When basic supplies are missing, what to do? Specific demands of the local street population in times of coronavirus – a concern of social psychiatry
Identifieur interne : 000514 ( Pmc/Corpus ); précédent : 000513; suivant : 000515When basic supplies are missing, what to do? Specific demands of the local street population in times of coronavirus – a concern of social psychiatry
Auteurs : Modesto Leite Rolim Neto ; Ricardo Inácio De Souza ; Rosa Magda Martins Quezado ; Elayne Cristina Santos Mendonça ; Tallys Iury De Araújo ; Dayse Christina Rodrigues Pereira Luz ; Willma José De Santana ; Juliana Ribeiro Francelino Sampaio ; Poliana Moreira De Medeiros Carvalho ; Tereza Maria Siqueira Nascimento Arrais ; José Marcondes Macedo Landim ; Claúdio Gleideston Lima Da SilvaSource :
- Psychiatry Research [ 0165-1781 ] ; 2020.
Abstract
Homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless. In terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. In this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go? With more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside already have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop COVID-19. A large population of homeless people experience their pain and psychological distress intermittently. For low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. This is a serious concern when linked to the pandemic.
Url:
DOI: 10.1016/j.psychres.2020.112939
PubMed: 32304928
PubMed Central: 7152880
Links to Exploration step
PMC:7152880Le document en format XML
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<author><name sortKey="Sampaio, Juliana Ribeiro Francelino" sort="Sampaio, Juliana Ribeiro Francelino" uniqKey="Sampaio J" first="Juliana Ribeiro Francelino" last="Sampaio">Juliana Ribeiro Francelino Sampaio</name>
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<author><name sortKey="Da Silva, Claudio Gleideston Lima" sort="Da Silva, Claudio Gleideston Lima" uniqKey="Da Silva C" first="Claúdio Gleideston Lima" last="Da Silva">Claúdio Gleideston Lima Da Silva</name>
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</affiliation>
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</affiliation>
</author>
<author><name sortKey="De Santana, Willma Jose" sort="De Santana, Willma Jose" uniqKey="De Santana W" first="Willma José" last="De Santana">Willma José De Santana</name>
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</affiliation>
</author>
<author><name sortKey="Sampaio, Juliana Ribeiro Francelino" sort="Sampaio, Juliana Ribeiro Francelino" uniqKey="Sampaio J" first="Juliana Ribeiro Francelino" last="Sampaio">Juliana Ribeiro Francelino Sampaio</name>
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</affiliation>
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<author><name sortKey="Carvalho, Poliana Moreira De Medeiros" sort="Carvalho, Poliana Moreira De Medeiros" uniqKey="Carvalho P" first="Poliana Moreira De Medeiros" last="Carvalho">Poliana Moreira De Medeiros Carvalho</name>
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<author><name sortKey="Arrais, Tereza Maria Siqueira Nascimento" sort="Arrais, Tereza Maria Siqueira Nascimento" uniqKey="Arrais T" first="Tereza Maria Siqueira Nascimento" last="Arrais">Tereza Maria Siqueira Nascimento Arrais</name>
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</affiliation>
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<author><name sortKey="Da Silva, Claudio Gleideston Lima" sort="Da Silva, Claudio Gleideston Lima" uniqKey="Da Silva C" first="Claúdio Gleideston Lima" last="Da Silva">Claúdio Gleideston Lima Da Silva</name>
<affiliation><nlm:aff id="aff0001">School of Medicine of Juazeiro do Norte – FMJ/Estácio, Juazeiro do Norte, Ceará, Brazil</nlm:aff>
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<series><title level="j">Psychiatry Research</title>
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<front><div type="abstract" xml:lang="en"><title>Highlights</title>
<p><list list-type="simple" id="celist0001"><list-item id="celistitem0001"><label>•</label>
<p id="para0001">Homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless.</p>
</list-item>
<list-item id="celistitem0002"><label>•</label>
