Hannah Baillie on the impacts of COVID-19 on the homeless population of San Francisco

To start off with, can you explain who you are and what you do?

Yeah, sure! I’m Hannah Baillie and I’m a Registered Nurse in San Francisco, California. I’ve been a nurse for three years, in the operating room in a hospital in Redwood City - south of San Francisco. We aren’t a trauma center but we do a lot of emergency work. This is where I was working when the pandemic hit. Now I work for the San Francisco Department of Public Health - we are within a novel vaccine team. We go to different shelters and safe sleep sites and provide the vaccine and outreach education. 

Obviously, the homeless population are most at risk.

Yes, they are really vulnerable in the congregate settings. When you have to share facilities - we have different ‘hotels.’ Some of them you have to share a bathroom and a kitchen. Very much dorm style. We prioritised these groups, then we branched out to people who had their own bathrooms and sleep sites. We actually had more fentanyl related deaths than COVID deaths. 

Do you think this is a reaction to the pandemic?

I don’t know, really. But I do think the isolation could’ve played a part, because a lot of the places people went to and could rely on were shut down in response to the pandemic. A lot of restructuring happened. A lot of people do think the lack of services was a factor in the overdoses.

What was the reason that you moved from the operating room to the new role?

I wanted to get new experiences and had always wanted to move into public health. That was my initial thought. I changed that in the operating room we were seeing COVID patients but I felt disconnected from the frontline work that a lot of my friends and colleagues were doing around the world. I wanted to be a part of that help and the team addressing the pandemic.

When I found out that I could play a role in helping the most vulnerable people in the city I grew up in - during the pandemic - I knew it was something I really wanted to do. They were also a really trustworthy and established unit within the Department. 

We have a lot of traveller nurses, with many coming from the south, like Georgia, Kentucky. It was through the California crisis fund that we were able to request traveller nurses to come. They were surprised when they saw the extent of our homeless population, and also our harm reduction policies that are very non-judgmental (e.g. safe needles). 

San Francisco has been at the forefront of these policies. They know that’s where we are coming from - and feel safe around us. We take a non-discriminatory or judgmental approach, and it allows this population to express fears around getting the vaccine with their lifestyle, and having the open space to talk about it. So I think that was a strong part of our work - using that established, historical trust between the Department and the homeless population.

Yeah, because presumably the information they are getting about COVID is different than what we are getting.

Yes, we saw a lot of conspiracies. Many members of the community have been on the fringe of society, and have had bad experiences with the healthcare system. They can hear misinformation through their friends. This builds up to a conversation when they say ‘I’m not getting the vaccine.’ We see a lot of that happening at different sites. We see it takes 3-4 turns to get people to feel comfortable and get the vaccine.

When I’m scheduling, I’ll try and get the same doctor to go back to the same sites during the month so the individuals there can see a familiar face. Just recognising that so many of these people come from traumatic backgrounds, and can often have bad experiences with healthcare. So you have to honour that and try and get the correct information through to them. Saying the scientists developed the vaccine, and that the government funded the scientists.

Here in Australia, we were handling COVID really well, and were watching American being like, wow. Have you noticed a difference across the administrations, with Trump and Biden?

That’s a really good question. Maybe the coordinated communication between CDC, the White House and the Federal Government has helped ease concerns about guidelines. With funding, I’m not too sure. Just the government saying ‘this is real, we have to wear masks.’ Just the government saying that masks prevent the spread of the virus. It helped us be on the same page. It was hard waking up every day being like what the hell is this person going to do now? It was creating confusion - we needed to be giving out the same information, and we all had to be on the same page. It’s hard to know the long lasting impacts, like what would’ve happened if we have had Hilary. But now, it’s definitely not as fear provoking when waking up in the morning. 

Until the shoe starts being on the other foot - in Australia, in NSW, we are currently in lockdown. They mangled the vaccine rollout. You guys were mainly using Pfizer?

Yeah, but it’s so hard to handle. Once you defrost it, it’s hard to handle. We give J&J and Moderna. Moderna is two shots, but they are a little bit different. Time frame is also different - Moderna is 4 weeks. So many countries are still waiting for non-AZ vaccines. 

There’s clinics that mainly serve homeless populations that have a really good reputation with the population. So many people experiencing homelessness will generally know where to go to get the vaccine. For the most part, we tell them that they may feel sick afterwards etc just to prepare them. Many people can also have Hep C, so we need to be careful about what to advise for post-vaccination. It does suck, especially for unsheltered people. I vaccinated a young woman who couldn’t find a shelter to get into, after J&J vaccine which you normally feel a bit sick after because it’s the one shot. 

I felt really bad that I couldn’t really get anything to her, especially because she didn’t have shelter and was actively trying to get housing - and I knew she was going to feel really sick after the vaccine. What made me feel better is that the vaccine would reduce her chances of going to ICU with COVID. We were giving out care packages that included some gatorade and other bits and pieces that could help ease the pain etc. But these are limited and we don’t have any more of those. 

We just started to provide incentives to get the vaccine, like we have $10 giftcards for Starbucks and McDonalds. We finally got approval. Other cities have not been ethically conflict to offer incentives, however ours has. So we finally got approval and are giving those out. We have a limited supply so we have to be careful with how we advertise it. We are trying to use the giftcards as a tool, but don’t want to promote it so much that we get inundated and don’t have the vaccine supply. 

