In 2023, more than 653 000 people experienced homelessness in the US on any given night, the most since counting began in 2007.¹ Research has consistently shown that homelessness leads to poor health.^2,3 Staying in congregate homeless shelters increases risk of infectious diseases like einfluenza,COVID-19, and tuberculosis, whereas living outside increases risk of motor vehicle–pedestrian injuries, sanitation-related concerns, and elemental exposures.^2,4 Challenges accessing health care while unhoused complicates management of conditions like diabetes, heart disease, HIV, substance use disorders, and mental illness.^5,6 People commonly cycle between sheltered and unsheltered settings, thus face the health threats of both.

Around 256 000 people (40%) experiencing homelessness in 2023 were unsheltered, meaning their “primary nighttime location was outside, in a car, tent, or other place not meant for human habitation.”¹ Living or spending substantial time outside brings risk of involuntary displacement by local authorities.⁴ Involuntary displacement—sometimes referred to as encampment sweeps or closures—often involves dislocation of people sleeping outside without consent and without providing suitable alternative living arrangements.⁴ Conversely, voluntary displacement efforts include establishing connections to low-barrier housing and supportive services.

Although involuntary displacement might reduce the visibility of homelessness, it rarely results in permanent housing and can exacerbate health and safety challenges for people who are unhoused.^3,5 In Grants Pass, Oregon, people experiencing homelessness challenged the city’s policy to charge fines for sleeping outside, citing the 2018 Ninth Circuit Court of Appeals decision in Martin v City of Boise, which held that fines for sleeping outside when no alternative shelter was available was considered cruel and unusual punishment under the Eighth Amendment.⁷ The June 2024 US Supreme Court decision on City of Grants Pass, Oregon v Johnson ruled that the Eighth Amendment does not prohibit cities from imposing fines or criminal penalties for public camping.⁷ Consequently, municipalities may continue relying on displacement and punishment as the primary response to unsheltered homelessness.

Historically, the public health rationale has been used to justify encampment clearings when there have been concerns about sanitation, violence and safety, drug use, and other hazards. These public health concerns warrant attention and prevention. However, the health hazards of living outside should be weighed against the health hazards of involuntary displacement. Otherwise, attempts to eliminate one set of health concerns may unintentionally introduce new ones. In extreme circumstances, involuntary displacement can result in immediate death.⁸ Involuntary displacement exacerbates chronic diseases when medications and survival items are taken or destroyed.⁵ Moving to less visible locations may separate people from health and social service providers, resulting in worsening of conditions that require regularcare.⁵ Interactions with law enforcement during displacement can lead to stress, anger, mistrust, and further marginalization.⁵ Emergingliteratureshows statistically significant relationships between involuntary displacement and stress-related adverse health outcomes, namely substance use (including overdose), infectious diseases, mental health, and climate-related conditions (eg, frostbite, heat stroke).^3,4 Displacement can also create interpersonal tensions that lead to physical violence.⁵

Furthermore, involuntary displacement limits future rehousing opportunities, perpetuating homelessness and associated health risks.⁵ Identification documents, work uniforms, and job-related tools lost during displacement take time to replace and may lead to employment loss.⁵ When displacement is accompanied with fines, arrest, and jail time, it can result in debt accrual and criminal records, both of which hinder employment and housing opportunities and threaten health and well-being.⁵

Municipalities do not have to choose between only allowing encampments to persist or only involuntarily displacing people. Another option is humane and trauma-informed encampment resolution, which could reduce the public health risks of encampments and the harms of involuntary displacement while simultaneously addressing the concerns of the community at large.⁹ A humane encampment resolution would involve assessing encampments for health hazards and health needs to prioritize immediate services and resources, and providing those services and resources while encampment residents are connected to and placed into housing.

The primary long-term solution to homelessness is housing. Responses to unsheltered homelessness and encampments can focus on stabilizing and supporting clients, using harm reduction approaches, and creating permanent housing with supportive services. Although these approaches take time, they yield better health and housing outcomes long-term.¹⁰

Once matched to a permanent housing destination, people in encampments should be provided with temporary housing or shelter while they await entry. It is insufficient to simply direct encampment residents to existing congregate shelters when those shelters may not be resourced to meet their physical, social, emotional, or material needs.⁵ People with mental illnesses may experience exacerbated symptoms being in crowded situations with unfamiliar people. Many congregate shelters only operate during night-time, giving people no place to stay or keep their possessions during the day. People with pets may have limited shelter options that allow pets and accommodate their needs. Adult pairs or couples may be forced to choose between splitting up between gendered shelters or remaining together outdoors. Some people understandably fear the spread of respiratory viruses and other infectious diseases in congregate shelters.

There are 4 ways public health agencies can support humane encampment resolution:

Several communities are successfully implementing these approaches, bringing services directly to where people are, and connecting people to housing, health, and social services. Houston, Texas, for example, assembled a multisector encampment response strategy design team to establish roles, procedures, and plans for closing encampments.⁹ This team conducted encampment site assessments to document encampment location, population and safety features, and health concerns. Outreach teams visited encampments, whereas others worked behind the scenes with housing agencies and landlords to secure housing placements. As people moved into housing or transitional living environments, encampment size decreased, and vacated areas were cleaned. Hennepin County, Minnesota, used a similar multidisciplinary approach to help more than 300 people move into permanent housing and almost 200 move into emergency shelter or temporary housing.¹⁰ In a 3-month period, a cross-sector team in San Diego County, California, used this approach to connect more than 100 people to shelter and housing, distributed 200 hygiene and 200 Narcan (naloxone) kits, and administered almost 50 vaccines.¹⁰ To date, Denver, Colorado, has housed more than 1200 people.¹⁰

In jurisdictions where involuntary displacement without provision of services is the norm, public health agencies can take several actions to minimize health harms. First, these agencies can track displacement efforts and document changes in encampment resident health in existing data systems to continue highlighting the harms to those displaced and to health care systems. Second, these agencies, in partnership with other community groups and people with lived expertise of homelessness, can develop processes for maintaining contact with encampment residents during and after clearings for ongoing care. Lastly, these groups can continue to support research and its translation into communication materials to support discussion about and implementation of alternative responses.

Addressing homelessness will require a multisector approach, including government, nonprofit, and private sector partners working in health, housing, human services, and justice. As we continue to understand more about the threats to health and human rights that people face while experiencing homelessness, a community-based, coordinated, multisector way forward is becoming clearer.