Building While Burning: Crisis Implementation In New York City from HIV/AIDS to COVID-19

Background and Purpose: During the COVID-19 pandemic, people experiencing homelessness in New York City had few options for isolation, quarantine, and healing, exposing systems unprepared to meet the needs of the city’s most vulnerable and echoing generations of structural barriers to equitable health care during public health crises. To address this gap, a large housing and healthcare service organization (HHSO) in NYC mobilized with a coalition of community advocates to demand Department of Homelessness resources to implement COVID-19 Quarantine and Isolation Hotels (CQI Hotels) for those experiencing homelessness. Between April 2020 and April 2022, the HHSO implemented four CQI Hotels across New York City. In doing so, the HHSO drew on its long history of community mobilization and service provision addressing HIV/AIDS. In this case study, authors examined how this organizational legacy shaped the culture, structure, and specific strategies of the CQI Hotel implementation.

Methods: Authors conducted 10 in-depth qualitative interviews with HHSO staff and consultants who served on the CQI Hotel implementation leadership team. Interviews were guided by a semi-structured interview protocol rooted in equity centered implementation science. Qualitative data were initially analyzed using a rapid matrix framework method. The impact of the HHSO’s history of HIV/AIDS response on the contemporary COVID-19 response was an emergent theme, resulting in a set of emic codes, which were then used to reanalyze the data.

Results: Analysis identified four ways that the organization's history in HIV activism and service provision informed their approach to crisis implementation during COVID-19. 1) In both contexts, the crisis response was rooted in intensive community-led advocacy to demand needed services. Successful advocacy then necessitated rapid programmatic innovation and implementation without a blueprint. 2) The CQI Hotel implementation team relied on organizational cultural characteristics that were established during the HIV/AIDS epidemic, including willingness to take political risks, building systems while implementing them, and working with minimal resources. 3) Working in the early HIV/AIDS epidemic prepared the HHSO to work with populations that are highly stigmatized and marginalized using strategies such as radical inclusion, low threshold programming, and harm reduction. These approaches characterized their COVID response and facilitated trust among clients. 4) The institutional memory of high-stakes implementation in a traumatic HIV/AIDS environment was activated during the COVID response and was evident in echoing challenges with worker burnout and managing crisis implementation over a long-term epidemic.

Discussion: Implementation science often relies on ahistorical frameworks and checklists, while long-term organizational culture and multi-level power dynamics fundamentally shape implementation on the ground. Critical archival scholars have long contested the idea that the arc of the moral universe in democratic societies exclusively bends toward justice, arguing instead that oppressive structures work non-linearly, reappearing and reconstituting themselves as contexts shift (Caswell, 2021). Studying patterns in historic crisis response cycles can therefore reveal strategies to build responsive, equitable public health and social service structures which serve our most marginalized communities.