Inequities of COVID-19: You Cannot Shelter-In-Place If You Have No Shelter

Authored by HEAL Fellow Abhi Kole & HEAL Alum Bassem Ghali

How can we ask someone to shelter in place while simultaneously denying them shelter? It sounds cruel and counterintuitive, but this is exactly what is happening in our liberal bastion of San Francisco. After our shelter-in-place orders were enacted, restaurants and businesses scrambled to restructure their operations. Washington injected over a trillion dollars into the economy to keep corporations afloat. The individual will only get $1200, perhaps months later and only if the IRS has an address or a bank account on file. And the unhoused population is once again an afterthought.

Last week, we took care of Leroy Robinson (name changed). Leroy lived at the Navigation Center, a homeless shelter in San Francisco. Leroy caught a stomach bug and due to the potential for infectious spread, he was transferred to the hospital. His symptoms resolved on their own in less than a day, but when he was ready to leave the hospital, he found himself with nowhere to go. Navigation Center had stopped taking new residents due to COVID-19, and his one day in the hospital caused him to lose his previous bed.

San Francisco is using its many empty hotel rooms to house the homeless during this time, but only if the individuals require isolation. The city is essentially telling the homeless, “We will provide you shelter, but only if you pose a threat to the rest of us.” But what about Leroy? Does he not need protection from strangers too? Is he not at greater risk without access to a bathroom to wash his hands? The rate of new cases among the homeless in Massachusetts is seven times higher than the rest of the state. Where is the reciprocity in our social contract?

We tested Leroy for COVID-19, even though he did not have a cough or fever. This was standard procedure for anyone coming from a congregate setting, but in some perverse way, we were hoping he was an asymptomatic carrier, so that his disease could justify a roof over his head. Medical anthropologists describe this phenomenon as “biological citizenship,” in which a person’s disease state makes one eligible for basic services the government should have been providing all along. We have seen this with HIV/AIDS wherein a positive diagnosis opens up access to new funds and clinics. But what does biological citizenship say about us as a society? That we would rather treat your illness than prevent it. That you are only human during catastrophe. That we will only extend privilege when it is too late.

Governor Newsom has announced Project Roomkey, an initiative to secure 15,000 hotel rooms for those experiencing homelessness, but California has over 150,000 persons needing rooms. Those at highest risk of infection will be prioritized, but figuring out which person without shelter or access to hygiene is not at high risk of contracting an infectious disease is absurd. Mayor London Breed announced a plan last Friday to use the Moscone Center and the Palace of Fine Arts as temporary shelter. While this provides more space than a traditional shelter, it is a far cry from the isolation that the rest of us are privileged enough to have. San Francisco has 8,000 persons experiencing homelessness and over four times as many hotel rooms. We must be able to bridge this mismatch for humanitarian reasons, even if as the mayor’s office claims, “it would not be fiscally prudent.”

The rationing of hotel rooms for those who have confirmed COVID-19 infection exposes how our government leaders think about marginalized populations. Rather than try to address the larger social disaster of homelessness and need for shelter, particularly for vulnerable people, the government sees this population as a liability to the housed and affluent, a threat that needs to be contained, to be discharged to the street, and ignored once they are no longer infectious. This is a unique opportunity to reorganize our priorities to offer a clear vision for what society emerges post-COVID-19. Do we go back to business as usual, or do we start to build the structures that ensure that all people have the basic human rights of housing, food, water, health care and education.

Leroy tested negative for COVID-19. Instead of being relieved, Leroy was left no option but to take his discharge papers and walk onto the street.

Originally posted on April 7, 2020 in SFist here.

Disclaimer: The participants are staff & faculty at UCSF. However, the views and opinions expressed herein do not necessarily state or reflect those of The Regents of the University of California, UCSF, UCSF Medical Center, or any entities or units thereof.



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Abhi Kole

Abhi Kole

MD/PhD, Internal Medicine, HEAL Fellow. I care about health equity. I worked at JSS in rural Chhattisgarh, UCSF, and Emory/Grady.