BHCHP Podcast Episode 1: The Tents

Jessie Gaeta: Hello and welcome to Boston Health Care for the Homeless Program’s podcast series, COVID in the Streets of Boston. I'm Jesse Gaeta, and I'm a physician here at BHCHP. In this series, we tell the story of how we beat the odds and provided compassion community, and world-class healthcare to people living in the shadows of society during a global pandemic. Listen and subscribe on Spotify, Apple Podcasts, Google podcasts, or wherever you get your podcasts. This is episode one, The Tents.

Jim O’Connell: January 2020 at Boston Health Care for the Homeless Program started out like any other frigidly cold winter in Boston for us. Our lobby at 780 Albany Street teemed with patients and staff dealing with myriad medical and behavioral health issues: frostbite, overdoses, wound care, routine clinic appointments, dental appointments. Our respite program upstairs had 104 beds, all spoken for by patients recovering from surgeries or too sick for the shelter. And our street team had been out for hours, combing the streets, coaxing folks to come in from the cold for care. Homelessness is a very dangerous condition.

I'm Jim O'Connell, founding physician and president of the Boston Health Care for the Homeless Program, and my clinical focus over the years has been caring for people living on the streets and avoiding shelter. While we were working furiously to cope with the increasing number of deaths from opioid overdose cancer and a host of other diseases, looming on the horizon was the specter of this virus that could potentially be deadly to vulnerable populations like those living in shelters and on the streets.

Jessie Gaeta: You know, I remember like everyone else sort of listening to the reports from China, like on the radio, on my way into work, and kind of sighing and just allowing my mind to spin for only a short time about what the implications could be for us.

My name is Jesse Gaeta. I'm an internist and addiction medicine specialist, and I'm the chief medical officer at Boston Health Care for the Homeless Program. I think just in the way that I, you know, I've kind of evolved to be able to compartmentalize things, I think I compartmentalized it away so I could kind of continue on with the usual work. But by the end of January, I was increasingly alarmed.

Jim O’Connell: As Wuhan, China, went into lockdown cases, began popping up across Asia, Europe, and North America. On January 31st, the World Health Organization declared a global health emergency. And then on February 1st, Governor Baker's office announced the first case of COVID in Massachusetts, and our leadership team began to scramble to prepare.

Denise De Las Nueces: We were all probably a group of maybe 10 of us leaders here at the program, all in a small conference room, gathered around a table, no masks on, you know, in the beginning of the pandemic, when cases are definitely here, and spending hours together, strategizing planning, troubleshooting,

Jim O’Connell: Denise De Las Nueces is our amazing medical director. Denise is an expert in infectious disease outbreaks in the homeless population, and she led us through a very deadly outbreak of meningococcal meningitis that was recognized by the CDC as one of the more creative responses by a homeless program.

Denise De Las Nueces: There was just this deep sense of we’re—none of us is in this alone. We are in this together.

Maggie Beiser: My name is Maggie Beiser, and I'm an adult nurse practitioner. And I've been at Health Care for the Homeless for the last 13 and a half years.

Jim O’Connell: Maggie completed a craft fellowship at mass general hospital during which she honed her skills in hepatitis C. And she has been running our hepatitis C program here at Health Care for the Homeless, which has been recognized internationally as the most innovative hepatitis C model of care for people with substance use disorders in North America.

Maggie Beiser: Jessie was sort of running between multiple marker boards and just like, you know, we need to like laser focus on things. First thing we have to know how we're going to screen people, potentially. What we're going to do, where they are going to go.

Jessie Gaeta: We knew we would have some people diagnosed COVID who needed to be in the hospital. They were that sick. And so that was simple. They would go to the hospital. Hopefully there would still be room in the hospital. There would be another group of people who would be infected with COVID, but not sick enough to need a hospital.
The next cohort was people who had symptoms of COVID, but we didn't know what they had yet. And if you think about it, that's the group that needs the very highest level of infection control because they don't all necessarily have the same infection. Some of them will have influenza, some will have other routine colds. So you can't put them with people who might be infected with COVID while you're waiting for a test result. So this was the group of people that we wanted t, have space for where we could keep each individual person separate from each other. And we didn't have any space to do that, let alone space for the fourth and final group we were thinking about and worried about, which was people who we knew had a prolonged, close exposure to unknown positive case.

