Reprinted with permission from ProPublica.

While most Americans huddle inside their homes watching and worrying as the coronavirus pandemic stalks the country, desperate emails have poured into ProPublica, some almost shouting their fears for the unseen victims of the vast and unprecedented national shutdown.

A Florida social worker wrote of her panic for her developmentally disabled clients, who are shut in their homes, unable to even use the bathroom without help. What will happen to them if she and her colleagues fall ill?

“We’re going to be seeing some deaths in our caseloads,” she said in an interview. “We might not even know about it until they’ve been dead for several days.”

In Oklahoma, a medical technician begged us to keep an eye on the nation’s elderly, describing retirement homes that were relying on “cans of Lysol in poorly ventilated hallways as their major defense.” Social distancing in such places, he wrote, “is nonexistent.”

A child protective services worker in the Northeast sent a terrifying list of what kept her up at night: “That my families will literally run out of food, formula, diapers. That some of them may die for lack of treatment. That some children may be injured or harmed through inadequate supervision as their desperate parents try to work. That stress may lead to more child abuse.”

And in Manhattan, an outreach worker who takes food and supplies to the homeless, wrote simply: “We are drowning.”

“It feels,” she wrote, “like our city completely abandoned our clients, and our company abandoned our workers.”

These are dispatches from the front lines of America’s beleaguered social service system, which strains to care for millions of vulnerable people in the best of times. By the dozens, they have written, urging that the country not overlook a secondary crisis growing out of the global pandemic: that those who already live on the margins, many of whom rely on consistent, face-to-face support for survival, will suffer out of public view, behind doors kept shut to keep the virus out.

In emails and calls, they worried that skyrocketing unemployment will further stress households prone to violence. They foresaw elderly people, already at highest risk, losing both family and social work support as they further isolate. Others agonized over the consequences if they couldn’t visit children in neglectful or abusive households or help the disabled or ailing.

Then there are the collateral victims of the virus who perhaps few have pondered, like the victims of rape or sexual assault, who may stay away from overrun hospitals for fear of exposure.

“I think we’re seeing the public health system in the United States being revealed for what it is, which is really a patchwork of extremely vulnerable microsystems that are each on their own scrambling to respond as quickly as possible,” said Rachel Walker, a nurse and incoming director of the Ph.D. program at the University of Massachusetts Amherst College of Nursing.

In New York, where the pandemic is upending millions of lives, Gov. Andrew Cuomo announced tighter restrictions to control movement on Friday. He exempted human services workers but didn’t offer specifics to protect them or their clients.

Over the past week, ProPublica reporters have spoken with more than two dozen such workers in New York and across the country. What they describe is a system unprepared to deal with a national health crisis, lacking clear backup plans and rife with confusion over guidelines from federal, state and local agencies. The choices foisted on them, they said, were gutting. Some said they themselves are living just above poverty level; a missed home visit could mean a missed paycheck at a crucial time.

Here are some reports from the front:

Child Welfare

Georgia Boothe, the executive vice president of Children’s Aid, now starts each day in a once-unimaginable bind.

Her nonprofit agency oversees the cases of more than 700 children who New York City’s child welfare officials believe are at risk of abuse or neglect. The stakes are high normally, but now she also must worry about the health of her nearly 300 workers as they make critical home visits.

Will they bring infection to the door or become infected while inside? Many workers must use the bus or subway to see clients. And the visits are required by law. If she misses them, her agency could lose its city contracts, or worse, fail to spot and intervene in a situation that puts a child at risk of harm.

And unlike many workers in other professions, video visits or phone calls by her staff are risky, Boothe said. The remote visits may not offer a full picture of conditions in the home. Many homes are crowded, making people less inclined to speak frankly if they know they can be overheard.

She said conditions in troubled homes could easily deteriorate without proper support from agencies like hers — even without the added stress of the global pandemic that is robbing many families of jobs and child care.

“Neglect happens because people make difficult decisions due to a lack of resources,” she said. Families will struggle if relatives become sick, she said, or parents may leave children unsupervised to go to work.

On Friday, the Administration for Children’s Services told Boothe her staff could only use video calls if either the families or specific staff members were currently experiencing symptoms that could be related to COVID-19 or had underlying health conditions that might make them more vulnerable to it.

Her agency can use its discretion, and Boothe is worried that she might lose workers under those terms, which will put additional pressure on those who remain.

Ronald Richter led New York City’s child welfare agency during Superstorm Sandy. Now he is at the helm of the Jewish Child Care Association, one of the city’s largest providers of foster care and other services for kids and families in need.

