Homelessness Medicine Nonfiction Policy Seattle Systems

More Reflections about COVID-19 from Seattle.

This is another unpolished post. Several physicians and nurses in other states have reached out to ask for suggestions and perspectives related to behavioral health and homelessness during this COVID-19 epidemic in Seattle. Here are some reflections:

Coordination with partners is not only essential for services, but also to maintain morale. No single agency is able to address this alone. Government partners need feedback and information about what the community needs (and, I’m sorry to say, sometimes the community ends up providing government officials with updates that government should be telling us). The actions and energy of partners can buoy others when it seems things are stuck.

There aren’t enough supplies. Clinics, hospitals, and agencies can’t get face masks, hand sanitizer, and other sanitation supplies. Vendors are all sold out. Local governments are appealing to the federal government to provide supplies; I understand that the US military protects a national stockpile of such items? Which is something I had never considered in the past. And, perhaps most importantly, there aren’t enough COVID-19 tests! It seems that most of our local publicly funded primary care clinics have, at most, 30 test kits on site with no replenishment coming. Some private labs are only now agreeing to provide COVID-19 testing.

Many employees don’t have enough paid time off accrued to take time off of work for self-quarantine. Thankfully, our state and federal governments have passed or will pass legislation to address this and ensure that people can still get paid despite having to take time off of work. HR departments everywhere would do well to look out for their employees, particularly those who provide direct service to people who are higher risk of experiencing illness due to COVID-19.

People may (or may not) bristle at the infringement of civil liberties. The Washington State Governor has banned gatherings of more than 250 people. The CDC has provided “mitigation strategies” specific to Seattle-King County for the next 30 days, some of which are about workplace behaviors and COVID-19, which includes checking temperatures for fever and screening for illness when employees show up to work. The CDC has also recommended prohibiting visitors to certain sites. These are extraordinary times, hence these extraordinary measures… and some people may bristle at having to follow these rules. So far, people have been voluntarily complying with these changes.

The balance of individual patient health information and public health wobbles. For the past two weeks, a local clinic and our shelter have gone back and forth (in a collegial way) about protecting an individual’s privacy versus protecting the health of other people staying in the shelter. In short, the clinic argued that if Mr. Doe, a person who stays in the shelter, gets tested for COVID-19, the shelter isn’t entitled to know (a) that the test occurred and (b) the test results. We have countered that the shelter should know about Mr. Doe’s testing and the results during this extraordinary time because we want to do everything we can to prevent or minimize a localized outbreak within our shelter. Thankfully, the State Attorney General issued guidance that sided with our view (to be clear, the clinic was sympathetic to our view and did not balk with the change in practice… and I completely understood where the clinic was coming from). However, this is something that the clinic and our shelter had to pursue on our own; this was not proactive guidance we received from our government officials.

Government bureaucracy is in full effect. In this instance, I’m referring to practice of government officials who are unwilling to send out official communication until numerous gatekeepers have vetted it. Thus, guidance is slow to come out, so everything slows down. I understand the reason for vetting—confusion isn’t helpful, either—but we also feel frustrated when we feel like we’re losing a race against an invisible enemy.

People staying in shelters are resilient. Many staff feel anxious about how COVID-19 will impact the people who stay in shelters and receive clinical services from us. I find that I have to remind myself that many of the people who stay in shelters have experienced traumas and horrors that we will never know or understand. Many of them have already experienced illnesses and pain that we cannot fathom. I do not mean to minimize the very real possibility that some of them, should they contract COVID-19, will develop severe illness and die. I don’t want that to happen, which is why we are in constant communication with our partners to coordinate services and care. However, many of them will either not get sick, or they will recover despite our anxiety and efforts. It is a privilege that these individuals even let us into their lives.

Screening guidelines for COVID-19 are mushy. Some of our local infectious disease experts have taken to crafting their own screening guidelines because they are dissatisfied with the vague guidelines from the CDC. (This ties back to the lack of available tests—if we had more COVID-19 test kits, then we wouldn’t be wringing our collective hands about screening guidelines, particularly for vulnerable populations like people staying in shelters, which, no kidding, includes a significant proportion of people who are over the age of 60.)

The workforce shortage seems like it will only get worse. Social service and health care agencies often struggle with having a sufficient number of staff to address the clinical need. As people call out due to illness, whether COVID-19 or otherwise, this will turn into a vicious cycle: Fewer staff for a constant or growing need means that those staff will get tired and sick, which increases the likelihood that they will call out, and if the return to work rate doesn’t match the “attrition” rate, then soon there will be only minimum staffing at best. We also cannot expect individual people to successfully address systemic problems. It is not uncommon for people who go into social and health services to overwork (whether in quantity, quality, or both); this is unsustainable during usual times, let alone during an epidemic.

Social distancing seems like it will have the highest yield. The Institute for Disease Modeling published a paper specific to King and Snohomish Counties (the “epicenter” of the outbreak in the US) about the importance of social distancing. It is both compelling and disturbing. I don’t know how to successfully balance this with the clinical services that the medical team provides to the agency. Telehealth options are limited because of the population we serve (i.e., they generally don’t have telephones), though we plan to implement some creative ideas to at least try to keep people out of emergency departments.

It’s a weird time. We continue to do the best that we can, while recognizing that what comes next may knock us off our feet.