Category: Homelessness

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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.

Categories
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.

Categories
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.

Categories
COVID-19 Homelessness Medicine Seattle

Surge.

When I was younger, my intention was to become an infectious disease doctor. Forces, seen and unseen, pulled me into psychiatry.

My undergraduate studies were in microbiology, virology, and immunology. Had someone told me twenty years ago that I would someday use that knowledge on a daily basis, I would have shrugged and said, “Well, that makes sense. That’s the plan, right?”

Had someone told me ten years ago that I would use knowledge from my undergraduate studies during a pandemic, I would have snorted: “But now I work as a psychiatrist. And a pandemic? What are you talking about?”

Had someone told me two years ago that I, as a psychiatrist, would be leading a public health response for a homelessness services agency during a global pandemic, I would have furrowed my brow: “What are you talking about?”

And here we are.

We’ve never had so many people—staff and patients—test positive for Covid at one time during the pandemic as we have in the past three days. Thankfully, most have had only mild symptoms and none, thus far, have needed hospital-level care.

The work we’re doing for Covid isn’t as intense or heartbreaking as the work my colleagues are doing in emergency departments and hospitals. Never before had I thought that a homelessness services agency could play a vital role in prevention and early intervention.

And here we are.

Throughout the pandemic, our team has framed our efforts as one way to keep people out of emergency departments and hospitals. These could be our humble contribution to our colleagues working in inpatient settings. We have been largely successful, though I worry that our luck is running out.

We continue to witness the indirect effects of the pandemic. Some have been lethal: Suicides and overdoses, whether intentional or not. Some are worrisome: More irritability and increasing intolerance for the challenges and annoyances of life, regardless of one’s station. I wince when I consider what might come next as we witness this surge of cases.

God have mercy on us all.

Categories
Homelessness Nonfiction Observations Seattle

Leaves of Remembrance.

Throughout Seattle there are small metal plates in the shape of maple leaves that are embedded into the sidewalk. These are “Leaves of Remembrance” that “bear names of homeless women and men who’ve died, so that every person will have a place to be remembered”. People walk on and around them all the time, unaware of the purpose or significance of the leaves.

Only a few people were on the block that morning. It was not yet 8am, so the offices were still closed. The door to the corner store was open, though no customers were inside. A man was leaning against the building on the far end of the block, smoking a cigarette. The light of the sun was just starting to break through the grey clouds.

A man was squatting on the ground, inspecting the Leaves of Remembrance surrounding him. Near him was a styrofoam container of Cup Noodles, the lid removed. He dipped a white napkin into the ramen cup and rubbed it on a metal leaf. He leaned forward to inspect his work, leaned back to change his perspective, then wiped the entire leaf clean. After rotating his body, he began washing and wiping the neighboring leaves.

I’m not sure if he ever lived outside, though he has had his own apartment for years now. Does he recognize the names on the leaves? Was this his way of commemorating someone he once knew? Was this his way of helping to beautify the neighborhood? Is this part of his routine and I simply had not noticed until that morning?

He looked up when I walked past, though he did not recognize that I work as his psychiatrist. I did not greet him, though thanked him silently for his act of kindness during this time of calamity.