<p id="para0002">In terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. In this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go?</p>
</list-item>
<list-item id="celistitem0003"><label>•</label>
<p id="para0003">With more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside already have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop COVID-19.</p>
</list-item>
<list-item id="celistitem0004"><label>•</label>
<p id="para0004">A large population of homeless people experience their pain and psychological distress intermittently. For low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. This is a serious concern when linked to the pandemic.</p>
</list-item>
</list>
</p>
</div>
</front>
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<front><journal-meta><journal-id journal-id-type="nlm-ta">Psychiatry Res</journal-id>
<journal-id journal-id-type="iso-abbrev">Psychiatry Res</journal-id>
<journal-title-group><journal-title>Psychiatry Research</journal-title>
</journal-title-group>
<issn pub-type="ppub">0165-1781</issn>
<issn pub-type="epub">1872-7123</issn>
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<article-id pub-id-type="doi">10.1016/j.psychres.2020.112939</article-id>
<article-id pub-id-type="publisher-id">112939</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Article</subject>
</subj-group>
</article-categories>
<title-group><article-title>When basic supplies are missing, what to do? Specific demands of the local street population in times of coronavirus – a concern of social psychiatry</article-title>
</title-group>
<contrib-group><contrib contrib-type="author" id="au0001"><name><surname>Neto</surname>
<given-names>Modesto Leite Rolim</given-names>
</name>
<email>modesto.neto@ufca.edu.br</email>
<xref rid="aff0001" ref-type="aff">a</xref>
<xref rid="aff0002" ref-type="aff">b</xref>
<xref rid="cor0001" ref-type="corresp">⁎</xref>
</contrib>
<contrib contrib-type="author" id="au0002"><name><surname>de Souza</surname>
<given-names>Ricardo Inácio</given-names>
</name>
<xref rid="aff0001" ref-type="aff">a</xref>
</contrib>
<contrib contrib-type="author" id="au0003"><name><surname>Quezado</surname>
<given-names>Rosa Magda Martins</given-names>
</name>
<xref rid="aff0001" ref-type="aff">a</xref>
</contrib>
<contrib contrib-type="author" id="au0004"><name><surname>Mendonça</surname>
<given-names>Elayne Cristina Santos</given-names>
</name>
<xref rid="aff0001" ref-type="aff">a</xref>
</contrib>
<contrib contrib-type="author" id="au0005"><name><surname>de Araújo</surname>
<given-names>Tallys Iury</given-names>
</name>
<xref rid="aff0003" ref-type="aff">c</xref>
</contrib>
<contrib contrib-type="author" id="au0006"><name><surname>Luz</surname>
<given-names>Dayse Christina Rodrigues Pereira</given-names>
</name>
<xref rid="aff0004" ref-type="aff">d</xref>
<xref rid="aff0005" ref-type="aff">e</xref>
</contrib>
<contrib contrib-type="author" id="au0007"><name><surname>de Santana</surname>
<given-names>Willma José</given-names>
</name>
<xref rid="aff0004" ref-type="aff">d</xref>
<xref rid="aff0005" ref-type="aff">e</xref>
</contrib>
<contrib contrib-type="author" id="au0008"><name><surname>Sampaio</surname>
<given-names>Juliana Ribeiro Francelino</given-names>
</name>
<xref rid="aff0005" ref-type="aff">e</xref>
</contrib>
<contrib contrib-type="author" id="au0009"><name><surname>Carvalho</surname>
<given-names>Poliana Moreira de Medeiros</given-names>
</name>
<xref rid="aff0004" ref-type="aff">d</xref>
<xref rid="aff0005" ref-type="aff">e</xref>
</contrib>
<contrib contrib-type="author" id="au0010"><name><surname>Arrais</surname>
<given-names>Tereza Maria Siqueira Nascimento</given-names>
</name>
<xref rid="aff0004" ref-type="aff">d</xref>
<xref rid="aff0005" ref-type="aff">e</xref>
</contrib>
<contrib contrib-type="author" id="au0011"><name><surname>Landim</surname>
<given-names>José Marcondes Macedo</given-names>
</name>
<xref rid="aff0004" ref-type="aff">d</xref>
<xref rid="aff0005" ref-type="aff">e</xref>
</contrib>
<contrib contrib-type="author" id="au0012"><name><surname>da Silva</surname>
<given-names>Claúdio Gleideston Lima</given-names>
</name>
<xref rid="aff0001" ref-type="aff">a</xref>
<xref rid="aff0002" ref-type="aff">b</xref>
</contrib>
</contrib-group>
<aff id="aff0001"><label>a</label>
School of Medicine of Juazeiro do Norte – FMJ/Estácio, Juazeiro do Norte, Ceará, Brazil</aff>