“With Sandy you could take to the streets and address urgent human needs like food, medicine and finding alternate places to live,” he said. “This feels like you are constantly waiting for guidance about how to engage in mandated services, but you are hamstrung in that you are trying to engage in human services without human contact.”

He regards his staff as first responders to children in crisis, but right now, he said, they lack basic supplies to function that way.

Like Boothe, Richter worries about the infection risk for his workers. But while his agency received some personal protective equipment supplies this week, they are already running low, he said.

“We’re not nearly in the position that we need to be for the long haul of this,” Richter said.

The stress on his workers and their families is growing, too. The city has set up free child care for health care workers in light of the school closures, but as of Friday, there was no clarity on whether front-line child welfare workers would also qualify for it.

In response to questions, Administration for Children’s Services spokeswoman Chanel Caraway said in a statement that the health and safety of child welfare workers and their clients are a “top priority” and that the agency is “currently working with input from our State oversight agency on guidance that will allow for more flexibility when it comes to conducting home visits to ensure children are safe.”

In Washington, D.C., Judith Sandalow, the executive director of the Children’s Law Center, said the closure of schools is having dangerous consequences for children, starting with hunger. There are normally 200 schools serving two free meals a day to kids throughout the nation’s capital, she said. But, as of Tuesday, all were closed and only 20 continued to serve food.

“Not every family can get to one of those schools,” she said. “If parents are at work during the hours that it’s open, kids may not be able to go on their own.”

She said she understood the need for the closures, but that it removed a crucial safety net for at-risk children. Teachers and school employees are often the first to see signs of abuse and neglect, such as bruises, cuts or signs of malnourishment, and they are legally required to report such concerns to authorities. Without them, those problems could go unnoticed, she said.

Sandalow predicted that COVID-19 will cause “very significant negative costs in the form of child abuse, domestic violence, hunger and long-term educational and behavioral health problems.”

In Texas, doctors at the Cook Children’s Health Care System saw a sudden spike in severe child abuse cases this week, six children under the age four, which they suspect are linked to stresses from the pandemic. Christi Thornhill, director of the system’s trauma program, said “We knew an increase was going to occur, but this happened faster than we ever imagined.”

Domestic Violence

When Gwyn Kaitis heard that the measures to prevent the spread of the virus required families to stay in their homes, her mind raced through the consequences. Kaitis is the policy coordinator for the New Mexico Coalition Against Domestic Violence, and one thing she knows is that “violence increases when you have circumstances such as unemployment and isolation.”

Sequestered with their abusers, victims will lose a safe space to call for help, she said. “A lot of the time, survivors will contact us when the abuser isn’t in the home, when they are at work. There isn’t an opportunity to do that now.”

She used to run a shelter herself and is still haunted by the memory of a man who waited outside it one day with a shotgun. “Probably waiting for his spouse to come out,” she said. “Sometimes nothing stops these offenders, and that’s very, very frightening.”

In Ocala, Florida, Tara Dalrymple, a 20-year volunteer at a women and children’s crisis center, echoed Kaitis’ concerns. She worried too that victims of sexual assault may fear exposure to the virus and avoid hospitals. They may not know there are local crisis centers available for critical, sensitive procedures like rape examinations, Dalrymple said.

“I just don’t want to see victims feel like they have nowhere to go,” she said.

Homelessness

On Wednesday, an outreach worker in Manhattan, who delivers food and supplies to the homeless, sent ProPublica a desperate plea.

The majority of her clients, she wrote, are at high risk of dying from COVID-19 because they already suffer serious underlying health problems. Fewer pedestrians, she said, means fewer handouts of food and money. Most of her clients don’t have cellphones, so she needs to see them every day. That creates its own risk, she said. She could unknowingly contract the virus and spread it to them.

Asked about the worker’s allegations and other concerns, the city’s Department of Social Services said on Wednesday that several city agencies are “always prepared to connect clients to any medical services they may need for any reason, including as it relates to COVID-19.”

But in a phone call Wednesday evening, the outreach worker said she and her team had seen 50 clients that day, all of them living on the streets, many of them elderly, with no friends or relatives, and suffering illnesses like emphysema, diabetes and cancer. “For a lot of those people,” she said, “I’m the only other person in their lives.”

To her knowledge, the city had not established any clear guidelines for how to get homeless people who are infected with the virus off the streets. There aren’t enough hospital beds. And, even for those who don’t need to be hospitalized, there aren’t any quarantine centers where they could be moved until they recover.

