key: cord-253653-y4a6yan7
authors: Schiff, Rebecca; Buccieri, Kristy; Schiff, Jeannette Waegemakers; Kauppi, Carol; Riva, Mylene
title: COVID-19 and pandemic planning in the context of rural and remote homelessness
date: 2020-09-24
journal: Can J Public Health
DOI: 10.17269/s41997-020-00415-1
sha: 
doc_id: 253653
cord_uid: y4a6yan7

Addressing the vulnerability and unique needs of homeless populations during pandemics has been a major component of the Canadian federal response to the COVID-19 crisis. Rural and remote communities, however, have received little to no funding to aid in their care of homeless people during the pandemic. Similarly, there has been little to no research on rural communities’ pandemic preparedness in the context of homelessness. There are large numbers of homeless individuals in rural and remote Canada, including Indigenous peoples who are over-represented in homeless populations. Rural communities, including rural and remote Indigenous communities, are often isolated and more limited than urban areas in their capacity to respond to pandemics. They are particularly vulnerable due to fewer healthcare and social service resources—the lack of which has been particularly evident during the COVID-19 pandemic. In this commentary, we suggest that policy-makers need to take seriously the situation of rural homelessness in Canada, its implications for individual and community health, and consequences in the context of pandemics. Policy- and decision-makers can address these concerns through increased homelessness funding and support for rural and remote communities, policy change to recognize the unique challenges associated with rural pandemic planning and homelessness, and more research that can be translated into policy, programs, and supports for rural homelessness and pandemic planning response.

La prise en compte de la vulnérabilité et des besoins spécifiques des populations itinérantes lors des pandémies a été un élément majeur de la réponse fédérale canadienne à la crise de la COVID-19. Toutefois, pendant la pandémie, les communautés rurales et éloignées n'ont reçu que peu ou pas de financement pour les soutenir dans leur offre de soins et de services aux personnes en situation d'itinérance. De même, il n'y a que très peu de recherche dans le contexte de l'itinérance sur la préparation des communautés rurales en cas de pandémie. Or, il existe un nombre important de personnes en situation d'itinérance dans les mileux ruraux et éloignés, parmi lesquelles on observe une surreprésentation de personnes d'ascendance autochtone. Les communautés rurales, incluant les communautés autochtones rurales et éloignées, sont souvent isolées et plus limitées que les milieux urbains dans leur capacité à répondre aux pandémies. Elles sont particulièrement vulnérables en raison du manque de ressources en matière de soins de santé et de services sociaux; ceci est particulièrement évident dans le contexte actuel de pandémie de la COVID-19. Dans ce commentaire, nous appelons les décideurs politiques à prendre au sérieux la situation de l'itinérance en milieu rural au Canada, ses implications sur la santé individuelle et communautaire, et ses conséquences dans le contexte des pandémies. Les responsables politiques et les décideurs peuvent répondre à ces préoccupations en augmentant le financement pour contrer l'itinérance et mieux soutenir les milieux ruraux et éloignés en modifiant les politiques afin de

Addressing the vulnerability and unique needs of homeless populations during pandemics has been a major component of the Canadian federal response to the COVID-19 crisis (Office of the Prime Minister 2020). Rural and remote communities, however, have received little to no funding to aid in their care of homeless people during the pandemic (Kelford, personal communication). Some funding was made available under the competitive Rural and Remote stream of Canada's National Housing Strategy-Reaching Home-for rural homelessness response to COVID-19. The amounts available under the Rural and Remote stream, however, have been disproportionately less (if comparing population size) than what is made available to urban communities-"designated communities" in the Reaching Home terminology (Kelford, personal communication). This is despite emerging evidence that rural and remote communities experience homelessness rates that are equivalent to or potentially higher than those experienced in urban areas. 1 Rural and remote communities must apply for and compete for funding against other rural communities, whereas urban "designated" communities are guaranteed a certain amount of funding under the Strategy. Some rural and remote communities, particularly larger centres, have more resources than others, which makes it more difficult for smaller communities to complete funding applications and successfully compete for funding. These issues are further complicated during pandemics, when scant resources are stretched even further and result in more limited capacity to complete funding applications.

There has also been little to no research on rural communities' pandemic preparedness in the context of homelessness. Pandemic Preparedness and Homelessness (Buccieri and Schiff 2016) was the first book to bring together the work of Canadian researchers exploring the vulnerability of homeless populations in the event of a pandemic, and was utilized by the Public Health Agency of Canada (PHAC) in their Pandemic Preparedness Guide for the Health Sector (PHAC 2018). There is little other literature examining pandemic preparedness in the homeless sector. The chapters in Buccieri and Schiff (2016) had a primary focus on urban populations in four Canadian cities-analyzing the impact of the H1N1 outbreak within the context of urban homelessness, with little attention to rural contexts. Similarly, the PHAC guide contains no mention of rural communities and their unique needs during pandemic crises. There is clearly a large gap in current supports for, and understandings of, pandemic responses in the context of homelessness in rural settings.

