Coronavirus Could Cost Parents Custody of Kids in Foster Care

“[My one-year-old] sees me, he hears my voice, he looks at me for a second, but that’s all,” said Juanita Moss, a mother in San Francisco, California. Her three children are in foster care, and for the past six weeks, video chats have replaced in-person visits. “My son, [who is] four years old, has a hard time expressing feelings. He’s very verbal about it, it’s painful to watch. He will kick and scream about how much he wants me…he’s constantly saying he wants to ‘come home, mommy.’”

San Francisco enacted a citywide shelter-in-place order on March 17. Prior to the lockdown, Moss was seeing her three children twice a week in supervised settings like the public library or a designated visitation center. Now, she can only see her children through a screen.

In response to the pandemic, child welfare agencies around the nation have been limiting or completely cutting off in-person visitation between children and their parents, leaving many families wondering when they will be in the same room again. It’s not just the immediate emotional consequences at stake: the extended time apart is bound to weaken some parents’ reunification cases. Experts are concerned it will lead to permanent dissolution of families unlucky enough to have open cases during the pandemic.

Although people unfamiliar with child protective services might believe the term refers to a unified national agency, “CPS” is actually an informal moniker that references a network of individual agencies run at state and jurisdictional levels under a variety of names, which are held together by a loose set of federal guidelines and a complex web of federal and state funding sources.

In some states, like New York and California, there have been no official statewide orders cutting off all in-person visitation; instead agencies have been directed to make decisions on a case-by-case basis. But those on the ground say this is still leaving many parents without a voice in the decision-making process.

Despite state-level guidance that visits take place whenever possible in New York, for example, “in individual cases we are seeing visits being curtailed…you might have a foster mother who has a vulnerability to COVID so she doesn’t want the children in her care going home for the weekends with their parents and coming back,” said Emma Ketteringham, managing attorney for the family defense practice with the Bronx Defenders.

In other states, like Idaho and Illinois, all in-person supervised visitations have been suspended. A few states, like Louisiana, continue to legally allow in-person supervised visitations, but are closing their buildings to the public and directing employees to work from home, which means supervised visitations, which often take place in these buildings and require staff to be physically present, cannot practically take place. While agencies appear to be allowing remote visitation when possible, for some — like parents with newborns and toddlers or children with developmental delays — remote visits just don’t work. In other cases, the parents, foster families, or agencies themselves might not be equipped with the technology necessary to facilitate remote visits.

Even in cases where these factors don’t apply, video communication is a meager replacement for face-to-face contact between a parent and a child, interrupting crucial bonding and raising the possibility of increased anxiety and depression in both parties, according to Richard Pittman, deputy public defender at the Louisiana Public Defender Board. Pittman expressed particular concern that parents might become so dejected by the loss of substantive contact with their children, as well as the loss of therapeutic services and mandatory classes that has gone hand-in-hand with the curtailed visits in many locations, that they might disengage altogether from the case. “Any progress they’ve made healing from the trauma of the initial removal is going to be reversed through all of this,” said Pittman.

Moss’ youngest child turned one shortly before the lockdown but had been in Texas with his foster mom on his birthday. Moss has still not been able to celebrate with him in person, and she’s terrified that she is now also going to miss his first steps.

“[He] had a long hard time learning to sit up and crawl. Luckily before this [lockdown] happened I got to see him to crawl and sit up. Now he’s on the verge of standing up on his own and I should be there for that. [His foster mom] is experiencing all this stuff that I should experience…I think it’s just going to break me if I don’t see my son walking,” she said. Moss also noted that her son has struggled with a recurring bronchial cough, which is particularly stressful during the pandemic, but she is barred from even texting his caregivers to inquire about his health without the social worker’s permission.

