Categories
COVID-19 Homelessness Nonfiction Observations Policy Public health psychiatry Seattle

Gifts of Our Lives.

Photo by Leeloo Thefirst

(I know it’s the holiday season and I promise I’m not actually a grinch, but here’s your warning: This is going to be kind of a bummer of a post.)

Some recent scenes for your consideration:

  • The sliding wooden gate did nothing to dampen the sounds of traffic on the boulevard. Inside the wooden gate was a parking lot that was now occupied by around 40 small sheds, each painted a different color. At one end was an open-air shared kitchen and a set of small bathrooms. It was snowing, the kind of wet, clumpy snow that doesn’t stick, but instead seeps immediately into clothes, hats, and sleeping bags. Though people in this “village” are still technically homeless, they were at least protected from this unusual Seattle weather. Within a few minutes of my arrival, a skinny kid, maybe eight or nine years old, wearing a sweater, shorts, and sandals, ambled outside alone to look up at the sky. Later, another skinny kid, maybe thirteen or fourteen, came out, his hands shoved into the pockets of his sweatpants and his eyes fixed on the ground. I wondered what their ACEs scores were and hoped that, as adults, they would escape and remain out of homelessness.
  • As I threaded my way through the city and the morning chill, I kept a mental tally: One man wearing a tank top and making grand gestures at the sky; another shirtless man pacing in tight circles; one woman wearing a soiled hoodie, with either black ink or a black substance smeared across the bottom half of her face, picking up trash from water pooled in the gutter; a man hobbling with a cane and screaming a melody; a man emerging from a collapsed tent to fold up a crinkled black tarp; a woman with bare legs and swaths of bright green caked on her eyelids who, in slurred speech, offered me a wristwatch dangling from her fingers.
  • “We have burned down the house of mental health in this city, and the people you see on the street are the survivors who staggered from the ashes,” writes Anthony Almojera, an N.Y.C. Paramedic [who has] Never Witnessed a Mental Health Crisis Like This One, who also comments that “there’s a serious post-pandemic mental health crisis.”

Maybe my expectations about the pandemic response were too high. A pandemic is an act of God; what could mankind possibly do that can deter the power of God?

And yet.

There were things we could have done to protect mental health during a pandemic. I am not the only one who was (and remains) worried about the psychological consequences of this pandemic in the years to come. There remains insufficient mental health policy or policy implementation, insufficient resources, and insufficient political will, among other implementation failures of public mental health.

I do believe that hope is a discipline. It’s hard to practice every day. But this is why I still question whether my expectations were too high. God spared us—you, dear reader, and me—during this pandemic. For what reason? What can and should we do with the gifts of our lives?

Categories
COVID-19 Medicine Nonfiction

Stairwell as Sanctuary.

Old, concrete stairwell with brightly-lit windows in the background.
Photo by Ryutaro Tsukata. This stairwell looks similar to the one I frequently used for myriad reasons while I was in residency training.

I wrote the following op-ed in late July, though never submitted it for publication: While I share an opinion, I don’t offer any solutions (and none have come to mind since then). Since President Biden has announced that the pandemic is over, now is the time to share this essay.


There is a stairwell or bathroom in every health care setting that has served as a sanctuary for medical professionals. We hold our breath and stifle our sobs while we stride towards the sanctuary; we wish to get there before anyone sees us weep. The tears fall because we learn a vulnerable patient died. A cherished colleague is leaving. A faceless health insurance reviewer has denied treatment. We run out of options to help someone because of choices an institution made. We wish we knew more, could do more.

As health care professionals, we are familiar with disappointment and sadness. Both are a part of our training and professional experience. We, however, are now experiencing enormous, unprecedented loss. Like ripples on a lake, our reactions to this loss will radiate forth and touch everyone in our communities.

The loss of life from the Covid pandemic looms over us. Over one million people in the United States have died from SARS-CoV2; we provided care to them in clinics, homeless shelters, jails, crisis centers, emergency departments, and hospitals. The individuals did not only die from Covid; others died from social consequences of the pandemic. Under- and untreated medical problems took away quality and quantity of life. Drinking, smoking, and injecting in doses too large offered relief from pain that defied description. Suicide seemed like the best choice among miserable options. We said their names and saw their faces, even as ours were covered with masks and goggles. Out of respect for patient privacy, we do not share these stories. In silence, we think of those who have died. This silence grows because we cannot find words to describe the shape, size, and saturation of our growing grief.

Even if we are able to share our sorrow, we have fewer colleagues around to listen. Diminishing clinical guidance, financial resources, and infrastructure support for health care professionals caused nearly 20% of us to either flee or flame out. (We understand why they left. We think about leaving, too.) Some retired early, others left for jobs that require less contact with distress and disease. They took with them their experience and expertise, which helped not only patients, but also us. Still others, recognizing already limited support dwindling further, took advantage of market forces and took jobs that were circumscribed in time and substantial in compensation. Health care delivery largely occurs in teams. When team members turn over frequently, the lack of team trust and cohesion often erodes the quality of care patients receive.

