[oby] From the campus of Harvard Medical School, this is Think Research, a podcast devoted to the stories behind clinical research. I'm [oby]

[brendan] And I'm [brendan] And we are your hosts. Think Research is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center.

[oby] And by NCATS, the National Center for Advancing Translational Sciences.

[oby] In recent years, many US cities have seen a surge in homelessness and lack of affordable housing. This challenge represents a complex and intractable social crisis. During the COVID-19 pandemic, people experiencing homelessness and housing insecurity have faced unique challenges from practicing safe social distancing, to having adequate shelter, to being able to access food and health care. And because of the increased unemployment rates seen as a result of the pandemic, their concern is that the problem of homelessness will further be exacerbated.

On today's episode, Dr. Karen Emmons, the faculty director of the Community Engagement Program at Harvard Catalyst and Professor of Social and Behavioral Science at the Harvard TH Chan School of Public Health, speaks with Sheila Dillon of Boston's Chief of Housing and Director of Neighborhood Development, and Dr. Jessie Gaeta, the chief medical officer at the Boston Health Care for the Homeless Program, about what the pandemic means for homeless and housing insecure communities. They also discuss specific challenges and opportunities for healthcare providers, policymakers and researchers to ensure the community's health and safety during the pandemic, and how the recent efforts may inform future work in housing policy and service provision. This episode was produced in partnership with the Harvard TH Chan School of Public Health initiative on health and homelessness and was recorded on August 28, 2020.

Karen: Sheila and Jessie, thank you so much for joining us today. And thank you for your tremendous work on behalf of the citizens of Boston. I'm really excited that we have the opportunity to share your experiences with our listeners.

Now, although it seems like an eternity, it was just at the beginning of this year that we started to learn about COVID-19. Jessie, in those early days, what was Boston Health Care for the Homeless imagining the impact might be on your work? And how did your planning unfold as we learned more about the virus and how it was spreading?

Jessie Gaeta: Oh, when I think back to January, and February, and March, we were just increasingly worried about what the impact would be on the population that we serve. We were thinking about how much underlying burden of disease people who lack housing have. We were really worried too about people who are living in congregate spaces. We were worried about how quickly a virus like this might spread through those kinds of environments.

So we were getting increasingly worried, as we were learning more and also didn't know enough about this virus early on in the epidemic. So we had a lot of anxiety. And our community here in Boston pulled together remarkably to begin to plan for what we might do to help mitigate transmission in this population.

Karen: What were some of the biggest surprises that you encountered in that planning-- maybe positive things, but also challenges?

Jessie Gaeta: I think some of the challenges were trying to figure out how to promote much more stringent infection control in shelters, where it was really hard to imagine how to do that well. We were also worried about the unsheltered population and how to promote infection control for people staying outside. That was a daunting challenge. I think we're also recognizing, as the weeks went on, that we were going to need spaces to put people who were infected and didn't need a hospital. And I think one of our biggest challenges, as Sheila can also speak to, is figuring out where we were going to help people recover from COVID illness without transmitting to other people when they didn't have housing. That was probably our biggest challenge as a community.

Karen: That sounds like a daunting challenge indeed. Sheila, how about from the perspective of Boston's Housing and Neighborhood Development work. How did you approach this? And what were some of the challenges that you encountered as this unfolded?

Shelia Dillon: Well, if I think back, I think back of evenings in the mayor's office with health care professionals from the city doing a lot of what ifs and imagining worst case scenarios. And I will say that the mayor was listening to experts early on and also was imagining a very, very dire situation and taking it very seriously.

So we started to plan for what happens if half of the homeless population-- and not just the homeless population, but other situations where people are in crowded housing-- get infected or impacted, where do they go, as Jessie was mentioning. And so we started to look for space. And space in Boston's tough. It's a small city. It's a growing population. And space is precious.

So we started looking at the Convention Center, dormitories, hotels, you name it. We were doing speed dial, calling around, looking for space. And I think I will agree that it was the partnership's early on that made this really workable. The city was able to call and use its heft.

