Title
A GUIDELINE AND RECOMMENDATION to inform jurisdictions working at regional, county, and city levels on alleviating the unsheltered homelessness public health crisis for the benefit of the health, well-being and survival of unsheltered people throughout King County.
Body
A. The Board of Health adopts this guideline to urge, inform and assist regional, county and city jurisdictions to address the problem of unsheltered homelessness for the benefit of the health, well-being and survival of unsheltered people throughout King County.
B. The Board of Health adopts this guideline based on the following:
1. The continued lack of shelter for thousands of people experiencing homelessness in King County is a public health crisis with imminent threats to the health, well-being and survival of unsheltered people;
2. The November 2015 proclamations of emergency by the King County Executive and the City of Seattle Mayor have not preserved public health or protected the safety and welfare of individuals. According to the 2018 All Home Count-Us-In/Point-In-Time Count, current efforts to alleviate the unsheltered homelessness public health crisis have been unsuccessful and the number of unsheltered people has increased approximately sixty-eight percent in King County (three thousand seven hundred seven-two to six thousand three hundred twenty) between 2015 and 2018;
3. The March 2018 Report on Homeless Deaths by the King County Medical Examiner Office ("MEO") reported a greater-than-doubling (seventy-eight to one hundred sixty-nine) of MEO investigated deaths involving "presumed homeless persons" between 2012 and 2017, where almost half of the deaths occurred in downtown and central Seattle, Beacon Hill and south Seattle and north Seattle and Shoreline. The MEO defines "presumed homeless persons" as individuals without permanent housing who lived on the streets or stayed in a shelter, vehicle or abandoned building at the time immediately preceding death;
4. Noncommunicable diseases are prevalent amongst unsheltered people where:
a. According to the 2018 King County Count-Us-In survey, half of respondents reported at least one disabling condition, including psychiatric or emotional conditions, drug or alcohol abuse, posttraumatic stress disorder, chronic health problems and physical disability;
b. Also according to the survey, serious mental illness, substance use disorder and HIV/AIDS are two to three times more common among unsheltered adults than sheltered adults; and
c. The March 2018 Report on Homeless Deaths by the MEO determined that half of the six hundred ninety-seven presumed homeless decedents, from 2012 to2017, died outdoors, primarily of "natural causes," which are illnesses or internal malfunctions of the body, as the leading cause of death, followed by drug overdose or alcohol poisoning;
5. Unsheltered people face increased risk for communicable diseases particularly diseases that either or both can be made worse in individual cases or can spread to other people because of inadequate housing, sanitation and hygiene resources. Some examples include: hepatitis A; diarrheal illnesses, such as Shigella infections; bodily, clothing and bedding infestations by ectoparasites such as fleas, bedbugs, lice, scabies mites and ticks; ectoparasite vector-borne infectious agents; and bacterial skin infections, such as methicillin-resistant Staphylococcus aureus (MRSA) or Group A Streptococcus infections, which can cause flesh eating wounds;
6. Public Health - Seattle & King County recently issued public health advisories due to outbreaks among homeless persons of group A Streptococcus, Shigella and body lice-transmitted Bartonella quintana infections;
7. Harborview Medical Center reported that a highly contagious strain of respiratory syncytial virus (RSV), spread through homeless people during the 2017-2018 winter flu outbreak;
8. Adequate shelter, water, sanitation and hygiene infrastructure can control or eliminate the spread of contact-transmitted, ectoparasite-borne, foodborne and waterborne communicable diseases;
9. Healthcare, navigation and other supportive resources can be delivered more effectively and more efficiently at large, established shelter locations rather than at scattered and tenuous outdoor locations;
10. Creating and maintaining temporary large-scale disaster shelter infrastructure with supportive and navigation services will not resolve the homelessness crisis but will reduce death, disability and disease for unsheltered homeless people in King County;
11. The unsheltered public health crisis exists throughout the year but will worsen when inclement weather and flu season return in the fall and winter of 2018-2019, and annually thereafter;
12. According to the 2018 All Home Count-Us-In/Point-In-Time Count and the 2016 Annual Homeless Assessment Report to Congress, homelessness disproportionately affects the most vulnerable populations in our society, including people of color, particularly American Indians and Alaska Natives, veterans, youth who identify as LGBTQ+, people with chronic disabilities and people who report histories of domestic violence, partner abuse and foster care;
13. The Centers for Disease Control and Prevention defines a public health disaster, on the basis of its consequences on health and health services, as a serious disruption of the functioning of society, causing widespread human, material or environmental losses, that exceeds the local capacity to respond, and calls for external assistance. Unsheltered homelessness in King County is a public health disaster; and
14. Article 25 of the United Nations Universal Declaration of Human Rights declares that "everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including…housing."
