On the morning of Friday, March 13th, Mary Beth Appel and Johanna Berrigan, two health-care workers who run a free clinic in North Philadelphia, were preparing for the morning rush. Their clients are experiencing homelessness, and sleep in abandoned buildings, shelters, or on the street nearby. “We see the same things that an urgent-care clinic does,” Appel, a sixty-year-old nurse practitioner, told me. The most common ailments included colds, wounds, chronic illnesses, and some frostbite. Today, though, they were bracing for the arrival of COVID-19. “I fully expect we’ll both get it. Don’t you?” Appel asked Berrigan, a sixty-four-year-old physician assistant. The women were seated on the first floor of the clinic, a converted row house, discussing how to contain infection among their clients. “The protocol now, if you feel sick, is go home and isolate,” Berrigan said. “Where are our people going to go? We’re going to isolate them under a tree in the park?”
The health-care clinic is one of two or three in the country that are part of the Catholic Worker Movement, a loose-knit social-justice organization started by Dorothy Day and Peter Maurin, in 1933. Appel and Berrigan had been running the clinic for almost twenty-nine years, and had treated patients through the AIDS crisis, the crack epidemic, and, more recently, widespread addiction to opioids. They were well-acquainted with the difficulties of meeting human needs during a crisis: Berrigan travelled to Iraq, in the nineties and early two-thousands, to document the impact of economic sanctions on its people, and helped provide care in Haiti in the aftermath of the earthquake that devastated the island in 2010. Still, they had never seen anything like the coronavirus. When I arrived, Appel had just spoken to a fellow Catholic Worker, in New York, to ask for advice on how to pray for the protection of their patients. “I was looking for the patron saint of spit,” she told me, only half joking. “There is one for bed bugs.”
At the time, in Philadelphia, there were still fewer than two dozen confirmed cases of COVID-19, and it had yet to manifest among the homeless population. In the early days of the pandemic, the homeless were surprisingly insulated from the disease, because they weren’t travelling internationally. “It’s unlikely that our community has been abroad in the past few weeks,” Berrigan said. The virus seemed most likely to reach them through contact with middle-class people in public places, including with college students who volunteered at soup kitchens. “For this community, service providers and librarians are vectors,” Appel said. But, once the virus became more widespread, Appel and Berrigan knew that cases among the homeless would increase rapidly.
The women had received little guidance on how to care for homeless patients, and some of the advice seemed nonsensical. At a recent meeting with health professionals, they’d been told to take sick homeless people to the E.R. “for testing.” “It’s ridiculous,” Berrigan said. “We know they don’t have tests.” (Today, tests are available, but in limited circumstances.) In the absence of formal protocols, they had been improvising; they had bought a box of rubber gloves and some face masks, though they knew these would offer little protection. In addition to their practical questions, Appel and Berrigan were confronting ethical ones. The clinic was vital to the lives of its clients: people came for medical services, as well as to make phone calls, borrow books (the shelf included copies of “American Pastoral” and “Atlas Shrugged”), take showers, and use the bathroom. But, though only about a dozen people were inside the row house at any time, there was a danger that the virus would pass between clients there. “What’s our responsibility—to be here or not to be here?” Berrigan asked Appel. “What gives the least risk?”
In the late morning, Appel opened the doors to the clinic. Outside, half a dozen people were waiting at the bottom of the stairs. Arnetta Ferguson, a fifty-four-year-old homeless woman with auburn hair, came in for the first shower. “I’ve been out there since 7 A.M.,” she told me. She disappeared into the shower stall, and, after her bath, she sat with me in the center’s former dental clinic. (The dentist had stopped coming some months earlier.) Ferguson told me that she had been living on the street for around thirty years, since she became addicted to crack and alcohol. Her children often called and visited the clinic asking to see her, but she didn’t want to go home while still in the throes of addiction. “I don’t want my family to see me,” she said. “I’m trying to be a functional addict.” Most often, Ferguson slept on a bed of cardboard, under a corrugated-metal awning, a few hundred feet from the clinic. “Those are my boxes,” she said, pointing out the window to two pieces of cardboard that she had leaned against a utility pole. “I prefer to sleep outside. Shelters treat you like shit.” She also knew that, in the close quarters of shelters, there was additional risk of exposure to COVID-19. The street felt safer.
