By Erica C. Barnett

An alarming increase in COVID cases among people experiencing homelessness has been exacerbated in recent weeks, homeless service providers say, by rumors that if people enter a county-run isolation and quarantine site, they won’t be allowed to leave.

And even before these rumors began circulating widely, many unhoused people who tested positive for COVID were reluctant to enter isolation and quarantine, for reasons that ranged from active substance use to the fear that if they left an encampment, they would lose everything they had—a not unreasonable assumption, given the recent uptick in encampment sweeps.

“The resistance, in my experience, has been across the board,” Dr. Cyn Kotarski, medical director for the Public Defender Association, said. “I haven’t met anyone so far who doesn’t have some fear and some resistance to go, and that’s mostly just because it’s overwhelming. It can feel pretty scary to think that you don’t know where you’re going or why, especially when you’re taking someone out of their own environment and their own community,” Kotarski said. The PDA is a partner on several efforts to move unsheltered people into hotels during the pandemic, including Co-LEAD and JustCare.

Although early reports suggested that people living outdoors are less susceptible to COVID infection than those living in group quarters like congregate shelters, the more contagious delta variant could lead to more infections in both indoor and outdoor locations. During the week that ended September 10, King County counted 41 people experiencing homelessness who tested positive for COVID—an undercount, since it only accounts for county testing events.

According to King County Public Health spokeswoman Kate Cole, as of last week, there were 22 active COVID cases associated with encampment outbreaks, defined as two or more people who have tested positive at an encampment—an “increase from baseline” of “one to four cases per month associated with encampments.” A review of the county’s weekly reports shows a steady increase in cases that began in early August and hasn’t abated.

The increase in COVID cases has impacted every part of the county’s service system. The county’s public health department offers testing and transportation for people who test positive, but service providers and county officials say the system is stretched thin, with long waits for transportation and even testing. According to Cole, the current wait for a test by the county’s HEART E Team, one of two teams that performs testing at homeless encampments, can be as long as five to seven days. When someone living in an encampment tests positive, an outreach provider often must wait with them for hours until a county vehicle arrives to take them to isolation and quarantine, increasing the likelihood that they’ll give up and decide not to go. 

Just getting someone on the phone, outreach workers say, can be a challenge. “You call in and they take your number, but if you call back, it’s an automated line and you have to try to reach the person you were talking to,” Dawn Shepard, the south district outreach coordinator for REACH, said. If an outreach worker or unsheltered person misses a call from the county’s COVID hotline, Shepard says, they’ll have to start the whole process over again, “and by that point the person’s just losing interest.” Currently, Shepard added, “It’s taking us about eight hours from coordination to pickup.”

The county, through a partnership with T-Mobile, has handed out about 500 cell phones for outreach providers to distribute to clients, according to Cole, but Stewart says they need more, along with rapid COVID tests so that people don’t have to wait for days to get tested. Currently, rapid tests are hard to come by and expensive when they are available.

Meanwhile, the number of people staying at the Kent isolation and quarantine site, where 60 rooms are currently available, has increased from zero to 50 virtually “overnight,” King County COVID Emergency Services Group director Hedda McClendon said, stretching resources thin. If all the rooms fill up, the county will have to start triaging people based on test results, exposure, and other qualifications, turning people away if their cases aren’t severe.

Shepard said that in the early days of the pandemic, “we really didn’t see folks that were living outside contracting the disease…  largely because the viral load is much lower when you’re outside. Now, though, I think it’s safe to say that with the delta variant, our clients don’t have the same protection, because we’re seeing it all over the city.”

Shelter providers, including Compass and WHEEL, also confirm that they’ve seen an increase in cases; according to WHEEL organizer Michele Marchand, COVID “is ripping through many, many homeless programs and communities,” including WHEEL’s women’s shelter at First Presbyterian Church on First Hill, which has seen at least 11 positive cases in the past few weeks. “We’ve had to stop doing intakes now because of this outbreak,” Marchand continued, adding that the organization is seeking funds for hotel vouchers “to meet the immediate need during this current crisis.”

