COVID-19 Homelessness Nonfiction Systems

The Third Line.

My eyes skimmed the document to find The Graph. Compared to past editions of the Behavioral Health Monthly Forecasts (that I described in a recent post), The Graph featured a third line:

The authors in the source document comment:

There are three behavioral health areas of focus:

(1) Omicron and other COVID variants: ongoing and
potentially severe disruptions to health care, social,
economic (supply chain), and educational systems caused
by the Omicron (and potentially other) variant(s).

(2) Children, youth, and young adults: concerning behavioral
health trends for children, youth, and young adults.

(3) Collective grief and loss: not just related to the loss of
individuals, but social and systemic losses as well.

How do we reconcile the three areas of focus above with the three lines in the graph? Are the people in the top yellow line experiencing collective grief and loss? Is it just a matter of degree across the three lines, depending on how much people have lost?

While wondering about this, I came across this article: How Epidemics End. I was surprised to learn that this article was published two thousand years ago in June of 2020. Vaccines weren’t even available at that time. (It’s hard for me to believe that it was only just over a year ago that I received my second Covid vaccination.) The tag line summarizes a major point in article: “History shows that outbreaks often have murky outcomes—including simply being forgotten about, or dismissed as someone else’s problem.”

Of course pandemics don’t just abruptly end. The authors note that “epidemics are not merely biological phenomena. They are inevitably framed and shaped by our social responses to them, from beginning to end”. They then describe societal reactions to the 1918 flu pandemic, the 2002 SARS epidemic, and the adoption of the polio vaccine. There is no “singular endpoint”; rather, epidemics end:

  • when there is “widespread acceptance of a newly endemic state” (like HIV)
  • “not when biological transmission has ended… but rather when, in the attention of the general public and in the judgment of certain media and political elites who shape that attention, the disease ceases to be newsworthy” (like polio)
  • when the new disease in question emerges abruptly, rather than gradually (like Legionella and tuberculosis)

In forecasting the end of the Covid pandemic, they comment:

At their best, epidemic endings are a form of relief for the mainstream “we” that can pick up the pieces and reconstitute a normal life. At their worst, epidemic endings are a form of collective amnesia, transmuting the disease that remains into merely someone else’s problem.

That brings me back to the third line, the lowest line, in the graph above. It is not with pride that I recognize that I, along with many of my colleagues, are following the course of the lowest line. It also brings me no satisfaction to acknowledge that the Covid pandemic will likely end for the majority of people in the US before it ends for those of us who work in and use safety net programs, such as emergency departments, homeless shelters, and immigrant and refugee clinics. (When I consider the consequences for other nations, the weight of sadness feels great: There are many people around the world who want to receive a vaccine, but still have not gotten their first dose. The pandemic will also continue for them after it has ended for many others.)

Back in December 2020, I counseled myself:

For those of us in the third line, it has become more difficult to answer either question with confidence.

COVID-19 Nonfiction Policy Public health psychiatry Reading

Public Mental Health Implementation Failure.

Throughout the pandemic, I have routinely reviewed the major psychiatric journals in the United States, hoping for commentary about and guidance related to the prevention or minimization of psychiatric conditions due to the Covid-19 pandemic. Surely there are practices or protocols we could implement to prevent bad outcomes that we knew would happen! While the work we do with individuals might have some potential benefit, the scale of the pandemic meant that population-level interventions would have better effects for a greater number of people. From my point of view, if my finite time and energy could help more than the sole person in front of me, that would be better for all involved.

Three thousand years ago, back in December 2020, I commented that “collective problems require collective solutions; expertise must be decentralized and shared” while reflecting on the need to Protect Mental Health During a Pandemic. Now that three thousand years have passed, it seems that anyone at the federal level who tried to implement the Pan American Health Organization or World Health Organization recommendations from the flu or ebola epidemics was foiled. I lamented then that

We’ve already witnessed psychological stumbling across the population; none of us want to see ourselves, our neighbors, our communities, and those beyond beyond fall further.

We’ve graduated to chronic psychological lurching, floundering, and tottering. Most of the psychiatry journal articles have only described consequences from the current pandemic: who was more likely to get Covid-19? how did it affect the use of substances? how was the pandemic affecting the workforce?

Where were the articles with broad vision, that take the perspective of public health psychiatry?

The Lancet Psychiatry recently published an article that I found refreshing: Public mental health: required actions to address implementation failure in the context of COVID-19:

  1. It acknowledges how the mental health system—one of many—has failed during the pandemic (people may have opinions about whether it was succeeding prior to the pandemic);
  2. It lists specific failures and how to fix these problems (and there are a lot of problems to fix);
  3. It reinforced the need to direct attention and resources to all stages of the lifespan and the various roles, from individuals to national governments, each could play to prevent future failure.

