An empty Bourbon Street during the start of the Coronavirus quarantine

Hi world. I am a 4th-year medical student and a harm reduction worker. Yesterday, I went to volunteer with the New Orleans Medical Reserve Corps (NOMRC) to provide temperature checks for the homeless residents who are being put up in a hotel by the city. The hotel is staffed by Workforce and Franklin, and a Franklin subsidiary CHOICES. I was very disturbed by what I saw. I articulated my concerns to staff there and was repeatedly shut down. Several hours later, I was called by NOMRC and told that I was no longer permitted to volunteer there. Here is the email I wrote back to NOMRC detailing my observations from the day and my concerns.

UPDATE: Approximately 90 of the residents of the Hilton Garden Inn have been moved to a Quality Inn motel in New Orleans East (further out of sight).

UPDATE 2: The NOMRC coordinator who informed me I’m banned from volunteering at this site replied: “Your concerns (and concerns from several other volunteers) have been heard and we’re actively working on this. I will be on site tomorrow morning around 9 AM to see what changes can be made immediately versus those requiring more resources. I was on a call this afternoon looping in MHSD to provide behavioral health provision for residents, but I am looking at ways that we can promote better infection control precautions and harm reduction measures in this facility.”

Dear XXX,

I was concerned today after what I observed at the temporary housing site for chronically unhoused people (Hilton Garden Inn CBD), particularly regarding the lacking implementation of appropriate infection prevention precautions and the inadequate provision of harm reduction services for people who use drugs at the facility.

From the moment I entered, it was clear that even the most basic infection prevention precautions that grocery stores across town have managed to successfully implement for weeks were not being enforced for residents, volunteers, nor staff. No one was standing at the registration table donned with sufficient protective equipment to collect the temperature of any new staff or volunteer person before starting their shift. When I mentioned establishing a protocol that would require staff and NOMRC volunteers to have their temperatures checked at the start of each shift to Amy, she said that this would be an overburdensome requirement that was medical in nature and thus not the concern of the staff at this site. As an NOMRC volunteer who was there to monitor temperatures of the residents, I was puzzled by this pushback, as it ultimately took less than an hour to collect temperatures for all 190 residents and there were fewer than 20 new staff people present at the start of my shift. I was also not told where I could wash my hands (which everyone should do upon entering any building), nor reminded to do so upon entering. I never once saw routine disinfection of commonly touched surfaces, and it took until at least midday (several hours past the morning curfew established by the site) for the elevator buttons and surfaces to be disinfected. Temperature checking, washing hands, and routine disinfection are all infection mitigation practices that have been recommended by the CDC for weeks but are not being practiced with any systematic regularity by staff at this site.

Over the last few weeks, we’ve all grown accustomed to practicing responsible social distancing as a means of limiting community spread of this infection, as it is now known that up to 86% of infection transmission is due to asymptomatic cases and the virus can be aerosolized (and viable for up to 3 hours) by simply talking. Efforts made to implement this social change have included standing six feet apart from each other, taping lines six feet apart in public places where people need to line up, and limiting densely packed groups of people. However, at the Hilton Garden Inn, there is only one taped line 6 feet from the registration desk, and no additional lines 6 feet apart to suggest residents stand that far away from each other if they are waiting for assistance. While there is a sign on the door that says “Please Stand 6 Feet Apart”, no staff nor volunteers are consistently monitoring people who are crowding together in front of the registration desk to request that they stand further apart or return to their rooms if there are more than a set number present. I was also unsure of why residents needed so much face-to-face contact with staff in the first place when every hotel room is equipped with a phone that can call down to the lobby desk. The incompletely thought-out implementation of this basic social distancing measure suggested, as is a theme of my overall observation, that this site is superficially concerned more about mitigating risk to staff and volunteers from residents, rather than minimizing the overall spread of the infection, which is already considered endemic. This reflects the staff’s overarching characterization of residents, an already socially marginalized population, as the sole vectors of infection transmission. Indeed, this is the perception I gleaned from just a few hours there, as one staff member mentioned at the beginning of the site that “you don’t know what else these people could have…something worse than Coronavirus even,” with others nodding in agreement. However, the advice from our own governor for weeks has been to act as if each of us is already infected and to practice appropriate infection transmission precautions accordingly. Sadly, throughout the day in the lobby where staff were located, fewer than 5 people wore masks consistently (disregarding the CDC’s most recent recommendation for everyone to mask in public), and almost none of the staff were ever standing at least six feet apart from each other. In fact, a conference call was held in the lobby area with six senior staff people all sitting tightly packed together around one laptop for over 40 minutes. As physicians-in-training, we are taught to model the same health practices we recommend for our future patients. Correspondingly, if we expect these residents to follow social distancing practices then they must be modeled by staff, and periodically instructed to residents.