Jim O’Connell: The usual public health responses of isolating and quarantining folks during an epidemic were very difficult when you put it into the context of a homeless shelter.

Jessie Gaeta: When you put your head down in a bunk bed at one of the homeless shelters in Boston, you are within five feet of 12 other heads. Like, I don't know how else to say how extremely crowded shelter can be.

Jim O’Connell: The more crowded and congested a shelter is, the more efficiently and quickly the virus will spread.

Jessie Gaeta: I remember with tuberculosis outbreaks, you can literally keep a cough log each night, and you can, night to night, sort of watch the progress of this virus as it goes through a ward of a hundred people sleeping that closely together.

Jim O’Connell: As a Health Care for the Homeless Program, we have learned much about how infectious diseases spread, like tuberculosis and meningococcus. But with the novel coronavirus coming, we knew virtually nothing about how it would spread and the effect would really be on our population.

Barry Bock: We literally were terrified that thousands of people that we serve may die or become gravely ill. And, you know, there's no fault in this, but to see how flat-footed so much of the world was in trying to respond to this new communicable disease was really overwhelming and terrifying.

Jim O’Connell: Barry Bock is our CEO. I first met Barry in the 1980s when he was the nurse in charge of Pine Street Inn’s nursing clinics, and our collaboration resulted in us recruiting Barry to run a respite program, to be our COO eventually, and then to be for these past eight years our CEO. He has done virtually every job in our program is really the heart and soul of Health Care for the Homeless. So in February of 2020, we knew very little about COVID how it spread, how efficiently it's spread, how deadly it might be, and our fears and concerns were escalating. We knew there was a desperate need for three separate spaces for homeless people living in shelters. One for quarantining those who have been exposed to the virus; one for isolating those with symptoms awaiting testing; and then very importantly, a place for people to go who are diagnosed with COVID.

Barry Bock: So hotels were like the elegant solution because if you're quarantined and you turn positive, you get to stay in a hotel.

Jessie Gaeta: We were each like personally calling hotel owners to try to convince them to allow us to use hotel rooms.

Barry Bock: And it scared the hell out of all the hotel owners. They said look, at some point COVID is going to be over, and there's no way we can say like, oh yeah, we're the COVID hotel, come on in and sit by our pool and have a drink. It just is like insane. No one's going to ever come back to us.

Jim O’Connell: When we learned that the hotels were not an option, we looked into the traditional places we used to use for overflow shelters: gymnasiums, which have open space and also armories, because in the old days we had used armories for overflow shelter during the winter time.

Jessie Gaeta: And at that point, the answer everywhere we went was no.

Jim O’Connell: So as we faced a dead end with all our hopes for a hotel or gymnasium, Jessie Gaeta suddenly decided maybe we should use tents

Denise De Las Nueces: We decided, that the best course of action in the immediate short term was to pop up tents really, right outside of one of the largest Boston Public Health Commission-run shelters here in the city, a large men's shelter called 112 Southampton Street.

Barry Bock: It wasn't something that we were like, woohoo, we're going to operate tents! In winter, by the way, right? In Boston. But we also realized we could have some control. And by the way, we had no idea where the money was coming from.

Jim O’Connell: We had no idea how we would pay for any of our interventions, and we had to rely on faith and the hope that the people who have kept us afloat for all these years, our wonderful donors, our partners in the federal and state and city level, would come through with the funding if we had the solutions.
Once the idea of tents, crystallized things began to happen with lightning speed.

Jessie Gaeta: All of the sudden there wasn't just support, it was like, we have a company to do the construction, and we can build these in three days.

Jim O’Connell: One major question remained: what would these tents actually look like?

Jessie Gaeta: I remember just thinking, let me think about this for a two seconds. So thank goodness you know, I had as a very close partner, Josh Barocas, who was an infectious disease expert from BMC at the time, you know, pretty much dropped everything he did and was working with us night and day as soon as we were thinking about this issue.