<aff id="aff0002"><label>b</label>
School of Medicine, Federal University of Cariri – UFCA, Barbalha, Ceará, Brazil</aff>
<aff id="aff0003"><label>c</label>
Rigoberto Romero de Barros Maternity Hospital, Amontada, Ceará Brazil</aff>
<aff id="aff0004"><label>d</label>
Postgraduate Program in Health Sciences, School of Medicine of ABC, Santo André, São Paulo, Brazil</aff>
<aff id="aff0005"><label>e</label>
College of Juazeiro do Norte – FJN, Juazeiro do Norte, Ceará, Brazil</aff>
<author-notes><corresp id="cor0001"><label>⁎</label>
Correspondence author at: Modesto Leite Rolim Neto, School of Medicine, Federal University of Cariri, UFCA, Barbalha, Ceará, Brazil. <email>modesto.neto@ufca.edu.br</email>
</corresp>
</author-notes>
<pub-date pub-type="pmc-release"><day>13</day>
<month>4</month>
<year>2020</year>
</pub-date>
<pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>6</month>
<year>2020</year>
</pub-date>
<pub-date pub-type="epub"><day>13</day>
<month>4</month>
<year>2020</year>
</pub-date>
<volume>288</volume>
<fpage>112939</fpage>
<lpage>112939</lpage>
<history><date date-type="received"><day>20</day>
<month>3</month>
<year>2020</year>
</date>
<date date-type="accepted"><day>23</day>
<month>3</month>
<year>2020</year>
</date>
</history>
<permissions><copyright-statement>© 2020 Elsevier B.V. All rights reserved.</copyright-statement>
<copyright-year>2020</copyright-year>
<copyright-holder>Elsevier B.V.</copyright-holder>
<license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p>
</license>
</permissions>
<abstract abstract-type="author-highlights" id="abs0001"><title>Highlights</title>
<p><list list-type="simple" id="celist0001"><list-item id="celistitem0001"><label>•</label>
<p id="para0001">Homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless.</p>
</list-item>
<list-item id="celistitem0002"><label>•</label>
<p id="para0002">In terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. In this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go?</p>
</list-item>
<list-item id="celistitem0003"><label>•</label>
<p id="para0003">With more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside already have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop COVID-19.</p>
</list-item>
<list-item id="celistitem0004"><label>•</label>
<p id="para0004">A large population of homeless people experience their pain and psychological distress intermittently. For low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. This is a serious concern when linked to the pandemic.</p>
</list-item>
</list>
</p>
</abstract>
<abstract id="abs0002"><sec><title>Background</title>
<p>Homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless. In terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. In this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go?</p>
</sec>
<sec><title>Method</title>
<p>The studies were identified using large-sized newspapers with international circulation</p>
</sec>
<sec><title>Results</title>
<p>With more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside already have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop COVID-19 (Global News, 2020). These people face lack of sleep, malnutrition, and “extreme stress levels just to meet their daily needs”, all of which weakens the immune system. Along with mental illness or substance abuse disorders, they are “incredibly vulnerable to this virus”.</p>
</sec>
<sec><title>Conclusions</title>
<p>Health organizations are well aware of the risks involved in mental health. A large population of homeless people experience their pain and psychological distress intermittently. For low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. This is a serious concern when linked to the pandemic.</p>
</sec>
</abstract>
<kwd-group id="keys0001"><title>Keywords</title>
<kwd>2019 coronavirus disease (COVID-19)</kwd>
<kwd>Homeless</kwd>
<kwd>Social psychiatry</kwd>
</kwd-group>
</article-meta>
</front>
<body><p id="para0009">Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is infecting people around the world. Coronavirus disease (COVID-19) will probably be transmitted to people experiencing homelessness. This will become a major problem, especially in North America, where there are sizable populations of people experiencing homelessness in nearly every metropolitan city in the USA and Canada. In the USA, more than 500,000 people were reported to be experiencing homelessness on any given night over the past decade (2007–2019) (<xref rid="bib0009" ref-type="bibr">The Council of Economic Advisers, 2019</xref>