The authors rightly comment

This failure of [public mental health] implementation results in population-scale preventable suffering of individuals and their families, a broad range of impacts…, and large economic costs. The failure also represents a breach of values and the right to health.

Panel 5 lays out how the implementation failures of public mental health:

  1. Insufficient public mental health knowledge
  2. Insufficient mental health policy or policy implementation
  3. Insufficient resources
  4. Insufficient political will
  5. Political nature of some [public mental health] activities
  6. Insufficient appreciation of cultural differences
  7. Causes of mental disorder treatment gap

Oof. It’s a valid list and, indeed, some of the responsibility falls upon mental health and substance use disorder clinicians ourselves. (Different posts for different days.) It’s also striking that, despite the United States being a high income country, we suffer from the same problems listed above that apply to low income countries. (We, however, continue to learn the many ways how the US was and is never different from “those” low income countries.)

As I noted a few weeks ago, “We continue to focus on the viral pandemic; the psychological pandemic has already arrived.” Because of our missteps, the psychological pandemic will also outlast the viral pandemic. The authors note that

The COVID-19 pandemic has widened the implementation gap but has also increased mental health awareness and highlighted the need for a [public mental health] approach.

Now that we are minding the gap, I hope that we can indeed close it.

Homelessness Nonfiction Policy Public health psychiatry Seattle

Shelter “Isolation” and “Quarantine”.

Though the room layout follows pandemic guidance, it still feels crowded.

Dozens of beds are placed six feet apart. In a homeless shelter, each twin mattress is multipurpose furniture: Yes, it is a bed where people sleep. It is also a table upon which they eat simple meals stuffed into brown paper bags. It is a living space of 38 by 75 inches that offers no privacy and no isolation.

Say someone living in the shelter falls ill with Covid. Should this person be allowed to stay in the shelter, but risk infecting others? Or should the shelter ask this person to leave and recover in the chill and darkness of January?

Seattle-King County has been a leader in implementing isolation and quarantine (I&Q) sites for people who don’t have their own place to live. These are hotels that allow people who were exposed to or infected with Covid-19 to rest and recover away from others. The hotels have specialty staff who provide physical and behavioral health care. Once recovered, people can return to shelter or similar congregate settings. It is difficult to prove the success of prevention, though removing people from congregate settings likely reduced infections. This, in turn, reduced hospitalizations and deaths.

Last winter, there were four I&Q sites. This winter, there are only two.

This reduction isn’t for lack of need. As with the general population, the omicron variant has caused a crush of infections in shelters. The I&Q sites, like most health care agencies, cannot hire enough people to provide services. This reduction in I&Q sites is entirely due to an insufficient number of staff.

Because fewer health care workers now work at the I&Q sites, the county has had to enact more exclusion criteria to preserve this service. Providing support for people with multiple health conditions requires professionals with expertise and experience; physical space and supplies are not the only considerations.

This means that people living in shelters who are ill with Covid will be denied admission to I&Q sites.

That means that people who are sick with Covid may only have bad options to choose from. If they’re lucky, they may be able to stay in a shelter. However, their living space of 38 by 75 inches has no walls. Sights, sounds, and air are all shared.

The average age of someone experiencing homelessness for the first time is now 50 years old. People who live in shelters, cars, or outside are more likely to have chronic health conditions like high blood pressure, diabetes, depression, and anxiety. These conditions are risk factors can result in more severe cases of Covid illness. These same factors also increase the risk of disease and death if people are sent outside.

With the attrition of health care and essential workers, the burden of illness and disease will fall upon the most vulnerable people in our communities.

This also means that staff who are still able and willing to work at the shelters–all essential workers–are at increased risk. Most shelters do not have access to medical expertise or consultation. If there is nowhere to send people who are ill with Covid, shelter workers will have to decide what to do if someone in the shelter gets sick. We cannot expect all shelter staff to have the skills, knowledge, and desire to provide isolation and quarantine support. If shelter workers send someone out, that will only put more burden on the safety net of first responders and emergency departments. This safety net is already fraying and breaking after two years of crisis.

Systems cannot rely on single individuals, though this has been happening more and more as the pandemic has dragged on. As various systems falter and crumble, we see the demoralization and exhaustion of all who provide essential services. More distressing are the detrimental effects these system failures have on vulnerable people we want to serve well, but cannot.

This is unfair to all involved. Inside and outside of the crowded room of the shelter, it is with horror that we realize that all of our options are bad.

COVID-19 Homelessness Nonfiction Public health psychiatry Seattle Systems

Faltering and Failing.