Jim O’Connell: Our three-decade relationship with Boston Medical Center proved critical in our response to the pandemic. As often in the past, Boston Medical Center came immediately to our aid ,offering Josh Barocas to help us with the design of our response.
So it's Sunday night, Jesse and Josh have been in a conference room since early morning and they're trying to design medical tents, something neither of them had ever done before.

Jessie Gaeta: So we had a whiteboard, and the whiteboard in the room was already filled with all of our thinking about how we're going to do infection control. We didn't want to erase that. And we didn't even have a piece of paper in front of us. We had a couple napkins that we grabbed from the corner of the room, and we just, both of us started furiously drawing out spaces. And then we would easily crumble one up. No, no, that's not going to work. Wait, we don't even have bathrooms here. And what about an anteroom? We were struggling.

Jim O’Connell: Then Jesse got an idea.

Jessie Gaeta: I remembered that we had worked so closely with this amazing architectural firm called Mass Design, an dthey had helped design an office space. And it was just such an amazing, they did it in an amazing way, and they thought of all kinds of things we would never think of. But I also remembered that they had designed lots of spaces in other countries. They had designed tuberculosis sanatoriums. They had a role in designing, some of the Ebola spaces in parts of Africa.

Jim O’Connell: Our program had worked with Mass Design several years ago, and Jessie still had the number of their key architect, Chris Scoville.

Jessie Gaeta: And so I texted him and I remember my text was like, I'm not sure if this is still your number, and I realize it's a Sunday night, but we are designing tents for isolation and quarantine, and if you get this message, please reach out. And he immediately wrote back and said, I'll be there first thing in the morning.

Jim O’Connell: The next morning, Chris took the napkin drawings, turned them into a blueprint, and construction began.

Barry Bock: That was an insane time getting the tents open, but kind of exciting at the same time because we felt like, wow, we're able to bring something to the table that will impact our population. And again, even though they were tense, there was a lot of dignity.

Jim O’Connell: Two tents were constructed, each about 80 feet by 20 feet. Tent A had 20 beds , while Tent B had 16 beds. Each bed was in its own pod, separated from the others to keep people from spreading infections as much as possible. Outside, there were 16 porta-potties, a trailer was showers, two giant diesel generators to provide power, heat, and internet. There was even negative pressure to minimize the spread of infected air within the tents. Jesse, Josh and Chris had done amazing design work, but there were still some quirks.

Jessie Gaeta: I remember trying to problem solve how are we going to have in each pod, separate vital sign supplies, like blood pressure cuffs. And in a setting where you're not sure what each person has yet, you need a separate one of those for each person.

Jim O’Connell: As we invited people to quarantine or isolate in our tents, we had to be sure that we maintained their regular medical care, meaning vital signs, et cetera. for those who needed it, at the same time that we maintained exquisite infection control. And there was a problem of room and space.

Jessie Gaeta: So we had this idea that we would just use some plastic baskets that we could easily clean between patients, and that we would string them with rope through the ceiling of the tent. So we use bowline knots, carabiners, and then we, you know, basically begged, borrowed and stole all of the blood pressure cuffs we could from across the program so that we had enough one for each patient. So there were lots of moments like that, problem solving the physical aspect of the tents
The other dramatic thing for us was how the heck are we going to staff these tents? And the first question is, you know, who internally has the bandwidth and the skill set to kind of operate the tents?

Jim O’Connell: Jesse knew exactly who she wanted Maggie Beiser.

Jessie Gaeta: The first and foremost reason I thought of Maggie is that she's meticulous, that she would understand infection control, which was not going to be simple. It would be the opposite of simple. So I really, I really wanted her mind, but I also wanted her ability to be creative and flexible, and, and to help alleviate concerns and address concerns that patients have. She's just extremely good with patients. So all of the skills that she has been, you know, honing for more than a decade in that work were, I think, really easily translatable into running a COVID tents, although no one would have ever imagined it. She was the perfect person for that job.

Jim O’Connell: Jessie sought out Maggie where she was doing COVID testing in the booth behind our building and pitched the idea to her.