The consequences go further than feelings

In child welfare cases, the consequences go further than feelings. Under the Adoption and Safe Families Act (ASFA), agencies are required to file for termination of parental rights when a child has been living in a non-relative out-of-home placement for 15 of the past 22 months. Some states have shortened that timeline to be as few as 12 months. Although parent attorneys should have a good case for requesting an extension — ASFA allows for consideration of mitigating circumstances and it’s hard to think of a better one than a pandemic — those extensions are neither guaranteed nor infinite. And once a termination petition is filed, bonding between parent and child is a crucial determining factor.

The factors that are used to determine whether or not it is in a child’s best interest to keep them permanently separated from their parent vary somewhat by state, but typically revolve around the ASFA timeline, the parent’s completion of court-ordered services like drug treatment and parenting classes, and the bond between parent and child, which is often measured by the frequency and quality of their visits.

“An agency can say ‘we understand the reason there weren’t visits is because of the coronavirus, but at this point it’s been x many months in foster care and they haven’t made progress and it would hurt the kids to go home now,’” said Amy Mulzer, a family defense appellate attorney in New York and an Elie Hirschfeld Family Defense Fellow at the NYU School of Law Family Defense Clinic.

Shayna, a Native American mother who lives in Wisconsin and asked that her real name not be printed in this story, has two children out-of-home in two different counties. Her youngest child has been on an adoption track, which means Shayna is fighting an uphill battle to have him returned home rather than having her parental rights terminated and her child forcibly adopted to his current caregivers. For her, the issue of bonding is not an abstract future hypothetical; it’s a very real factor she must now find a way to prove without being able to interact with her three-year-old in person.

Visits could literally make or break her reunification case

“It seems like they are using the coronavirus as a reason to keep my son from me because they know the court date is coming up, which is not good because they don’t have observations on me from now to then,” she said. Her son’s foster placement had been in pre-adoptive status, but she was recently able to get her case placed back on a dual track, which means adoption and reunification are both on the table for the next six months. For her, visits could literally make or break her reunification case — but she says the social worker is refusing to use an approved family member as a supervisor in order to continue visits, even though that is technically allowed. “They are not utilizing any other options, just using this coronavirus to stop and hold the visits. I think they should look at the bigger picture: this little boy needs to be back with his mom.”

Less restrictive alternatives exist. For example, Richard Wexler, executive director of the National Coalition for Child Welfare reform, suggested moving visits to open spaces like parks when possible, and expediting the return of children who can safely be returned home. San Francisco recently issued an order requiring agencies to make efforts to supply families in need with the appropriate technology to engage in remote video visitation. It also directed agencies to analyze and identify cases in which children were nearing reunification, and to fast-track their return home when possible. Advocates in New York City say similar efforts are being made, though it is unclear (in both locations) exactly how many families are on track to actually receive these benefits. These directives also leave a host of other details unanswered, such as the minutiae of moving a child from one location to the next — suddenly far more complicated when having to also consider infection control.

The Children’s Bureau within the federal Department of Health and Human Services issued a letter in response to the pandemic that included suggestions to state agencies about how to handle a variety of topics, including parent-child visitation. The guidelines discourage courts from “issuing blanket court orders reducing or suspending family time,” and asks agencies and courts to “be mindful of the need for continued family time, especially in times of crisis and heightened anxiety.”

While these suggestions come from a credible source and can bolster arguments in favor of continued family visitations, without Congressional action or agency rulemaking, they are not actual orders. This leaves states and agencies the license to develop their own pandemic protocols.

“If a child can’t see their parents for months at a time, they start to believe maybe their parents don’t love them,” said Michelle Chan, a mother with prior child services involvement, and founder of California Rise, a Bay area child welfare activist group. “I really am worried about the deterioration of the parent-child bond. I feel it should be the most important thing.”



What Happens When a Grocery Store Job Is the Only One You Can Get?

My great-aunt works at a grocery store in a populous suburb of Philadelphia. She’s worked there for about two years, following a stint of part-time jobs, including one at a temp agency working in factories. Normally she works behind the deli counter with a team and helps customers on the floor; now she mostly works alone behind the counter because there’s not enough space for multiple people to social distance back there. She pre-slices the most popular cold cuts to place out in front of the counter, so people don’t have to ask for them.

