Los Angeles, home to some 59,000 homeless and thousands of undocumented migrants, is at risk of a major spread of coronavirus as it runs unchecked through underserved communities, the director of a network of 18 federally qualified health centers warned.
In the last 10 days, saw 879 low-income patients with symptoms of coronavirus who were referred to its newly erected isolation tents.
Of the 39 individuals who could be tested, seven were confirmed positive, and three are now hospitalized, according to Jim Mangia, president and CEO of the health center, which serves South Los Angeles. Those results took more than a week to come back -- coming only after "we called and yelled and screamed" -- and some still have not been returned.
The rest of those seeking help were given instructions on how to stay safe and prevent transmission and some are housed in motels provided with new state coronavirus funds.
Mangia's plea echoes the cries for help from many homeless and migrant rights advocates around the country, including those from San Francisco and New York, who fear that the healthcare system is overlooking a mobile and challenging population that is as vulnerable as it is at high risk for transmitting infection to much larger regions.
Cities across the country have already taken steps to help these vulnerable populations in order to mitigate their own outbreaks.
In New York City, health providers aggressively responded to advocates' cries for help by providing the homeless with hundreds of isolation beds, even if they have only suspected COVID-19 symptoms. However, the number of positive COVID-19 patients among the has exceeded 100, with at least 27 hospitalized after several shelters reported infection.
In New Orleans, law enforcement personnel in masks and rubber gloves, and workers in white hazmat suits homeless living in camps to hotel rooms, and one homeless person had tested positive as of 3 days ago.
In , which so far has avoided an anticipated onslaught with 434 patients with COVID-19, the city has secured leases for 300 hotel rooms for any of its estimated 8,000 homeless or unsheltered residents.
Officials in King County, at the center of Washington state's outbreak, homeless shelter density by moving nearly 400 people to hotels.
And in San Diego County, health officials said on Tuesday that three unsheltered individuals have tested positive for coronavirus and are now housed in some of the 1,600 "public health" hotel rooms reserved by the county during the pandemic. They were referred by homeless outreach teams or public health nurses.
Frontline Providers Left Out
Mangia noted that the focus of the epidemic has been on hospitals, and the need for acute-care equipment like ventilators, which of course is vital.
"But what's being left out is the frontline community health providers that are in low income and inner city and rural communities, where this front line of patients are presenting with COVID symptoms," Mangia said. Some 8,000 of the 100,000 unique patients seen each year by St. John's 45 physicians and 30 nurse practitioners are homeless and about 30,000 are undocumented, he said.
"If we had the tools that we need, and we had the protective gear, we would be able to help contain this virus," he said. "We could prevent the surge that hospitals will be experiencing, which we're seeing already in New York and we will be experiencing here in LA in a couple of weeks."
These homeless populations, in particular, may have additional challenges of addiction or substance use, which may make it difficult for them to follow or remember instructions on how to prevent themselves from being infected, the necessity to adhere to guidelines, and the importance of not putting others they may come in contact with at risk. But Mangia said so far that has not been a problem. Patients who have been told they have to be hospitalized are doing so without objection.
"Doctors are incredibly trusted people, and I think that if a doctor instructs a patient to behave in a certain way, I'd say 99 times out of 100 those patients will adhere to the advice," Mangia said.
Efforts in Southern Los Angeles
Two mobile clinics make calls "into the riverbeds" and homeless shelters, distributing bottles of soap and sanitizer, as well as blankets and other necessities throughout South Los Angeles, Compton, and Lynwood. The patients are seen at the extreme ends of the mobile clinics to better isolate them.
What is most needed for this population is point-of-care rapid tests, Mangia told journalists at a news conference on Tuesday. "We're arguing that the federal government should get those to frontline healthcare providers so we can do the test right there. And if someone tests positive and their symptoms are minor, we can explain to them how to self-isolate, how to not infect others, and we can give them protective equipment" without infecting anyone else.
"Without that capacity, we're flying blind," he said, in an area that he described as "the largest area of contiguous poverty in the continental United States."
Mangia emphasized that a major concern for the clinic are Trump administration policies and "intense threats" prompting fear that Immigration and Customs Enforcement personnel will deport their patients if they try to seek care, and has prevented some from reaching out. Additionally, the administration's threatened , which would limit the ability of patients receiving government support from staying in this country, is keeping patients from seeking help. "Fear is palpable and our patients are very, very afraid," he said.
Officially, ICE now encourages anyone, "including aliens with symptoms that resemble Coronavirus 2019 (COVID-19) (fever, cough, shortness of breath) to seek necessary medical treatment or prevention services," adding that such services "won't negatively affect any alien as part of a future Public Charge analysis."
Nevertheless, patients are worried, asking, "can I get extra diabetes medication in case I get deported or can I get extra copies of my children's medical records," Mangia said, adding that St. John's is the largest provider of services to the undocumented in the country. His team has had to repeatedly try to reassure patients that seeking care will not result in federal action against them.
Protecting Aid Workers
Mangia is particularly concerned because his team is experiencing a shortage of masks and protective gear, especially gowns, goggles, and face plates, which they will run out of by the end of this week.
"We are scrambling to try to purchase that through factories in China, through relationships with local labor unions that are trying to help us ... but we still don't have the protective gear that we need to contain the spread and isolate our patients." A shipment of masks from China was ordered and is expected in the next few days.
"The fact that we can't get the protective equipment we need, the fact that we don't have the test kits, is crippling our ability to contain this virus," he said.
Mangia said Los Angeles city and county and the state of California "have been incredibly helpful. And we've been partnering very closely with them. Our difficulty is in getting support from the federal government," Mangia said.
What's more, Mangia is concerned that in his weekly conversations with directors of other federally qualified health centers nationally, all of the 1,200 FQHC networks are having some problems, but that those "in red states" don't seem to be having as much of a problem getting equipment and other resources as some "blue states."
"I haven't heard the same alarm at not being able to get tests or protective equipment as we have in California and New York," Mangia told MedPage Today.