Jessie Gaeta: I just remember going to Maggie and saying, Maggie, you're the right person to do this. Please consider it. It is going to mean that your life is going to be absolutely crazy for the next couple months. It's going to be frantic. It's going to be all hours of the night and day. It's going to be very operational. We're going to have to figure out how to make sure these tents don't burn down. That, that temperature is okay. You're going to have to learn how to operate the generator. You're going to have to do our best to keep staff safe, donning and doffing. To make sure people aren’t dying in the tents.

Maggie Beiser: And I said, that seems really, really challenging. I am not sure that I'm the right person for that.

Jessie Gaeta: Yes, Maggie I'm positive, and we need you. And she, she was all in.

Maggie Beiser: I was terrified. I was totally terrified.

Jim O’Connell: Maggie assembled an all-star team to help manage the tents, including director of our case managers, Diana Aycinena, and our senior healthcare policy advisor, Mary Takach. And together, they went back to the whiteboard.

Maggie Beiser: The whiteboard was just covered in notes, and who's going to cover what, and who's going to develop a training manual, and who is going to figure out we're getting food from how we're going to feed patients. And then somebody else is going to figure out a work schedule for everybody. And then there were, you know, all these other considerations of like, who's going to staff this? How many people do we need? How long are the shifts? Where are they going to eat? Where are they going to rest or change into scrubs? Where are we going to store supplies? PPE supplies, snacks, sheets, bedding, trash. We had no idea how to do any of that. And as quickly as we said it out loud, something would happen. Somebody, something would materialize because there were so many people working so fast and so hard to try to make it come together. So, you know, we had a giant, like a shipping container on the site, and that became our, our supply area. We didn't have really like walls around the area, so to speak when we first started and recognized that it really didn't afford enough privacy or security for people kind of being able to walk onto the area in the middle of the night. And so all of a sudden we had Jersey barriers, and we had fencing with privacy screens. It was just like a very frenzied, we're all in it together, I guess we'll figure it out as we go kind of scenario.

Jim O’Connell: In a profound way, the tents challenged us to look at the foundations of our program. We were started in 1985 through a coalition of stakeholders, homeless people and advocates who decided how they wanted to be cared for. Foremost in what they wanted was continuity of care. They were looking to avoid the fragmentation that is so common among homeless populations trying to survive in the shelters and on the streets. We were asked to be consistent, to be present, to earn trust through soaking feet or being present each night in the shelter clinics, and through that trust develop the relationship that would be necessary for longstanding health care. And the tents to many degrees presented the challenge of how do you entice someone out of the shelters or off the streets to come inside and be isolated when that is one of their dread fears. And what we learned, and what we tried to address through the tents, is that people familiar to them—the nurses, the doctors, the case workers, the recovery coaches, the people that have been following them for years—were exactly the people we needed to be staffing the tents. So in many ways it became an all hands on deck experience.
To manage the tents safely, we realized we needed to have nurses 24 hours a day, with doctors available at any time. And Jessie took on the challenge of recruiting people for this daunting task.

Jessie Gaeta: This moment was one of the hardest moments, like as a, as a person in a leadership role. To say, we don't know enough yet about this virus, but if you're willing to take some risks that we're all going to take, and they could be significant risks, we're going to do our best to mitigate transmission and decrease deaths in this population.

Maggie Beiser: Providing medical care in an isolation space means that you're potentially going to be exposed, you know? And so the training is all around the PPE safety. You know, we did a lot of like everyone dawns together, everybody checks everybody else. A lot of teamwork.

Jessie Gaeta: One particular staff member probably first year working in healthcare, someone who's never worked in a hospital, completely committed, shows up at the tent. And, you know, eyes are this big watching colleagues go through this donning procedure, thinking, and saying out loud to me, I am not sure I can do this. this, this is a lot. And I said, I completely understand if you can't stay. If you want to stay, I'll walk you through this and try to teach you how to be a safe as you can be. And he stayed,

Jim O’Connell: This on-the-spot pivot reminds me of the early days of our program. One of the things we learned was that we need to be flexible and never fixate on a plan. Every time we thought we had our sights fixed on a plan for the future, something would happen That would completely derail it.