Estimates suggest a rise in homelessness in Canada and that 235,000 or more individuals use homeless shelters annually (Gaetz et al. 2016) . The extent of homelessness in Canada is a major social and public health concern, particularly in the context of pandemics. Homelessness presents key challenges for emergency and pandemic planning due to complex health, situational, and structural vulnerabilities. This has been particularly evident during the COVID-19 crisis (Government of Canada 2020a). Housing is a key social determinant of health, and it is widely documented that homeless people (including hidden homeless/housing-insecure individuals) suffer from much poorer health status and health outcomes than the general population (Frankish et al. 2005 (Frankish et al. , 2009 Hwang et al. 2009 ). These medical-and health-related issues combine with social exclusion to create particularly significant vulnerability to infectious disease transmission and recovery (Buccieri et al. 2018) . The homelessness response system has historically been focused on emergency response. This service system is characterized by overcrowded sleeping conditions, poor air quality, and a range of other public health issues that are alarming in the light of high transmission rates and the need for social distancing during pandemic situations. Even in urban communities, homeless shelters are often not open for clients during daytime hours, meaning that if you are homeless and ill then there are limited options for rest and recovery. In rural settings, these shelters have even more limited services and availability. Homeless people typically suffer from poor health, nutritional vulnerability, compromised immune systems, and barriers to accessing health services (Frankish et al. 2005) . Their health is further compromised when food sources are very restricted, supplies limited, and opportunities to store supplies non-existent (Buccieri and Schiff 2016) . It is essential to ask what kind of impacts a pandemic is having on homeless individuals and others living in precarious housing situations across the country. During the current COVID-19 pandemic, it is clear that the infrastructure to address homelessness and the associated public health and healthcare services have not been prepared to adequately respond to the risks faced by the homeless population. This is particularly concerning for rural Canada.

Until recently, there was little acknowledgement that homelessness existed in rural areas in Canada (Waegemakers Schiff et al. 2015) . Understanding of rural homelessness is minimal compared with that focussed on urban populations, and assessment of needs within the non-urban population is often overlooked. Rural homelessness was unacknowledged in this country until reports from diverse rural areas of Canada began to emerge in the last decade which shed light on the unique context of the issue (Kauppi et al. 2017 (Kauppi et al. , 2020 Waegemakers Schiff et al. 2015) . Rural and remote homelessness is indeed a significant issue in Canada (Kauppi et al. 2017; Taylor 2018) . There are large numbers of homeless individuals in rural and remote Canada, and undercounts of those who are without permanent housing are alarming. However, the majority of homelessness funding in Canada continues to be directed towards large urban centres (Government of Canada 2020b). Rural communities are often isolated and thus more limited than urban areas in their capacity to respond to pandemics. They are particularly vulnerable due to fewer healthcare and social service resources, scarcity of soup kitchens and food banks-the lack of which has been particularly evident during the COVID-19 pandemic and which has significantly impacted their ability to respond to the needs of homeless people (Kelford, personal communication) .

It is imperative that pandemic responses be specifically designed for rural communities, rather than simply being extensions or adaptations of existing urban strategies. For rural communities to be better prepared for the ongoing COVID-19 crisis, and future pandemics, it is critical to understand their capacities for pandemic planning. We must consider the unique strengths of rural communities, such as the potential to mobilize existing networks and local knowledge that already exists among residents. We must also consider the unique challenges that accompany pandemic response in rural settings, such as accessing remote dwellings, limited or nonexistent public transportation, the increased potential for fuel poverty, and less access to technology such as high-speed internet connections. We must also consider situational vulnerabilities (e.g., housing insecurity, food insecurity, poverty) that might be exacerbated in the context of pandemics and which might force some individuals and families into even more precarious housing situations and homelessness. Because mobility between regions can be limited because of confinement protocol, it is also important to understand the impact of the pandemic on the ability of rural service providers and homeless individuals to access resources that are usually provided by their urban counterparts.

Policy-makers need to take seriously the situation of rural homelessness in Canada, its implications for individual and community health, and consequences in the context of pandemics. Policy-and decision-makers can address the pandemic preparedness needs of rural and remote communities through increased homelessness funding and support which is more equitable and in line with that available to urban communities. We also suggest a need for policy change to formalize recognition of the magnitude of rural homelessness and the unique needs and capacities of rural communities in the context of pandemics, and to include rural and remote homeless persons as a vulnerable population in the context of pandemics. There is also a need for more applied research on rural and remote homelessness that is readily translated into policy, programs, and supports-to ensure that rural health and social service providers are better prepared for future waves of the COVID-19 pandemic and future pandemics.

Conflict of interest The authors declare that they have no conflict of interest.

Pandemic preparedness and homelessness: Lessons from H1N1 in Canada

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Homelessness and health in Canada: Research lessons and priorities

The relationship between homelessness and health: An overview of research in Canada

Guidance for providers of services for people experiencing homelessness (in the context of COVID-19)

Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study

Homelessness and hidden homelessness in rural and northern Ontario

Homelessness enumeration in the Cochrane District

Prime Minister announces support for vulnerable Canadians affected by COVID-19

Public health measures: Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector

How is rural homelessness different from urban homelessness? Available at

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