As the COVID-19 pandemic swept the nation, people were told to isolate at home to stay safe from the highly contagious virus. It quickly became clear, though, that “stay-at-home” orders were meaningless to scores of people, like the 1.3 million elders in nursing homes, the 2.3 million victims of our mass incarceration system, and the 600 thousand people experiencing homelessness throughout the United States. COVID-19 tragedies in nursing homes have been widely reported, and the less-monitored spread of the virus through prisons is being protested. Working at Boston Health Care for the Homeless Program (BHCHP) when the pandemic hit, we witnessed firsthand the unique chaos it brought to the lives of people experiencing homelessness.
In early March, universal testing at Boston’s three largest shelters found that at each location, more than one in three guests tested positive for SARS-CoV-2, the virus that causes COVID-19. One look at the tightly-packed rows of bunk beds that fill most emergency shelters is enough to understand how the virus spreads easily in this setting. Thus, people left homeless due to societal injustices and lack of affordable housing became inescapably exposed to the virus. The outbreak of SARS-CoV-2 in the shelters was understood as both an emergency for those in them and a threat to public health.
These are the conditions that gave rise to Boston Hope. Part field hospital, part respite facility, Boston Hope was a public health endeavor we could never have imagined weeks earlier. In collaboration with the City of Boston and Partners Healthcare, BHCHP erected a 500-bed medical shelter in a vast convention center downtown.1 Boston Hope served people who tested positive for SARS-CoV-2 while staying in the city’s shelters, had mild symptoms, but had nowhere to isolate.
While BHCHP staff worked overtime to set up the clinical intricacies of Boston Hope, we were asked to apply our Patient Activities Coordinator experience to the space. Our task: help build community by imagining and implementing an activities program for our guests. We hoped that movie nights, poetry groups, Bingo games, art activities, and karaoke sessions would alleviate some of the stress of isolating in a strange place with a worrisome diagnosis. The Boston Hope medical shelter also presented an opportunity to rethink the standard shelter layout and make it more welcoming. BHCHP built individual rooms, 3-sided cubicles enclosed by a curtain door. Each had a bed, a shelf, and a locking cabinet to store belongings. The facility included services like a 12-laptop “café,” a substance use recovery group meeting space, a laundry drop-off, a bilingual library, a case management station, and an art supply cabinet.
In mid-May 2020, the first wave of COVID-19 began to wane and Boston Hope closed. After two months of surreal 12-hour shifts running activities in Tyvek suits and face shields, we left the facility with a pair of lessons we want to share. First, we came to believe that when it comes to health care, doing right by one person is usually doing right by the world. Second, we witnessed how active support empowers patients to make positive change in their lives.
Lesson 1: The Nonsensical Pie of Healthcare Resources
In a country besieged by rising healthcare costs and a tangled health insurance system, resource allocation in healthcare is a hot topic. Public discussion often gets caught up in the “fixed-pie” fallacy, presuming that any resources spent caring for one person are lost to others in a zero-sum game. Many publications, though, break down how community health spending (and a single-payer system) is healthier and cheaper than our individualistic model. At Boston Hope, we were struck with poignant examples of how community health spending benefits the public good.
Sasha, a conscientious mother and talented artist, explained over rock painting that after testing positive for SARS-CoV-2, she was brought to an isolation facility where resources and staff were stretched particularly thin.2 Alone in her bed, with nothing to do and no one to talk to, she became unbearably depressed and anxious. She had steeled herself to stay, but found herself spiraling into such a dark place that after several days, she had to leave. After two nights on the street, though, she found she couldn’t isolate from people effectively and felt guilty—so she “turned herself in,” expecting to return to the place she had come from. Instead, she was sent to Boston Hope where she became an active participant in exercise classes and Bingo. She said that the attention from staff, personal space, and a sense of community made Boston Hope a reprieve, and that she felt well able to stay as long as needed.
In a true “fixed-pie” scenario, resources spent on one person are taken from others. At Boston Hope, though, the city spent resources to provide people experiencing homelessness with the physical and emotional support they needed to remain sustainably in quarantine; this in turn reduced viral spread and benefited public health. Ultimately, the pie expanded, fewer people needed pie, or people were better off because others had pie. This affirmed our belief that doing right by one person is doing right by the world.
In the context of a pandemic, supporting people at Boston Hope saved lives. Outside of a pandemic, equitable investment in community health leads to equally powerful outcomes. Ensuring health insurance for all allows patients to present before reaching advanced illness that endangers recovery and requires costly treatment. Funding nutritious school meals helps children remain healthier and happier for longer. Creating affordable housing helps people avoid the physical and emotional trauma of living on the street, as well as the emergency room visits required to address it. As we saw at Boston Hope, supporting inequitably under-resourced people does not simplistically subtract from the wellbeing of others—it benefits everyone. Moreover, such investments recognize that health disparities are created by past and ongoing injustices.3 Healthcare professionals must support resource allocation that rectifies injustice head on.
Lesson 2: Everyone Needs an Island of Relief
In preparation for starting our AmeriCorps year at Boston Health Care for the Homeless Program, we both read In the Realm of Hungry Ghosts by Gabor Maté, a physician who treats patients experiencing homelessness and addiction in Vancouver’s “skid row.” Maté documents how desperate conditions beget more desperation and writes convincingly that a break in the clouds—an “island of relief”—provides people with the best chance to improve their lives. Boston Hope, a COVID-19 ward in the middle of a pandemic, was a strange place to recall this phrase, but we found ourselves doing so at an afternoon poetry group.
