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Lessons from How We Prevented COVID-19 from Ravaging Our Homeless Clients

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Food distribution during the covid crisis (photo: Ed Reed/Mayoral Photography Office)

COVID-19 has taught us painful lessons about inadequate disaster preparedness and a vulnerable health-care ecosystem. In the midst of access obstacles, insufficient resources, and a limited federal response, a virus of moderate virulence and lethality has taken an appalling toll — over 140,000 Americans have died of COVID-19 including more than 700 health-care workers. Local providers and governments have had to scramble and improvise to manage the onslaught to prevent an even worse disaster. 

At the Center for Urban Community Services, one of New York City’s largest health-care providers to people who are homeless, we have managed to scramble and improvise effectively for our clients and workforce. Our client infection rate has remained below 5 percent, well under the estimated 15-20 percent infection rate for New York City residents. We have also managed to keep our staff infection rate low, and even more importantly, we have had zero staff fatalities.

As COVID-19 cases continue to surge across the American South and Southwest, and in anticipation of influenza season, which we fear will exacerbate the pandemic, lessons of the spring in the Northeast can mitigate a possible second coronavirus wave. Here is some of what we learned:   

Communicate, including about your ignorance.  
Effective action always starts with accurate, relevant information people trust. A crucial ingredient of earning trust is to also be open about one’s ignorance. An early challenge of COVID-19 was that so much was unknown in the early spring about how SARS-CoV-2 transmits, causes illness, and leads to death — we didn’t really know what we were up against.

It was difficult to strategize about reducing transmission when it wasn’t clear how the virus was spreading, and it was difficult to screen people when it wasn’t clear what symptoms reliably correlated with infection. Furthermore, a lack of testing meant we didn’t even know how widespread a problem we were facing. The first thing to be up front about, then, is what you don’t know.

In March and April we communicated frequently with our clients and staff about our plans for trying to keep people safe, but also that we were committed to changing course as new information and understanding developed. An important example of this was the shifting understanding and recommendations about the value of face coverings. Early on we recommended against mask-wearing but shifted gears as evidence mounted about the effectiveness of face-covering. Because we prepared people for course changes, however, our clients and staff embraced mask-wearing easily and quickly.    

Another example of ignorance we allowed ourselves to be open about was the lack of clarity about the symptoms of COVID-19 and about the relative importance of asymptomatic and presymptomatic spread.

Realizing that confusion about these issues made it impossible to reliably identify who might be contagious at any given moment profoundly influenced our strategy in a way that we believe kept our infection rate low. Since we understood we could not completely prevent people who are contagious from being at our workplaces, we transformed our programs and operations to be safe even if people were contagious.

We eliminated as many “close contacts” between client and staff and among staff as possible. A contagious person cannot infect you if you keep your distance, avoid prolonged interactions and wear a mask. We believe our workplaces are currently safer than people’s homes.

Get ahead of the problem and on the side of caution.
By the time there was a first confirmed case of COVID-19 in New York City, we had been closely monitoring developments in China and Italy and we had already started educating our staff and clients about the seriousness of the situation. Sensitizing people to the grave nature of the crisis prepared our team to rapidly develop protocols that we ended up executing well before the city and state began issuing guidance.

We had decided how we were going to respond to the closing of the New York City school system and the stay-at-home order before those measures went into effect. Given how quickly SARS-CoV-2 can spread, we believe this foresight and rapid mobilization prevented a significant outbreak at our agency.  

In mid-March we transitioned most staff to remote work, a significant challenge for a client-facing service-provider. Much of our medical team shifted to two-week, staggered rotations to limit the number of providers who would be risking exposure at any given time while also ensuring our clients access to necessary care. Acting swiftly and decisively, with healthcare workers’ well-being driving every decision, minimized the number of clinicians who became infected and allowed us to keep providing care to people. 

Although COVID-19 prevalence in New York City is currently quite low, and the city has moved on to phase 4 of reopening, we recognize this is a fragile state of affairs and that we cannot let our guard down. Our protocols continue to be informed by the assumption that everyone you might interact with might be contagious. SARS-CoV-2 can spread easily and case counts can quickly grow exponentially. We move forward assuming that might happen any time, and we believe this is the only prudent assumption until there is a widely available, effective vaccine. 

Be flexible.
A significant, unanticipated early challenge of this pandemic was the shortage of personal protective equipment (PPE) — just as toilet paper disappeared from the stores, so did face masks from our suppliers. To address this unprecedented challenge, Center for Urban Community Services formed an informal team to become equipment hunters and importers. For example, we deputized procurement officers who had no such previous experience.

This team collaborated with different organizations in a national, and in some cases international, effort to obtain face masks for frontline workers on our outreach teams and shelter and housing programs. People from all over the country supported this cause, mailing in hand-sewn face masks not only from New York City and State, but also from as far away as Alaska, California, and Washington State.

Through this effort, Center for Urban Community Services was able to distribute over 8,000 face masks to frontline staff and our clients who are homeless. Our investment in this effort has built new supply chains to ensure we have sufficient PPE to protect our staff and clients in future surges. 

Although New York City is experiencing a brief respite, it would be unwise to become complacent. COVID-19 is surging through much of the country and people travel from hot spots to New York every day. The onset of influenza season will almost certainly exacerbate whatever COVID-19 is prevalent in the city this autumn and winter. COVID-19 safety and preparedness has become embedded into all that we do — it must be inherent in our new normal — in order for us to keep people safe and to continue to provide the care and services that are so crucial to our clients.  

As scientists and physicians learn more, and COVID-19 has become less mysterious, it has become clear that good old-fashioned, basic public health measures can reverse outbreaks and control the spread of SARS-CoV-2. Social distancing; testing, tracing and isolating; hand hygiene; and mask-wearing are unfancy interventions well within the capacity of a country with the political will to resource such efforts.

By now there are dozens of examples of whole populations of people who, with clear, consistent communication and leadership, are happy to work together to protect everyone. A coordinated effort by government and citizens to employ simple, straightforward tactics could allow this country to enjoy a semblance of normalcy — being with loved ones, going to school, helping one’s neighbors — until an effective vaccine can finally put an end to this pandemic.  

Dr. Van Yu is Chief Medical Officer at the Center for Urban Community Services. On Twitter @CUCSnyc.

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