icon The Guru Is In

Public Health and the Invisibly Housed

5 min read

Vaccines don’t save lives; vaccinations do. – Medical adage

COVID-19 is in headlong retreat: infections down 70 percent since January, seven-day average hospitalizations and deaths down 66 percent and 77 percent. In less than six months, Covid-19 vaccines in America will have gone from impossibility through scarcity to surplus, with the administration announcing that “all willing American adults will be able to receive a COVID-19 vaccine by the end of May.”

Herd immunity, which is America’s only stable endgame, requires that “enough” people have antibodies – preexisting antibodies, COVID survivor or vaccinated. Because every additional person vaccinated makes all of us a smidgen safer, all of us who are or intend to be vaccinated want others to be as well. What makes a person willing?

The takeup of any new product is influenced by three variables:

  • Availability – Having enough for everyone who wants one;
  • Affordability – Delivering a price point within customers’ reach; and
  • Accessibility – Getting the product to the customer, or the customer to the product.

For COVID vaccines, availability will soon vanish as a constraint in America (though global availability is still critical for all of us worldwide). Affordability is likewise broadly taken care of for all but the very poor. That leaves only accessibility, which has two strands: bringing people to the shots, or the shots to the people. Soon we will have plenty of formal medical venues for giving shots, and for the one-third of Americans who weren’t sure they’d take a vaccine, the experience of their friends and neighbors is rapidly driving that number upward. But there’s one group whose reticence to be vaccinated won’t be grounded in health – the invisibly housed, either undocumented immigrants (as the phrase goes) or off-lease guests.

At any given moment, there are at least 10 million undocumented people living in America. Two-thirds or so of them are working. Cash is their traceless currency, both to be paid and to pay. The human consequences of traceless commerce were recently illustrated in a Boston Globe story of an immigrant family “who asked to be identified only by her first name because of her immigration status.” Noemy, a housecleaner, her husband a house painter and their two children, all live in a single room, rent from “a tenant-in-charge, known in Spanish as an encargado…who also lives in the home and deals directly with the landlord.”

With housing being where jobs go to sleep at night, there follows this syllogism:

  • Informal immigration status
  • Informal employment
  • Informal housing
  • Overcrowding
  • High infection risk.

Don’t tell; don’t ask; don’t sign anything; deal in cash. Above all, don’t call attention to yourself – and we cannot vaccinate those who do not want to be found.

With invisible overcrowding representing at least three percent of all housing tenures nationwide, it’s present in every major U.S. city. This makes vaccine accessibility not a supply-side exercise of getting the right product to the store, but a demand-side challenge of finding means of reaching for the right people, with innovations like these:

  • Current affordable housing as pop-up vaccination sites, with one-day-a-week scheduling handled by the resident manager, especially in partnership with local hospital systems, many of which are already prioritizing public and affordable housing residents;
  • Homeless shelters as consistent vaccination sites, which can offer vaccination to every overnight guest: arrive, get checked, get vaccinated, no charge. Food pantries offer a similar potential outlet;
  • Vaccines free for extended family members of affordable housing residents. For every resident living in these properties, chances are several relatives live nearby or within easy communication. Offer vaccination access to extended family members of current residents, even if they live somewhere else;
  • Vaccine gift cards, funded by donors, such as the large institutions that specialize in public health, the elderly or children, available at any convenience store that sells phone calling cards or takes SNAP (similar populations, similar transactional dynamics);
  • Public housing guests. Many a public housing household hosts permissible temporary guests, including extended-family members. Have public housing community centers as vaccination points, appropriately staffed, where it’s walk-in with a public housing householder, get checked or tested, get vaccinated and walk out;
  • Certified community centers as grass-roots hubs where public health staff can engage the invisibly housed during the day; and
  • In-place vaccine ambassadors and vaccinated testimonials. Residents or employees who speak their language (both figuratively and literally) who’ve had COVID or been vaccinated and can tell their stories, in person or via short phone-compatible videos.

Though free to the vaccinated, this will be a significant lift for the housing realm, so find the money among the billions just appropriated to the Department of Health and Human Services, states and cities.

Epidemiological savant Yogi Berra once said, “If people don’t want to come out to the ballpark, nobody’s gonna stop ‘em.” If we want herd immunity via vaccination, we have to make it easy, safe and familiar for the invisibly housed.

Special thanks to Lyndia Downie (Pine Street Inn), Betsey Martens (Bringing School Home), Michelle Norris (National Church Residences) and Wyman Winston (Wealth Concepts), all of whom provided valuable current insights.

David A. Smith is founder and CEO of the Affordable Housing Institute, a Boston-based global nonprofit consultancy that works around the world (60 countries so far) accelerating affordable housing impact via program design, entity development and financial product innovations. Write him at dsmith@affordablehousinginstitute.org.