After our uncomfortably socially-proximate team meeting in the morning, wherein residents were oft referred to collectively as untrustworthy, dangerous criminals, we proceeded to distribute breakfast to the 190 residents. However, unlike the scrappy harm reduction collective I work with, this distribution effort did not follow a protocol to mitigate infection transmission. Instead, we all proceeded in a tightly-packed group at least 6 people deep to visit every room on each floor, knock on each resident’s door, and physically hand residents their meals before I took their temperature, wearing a surgical mask and gloves (but no face shield). I was surprised that there was no consideration among staff for how to limit physical contact with residents. I suggested that staff could place meals at the residents’ doorsteps, knock, and then walk to the next door while the residents retrieved the meal and I took their temperature and asked them targeted questions about symptoms and any preexisting medical conditions they would like addressed. I was told that there was no time for this, and moreover that I could not be left alone in the hallway as it was considered a safety risk, despite the presence of a hall monitor on each floor and the simple fact that I would be removed from a crowd of people. As such, I was unable to use this time to routinely ask residents about medication refills they required or collect information we were lacking about their preexisting conditions. Later in the day, I asked Stacy (Stacy Horn Koch, Director of Housing for the State of Louisiana) to clarify statements made at the morning team meeting that claimed staff must physically enter each resident’s room 2–3 times per day. She stated that this was unavoidable because it was necessary to ascertain whether any property damage had occurred in the rooms, because we did not want the state to be stuck with a bill from the Hilton for such damage. She did not mention any infection precautions taken by those entering the rooms nor any established disinfection protocol for rooms that had been vacated.