I remember when we opened our first respite program in September of 1985 in the Lemuel Shattuck shelter, we had a plan for what we were going to do. We were going to care for people with infections, people with pneumonia, heart disease, who had been in the hospital and needed a place to recover and continue their care once they left.
Then two things happened almost simultaneously. A multi-drug resistant tuberculosis organism took hold in the shelter, and over 60 people got TB disease, and over half the shelter became infected with the organism. Each person required four medic medications each day for 18 months in order to treat this disease effectively. And this challenge taught us how to be flexible in a public health mode and to work with everyone in our community to care for it.

But then right after the tuberculosis epidemic began, the first person to be diagnosed with HIV/AIDS in the shelter system came into our respite program, and everything from that moment on changed as we face this devastating epidemic, which resulted almost invariably in death and for which we had, for the first 10 years, virtually no treatment and no idea how to take care of people other than to treat their opportunistic infections.
What didn't change was our focus on giving access to quality care to each of our patients. Continuity of care, consistency presence in the lives of our folks was key to providing that care. COVID faced us with many of these same challenges for which we had been preparing for these past 35 years.

Maggie Beiser: We were incredibly lucky to have like really, really incredible staff that want to be there. And also they know our patients. And so having a case manager in the tents who knows the people that are in there, it wasn't, you know, it wasn't always perfect like that, but, that made the patients feel more comfortable, and case managers actually did stuff in there, like help people with housing and help like continue on things that they'd been working with in the outpatient setting.

Our patients have a very high level of co-morbidity with mental illness and substance use disorder. And so that is, you know, that was true in the tents as well as the rest of our practice. So, from the very beginning, we tried to approach it with a pretty, open assessment at the very beginning, trying to get a sense of what people's main priorities were and what was going to help support them to like, get over this hump. And I, I likened it a bit to sort of being like a hotel manager sort of saying, you know, this is a tough moment. We wish it could be easier and better, but how can we make your stay more enjoyable? You know, I mean, not, not obviously not an enjoyable moment for most people, but, what else do you need to be able to sort of stay here safely? And what do we need to know?

Jim O’Connell: Some patients coming into our tents were experiencing drug and alcohol withdrawal. Others had severe mental health needs, while others were coping with chronic diseases, such as diabetes and heart disease, and others had lives and jobs outside the tents that they couldn't simply walk away from. So Maggie and her team had to figure out how to keep people connected to their lives while they were in isolation and quarantine.

Maggie Beiser: We were able to do some telehealth, actually, from the tents to psychiatry in our, in our building. And then we had a runner who would like go to the pharmacy and pick up meds. And so we were able to actually do some, some direct medical care and direct like, treatment. But a lot of it was really just support.

Jim O’Connell: A major need of many of our patients was the management of active addiction. Many people were happy to get methadone and other withdrawal meds to manage their opioid addiction, but others were not yet ready to stop using. And we had to come up with ways to help them stay in the tense while managing their addictions.

Maggie Beiser: To kind of balance that we offered, sort of, basically fresh air breaks. And we sort of said, you know, ideally we want you to be in this isolation or quarantine space most of the time. but once or twice a day, if you want to leave the grounds, take a walk, whatever you may end up wanting to do in that moment, that is going to be fine. Because otherwise it's unlikely that you're going to come back and stay. So it was, you know, you can't let the perfect be the enemy of the good. I think in a traditional medical setting, we might say, well, they're isolated. They can't go anywhere. And that's just not realistic. And it's not possible to maintain that level and actually have people voluntarily maintain that. Having some ability to sort of offer a compromise was really important

Jim O’Connell: The creativity and adaptability of our staff in the tents was breathtaking. And it recalled for me how often in the past Health Care for the Homeless Programs like ours have to think way outside of the box in order to overcome the obstacles to quality care for the people we serve. I recall in the TB epidemic, one of the ways that we were able to get the medications to people each day was, through a bartender, for example, at JJ Foley's, who would give the medication to seven men who came there every afternoon before they went to the shelter. And before he poured their beer, he would give them their four medications. And he did that for basically the entire 18 months until they were treated. We also had a barber in South Boston who had a coffee klatch in the morning, and four of the men with tuberculosis, would have coffee there, and he would make them take their medication before he poured their coffee.
And we have also learned a lot through caring for people who refuse to come to our clinics or to the shelters but live outside. We've learned that psychiatric care can be done over a table at McDonald's, that heart failure can be managed at inside a train station with the proper equipment. And we've had to adapt to all sorts of challenges in order to keep continuity of care and quality of care available to our folks.

