Category: Homelessness

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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.

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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.

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COVID-19 Homelessness Nonfiction Seattle

Dear Maria in March 2020.

Dear Maria in March 2020,

Hi. This is Maria in March 2021. I just want to let you know that you will be alive and well a year into the Covid-19 pandemic. Said nicely: You aren’t prepared for the next 12 months. To be fair, no one is prepared. You and your colleagues who serve people living outside, in shelters, and in permanent supportive housing are going to have a rough year.

First of all, remember that relentless fatigue you felt while you were in training, particularly as an intern? The constant realization that there was so much you didn’t know, the chronic anxiety of what harm you might cause because of your inexperience, and the physical exhaustion that came from working long hours and trying to keep yourself together? There will be many days in 2020 when you will feel something like that. The quality, though, will be different for two main reasons: One, because you do have more experience now, you will have more confidence in what you do and do not know. Two, you unfortunately will not be able to escape this fatigue. It will only worsen as the year goes on. There will be no resolution in March 2021. You won’t be able go off service; there will be no “golden weekends”. You will think about the pandemic and consider what you could or should do about it every single day.

People who receive services in the agency you work in will die from Covid-19. The number will be small—not even double digits—which will surprise everyone, especially you. Initially, you will think the low numbers must be due to luck. Once a Covid outbreak happens in the White House, however, you will recognize the value of the policies and procedures you and the team enacted. You will feel bountiful gratitude to staff for their willingness to follow these protocols, as annoying and inconvenient as they will be. It is because of staff efforts that so few people will get sick.

An uplifting event—one of only a few, I’m sorry to say—will happen in early 2021. You and your teams will establish an in-house Covid-19 vaccination clinic! During those vaccination clinics, staff from all over the agency—older people with various medical conditions, young people who just got out of school, people who left other careers to work in social services, people who do not speak English as their primary language—will come to receive vaccinations. They will express the hearty thanks to you and your staff. You will recognize the depths of their thanks because you will have felt the same way when you get your vaccinations from the beloved county hospital. By March 2021, you and your teams will be eager to vaccinate people receiving care from the agency, but the agency won’t have either the supply or permission to do so just yet.

It will be a terrible year. For many weeks, you will worry you will burst into tears at work. Instead, you will weep at home. It’s the kind of crying where you need to breathe, but all the muscles in your torso contract, so nothing moves. Anger and frustration are your constant companions; what will happen if you let them go? Must you be alone with the grief that you and everyone else feels?

Though few people will die from Covid, people will die. Data will show that the number of people who died in 2020 isn’t greater than the number of people who died in years past, but there will be more deaths on site. People will tumble from windows. The Women in Black will state a stunning number of people—young people, all under the age of 30—died from apparent suicides. The medical examiner will report again and again that someone died from an overdose. Older people won’t exit their apartments; their bodies will be found inside when they don’t respond to door knocks and phone calls.

You will feel anger towards a federal administration that will not demonstrate any concern towards the health and well-being of the nation’s residents. You will witness multiple system failures because there will be no federal coordination or planning. In conversations with state and local public health officials, you will preface your comments with an acknowledgment that they cannot provide optimal support to the community when they are not receiving support or information from the federal government.

Despite your grief and anger, you will often feel gratitude. Is this is a coping mechanism or a genuine reaction? It doesn’t matter. You will be grateful for the generous, non-reactive, and dedicated natures of the colleagues on your teams. You will express thanks that staff don’t quit in droves. You will feel gratitude to people under your care who follow guidance and demonstrate astonishing resilience. You will feel ongoing thanks that no one on staff gets sick and dies. You will be grateful that you still have a a job and are able to buy food and pay your bills when so many others cannot.

I am sorry to say that the pandemic is still ongoing in March 2021. Maria in March 2022 may be able to say more about how much you (and I) have learned and changed. (Perhaps it will be Maria in 2023 or 2025 who will comment on this.)

Do what you can to take care of yourself every day. I might even suggest that you write more, though will understand why if you don’t.

Sincerely,
Maria in March 2021

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Consult-Liaison COVID-19 Homelessness Medicine Nonfiction Seattle Systems

“The Impact of Covid-19 on Homeless Services in Seattle.”

On Friday, I presented Grand Rounds to an agency in New York City. The title of my presentation was “The Impact of Covid-19 on Homeless Services in Seattle, Washington”. The audience was comprised mostly of psychiatrists who also work with people who are currently unhoused or have been homeless in the past.

In some ways, this presentation was easy to create: I simply described the agency I work for and walked the audience through the timeline of events:

While the Seattle-King County region was scrambling due to the first death from Covid-19, the first case of Covid-19 was diagnosed in New York City on March 1.