After distributing meals and collecting temperatures (several of which were under 100.4º but over 99.6º; no clear cutoff for concern or re-checking temperatures were established and no protocol for re-checking residents with subacute fevers was ever mentioned), we returned to the lobby to tackle the most pressing issue: a resident who had been sent to the hospital out of concern for COVID-19 infection had been discharged back to the hotel and currently had a temperature of 100.2º with visibly labored breathing and a complaint of chest pain. After talking to the nurse on site, it was revealed that this resident was likely immunosuppressed and had not taken any medications for months. When I reviewed her discharge summary, it stated that she was a COVID rule-out who had been administered a test that would result in up to 7 days. When the nurse and I brought up our concerns for a COVID rule-out patient housed at the hotel, Amy insisted that this resident must not have been tested for COVID because if she had, she wouldn’t have been sent back to the hotel as that was not the protocol, but instead she would have been sent to Bayou Segnette. I requested to read said protocol but it was never procured, and there existed great confusion among staff as to what exactly it contained. One staff member said that residents would only go to Bayou Segnette if they had a fever of 102º, for example. After obtaining the discharge summary for Amy to review, she returned an hour later to state that she had talked to the charge nurse in the ED who said that the patient had been given a rapid COVID test and it resulted negative, but it was not included in the discharge summary and that I would just have to trust Amy about this. To review, a patient who only had documentation of being administered a COVID test and no written documentation of a negative result, who was likely immunocompromised and symptomatic for COVID-19, was being kept in a hotel room on the same floor as dozens of other residents. Furthermore, as we know, the nasopharyngeal swab tests have a sensitivity ranging from 53–87%, far below what would normally be deemed sufficient for a rule-out test. Regardless, there was no clear understanding of where symptomatic COVID rule-out residents should go, how they should be dealt with, and how infection transmission should be mitigated at the hotel. We then got a call from a hall monitor that this resident had a new complaint, and went upstairs to evaluate her. While her temperature was still afebrile, she looked ill and exhibited labored, rapid breathing. I auscultated concerning lung findings. We went down to try to obtain a pulse oximeter to check her oxygen saturation, as asymptomatic hypoxemia is an ominous sign of imminent and precipitous clinical decompensation of COVID-19 patients. However, there was no pulse oximeter on site. We then decided to at the very least offer her an OTC painkiller and antipyretic for her chest pain and slightly elevated temperature. Given the recent research about NSAIDS upregulating the ACE2 receptor that COVID-19 uses to infect your lungs, I suggested giving her acetaminophen instead of the ibuprofen from one volunteer’s personal stash which presently comprises the full extent of medication available to residents. After the acetaminophen was obtained, we went to administer it and recheck her temperature. It was now 102º. Even if she was not positive for COVID, given her possibly immunocompromised state, housing status, and clinical presentation she could have had other concerning pathologies: opportunistic infections like Pneumocystis Jirovecii Pneumonia, Mycobacterium Avium Complex. She clearly deserved a higher level of care than a hotel where staff had repeatedly told me their role was not concerned with anything medical. After we left her room, I disposed of my jumpsuit in a biohazard bag and went to obtain some disinfecting spray for her door handle and frame. I was then publicly berated by Amy as acting hysterical for taking this simple infection mitigation measure. Thankfully, after a few minutes of arguing on the phone, we were able to get EMS to take her somewhere with the capacity to monitor and care for her. I did not hear anything about how her room or the floor would be disinfected to deal with potential contamination, however.

While it has been made clear to me that this temporary housing site is not a medical establishment, I do believe that, in the midst of a health crisis, once people who have a 5–10x higher rate of all-cause mortality at baseline (not to mention disproportionate rates of comorbidities that place them at increased risk of poorer prognoses from COVID-19 infection) are densely housed by an organization, it is that organization’s moral responsibility to systematically catalog and address their chronic health conditions in order to stratify and manage their risk of poor outcomes from this pandemic. However, while there has been some initial collection of residents’ chronic medical conditions and required prescription refills, this is not done routinely and is apparently now considered incumbent upon residents to bring to the attention of staff. Furthermore, there is only one licensed paid medical staff person (today, a nurse) present at the site to handle the immense task of ensuring adequate management of their 190 residents’ comorbidities. There are people living there with diagnoses of hypertension, diabetes, HIV, Substance Use Disorder, psychiatric diagnoses, and other high-risk conditions who haven’t had access to their medications for days or weeks and only one person is devoting any compensated time to addressing this situation. Compare this to the 4–5 hired security personnel present and it’s clear where the priorities for managing this population lie.

