By Bernie Pauly and Corey Ranger

It is better to get ahead of a pandemic than chase it. While the efforts of public health to prevent illness and disease are often operating in the background of our health-care system, during COVID 19, prevention is upfront and critical to ensuring our health systems can cope.

Daily, we wait with eager anticipation to hear from our public-health officers, hoping that our prevention efforts of hand-washing, physical distancing, and staying at home and isolating are working to flatten the curve.

As public-health teams work tirelessly with intelligence, tenacity, care, and concern, the public is learning quickly the basics of epidemiology, population health, and prevention.

As public-health and community-engaged nurses, we struggle with this question: "Why is it so hard to understand prevention for people who are experiencing homelessness?"  We have heard time and again: "How do you wash your hands without a sink and soap? How do you stay at home and self-isolate without a home? How do you physically distance when you live in overcrowded shelters or high-density areas?"

The call that disaster is imminent in homeless populations has resounded from coast to coast. Communities are decrying the overcrowded and unhealthy conditions in which homeless people are forced to live—conditions that will enhance the spread of COVID-19. So why do we continue to embrace inadequate emergency responses such as more homeless shelters or housing people only when symptomatic? That is not prevention; that is second-class care.

The United Nations Rapporteur on Housing said on March 18 that “housing is first-line defence against coronavirus”, and never has housing been such a matter of life and death. On April 2, the UN produced guidance for protection of homeless persons during COVID. This guidance focused, first and foremost, on prevention measures that many of us take for granted: housing with running water; a place to stay at home and self-isolate. Emergency shelters, even with physical distancing, are not considered adequate. 

In Canada, we have already embraced "housing first" as an evidence-based strategy that will prevent and reduce homelessness. It is possible to immediately and without conditions offer housing in hotels and motels using this same tried-and-true approach. This move would be of incredible benefit to prevention efforts for a group of people at high risk of contracting COVID due to pre-existing health conditions and two to three times more likely to die of COVID. It would be of economic benefit to hotels and our health-care systems. Permanent housing could be brought online by purchasing vacant buildings and repurposing so that when COVID ends, people can remain housed (as recommended by the UN). 

If we continue to focus on emergency responses, we will be, if we are not already, chasing the pandemic. Failing to enact prevention now is contributing to further sets of systemic assaults and injustices for people already impacted by homelessness, food and income insecurity, and other public-health epidemics.

When we consider that Indigenous peoples are overrepresented among homeless populations, this is a further example of structural violence perpetuated by medicalized and colonial systems. We need a prevention response immediately that includes the Province of B.C. acting on already-in-place emergency legislation to acquire and use public and/or private property as required to prevent the spread of COVID-19.

Under the already declared state of emergency, the province can and should requisition—not negotiate with—hotels and motels to provide immediate accommodation for those who are unsheltered and inadequately housed, and enhance availability of COVID-19 testing. This is prevention.

People who are homeless are at high risk for COVID due to pre-existing health conditions and pre-existing inequities in basic determinants of health such as lack of housing and income and food security, as well as stigma and discrimination that make it challenging to enact public-health measures and access services.

The burdens of COVID-19 are and will be borne disproportionately by those subjected to living in overcrowded conditions, including prisons, homeless shelters, high-density city cores, and reserves. COVID-19 has not only revealed that we are all in this together, it has revealed ever-widening inequity gaps.

Public health is about population health, but it is also always about equity and social justice as a matter of life and death.