In other ways, this presentation is the only one I’ve made where I had to take breaks while making it because of anger, grief, and sadness.

The month of March was hectic for us and everyone else: We tossed routine policies out the window and scribbled new ones down. We shattered many of our old habits and hastily introduced new practices. Our collective workload increased significantly as we tried to be as flexible and responsive to the changes that were coming at us. We watched systems grind to a halt because systems can’t change that fast: We had to buy hand sanitizer from local distilleries and we donated N95 masks to hospitals. Systems that had long failed us suddenly had the harsh glow of media light on them: In all of Seattle, there were only five bathrooms with hand-washing sinks that were open 24/7. Congregate shelters, where over 200 people had no choice but to share one giant room and one bathroom, suddenly became unacceptable because the beds were not at least six feet apart.

And, yet, eight months later, not much changed. We haven’t had the opportunity to abandon restrictions; many of these new practices are now status quo because the situation hasn’t gotten better. I was honest with the audience: There was no resolution or hopeful conclusion at the end of my talk. Why was that? How could it be that, eight months later, things hadn’t actually changed much?

The audience said nothing. What is there to say? The lack of ownership and coordination at the federal level is the same now as it was in March/April. New York City has significantly more resources than Seattle, though those resources only go so far while SARS-CoV2 can cross state lines and national boundaries when no barriers are erected and no interventions happen. If people in a boat are not rowing in the same direction—or if people aren’t rowing at all—then the boat and everyone in it wastes a lot of time and energy.

I was surprised by the gifts of validation from the audience. Yes, we all work as psychiatrists and the last time most of us saw someone get intubated was when we were residents. However, we all recall doing consults on people in the ICU who were sick. Ostensibly, we were there to take care of the patient and maybe their family members. We also know, though, that an important (and often unspoken) part of psychiatric consults is to support the treating team.

We all have a sense of how terrible it is for the treating teams. These are the reasons why we desperately try to keep people healthy and out of hospitals. We know that our contributions are small—most people don’t live on the streets, in shelters, or in supportive housing; most people don’t have diagnoses of schizophrenia or severe substance use disorders—but we also know that our people are often maligned when they pass through the doors into traditional health care systems. We all have a sense of how terrible it is for our people. We also know that, due to the stress of living marginalized lives, our people often have more severe health conditions. They already have many risk factors that increase the likelihood of complications and death due to Covid-19. We’re trying to mitigate the stress of everyone involved.

It’s heartbreaking, terrible, and unfair.

To end the talk on a positive note, I mentioned several things I am grateful for:

  • The rainy season has arrived in Seattle and I get to sleep in a dry bed indoors.
  • I have confidence in where I am going to sleep tonight.
  • I have a job and can pay my bills.
  • I know I will eat (again!) today.
  • There now exists technology where I can speak to an audience of colleagues on the other side of the continent!

These both mean a lot and nothing at the same time.

In the meantime, we continue to do what we can while we wait.

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Consult-Liaison COVID-19 Homelessness Nonfiction Reflection

How One Psychiatrist is Coping with the Pandemic.

Context: I work as the medical director for an agency that provides shelter, permanent supportive housing, and crisis and behavioral health services. I also do clinical work there as a psychiatrist, where I see people in shelter, housing, and in clinic.[1. A few of the people I see agree to use telehealth, but those who have phones tend to prefer telephone over video.]

Like many other essential workers, my colleagues and I have worked long hours, spent even more hours worrying and planning, and have had to figure out how to manage ourselves in the midst of uncertainty. Though we have been fortunate to be able to move many people out of congregate settings into motel and hotel rooms,[2. Here are some anecdotes about what happens when people move from a congregate setting into their own room with a private bathroom, a bed, and a door that locks: 911 calls go down. People who previously did not routinely take showers start showering daily. Some people use less drugs; some people stop using drugs and alcohol completely. People start planning and taking steps towards goals, such as school, employment, financial planning, relationships.…] we still have some people staying in congregate settings, which is undesirable during a pandemic. Many of the people who stay in shelter and housing have significant and chronic medical problems, which makes us nervous that they will have worse outcomes if they contract Covid-19. I express gratitude every day—though maybe not out loud—for the very few cases that have occurred within the agency. With over 500 people in shelter (though, again, many have moved into motel and hotel rooms) and over 1000 people in permanent supportive housing, plus hundreds who have different living circumstances but are enrolled in our clinics, we thus far have had fewer than 50 positive cases of Covid-19.