My great-aunt’s workplace hasn’t provided her with any protective gear, even though grocery workers are, as Vogue decreed, “the new first responders” under COVID-19. She had to purchase masks for herself off Groupon for $30, no small expense on her wages. She was excited about her recent COVID-19-induced raise from $11 an hour to $13 an hour, even though the store cut her hours so ultimately she’s making about the same amount.

“Before I guess I didn’t take this all serious,” my aunt says. “But I am anxious now, because people just keep coming in here. They’re not listening to the stay at home order. People come in there, and they’re not wearing masks.”

My great-aunt has a felony record, so she’s limited in the work she’s able to get. She can’t quit her job, because she went through so much to get this one: working at the temp agency and being driven across state lines to work in factories, getting rides to local hotels to beg for housekeeping work, struggling to make enough to get out of her recovery housing. “I just couldn’t get a job,” she recalls.

Nearly three-fourths of people released from prison remain unemployed a year after their release, and a criminal record can halve the chances of a job callback or offer; those chances are worse for Black applicants than white applicants. Gender complicates it further: Because women often work in fields that require background checks, like retail and caregiving, they may have an even harder time finding employment. In many states, including Pennsylvania, state law bars people with criminal records from caregiving jobs.

Many parole deals include an offer of employment as a requirement of release, increasing the urgency of the job search. It took my great-aunt, who is white, a year to get her part-time job at the grocery store; she’s worked there ever since.

People with a history of incarceration tend to be pushed into dangerous jobs.

Despite the risks, her position at the grocery store is a blessing. Other re-entry-friendly fields like retail have faced massive layoffs — more than 33 million Americans have filed for unemployment since late March, with Pennsylvania hit particularly hard — leaving more people with records looking for jobs. Grocery stores, on the other hand, are desperate for employees. Since they are considered essential, grocery stores are among the few establishments open, making them the main place for people to purchase household goods.

As a result, grocery stores may be where formerly incarcerated people turn first for work, despite the dangers. My great-aunt says her friend’s son was released from a Philly prison a few weeks ago with no warning — presumably due to COVID-19 concerns, but they’re not sure — and showed up on her friend’s doorstep. After a few days, they were able to get him into a halfway house a few towns away. He got a job at a local grocery store a week later.

People with a history of incarceration tend to be pushed into dangerous jobs, like construction, maintenance, and factory lines, with wages below the poverty line. These are often the jobs that others see as menial work; right now, these are the jobs that are on the frontlines of the COVID-19 pandemic, because they don’t allow for social distancing and provide essential services to protect us all.

After all, you need to get your groceries somewhere. And when you get them, my great-aunt will be there, in the deli section, slicing your cold cuts, at great risk to her health. “I’m a little nervous about going, but I don’t have a choice,” she admits. “I need my paycheck. I’m grateful I still have a job, I look at how many people are unemployed and I’m just grateful I have a job.”



Closed Mosques Mean Many Are Going Without Food During Ramadan

Throughout the month of Ramadan, Muslims who are able fast from dawn to sunset. For many, the hardest part of Ramadan is not the physical fast itself but finding food for iftar — the nightly meal breaking it. Often, iftars are pictured as giant meals with plenty of fresh, juicy fruit and deep-fried foods like sambusa to share with your family or friends, but that’s not an option for everybody. Numerous times, I would not have been able to break my fast with more than some basic ramen if it wasn’t for a local masjid providing nightly iftars.

I’m not alone: A 2018 study from the Institute for Social Policy and Understanding found that one-third of Muslims in America are at or below the poverty line. In fact, Black Muslim households are more likely than any other racial group to earn less than $30,000 a year. Of course, Muslims are feeling the economic impacts of the coronavirus crisis, such as soaring unemployment. However, the pandemic is also changing how Muslims will practice their faith. This year, Muslims in the United States must adapt to a Ramadan under the shadow of the novel coronavirus.