But then, you look around, and who's going to operate? And then, you're looking at Boston Health Care for the Homeless, and the shelter providers, et cetera. So it was really a race for space, and then figuring out the best care after that space was secured.

Karen: So in many ways, these kinds of emergencies can bring out the best in people, and sometimes they can bring out the worst. But it sounds like, in this case, those partnerships and the groundwork that's been laid over time between the community, and government, and health care really were incredibly important in this time.

Shelia Dillon: They were very, very impressive. Boston, probably like other major, fairly sophisticated cities, we love our process. We like our conversations. We like our planning. We like our community meetings. And there wasn't time.

And so we were grabbing space with notification but not input. And it's always important to notify neighbors if you're setting up additional homeless shelters or medical facilities. But it was much more notification.

And I was holding my breath, thinking that there going to be a lot of push-back here. And there was not. There was not. We were siting homeless people to live on Beacon Hill.

And if you're not from Boston, Beacon Hill is a very high end, tony area. And people were like, what can we do to help? It was very, very refreshing. We could learn from that. And I think it's always good to get input. But sometimes, you just need to act.

Karen: That's a fantastic story and makes me feel so proud of Boston. I suspect that a big part of why that has worked so well is because of the groundwork that's been laid over the many years of that inclusive process. And then, when you're very inclusive, sometimes when there's an emergency, and that's harder to be, people will be forgiving and join together. So that's true.

Shelia Dillon: We did set up-- and it's a good lesson learned, I think if you do have to act very quickly, and you can't get a lot of buy-in, or you can't do a lot of process before you establish something new-- we did have weekly calls with Beacon Hill residents. We set up another shelter in Brighton with Brighton residents. So once it was established, then we're checking in on a regular basis to see if there's issues. Of course, there always is going to be. But then, resolving those issues quickly, it goes a long way.

Karen: Yeah, well you gave people an opportunity at a forum to continue to be engaged. So that's terrific. Jessie, can you tell us about Boston Hope, how was conceived and implemented, and what the experience was for both community members, as well as providers?

Jessie Gaeta: Oh, it was a completely remarkable story, a remarkable place. It was amazing to work there. How it came to be is actually probably better answered by Sheila.

From of view, as a health care provider, all of the sudden, it happened. It was such a godsend. We needed a release valve. We had so many more people infected than we thought we would have. And thank goodness, most of the infection was mild. So they didn't need to be in a hospital.

But we wanted to mitigate spread. And while we were pivoting a whole section of our medical respite program, the McGuinness F, to take care of about 52 people who were infected. And we were, with the city's help, setting up tents to fit another 45 people who were infected. We had a third location. And all of these together just didn't end up being quite enough.

And thank goodness. It was really the city and the state that made Boston Hope happen. So from of view, it was just magical. But I think Sheila can talk about how it came to be better than I.

Shelia Dillon: Yeah, I would just add that once again, the mayor knew that this could be very, very bad. He knew that Boston could have high, because of lots of travelers and the conf- now, we're learning how impactful their conferences were early on on the infection rates.

But he knew that we could have a very, very dire, bad situation on our hands and really started working with the hospitals on a weekly basis to talk about hospital capacity. And then, it lend itself to having this respite for folks that were homeless or unstably housed. So those components came together.

And I think Jessie would agree that they worked really well together. I mean, both sides of the Convention Center were really working well. So it was the mayor that got the hospitals and the state and insisted upon additional capacity in Boston. It was him that pulled it off.

Jessie Gaeta: I really don't know what we would have done without Boston Hope. If you remember, in the early part of the pandemic in the United States, we were affected in the Northeast very early on. And so while there were outbreaks happening in Washington State and Seattle, we were in touch with our colleagues, who work in health care for the homeless programs there. We were really out in front with how are we going to manage this for this population? And we were scrambling for space, like Sheila said.