The strain on staff is significant. People will have different memories of this pandemic: Some people (reportedly; I don’t personally know anyone who falls into this group) have expressed some relief during this time, as they have the time and resources to do things like learn new languages, travel to cute cabins in remote places, and other things that seem like fiction to me. Others have had to learn how to navigate congregate settings and provide care to people with significant health conditions in the absence of national guidelines and plans.[3. Do I sound resentful? I think the underlying emotion is disappointment.]

I don’t think people who are trained as psychiatrists are necessarily more skilled at coping during a pandemic, as none of us in the US[4. Recall that there have been epidemics in the recent past. I found Mental health and psychosocial support in ebola virus disease outbreaks and Protecting Mental Health During Epidemics helpful… and don’t get the sense that the CDC or other federal agencies have reviewed these articles and/or are interested in providing this sort of support to any of us. Am I still sounding resentful?] have ever lived through one. Here’s what I’ve been doing (or at least trying to do) to manage myself:

Get up early to do stuff to take care of me. (Because I wasn’t born a doctor and, God willing, I will be able to retire before I die.) I aim to get out of bed at 5am. This tends to be the quietest time of day and few, if any, people want or need my attention. The long summer days in Seattle make getting up that early easier, but, let’s be real: Sometimes the spirit is willing, but the flesh is weak.

Exercise. Sometimes this means what most people mean by the word “exercise”, like push-ups, squats, etc. Sometimes this means “movement”, which can be a one-person dance party. The face covering mandate has interfered with my willingness to run. I do want to run, but I haven’t been able to get over the hump of running while wearing a mask. (I live in a neighborhood where there are at least some people around, even at 5am. I am committed to wearing a mask when I am out and about.)

Invest time on hobbies. During those early morning hours I study Chinese to improve my literacy. Though I haven’t posted much here, I am trying to write daily (I continue to use 750 Words, which helps me with quantity, even if the quality is terrible).

Eat cookies. Sometimes I eat only a few; sometimes I end up eating over half the box. This is not the greatest coping mechanism, though it is something I have done because my frustration tolerance is sometimes low and impulse control is hard.

Walk during meetings. I’m that person who often joins a video call by telephone. This is related to technological deficits, as well as willfulness: If the meeting doesn’t require video presence, then I will take the less stimulating option of audio only. I occasionally quip that I’m like tuna: If I stop moving, I will die. If I’m able to walk during a meeting, that not only helps me dispel anxious energy, but also reduces the likelihood that I will get distracted by e-mail or other tasks during the meeting. This also helps me feel like I’m taking advantage of the summer weather while we still have it.

Talk to myself. Out loud. And often in an effort to meet and greet whatever emotion I’m feeling. (Hang in there with me.) Earlier this week I exclaimed much louder than I intended, “I feel so anxious!!!” and then proceeded with this conversation:

Hello, Anxiety! What brings you here today? Are you enjoying this summer weather? What are you worried about? What are you trying to tell me today? What can I do to help you feel better?

This is a concrete way to acknowledge whatever it is I am feeling because avoiding emotions is generally impossible and ineffective: It’ll come out some other way (e.g., eating half a box of cookies).

Observe the sky. The sky is bigger than me. The pandemic is bigger than me. The sky changes. The pandemic will change. I want to witness the sky. I want to witness the pandemic. To stop and look at the sky—the clouds, the moon, the sun, the colors—allows me to pause and claim time that sometimes never feels like mine.

Try to make other people laugh. During this time of differing degrees of isolation, sharing laughter with someone is a treasure. Sometimes the humor is admittedly dark, though I much prefer that people get it out of their systems with trusted confidants, rather than on others (like patients).

Sleep. Sometimes sleep doesn’t feel restful—I am sorry to confess that, sometimes, my dreams center on Covid-19—and occasionally I wake up from sleep thinking about all the things I should do related to the pandemic. Having a fixed “get out of bed” time helps with regulating sleep.

Thank people. There is no way any of us could manage this ridiculous time by ourselves. There are so many people to thank: The janitors who clean and sanitize spaces to keep us all healthy. The grocer who is there so you can buy food. The doctors and nurses who provide Covid-19 testing and counseling. The sanitation staff who continue to empty out the garbage and recycling bins. The plumbers who fix emergency sewage leaks. The person on the street who acknowledges you and makes an effort to stay at least six feet away. The bus drivers who continue to transport essential workers around the city. The first responders, including police, who are kind to the seemingly increasing number of people who are sleeping outside. God/the Universe/whatever Deity that I still have a job, a stable place to live, and, thus far, good health.

Do you have other suggestions?