Mary-Anne Bédard hasn’t been sleeping much lately.

As the city’s general manager of shelter, support and housing, Bédard has been heading the response to COVID-19 in Toronto’s emergency shelter system, where at least four people have tested positive as of Friday.

Adding to those sleepless nights: Modelling suggesting that on average there could be, in several weeks, as many as 800 to 1,200 people in the homeless population testing positive for COVID-19 at any given time.

“Sometimes it feels a little bit like we’re holding back a tidal wave that we know is coming,” said Bédard. “But every hour that we are able to do that I think is an hour more that we get to plan.”

In order to not overwhelm hospitals, public health experts say social distancing is key to “flattening” the curve — giving healthcare workers time to better manage cases over a longer period.

But imposing social distancing rules on an already-stretched shelter system is no easy task. And frontline workers and advocates say that decades of inaction on housing and inadequate shelter space are compounding the immediate public health crisis.

Preparing the response to COVID-19 for the homeless population is taking an effort “that no city has ever tried to marshal before,” said Dr. Andrew Bond, medical director of Inner City Health Associates (ICHA).

The city has partnered with ICHA — a group of 100 physicians with experience working in shelters and drop-ins across Toronto — and the nursing expertise at Inner City Family Health Team, which Bédard said has been “critical.”

ICHA is rapidly scaling up its ability to respond to the healthcare needs of the homeless population during the outbreak, to be funded by the province. That includes hiring as many as 100 nurses with the help of their associations from the thousands who have answered the call from retirement and elsewhere to help during the outbreak — a necessary measure for these facilities to operate, said Bond.

Adding to the risk for the homeless population is the prevalence of underlying heart and lung disease — and their limited access to the healthcare system, added Bond.

“This is a really compounded phenomenon that is going to lead to disastrous outcomes very predictably,” Bond said.

The city is trying two key ways to keep the outbreak from devastating the shelter population: Putting distance between people in the existing system by opening new shelters and creating sites to isolate those awaiting test results and with confirmed cases staffed by medical professionals.

In the last seven days, the city has opened eight new facilities to try to space out people in shelters to prevent further spread.

That created 350 spaces to help with distancing, with two more sites — a vacant rental building and a hotel — toured by staff this week for suitability.

Also opened was a medically supported isolation site for people being tested — the first of its kind in Canada.

That 40-bed isolation site in Scarborough, led by a team of nurses, houses people while they await test results. By midweek there were about 30 people staying there.

A tenth site will open soon. The 200-person capacity hotel is for people under investigation and for some who test positive for COVID-19 until a larger site can be opened. Those who test positive will be housed there in individual rooms, with private washrooms, food and cleaning service.

The city is already working on a second COVID-19 positive site that will likely be more of an open-concept setup to care for those suffering as a result of the virus.

The unprecedented setup has required taking sites like hotels that were never intended to be shelters, let alone care facilities, and outfitting them with the necessary supplies, as well as staffing them with shelter workers and medical professionals.

But the number of new sites to improve distancing only increases the traditional shelter system — with a capacity of just over 7,100 — by a small margin (about a third of those spots are in motels, meant for family use, and allow for distancing already). When you consider drop-ins, where people sleep in even closer quarters on mats, chairs or the floor — wherever there is space — that increased space becomes even less significant.

Keeping people at the recommended two-metre distance remains the key challenge, Bond said.

One of the most important preventative measures they’re working on is identifying those most at-risk in the homeless population and helping to ensure proper social distancing and protective measures for them.

“The tragedy of the situation is that it may not be possible to go fast enough,” he said, adding: “There’s nothing more I can do than feel that loss and pain in advance and then just work harder.”

The city has had to meet additional challenges early on, including putting WheelTrans, fleet services and other resources in place so that a sick person is not walking, taking TTC or calling a cab to go between the testing and the isolation sites. Hospitals will be able to call and send a client, once tested, to the isolation site the same way.

The isolation site saw an uptick in people as test results lagged, Bédard said. And the number of people experiencing homelessness being tested also increased after provincial protocols for who was prioritized changed, she said.

The city and the medical teams are already preparing to use the new COVID-19 positive site as a mixed facility, with some awaiting results and some in recovery — separated from each other — to help with the flow of people being tested.

“We are trying to minimize the ultimate impact as much as we can by being innovative and creative and pushing boundaries I think a little bit,” Bédard said.

