Coronavirus Magnifies Social Inequity In At-Risk Communities, Like The Unsheltered Population
Jessie Angeles Jr. tossed a bag of food into his trunk and got into his car. On a late May afternoon, Angeles drove through San Diego’s North Park neighborhood to deliver the package to some of his clients: people who are living on the streets.
I sat in the passenger seat of his car and walked beside Angeles as he spoke to different people.
“Since COVID, my workload has been almost double because of the need,” Angeles said.
Angeles works with a homeless nonprofit group, PATH, or People Assisting The Homeless.
“Now clients, they’re saying like, we don’t have places to eat, we don’t have places to use the restroom,” he said.
Angeles has been working with the homeless community for years. And during that time, he’s developed a certain skill-set: empathy, knowledge of mental health issues and substance addiction, as well as approachability.
But he still has to meet some clients with caution. At a street intersection, he turned to me and asked me to stay back.
“We’re trying to build rapport with him. I'm going to drop off a bag for him just to let him know we’re still here for him,” Angeles said.
Angeles started up a conversation, but offered to leave if the man felt uncomfortable. The man said he remembered who Angeles is and was happy to receive some food.
“I just kept it very simple,” Angeles said, adding that he’d check in again another day.
Contact Tracing Key To Controlling Pandemic, But Challenging In At-Risk Communities
Now that San Diego is opening up again, county officials have increased testing and started contact tracing to prevent coronavirus outbreaks. Officials hire people who can find infected residents and their contacts. Officials ask them to quarantine to avoid spreading the virus.
Public health officials say contact tracing everywhere is key to controlling this pandemic. Angeles said while he doesn’t know much about contact tracing, he said asking for information isn’t easy.
“I would say it is sensitive information for people, cause if you don’t have that trust with them, like someone just asking a question like where you've been and stuff like that, it all has to come from a relationship first,” he said.
San Diego County has distributed close to 8,000 hygiene kits and masks to people who are homeless. And officials have offered testing and shelter in hotels and the convention center. The county says relatively few homeless people have tested positive for coronavirus.
“The unsheltered community presents unique challenges both in terms of engaging them and building that trust,” said County Supervisor Nathan Fletcher.
“I think the reason why the positives at our convention center have been exceedingly low, compared to Boston and San Francisco and other places, is because of the early work we did with temperature screening and engagement with our unsheltered.”
But while the county generally knows where positive cases are, there’s currently no map of all the unsheltered communities. That makes it difficult to create a regional approach for serving, testing and contact tracing this population.
Just the city of San Diego has nearly 5,000 people who are experiencing homelessness.
The county says it’s going to pilot a project where homeless outreach teams can use a map of unsheltered populations. But that pilot program is still a month or more from happening.
And meanwhile, UC San Diego infectious disease and public health professor Rebecca Fielding-Miller says there is still the issue of trust.
“With people feeling like the government hasn't treated me well in the past. Why would I feel like they will treat me and my community well in terms of contact tracing?,” Fielding-Miller said. “Just because there's an outbreak doesn't mean the pre-existing social issues go away. They actually come to the fore even more."
The county has already hired just over 400 diverse contact tracers who plan to call or text people.
But many homeless people don’t have phones. And Fielding-Miller says they may not trust those calls and texts.
She recalled the Ebola outbreak in 2014, which killed more than 10,000 people in West Africa and globally.
“One of the first things the CDC did was they actually put out a call to return Peace Corps volunteers. [That’s because they] really have a skill set around ... forging real community ties," Fielding-Miller said.
She suggested hiring people, like Angeles, who have the expertise. “We know in any community there are people who are leaders formally or informally, who are trusted by their community,” she said.
Basic Cultural Sensitivity May Not Be Enough
The county’s job description for tracers asks for people with “cultural sensitivity” alongside skills for keeping spreadsheets and doing data entry.
But, it’s evident from watching the work of homeless outreach specialists that cultural sensitivity may not be enough. Building relationships is a key part of the job.
After spending a couple hours in one part of North Park, Angeles got back in his car and headed toward Loma Portal. He intended to make multiple stops that day.
During the car ride, he received a phone call from a woman, Lory Buck, who he had helped get off the streets at the onset of the pandemic.
“When the pandemic started and everything had started shutting down, I talked to her in the lightest way I could about the seriousness of COVID. And she got scared a little bit, but she had no idea,” Angeles said.
“One of her friends brought the news to her that we could potentially die from this. Her friend asked her if she was still homeless, and she started crying, because she wasn’t informed about it,” he said.
Angeles headed to a motel in Loma Portal. He helped Buck and a number of other clients get into this motel. She had been homeless for eight years.
“It was extremely frightening because you’re supposed to be inside and when you’re outside that’s extremely difficult. I’ve never lived through a pandemic,” Buck said.
Now that she lives in this motel she tries to follow guidance: social distancing, wearing a mask, hand washing.
“Absolutely, I’ll abide by anything that’s asked of me. Anything to be done, anything to stop it.”
Buck says she’s happy to have housing, and it’s completely changed her life.
But, she says it’s not that easy for people on the street to follow certain rules. For example, she says when she was a single woman on the street, she didn’t want to socially distance because there’s safety in numbers.
And the pandemic also brings up hygiene concerns. The county has put a number of hand washing stations throughout the region. But Buck says when the pandemic started and she was still on the street, she wasn’t sure how she could even go to the restroom. Even trolley stations were shut down.
When it comes to contact tracing, she says success will likely be hit or miss for some people, especially when they’re concerned about other issues, like their next meal.
“It all depends on how you approach them. They’re people too. Some you’re going to be able to get through. Some that are mentally challenged may have a little bit of difficulty.”
Health experts say contact tracing is critical to controlling the spread of coronavirus. And while working with at-risk communities has always been a challenge, the pandemic highlights the need to find long-term solutions to social inequality, says infectious disease professor Fielding-Miller.
“The thing about any major health issue is that it’s always the people at the edges who are hit the hardest,” Fielding-Miller said. “If we can orient our response to the most vulnerable, then everybody is going to benefit the most.”