Inside the outbreak: No shelter

On a drizzly Tuesday morning in South Los Angeles, the St. John’s Well Child and Family Center mobile clinic had two tents set up for their walk-in patients: One for incoming patients and another to isolate patients who show symptoms of COVID-19 such as coughing, fever, and shortness of breath. Most of these patients are homeless.

A masked healthcare worker screened them all before they signed in: Do they have a fever? Are they coughing or short of breath? Have they traveled or recently been near someone who’s sick? If the answer is “yes” to any question, the patients go to the isolation tent for more testing.

Several times each day the mobile clinic’s physician assistant, Dana Goldberg, checks on the latest COVID-19 information. So far, because of the shortage of coronavirus test kits, she’s only tested two patients for the virus: a homeless individual and a healthcare worker at St. John’s who may have been exposed to the virus. The second specimen container sat on a white table in the mobile clinic, while the first is undergoing testing with the U.S. Centers for Disease Control and Prevention (CDC).

Homeless service providers across the nation (including ministries) are concerned about how the coronavirus will impact that group. California, New York, and Washington state—states with the some of the highest numbers of reported coronavirus cases—all also have the largest numbers of homeless people. California, where multiple counties have already ordered residents to shelter in place, has 151,000 homeless people, a majority of them unsheltered. In Los Angeles County, about 59,000 people are homeless, with 75 percent of them (about 44,000) unsheltered.

Goldberg thinks a coronavirus cluster among the homeless will happen no matter what. She worries most about the elderly and people with preexisting conditions such as hypertension, diabetes, and cardiovascular disease. That’s a significant portion of homeless folks: “Everyone will be infected at some point, whether they show symptoms or not. I think it’s inevitable.” State officials, and some homeless people themselves, are worried too.

Because of lack of sleep, stress, and malnutrition, the chronically homeless have severely weak immune systems. Many have chronic lung disease and respiratory infections. More than one-third of them have mental illness and/or substance abuse addiction, which means they’re less likely to care for themselves or seek care. Those who sleep on the streets have limited access to showers and hand-washing facilities, and don’t have enough resources to buy toilet paper, hand sanitizer, and other hygiene products. Those who live in shelters sleep in cramped quarters, where social distancing is nearly impossible. Should these homeless people get sick, they also have no adequate resting place to recover. The public health officials’ recommendation for people to stay at home, wash hands often, and contact a doctor is not applicable to the homeless population.

Weeks before L.A. reported its first case of the coronavirus on March 11, St. John’s CEO Jim Mangia and his team were already talking daily with state and county public health officials about containment strategies, hygiene guidelines, and prevention plans. St. John’s two mobile clinics serve about 8,000 homeless people a year, and its health centers serve a lot more older patients with chronic diseases. Three staff members were on the phone round the clock, calling every medical supply company in the country to beg for masks. It took two weeks for them to receive about 4,000 masks, and when I spoke to Mangia on March 12, he had only just received the coronavirus test kits. “That’s seven weeks too late,” Mangia told me.

In early March, the U.S. Department of Housing and Urban Development issued guidelines for homeless service providers on how to prevent and manage the spread of infectious diseases among the homeless. On March 15, Gov. Gavin Newsom promised to prioritize the 108,000 unsheltered homeless people in the state by encouraging them to find some kind of shelter, such as motels or state-owned trailers. San Francisco announced a $5 million fund to protect the homeless, but most of that money will go toward cleaning shelters and single-room-occupancy hotels, or extended meal services.

So far, the city of Los Angeles has distributed 120 hand-washing stations. But advocates tell me that’s too little for the city’s more than 36,000 homeless people. Three L.A. city council members are calling for the city to allow homeless tents to stay up all day, halt confiscation of the homeless people’s possessions, and install more hygiene facilities near major homeless encampments. No state or local official has proposed mandatory emergency sheltering of the homeless.

“I mean right now it’s concerning. It’s depressing,” said Mel Tillekeratne, who runs a grassroots group that provides mobile shower services to the homeless in L.A. “I’m not someone to worry or panic, but I’m concerned if a major outbreak happens, how do we respond to it? How do we protect the homeless? I'm concerned we don’t have enough prevention plans.”

When Tillekeratne first heard about the coronavirus outbreak, he didn’t take it very seriously. He rolled his eyes at people frantically stockpiling toilet paper and canned goods. But as the virus spread nationwide and the number of cases doubled each day, he became alarmed: “What really stood out to me is how easily the virus is being transmitted.”

The homeless are some of the most vulnerable to infectious diseases. In 2017, a hepatitis A outbreak in San Diego infected about 600 people and killed 20, most of them chronically homeless. The hepatitis A virus travels person-to-person from contaminated food or water. Last year, downtown Los Angeles faced an outbreak of typhus, a centuries-old disease that spread via infected fleas riding on rodents. Washington state also saw an outbreak of Group A Streptococcus and shigella. All those were preventable diseases that spread under crowded conditions with poor hygiene and sanitation.

Mangia said hundreds of patients have been calling the St. John’s center, wondering if they have symptoms. Walk-in patients to the mobile clinics have increased by 25-30 percent, said director of chronic disease management and health equity Sharine Forbes. She said some of them come thinking they have coronavirus because they’ve been coughing or sneezing: “It’s on everybody’s minds.” To date, no homeless individual has tested positive for coronavirus—yet.

Meanwhile, some homeless individuals don’t express much concern about contracting the coronavirus. Tony Tena, a 33-year-old homeless man who had just gotten out of jail and had visited the mobile clinic for a new asthma inhaler, said he’s “not worried about it at all. It’ll go over quick. I know I’ll be fine. Even if I get it, I’ll [obscenity] get rid of it.” But he won’t be surprised if the virus “wiped out” a number of the homeless population: “But the government won’t care. They’ll use that money for other things they see more important.”

James Brookhyser, a 50-year-old homeless man who has lived for six years in Skid Row, told me most homeless people he knows don’t care much, either: “Are they concerned about coronavirus? No, they’re looking for something to kill themselves anyway. They’re expecting to die on the streets. They just do drugs, because there is nothing else for them to do. You don’t know what it’s like to have no purpose in life.”

But another 65-year-old homeless man (who didn’t want to identify himself) I met in downtown Los Angeles told me he was very worried: “I've been reading up on it on the news. I’m scared. I don’t even shake hands, don’t touch no one anymore. But I have nowhere safe to go.”