SAN DIEGO — As the head of a homeless shelter in San Diego, Bob McElroy knows firsthand how epidemics can turn deadly for people living on the streets. Three years ago an outbreak of hepatitis A, an otherwise preventable and treatable disease, killed 20 people in San Diego County alone, most of them homeless.
Now as the coronavirus spreads across the country, Mr. McElroy is faced with a new threat, one that he can only hope to ward off with a stockpile of hand sanitizer. Under a single tent in downtown San Diego, his shelter sleeps more than 300 people, a majority of them over 50 years old, a warehouse of human beings arrayed like cadets in military barracks. Numbered bunk beds are spaced just two feet apart.
“We’re just saying our prayers,” Mr. McElroy said. “If it gets in here it would be a disaster.”
Medical researchers say the 550,000 people currently homeless across the United States have a double vulnerability to the coronavirus. They are more susceptible to contracting the disease caused by the virus because of the cramped quarters in shelters, the sharing of utensils and the lack of hand-washing stations on the streets.
Once infected the chronically homeless are more likely to get much sicker or die because of underlying medical conditions and a lack of reliable health care. One study last year found that 30 percent of homeless people had chronic lung disease.
Phoenix; Portland, Ore.; Washington, D.C.; Austin, Texas; and many cities across California have large homeless populations that are vulnerable to an outbreak. New York City, which has the largest homeless population in the country, issued an 11-page document instructing shelters to screen people for symptoms and quickly identify and isolate those who have contracted the virus in a separate room “as much as possible.”
4 SLIDES © Eros Hoagland for The New York Times
An underground tunnel in San Diego where many homeless people seek shelter.
“We should be very worried,” said Helen Chu, an infectious disease doctor in Seattle, a metropolitan area with one of the highest rates of homelessness in the nation and the current center of America’s coronavirus outbreak. So far, none of the more than 100 confirmed cases in Washington State have been among the homeless population.
Over the past several years Dr. Chu has conducted studies of diseases at homeless shelters in Seattle where mattresses, she said, are less than one foot apart from each other. Homeless people are “extremely vulnerable” to the coronavirus, she said.
Dr. Chu has argued for urgent steps to test homeless people in shelters for the coronavirus to stop the chain of transmission. But she and other experts acknowledged how difficult halting an outbreak would be.
The global response to coronavirus outbreaks has been to order people to self-quarantine. Homeless people, by definition, have nowhere to go.
There are also concerns for employees at shelters — nurses, administrators, charitable workers — who, like health care workers at hospitals, could find themselves exposed multiple times if the virus were to spread among the homeless community.
In some cases it was illness that sent many of those living on the street there in the first place. Tracy Semrow, who was a school psychologist earning a six-figure salary working with children with disabilities, learned two years ago that she had a degenerative connective tissue disorder. The costs of medical care have drained her savings.
Since August her home has been one of the bunk beds in the shelter run by Mr. McElroy’s charity, Alpha Project. She is frequently sick and sometimes cannot get out of bed.
“My immune system has gone haywire,” Ms. Semrow said.
The breadth of the homelessness problem in San Diego County, where by last count more than 8,000 people were without homes, shows the challenges that a coronavirus outbreak would pose.
Homeless people sleep in rows on sidewalks in downtown San Diego, huddling in half-mile-long drainage tunnels filled with rats. And they have erected makeshift homes in the canyons that run through the county.
Doctors say that when homeless people arrive at emergency rooms, they are often already very sick.
Homeless people have rates of respiratory infections far greater than in the general population. At one hospital in Seattle, 32 percent of people who had a common respiratory illness were homeless, compared with 7 percent of all patients hospitalized, according to a study published last year that was written by Dr. Chu and others.
Norbert Alarcon, a former janitor, has been homeless for two years and sleeps in a tent made from plastic sheeting in a forested area of National City, near San Diego. When police officers and outreach workers approached him last week he had a severely swollen hand from a deep cut he sustained in a bicycle accident. The officers urged him to seek treatment but Mr. Alarcon insisted his hand was fine. “It has color now,” he said of his hand, which was bandaged with postal packing tape. “Before it didn’t have any color.”
The hepatitis A outbreak of 2017-18 infected approximately 600 people in San Diego County, according to Natasha Martin, a specialist in infectious diseases at the University of California, San Diego. Hepatitis A is transmitted through fecal matter, sometimes by people who prepare food with unwashed hands.
The authorities and charitable organizations fought the spread of that disease aggressively with a vaccination campaign, street cleaning and the placement of hand-washing stations on sidewalks. But the measures did not arrive in time to prevent the 20 deaths.
“Had the emergency campaign occurred earlier, it would have had an even greater impact on preventing transmission,” Dr. Martin said.
Doctors say the threat of coronavirus is analogous to that of hepatitis but with at least one key difference.
“Obviously we don’t have a vaccine for coronavirus,” said Dr. Robert T. Schooley, an infectious disease expert who advised the San Diego city government during the hepatitis outbreak.
Dr. Schooley said that early studies of the coronavirus show that it spreads easily within households, and that homeless shelters can be considered giant households.
He called those experiencing homelessness a “silent population” because outbreaks are recognized more slowly in that group than in groups that have better access to medical care.
David Corpus, a former dishwasher at a restaurant who has been homeless for a decade, is not only silent but hidden, too. On Wednesday a police officer, Daniel Duran, had to walk 200 yards in a pitch-black, dank subterranean drainage ditch to order Mr. Corpus out of the tunnel, which runs under a shopping center.
“Police Department! Who’s in there?” Officer Duran said as he spotted the piece of plywood that Mr. Corpus was hiding behind.
Mr. Corpus has diabetes and high blood pressure, and his hands cramp up for unknown reasons. He has not seen a doctor in months, he said.
“I don’t like it in the tunnels,” Mr. Corpus said as he emerged into daylight, squinting under the California sky. “But it’s the only place I can go.”