Maggie Beiser: If you get rid of what you don't really need and take away some framework that is actually pretty arbitrary and crappy, most people actually do want to be able to take care of themselves, and they are able to do almost everything you need, you know, to, to really be meaningful in terms of their care, whether that's medical care, addiction, care, mental health care, or whatever.

Jim O’Connell: Days and nights in the tents were long and busy.

Maggie Beiser: Every morning, we'd run through who is in what bed, who was anticipated to be discharged. I would then call admissions that Michelle Whitaker was running sort of a COVID command post. And they would say, we think these are the people in the beds, and I'm like, oh no, it’s actually a little bit different. That person left in the night or that kind of thing. And she said, okay, these are the admissions we're anticipating today. And also these folks who, their test results are back

Jim O’Connell: Every 12 hours, there was staff turnover, patients with discharged who had negative results, other patients transferred who had tested positive, everything was cleaned and prepared for the next batch of patients.

Maggie Beiser: And then, you know, breakfast arrives and then lunch arrives. You know, it was sort of this constant motion. And then April would show up and she'd be like, we got a new delivery of, goggles or we had a new delivery of N95 masks, we'd be like, great, cause we're almost out.

Jim O’Connell: April Ramsay has been a nurse with our program for the past 10 years, and she is our associate director of clinical operations. And during the COVID pandemic, she became our guardian angel watching over dispension of PPE from all over our program. In the early days, gowns in particular were in short and desperate supply.

Maggie Beiser: We get to like halfway through the day and people would come out for breaks and then they'd be going back into breaks and I'd be like, April, we need more gowns by the end of the day.

Jim O’Connell: To keep track of all the supplies, the overnight staff would do an inventory and write the requests in marker right on the glass doors of the tents so it can be seen by someone outside the tent who doesn't have to enter.

Maggie Beiser: And so every morning I'd come in and be like, oh yep. I can go get those. Let me go to our storage container and I'll run a bunch of sheets and I'll run a bunch of garbage bags. And it was pretty hilarious. You know, In a very serious and scary time, there was a lot of hilarity and, and just sort of good natured will to try to like just make things, make things work and make things fun. We also had so many patients doing like coloring or creating different art and we ended up posting it kind of everywhere. And so really trying to just create as best scenario as possible for everybody, both staff and patients, to kind of exist in that space.

Jim O’Connell: The aim was to make the tents dignified, comfortable, and to whatever extent possible, even a little fun. But many patients in the tents were actively experiencing symptoms, and for many, their stay ended with a positive COVID diagnosis and transfer to a safe facility. We were still very early in the pandemic at that point, and for many people, the diagnosis of COVID was read as a death sentence and was frightening to them.

Maggie Beiser: In some cases people said, you know, I don't believe you, and show me the proof that I'm positive.

Jim O’Connell: The problem was, they couldn't. Only a couple of people in the program had access to the state lab results, and they couldn't just pull them up to show a patient. They couldn't even say much about what a positive diagnosis meant because at that time we still were uncertain about the natural course of COVID disease.

Maggie Beiser: You know, we're used to talking to people about scary medical things, potentially new diagnoses, but usually on the clinical side, we have some guidance or we still have some answers. And that was much less clear with COVID. And so I can understand why people were scared and potentially angry and frustrated. And there are unfortunate examples throughout history where medicine has exploited and abused people who are marginalized. And so in that moment, really trying to balance the respect for person and the, the, the attempts to try to manage public health as much as possible. And often it was many conversations, or sometimes we would like call in additional experts—we had an infectious disease expert—and just to try to explain what we knew, what we didn't know, and try to be really upfront about what that meant. And also admitting our own uncertainty. I think that was pretty important. And when people said, you know, I'm outta here, then we, they had to, we had to let them go.

We had one gentleman who tested positive and he was supposed to go to, I think McInnis house. And he just, he just disappeared. He just absolutely left. And then he showed up again, like the next day and said, well, okay, well, I'm ready to go back in the tents now, and try and, sort of said, you know, that's not where, what we need now. We need to move on. And we ended up putting him sort of in a, in a vestibule of one of the tents and giving him a sandwich and just kind of trying to work with him and, and trying to get, and trying to give him a pretty good picture about what it was going to be like.