In early April, the Fiqh Council of North America, a body of Islamic scholars from the United States and Canada, wrote “masajids and Islamic centers shall strictly follow the health and state official guidelines for social gatherings and distancing.” These necessary guidelines mean Muslims will not have access to some of the usual spaces for community in Ramadan, including the masjid’s iftars. For Black Muslim hubs, like Philadelphia, where community leaders estimate the Muslim population to be at 150,000 to 200,000 — or 10 to 15 percent of the total population — a Ramadan under lockdown can have drastic impacts on the community.

In Philadelphia, five masjids are responding to the pandemic with Philly Iftar 2020 where volunteers will help deliver iftars. It is one way to ensure that those who normally rely on the masjid to provide iftar are able to still access that service. Qasim Rashad, Amir of the United Muslim Masjid (UMM), located ten blocks from Philadelphia’s City Hall, told TalkPoverty, “We do service a low-income population and we rely upon those who have greater resources to help us do that.”

Outside of Philadelphia, Muslims continue to worry about how their communities will fare. Aicha Belabbes, a Muslim living in Boston, shared that she was furloughed due to the pandemic and it has amplified some of her pre-existing concerns for her community.

“In Boston, there were iftars galore. If you needed food, there was always a place to go,” Belabbes told TalkPoverty. “Now, I think for students, for low-income people, for [essential workers like] delivery drivers, Uber drivers, there’s no longer those places of food. Ramadan served as an escape for so many people who had difficult relationships with their families and things like that and were able to find their safe spaces. Now, that’s no longer the case.”

“There’s no longer those places of food.”

Belabbes said pre-existing organizations who deliver food to Muslims have been “at capacity during the virus.” In addition, a food bank run out of a local Black masjid shut down after the imam showed COVID-like symptoms. Safiyah Cheatam, a Baltimore-based interdisciplinary artist, also told TalkPoverty that go-to gathering spots in her city are no longer viable. Many in Cheatam’s community rely on masjids or Muslim-owned establishments like Nailah’s Kitchen, a Senegalese restaurant, for iftar and she sees a need for relief like the mutual aid grants popular on social media.

Masjids are not the only ones taking on the issue of food access. In Buffalo, New York, Drea d’Nur, an artist and mother of five, founded healthy and halal food pantry Feed Buffalo in 2018. She was inspired by her own experiences using food pantries where there were no halal options and few healthy foods. d’Nur told TalkPoverty, “In the discussion of building healthy communities, we stand on the truth that no one should be exempt from healthy food access despite health conditions or spiritual practices. It was important to me that Muslims have a space that honors the halal standard and that all are served with love.”

Because of the coronavirus pandemic, Feed Buffalo is now functioning as an emergency food relief center for at least four hours every day of the week. In addition, the pantry will hold its second annual Ramadan Healthy Food Giveaway, where d’Nur estimates that Feed Buffalo provides 200 healthy food bags to fasting families, and commits to preparing soups for at least 50 families using ingredients from local farmers once a week.

Support for low-income Muslims in Ramadan extends past food alone. For example, while some Muslims may be able to access community by congregating with their families (or whoever else they’re already social distancing with) in their homes, this isn’t an option for everybody. Both Belabbes and Cheatam raised concerns over reports of rising domestic violence rates during the pandemic. Home may not be a safe space or, like myself, you may live alone and be the only Muslim in your family. Rashad shared that the UMM is conscious of this and will continue making plans to look after the spiritual needs of its community. Rashad said, “We want to keep and maintain that spiritual connection because spiritual mental health is important. We want to maintain their connection to Allah and their connection to the masjid.”

Belabbes hopes that the larger Muslim community understands issues amplified by the pandemic will not disappear when it ends. Belabbes said, “I’ve seen a lot of people saying, ‘I’ve never had to do things virtually.’ But a lot of Muslims who are marginalized had to do things virtually for a long time. I would like there to be an understanding that in the eyes of Allah, everyone’s equal, and everybody deserves to be seen equally in the community.”