When Boston Hope became possible, it was one of the most amazing things I've ever participated in my career. I just remember walking into that building for the first time, seeing the amazing transformation of that space, feeling like this tremendous sense of relief that we had not just a space, but somewhere where people were going to have their own rooms that they could spread out, that there was going to be some dignity also. To the time that they were going to need isolation, it would be a dignified space.

And it was inspiring and also daunting. And we think there was a 48 hour period where we were trying to set up, getting all the equipment that we needed, trying to figure out what the model will be, imagining needing to take care of hundreds of people at a time. We had to really quickly hire new clinical staff. We had to begin to think about disaster medicine in a new way.

I remember just looking to a military field hospital models as one model for how to do this really quickly, how to stand up such a massive facility. So it was a remarkable project. And I can't imagine what it would've been like without it.

Karen: That is such an inspiring and important story. And one of the things that really strikes me, as you're both talking, is that there is this need to innovate real time in a terrible emergency, but also thinking about how you look at scientific evidence, and then turning to the military field hospital model, and thinking about what our models that could be utilized and brought to bear in this case. And I think, as a translational scientist, that is really wonderful to hear. It's like we have to move in different ways. But we can certainly adapt from strong evidence. So that's terrific. Jessie, can you say a little bit more about how the service providers, as well some of the residents of Boston, who were using, who were patients in Boston Hope, experienced it. The response to the pandemic, for them, was really epitomized, I think, in many ways by Boston Hope.

Jessie Gaeta: The health care providers, I would say, were just exhausted by this point. Because we were already a number of weeks into pulling long shifts, managing 24/7 isolation facilities. But I think it felt, and still feels to a lot of people in the health care industry right now, basically like this is our moment to just stretch as far as we can. And it definitely felt like that in Boston Hope.

We're a community health center. So we work in a lot of unusual spaces. But this was more extreme. And we needed to manage this space 24/7. So we immediately hired a number of nurses and doctors who had been furloughed from other outpatient settings that just weren't in operation at the time.

We pivoted a lot of our clinical practice from outpatient to these inpatient isolation facilities. And there was a real camaraderie. We just came together. We're going to do is. All of us are going to take over night shifts. And we just put as much structure in place as we could. We were working in such a different way than we usually do. And I have so many examples of that.

But you asked about the patients of Boston Hope too and what their experience was like. And I think for most people, it was a good experience. I think we've felt certainly a lot of gratitude from people that we tried to pass onto the city and the state.

The structure inside was such that we had 500 separate rooms that were all constructed out of drywall. And these were white walls everywhere. And there were several long, white walls, these hallways of 60 rooms that were really long, that people would start to take up and use to create art on these beautiful, white walls. And the artwork across this massive space was just so uplifting.

People had a lot of time on their hands, as they were in isolation. And they were mostly not very sick. And so we were trying to find things for them to do. And a lot of people took up creating art on the walls. And they were mostly messages of thanks and worry about whether they would get sicker, really grateful to be in a place where they could receive care, and be in from the elements, and feel confident that they weren't going to be forgotten. So I think mostly, I felt so much gratitude from people.

It was a strange environment. I think one of the struggles was figuring out how to help people with severe mental illness, who were going to walk into this gigantic space that they hadn't seen. But we had to convince them to come even. That was a struggle. Really needed to build a lot of trust, even just getting people to Boston Hope.

And when they were there, I remember thinking managing the psychiatric needs that people might have was an afterthought. I think our first mission was how can we make sure that we can take care of people with COVID if they decompensate and get them out quickly to an emergency room? And that's our first goal.

And it was an afterthought to go back and then think, how can we implement some psychiatry first aid, so to speak, for people who are in crisis in a really strange environment, who are suffering from severe mental illness? And so it was probably a couple days in, where we decided to bring in psychiatrists to really help us figure out how to manage psychiatric illness in that setting. So a lot of gratitude from people. Most people wanted to stay the whole time, weren't excited to leave even after a period of isolation. And some people really struggled though with the unusual environment. So we had to had to figure out how to help people manage that.