Jim O’Connell: When individuals tested positive in the tents, they were often moved into our respite program called the Barbara McInnis house. Medical respite was another program designed by the homeless population of Boston back in 1985. Those early stakeholders who gathered at City Hall laid out a particular problem level that the hospitals and doctors like myself: they had no way to go when they were too sick to be in a shelter but discharged from a hospital. I had never heard of the term respite at that time, but we followed their lead and created, by mandate, a 25-bed unit in the Lemuel Shattuck shelter. Respite has taken on many things over the years. It is basically something we have created to fill in the gaps in the continuum of care for homeless people who still need to recover or to heal without the benefits of home.
When the tents were going up, Omar and his team were transforming half of the 104 beds in our Barbara McInnis house into a COVID unit. They didn't have a closed off space. So they created something like tents inside the building.

Omar Marrero: So imagine like a lot of shower curtains, taped to the floor, taped to the ceiling and we put a zipper in the middle. And that was the, the barricade between the regular floor and the COVID unit. When you are trusting the safety of everyone on plastic walls, and it's something that you have never seen, it is very unique. And honestly it worked.

Jim O’Connell: People coming in for the non-COVID problems were frightened about going into a building that was infested with COVID.

Omar Marrero: So you're telling me that I'm going to be in a building where I'm going to have in the same floor, in the same area, people infected with this virus? How are you going to protect me?

Jim O’Connell: To protect everyone at respite, those with COVID and without COVID, Omar's team had to remove much of what makes respite such a pleasant and communable place to be. Meals had to be served at the bedside instead of the common cafeteria, and the atrium where people could gather and was closed down.

Omar Marrero: Volunteers were no longer allowed in the program and they play on such a, an essential role when it comes to patient experience here. So we needed to become those volunteers and do the events and do the activity. So we were doing the activities in the hallway, on the floor.

Jim O’Connell: Omar creatively found premium channels to put on the individual TVs so that people would have movies to watch and sports to watch.

Omar Marrero: That was part of my selling points. Hey, you can come me in. I know that you're going to be in our room and you will not be able to go out, but we have Showtime and HBO, and you have a hot meals, three meals a day. You will have coffee as many times as you want. Things that you know, that they really appreciate. Even in, in so many restrictions in place, at least there's something that, that we can offer you.
The patients reacted not necessarily happy about the restrictions, but a few days after, when they started to see the news, when they started to see the numbers coming up in, in the city of Boston, they were like, wow, you guys did actually did the right thing. Thank you. So it, it, it was, it was good. That was one of the only good moments of that, during that time, I have to say.

Jim O’Connell: The other thing that the staff offered was honesty.

Omar Marrero: We want to build a culture of trust and that starts with just being honest. If you don't know something, just be honest and let them know. Patients will appreciate that so much.

Maggie Beiser: This organization has been around since 1985. We're not a flash in the pan. And so by offering, I think longitudinal, consistent, nonjudgmental care in shelters on the street—in particular like those, those spaces that really get us out of the office and into the places that are more convenient for people who are homeless to engage in care—that sends a consistent message. You know, we're here. We, we, we're going to treat you well, we're not going to discriminate against you, hopefully. We're not going to make you feel bad about your substance use. And, and that we might be able to actually sort of help with the things that you want help with.

Denise De Las Nueces: The clinics embedded within our shelters as well as our street team and the family team, these outreach pieces of our infrastructure, those pieces are what really positioned us exquisitely well to be able to, to help in the city and state's efforts in managing this outbreak among individuals experiencing homeless.

Omar Marrero: The tents were a very concrete example of what we need to do to come to you and care for you. So we brought this up from nothing and we recognized that, hey, this is what we have. And you may not necessarily want to be here, but we have a space for you.

Jessie Gaeta: The tents were like this very intense, brief supernova of programming and they burned brightly and so intensely and took up so much of our effort for like seven weeks.