).</p>
<p id="para0010">Homeless experts and some federal housing officials are sounding the alarm that the patchwork of government efforts to address the coronavirus outbreak risks leaving out one group of acutely vulnerable people: the homeless. Housing advocates say they fear an outbreak could occur in large homeless encampments, where thousands of people live on the streets and lack the ability to self-quarantine, receive medical attention or access cleaning facilities (<xref rid="bib0011" ref-type="bibr">The Washington Post, 2020</xref>
). The idea of police arresting homeless people, many with complex health and addiction issues, without proper testing, and placing them in detention centers, just does not sit right (<xref rid="bib0002" ref-type="bibr">BBC, 2020</xref>
). In terms of isolation, it is too unclear what that looks like if you normally sleep on the streets. In this tough moment, when people should be turned away, not only it feels inhumane, but it is also a big public health risk, because where are they going to go? (<xref rid="bib0007" ref-type="bibr">Sky News, 2020</xref>
).</p>
<p id="para0011">The plans in each country differ in scope, pace, and ambition and reflect the specific demands of the local homeless population, which has yet to report a case of COVID-19. Whether these approaches will be effective in the long-term remains unclear. For those living in encampments scattered throughout cities or bedding down in crowded shelters, containment or mitigation might prove elusive (<xref rid="bib0006" ref-type="bibr">Los Angeles Time, 2020</xref>
). People experiencing homelessness not only have a set of challenges that make it really hard to do what has been asked – stay home when you are sick, wash your hands frequently, talk to your medical provider if you are feeling ill –, but also their health condition is worse than of many other people. Although the coronavirus is affecting people around the world, it is imperative that we have a lens focused on the potential to endanger those living on streets (<xref rid="bib0012" ref-type="bibr">USA Today, 2020</xref>
). But what happens when you do not have a home? How do you practice social distancing when, at best, the only barrier between you and your neighbor is a nylon tent wall? That is the question facing the homeless individuals, and one that is vexing lawmakers and public health workers as they try to prevent the spread of COVID-19 among a particularly vulnerable segment of the population (<xref rid="bib0004" ref-type="bibr">Fox News, 2020</xref>
).</p>
<p id="para0012">With more cities suspecting community transmission of the novel coronavirus, people who sleep in shelters or hunker down outside have a lower life expectancy and often have underlying health conditions that put them at greater risk if they develop COVID-19 (<xref rid="bib0005" ref-type="bibr">Global News, 2020</xref>
). These people face lack of sleep, malnutrition and “extreme stress levels just to meet their daily needs”, all of which weakens the immune system. Along with mental illness or substance abuse disorders, they are “incredibly vulnerable to this virus. And the more obvious: They may have trouble accessing hand sanitizers and hand-washing facilities” (<xref rid="bib0001" ref-type="bibr">ABC News, 2020</xref>
). Public health agencies at all levels of government have a role to play in mitigating the coronavirus effects. If public health agencies from local governments to the Centers of Disease Control (CDC) do not have the capacity because of budget cuts or a lack of commitment, local jurisdictions will not have the tools necessary to reach out to those at risk that will be necessary to contain the virus and mitigate its effects on our most vulnerable groups (<xref rid="bib0008" ref-type="bibr">The Conversation, 2020</xref>
).</p>
