Mental health of homeless people in China amid and beyond COVID-19 Zhaohui Su, a,b * Barry L. Bentley, c,d Ali Cheshmehzangi, e,f Dean McDonnell, g Junaid Ahmad, h Sabina  Segalo, i Claudimar Pereira da Veiga, j * and Yu-Tao Xiang k * a School of Public Health, Southeast University, Nanjing, 210009, China b Center on Smart and Connected Health Technologies, Mays Cancer Center, School of Nursing, UT Health San Antonio, San Antonio, TX 78229, USA c Cardiff School of Technologies, Cardiff Metropolitan University, Cardiff, United Kingdom d Collaboration for the Advancement of Sustainable Medical Innovation, University College London, London, UK e Faculty of Science and Engineering, University of Nottingham Ningbo China, Ningbo, Zhejiang, 315100, China f Network for Education and Research on Peace and Sustainability (NERPS), Hiroshima University, Hiroshima, 739-8530, Japan g Department of Humanities, South East Technological University, Ireland, R93 V960 h Prime Institute of Public Health, Peshawar Medical College, Peshawar, Warsak Road, Peshawar, 25160, Pakistan i Faculty of Health Studies, University of Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina j Funda¸ c~ ao Dom Cabral - FDC, Av. Princesa Diana, 760 Alphaville, Lagoa dos Ingleses, Nova Lima, MG, 34018-006, Brazil k Unit of Psychiatry, Department of Public Health and Medicinal Administration; Institute of Translational Medicine, Faculty of Health Sciences; Centre for Cognitive and Brain Sciences; Institute of Advanced Studies in Humanities and Social Sciences, University of Macau, Macao SAR, China Homelessness is seldom a choice. Oftentimes, homeless- ness reflects the systemic failures that can result from social issues being dismissed or disregarded. 1 Globally, approximately 1.6 billion people lack adequate housing, with 15 million more individuals being evicted on an annual basis. 2 This situation is often profoundly worse in low- and middle-income countries like China. It is esti- mated that 300 million people in the country—home to 1.4 billion Chinese—are homeless. 3 However, despite the scale of this issue, China does not have a robust health and social infrastructure—preventive and proactive sys- tems that could ensure people have stable and sustainable access to opportunities that are essential to their survival (e.g., food and shelter) and growth (e.g., training, educa- tion, and employment programs)—for homeless people. Research shows that, for instance, rather than relying on services provided by the local government, homeless peo- ple in Shanghai, one of the most advanced metropolitan areas in China, often have to address basic needs such as food and shelter on their own, 4 let alone illnesses that demand structured mental or physical health services. Although this lack of care is a threat to every member of society, especially disadvantaged homeless people, it disproportionately impacts those with mental health challenges. Accumulated evidence shows that homeless people often suffer from mental illness. In a study conducted in Hong Kong, researchers found that rates of depressive disorders amongst homeless people are four times greater than those in the general population. 5 While conditions are already alarming, the pandemic could further compound the situation. To control COVID-19, China is substantially reliant on measures such as partial or full lockdowns. 6 Though necessary to curb virus spread, 7 these strategies could nonetheless cause unintended consequences such as the loss of homeless people’s access to food, shelter, and essential health services. In a study conducted in 2020, research- ers found that homeless people in Guangzhou have faced atypical discriminatory treatment amid the pandemic. 8 Specifically, in the name of pandemic control, local offi- cials have been observed to not only reduce or remove essential services, like rescue stations and shelters, but also intensify efforts to evict homeless people away from urban areas, 8 often to their birthplaces located in less developed rural regions. This could subject homeless people to further hardship, as they often rely on social opportunities that only large cities provide, such as the availability of well-equipped shelters, accessible food waste and salvageable materials, as well as donations and voluntary aid from members of the community. Just as homelessness is seldom a choice, so are the circumstances that homeless people are subjected to. The lack of humane care seen in the evictions reported from cities like Guangzhou, 8 even in times of crises like COVID-19 that demand social unity to address, can and should be eliminated and eradicated. First, society should ensure homeless people are treated with proper respect, dignity, and care. Rather than closing rescue stations and shelters, officials could develop creative sol- utions, such as the “Pandemic Bubbles” seen amid the *Corresponding authors. E-mail addresses: suzhaohuiszh@yeah.net (Z. Su), claudimar.veiga@fdc.org.br (C.P. da Veiga), ytxiang@um.edu. mo (Y.-T. Xiang). © 2022 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/) The Lancet Regional Health - Western Pacific 2022;25: 100544 Published online xxx https://doi.org/10.1016/j. lanwpc.2022.100544 www.thelancet.com Vol 25 Month , 2022 1 Comment