The small group of protesters gathering near Spokane's Public Safety Building last Thursday catches Dr. Bob Lutz's eye as he's heading back to his office around lunchtime.
One of them is holding a sign that reads, "Lutz is Nuts."
They're mad that as the county's health officer, he used a rare but important public health tool on July 1, mandating that a man sick with COVID-19 be held against his will at the jail's medical facility for a 10-day isolation period. Lutz will later watch from his office window in the Regional Health District building as the group of about 15 makes its way into the building to demand answers. Staffers end up calling the police.
"One person apparently made some threatening comments about doing something to me that wasn't great," Lutz says.
The health order was one of only two that Lutz has issued since the pandemic began, and he says it was issued only as a last resort, as he believed it necessary to preserve overall public health.
When he tested positive, the man was not sick enough to be admitted to a hospital. He was homeless, and letting him stay at a shelter or on the streets could swiftly spread the virus, Lutz says. After the man refused to stay in a publicly funded isolation room at a local hotel, Lutz ultimately ordered him to stay in the jail's medical bay for a 10-day isolation period.
"He was not someone the hospital wanted to admit," Lutz says. "We did what we had to do."
The move prompted criticism from Spokane County Commissioners and members of the public, who questioned whether enough had been done to find another solution before the extremely rare health order was issued.
While the man's case is definitely an exception, mandatory isolation and quarantine are both part of the public health strategy. With enough time, people who once were contagious won't be anymore. With enough time, the spread of the virus can be stopped, if people follow the rules.
The strategy has so far proven highly effective at preventing spread among people staying in homeless shelters. Public health triage teams go to the shelters nightly to check for symptoms and pull people to the isolation site if they have to be tested. They often stay overnight while waiting for rapid test results. They could stay longer if they're positive.
Mandatory home isolation is becoming even more important as young people have driven a spike in infections recently, with about 1,000 Spokane County residents testing positive over the last two and a half weeks. That's nearly enough people to pack the Knitting Factory for a show.
Each of those individuals is supposed to isolate at home for at least 10 days following news of their test results, and longer if they have symptoms. The effects cascade from there, as the people they live with or have close contact with also need to quarantine for at least 14 days to ensure they aren't asymptomatic or contagious.
In fact, isolation is a strategy that's so important, Lutz has an entire team dedicated to making sure people without adequate support systems can still shelter in place at their homes while the virus impacts them and their family. Staffers who previously focused on public health issues like immunizations and child abuse prevention are now figuring out how to get fresh food for a family of 13, and running to Walmart to buy clothes for someone who was discharged from the hospital naked.
"The goal is really that people are able to safely and in a healthy way isolate or quarantine in their home. We want to remove any barriers from that," says Heather Wallace, who helps lead the team of care coordinators.
While isolation numbers were initially small, the county suddenly has thousands of people who shouldn't leave home to grocery shop, pick up medications, or generally go about their lives. The public health fear is that if people don't follow the rules and stay home, hospitals could soon become overloaded with patients too sick to stay home, Lutz says.
It's already happening in the Yakima area, where hospitals are at capacity and understaffed due to a massive COVID-19 outbreak. Some of the overflow cases are being sent to Spokane, which is the largest medical hub between Seattle and Minneapolis.
As Lutz expects to hire on 18 more people this week to help contact the ever-growing list of people exposed to the virus, and negotiations are happening with Catholic Charities to provide dozens of additional isolation beds for those who can't isolate at home, staying home remains the emphasis.
"If you've been tested: Stay home, stay home, stay home," Lutz says Monday. "With the amount of community spread right now, this is all too high."
MORE ISOLATION SPACE
At the start of the pandemic, the city and the county's emergency response team quickly opened a 100-bed isolation space at the Spokane County Fairgrounds. The worry was that many people soon wouldn't be able to isolate in their homes.
But that isolation space was rarely needed, and by mid-May it was closed.
Afterward, the health district located space for up to about 20 people at a hotel, where infected individuals can wait out the virus as meals are provided and other needs are coordinated.
Some who've had to stay there can't isolate at home because their loved one has cancer or another compromising illness.
Others had planned to stay at a homeless shelter, but after a volunteer triage team from the health district said they should get tested, they were brought to stay the night while waiting for results.
"There could be a clinic down the street within a couple minutes walking distance, but there's a multitude of reasons why people may have a hard time going," explains Kylie Kingsbury, the health district's homeless outreach coordinator who works with volunteers to screen people at the Spokane Arena and House of Charity each night. "So we bring the screening and the testing and the isolation to them."
The health district isn't releasing the name of the hotel to protect the privacy of people voluntarily isolating there. However, health district staff note the air system for each room is isolated and they're in a completely separate wing from other guests.
"The other reason why the isolation facility is used is to minimize the impact to other working adults in the home," explains Mark Springer, an epidemiologist for the health district. "The quarantine period for other people who are in the home doesn't actually start until that person is no longer infectious. That's about 10 days, so that person in quarantine is potentially out for up to 24 days."
That timeframe may shrink if the other person tests positive for the virus, but isolating someone with symptoms outside of the home can help ensure a shorter quarantine for others.
Because of the medical-grade cleaning that must take place between guests, the current site can only effectively provide space for about 15 to 18 people at a time, Springer says.
To help with a potential influx of people who can't isolate on their own, Lutz's staff has been negotiating with Catholic Charities. The nonprofit, which operates House of Charity shelter and supportive housing units, has offered to provide space for another 40 to 50 people.
Unlike at the health district's isolation site, which doesn't have medical staff on hand, the thinking is the nonprofit can provide more wrap-around services for those who may have behavioral health or substance use issues.
Lutz says his staff will likely bring the expanded isolation proposal to the Spokane County Board of Commissioners next week, while updating them on other necessary steps, including the likely hiring this week of two contact-tracing teams from third-party Public Health Institute. Neither of those needs had come up yet when the health district got $6 million in CARES Act funding from the county to backfill other unforeseen expenses of the pandemic.
"We're not responsible and don't have a division of homelessness, that's the city and county's responsibility," Lutz says. "The funds need to come from, I would argue, the CARES money. If we need a place to provide isolation for individuals that are living homeless, we need the financial support to do so."
KEEPING PEOPLE HOME
While the additional isolation space will likely be needed, wherever possible, it's ideal to help people stay in their own homes, Wallace explains.
Those who don't have friends, family or other support are identified during the initial case investigation, Wallace says. The team has connected 75 households with food, diapers, medications — anything that might otherwise make them leave their home.
"It's been especially difficult for families who may require differences in their diet for cultural reasons, especially those where meat is a heavy portion of their diet," Wallace says.
Food banks and neighborhood organizers have helped fill those gaps.
The Marshallese community in Spokane has been hit extremely hard by the epidemic, with large families told to isolate from loved ones in the next room, even as many of them are already on their way to developing symptoms, Wallace says.
"We had a family with nine people in the household, adults and children, and they were a pretty independently functioning household until COVID hit," Wallace says. "We got the notice on a Friday and had to scramble, because they needed food."
Because of the delay in infections, a family may have to quarantine for much longer than two weeks, so the team will help as long as needed.
"We want to make sure we are, within our ability, helping as many families do that as possible," she says. "In doing that, we're protecting the community from further spread." ♦