the fact that COVID-19 kind of served as a catalyst to shine a light on so many issues that were likely already in existence, but needed to be helped, needed to be advanced. Would you agree with that? Do you think that COVID-19 kind of served as a catalyst in some communities to help?

Emily Mosites: Yeah, that's a great point. Not just a catalyst, but also it brought things to the surface, existing systems and patterns that were already not serving us. It brought them to light as the pandemic disproportionately impacted particular groups of people.

Claire Stinson: Absolutely. So what is CDC doing to address the issue of homelessness?

Emily Mosites: Well, first we have a new team, so I am the senior advisor on special populations in the deputy director for infectious diseases office. And we have a small group that's working specifically on homelessness in a cross-cutting way. We also have, as I also mentioned, the working group that's across CDC and has staff members throughout the agency working on homelessness and interested in homelessness. And then we have our disease program areas that do work with specific diseases and homelessness like tuberculosis, HIV. And then our team, we have some really, I would say, energetic partnerships with the U.S. Department of Housing and Urban Development, National Healthcare for the Homeless Council, the U.S. Interagency Council on Homelessness, and so many others at the national level to align our activities in the homelessness space.

There's a couple exciting projects that we've been working on that I want to highlight. One is with the CDC Foundation to support three jurisdictions as homelessness and public health centers of excellence. These are hubs that are led by health departments who are developing best practices for addressing health and homelessness. And I'm just so excited to see the kinds of work that will come out of there.

We also just wrapped up a deep dive project to better understand the best ways to reach people experiencing homelessness with health communications, just a really central element of what we need in public health. We have a forthcoming training on homelessness for public health professionals to help get more public health professionals on board and understanding the homelessness space. And then we're doing a number of data analyses on homelessness and health to understand the burden of disease and understand effective interventions for reaching people experiencing homelessness.

Claire Stinson: We'll be right back with Dr. Emily Mosites.

Homelessness and the health impacts of those experiencing homelessness are a national challenge. As the COVID-19 pandemic shown a spotlight on health inequities across the United States, it is critical that public health efforts include a focus on the unique challenges faced by people experiencing homelessness. For more information on CDC's work on homelessness, visit www.cdc.gov/ddid/homelessness.

And now back to our conversation with Emily.

Would you say that there's a need for more understanding, generally, in the public health community about this issue?

Emily Mosites: I think that has happened through the pandemic. Previously, in public health there was a lot of disease-specific knowledge and disease-specific connections between public health and homelessness in particular, thinking of tuberculosis or HIV. But the pandemic made it clear that homeless services, they need to be connected with public health. Everybody's working towards the same goals. And so public health and homeless services working together, I think that's really been fomented by the pandemic and has pushed a lot of it forward.

Claire Stinson: That's really interesting. Thank you for sharing that perspective. So people experiencing homelessness is a national, regional and local issue. Can you talk to us about successful approaches that you've seen at the local level?

Emily Mosites: Even though homelessness might be a national and regional issue, problem solving and innovation really occur at the local level. We learn most from our local partners. And our primary role on our team is to support state and local health departments.

Some of the inspiring things that we've seen recently is local communities are really doing an amazing job of gathering the voices of people experiencing homelessness to integrate into planning, using lived experience boards. So that's making a board of people who are experiencing homelessness or who have lived experience of homelessness, who can give input on policies or give suggestions about health practices for people experiencing homelessness.

On the local level people have also been finding ways to capture homelessness in public health data collection. That's been a problem for a long time is figuring out how to incorporate homelessness as a data element in public health data. And on the local level, there's been some really great problem solving in that area.

And also just local health departments are just showing up. We've heard from local communities that their public health nurses are there. They're available at encampments and at shelters and they're ready to provide services.

Claire Stinson: Well, that's great to hear. Thank you so much for sharing successful approaches that you've seen. Can you talk about the role that race and equity play in homelessness?

Emily Mosites: Homelessness is absolutely racially inequitable, in particular disproportionately affecting Black and Native Americans. This is the outcome of compounded effects of systemic racism. But the public health lens here is recognizing that both racism and homelessness are a threat to public health and an intolerable threat to public health.

So, there are a couple things that we need to do and the public health cannot always do on their own, but can partner with homeless services to support. So, undoing housing policies that have negative impacts on individuals and families of color and recognizing the public health outcomes of those housing policies, making sure that people of color at the table, public health and homeless service staffing and leadership needs to include people that represent the racial diversity of the people that we're serving. And then, finally, empowering communities of color by ensuring that they have the resources to address homelessness. As I mentioned, innovation and problem solving happen best at the local level.

Claire Stinson: Really important points. Thank you for sharing that. And we absolutely need to have a health equity lens on this issue. So Emily, what do you see as the biggest public health challenges ahead with working to address homelessness?

Emily Mosites: Right now, I think there are actually more opportunities in this area than challenges. Well, the challenges that we have to act on them. So, there are opportunities with the COVID-19 pandemic.

The story of the pandemic is not yet written because we don't have an ending and we get to write that ending. So, that's a major opportunity to reconfigure public health, to be people-focused rather than disease-focused. Integrating work on homelessness throughout public health is one part of how we can do that. And then the challenge will also be just supporting a tired workforce, but also harnessing the momentum of change.

Right now, we have so much change happening right now. And if we just remind ourselves that even with issues that seem intractable like homelessness, there are things that we can do.

Claire Stinson: Absolutely. It sounds like while there are a lot of challenges with this issue, there's also a lot of opportunity. So, thank you so much for sharing this perspective with us today and thank you for being a part of Contagious Conversations.

Emily Mosites: Thank you so much.

Claire Stinson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes. And if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review and tell others. It helps us get the word out.

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