<p id="para0013">In the state of Washington, the number of schoolchildren on the streets increased dramatically in the past decade, now reaching about 40,000 students. A fifth of them are in Seattle and King County. This is worrying and alarming for decision-making in the spaces of social psychiatry. As a whole, the homeless are disproportionately young. In the USA, in general, 22% are aged 60 or older, but among those who stayed in a shelter at some point during 2017, only 5.4% were 62 or older. In San Francisco, 10% of the homeless are aged 61 or older. In New York, 7% of sheltered single adults are over 65 years old. Los Angeles county reports that 6.5% of its street population is aged 62 or older. The relative youth of the homeless is likely a macabre testament to their low life expectancy and poor health (<xref rid="bib0003" ref-type="bibr">City Journal, 2020</xref>
).</p>
<p id="para0014">Spreading information, providing easier access to washing facilities and monitoring health would be a start. However, on a wider scale, this situation seems to shine a light on the ways in which, as a society, we forget about people among us who have nothing. Perhaps it is time to reconsider the ethical basis of our communities and our social system. What moral nation can allow its citizens to live without shelter, safety or dignity? (<xref rid="bib0010" ref-type="bibr">The Guardian, 2020</xref>
). Health organizations are well aware of the risks involved in mental health. A large population of homeless people experience their pain and psychological distress intermittently. For low-income patients, the various borderline situations related to health/illness involve growing expectations regarding the basic needs. This is a serious concern when linked to the pandemic.</p>
<sec id="sec0001"><title>Authors’ contributions</title>
<p id="para0015">MLRN, DCRPL, WJS, and JMML designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript.</p>
<p id="para0016">MMM, RIS, RMMQ, ECSM, TIA, PWGF, and JLSM reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript.</p>
<p id="para0017">MLRN, JMML, CGLS and TMSNA reviewed the study protocol. MMM read and screened articles for inclusion. All authors critically reviewed drafts and approved the final manuscript.</p>
</sec>
<sec id="sec0002"><title>Funding</title>
<p id="para0018">The Research Group: Suicidology – Universidade Federal do Ceará (UFC) and Brazilian National Council for Scientific and Technological Development (CNPq) – institution linked to the Brazilian Department of Science, Technology and Innovation to encourage research in Brazil.</p>
</sec>
<sec sec-type="COI-statement"><title>Declaration of Competing Interest</title>
<p id="para0019">The authors declare that they have no competing interests.</p>
</sec>
</body>
<back><ref-list id="cebibl1"><title>References</title>
<ref id="bib0001"><mixed-citation publication-type="other" id="othref0001">ABC News, 2020. Coronavirus and the homeless: why they're especially at risk, ways to stop a spread 'like wildfire'. <ext-link ext-link-type="uri" xlink:href="https://abcnews.go.com/Health/coronavirus-homeless-risk-ways-stop-spread-wildfire/story?id=69505076" id="interref0001">https://abcnews.go.com/Health/coronavirus-homeless-risk-ways-stop-spread-wildfire/story?id=69505076</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0002"><mixed-citation publication-type="other" id="othref0002">BBC, 2020. Coronavirus: 'safe spaces' needed for homeless to self-isolate. <ext-link ext-link-type="uri" xlink:href="https://www.bbc.com/news/uk-politics-51900405" id="interref0002">https://www.bbc.com/news/uk-politics-51900405</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0003"><mixed-citation publication-type="other" id="othref0003">City Journal, 2020. Another vulnerable population – the homeless present special challenges in the current crisis. <ext-link ext-link-type="uri" xlink:href="https://www.city-journal.org/homeless-coronavirus" id="interref0003">https://www.city-journal.org/homeless-coronavirus</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0004"><mixed-citation publication-type="other" id="othref0004">Fox News, 2020. California moving homeless to hotels, in scramble to prevent coronavirus explosion on the streets. <ext-link