Few Jails Provide Addiction Treatment, Making Release Fatal

When Tom Derbyshire woke up on the floor of his former jailmate’s house, he didn’t understand what had happened. All he knew was that he was in withdrawal — again — and needed to fix it as soon as possible.

He would eventually learn that he had overdosed while using heroin, possibly laced with fentanyl, with a couple of guys who he met during his recent stint in jail. A few days later, Derbyshire woke up withdrawing and confused again. This time, he was in the bathroom of a Wal-Mart, and he had been revived by paramedics — which meant he had to run, because if the police took down his information, he would probably go right back to jail for violating the terms of his release.

The two overdoses took place within days of each other in early April 2018, both less than two weeks after his release from Atlantic County Jail in New Jersey. Derbyshire, a 40-year-old tile setter with a history of opioid addiction, had been picked up for a bench warrant and a probation violation related to drug use.

He spent two months inside, during which he was involuntarily detoxed from opioids. He described the jail’s withdrawal protocol as two daily cups of a sports drink while being held on 23-hour lock down in a cell with two other men. Every other day or so, someone would check his vitals, and that was it. No methadone, no follow-up care after his release. And Derbyshire isn’t unique. In his case, he was not able to get methadone because he had not been incarcerated enough — one of many requirements at his facility’s program.

David Kelsey, the Atlantic County Jail warden, commented that “since its inception [the methadone treatment program] has provided services and referred to treatment eight hundred individuals.” In most other facilities, evidence-based treatment is not offered to anyone. But unlike Derbyshire, many of those who overdose after release don’t get up again.

As the nation struggles to slow the spread of the novel coronavirus, jails and prisons are beginning to release groups of people who are deemed safe for community return. Detention facilities in the United States are notoriously overcrowded, making them transmission hotbeds should the virus find a way in. Already, staff and inmates have tested positive in facilities in Florida, New York, and other places around the nation. California recently announced plans to release 3,500 people from state prisons, and New York City has already released 900. Montgomery County, Alabama, released over 300 people. The majority of people being identified for early release are those who have been accused or charged with non-violent offenses, many of which involve drugs.

A study out of Washington State found that in the first two weeks post-release, the relative risk of fatal overdose among former inmates was 129 times higher than the general population. A longitudinal study out of North Carolina found the risk of fatal overdose was 40 times higher than the general population in the first two weeks after release; for heroin users specifically, the risk was 74 times higher. And a 2019 article published in the journal of Addiction Science and Clinical Practice named post-release opioid-related overdose the “leading cause of death among people released from jails or prisons.”

The reasons behind this dramatic rise in risk are complex. The most obvious factor is that when people are forcibly detoxed from opioids but not provided adequate treatment for the underlying addiction, they return to their communities with significantly decreased tolerance but no more tools to help them deal with cravings than they had when they went in.

“They’re not cured, they’re not treated, they’re not in recovery, they just haven’t been able to use,” said Lipi Roy, a clinical assistant professor at NYU Grossman School of Medicine and an internal medicine physician who specializes in addiction. “Whether [the period of incarceration] be three months or three years, it doesn’t matter … The brain doesn’t forget.”

But new research suggests it’s not just a matter of simple tolerance. The unique social, environmental, and psychological factors faced by people who were recently released from incarceration also contribute to the enormous elevation in overdose risk. Now more than ever, as community supports shutter or limit their services in response to the pandemic and people are urged to stay home, those being released from incarceration are entering a new world filled with more stress and less stability and support than ever before.

“Decarceration without re-entry support systems is only going to be a halfway measure,” said Sheila Vakharia, the deputy director of research and academic engagement at the Drug Policy Alliance. “You can’t let people walk out the doors and assume they will be safer outside than inside.”