Karen: A very inspirational story. Sheila, can you share the policy and governmental perspective on Boston Hope? What are the lessons that we learned from this experience that we want to think about for next time?

Shelia Dillon: I think the lesson that I have learned, and I think many of us have learned, that Boston is a very caring, very impactful place, and that when we work really hard, and we have a sense of urgency, we certainly can accomplish anything. And I think we see that on a very regular day-to-day basis, when it comes to our unsheltered population. But I do think this pandemic and the experience of Boston's Hope and those months should make us all work more quickly together.

Like I said earlier, we're a very thoughtful city. We're a city that likes to process and plan. And sometimes, if you have a situation where a lot of lives are impacted negatively, you need to move quickly.

So that's what I have personally taken away, especially as we look at what is next. And we're all starting to plan for a second surge. But we also know that in the United States in most major cities, there are too many people in shelter and too many people on the street. And I think we really do need to act quickly, and with purpose, and get those folks housed.

And we have been doing a lot of good housing work. Boston's got a fairly-- compared to other major cities-- contained homeless problem. And we've been doing a lot of good housing work. So we need to resume that work. And we need to resume it now and with great dedication and purpose. It would be nice when, at some the future, that less people are impacted, because more people are in housing.

Karen: Picking up on that note, Sheila, the mayor's administration has devoted significant resources to think about housing in the city, to expand affordable housing, including the city's first city funded rental voucher program, and really just tremendous work in the housing space. What's the impact of the need for them and the ability to move them forward?

Shelia Dillon: I think you're right. I think sometimes you have to stop and take account of what has been accomplished. We have created a lot of new housing-- market rate, middle income, but most importantly, I think for many of us, housing that's affordable to low income families and our homeless individuals. So we have to continue that work.

We've been also trying to expand our own resources. Because we're not getting a lot of additional resources from the federal government. Maybe we will in the future. Maybe it's right around the corner. But it has not been forthcoming.

So we're very dedicated to continuing to do that. What we are now working on is creating a very large pipeline of projects that are going to serve our homeless individual population more than we ever have. And I'm very excited about this work.

We've got a pipeline of about 600, maybe more, of new housing that we're going to see in the next several years come online. And this is going to be housing that's very affordable for folks coming out of shelter with wrap around, very rich services. And we've been housing homeless individuals everywhere that we can, using vouchers, placing in our more typical affordable housing. But this is going to be housing that's dedicated to homeless individuals and meeting their needs. So I'm very excited about this next chapter of work.

And the pipeline is real. The resources are being put in place. And I think that's a missing component that we've had in our affordable housing delivery system.

Karen: It sounds like the approach is going to be much more deliberative and planful than has been possible before. That's very exciting. I'd like to ask you both about the impact that COVID-19 housing stability act has had on homelessness. Sheila, from the perspective of city government, what has the impact been? And how is preparing for when this program ends?

Shelia Dillon: The eviction and foreclosure moratorium is in place until mid-October. We are looking, working with our researchers and the Metropolitan area Planning Council about the number of households that could be impacted by the moratorium coming to an end and planning. The numbers are staggering. They're staggering in every major city. They're staggering in Massachusetts. But in Boston, it could be tens of thousands of families and households that can't pay their rent.

So we're doing several things. We're starting to work with the court systems on how the eviction process works so that early on, we can help with rental assistance. We're trying to bring on more public service attorneys. We're adding people to answer phones at the Office of Housing Stability. And we're finding both internal and external sources to help us with rent arrearage.

With all of that in place, it may not be enough. And I've been stressing to anyone who will listen. And certainly, the mayor is stressing it as well to State and Federal partners that we can't have people become evicted or families become evicted and have them enter the shelter system. That would be tragic.

It impacts everything. It impacts education. It impacts health. It impacts employment stability. We cannot have that happen. So we've got to do everything we can at the front end to keep people in their homes.