The omicron variant has resulted in a surge of cases here in Seattle-King County:

Our hospitals have not been spared. They, like in other areas, are in a crisis situation:

There are similar surges in Covid cases in homeless shelters and other congregate settings. This, combined with an insufficient number of people who are willing and able to work at isolation and quarantine (I&Q) sites, has led the I&Q sites to limit the number of admissions. The admission criteria now are the most stringent they have been at any point during the pandemic:

What this means in practice is that people living in shelters who are sick with Covid may have nowhere else to go. If they are lucky, they will be able to stay in the shelter. Their only other option may be staying outside in the chill and darkness of January.

Which is worse? Covid infections sweeping through a homeless shelter? Or people exiled outside because they are sick? (They may end up seeking help at an emergency department, all of which are already strained and overburdened.)

To be clear, I do not blame the county for this. Health care workers are fleeing their jobs due to the crush of the pandemic. Everyone is struggling with hiring health care and essential workers.

We cannot look away from the horror of systems faltering and failing. We must witness that the most vulnerable people in our community will bear the greatest brunt of these failures.

COVID-19 Education Public health psychiatry

Reactions and Behavioral Health Symptoms in Disasters.

The Washington State Department of Health started posting Behavioral Health Monthly Forecasts in April 2020. Two disaster psychologists, along with other staff, compile and share useful information such as the anticipated course of psychiatric symptoms across the population, how different populations might manifest their distress (e.g., children), and data related to changes in substance use and firearm purchases. It makes for interesting reading, though it’s frequently a bummer.

One chart that appears every month is “Reactions and Behavioral Health Symptoms in Disasters”. In the inaugural issue in April 2020, the forecast oriented readers to general model from SAMHSA[1. SAMHSA is the Substance Abuse and Mental Health Services Administration. What a shame that it is a distinct department from the Centers of Disease Control and Prevention (CDC). The mind remains split from the body in our administrative and health care systems, which is why there is no formal framework for public health psychiatry.] of reactions in disasters:

Note that there is no indicator here about where Washingtonians were at that time. The Y axis uses color to depict emotional states and the X axis, so optimistic, has only a notation to mark one year.

In May 2020, the forecast made a proclamation about where Washingtonians were. It was a warning: We were on the precipice of disillusionment:

We took braced ourselves for this. Yes, we had witnessed heroism from so many, whether health care workers or first responders or neighbors dropping off food for those who were medically vulnerable or distilleries producing hand sanitizer or seamsters and seamstresses joining brigades to make cloth masks. Of course this level of concern and anxiety was unsustainable. How bad could it get?


By December 2020, we were in a trough of disillusionment and it felt like it:

Thousands of people were dying a day in the US and other countries around the world. Hospitals were overrun with sick people. People were starting to leave their jobs due to overwhelm. When would the vaccines become available? I remember looking at this graph and thinking, “I thought the graph last month had us in the nadir of disillusionment.” But there was a branching of lines! Maybe we, as a state, would follow the yellow line and things would improve for us all, regardless of station in life.


A terrible winter passed. The days got longer, there were more opportunities to be outside, many people got vaccinated… but the yellow line never manifested for those in my professional and personal communities. By June 2021, we were still in a trough:

In retrospect, that “secondary honeymoon” was accurate. All the numbers we hoped would drop, did: Reproductive number, cases, hospitalizations, and deaths. People in the Seattle-King County area were getting vaccinated. But so many of the people under our care were dying from overdoses, suicide, and chronic medical diseases.

Then came Delta, Omicron, more cases, hospitalizations, and deaths. Health care workers and others left their jobs out of frustration and demoralization. A contingent of people continued to decline vaccinations, despite knowing the possible outcomes… including chronic disease and impairment that still has no effective treatment.

When the December 2021 graph came out, someone observed, “The trough just keeps getting longer.” I wondered who on Earth was experiencing the benefits of “reconstruction”.

I have never had so many people under my care die during a comparable period of time. At least 10 of my patients have died since the beginning of the pandemic; the first death occurred in July 2020. The most recent death (that I am aware of) happened in November 2021. None of these people died from Covid. They either died by suicide, overdose, or their chronic illness collided with an acute, fatal event.

We know from history that pandemics do not last forever. The 1918 flu pandemic lasted just over two years. The 2002 SARS outbreak was declared over in less than two years. The 2013 Ebola epidemic persisted for less than three years. All things change, all things end.

I, like so many others, hope that we all will exit this trough sooner than we anticipate. I worry about the psychological consequences of this pandemic in the years to come. We continue to focus on the viral pandemic; the psychological pandemic has already arrived. We have yet to see an organized response to that.