“If you think of a person in this situation, they may not have a place to live or the same social networks as when they went in. They might be more worried than usual of being arrested so they may be more likely to inject in hidden places and alone and to rush the shot,” said Megan Reed, a PhD candidate at Drexel University’s school of public health and the principal investigator in an NIH funded study on overdose risk after release. “Very few of the harms we associate with drug use have to do with the drug itself or the actual drug impact on the body; it’s the conditions in which somebody is using.”

The brain doesn’t forget.

Incarceration is a highly destabilizing experience that carries a host of other potential negative outcomes. While incarcerated, people are at risk of losing employment, housing, and even custody of their children, especially during long periods of detainment. Furthermore, the stigma associated with arrest and incarceration, or simply the difficulty and expense of communicating with the outside world while behind bars, can disrupt important familial and social relationships, leaving people with a smaller and weakened support system upon release.

Reed also pointed out that many people who have criminal justice involvement enter the system at heightened risk of fatal overdose. For example, people experiencing homelessness are at both heightened risk of overdose and incarceration. Rates of HIV and mental illness — both independent risk factors for fatal overdose — are also high in detention facilities. Many of these are also thought to be risk factors for severe cases of COVID-19, adding an extra source of anxiety for vulnerable people during the outbreak.

This pre-arrest susceptibility combined with decreased tolerance and the stress and uncertainty that people are facing after they have been released from jail or prison creates a perfect storm of dangerous vulnerabilities. “You have concentrations of other overdose risk factors already inside, and the communities that people are returning to are the same communities that are most impacted in the first place,” said Reed.

Exacerbating all of this is a lack of access to the most effective treatments for addiction to opioids, methadone and buprenorphine. Both are opioid-agonist medicines that reduce craving and withdrawal by filling the same receptors as short-acting opioids like heroin, but without delivering a euphoric high in patients who are properly maintained. They are both approved by a slew of licensing bodies, including the World Health Organization, which has included them on the list of essential medicines because of their proven efficacy in treating opioid use disorder and reducing harmful consequences of use, such as fatal overdose. Unfortunately, the majority of detention facilities in the United States do not offer these medications to inmates who are not pregnant.

“Because most correctional facilities still don’t offer standard of care treatment for opioid use disorder with methadone or buprenorphine, people are released not on treatment back to the community. Unsurprisingly, recurrence rates for opioid use are high and because people’s tolerance is reduced their risk of overdose increases dramatically,” said Sarah Wakeman, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital and an assistant professor of medicine at Harvard University.

The federal government recently loosened regulations around the prescribing of methadone and buprenorphine during the pandemic, but did not address access to people who are currently incarcerated.

Research has shown that maintaining people on medications for opioid use disorder while incarcerated and providing low-barrier referrals upon release will dramatically reduce the post-incarceration overdose rate. Wakeman and other experts also suggest dispensing naloxone, the drug that can reverse an opioid overdose, to people who are being released back into the community.

Spurred by lawsuits and activism, an increasing number of facilities are beginning to offer access to these medicines, but the majority of detention centers remain reticent. This is unlikely to change without a major shift in the way the criminal justice system views and handles drug use and addiction.

“Our justice system is the biggest houser of people with substance use disorders and mental health disorders in this country,” said Vakharia. “[But] they weren’t built for this…they were built to house the ‘bad guys’ in the most simple understanding of how that works and what that means. They were never built or staffed to think of the long term, nuanced needs of people with these multifaceted challenges.”



COVID-19 Proves San Francisco’s Housing Crisis Is A Health Emergency

Ako Jacintho remembers when people weren’t living in tents on the streets of San Francisco. Or if there were tents, there weren’t encampments. This was back in the late ‘90s, right at the base of the first tech boom, years before displacement and gentrification, before there were SARS and MERS and the newest novel coronavirus, which causes COVID-19.

The spread of this coronavirus coincides with the greatest number of unsheltered residents living on the streets of San Francisco: about 8,000 adults, 71 percent of whom once had a permanent home in the city. Jacintho, the director of addiction medicine at HealthRight 360, a clinic that has provided comprehensive support to people experiencing homelessness for over 50 years, says health care practitioners who serve those experiencing homelessness are rushing to aid a population that has long been forgotten by the city.

