For pandemic control, housing is the best medicine

News reports have revealed glaring inequities in management of the COVID-19 pandemic, with returned overseas travellers hosted in quality hotel accommodation, while overcrowded housing presents a threat to Aboriginal people in remote communities.

Ensuring access to adequate housing, for community members and health workers, is critical for pandemic control, according to the authors below.

Jason Agostino, Liz Sturgiss, Katherine Thurber and Nicole Gurran write

Current Australian federal isolation advice states that people infected with COVID-19 should have a “separate bedroom where they can recover without sharing an immediate space with others” and should use their own bathroom.

However, for most people living in overcrowded or unstable housing, it is impossible to follow these directions. This means these people have reduced capacity to protect themselves and others from infection.

Three groups immediately stand out.

Crowding within the Aboriginal and Torres Strait Islander population occurs at around three times the rate of the non-Indigenous population, with over 115,000 Aboriginal and Torres Strait Islander households living in overcrowded homes, across urban, regional, and remote settings.

Combined with inadequately maintained and often substandard accommodation, as well as a population with a high burden of chronic disease which is already more vulnerable to COVID-19 pandemic, this is a recipe for disaster.

Similarly, the 116,367 homeless Australians and the additional 96,997 Australians who are marginally housed and at risk of homelessness, need urgent assistance. Of these, 13,625 are aged over 55. Many are already waiting for social housing, but with wait times in states such as NSW typically 5-10 years, these groups need urgent intervention.

Further, there is troubling evidence about overcrowding and room sharing in the private rental sector, likely particularly concentrated amongst international students and recently arrived migrants. There is a need to immediately establish arrangements for residents of share accommodation to safely self-isolate or quarantine.

In sum, without adequate quarantine accommodation for suspected cases and isolation for positive cases, COVID-19 has the potential to spread rapidly through vulnerable communities in Australia.

Staff issues

At the height of the epidemic in Wuhan, each individual with COVID-19 infected two to three other people. Analysis of data from Wuhan showed that the majority of clusters were infected by someone in their family. This drove Chinese authorities to implement strict isolation measures, including removing positive cases from their home environment.

The reported rate of infection between members of a household is as low as 3 percent and as high as 10 percent; it is unknown what factors underlie this variability. This demonstrates that while household transmission is a concern, it is not inevitable.

It is not only patients who are experiencing overcrowding and unstable housing – healthcare workers and support staff are also living in these conditions. One Queensland clinic has estimated that 70 percent of their Aboriginal and Torres Strait Islander staff live in overcrowded housing.

The World Health Organization investigation in China suggested that many infections of health care workers occurred in the household, rather than the healthcare setting.

COVID-19 is on track to be another example of the “Inverse Care Law”. Since the early 1970s, medical authorities have documented in multiple studies, and many countries that the people who are most in need of medical care in a community receive the least medical care. This phenomenon is most apparent in healthcare systems driven by “market forces”.

From a baseline of inadequate housing, our Aboriginal and Torres Strait Islander communities and other at-risk communities have the potential to have the worst health outcomes from the COVID-19 pandemic.

Priorities matter

Yet, things can be different. One way to decrease the potential impact of COVD-19 on vulnerable communities is to prioritise securing self-contained, appropriate accommodation for our most at-risk community members.

Accommodation options need to be implemented in a way that centres on patients and community choice. People should have a choice about where they recover from COVID-19, and if people believe they can safely isolate themselves at home, they should be supported to do this in the safest possible way.

Communities must be able to identify the solutions that will work for them. Aboriginal and Torres Strait Islander communities in remote Australia have begun identifying alternate accommodation.

There are multiple options for emergency accommodation options, including:

• Local hotels or motels – those in metropolitan and some regional areas may already be empty of travellers;
• Vacant holiday homes or temporary workforce accommodation;
• Other health accommodation used for rehabilitation that can be re-purposed;
• The construction of temporary dwellings; and,
• Opt-in evacuation from remote communities with no excess housing stock to a regional centre, for example in the case of a confirmed case in the community.

Creative solutions

Managed access to tourism accommodation is a solution already being mobilised internationally.

Just like during Australia’s bushfire crisis, it is likely that many holiday rental companies and second home owners would cooperate with health authorities in offering accommodation for local cases in need.

Similarly, as is occurring with international returnees in capital cities, urban and regional tourism agencies could help source appropriate accommodation within currently empty hotels and motels across Australia, potentially extending an economic lifeline to the ravaged industry.   

In signalling a commitment to protect home owners and renters, Australian governments seem clear on the need to prevent further risks arising from evictions during a pandemic. Securing adequate housing for those in unstable accommodation, particularly those who need to isolate, is the next step in this public health response.

At any time, a stable, safe, and welcoming home environment is an immense source of comfort and wellbeing.

The crisis in Australian housing has ramifications for the COVID-19 pandemic that are not reflected in official advice on isolation, and there currently seems to be no plan for dealing with those in overcrowded or unstable housing.

With no pharmacotherapies shown to be effective in treating COVID-19 and a vaccine many months away, housing is currently the best medicine to combat COVID-19.

Authors

• Dr Jason Agostino, Medical Advisor, National Aboriginal Community Controlled Health Organisation (NACCHO); Lecturer, ANU
• Dr Liz Sturgiss, Senior Research Fellow, Monash University
• Dr Katherine Thurber, Postdoctoral Fellow, ANU
• Prof Nicole Gurran, Professor, Urban Planning, The University of Sydney