CoViD-19 in Italy: homeless population needs protection
1Doctors for Human Rights Italy (MEDU), Rome, Italy.
Received and accepted on April 29, 2020.
Summary. Italy is one of the most affected countries by the new coronavirus (CoViD-19) pandemic. In the country, there are an estimated 49,000-52,000 homeless people. People experiencing homelessness are among the potentially most vulnerable groups to the CoViD-19. Despite this, in Italy there is a worrying delay in implementation of a national coordinated strategy to protect homeless people from the potentially devastating effects caused by CoViD-19. In order to contain the epidemic among the most vulnerable people, we propose a short operational agenda based on the field experience of the medical-humanitarian organization Medici per i Diritti Umani (Doctors for Human Rights, Italy - MEDU) as well as on the example of initiatives taken by other countries.
CoViD-19 in Italia: la popolazione senza dimora ha bisogno di protezione.
Riassunto. L’Italia è uno dei paesi più colpiti dalla pandemia provocata dal nuovo coronavirus (CoViD-19). Nel paese si stima vi siano tra le 49.000 e le 52.000 persone senza dimora. Esse costituiscono uno dei gruppi di popolazione potenzialmente più vulnerabili alla CoViD-19. Nonostante ciò, l’Italia accusa un preoccupante ritardo nell’attuazione di una strategia nazionale coordinata per proteggere le persone senza dimora dagli effetti potenzialmente devastanti causati da CoViD-19. Al fine di contenere l’epidemia tra le persone più vulnerabili, proponiamo una breve agenda operativa basata sia sull’esperienza di campo dell’organizzazione medico-umanitaria Medici per i Diritti Umani (MEDU) sia sull’esempio di iniziative prese da altri paesi.
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has taken on pandemic proportions, affecting over 210 countries in a matter of months. Italy is one of the most affected countries by the new coronavirus disease 2019 (CoViD-19) as it had 197,675 confirmed cases according to the Istituto Superiore di Sanità as of 26th April 2020, and 26,644 deaths. People experiencing homelessness are among the potentially most vulnerable groups in this pandemic1. Indeed, homeless people often present multiple chronic conditions; have difficulty accessing health services; live together in shared, overcrowded and cramped accommodation, or on the streets; might not have regular access to basic hygiene supplies or showering facilities. They are, therefore, vulnerable to high rates of infection and mortality without appropriate intervention2. Despite this, in Italy there is a worrying delay in implementation of systems to protect homeless people from the potentially devastating effects caused by CoViD-19. There are an estimated 49,000-52,000 homeless people sleeping rough or in temporary hostel accommodation in Italy. Among them, 85.7% are men, 76.5% live alone, 58.5% are foreigners. The mean age of this population is 44.0 years while most of them (75.8%) are under 54 years of age. People experiencing homelessness condition are particularly concentrated in great cities like Milan (12,000), Rome (8,000), Palermo (3,000) and Florence (2,000)3. Moreover, among homeless people, there are groups deserving particular attention because of their heightened vulnerability: people aged over 50 and/or with chronic diseases, people with mental health problems, migrants and refugees. Homeless people tend to report a worse mental health condition than the general population4; indeed, people who experience both homelessness and mental health problems may be particularly affected by the epidemic and, at the same time, pose specific problems in CoViD-19 containment strategies5. Also migrants and refugees are particularly vulnerable to the impact of CoViD-19 and are over-represented among the homeless population in Italy and Europe6.
Despite these premises, Italy has no national coordinated strategy regarding homelessness and CoViD-19. This is mainly due to the characteristic of the decentralized Italian National Health System (NHS) which entrusts health management to 20 regional administrations, generating inhomogeneous health strategies in the different territories of the country. Medici per i Diritti Umani (Doctors for Human Rights, Italy - MEDU), as independent medical-humanitarian NGO, is currently implementing a CoViD-19 containment intervention among over three thousand people experiencing homelessness or very precarious housing condition in three regions: Tuscany (metropolitan area of Florence plan supporting adequate accommodation for the homeless population during the epidemic, Prato and Pistoia), Lazio (metropolitan area of Rome) and Calabria (Piana di Gioia Tauro at informal settlements of refugees and migrants employed in agriculture). None of these regions have yet developed an emergency structured plan supporting adequate accommodation for the homeless population during the epidemic. Information, screening and active surveillance activities also appear to be more entrusted to the independent initiative of associations and charities operating in the sector than to overall strategies of regional health systems. The situation does not appear better in the other Italian regions. To date, only the Piedmont Region has issued official guidelines indicating the measures to be taken to protect homeless people during the CoViD-19 epidemic7.
In light of these serious critical issues, we believe that the activation of a national strategy aimed at containing the epidemic among the homeless population is urgent. In this regard, we propose a short operational agenda based on our field experience as a humanitarian organization as well as on the example of initiatives taken by other countries.
1. Public safety and protecting the most vulnerable people from coronavirus should be among the government’s top priority. It’s paramount that the government work closely with regions, councils and charities/NGOs to ensure them the necessary support throughout this period.
2. A national emergency fund should be implemented to prevent the spread of CoViD-19 among people experiencing homelessness, or those at risk of rough sleeping. The funding should be available to all regional and local authorities in Italy and should help cover costs of providing accommodation and services to those sleeping on the streets during the epidemic.
3. It would be important to implement a homogeneous national program divided into three strategic lines: 1) active surveillance on the territory; 2) CoViD-Care, for people who are symptomatic or have tested positive; and 3) CoViD-Protect, for people who have other medical vulnerabilities who are asymptomatic or screen negative, but who also need to self-isolate2. In this regard it would be particularly important to protect the homeless population over 50 years of age and/or those with risk factors for mortality, such as existing respiratory illness or heart disease.
4. Care and Protect facilities (unused hotels, hostels, reception centres etc.) need to be in separate locations with separate staff. Each of these structures should have one room and one bathroom per person in order to help them successfully self-isolate. The Care facilities should provide medical support to the patients but also the Protect units should monitor the clinical conditions of the hosts in order to rapidly transfer to a Care facility those displaying CoViD-19 symptoms.
5. In both facilities it should be important to ensure psychological and psychiatric support as people using these services are likely to experience particularly high mental distress. As addiction figures prominently among homeless persons8, services dedicated to people with addiction problem (alcohol, drugs) would also be needed to prevent withdrawal symptoms and other related problems.
6. An active screening and surveillance program among the homeless population is essential in large urban centres but also in overcrowded migrants and refugees’ informal settlements in the countryside of southern Italy (i.e., Piana di Gioia Tauro in Calabria and Capitanata area in Puglia) where hygienic and housing conditions are very poor. These outreach activities should support the intervention carried on by many associations already present in the field and should be implemented jointly by the NHS and associations, NGOs and charities.
7. Medical masks and hand sanitizer gel should be systematically distributed to the entire homeless population. In large cities, toll-free numbers should be active in order to allow social and health operators working in the street to: a) report people in need, and b) make use of a CoViD-19 telephone triage. An agile referral system should make possible the rapid transfer of people in needs to the Care or Protect facilities. A safe transportation system (equipped vehicle, trained staff with personal protective equipment) should be implemented for people who are symptomatic or have tested positive.
All these measures can help limit the spread of the epidemic, avoid the onset of new outbreaks, relieve pressure on the hospital system and ultimately avoid more deaths. Definitely, all measures must be taken to prevent an already highly vulnerable population from becoming even more marginalized due to the pandemic.
Conflict of interests: the author has no conflict of interests to declare.
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