At the outset of the coronavirus pandemic, it seemed a given that the virus would ravage the homeless community, which is especially vulnerable to death and illness. However, the number of COVID-19 cases amongst unhoused people in Alameda County has been consistently lower than that of the population as a whole. Of the 5,285 tests Alameda County has given to unhoused people on the street and in shelters since the onset of the pandemic, the positivity rate is 2.2 percent. (This number excludes the COVID-positive people living in isolation hotels.) That’s compared to 5 percent in the county as a whole since the start of the pandemic. The reason behind this low percentage positive rate is hard to pinpoint. Some have speculated that it is in part because many homeless people live outside, which makes it easier for carriers to avoid spreading the virus. Additionally, shelters have cut capacity considerably, and taken on new safety measures to prevent viral spread. 

A headshot of Dr. Alter, a white man with white hair wearing clear framed glasses and a blue button up shirt.
Dr. Harrison Alter. (Courtesy of Dr. Alter)

It could also be thanks to a contingent of Alameda County employees who have been working tirelessly to keep COVID-19 cases low amongst unhoused people. Since the outset of the pandemic, Alameda County Healthcare for the Homeless (ACHCH) has been laser focused on containing viral spread on the street. They orchestrated Operation Comfort, a program that places homeless people who have been exposed to COVID-19 in motels, as well as Operation Safer Ground, through which unhoused people in at-risk groups can also get motel rooms. Additionally, ACHCH has done extensive coronavirus testing in encampment settings. They have also done considerable street outreach, occasionally working to help COVID-positive homeless people shelter where they are when they are not able or willing to move into a motel. 

Since June, Dr. Harrison Alter has been at the helm of the County’s response. Having spent much of his career studying Social Emergency Medicine, which he describes as “an emerging field that incorporates social context, such as housing, food, safety and more, into the structure and practice of emergency care,” he easily fit into the role of interim Medical Director for ACHCH. However, he had been ready to retire—until the coronavirus pandemic hit the Bay Area last Spring.

“I just felt like a pandemic wasn’t a very good time to be on sabbatical,” he told Street Spirit. 

Instead of retiring, he got in touch with some friends of his who work for Alameda County to ask if they needed any help. That happened to be the very day that Governor Gavin Newsom signed onto Project Roomkey. He ended up helping develop the policies and procedures that would be used to roll out the project, and was eventually hired on in the interim Medical Director role, where he served for six months before retiring in January. 

We caught up with Dr. Alter to discuss COVID-19 in the homeless community and the county’s strategy for containing it. Our conversation has been edited and condensed.


Alastair Boone: Broadly, why hasn’t there been more COVID-19 in the homeless community? What have the most successful strategies been in preventing viral spread on the street? 

Dr. Alter: The truth is we don’t really know what the magic sauce is but we know what some of the components of it are—we just don’t know whether each one of these components is a teaspoon or a cup. Some of the components are, number one, people are very careful. People who know that they are vulnerable to this disease, who have seen a lot of disease and death depending on how long they’ve been on the street, and they don’t want to get it. So they’re careful. They’re receptive to messages about safe physical distancing and careful hand and surface hygiene to the extent that they’re able to do that. And mask wearing, which is a little bit harder but which people do. So being careful is important. 

I think that decompressing the shelters helped shelter-dwelling people experiencing homelessness maintain [safety in] those environments. The shelter operators have gotten extremely sophisticated about disease containment. And you know, out on the streets, the street teams have been providing support and education and have been available for questions and concerns that people have about the pandemic. And they’ve all been a crackerjack team in terms of staying current on the best guidance, and being creative with messaging. 

Then I have to say that I think our testing strategy is helping. We do a combination of response-related testing and community care testing. And I think the balance of those two strategies has provided our homeless community in Alameda County with a pretty comprehensive approach to testing. 

AB: Tell me more about the street outreach component of the county’s response. What happens on a weekly basis when it comes to street outreach and testing? 

Dr. A: When we get somebody with symptoms or who’s tested [positive], we refer them to Operation Comfort [the program in which the county places COVID-positive homeless people in motels]. That referral triggers an investigation within Alameda County Healthcare for the Homeless to see whether that person is coming from an environment at risk. That process is actually fairly detailed, but reproducible. 

So Operation Comfort, in addition to being an isolation and quarantine environment, is an early warning system. When somebody goes to Operation Comfort we try to backtrack to find out where they came from, to assess whether we need to go in and do testing or go in and just quarantine people, or support them in quarantine, or bring them to Operation Comfort if they’re willing, or [determine] whether we can contain it on site [and] work with the people in that encampment or that shelter to contain the exposures. This sometimes requires extra support, meals, extra hygiene supplies. So all those actions are sort of triggered by a referral to Operation Comfort. And then one of our street teams will go in and do widespread testing in that environment in response to that case. 

AB: So that’s where the percentage positive numbers come from in the homeless community? 