Physicians and other care providers say what’s notable about the city’s response in assisting the most vulnerable San Franciscans is that the strategies deployed during the emergency are exactly the tools city leaders had been dragging their feet on implementing, such as stopping police sweeps, working with hotels to set up housing, and making sure those experiencing homelessness have access to comprehensive preventative health care.

California’s Bay Area was one of the first regions in the country to institute a shelter-in-place order, which drew ire among advocates. At first, those experiencing homelessness were exempt from the order, and later were advised to “seek shelter.” How exactly were the tens of thousands of those suffering from homelessness supposed to follow the order? And, because sheltering in place is the centerpiece of the public health response to the pandemic, how do we provide everyone with the space and security to follow these recommendations?

These are exactly the kinds of questions that Margot Kushel, a physician at Zuckerberg San Francisco General Hospital and Trauma Center, the city’s safety net hospital, thinks about. “There is no medicine as powerful as housing,” she says. “Homelessness is completely incompatible with health.” Housing stability has manifold impacts on those experiencing homelessness, and studies have shown that nearly 90 percent of recipients of organization-supported rehousing or rental assistance are housed in permanent homes a year after their initial transition.

Kushel, who has advised on what model policies should look like to help people make the transition from living on the streets to secure housing, says city medical teams are now conducting direct outreach to those living in unstable housing, like tents. Based on age and other medical vulnerabilities, physicians help those living on the streets understand what their options are for locating temporary shelter. Given that shelter is the first priority of physicians and policy makers, the epidemic has exposed how closely tied housing and health are.

The epidemic has exposed how closely tied housing and health are.

Shelters, which typically offer clients housing for a set number of months, have relaxed some of these requirements and the city is working to make 6,555 hotel rooms available. But it’s work that has to be conducted carefully; the city can’t force someone to live in a room that’s not in their neighborhood or is located away from their community. “That’s a huge thing for the homeless population,” Jacintho says, “the shuffling of them to shelters.” This temporary housing is also the first step in seeking permanent housing solutions, not an ultimate solution.

Educating those seeking aid has made some of the everyday care work more complex. In pre-COVID times, Jacintho says, he would sit face to face with a client to go over their needs, symptoms, progress, and concerns, but now he’s communicating with them via a computer or a phone. Telemedicine might be a natural shift for someone who uses devices every day, but for those experiencing homelessness, Jacintho says it’s “definitely a shift for [his clients] culturally.”

The outbreak has meant a downturn in those coming into clinics, for others. Chuck Cloinger, the chief medical officer at St. James Infirmary, an occupational and health safety clinic for sex workers in the Bay Area, says that their mostly-volunteer team has focused on street support in order to aid clients.

Cloinger and his team are focused on making sure that essential health services that may not appear to be directly related to coronavirus management don’t fall through the cracks. Though they’re no longer conducting health screenings in their mobile clinic, the St. James Infirmary van goes out once a week to facilitate needle exchange and deliver other essential goods like hot foods and groceries.

At first, the spread of COVID-19 among unhoused residents was slower than those with shelter, but as of April 13 at least 90 people at a shelter in the city have tested positive. Unsheltered San Franciscans are already medically vulnerable, and with coronavirus testing still lagging far behind the necessary levels, the true number of impacted unsheltered residents is unknown.

If anything, Kushel hopes the recognition of homelessness as a public health crisis in and of itself — and one that can be remedied or even eradicated through systemic change — is a matter of what she calls “political will.”  Even though San Francisco voters passed Measure C in 2018, which would tax large companies to fund services for those experiencing homelessness, the money is still tied up in court. With early action from the San Francisco Department of Public Health and coordination with hotels to mitigate coronavirus as a public health concern, advocates may be right to wonder when it is that living on the streets without shelter will be seen as an issue of public concern as well.

The San Francisco Homeless Outreach Team was unable to respond to a request for comment.