ext-link-type="uri" xlink:href="https://www.foxnews.com/politics/california-homeless-hotels-prevent-coronavirus-explosion-on-the-streets" id="interref0004">https://www.foxnews.com/politics/california-homeless-hotels-prevent-coronavirus-explosion-on-the-streets</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0005"><mixed-citation publication-type="other" id="othref0005">Global News, 2020. Coronavirus: homeless Canadians need help from governments, advocates say. <ext-link ext-link-type="uri" xlink:href="https://globalnews.ca/news/6688132/coronavirus-homeless-canadians-assistance/" id="interref0005">https://globalnews.ca/news/6688132/coronavirus-homeless-canadians-assistance/</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0006"><mixed-citation publication-type="other" id="othref0006">Los Angeles Time, 2020. An unexpected side effect of the coronavirus? A new urgency about helping homeless people. <ext-link ext-link-type="uri" xlink:href="https://www.latimes.com/homeless-housing/story/2020-03-15/coronavirus-homeless-infection-prevention-fear-policy" id="interref0006">https://www.latimes.com/homeless-housing/story/2020-03-15/coronavirus-homeless-infection-prevention-fear-policy</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0007"><mixed-citation publication-type="other" id="othref0007">Sky News, 2020. Coronavirus: how do you self-isolate if you are homeless?<ext-link ext-link-type="uri" xlink:href="https://news.sky.com/story/coronavirus-how-do-you-self-isolate-if-you-are-homeless-11958562" id="interref0007">https://news.sky.com/story/coronavirus-how-do-you-self-isolate-if-you-are-homeless-11958562</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0008"><mixed-citation publication-type="other" id="othref0008">The Conversation, 2020. Coronavirus could hit homeless hard, and that could hit everyone hard. <ext-link ext-link-type="uri" xlink:href="http://theconversation.com/coronavirus-could-hit-homeless-hard-and-that-could-hit-everyone-hard-133214" id="interref0008">http://theconversation.com/coronavirus-could-hit-homeless-hard-and-that-could-hit-everyone-hard-133214</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0009"><mixed-citation publication-type="other" id="othref0009">The Council of Economic Advisers, 2019. The state of homelessness in America. <ext-link ext-link-type="uri" xlink:href="https://www.whitehouse.gov/wp-content/uploads/2019/09/The-State-of-Homelessness-in-America.pdf" id="interref0009">https://www.whitehouse.gov/wp-content/uploads/2019/09/The-State-of-Homelessness-in-America.pdf</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0010"><mixed-citation publication-type="other" id="othref0010">The Guardian, 2020. Coronavirus and the risk to the homeless. <ext-link ext-link-type="uri" xlink:href="https://www.theguardian.com/world/2020/mar/12/coronavirus-and-the-risk-to-the-homeless" id="interref0010">https://www.theguardian.com/world/2020/mar/12/coronavirus-and-the-risk-to-the-homeless</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0011"><mixed-citation publication-type="other" id="othref0011">The Washington Post, 2020. Fears mount about impact of coronavirus on homeless. <ext-link ext-link-type="uri" xlink:href="https://www.washingtonpost.com/business/2020/03/15/fears-mount-about-impact-coronavirus-homeless/" id="interref0011">https://www.washingtonpost.com/business/2020/03/15/fears-mount-about-impact-coronavirus-homeless/</ext-link>
.</mixed-citation>
</ref>
<ref id="bib0012"><mixed-citation publication-type="other" id="othref0012">USA Today, 2020. Why the homeless, 'surviving the best way they can,' are vulnerable to coronavirus. <ext-link ext-link-type="uri" xlink:href="https://www.usatoday.com/story/news/health/2020/03/14/coronavirus-news-california-seattle-homeless/5012958002/" id="interref0012">https://www.usatoday.com/story/news/health/2020/03/14/coronavirus-news-california-seattle-homeless/5012958002/</ext-link>
.</mixed-citation>
</ref>
</ref-list>
<ack id="ack0001"><title>Acknowledgements</title>
<p>The authors would like to thank the Research Group: Suicidology – Universidade Federal do Ceará (UFC) and Brazilian National Council for Scientific and Technological Development (CNPq) – institution linked to the Brazilian Department of Science, Technology and Scientific Writing Lab, Medicine School – Universidade Federal of Cariri (UFCA).</p>
</ack>
</back>
</pmc>
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