“I’ve seen a lot. I’ve seen fires. I’ve seen earthquakes. I was in the Dominican Republic when Hurricane George hit—I was in Peace Corps training. I survived the Ice Storm of ’98 at Colby. The Loma Prieta quake of ’89. I’ve seen my fair share of disasters. But nothing like this.”
Before COVID-19, what was your job?
I’m the nurse manager, and I oversee clinical and daily operations for three different healthcare for the homeless programs in San Francisco: a 75-bed medical respite program, a 12-bed sobering center, and nine nurses in the city-run permanent supportive housing sites.
What risks do the homeless population face on a day-to-day basis, even without a pandemic?
Aside from what people see as the obvious—exposure to the elements, risks of violence, threats to personal safety, housing and food insecurity, being hungry, PTSD—what we’re really seeing is a trend now that the homeless population is aging. In our medical respite program, on average 25 percent of the people we’re serving right now are over the age of 65. In the last calendar year, we saw 14 people who were in their 80s. I don’t think people realize that our homeless population is aging, and it’s a big problem.
Why is it so important to protect this population right now?
In the world that I live in, the homeless population is absolutely one of the most vulnerable populations because you already have people who are aging, right? They already have a lot of comorbidities. So just by that nature, they’re high risk. And they don’t have access to care, they don’t have access to monitoring. They’re living in congregate living situations. It just creates a high-risk environment for a huge outbreak. And it’s a population that is very mobile and transient.
With the number of cases rising, where are you putting everyone?
It’s ever-changing. As the curve is growing exponentially, we’re going exponential. We’re actually looking at trying to fill services and 4,000 beds. So what we’re doing now is contracting with hotels in San Francisco, because the hotels are empty and several hotels have approached the city wanting to help. We’re setting up nursing stations in hotel lobbies.
What’s happening in the rest of the shelter system?
The shelters in San Francisco are sheltering in place, and our permanent supportive housing sites are doing a lot of work to help people who are really struggling with shelter in place because of their mental health or their behavioral health needs.
San Francisco is working to create social distancing and to create six feet of bed space between beds. But we lost about 1,600 beds doing that in the shelter system. We’re looking for large venues where we can put up new shelters, where people can socially distance and shelter in place. So all of our shelters have a freeze on intakes.
Does that affect the beds you’re using for isolation and quarantine?
It’s a struggle because we can’t safely discharge someone. If we have a PUI or someone who has completed their isolation, where are we going to discharge them? All of the shelters are closing. So we’re actually holding on to those folks until these new shelters are up and running.
Is it a problem for your programs if emergency rooms are taxed with COVID patients?
It is a huge issue, and there’s been a lot of effort to keep people who are frequent, high utilizers of emergency services out of emergency departments.
About 90 percent of the people we serve are experiencing homelessness with chronic alcohol use disorder. And all of those folks would end up in the emergency departments if we were to close our sobering center. That was actually a programmatic decision, to think about how many emergency-department visits we would be avoiding by making sure that we stay open versus creating this space for COVID needs. Every single decision that’s made has that kind of cost-benefit analysis.
“It’s ever-changing. As the curve is growing exponentially, we’re going exponential. We’re actually looking at trying to fill services and 4,000 beds. So what we’re doing now is contracting with hotels in San Francisco, because the hotels are empty and several hotels have approached the city wanting to help. We’re setting up nursing stations in hotel lobbies”.
How do people make their way to your sites?
In our isolation and quarantine sites, we’re taking people from all 10 hospitals in the city—we’re all in it together. We’re trying to focus a lot on urgent care. All shelters have a screening protocol in place, and if someone is symptomatic, we are trying to either test them in the field or send them to an alternative testing site. And then they just come directly to us so that they’re bypassing the emergency department and the healthcare system altogether. I have nurses onsite 24/7, so we’re monitoring people to make sure that if someone does have more severe disease progression, then we can send them out.
Have you seen anything like this in your healthcare career?
No, no. I mean, this is a once-in-a-century thing, right? I’ve seen a lot. I’ve seen fires. I’ve seen earthquakes. I was in the Dominican Republic when Hurricane George hit—I was in Peace Corps training. I survived the Ice Storm of ’98 at Colby. The Loma Prieta quake of ’89. I’ve seen my fair share of disasters. But nothing like this. And we’re just in it. This is what, day 21 in a row for me?
How is all of this affecting you personally?
It’s been quite a ride. My hours have been incredibly long. My husband is also a deployed disaster-service worker—he’s an engineer for the local water company. We have two children, 5 and 7, who are not in school. I grew up out here—I’m from California. We have two sets of grandparents who, of course, are sheltering in place who usually help us, but can’t. We have a tremendously strong neighborhood support system that we can also usually depend on, but we can’t. I go to work during the days, and when I come back in the evenings, my husband goes to work.
So what motivates you to get up in the morning?
I’m driven by making sure that we’re serving really the most vulnerable people, our most vulnerable citizens. Trying to help people feel better and supported is a big thing that drives me.
Why public health? What drew you to this sector?
After Colby, I joined the Peace Corps, and then I went to nursing school at Johns Hopkins. In the Peace Corps, I saw how hard HIV was hitting developing countries—that’s when I became interested in international health. It was through my master’s work that I became much more interested in mental health disorders and substance use disorders and their impacts on health, and that just drove me toward a career working with people experiencing homelessness.
How has your career prepared you for this unprecedented moment?
This is truly public health at its finest. I think all of my experience in harm reduction has been great, and my Peace Corps experience, being able to set up and figure out what’s really needed in a resource-poor environment, is really important.
What’s the hardest part right now?
Having to realize I can’t give them wraparound services. I can’t send them to the DMV to get their I.D. I can’t send them to the General Assistance Office to get food stamps. I can’t help with that piece right now. That has been a major way we’ve had to shift our thinking. But for us, at this point, it’s about making sure that we’re able to isolate as many people as possible.
This interview was recorded during Moughamian’s off hours. Her comments are solely her own opinions and not those of the San Francisco Department of Public Health or the city and county of San Francisco. Moughamian is also a fellow with the California Health Care Foundation, Health Care Leadership Fellowship, where she’s focusing on the aging homeless population.