Dr. A: Well that number is a combination of the response testing and the community care testing. 

AB: And that’s widespread testing in environments where you aren’t already aware there’s an infection?

Dr. A: Exactly. For weeks back in the early part of the pandemic we went to [the encampment on] High Street [in East Oakland]. We were a regular presence on Tuesday afternoon at High Street, and people just knew that if they wanted to get tested they could come on Tuesday afternoon. Now we have a similar thing at St. Vincent de Paul, in the courtyard. [So] if people want to get tested that’s where they should go.

AB: Is that fairly popular?

Dr. A: [Yes.] I mean there are days that we do, you know, more than 50 tests at those settings. 

AB: There’s a lot of discourse right now about shelters being less safe than encampments when it comes to COVID-19 because of the congregate element. What do you think—are shelters are in fact less safe of a housing option during the pandemic?

Dr. A: I would never want to advocate that somebody who didn’t want to be living on the street and who wanted to live under a roof wouldn’t have that option. I think we’re taking great care in shelter environments at the moment to contain the disease. We’re working with them on their ventilation systems, we walk through with them to review their safety practices and how they move people from one place to another, and they’re all very eager to get it right. I think that their clients are the same way and so, it’s been a sort of unfortunate restriction in the shelter population because shelters can’t accommodate everybody that they used to, but it has meant that people who don’t want to be on the street aren’t stuck there.

AB: Once homeless people become vaccinated, what will that mean about how life can change?

Dr. A: Here’s what it means. For the individual person, it means that the risk is much, much lower of needing to go to the hospital with COVID-19, or needing to go to the ICU with COVID-19, or dying of COVID-19. It means that the pandemic will be shorter, and that we can get back to not being completely consumed by keeping people safe from the virus. 

What it won’t mean is a near-term end to [wearing masks] and safe physical distancing and careful hand and surface hygiene. Because until we understand the vaccine better and what it means for contagiousness or transmission of the virus, we can’t let back on any of that stuff. So that’s kind of a hard pill for people to swallow, because they’re done with this already. They want to gather with friends and not worry about reaching out their arms and not being able to touch, to know that they’re six feet apart. And so that’s tough. People like to visit in their tents if they’re living in an encampment or they like to visit in common areas in shelters if they’re living in a shelter, and they can’t right now. And people are losing patience with that. But we just have to keep it up for 6 months or so. I would estimate that by the end of the summer we will have that behind us. But what [the vaccine] will mean [in the short term] is that you’re not going to die from the virus and you’re not going to go to the hospital from it.

AB: So the individual doesn’t have to worry quite so much about their own heath, but they do still need to worry about people around them who haven’t been vaccinated?

Dr. A: That’s right. 

AB: What if you’ve already had COVID—same thing? 

Dr. A: Um, probably. Although we’re still struggling to master what natural immunity means. We haven’t really pinpointed how long it lasts and how comprehensive it is. 

AB: Do you think the coronavirus pandemic has shed any new light on the meaning of housing as healthcare, or changed the discussion around the subject?

Dr. A: You know the National Academy of Medicine decided two years ago that there wasn’t enough evidence to support that notion that housing is healthcare. But I think that we’re going to find that evidence in the pandemic. I think that Operation Safer Ground is that proof of concept. To take the people who were most likely to die from COVID-19 away from transmission risk to the greatest extent that we could, transmission risk was much much lower. We have not had a death from COVID at Operation Safer Ground. So I think pretty soon that will become an accepted equation. that housing equals healthcare. 

AB: In general, it seems like the pandemic has changed the way a lot of people view the solution to homelessness, and created a lot more political will to do things that were kind of stuck in the gears before. In your mind, how has COVID changed the way we view the solution to homelessness?

Dr. A: I think in part it’s housing as healthcare. But in part it’s also that [the pandemic] has reinforced the personhood of people on the street, because they are now people that deserve the same level of protection as anybody else does from this scourge. So if you’re going to protect them from this virus then oh, maybe we should be offering them the same level of social protection that we offer other members of our society. I do think that some good may come of this in terms of narrowing the chasm of attention and care that different populations get.

AB: Any advice for volunteers or people who want to drop off supplies at encampments, how should you change your behavior during this unprecedented spike in COVID cases? 

Dr. A: I think that our outreach partners have developed a set of protocols and sort of an understanding about how to do this in the safest way. They have really thought through it and they’ve created these protocols with their clients. So my preference would be that people support the community-based organizations that do the work that they want done. For example, if they want more distribution of blankets, then rather than buying a lot of blankets and dropping them off at an encampment, I think finding a community based organization that is doing that and supporting them to do it is a much safer alternative at this moment in history. Not that it should quench their thirst for helping their neighbors, they should just make sure that they are only drinking from their own cup.

In Dialogue is a column in which Street Spirit speaks with community leaders.

Alastair Boone is the Director of Street Spirit.