A Lethal Inequity

On any given night, about 12,500 people in Seattle are living on the streets, in encampments or in shelters — communal places where social distancing is difficult.

For people who are homeless, COVID-19 creates an especially heavy burden. Many of them have underlying health conditions and other stressors that make them vulnerable to becoming seriously ill. And living outside makes it harder to recover from an illness or to follow medical advice.

“The consequences could be very serious if the homeless community is hit hard by COVID-19 — not only for those who become sick, but also for the larger community and our health system,” says Paul Hayes, RN, chief executive officer at Harborview Medical Center.

To help lessen the danger to people facing homelessness, UW Medicine’s Pioneer Square Clinic launched a mobile testing program in April, with support from the Paul G. Allen Family Foundation and hundreds of individual supporters. The van traveled to homeless shelters and downtown emergency services, with stops in South Seattle two days a week, offering free COVID-19 testing and guidance on next steps.

For those who became sick, Harborview Hall, on the Harborview Medical Center campus, was transformed into a 50-bed facility to care for homeless people who tested positive for COVID-19. The facility, staffed with UW Medicine healthcare professionals based at Harborview, offered 24/7 care until patients recovered.

So far, these efforts have prevented a widespread COVID-19 outbreak among people facing homelessness. But UW Medicine leaders say the health of this population must remain a priority.

Since April, UW Medicine’s two mobile testing vans have conducted more than 20,000 tests in downtown Seattle and South King County neighborhoods, thanks to generous funding from the community.

In Washington state and nationwide, people of color are at much higher risk from COVID-19. In the first months of the pandemic, Public Health – Seattle & King County data showed that rates of confirmed COVID-19 cases for Latinx, Native Hawaiians and Pacific Islanders were four times that of whites. The rate of confirmed cases for Blacks was twice that of whites. And higher rates were found in south Seattle and south King County, in locations that overlapped with communities of color.

Several factors are responsible. First, people in these communities have higher rates of the underlying conditions that are linked to serious cases of COVID-19. This is because of a long history of structural racism, including racist housing policies, employment discrimination and lack of access to healthy foods and neighborhoods. Second, they may have limited access to healthcare or experience discrimination in the healthcare they receive. Third, many people of color are essential service workers — such as grocery store cashiers, delivery workers or cleaners — who can’t work from home and whose jobs increase their exposure. These jobs are also less likely to provide healthcare or sick leave.

“These are community members who have been marginalized and oppressed,” says Houston. “We have a moral obligation to make sure that all members of our public have the same opportunity for good health.”

Mobile testing was an early priority, but Houston’s team knew they couldn’t simply park a van in communities of color and expect people to show up. Instead, they partnered with the Seattle Department of Neighborhoods, meeting online with community organizations to explain what they were doing — and, crucially, to listen to their concerns.

“We dispelled myths that we would be reporting their data or reporting them to immigration,” says Houston. “This was an opportunity to build relationships and trust. We made sure they understood that we intend to continue to do the work to help their communities stay safe and healthy.”

Washington’s first major COVID-19 outbreak — and the country’s first confirmed coronavirus-related death — occurred at a nursing home in Kirkland, a suburb of Seattle. Not only did that outbreak highlight the vulnerability of both patients and staff, but it also revealed a gap in critical clinical support that made national headlines.

Skilled nursing facilities are home to perhaps the highest-risk group of all: older people. About 2.1 million Americans live in long-term care facilities, less than 1% of the population. Yet 42% of all COVID-related deaths in the U.S. have taken place in these facilities.

UW Medicine’s Post‐Acute Care Network stepped in to help address the gap by developing guidance for skilled nursing facilities, rehabilitation centers, assisted living and long-term care facilities to follow in monitoring, slowing disease spread and managing COVID-19 outbreaks. By following the recommendations, skilled nursing facilities can help reduce cases and decrease the burden on hospitals, clinics and emergency medical services.

With the possibility of recurring or seasonal COVID-19 outbreaks — and until vaccines are available — future recommendations for facilities could include broad-based testing of residents and staff, increased use of telemedicine and better communication between facilities and local public health officials.

UW Medicine, in collaboration with county and state health officials, is sending “drop teams” to conduct universal COVID-19 testing at long-term care facilities.