Jessie Gaeta: I agree completely. Even just thinking about it from a Public Health lens, knowing how we saw this virus spread through congregate settings in Boston, including nursing homes, including the large adult congregate shelters, I think having more people enter that system, more people who need shelter right now from a Public Health of view, is just not the right thing to do. It's an unprecedented time. I know the eviction moratorium causes hardship for landlords, people who are renting for sure. But the last thing we can do right now, as a community, is let more people enter into a system that necessarily requires congregate living. That is exactly what the environment where this virus thrives.

I was just thinking back to when we started to do universal testing in the large shelters in Boston. And in the midst of our first wave, we really quickly found that 35% to 40% of people in the large shelters were infected. And that's why we scrambled so fast to find spaces to isolate people. We just wanted to mitigate that spread. And it was really difficult. And it took many, many weeks through that first wave.

And so having more people come into that setting after we decongested, in the midst of this pandemic, is not the right thing to do from a Public Health standpoint. So we have to figure out how to not let that happen.

Karen: That's a really helpful perspective, getting ahead of the problem that we know that will come from increased evictions and movement into the shelters, not only for all of the things that impact on people's health and ability to thrive, but also on the disease outcomes. At Harvard Catalyst, our community engagement and policy team spend a lot of time thinking about the role that data and research play in addressing housing stability and homelessness. This is an area that we think is just incredibly important. Jessie, how can the research community be an effective partner at addressing homelessness, both in terms of the COVID times, but also just generally?

Jessie Gaeta: I think research is so important in forwarding policy. And that is absolutely the case, when it comes to homelessness and housing policy. So I'm thinking about COVID in particular. It's been, I think, really helpful and important to try to document what we're observing, in terms of transmission. I think we have a lot more that we could do to learn about how this virus spreads through environments, like congregate shelter, or low income housing, or crowded housing. I think those are areas that we need to study more.

I was just thinking about a recent study that we were just minimally involved in, which was to look at the genomic sequences of various SARS CoV2 viruses that circulated in the first wave in Boston. And in that study, the research team, which was really from Brood, and from Harvard School of Public Health, and from the State's Department of Public Health found that the virus that was circulating in the Biogen conference in late February took about four weeks before it really impacted two very vulnerable populations-- the nursing home population in Boston and the sheltered population in Boston.

So most of the virus circulating at the large shelters, where we did universal testing, turned out to be direct descendants from the virus in the Biogen conference. So that told us that first of all, our community is really tight knit. We're only a few steps removed from these two seemingly disparate populations.

I think there's a lot more that we could do to learn with genomic sequencing, with more epidemiologic study to learn about how respiratory viruses like this are transmitted in a congregate shelter, for example. I think we have a lot to learn about the risks of this particular disease in unsheltered folks. Research has been really important. We've quickly learned a lot. But we have so much more to learn about COVID and homelessness.

I think, in general, thinking about housing, I think, from my vantage, there's been a lot of work to try to document and study the effects on health of poor housing, or crowded housing, or a lack of housing. And there's more to more to be done there, especially at a time when we're just inundated with the importance of Public Health and trying to cope as a country, as a world, with a new virus. And we're beginning to realize so much that our policy decisions really have a direct impact on people's health. So it's a moment in time where that's understood, I think, more than I can remember in my career. And so I think we should seize that opportunity and continue to document, study, define how a lack of housing contributes to poor health, so that we can make better policy decisions about the importance of housing moving forward.

Karen: Thank you for that. Sheila, how can we more effectively and efficiently translate science into evidence based policies and practices? How can researchers help with that?

Shelia Dillon: So I think in the last five or six years, there has been a real shift that we are looking at good research coming from lots of different sources and good data. We're doing a better job at the city-- and most major cities are-- of really looking at, for instance, who is homeless, how long they're there. What are their characteristics? Who leaves and comes back? Who has been there the longest? What are the barriers?

So instead of just saying, someone shows up for an appointment and gosh, nice man, we're going to get him housed. It's instead now, looking at who has the most barriers to housing. And our resources go there first. They get that person housed.

