Blog by Joshua Mizels, Lauren Holt, and Madeline Hooper
In all honesty, social distancing hasn’t been too tough for us medical students. Sure, it’s been frustrating to sit on the sidelines while our various medical colleagues are on the front lines fighting this COVID-19 pandemic; after all, this is what we signed up for. But now we have the opportunity to work from home, get some extra sleep, stay connected with friends and family, and maybe even watch a little too much Netflix. If we turn the news off for a few minutes, social distancing really isn’t too bad for many of us.
However, social distancing poses a unique challenge for the already vulnerable homeless population. Many homeless patients are living with multiple chronic medical conditions, which puts them in a high risk COVID-19 cohort. The combination of these chronic conditions with a lack of stable housing, frequent inhabitation of small areas with others, and need for adequate hygiene resources makes this population alarmingly vulnerable. How can they be expected to “shelter in place” if they don’t have a shelter? How can those of us who are able to “shelter in place” support this population?
We are leaders of a student-run organization that provides medical and social services to our local homeless population. As such, our perspective on the impact of COVID-19 is informed by our experiences with that population. Through our organization, we see patients on a weekly basis in myriad clinical settings. We operate biweekly “street runs” during which, under faculty supervision, we walk through our downtown area and provide over-the-counter medications, wound care, socks and clothing, Narcan, hygiene supplies, and social support, as well as referrals to our permanent clinic location. This clinic, which we also operate biweekly, allows our patients to manage their chronic medical conditions and receive prescription medications. We are often our patients’ only healthcare option.
The Association of American Medical Colleges recently published guidelines that advised medical students to refrain from patient interaction. Because of this announcement, and our community’s declaration to “shelter in place,” our organization’s efforts have come to an abrupt halt. We can no longer provide for our patients at all.
It was important to us to not stop our operations without properly informing our patients. For some of them, we are the only consistent part of their week. Many of our patients know our schedule and know us by name, just as we know them. Since communicating with our patients has its inherent challenges, we made the decision to tape flyers throughout downtown that explained we would be unable to continue our operations. While out posting these flyers, we ran into patients who were understandably concerned. They asked us where they would be able to get basic items we normally provide, like ibuprofen, socks, and deodorant. We were helpless. Yet, instead of meeting us with anger or disappointment, our patients told us to “stay safe out there” and “stay positive.” All we could do is tell them the same.
Our patients need our help now more than ever. Not only do they need help staying safe from COVID-19, but they also need the routine care and support we normally provide. The Center for Disease Control (CDC) recently released guidance for how to support people experiencing unsheltered homelessness during this crisis – an important first-step towards ameliorating this problem. These guidelines include maintaining a six-foot distance; a screening protocol for COVID-19; providing a mask if a patient has a cough; maintaining proper hand hygiene using soap and water or alcohol-based hand sanitizer; and providing hygiene products as often as possible. They also state that we are to “discontinue the interaction” if we are unable to maintain a six-foot distance between ourselves and our patients.
We simply cannot care for our patients while abiding by these guidelines. Given our intimate experience with the unsheltered homeless population, we are concerned for this vulnerable population. Here’s why:
Sure, we can converse from a six-foot distance and ask the proper screening questions. We can also provide bags with masks – ignoring the nationwide mask shortage for the sake of the argument – and other medications and hygiene supplies. Those things are relatively easy. The rest? Not so much.
First, we do not have the adequate personal protective equipment, or PPE. The lack of PPE is makes patient care especially difficult because it limits clinicians’ ability to safely approach potentially ill patients, and increases the likelihood that providers transmit the virus between patients. This obstacle is challenging for healthcare providers across the country. Without the physical proximity allowed by PPE, how do we conduct physical exams on patients with chronic medical conditions such as chronic obstructive pulmonary disease, heart failure, hypertension, and diabetes? How can we listen to their hearts and lungs? How can we assess or treat foot ulcers while maintaining a six-foot distance? These are important conditions to manage at baseline – and now, in the setting of COVID-19, managing them is even more important.
Regarding hand hygiene, many municipalities, including our own, have closed public parks and other facilities. In other words, many of the public restrooms that our patients regularly use are now closed. Even if we provided them with soap, where would they wash their hands or take a shower? We could provide them with hand sanitizer, but we do not have that either.
And then there are shelters. Although they provide crucial protection and security, shelters will inevitably reach full capacity, and the density of these living quarters poses its own challenge for social distancing and contagion. What happens if someone contracts the virus and spreads it throughout the shelter? Shelters will be caught between following the CDC recommendations and giving more individuals a bed.
Finally, what about the inevitable patient who has been exposed to COVID-19? For those of us with regular access to healthcare, we are told to first contact our primary care provider and get tested before going to the hospital. Our patients do not have that privilege. Should we tell them to go directly to the Emergency Room? This would likely place our patients at even higher risk for exposure and unnecessarily overwhelm the ER.
Logically, here is where we provide the solution to the problem. Unfortunately, we just don’t have one. All patients deserved to be treated with dignity and respect – this principle guides our organization – but at this time we can’t provide any care whatsoever to our local homeless community. The dangers posed by COVID-19 and the resulting restrictions on our efforts unfairly penalize an already vulnerable and ignored population. As a community and as healthcare providers, we must find a way to continue caring for at-risk and homeless patients without risk of transmitting the virus – us to them, or them to us.
Joshua Mizels, Lauren Holt, and Madeline Hooper are medical students at the University of South Florida Morsani College of Medicine.