Richard Cho, executive director of the Connecticut Coalition to End Homelessness, said a shelter in Danbury had closed because it was staffed almost entirely by elder volunteers who were worried about being exposed to the virus. Another shelter in Wyndham was close to closing for similar reasons, he said. In the meantime, he and his colleagues were scrambling to find alternative housing for the displaced wherever they could: hotels, public apartments, rooms with relatives, a friend’s couch.

“We call it, ‘shelter diversion,’” Cho said. “That’s how we’re spending a lot of our time right now.”

Some on the front lines said they were trying to tend to their clients without basic protections. A nurse at an addiction recovery program in Massachusetts that primarily serves homeless patients wrote that she and her colleagues were working with “zero access to alcohol-based sanitizer” because they can’t have anything alcohol-based in reach of their clients who are detoxing. Instead, she said, they use a less-effective hand sanitizer, though nurses were recently told they could keep small amounts of alcohol-based sanitizer on their person. That’s critical: Without a single sink in the nurses’ station, it’s not easy to wash their hands between appointments with clients.

“I worry for the patients that are HIV-positive or have COPD or uncontrolled diabetes,” she said in a follow-up interview. “These are typically people who don’t have access to regular medications. I worry what a disease like COVID could do to them.”

In New York City, Shelly Nortz, the deputy executive director for policy at the Coalition for the Homeless, said most shelters are crammed full; barely able to keep a roof over the heads of the 62,000 people they serve. They have even less space for “social distancing” and isolation.

In a telephone interview, Nortz said she’s worried that staff are not properly trained to identify people infected with the virus. And while state and federal authorities negotiate over whether to deploy the military to set up temporary medical centers, Nortz said, shelter and outreach workers are forced to send any homeless people infected with the virus to the hospital.

“I heard someone say there’s a tsunami headed for our health care system,” she said. “They’re right.”

Nortz said city officials on Wednesday night indicated that they were in the process of opening several hundred housing units, mostly hotel rooms, for clients who had contracted COVID-19. The city also plans to deploy nurses to city shelters to screen residents for fevers.

When asked when she expected the crisis to peak, Nortz pointed out that New York’s shelters have already reported their first confirmed case of the virus, which likely means countless others are already infected too. “The mayhem,” she said, “is here.”

The Elderly

Elizabeth Wilson, a 63-year-old home health care worker in Oregon, detailed the grim calculus that is likely playing out in the homes of millions of elderly clients across the country.

Wilson said she relies on the $500 a month she makes helping an 83-year-old client with medication and household needs. The money goes toward her share of rent for the subsidized apartment she lives in, she said, as well as a car payment and health insurance.

But this week, her client’s husband started coughing and feeling ill with symptoms that Wilson worried could be a sign of COVID-19 infection. Her employer initially offered her no personal protective gear but eventually provided a box of gloves.

“We are at the bottom of the totem pole out there with the clients,” she said. “It just seems kind of remiss.”

On Thursday morning, Wilson decided to stay home, foregoing her pay and the needs of her client to stay healthy. Since then, she has tried to assure herself that they will be OK without her for a shift.

She later received an email from her union, advising her and her colleagues not to visit clients exhibiting symptoms. Now she feels like she made the right decision but worries for her client and her own financial stability. She said she can’t file for unemployment because she only works part time.

“I’m in limbo,” she said. “But there is a lot of stuff in limbo.”

Raeann LeBlanc, a nurse and assistant professor at the University of Massachusetts Amherst College of Nursing, said “the vulnerabilities really stack up” when it comes to elderly patients and COVID-19.

On Thursday, she said, she visited a couple in their 60s, both with advanced diseases, but she could not even address their medical frailties because they had a more urgent concern: food. She wound up going to a pantry for them instead.

LeBlanc said there is already a shortage of home care workers throughout the country. They are among the lowest paid health care workers, she said, eking by on less than a living wage and sometimes lacking health insurance themselves.

She said equipment is always an issue, and she anticipates supplies dwindling sharply for home health workers in the age of the coronavirus.

“We’re hearing about it in the hospital setting,” she said, referring to equipment shortages. “Not even talking about it yet in the home health care system.”

Get Involved

Please point us to any stories about communities especially vulnerable during the pandemic, including people who are elderly or disabled, who are experiencing homelessness or who can talk to us about foster care, domestic violence, sexual assault and more by filling out our questionnaire. If you’d like to get in touch with us another way, send an email to coronavirus@propublica.org, message us on Signal at ‪201-701-0850 or visit propublica.org/tips.

Questions we’d especially like answered:

• What happens when social services providers can no longer see the people they care for?
• If you work with a vulnerable community: Do you feel prepared to help your clients get proper treatment and testing for COVID-19?