And people that might need less help, because the data is showing that, then we're tailoring our resources to meet that need as well. But I think all of our actions now are really a result of looking at data, both in the here and now in Boston, and also looking at successful programs, based on data in other cities and countries. So I do see a real healthy shift that we're making policy after. It doesn't happen every single day and every single hour. Sometimes we do things in the seat of our pants more. But I do think our decisions are being more thoughtful. And they are data driven.

And we are surrounded by the best colleges and universities in the world. And we do take advantage of them. And we welcome them. We really welcome the partnership, the meetings, the forums. We learn from them. And I think we have a very rich safety net and social programs, because of those relationships and partnerships.

Karen: I know that, speaking for myself and for many researchers right now in that COVID times, it has been so important to figure out how we can be most helpful. And I think if we can help with data, and thinking about the data, and really trying to understand this disease, as well as the impacts on populations long-term, and generally some of how these social issues intersect with health, it brings great meaning to our work.

Shelia Dillon: I would add one thing. The relationships can be time consuming-- generating data, and meetings, and thinking things through, people that are collecting and researching. It's always more impactful, for me, because time is short, that researchers help us understand problems, root causes. But it's best when they say, you know what? These are really helpful solutions. And these have worked other places. And you may want to try this. And we think this would work because.

Oftentimes, researchers will tell us that there's a problem. And if a lot of researchers are identifying issues and problems, but not necessarily providing proposed solutions or ideas, it's just half of the pie. So that would be my request. So give us your best thinking on how to solve things as well.

Karen: That is a really, really helpful thing for us to think about. I think we, as scientists, are really good about thinking about problems, and sometimes not so good about solutions. So I think we all want to move in that direction. This has been such a fascinating conversation. I so appreciate both of your time and that amazing work that you've been doing. As we move to end, I wondered if you could each share with us one takeaway for our listeners. What is the one thing that you would want them to remember?

Jessie Gaeta: I think the one thing that I just find so remarkable and that I want to keep remembering about the first wave in Boston was how much we accomplished, how well we took care of people who lack housing. It felt like such a massive effort and partnership, and so stressful. And I'm thinking, Sheila, I would have never imagined a moment where we're talking on a podcast about what we did just a few months back.

But we did something really remarkable here. We created spaces out of thin air. We used buildings in Boston that we'd never even dreamed of using for this kind of purpose. We did it quickly. We did it, because we had to. And if we can do those things in a crisis, we can do so much when it's not a crisis moment. We can move mountains as a community here for homeless people.

Karen: Thank you, Jessie. Sheila, what would you like to leave our listeners with?

Shelia Dillon: It's funny. I was just jotting down a note. And it was very similar. Together, and it's not just healthcare for the homeless or the city of Boston. But really, Boston at large saved a lot of very vulnerable lives during that time by being willing and welcoming.

Going forward, we need to use that same level of urgency to solve these problems that are now even clearer, even more compelling. We absolutely need to let nothing stand in the way of solving our homeless problem as a country. It's just unconscionable.

And we need to insist that all levels of government-- I'm really speaking to the Federal government right now-- that we don't find ourselves with homeless populations again subject to ravaged diseases. It's just wrong. And it's America. It should end.

Karen: I think that is a fantastic place for us to end. This has been such a fascinating conversation. Both the city Boston Health Care for the Homeless has done such an amazing job in this pandemic and in your everyday work outside of that pandemic. So I'm hoping that in maybe a year, we can follow up with the conversation to talk about all the progress that we've made on health and homelessness in the city of Boston and across the country. Thank you both very, very much for your time.

Shelia Dillon: Thank you.

Jessie Gaeta: Thank you so much, Karen.

[brendan] Thank you for listening. If you've enjoyed this podcast, please rate us on iTunes and help us spread the word about the amazing research taking place across the Harvard community.

[oby] To learn more about the guests on this episode, visit our website, catalyst.harvard.edu/thinkresearch.