Ferguson worried that she was at greater risk of contracting the virus because she slept in a public place, ate in communal settings, and wasn’t able to wash frequently. Still, she wasn’t sure how she could mitigate the dangers. “I’m not preparing for it,” she said. “What do I do?” She had heard that the most important precaution she could take would be to find a way to isolate herself, and Appel and Berrigan were encouraging her to do all she could to get off the street. “They’re my best friends,” she said. Over the years, she had occasionally managed to find a room for short periods, but she always left. In her purse, she had a crumpled paper with the name and number of a man who, she thought, might have a room that she could rent cheaply. She called several times, but couldn’t get through. Eventually, she gave up and went next door to the St. Francis Inn, a soup kitchen that is run by Catholic nuns and friars and has served meals three hundred and sixty-five days a year, without fail, since 1979. Usually, the friars served the food like a dine-in restaurant, as a sign of respect to their clients; that day, though, the meals were grab-and-go, and yellow caution tape blocked off the garden.
One by one, in Philadelphia and around the country, communal spaces, libraries, and soup kitchens were shutting down or drastically altering their services. Cities were scrambling to set up emergency measures to identify positive cases in the homeless population, which numbers roughly five hundred and fifty thousand people, and to isolate those who were not infected, to protect them from contagion. In Washington, D.C., shelters began taking the temperatures of volunteers and guests when they arrived for the night, turning away those who had a fever of a hundred degrees or more and at least one other symptom of COVID-19. King County, Washington, purchased an eighty-five-bed vacant motel to isolate Seattle’s sick homeless people. (This became controversial in the neighborhood of the motel, when a homeless man wandered off after being tested, shoplifted from a nearby store, and hopped on a northbound bus.) California leased vacant motels and bought trailers to isolate sick homeless people in Alameda County and other areas. San Jose temporarily halted sweeps of homeless encampments, out of concern that further displacing people would render them more vulnerable to the disease.
But most homeless people remained on the street, where they were at risk. “Housing is health care,” Charles King, the C.E.O. of Housing Works, told me. This is one of his mantras, and it is true even under ordinary conditions. “It’s impossible, under normal circumstances, to follow any kind of medication regimen or healthy diet, or to get proper sleep, if you don’t have a home,” he added. “And of course people need to have proper hygiene and be able to wash their hands.” The current outbreak only made the consequences more extreme. “Homeless people are ten times more susceptible to COVID-19, by the fact they have nowhere to go and to clean themselves,” he said. King noted that the need to provide these people with housing wasn’t only about our moral imperative to help vulnerable people. Public-health scholars, such as Randall Kuhn, a professor at U.C.L.A.’s Fielding School of Public Health, have argued that once the virus reaches the homeless population, it could ravage that community; this, in turn, would increase infection in the general population. For everyone’s sake, it is important to protect the homeless. “In an era of pandemic, housing is inherent to prevention,” King said.
The threat to the homeless is so great that, earlier this month, the U.S. Department of Housing and Urban Development took the unprecedented measure of issuing guidelines for curbing and managing infectious diseases among people living on the streets and in shelters, giving advice on stockpiling supplies and proper methods of disinfection. Shelly Nortz, the deputy executive director for the Coalition for the Homeless, told me she worries that the protocols, which urge shelters to send homeless people with mild symptoms to the emergency room, would overburden hospitals. Instead, cities should create space to isolate more sick patients by requisitioning vacant hotel rooms and dormitories. (Philadelphia recently announced that it is transforming a Holiday Inn Express with more than a hundred rooms into a quarantine facility for sick homeless people.) Nationwide, Nortz said, “We desperately need to reduce the density of the shelters so people can recover from this without infecting others.”
