COVID-19 Education Medicine Nonfiction Observations

Three Observations.

I. He was standing outside of the homeless shelter. The bouquet of bright tulips in his hand were splashes of color against the tired cement walls and grey skies.

A man staying in the shelter ambled towards him. “Hi,” he greeted, his eyes gazing at the buds of the young tulips. “Is today a good day or a bad day?”

The shelter manager laughed and warmly responded, “Why are you asking me that?”

“Because you got flowers….” the man said.

After a pause, the shelter manager reassured, “These are ‘congratulations’ flowers.”

“Oh, okay, good,” the man said. The wrinkles around his eyes revealed the smile that his mask obscured. “Congratulations.”

II. Earlier this year, I wrote:

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.

By the end of 2020, I had already read some literature about protecting mental health during epidemics. This information gave me confidence to share with others that, yes, pandemics do end in two to three years’ time.

Last month, I finally embraced “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“. And only in the past week did I finally recognize that these past epidemics and pandemics of course did not end in two to three years. That just seems to be the duration of time that societies can tolerate abrupt social restrictions and consequences.

I interpreted the published timelines as start and end dates of biological phenomena.

I feel foolish for having done so. Time is an artificial construct, so of course the expiration dates of pandemics are artificial constructs, too.

Someone somewhere can explain why two to three years is the maximum amount of time that people and societies can tolerate drastic changes before reverting “back to normal”. Of course, there is no way any of us can ever go “back”, pandemic or not.

III. The author of this tweet has since deleted it for reasons that will be apparent (profile photo modified by yours truly):

The tweet is dehumanizing, but that’s not actually the chief reason why this struck me.

The author of this tweet is a Big Name in the field of psychiatry. He is the chair of a Fancy Pants psychiatry department at a Hoity-Toity institution. He’s published seminal papers in the field related to psychotic disorders.

Over ten years ago I completed a fellowship at this institution (this is not meant to be a humblebrag, I promise) and I have a distinct memory from when Dr. Big Name when he spoke at the graduation ceremony. He grasped both sides of the lectern, leaned forward in his dark suit, and glowered at the audience.

“As a graduate of This Place, you now have a responsibility to This Place. Whatever you say, whatever you do, is a reflection on us. Make sure you don’t ever do anything that will reflect poorly on This Place.”

It was strange and uncomfortable. His warning about reputation management during a rite of passage was, in of itself, something that didn’t reflect well on That Place. Which is exactly why this memory resurfaced when I saw his tweet.

May God spare all of us and may we all avoid these errors, in public and in private.


New Year, New Reads.

A new lunar year has arrived. May the year of the tiger bring us all better health and fortunes.

Here are some things I’ve read over the past week that may also be of interest to you:

If Everything Is ‘Trauma,’ Is Anything? “It’s hard to talk about this without sounding like you’re policing the language,” said Mr. Haslam. “But when we start to talk about ordinary adversities as ‘traumas’ there is a risk that we’ll see them as harder to overcome and see ourselves as more damaged by them.”

Impossible Silences. “They seem to me to be the kind of silences that are mutually felt and acknowledged, that are a function not merely of the ceasing of sound but of a body at ease or eyes that remain fixed. These are silences that assure the other that they are being heard not ignored. Silences that, if attended to closely and with care disclose rather than veil, clarify rather than obfuscate.”

Black History, Black Freedom and Black Love. “The three-part class, Black History, Black Freedom and Black Love will be freely available on during Black History Month.” I must confess that it is John McWhorter‘s participation that tipped me to commit to watching this.

Fragrant Palm Leaves. The death of Thich Nhat Hanh prompted me to pick up this book. He writes more freely here than he does in his future books. I wonder who “Steve” is and if he is still alive.

The Reason Putin Would Risk War. “He is threatening to invade Ukraine because he wants democracy to fail—and not just in that country.” (There is plenty of troubling news within the US. There is a world stage to be aware of, too, though I wish the news were better.)

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.