Earlier in the pandemic, we viewed the CDC as a part of our health care teams, as they have what many of us who work in safety net settings don’t have: Authority, public health expertise, and resources, including time to read and think. Over time, the CDC let us down: Instead of providing reliable and proactive leadership, it dithered. The CDC’s inaction forced individual agencies and clinicians to craft guidance. Why was a psychiatrist left to lead a public health response for a homelessness services agency? We wanted concrete guidance to keep people healthy and out of hospitals; we received a meager menu that deferred to the whims of politics and skeptics. We wanted tests and data to decrease disease spread and deaths; the CDC delayed sending out both laboratory and rapid tests. Recall that wealthy individuals and companies remained at home and procured tests with ease. Meanwhile, people labeled essential workers were treated as inessential: They could not access tests to protect themselves or their families. The CDC betrayed those of us who provide health care; we thus betrayed those who entrusted us with their health.

Health care workers must leave the stairwell or bathroom when our crying stops. Our tears may end, but the needs of patients do not. Physicians experiencing distress may be more prone to making medical errors. Fewer health care workers and disruptions of teams increases the work burden on those who remain, which increases their exhaustion and heartbreak. Without reliable guidance and leadership from a health authority like the CDC, we are unable to deliver unified, coherent health care. This will adversely impact not only the experiences of people who are ill, but will also result in population outcomes no one wants: More disease, more suffering, and more death. It may be too late to reverse this vicious cycle. We wish that we knew more, could do more.

Categories
COVID-19 Nonfiction Public health psychiatry

16 People.

Content warning: This post discusses death and suicide.

Photo by George Becker

Early in my training, someone older and wiser than me made a comment in passing:

There are two types of psychiatrists: Those who have had patients die by suicide, and those who have not.

I assume (perhaps incorrectly) that all psychiatrists eventually join the group where someone under their care dies by suicide. These deaths change us.

The first time I learned that someone under my care died from suicide was during my intern year. I didn’t know him well; I do not remember his name. I was working in a psychiatric unit in a hospital and had worked with him for only one or two days. He had a diagnosis of a psychotic disorder. My sole memory of him is his flat, unblinking expression while he looked at me. Though his face showed little emotion and he said few words, he radiated discomfort.

Within a week of his discharge from the hospital, he had jumped off of a bridge.

I didn’t know how to react. I don’t remember if we had a conversation about him, if anything else had happened, or what we could have done differently.


I do remember the name of the person who killed himself after he and I had been working with each for nearly a year. He was the first of “my” patients who died by suicide.

He earned a professional degree long ago, but was living in a shelter. Alcohol brought him comfort, though it drowned his career. He argued a lot. This was the primary way he knew how to interact with people. Despite his pugnacious manner, he and I built and maintained a respectful rapport.

The medical examiner ruled that he had died from an overdose, though the official did not deem this a suicide. The toxicology report stated that there was methadone and alcohol in his system. He did not like and never used opiates.

I still think of him a few times a year. I still wish he had talked to me before he ended his life.


In any given year, I learn that one or two people under my care have died. Most of the time, the cause isn’t suicide. People age; people get sick; bad luck strikes.

Between January of 2020 and June 2022, sixteen (16) people under my care died. None of them died from Covid. The youngest was in their late 20s; the oldest was in their mid-60s. A few died from suicide; others died from medical problems (some acute, some not). Many died from overdoses. Maybe they were intentional; maybe they weren’t. I will never know.


I recently spoke with a former colleague about the various losses we have experienced over the pandemic.

“No one wants to hear it,” she said with some bitterness. “People are tired of hearing sad or bad news, so they don’t ask about our work or how we’re doing.”

She’s not wrong. It’s not easy for me to talk about it, either, as talking about it means I have to think about it, and it’s hard to think about things that do not make sense and may never make sense: What happened? What happened to us?

Maybe I just want people to know that actual human beings died, that I knew these people, that all these people meant something to someone, that they meant something to all of us who had the opportunity to know them. I wish I could tell you more about the guy who made a handmade Christmas card for me, even though he had yelled at me the first time we met just six months prior. I wish I could tell you more about the woman who had several weeks of sobriety before she collapsed on the sidewalk, her heart pulseless. I wish I could tell you more about the man who always called me “Ms. Dr. Maria” and offered me home-cooked food whenever I visited him at his apartment.

That’s only three people. There are 13 others.


If you’ve lost someone during the pandemic, you are far from alone. A poll from 2021 (!) revealed that about 1 in 5 Americans are close with someone who has died of COVID-19. (Recall that over one million people in the US have died from Covid.) Suicide remains a leading cause of death in the US, with certain groups at higher risk than others. (Also remember that we all can help prevent suicides; it doesn’t have to be the only option.)

It’s okay to feel sad, angry, or disappointed; you feel how you feel. Things will change, as they always do, though they may not change as fast as we want them to. It’s also scary to express vulnerability. Voluntarily shedding the crusty carapace to reveal the soft tissue within, however, may be the best (or only) path forward.

Categories
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.

Categories
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.