North Carolina is among several states facing criticism
Frank Galloway falls into the most vulnerable categories for COVID-19: He is 87, he is Black, and he is experiencing homelessness.
“It ain’t no joke,” Galloway said of the coronavirus, which has killed some of his friends in Greensboro, North Carolina. “I don’t mind taking something that will help my life to keep going.”
He’s waiting for a vaccine while staying in an emergency shelter. Although the state began vaccinating people age 65 and up in mid-January, Galloway, like many others without housing, doesn’t have access to the technology and transportation that people in many places need to get a shot.
Many homeless people have underlying medical conditions.  They are more likely to be people of color, and many are older adults—all groups disproportionately at risk for serious harm from the virus.
“If you look at the highest vulnerable population, it’s the homeless,” said Brooks Ann McKinney of Cone Health, a health care network that has provided regular coronavirus testing and medical care at the shelter where Galloway is staying.
Yet at least 20 states don’t include people living in homeless shelters in their vaccine distribution plans , according to the National Academy for State Health Policy, a nonpartisan research organization with offices in Washington, D.C., and Portland, Maine. Few state plans even mention homeless people not in shelters.
And some states that did prioritize shelter residents in early plans changed tack, moving them further down the list.
Advocates for homeless people want states to put this group at the top of the vaccine distribution list. Prioritizing those experiencing homelessness would allow medical providers to bring vaccines directly to shelters, advocates say, creating a more efficient system that could inoculate more people, keep track of who has which shot and confront vaccine hesitancy.
“There has been trust built with the shelters where we’ve been doing testing regularly,” said McKinney, director of vulnerable populations at Cone Health. “They’re more apt to take the vaccine because they trust the clinicians.
Last week, the National Health Care for the Homeless Council, a Nashville, Tennessee-based membership organization for groups that provide health care to homeless people, sent a letter to governors and state and local health authorities urging them to make adults experiencing homelessness eligible for the vaccine and to begin targeted outreach.
Advocates for those experiencing homelessness are one of many groups petitioning state officials, though. That and the lagging vaccine supply put enormous pressure on state agencies.
When the federal Centers for Disease Control and Prevention offered guidance in December on vaccination priorities, it listed health care workers and long-term care residents at the top.
Separately, the agency issued interim guidance on Feb. 2 focusing on the logistics of vaccinating people experiencing homelessness. The guidance noted that some states have prioritized those residents, but it didn’t say that states ought to do so.
The CDC did not respond to a request for comment from Stateline on whether the February guidance was its first on homeless people.
Hee Soun Jang, a University of North Texas associate professor who is studying care for homeless people during the pandemic, said the CDC was “silent on vaccinating homeless” until then and thinks the delayed guidance may have hindered states in prioritizing homeless people. “We waited so long to have any federal guidance for vaccinating the homeless population.”
Roughly half a million people are experiencing homelessness in the United States—two-thirds of whom are at emergency shelters or in transitional housing, according to a 2020 report from the U.S. Department of Housing and Urban Development. Little is known about how homeless people have been affected by the pandemic, aside from a patchwork of state and city research.
Because of those knowledge gaps and the lack of federal guidelines, each state went its own way on where to place homeless people in the vaccine line. Researchers tracking states’ plans said they have seen the priorities change—but rarely in a way that benefits people experiencing homelessness.
“We’ve seen a big wave of states moving populations around, moving elderly up, moving teachers and grocery store workers up,” said Ariella Levisohn, a research analyst with the National Academy for State Health Policy. “With individuals experiencing homelessness, there hasn’t been much of a pattern.”
In North Carolina, for example, an October distribution plan included people in homeless shelters in the first phase. But the current plan classifies homeless shelter staff as frontline essential workers, putting them in the state’s third group, and shifts people living in homeless shelters into Group 4 .
“We are further marginalizing an already marginalized population by moving them to a later category. That’s upsetting to me,” said Ryan Fehrman, director of Families Moving Forward, a short-term housing shelter for about 50 people in Durham.
Fehrman also criticized the decision to place shelter staff before shelter residents. “To create a power disparity between folks providing a basic service and the folks receiving those services is completely unnecessary.”
Fehrman, along with almost 90 organizations and 300 individuals, sent a letter from the North Carolina Coalition to End Homelessness to the state’s secretary of Health and Human Services, Dr. Mandy Cohen. They asked for people experiencing homelessness to be prioritized for vaccines.