What does the homeless population look like in San Francisco?

San Fran is the hub of technology. I work right near the Twitter headquarters. Then right around the corner is a methadone clinic with a high number of arrests and drug busts. So you have billionaires working on the same block as these homeless groups. You have house prices going up that has removed affordable housing to put in condos that will sell for millions. You have a lot of people who have been displaced, who were previously housed. Trying to find family members. A lot of people who hear about the services we offer these groups here and come here from other counties and other states. Our weather is also really mild all year round. This is very enticing for people who don’t have stable shelter. It’s not like NYC or Chicago. A lot of them have mental health or substance abuse issues - it’s hard to know what starts first. 

We have put in temporary shelter to house more people during COVID. We started giving out way more harm reduction tools during the pandemic. We have always had safe needle exchange places and now we have started offering like individual crack pipes and their own mouth pieces for their pipes to minimise transmission. All these things to help people stay safe when they are using drugs. 

What I saw when I was at these clinics - we would also ask how the wounds were on their arms etc. So it was another entry point into us giving them care for other issues and an entry point for them into our services. They knew we weren’t judgmental and we are able to build trust that way. 

There’s so many more with the displacement from the tech boom. So many tents and encampments popping up. We try and monitor these groups, and ensure safe sleep sites. Ensuring that there is at least some dignity for them. 

I created an orientation for newcomers coming in because it was a bit of a culture shock. Many saying it was such an eye opening experience for them. They are able to build relationships with the homeless populations while they are here. 

So had you been exposed to homelessness or their experiences before?

Yes, my mum is a public health nurse and actually works with me. She worked with the Department of Health and then retired, but then came back out of retirement during the pandemic to help out. I grew up around these groups, and was able to listen to difference people’s stories. I would spend time with them and they often just wanted someone to talk to. I found it’s people who have had bad luck, were ostracized from their families because of mental health and were led to substance abuse. 

What is the demographic like? Is it young people, people of colour? 

There’s definitely public data around it. It’s pretty mixed. Disproportionately affecting non-white people here. Even age range, I’m so surprised hearing people’s birthdates that are after mine. We are vaccinating people on the streets who were born in 2000. It’s people coming from all different parts of the country and the state. We truly get such a mixed bag. It’s not necessarily one age or race. 

You said that you guys are surging at the moment, are things OK?

The surge - in two weeks, COVID cases have spiked. Our positive caseload is increasing. Even though it’s small, it’s still alarming for a small city. We are in the red zone in terms of case load and are thinking about making masks mandatory again. We have managed to vaccine a large percentage of the homeless population here. We break it down by site e.g. shelters and safe sleep sites. 

What have you learnt about why people don’t want to get vaccinated?

A lot of people will say I don’t want to get vaccinated, and just walk away. We hear a variety of reasons though - they don’t trust the vaccine or the government - a lot of the conspiracies like there’s a chip in it. There’s a way to respond to them in a non-judgmental way, but get the right information to them. You have to understand where they are coming from and know how to respond to them in a positive way. Saying that the people who made the vaccine had nothing to do with the government. Many people also say they have gotten COVID, so don’t need to get the vaccine. Many people also say they haven’t gotten COVID yet, so why do they need it now?

What does COVID-19 look like for the homeless population?

The full shutdown really brought it to a halt. It didn’t feel real to a lot of people who weren’t in healthcare. It isn’t as scary to people as it was to people in NYC. It wasn’t really our experience, because we also handled it really well. But NYC was a whole other experience and that was caused by a variety of reasons, e.g. population and housing.

But I think the lack of fear around COVID also contributes to the lack of people coming forward to get vaccinated. It all contributes to vaccine hesitancy. 

Is everyone eligible for the vaccine?

We don’t offer Pfizer to everyone. But yeah, most people are eligible. Doesn’t matter if you are undocumented - it’s completely accessible. 

It’s good that it is slowly becoming more accessible. It’s getting slightly difficult here.

Yeah, we did it in a way that it was pretty easy. It was tiered, e.g. elderly people first. But come May, it was open to anybody. 

I’m curious to know what you have learned and how these experiences have helped you grow?

Just as a nurse in general, this experience has been really fulfilling. There’s so many people where getting the shot is them getting touched for the first time in a long time. Just having human touch and having someone’s hand on their arm. Getting to feel that powerful moment with a connection between people. As a nurse, I have really grown and learned about this. That’s what keeps me going, especially when you see a lot of trauma and suffering on the job. It helps remind me why we do the job. 

Just in the hospital, it was pretty stressful going into work when we didn’t know much about COVID-19. I felt supported by the hospital and we were running out of PPE. There was one time I was in a meeting with our infectious disease nurse and we were trying on ponchos and trash bags and got shaving cream and put it as though it was ‘germs’ - and could see how she could take it off the PPE safely, without getting the shaving cream onto me. It’s easy to do when you have the normal gowns - you pull it away from yourself. When we were really low, we were trying to find what we could offer people in a safe way, like ponchos and trash bags. 

It made me appreciate and made me realise how fragile even the American healthcare system is. I mean, our healthcare system is so broken, but this made me realise how I normally take having supplies for granted. So this made me realise all that we do have. We were running completely at full capacity, and didn’t have any more ventilators. It made us realise that we really needed the vaccine as soon as possible. It’s made me so passionate about getting the vaccine to vulnerable individuals with substance abuse, mental health issues.