Maggie Beiser: In seven weeks of the tents, we had 267 people pass through. You know, 267 people going through this hastily constructed tent in a parking lot. And we certainly had no idea it was gonna end up being like that many, that many people for, for that amount of time.

Jim O’Connell: In these early weeks of the pandemic, the tents provided an invaluable function and taught us how we were going to have to handle the coming pandemic. But as we learned in early April, the extent and breadth of this pandemic in the shelter community completely outdid our tents and the capacity of our respite program to care for people. Two weeks after the tents opened, Jessie and her team tested everybody at Pine Street Inn and found that 147 of over 400 people were positive, most of whom, the vast majority of whom, did not even have symptoms. And then began a search take what we learned in the tents and expand it to attend to a much larger number of people.

Denise De Las Nueces: I do remember them coming down in concert with the Hope Hospital infrastructure being put in place and us rapidly needing to redeploy all of those staff who had been working in the tents to now work in this massive cavernous space, very different, and very far from, from this nucleus of, of services here, in the Mass. and Cass intersection.

Maggie Beiser: The tents were in the middle of a lot of services. They're very close to our building, but also right next to the largest men's shelter run by the Public Health Commission, as well as the engagement center, between two methadone clinics, and right at the sort of feet of the, of the local jail. And I don't necessarily think that that, that's a good thing in and of itself, but it certainly was something that people could see and relate to. And so when we said, you know, you have symptoms, we're worried they might be COVID, we want you to come stay here for a couple of days so we can monitor you and wait for the results, we could say right there. We want you to go right there, you know, right over there. And it's not, we're putting you on a bus to go out of town or—so yeah, I mean, I think it was a tangible, approachable solution in the moment, that the fact that we staffed it, I thought it was really, important and meaningful.

Omar Marrero: Now more than ever everyone knew how essential they were to the operations of a, of a system like this. You give for granted how, how essential someone that is picking up the trash is a moment like this, or how essential for the morale of patients and staff is to have someone willing to cook and serve you.

Jim O’Connell: We trusted all these efforts with the tents, to the generosity of our donors, and they came through. Here's Barry talking about a phone call from one very generous donor.

Barry Bock: I had no idea why they wanted to speak to me. It was like six o'clock one evening. And they told me that they were going to give us this huge gift to help offset our costs. I had a hard time speaking with him for the first several minutes cause I burst into tears. Then when I finally got my act together, I was able to say thank you. So in some ways it was almost like they helped us sort of realize how much the community was behind us, which was just so heartening at such a raw time when we were moving so fast, it was, wasn't always possible to see how we weren't alone.

Jim O’Connell: The tents were a testament to the creativity and ingenuity, dedication, and compassion of our resilience staff. But when I stepped back and opened the lens on this pandemic, the fact that we use tents designed for disasters in developing countries to care for people living literally in the shadows of our world-renowned hospitals and medical centers illuminates a stark reality. What a shame that we had to resort to tents rather than housing, but my, how brilliantly and unselfishly our staff did them.

Credits: This episode was produced by Galen Beebe and directed by Sara Pacelle. It was sound designed, mixed, and mastered by Jack Pombriant. Music from the epidemic sound library and Jack Pombriant. Special thanks to our team, Barry Bock, Jesse Gaeta, Denise De Las Nueces, Maggie Beiser, Omar Marrero and Julie Bogdanski. We are grateful to Phil Stango and Aramis Fernandez in IT staff for helping to keep the engine going.

Our deepest thanks to our staff who worked in the COVID tents and cared for our homeless patients who had truly no one else; the nurses and nurse practitioners, doctors, case managers, Americorps members who fearlessly entered those tents in full PPE everyday; our facility and kitchen staff; dedicated board of directors; our remarkably kind donors, many who give without ever meeting a single staff member or patient, we have thankful for your trust. Thank you to our 40+ shelter partners, Boston Medical Center, Mass General Brigham, the Boston Public Health Commission, the City of Boston, the Commonwealth of Massachusetts, Mass Design, Suffolk Construction, Lee's Family Trailer of Maine, and to the restaurants and individuals who brought our tired staff nourishing meals. And of course, we thank our courageous and resilient patients who have had so many setbacks in their lives but continue to teach us every day about our shared humanity. And thank you for listening.