As Covid-19 surges among San Francisco’s homeless, doctors face difficult choices

SAN FRANCISCO — As a doctor at San Francisco’s safety net hospital, Katie Brooks takes pride in caring for the city’s most vulnerable patients. But as the Covid-19 pandemic puts further stress on city resources already stretched to the limit, Brooks says it’s harder than ever to help those who are homeless.

“I am having a really tough time discharging people from the hospital to anywhere but to the street,” said Brooks, a hospitalist at Zuckerberg San Francisco General Hospital.

The coronavirus is spreading rapidly through the city’s homeless population. Out of about 800 known cases in the city, 68 have been reported among people staying at the city’s largest homeless shelter, Mayor London Breed announced Friday — barely more than a week after the first case was identified in a homeless resident. And the pandemic has worsened San Francisco’s homelessness crisis; shelters stopped admitting new people over well-founded concerns about the risk of a Covid-19 outbreak among residents, eliminating precious shelter beds in a city with only 1,200 of them to serve 7,600 homeless adults.

The George R. Moscone Convention Center recently opened its doors to homeless people who are not sick. Yet homeless people who have the virus, or are being checked for it, are left with only one place to be isolated, doctors say: the hospital, even if the patients’ mild symptoms do not necessitate it.

“I’m not someone who says that I won’t admit people to the hospital who have nowhere to go,” Brooks said. “The issue is that we are using up things that we are going to be facing shortages of,” such as hospital beds, personal protective equipment, and health care workers.

Diagnostic testing for Covid-19 has been a major contributor to the problem, those on the front lines say, because patients must remain isolated until the test comes back. At best, it might take hours to return results; at worst, it has taken days.

“The number one issue has been testing turnaround,” Brooks said.

Jahan Fahimi, an emergency physician at the University of California, San Francisco, says he has admitted some homeless patients being tested for Covid-19 with symptoms so mild they wouldn’t ordinarily require a hospital stay.

“We have looked at the patient’s clinical scenario, which could have been managed at home or otherwise in isolation, and given the social situation, have found a way to get them admitted,” Fahimi says.

To give homeless people who need isolation a place to stay, city agencies have enlisted a handful of local hotels, offering private rooms and on-site medical supervision, toiletries, and meals. But clinicians say the rollout has been slow, and many of their patients — such as those with severe psychiatric illness — do not qualify for placement in hotels, still leaving them without options besides hospitalization. San Francisco Human Services Agency representatives did not respond to requests for comment.

Another doctor at Zuckerberg San Francisco General estimates that one-quarter of the referrals she has made to these sites were denied, often because so many patients have mental health or addiction issues that make it difficult to stay inside for 14 days, the incubation time for Covid-19. And even for patients who are accepted, she said, the vetting process and transportation to the sites often seems disjointed and confusing.

“All these efforts are siloed,” said the doctor, who asked not to be identified because she wasn’t authorized to speak to the media. “It’s like a serpent without its head.”

Margot Kushel, director of the Center for Vulnerable Populations at UCSF, said the city has been stymied in responding to the pandemic because the crisis is superimposed on top of the city’s pre-existing homelessness problem.

“Covid-19 is making clear what we have always known — that underlying structural conditions
leave those most vulnerable at highest risk,” she said.

In the meantime, clinicians are struggling even more than usual to do right by the city’s homeless residents. Brooks spends hours some days trying to convince patients who feel too well to be in the hospital to stay, to try to prevent disease spread; she estimates that the number of people looking to leave the hospital prematurely is four to five times higher than before the pandemic.

Doctors often feel conflicted about this difficult task, understanding both its necessity from a public health perspective and its impact on their patients, who may find being hospitalized difficult or even traumatizing. Still, they are on their own to try to keep people from leaving. The civil detention sometimes invoked for other highly contagious infections such as tuberculosis cannot be used for patients who may have Covid-19.

“This causes stress and trauma for both patient and clinicians,” said Hemal Kanzaria, an emergency physician and the director of the Department of Care Coordination at Zuckerberg San Francisco General.

Superimposing a pandemic on top of San Francisco’s homelessness crisis highlights the many holes in the area’s safety net, said Jack Chase, a family medicine doctor and leader of the hospital’s social medicine team.

“This pandemic, like any crisis, is unmasking the preexisting vulnerabilities in the system by placing greater pressure on an already stressed system,” he said. “We have to invest in the care and social needs for both the vulnerable people and everybody else,” he added. “It benefits everybody to care for the most vulnerable.”

If there is a silver lining to this pandemic, Brooks said, it’s the possibility that it may spur long-overdue changes to address homelessness, such as adequate housing. “This is going to unearth the fact that our society is not sustainable with this degree of a lack of a safety net,” she said.

This story has been updated with new comments from Margot Kushel made after the mayor’s announcement on Friday.