Many people experiencing homelessness use drugs, and many also inject. During a pandemic of unprecedented scale and social impact, it’s understandable and even expected that people who are not using may go back to using, and those who already use may do so in a riskier fashion. This risky use, amid the context of our second-most recent public health emergency (namely the drug war-induced fentanyl poisoning crisis), is compounded by compulsory social distancing and an inevitably erratic drug supply that will likely lead to increased overdose rates. You can read more about considerations for this “collision of epidemics” from a piece written by a NIDA researcher in Annals here. Indeed, per staff reports, this site has experienced 1–2 opioid overdoses per day but thankfully no fatalities, due to mostly sufficient naloxone inventory and response from staff. I was originally brought to this site over the weekend to provide syringes for IM naloxone, as the nasal naloxone that OHL had provided was almost gone, and an OHL staff member had taken back the IM syringes provided for the vials of naloxone present at the site due to a site staff member’s discomfort with needle usage by staff. When I arrived Sunday, I brought a half dozen of Trystereo’s own IM naloxone kits (each containing 3 doses), with the expectation that OHL would provide more nasal naloxone promptly. They did so this morning. However, there was much confusion over the scope of harm reduction services and training being offered to both residents and staff. It had been stated that OHL had conducted an overdose response training but staff were unclear as to if and when that was done. The other NOMRC volunteer, also Alex, mentioned that he had conducted an overdose response training recently. Nowhere was an actual overdose response and followup protocol referenced. No one mentioned anything about residents who had just witnessed or experienced an overdose being given any specific form of care, or even personal doses of naloxone (although the risk for opioid overdose is increased after experiencing one). Furthermore, OHL had provided perhaps a dozen harm reduction supply kits containing 2–3 loose, individual syringes, a piece of gauze, an alcohol pad, and an adhesive bandage, which were located furtively in a brown paper bag on a counter. It was unclear whether residents were ever made aware of the availability of these harm reduction supplies at all. The supplies themselves were also woefully inadequate. In Trystereo’s response to the COVID-19 pandemic, we have provided our participants at least a box of syringes (100), 3 times our usual full works kits (including cookers, tourniquets, and sterile saline), 3 times our naloxone kits, and fentanyl test strips to each of our participants, in an effort to limit their amount of unnecessary social contact. We do this as an organization with a budget of less than $100,000 and no paid staff. Why is OHL, a multimillion-dollar, fully staffed recovery facility without any extensive history of harm reduction service provision responsible for the harm reduction supply offerings at this temporary housing site, and why are they so picayune in quantity and quality? This is a site with a high density of people who use injection drugs, a logical place to provide adequate supplies that reduce the risk for negative health outcomes associated with injection drug use. When I suggested distributing IM naloxone to residents (as PWUD are most likely to respond to an overdose, and usually comfortable with syringes) and leaving the nasal for site staff, I received pushback at the possibility for distributing needles to residents, despite acknowledgment that residents are already injecting drugs themselves. I then suggested that perhaps we could have a biohazard bin located at each floor, similar to how we have erected such bins near homeless encampments in the streets, but was told that was also a bad idea without further explanation.

Reflecting on this now, I wonder why there is no medical director or someone trained in public health management overseeing the operations of a facility with 190 people, who as a demographic are already considered at high-risk for poor outcomes from COVID-19 infection? Why are there no pre-established written infection prevention protocols to refer to and practice regularly? Why is there no protocol on how best to evaluate a resident who is experiencing symptoms of COVID-19 and assess where they should be transported to for an escalation of care, or if they should be isolated, and how infection mitigation should look like? Why aren’t the staff standing six feet away from each other and wearing masks and gloves and washing or disinfecting their hands consistently? Why were my legitimate concerns about infection precautions dismissed as outside of the scope of the intention of this facility and its staff? Make no mistake about it, if someone were to get sick with COVID-19 and remain in this building, it is another Lambeth House waiting to happen.

As I left the hotel today, I had a brief exchange with one of the residents in the elevator, who stated flatly to me: “This isn’t about our health or safety, it’s never been about that,” and honestly, after my few hours there, I agree. This appears to be much more about the management and control of a population considered by the State to be surplus and expendable, rather than the preservation of the health and safety of some of the city’s most marginalized and at-risk citizens. In the months to come, we will be given ample opportunity to reflect on this slow-motion mass casualty event that is already disproportionately affecting Black people (70% of COVID-19 deaths in Louisiana) and those suffering from the impacts of other social determinants of health to such an extent that it can be considered a genocide of institutional neglect. We should begin now to consider how we would like to be remembered historically: as those who reinforced the same social standards that brought about such terrible outcomes for so many, or as those who stood up the social inequities conditioning the tragedies befalling these communities who have already endured such suffering at the hands of this callous, inhumane, and morally bankrupt political economy.

Sincerely,

Alex Niculescu