An example? Earlier this week, Bédard lay awake with another question — how would the city isolate people who have pets, for many a source of comfort and companionship? She’d go to work the next day trying to solve that issue, and others as they arose, on the fly.

But significant problems remain, at least in the short term, according to frontline workers.

Besides a lack of space, there isn’t enough personal protective equipment for the agencies running shelters and drop-ins. Keeping vulnerable clients isolated until they can be transferred for testing has proven difficult, and confusion about how to send people to isolation and what to do if they return to the shelter may be putting others at risk.

Tommy Taylor, a frontline shelter support worker at the Fred Victor 24/7 Drop-in for Women, said Thursday he believes the situation is becoming dire.

“There are too many people crowded together, there are too many systems that have fallen apart, there’s not enough equipment,” said Taylor. “It’s quite obvious that we weren’t prepared for this in the slightest and the reaction is just coming too slow.”

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Last Friday, Taylor said a woman in her 80s came in to the drop-in with a sore throat and cough, and reported that she was sore and felt she had a fever. But when she was told that she needed to go to an assessment centre, she refused — sparking a tense, 24-hour effort to keep the woman isolated and arrange for her to be tested for COVID-19.

After neither police nor paramedics were able to help, ultimately, the woman agreed to go to the hospital, was tested and the results came back negative. Taylor said they were “lucky” this time, but he doubts they will be next time.

Liam Michaud, a harm reduction coordinator at the Parkdale Queen West Community Health Centre whose team works in respites and shelters in the downtown west area, said they’re seeing shelters that are “incredibly under-resourced” and overcrowded while the challenges they face are not reaching the city officials who can help.

He described “totally negligent conditions,” including that people are still sleeping less than a few feet apart from one another.

“One person described it as he feels like they’re sitting ducks,” Michaud said.

Diana McNally, training and engagement coordinator for the Toronto Drop-In Network, said drop-ins are scrambling: trying desperately to get personal protective equipment, dealing with long lineups outside of the few drop-in centres that are still open — 10 of the city’s 59 — and accommodating people seeking somewhere to use the washroom, do laundry or just be indoors.

She said, wherever possible, health professionals such as nurses need to be on hand at the drop-ins to help with COVID-19 assessments — a screening protocol in place to keep people who may be sick from entering a shelter.

But she said the protocol “does not work for folks with high-level mental health and substance-use barriers.”

Advocates point to the decades of inaction on creating housing to end homelessness that has put people at risk before — and again now.

“They’ve had decades to fix this,” said Zoë Dodd, a long-time harm reduction worker. “This disaster is created and manufactured by the city.”

Toronto’s shelter system is responsible for much of the GTA’s homeless and is chronically short on space. At least 8,000 people are homeless at any given time in the city. Even in warmer months, shelters and drop-ins are at or near capacity with people being turned away.

Though council voted to have staff aim for 90 per cent occupancy in the shelter system to prevent overcrowding in 2013, that standard has never been met.

Dodd said the new isolation and COVID-19 positive sites are needed and medical teams welcome, but opening hotels and other places to allow for proper distancing is crucial to prevent further spread of the virus, she said, along with mass testing in shelters.

“Hopefully, what all of this is showing people is that we can’t live like this,” Dodd said. “We shouldn’t have people in shelters. We shouldn’t be warehousing people. People should have homes.”

Bédard agrees.

“The only solution to homelessness is housing,” she said.

Coun. Joe Cressy, who chairs the city’s board of health, said they look for opportunities to create permanent housing solutions post-outbreak — including purchasing sites instead of borrowing or leasing them, if possible.

“This outbreak has magnified the crisis,” said Cressy. “Our responsibility, if we’re smart, is not simply to protect the health and well-being of our homeless population during the COVID-19 outbreak but to transform those short-term measures into permanent solutions for after-the-fact.”

In the meantime, the city has been actively preparing for hundreds of patients in the homeless population, which officials hope will not come all at once.

“We absolutely acknowledge more is needed, which is why I sleep very few hours a day,” said Bédard. Despite that, what staff have been able to do so far in a short amount of time, she said, is a “phenomenal accomplishment.”

“I wish it was as easy as, you know, just opening the doors to a building and telling people that they can go inside. There are really critical logistics that have to be put in place — staffing, cleaning, food.”

Despite the fears, ICHA’s Bond remains positive. He is encouraged by the work he sees the city, his colleagues and community providers doing as they go “flat out” to prevent deaths in this narrow window that they have.

“It’s going better than I thought it could,” he said.