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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.

We want to hear from you: Are you a health care worker affected by the coronavirus outbreak? Please tell us about your experience.

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.

  • Why not provide nasal oxygen assistance and suppress the immune response before it results in severe damage to the lungs while sucking out the gummy yellow fluid from the lungs/air sacs before applying long term sedation and too much force to push oxygen into the lungs via a ventilator.

  • “Many patients have blood oxygen levels so low they should be dead. But they’re not gasping for air, their hearts aren’t racing, and their brains show no signs of blinking off from lack of oxygen.”
    Maybe this disease somehow affects the accuracy of the oximeters. Isn’t the response of the organism a more primary piece of information? We trust our gadgets to the exclusion of our senses.

    • This exact situation was described as having the hospitals treating the wrong disease, particularly when incubating. The virus destroys the red blood cell count and hypoxia sets in. They don’t need ventilators nearly as much as the need bountiful amounts of o2.

  • Could drugs that are used to treat altitude sickness such as Acetazolamide hold any promise? I’m not a doctor. Just a curious person.

  • Porta-potties: San Francisco hasn’t taken the easiest, most important step to mitigate the effect of COVID19 on homeless people, and the effect of homeless people on COVID19. The city lacks public toilets, and even on its best days finding human feces on the sidewalk is a more than daily experience. Now toilets are even more rare, with playgrounds, rec centers, and businesses shut down. So much feces is tracked along sidewalks in many neighborhoods, it’s impossible to avoid stepping on traces of it. Feces contains COVID19 virus, along with all its other pathogens. It puts homeless people and housed people more at risk of getting COVID19, and becoming vectors passing it on to others. If one person in a cluster of tents gets it, the whole camp will get it. Not to mention the shame of allowing fellow humans and neighbors to live like that. As a San Franciscan, it’s hard to bask in civic pride for flattening the curve while walking through fields of human feces. The mayor should pick up the phone and call all the shut-down local porta-potty companies and say “Look for tents and put one porta potty and one hand washing station on every block that has tents, and one more for every twenty tents. Maintain them and send us a bill.” Done. A few grumpy neighbors will complain that the porta-potties block the sidewalk, but the tents are already blocking the sidewalks, and we’re not in a hurry to walk anywhere these days, and anyway we are in a state of emergency so the mayor can just do it with a phone call. How hard is that?

  • This too shall pass. Mother nature always knows what to do , dont try to interfere with her methods

  • Bill Morton, Choice? My son was not asked to choose schizophrenia it simply came along and destroyed the life of the wonderful, gifted young man he was.

  • Dr. Brooks, Margot Kushel and any other care giver placed in this seemingly antithetical choice allow me, as a mom of a young man you may encounter as a patient, provide my perspective.
    My son is 32, afflicted with schizophrenia and D.I.D., has lived in a world of mental illness hell for 12 years. This is not the life he dreamed of. He once had a genius level I.Q. and began studying nuclear medicine. Then the demons took hold. No meds were effective and the diseases acted with fierce voracity much like COVID19.
    His mental state is gone, only a physical body exists. Though I don’t endorse euthanasia please understand if you are able to provide comfort and if he has any lucidity (he rarely does anymore) tell him his mom, brother and sister all love him then let him know peace.
    This is not easy for me to send but it has become inevitable. Whoever is watching these lost souls please know it is not fools but strong, brave care givers who walk In where angels fear to tread.
    Thank you for your all you are doing and being where I cannot be,
    Cindy Rumlow

    • Cindy: My heart goes out to you. My daughter has the same diagnosis, has been living at home for several years. She is unable to live without a great deal of family support. It can be exhausting to care for and support a loved one who has a very thin hold on reality, someone who shouts/speakers to herself ceaselessly, is careless and extremely disorganized. As with your son, her drug regimen is ineffective. Although her brain is habituated to neuroleptics for sleep, they made her much, much worse cognitively and otherwise. They have cemented in her psychosis for life, while other underdeveloped nations without psychiatric drugs enjoy higher recovery rates according to two back-to-back studies by the World Health Organization. People with refractory or treatment-resistant ‘schizophrenia’ are those very people who would have been much better served with psycho social support in a home-like, non-clinical environment during their first psychotic break. Instead, they were rounded up like animals, forcibly drugged and institutionalized for years. The combination of traumatic loss of civil liberties, being lied to constantly by so-called ‘doctors’, and iatrogenic harm (what Dr. Breggin, the conscience of psychiatry called drug induced chronic brain injury) have made many of these people so chronically ill they will be chronically dependent on expensive social programs or die early on the streets. This is a statement about psychiatry, not our children’s ‘illness’. Other countries using different approaches have much higher recovery rates than the US.

    • Jerry, thank you for your kindness.
      Sarah, I’m glad your daughter is able to live at home (if this is working for all involved). Unfortunately my son was furthest on the spectrum within the 1st year, assaulted me (previously we were extremely close) and eventually left. For a time I didn’t know if he was even alive. I live in Colorado and you are probably aware of HIPPA laws and the stronghold. I did find some kindness among some agencies and throughout the years get updates.
      Today I watch the numbers in SF rise especially among this group and I think the unthinkable.
      I wish you, your daughter and family the best. Stay safe and well. Thank you for your kind reply.

  • California is the largest state. And you people cant get the homeless in to ..oh …Idk a parking garage of some sort..something! You have the largest population of homelessness in the country. The gov never did anything about it. Now you lie about treating them? What for? Most are mentally unstable, crackhead (seen that for myself), all kinds of drug addicts, etc. Its a plague on society. Yes they are people. People that choose not to take their meds. People who had no choice. People who have no clue what is going on. I have an affinity for the homeless. I’m not one to waste precious medical equipment that could be used for a productive citizen of this twisted society….as it May be… It is a waste of everything medical. Sorry to say that, but if they’ ve nowhere to go they will spread it.

    • Yes, and most of them are mentally ill. Most of them are extremely untalented or unlucky or both. Many are drug addicts as well. They are doing all they know how to do, and most of them are not criminals, either. They cannot, in the final analysis, be held responsible.

      I suspect you are not too badly off yourself, but you do have one particular deficit, in common with the POTUS and psychopaths in general, which is (it seems to me) you lack empathy. Where IS your empathy? It’s not like these people are actually hurting you, and it’s not as if they really have much choice in the matter! They are victims of their usually poor genetics and environments, and fate. Like I say, most of them are not criminals, at least not out of anything short of desperation. You shouldn’t hate the homeless so much…

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