C. The Board of Health adopts the following guideline for the jurisdictions working at regional, county and city levels to alleviate the unsheltered homelessness public health crisis, to:
1. Affirm that the continued lack of shelter for people experiencing homelessness is a public health crisis that warrants a definitive emergency response;
2. Recognize the urgency of the unsheltered homelessness public health crisis by rapidly providing basic, enhanced and low-barrier emergency shelter sufficient to serve all unsheltered homeless individuals, in preparation for the inclement weather in the fall and winter of 2018-2019. Basic, enhanced and low-barrier emergency shelter should be maintained and enhanced beyond 2018-2019, until long-term housing is available for all homeless individuals. Basic, enhanced and low-barrier emergency shelter are defined as follows:
a. "Basic emergency shelter" means a physical space that provides protection from inclement weather, allows overnight or longer access and ensures basic needs including but not limited to personal safety, sufficient and safe sleep, a sanitary environment and hand hygiene resources;
b. "Enhanced emergency shelter" means a physical space with basic emergency shelter features and additional features including but not limited to: twenty-four hours seven days a week access, hygiene facilities, secure storage for personal belongings, safe food resources or meal services, case management and access to mental or behavioral health or both, medical, employment and housing navigation services; and
c. "Low-barrier emergency shelter" means a physical space, where a minimum number of expectations are placed on the people who wish to live there. It includes basic emergency shelter features or enhanced emergency shelter features and follow a harm-reduction philosophy; serving people with common barriers to shelter eligibility including individuals with partners, families, pets and mental health or substance use disorders;
3. Leverage existing resources to guide planning, deployment and maintenance of emergency shelter, such as:
a. Local jurisdictions' Comprehensive Emergency Response Plans, or other comparable local emergency action plans, particularly emergency support functions related to mass care, temporary housing and human services. As defined by the United States Federal Emergency Management Agency, mass care is congregate sheltering, feeding and distribution of emergency supplies;
b. Public Health - Seattle & King County's "Sanctioned Homeless Encampments Initial Planning and Management Checklist", included as Attachment A to this Guideline and Recommendation;
c. "Shelter Field Guide" (FEMA P-785) by the United States Federal Emergency Management Agency and the American Red Cross; and
d. The Sphere Project’s "Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response";
4. Consider available public lands to place temporary emergency sheltering and consider modification of existing policies or regulations to expedite the process to place temporary emergency sheltering on public lands;
5. Consider utilizing an Incident Command System or utilize the following principles of an Incident Command System to organize the rapid response necessary to provide emergency shelter for all unsheltered homeless individuals in an affected jurisdiction in time for fall and winter of 2018-2019. The Incident Command System is a standardized approach to the command, control and coordination of emergency response providing a common hierarchy within which responders from multiple agencies can be effective:
a. Recognize the distinction between rapid response efforts to maximize shelter capacity in time for fall and winter of 2018-2019 and longer-term efforts to maintain and enhance shelter, analogous to the "response" and "recovery" phases of emergency management;
b. Preserve primary authority, control and responsibility to local jurisdictions;
c. Develop a strategic plan that includes specific objectives and a timeline to provide rapid response emergency shelter, regular tracking of progress toward those objectives and preparation for eventual transition (demobilizing) from rapid response to longer-term sheltering efforts;
d. Leverage existing Comprehensive Emergency Response Plans, or other comparable local emergency action plans, to facilitate strategic, operational and logistic decisions for rapid response sheltering efforts;
e. Tailor and prioritize strategic and operational decisions to reflect the various needs, challenges and resources of different unsheltered homeless individuals. For example, could rapid response sheltering efforts be different or delayed for people living in recreational vehicles and emergency shelters be prioritized for people camping in tents or living in cars?;
f. Establish a temporary organizational structure in which leadership, decision authority, management and responsibility are streamlined to specific individuals, departments, agencies and organizations directly involved in rapid response sheltering efforts;
g. Consider whether some rapid response sheltering management functions might be most efficiently offered by a higher level jurisdiction, such as procurement of shelter materials, information tracking, subject matter expertise related to public health and other subject matter expertise to support planning and operations; and
h. Engage in concurrent planning for longer-term sheltering while the rapid response sheltering is on-going. Planning should consider enhancements to rapid response shelters and replacement of rapid response shelters with more durable structures;
6. Create and monitor performance metrics on unsheltered homelessness and temporary large-scale crisis sheltering including, but not limited to, entries to shelter, time in shelter, exits from shelter, exit destinations and reentries to shelter;
7. Coordinate with other local jurisdictions, nongovernmental organizations and state agencies to implement rapid and longer-term sheltering actions, monitor performance and broadly address the unsheltered homelessness public health crisis;
8. Explore best practices and initiatives in other regions that provide temporary emergency sheltering on a mass scale for unsheltered homeless individuals, such as but not limited to, large tent shelters for rapid response sheltering and durably constructed structures or modular housing for longer-term sheltering; and
9. Continue the separate but closely related initiatives by all jurisdictions to
prevent homelessness, make homelessness brief and one-time and expand regional options for affordable housing.