Charlene Mitchell, the program manager at the Compass Housing-run women’s shelter Jan and Peter’s Place, said that the shelter requires people who test positive to stay “in their bed area” while they wait to be taken to the site in Kent, a process that’s considerably faster than testing and moving people living unsheltered. (Currently, the county uses Yellow Cabs for this purpose). She can remember one recent case when a woman left the shelter for the Kent site and decided not to stay. “She turned around [after arriving] and stayed outside in the streets and at the bus stop” after family members refused to take her in. “She recovered, but I don’t know who all she infected” while she was contagious, Mitchell said.

Shepard says that she’s encountered an increasing number of unsheltered people who tell her they have COVID-like symptoms but don’t want to be tested or go into isolation and quarantine because they’re afraid they won’t be allowed to leave. “There was this big push, when isolation and quarantine opened, that they were not going to hold people against their will, but now there are stories coming out about that happening to people.” Shepard says she takes these stories “with a grain of salt—when I’ve asked who has had that experience, it’s just like, ‘everyone knows'”—but says they’ve had an impact nonetheless. “The big thing I’m hearing right now is, ‘No, I don’t want to go because they won’t let me leave.'”

McClendon, from King County, stresses that the county has never required anyone to stay in isolation and quarantine against their will. “The facilities are not secure, and staying is totally optional,” she said. “When people come in, we say, ‘Your isolation period is this long, your quarantine period is this long. If you do not want to stay the whole time, let’s talk about it.'”

McClendon is quick to acknowledge the anxiety many unsheltered people feel about moving into a medical facility with “structure and rules,” including the requirement that they stay indoors. “For a lot of people living unsheltered, they have had not the best experience in the homeless shelters. And then if that is the case, and that is their experience when they have sought services, that experience then translates to what happens with isolation and quarantine,” McClendon said. In addition, “people don’t want to lose their stuff or lose their location. So as much as possible, we do allow people to bring their stuff.”  The county also allows service animals and offers to board people’s pets while they’re in quarantine.

But some common barriers to isolation and quarantine are harder to address. Many people experiencing homelessness have substance use disorders or mental health conditions, including disorders that cause persistent, fixed delusions, that make it difficult for them to enter institutional settings.  Homeless service providers say this can be one of the most challenging barriers to overcome. “For those that have substance use disorders, they feel like they’re not going to be able to get their drug of choice or they might go through withdrawals,” Mitchell, from Jan and Peter’s Place, said. “I could imagine if you’re already sick [with COVID] and then you start going through withdrawals, what that would be like.”

The county does offer methadone and buprenorphine, two opiate replacement medications, to patients who already have prescriptions, and people who are dependent on alcohol can receive a predetermined number of drinks each day, McClendon said. (The county will also help people start on medication-assisted treatment in the rare event that they want to do so while in isolation, she added.) Cigarettes are also available to those who smoke. But for people actively using opiates, or those who use stimulant drugs like meth or cocaine, the county doesn’t have much to offer other than a trip to a hospital for managed withdrawal while they recover from COVID. And those accustomed to drinking more heavily than the county will allow may still have withdrawal symptoms that can be hard to manage, including restlessness, difficulty concentrating, and hyperactivity.

Dr. Kotarski, from the PDA, says she’s seen many people use cannabis products, including edibles and CBD, to ease withdrawal symptoms while they’re in isolation and quarantine. In addition, the PDA supplies its clients with incentives to remain in quarantine, such as candy, favorite meals, and “tinker kits”—sets of tools and parts that people addicted to meth can assemble and disassemble, an act that can relieve withdrawal symptoms and help pass the time. “People want to take the edge off,” Kotarski said

McClendon said the county also offers meals, food, and other incentives to help people deal with the anxiety and stress of isolation. And if people still decide to leave, she said, the county tries to help them find family or friends to stay with, set up transportation, and send them away with masks and hand sanitizer in their bags. “Very few people have left what we call AMA, against medical advice—it is a very, very small percentage, given the thousands of people we’ve served, and almost everybody leaves to go stay with family or to go stay with friends,” she said—a number that includes the 85 percent of county isolation/quarantine guests who are homeless. “And for us, that’s actually a pretty successful exit.”

erica@publicola.com