We expected discussion of Mary Oliver’s “Wild Geese” to be interesting since many of our guests were talented writers and poets. But when talk turned toward Boston Hope, we were surprised to hear people’s experiences. William, an introspective middle-aged man, felt moved by the poem’s assertion, “Whoever you are, no matter how lonely / the world offers itself to your imagination.” He wasn’t so sure. William had been struggling with alcohol use for years and was discouraged by his inability to progress. He felt, though, that at Boston Hope his cravings had subdued. Having a safe, private place to sleep made him feel calmer than he did in shelters, while joining the cornhole-game community and singing at karaoke night revitalized his sense of self. William had used the laptop café to research recovery programs, and said that for the first time in years, he felt optimistic about his future. Angela felt similarly. Using the community spaces and activities, she had made friends with women from whom she had kept her distance in the shelter, and she left with a stronger support system. Others echoed William and Angela.
It was bittersweet to hear such testimonials. Of course, we were glad that people felt safe and supported at Boston Hope. But the magnitude of people’s appreciation suggested that even limited support contrasted starkly with their daily reality. It prompted us to reflect on the current state of shelters, and why they can be so relentlessly dark.
We think the explanation lies, in part, in the reliance of US policy on simplistic economics. In introductory economics, we are taught that people choose how to behave by assessing costs and benefits. When applied to homelessness, cost-benefit analysis suggests that people stay in emergency shelters because they get great benefits at no cost. According to this model, people will only “decide” to improve their lives once benefits are minimized—when shelters are as uncomfortable and unsupportive as possible.4
While working at BHCHP, we saw this principle manifested in public shelters. In one Boston shelter, the doors have been removed from the bathroom stalls—a humiliating layout.5 In most shelters, there is little-to-no storage space, leaving guests unable to secure backpacks with ID cards, shoes, and medications while they sleep. Many recreation areas consist of TVs playing 24/7, while more empowering resources like technology labs, job training sessions, mental health services, and community-building activities are entirely absent. The cost-benefit analysis mentality suggests these are benefits that would stop people from ever leaving. Instead, the status quo of shelters piles on miseries—indignity, danger, monotony, and lack of resources—that get in the way of positive change.
Every day, we signal to people experiencing homelessness that they don’t matter—avoiding a woman’s gaze when she says “good morning,” or turning a blind eye when a man is attacked. We signal this structurally by keeping shelters underfunded and under-resourced. The testimonials at Boston Hope showed us that even amidst terrible circumstances, when people escape this judgement and are met with care, an “island of relief,” they can make positive changes. To apply this lesson beyond the pandemic, we must change our approach to shelters. This means guaranteeing beds for all who need one, providing secure storage for belongings, and offering supportive services such as case management, technology labs, job training programs, mental health services, recovery groups, and community-building activities.6 We must reject simplistic cost-benefit analysis, and transform shelters from desolate, dark places into islands of relief where people can restore, find joy, and begin anew.
In Conclusion
When the COVID-19 pandemic rattled the status quo, Boston Hope gave us a glimpse of what it might look like to move past some persistent problems in approaches to healthcare spending and services for people experiencing homelessness. We must appreciate that society does best when everyone is supported—community health spending and insurance for all move beyond the “fixed pie” model that has led to our current system. And we must recognize that compounding miseries in people’s lives to prompt rehabilitation is a failed experiment that has run for decades longer than it should have. Services for people experiencing homelessness must promote safety, joy, and empowerment. Ultimately, however, community health spending and improved shelters are not enough: we must rectify the injustices that lead to health disparities and end homelessness itself. As a Boston Hope resident painted in green on a communal canvas, “Hope is a new dawn with new promises.”7 After the turmoil and tragedy of the COVID-19 pandemic, we are resolved to join the healthcare community in pursuing new promises for a brighter, more equitable future.
Cecilia Wallace and Olivia Palmer served together as AmeriCorps members at Boston Health Care for the Homeless Program (BHCHP) from September 2019 through June 2020. Prior to the pandemic, Cecilia (Oberlin College ‘19) and Olivia (Boston College ‘19) each served as a “Patient Activities Coordinator”for BHCHP’s two respite facilities. During the pandemic, they applied this experience to BHCHP’s COVID-19 response efforts. Looking forward, they intend to carry what they learned at BHCHP with them as they pursue careers in medicine—Olivia will be beginning at the Perelman School of Medicine this August, and Cecilia has entered this year’s application cycle. They would like to sincerely thank Dan Maloney, Pam Sprouse, and Caitlin Pollard for all their work and support at Boston Hope. Cecilia can be reached at [email protected], and Olivia can be reached at [email protected].
- Boston Hope included both a 500-bed rehabilitation unit run by Partners HealthCare and a 500-bed medical shelter run by BHCHP. Moving forward, we will use the term to refer to BHCHP’s 500-bed medical shelter only.
- All names have been fictionalized for this article.
- As the outbreak of COVID-19 in shelters has demonstrated, diseases themselves are often manifestations of societal injustice. Therefore, the field of healthcare is uniquely positioned to help perpetuate or right them. By intentionally allocating resources to inequitably under-resourced populations, we can help transform the state of health in the country.
- There are many individuals who work incredibly hard to support and affirm the dignity of people experiencing homelessness, but we believe they are underpaid, and the services they provide are underfunded.
- There is a case to be made that this prevents overdoses, but BHCHP and other community health centers serve as proof that other solutions (including non-motion timers or milieu management staff) can achieve the same goal without dehumanizing costs.
- Currently, many Boston area shelters require people to arrive in the afternoon (around 3pm or so) to secure their bedspace. While it is rare that anyone seeking shelter is turned away, arriving late to the shelter often results in people receiving a top bunk despite health concerns, sleeping on a cafeteria chair, or curling up on the floor.
- Originally written in Spanish, “neuvo amanecer con nuevas esperanzas.”
