In a roadside motel with brown stucco walls and yellow awnings, Jeff Smith’s life began anew. Smith has been unhoused for nearly 10 years, and before the COVID-19 pandemic, he bounced among the homeless shelters of Portland, Oregon. There, he’d sleep in crowded rooms that offered only a brief reprieve from the streets. Each day between 5 a.m. and 6 a.m., per shelter rules, he had to leave, only to get back in line at 5:30 p.m. in hopes of getting a bed that night.
On top of the relentless stress of finding a safe space to rest, Smith had spent the past five years battling thyroid cancer. In that time, he also had three heart attacks, cellulitis, and an infection at the base of his spine. Between shelter stays, Oregon’s Medicaid program gave him rides to the hospital for bloodwork, surgery, and radioactive iodine therapy.
By the end of the five years, Smith was engaging less and less with his medical care—he just didn’t have the energy or will. He still made most of his doctor’s appointments, but had completely stopped taking the medication he needed to survive. “I had given up,” Smith says.
Then, a few months into the pandemic, his case worker at the local nonprofit Do Good Multnomah told him about an experimental housing initiative: All over Portland, The Portland/Multnomah County Joint Office of Homeless Services was leasing hotels to shelter those unhoused and at risk of severe coronavirus.
The county wasn’t alone in this initiative. When the pandemic began, urban areas across the country, from Seattle to New York City, struggled to come up with alternatives to densely packed homeless shelters, where the novel coronavirus was spreading fast. Hotels, emptied by the pandemic’s blow to the travel industry, seemed the logical solution.
At first, Smith was reluctant to take a room. He’d built friendships with caseworkers downtown, and didn’t want to leave them. He also worried about the mental toll of isolation. But at his case worker’s request, he accepted. He’s glad he did. “This place is a lifesaver,” Smith says. In his room, he’s been able to catch up on years of lost sleep. He can shower whenever he likes. He has his own toilet.
Most importantly, he has privacy and the stability to access medical care. Each day, he uses his new Chromebook to check his medical chart. He has a place to store the 31 pills he needs each day; onsite caseworkers remind him to take the medication on time and drive him to his doctor’s appointments.
“I would not be alive if I’d had to go through cancer and heart attacks on the street,” Smith says. “I wish I could find every Multnomah County person and thank them.”
How Being Unhoused Affects Health
Even outside of a pandemic, homelessness takes an extreme toll on health. A 2018 study published in The Lancet found mortality rates 3 to 11 times higher in unhoused populations. Other studies suggest this discrepancy persists even when researchers control for socioeconomic class and preexisting health conditions. “You’re exposed to the elements, you’re exposed to extreme stress and trauma,” says Deborah Padgett, a professor at the Silver School of Social Work at New York University and an expert in housing and homelessness. No wonder people’s health suffers under these conditions.
Traditional shelters and housing programs often require participants to meet certain criteria, such as sobriety or enrollment in substance-abuse treatment. Curfews can make it impossible to feel at home, and crowded rooms interfere with sleep and feelings of safety. Housing advocates have long called for change within the shelter system. By providing privacy and stability, the hotel shelters are an unexpected answer to that call. Early research suggests that the new shelters have not only led to a decrease in COVID-19 cases; they’re leading to better health outcomes overall.
When King County, Washington, which encompasses Seattle, first moved more than 700 unhoused people into hotels in April of 2020, the impact was almost immediate. The service providers contracted to run the shelters began calling up the county, reporting that their residents were looking better, sleeping better, in cheerful moods. “They were thriving,” says Gregg Colburn, a professor of real estate who studies affordable housing access at the University of Washington in Seattle.
Colburn, with researchers from the University of Washington and King County, led a study investigating the experience of those staying in the hotel shelters. The researchers interviewed 22 people living in the hotels and nine staff members from housing service providers, the city of Seattle, and King County. People living in the hotels reported better hygiene, less anxiety, and less substance use. They pursued hobbies ranging from watching television to hiking and fishing.
COVID-19 cases were down compared to traditional shelters. Of the 383 people living in the hotel shelters, researchers observed six COVID-19 cases between April 2020, when participants were moved into the hotels, and Sept. 8 of that year. During that same period, researchers observed 49 cases among 926 people living in congregate shelters. As mental health improved, shelters also relied less on police intervention. Among one group of participants, 911 calls to local police fell by 80% after they moved into a hotel.
The success of the hotel shelters is no surprise to researchers and advocates in the world of housing access. Research has long supported the idea of “housing first”—getting people into long-term housing before asking them to navigate health care, social work, and substance abuse treatment. One 2020 study found that people placed in permanent supportive housing received more mental health care: 37.3 visits per year, on average, compared to 19.7 for those who weren’t in permanent housing. They also experienced 38% fewer mental health emergencies. Similarly, in 2019, researchers in Glasgow found that people placed in permanent supportive housing had 37% fewer emergency department visits than their unhoused counterparts and 24% fewer hospitalizations.
It’s important to note that in this second study, researchers didn’t find any improvement in participants’ self-reported health. That makes sense: In studies of permanent supportive housing, these improvements can be difficult to detect, says Maria Raven, the chief of emergency medicine at the University of California San Francisco Medical Center. People often enter permanent supportive housing with a litany of health problems, often undiagnosed, Raven says. And after years of chronic homelessness, it may be impossible to completely reverse the effects of chronic health conditions. “They’re not at the primary or secondary prevention stage,” Raven says. “At that point, permanent supportive housing helps control the medical conditions that people do have.”
Smith, for example, is receiving more consistent care than he ever did on the streets. That’s the humane and necessary thing, Raven says: “When someone is sick and vulnerable, let’s get them housed and keep them housed.”
Hotels as Housing Going Forward
“As tragic as COVID has been, this is an incredible opportunity for the homeless response system,” Colburn says. “We’re able to try something that we would have never ever, ever gotten money for before the pandemic.”
As of now, the hotel shelters aren’t true permanent supportive housing, Colburn says. The housing they provide is temporary. That could change. King County is planning to purchase as many as a dozen hotels using revenue from sales tax, with the goal of placing 2,000 people—nearly half of its current unhoused population—in rooms permanently. In October 2020, Oregon legislative leaders approved $65 million for a project that will turn hotels into permanent supportive housing.
Smith is looking toward the next steps in his life. He just got a photo ID. He’s in the process of applying for Social Security. (“So I’ll be a real person,” he says.) And a month ago, he got his own dog—a caramel-colored, pot-bellied puppy he named Legend. He’s never had a pet before, and he’s crazy about the dog, whom he named out of hope for his future. “He’s going to be part of the legend of how Jeff got a house,” Smith says.
In an ideal world, Smith would move into the guest bedroom of LeBron James. But for now, he’s looking forward to moving to a place with housemates, his own roll of toilet paper, and a space for Legend to run—basics he never would have imagined for himself had it not been for the hotel and Multnomah County’s unconditional offer of shelter.
“It took me a long time to get to this place where I could fight for my life again,” Jeff says, “And I’m still fighting, all the time.”
Isobel Whitcomb is a journalist based in Portland, Oregon. Her work covering health and the environment has appeared in the New York Times, Slate and Bay Nature Magazine. Check out her work at: www.IsobelWhitcomb.com