San Francisco is using RVs as temporary housing during the coronavirus outbreak.
San Francisco is providing temporary quarantine in RVs for those who don't need to be hospitalized. David Paul Morris/Bloomberg

As Covid-19 cases climb, cities may face a shortage of locations to quarantine and isolate people. In the U.S., it’s a uniquely local problem.

When coronavirus cases first emerged in Washington state in February, King County officials spent $4.5 million in emergency funds to buy an 85-room Econolodge in the greater Seattle area, throwing another $1.5 million on top for renovations.

As the epicenter of one of the largest outbreaks in the U.S., King County anticipated that its hospitals would likely become overwhelmed with a surge of patients. The county needed to make more space to put sick individuals who would need to be isolated but wouldn’t require hospitalization, and for people who don’t have a home to be isolated or quarantined in — like the homeless or those living in shelters.

With coronavirus cases escalating in the U.S., other cities may soon also face a shortage of space. Whereas in Wuhan, China, where the global outbreak originated, the national government was able to step in to build two large hospitals in a matter of weeks to house the sick and protect the rest of the public, the division of power in the U.S. places that burden on the local government. (Plus, “it's too darn expensive,” says Howard Markel, a medical historian at the University of Michigan.)

America’s defense against epidemics “is divided among 2,684 state, local, and tribal public-health departments,” Emory University legal historian Polly Price recently wrote in The Atlantic. These localities are responsible for everything from monitoring cases and deciding when to close schools or ban public gatherings, to deciding how to separate sick individuals from the rest of the public.

The U.S. once owned quarantine stations, largely to house incoming immigrants and returning citizens who were sick or suspected of harboring a disease, but those have become a thing of the past. Facilities like those on Angel and Ellis Islands, which were equipped with hospitals, disinfecting plants, laboratories, and hundreds of beds, were torn down in the 1950s.

Today, “state and federal governments are not sitting around with a lot of facilities just ready for quarantine,” Price told CityLab. “It's not something they do, so you have to scramble to find appropriate facilities.” That is, facilities to quarantine people who are not sick but who may have been exposed to the virus, to isolate infected individuals with mild symptoms, and to house people in recovery.

This includes housing some people who might normally be sent to a hospital during less space-constrained times. According to a report from the Johns Hopkins University Center for Health Security, some 200,000 people across the country may need intensive care even in a moderate scenario, but U.S. hospitals only have about 46,500 ICU beds, with an equal number of other medical beds that can be converted during a crisis. And with a nationwide delay in testing, it's possible that hospitals could see a surge of patients at once.

So, should health departments be collecting vacant facilities, as some have suggested on Twitter, from hotels to dead malls to stadiums? It wouldn’t be uncommon. In times of crisis, particularly natural disasters, cities have converted public and private properties — like gyms, churches, and stadiums into treatment centers, says Amesh Adalja, an expert on pandemic preparedness at Johns Hopkins University.

Given the contagious nature of the virus, though, converted spaces will have to meet strict requirements to prevent the disease from spreading. They need to have individual rooms for each person with separate HVAC systems, and doors that open from the outside to  each room. Or the units have to be separate. They also have to be humane, Price says, as people in quarantine and in isolation are physically disconnected from the outside world for days and weeks at a time.  

Most of the tens of thousands of Americans who are currently being quarantinedthat is, healthy people suspected of possible virus exposure have been asked to stay home, where most people already have all these criteria in place. In fact, “the most logical place is in their own home,” says Markel.

But for residents who are homeless and vulnerable to eviction, cities will need to take extra steps. “I would expect large urban areas to already be thinking about what to do if there is an outbreak in a homeless shelter, and we have to shut it down,” says Price. In the U.S., homeless people are especially vulnerable because they skew older, tend to live in close quarters either in shelters or encampments, and lack access to basic hygienic services. That makes homelessness an especially large threat for densely packed cities already experiencing large outbreaks, including Seattle, New York, and San Francisco, all of which have some of the highest unhoused population.

King County will use four-room modular units like this one as temporary housing for patients. (Karen Ducey/Getty)

To move people off the streets, Seattle plans to expand up tiny-home villages throughout the city and convert a former rehab center into shelter. Both King County and San Francisco have also set up temporary housing for people who need to be quarantined or isolated but who are homeless or live in close quarters with multiple people. In addition to the motel King County purchased, officials are setting up more than a dozen modular units in parking lots. San Francisco plans to turn 30 recreational vehicles into temporary housing.

Other cities, meanwhile, are taking precautionary measures to stave off a mass outbreak among the homeless. To address its housing affordability issue, San Jose has adopted a moratorium on evictions during the outbreak, and San Francisco is expected to pass similar legislation. In Los Angeles, health workers are visiting shelters to encourage people to practice good hygiene while urging staff to find isolation spaces for anyone showing symptoms. They’ll also be on the streets to treat people living in encampments.

Seattle plans to expand tiny-home villages for additional shelter. (Chona Kasinger/Bloomberg)

It’s not just the homeless population that cities have to make room for. “Maybe you’re a patient who is out of the hospital, out of the active treatment phase, but you have someone who is high-risk, elderly or a pregnant spouse at home, so you can’t go there,” King County spokesman Chase Gallagher told a local T.V. station, adding that the motel would also serve those people.

Other local governments may follow in King County’s foot steps and buy private property like hotels with emergency funding to house people. Another potential site option, says Adalga, is vacant nursing homes, of which there are plenty in the U.S, despite the shortage of elder care workers. In some states, declarations of emergencies may expand officials’ power to temporarily take over private property for public use, according to Price.

Finding a place to house potential and confirmed Covid-19 cases can still be difficult. For one thing, it can be challenging to find a building that meets the strict requirements for isolation and quarantining. In Michigan, Kent County executive Adam London told Detroit News that finding “even a small number of units can be challenging,” in part because vacant hotels are hard to come by in the city.

Then there are American citizens being repatriated. In California, officials are still evacuating more than 2,500 passengers from the Grand Princess cruise ship who will need to be quarantined after 21 people on board tested positive for the virus. In this case, the federal government — which is responsible for the evacuation and working with state and city government to quarantine those people — is converting military bases, the most abundant of government-owned facilities, into quarantine sites in California, Georgia, and Texas

Medical personnel help passengers board a plane from the Grand Princess cruise ship. Thousands of passengers will be quarantined at several military bases, while the crew will quarantine on the ship. (Josh Edelson/AFP via Getty)

But even those are limited, and without all levels of the government on board, Price says, such plans spark conflict. A dozen passengers who have mild symptoms but have not been tested for the coronavirus were sent to a state-owned conference center in Monterey County. That prompted concerns from local officials who say the state did not notify them beforehand and essentially gave the county no option but to accept the passengers. A district supervisor told Mercury News that her residents are anxious, and that the sudden news is already affecting the city's tourism-driven economy.

Back in King County, Washington, the move to buy a hotel isn’t without controversy, as Kent city officials protest the county’s decision. “They are replicating and bringing a situation similar in scale to the Life Care Center of Kirkland and dropping it off in Kent,” Mayor Dana Ralph said at a news conference last Wednesday, referring to the nursing home that’s at the center of King County’s coronavirus-related deaths. The city filed a motion to put a temporary restraining order on the county, and after a county judge denied it, Ralph pledged to continue the fight in court.

“If you look back at our more distant past, it’s common for regions, if they see an outbreak spreading, to try to do everything to keep it from coming to them,” Price says. “The thought is, ‘We don't want these facilities in our backyard.’”

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