In addition to the immediate medical dangers of the pandemic, the economic crisis it is causing is already pushing more people into homelessness. “I totally agree with flattening the curve, and with people not overwhelming the health-care system, but that longer period of time has economic consequences,” Nortz said. The shrinking economy may also cause off-the-books jobs, like day labor, to disappear, making it harder for those who are transitory to eke out a living. Some advocates have argued that homeless people need their own federal stimulus package. H.U.D. has yet to announce specific measures, though the department spokesman Matt Schuck recently said, in a statement, “Funding to protect homeless Americans is very much part of the discussions between the administration and Congress as we work toward a final agreement.” Josh Goldfein, who works for the Legal Aid Society, said that the government didn’t need to reimagine the system. “They have the program; it’s called Section 8 housing,” he said. “They just have to pour money into it.”
On Monday, March 16th, in Silicon Valley, COVID-19 claimed its first fatality among the nation’s homeless population. The next morning, outside the clinic in Philadelphia, the mood had darkened. The sky was spitting rain, and the temperature had plummeted. The people who were gathered on the sidewalk, waiting to take showers, were stamping their feet and grumbling by the time Appel opened the door. “We are going to do things a little differently because of coronavirus,” she said. She explained that the virus could be transmitted through vapor droplets, and that they had to let the steam dissipate and clean the stall between each use, which reduced the number of showers that they could host each day. “We’re going to let people shower once or twice a week,” she said. The announcement was met with open outrage. “I need a shower today, Mary Beth! I have my period,” one woman called. Appel replied, calmly, “You probably aren’t going to get one.”
Ferguson managed to get a shower. After she emerged, we spoke in the alternative-medicine room, which was painted purple and usually hosted acupuncture and massage therapy. (Ferguson loved getting massages, but the service had been suspended during the crisis.) Some people she knew, who lived on the street, had told her that they thought the coronavirus was a Democratic hoax, but she didn’t believe that. She knew that cases were mounting and was desperate to find somewhere to stay. “We need a place to wash our hands and our behinds,” she told me. She called her contact several more times, to no avail. Eventually, she wandered over to the soup kitchen next door, where the aging friars—many of them between fifty and eighty—were serving breakfast through a Dutch door. But the next day there was good news: the room that Ferguson had been hoping for was available to rent, for five hundred dollars a month. An anonymous donor, who had found her through the soup kitchen, had given her a check to pay for it. Appel and Berrigan were delighted. “It’s really hard to stay clean and sober on the street,” Appel told me. “And, especially during the pandemic, she has a place to self-isolate should she need to.”
That same morning, Appel and Berrigan, for the first time, saw patients whom they suspected had contracted COVID-19; one young woman had a fever and a cough, and had been living in close quarters in a sober-living facility. With no way to help her isolate safely, the volunteers at the clinic sent her to the emergency room. They instituted more changes in the clinic’s protocol. “Now that we’re starting to see symptomatic people, we’re moving things outside,” Appel told me. They were also taking the temperatures of everyone who came to the clinic.
A tenor of discord was rising among the volunteers, some of whom thought the clinic should close. They worried that, by staying open and creating a place for people to congregate, they were exposing more of their clients to potential infection. Appel and Berrigan were torn, but felt that they were doing more good than harm: they were educating a population that had little access to information, and giving people at a high risk of exposure a place to wash their hands and get checkups. They could help direct patients to the Holiday Inn, where the city was quarantining people. Their services seemed more vital than ever. “We expect that as this virus continues to affect people’s lives, there will be more needs arising,” Berrigan told me at one point, by e-mail. “We will simply be there and do what we can to ease the suffering. Exactly how we will be called to serve remains to be seen . . . As long as we remain healthy, I think we are staying open to be there and to try as best we can to be a comforting presence for people and guide them through this.” But they were still concerned about the spread of the virus at the clinic. When I said goodbye to Appel for the last time, before leaving, she reminded me to keep my distance. “I’m a vector now,” she said.
A Guide to the Coronavirus
- How to practice social distancing, from responding to a sick housemate to the pros and cons of ordering food.
- How people cope and create new customs amid a pandemic.
- What it means to contain and mitigate the coronavirus outbreak.
- How much of the world is likely to be quarantined?
- Donald Trump in the time of coronavirus.
- The coronavirus is likely to spread for more than a year before a vaccine could be widely available.
- We are all irrational panic shoppers.
- The strange terror of watching the coronavirus take Rome.
- How pandemics change history.