The state’s current prioritization of homeless people aligns with the CDC’s Advisory Committee on Immunization Practices, said North Carolina Department of Health and Human Services spokesperson Catie Armstrong in an email.
The state’s framework is “designed to save lives and slow the spread of COVID-19 by first protecting health care workers, people who are at the highest risk of being hospitalized or dying, and those at high risk of exposure to COVID-19.”
But the state’s decision doesn’t match with its generally good track record on homeless issues, said Trisha Ecklund, vulnerable population program coordinator at Blue Ridge Health Services in Hendersonville, North Carolina.
“They have made a lot of great decisions for the homeless, especially during the pandemic,” she said. “That’s why it’s so disappointing.”
Health and housing officials in Denver also don’t understand why Colorado moved people experiencing homelessness down the priority list.
“It makes no sense that they would not be included early on,” said Bob McDonald, executive director of Denver’s Department of Public Health and Environment. “You can make an argument that it is very much like assisted living situations.”
Denver Mayor Michael Hancock has asked Gov. Jared Polis, a fellow Democrat, for more discretion in vaccine distribution to allow the city to inoculate people experiencing homelessness.
But during a news conference  earlier this month, Polis said that “it would cost lives to divert vaccine from people that are in their 70s to younger, healthier people just because they happen to be homeless.” Polis’ office did not respond to Stateline’s requests for comment.
In the meantime, Denver officials are sending teams to shelters to vaccinate homeless people age 65 and older—even though it’s inefficient, McDonald said, as they turn younger people away.
About 4,200 people  are experiencing homelessness in the city and county of Denver, according to a 2020 survey from the Metro Denver Homeless Initiative, an organization that coordinates services and housing for people experiencing homelessness.
“It’s not that many people,” said Britta Fisher, executive director of Denver’s Department of Housing Stability.
Yet homeless people have been hospitalized at three times the rate of others who have tested positive for COVID-19, she said. “When you look at the numbers, it’s pretty compelling.
“We understand that it is very difficult to make decisions, as there is not enough vaccine,” Fisher said. “We are also persistent in our values around equity.”
Facing vaccine hesitancy
Even in places where the vaccine has been made available to homeless people of all ages, medical teams face logistical hurdles.
“It’s been a massive endeavor,” said Dr. Denise De Las Nueces, medical director for Boston Health Care for the Homeless, which provides health care to homeless people. Massachusetts included homeless shelters in the first round of its vaccine distribution.
De Las Nueces’ team is working with about 40 shelters and as of early last week had vaccinated 1,076 people, or about 50% of eligible adults in shelters.
But many are hesitant to get the vaccine, she noted. During the first clinic in late January, the team vaccinated only about 90 people at a shelter with twice as many residents. De Las Nueces is hopeful the trend is changing with time: At one of their first clinics for second doses, a few dozen came looking for a first shot.
“There is still work to be done in terms of particularly supporting communities of color who are experiencing homelessness,” she said. “That’s not wholly unexpected, of course, because of all of the historical injustices, particularly against African American or Black communities in America.”
Her team is beginning a COVID-19 peer ambassador program for homeless people to encourage others to get vaccinated.
In Washington, D.C., city health officials are trying to overcome vaccine hesitancy by holding presentations at homeless shelters a few days before bringing vaccines. At these sessions, health experts answer questions and share stories like that of Dr. Kizzmekia Corbett , an African American scientist who helped develop the Moderna vaccine.
“Compounding the need to offer the vaccine was the need to recognize the history of exploitation that some of these folks would have experienced … regarding vaccines or medical environments,” said Dr. Anne Cardile of Unity Health Care, which is working with Washington, D.C.’s Department of Health and Human Services to distribute the vaccine to those experiencing homelessness.
By last week, over 1,000 people in D.C. shelters had been vaccinated, Cardile said. Each person was offered a waterproof wallet to hold their vaccine record card. The district is starting a round of second shots this week.
“It is deeply powerful to watch the investment in making sure that they are the first, or among the first, to get the vaccine,” Cardile said.
North Carolina advocates have seen the same hesitancy, said Helen Mangum, who previously experienced homelessness and is a board member of Durham’s Families Moving Forward.
“Of course, there’s the lack of trust in our community,” she said of Black and low-income people. “Are you really surprised by that when you’ve been treating us this way?”
But not being a priority on the vaccine list feels like another hit, Mangum said. “The coronavirus vaccine is another message to us that ‘We’ll get to you. You’re not that important.’”
Still, Mangum, who is in her 50s, plans to get the vaccine when she can.