Category: Homelessness

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Homelessness Medicine Nonfiction Policy Seattle Systems

More Reflections about COVID-19 from Seattle.

This is another unpolished post. Several physicians and nurses in other states have reached out to ask for suggestions and perspectives related to behavioral health and homelessness during this COVID-19 epidemic in Seattle. Here are some reflections:

Coordination with partners is not only essential for services, but also to maintain morale. No single agency is able to address this alone. Government partners need feedback and information about what the community needs (and, I’m sorry to say, sometimes the community ends up providing government officials with updates that government should be telling us). The actions and energy of partners can buoy others when it seems things are stuck.

There aren’t enough supplies. Clinics, hospitals, and agencies can’t get face masks, hand sanitizer, and other sanitation supplies. Vendors are all sold out. Local governments are appealing to the federal government to provide supplies; I understand that the US military protects a national stockpile of such items? Which is something I had never considered in the past. And, perhaps most importantly, there aren’t enough COVID-19 tests! It seems that most of our local publicly funded primary care clinics have, at most, 30 test kits on site with no replenishment coming. Some private labs are only now agreeing to provide COVID-19 testing.

Many employees don’t have enough paid time off accrued to take time off of work for self-quarantine. Thankfully, our state and federal governments have passed or will pass legislation to address this and ensure that people can still get paid despite having to take time off of work. HR departments everywhere would do well to look out for their employees, particularly those who provide direct service to people who are higher risk of experiencing illness due to COVID-19.

People may (or may not) bristle at the infringement of civil liberties. The Washington State Governor has banned gatherings of more than 250 people. The CDC has provided “mitigation strategies” specific to Seattle-King County for the next 30 days, some of which are about workplace behaviors and COVID-19, which includes checking temperatures for fever and screening for illness when employees show up to work. The CDC has also recommended prohibiting visitors to certain sites. These are extraordinary times, hence these extraordinary measures… and some people may bristle at having to follow these rules. So far, people have been voluntarily complying with these changes.

The balance of individual patient health information and public health wobbles. For the past two weeks, a local clinic and our shelter have gone back and forth (in a collegial way) about protecting an individual’s privacy versus protecting the health of other people staying in the shelter. In short, the clinic argued that if Mr. Doe, a person who stays in the shelter, gets tested for COVID-19, the shelter isn’t entitled to know (a) that the test occurred and (b) the test results. We have countered that the shelter should know about Mr. Doe’s testing and the results during this extraordinary time because we want to do everything we can to prevent or minimize a localized outbreak within our shelter. Thankfully, the State Attorney General issued guidance that sided with our view (to be clear, the clinic was sympathetic to our view and did not balk with the change in practice… and I completely understood where the clinic was coming from). However, this is something that the clinic and our shelter had to pursue on our own; this was not proactive guidance we received from our government officials.

Government bureaucracy is in full effect. In this instance, I’m referring to practice of government officials who are unwilling to send out official communication until numerous gatekeepers have vetted it. Thus, guidance is slow to come out, so everything slows down. I understand the reason for vetting—confusion isn’t helpful, either—but we also feel frustrated when we feel like we’re losing a race against an invisible enemy.

People staying in shelters are resilient. Many staff feel anxious about how COVID-19 will impact the people who stay in shelters and receive clinical services from us. I find that I have to remind myself that many of the people who stay in shelters have experienced traumas and horrors that we will never know or understand. Many of them have already experienced illnesses and pain that we cannot fathom. I do not mean to minimize the very real possibility that some of them, should they contract COVID-19, will develop severe illness and die. I don’t want that to happen, which is why we are in constant communication with our partners to coordinate services and care. However, many of them will either not get sick, or they will recover despite our anxiety and efforts. It is a privilege that these individuals even let us into their lives.

Screening guidelines for COVID-19 are mushy. Some of our local infectious disease experts have taken to crafting their own screening guidelines because they are dissatisfied with the vague guidelines from the CDC. (This ties back to the lack of available tests—if we had more COVID-19 test kits, then we wouldn’t be wringing our collective hands about screening guidelines, particularly for vulnerable populations like people staying in shelters, which, no kidding, includes a significant proportion of people who are over the age of 60.)

The workforce shortage seems like it will only get worse. Social service and health care agencies often struggle with having a sufficient number of staff to address the clinical need. As people call out due to illness, whether COVID-19 or otherwise, this will turn into a vicious cycle: Fewer staff for a constant or growing need means that those staff will get tired and sick, which increases the likelihood that they will call out, and if the return to work rate doesn’t match the “attrition” rate, then soon there will be only minimum staffing at best. We also cannot expect individual people to successfully address systemic problems. It is not uncommon for people who go into social and health services to overwork (whether in quantity, quality, or both); this is unsustainable during usual times, let alone during an epidemic.

Social distancing seems like it will have the highest yield. The Institute for Disease Modeling published a paper specific to King and Snohomish Counties (the “epicenter” of the outbreak in the US) about the importance of social distancing. It is both compelling and disturbing. I don’t know how to successfully balance this with the clinical services that the medical team provides to the agency. Telehealth options are limited because of the population we serve (i.e., they generally don’t have telephones), though we plan to implement some creative ideas to at least try to keep people out of emergency departments.

It’s a weird time. We continue to do the best that we can, while recognizing that what comes next may knock us off our feet.

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Homelessness Nonfiction Reflection Seattle

Remembering.

There were three shootings in a 25-hour period in Seattle this week. The third shooting occurred during rush hour. Multiple fire trucks raced past the lines of cars in the downtown grid; I remember thinking, “It must be a big fire.”

The newspaper later reported that the person who died in the third shooting was a woman who was previously homeless, but now had lived for nearly ten years in permanent housing. Based on her history of homelessness alone and the location of the shooting, some people might assume that she made an active choice to be there, that it was somehow her fault that she was shot. Would those people also assume that the others who were shot—including the nine year-old boy—made an active choice to be there, that they are to blame for getting shot?

There is now a vacancy in that apartment, and people will miss her.

Two days prior, I went to a homeless shelter with hopes of talking with a patient. He wasn’t there—maybe he was trying to avoid me; maybe he forgot; maybe he had more important things to do—but there was a makeshift memorial in the lobby.

As I made my way to the memorial, a man with fresh scabs all over his face and pants too big for his legs walked past. A woman with grey hair leaned forward and used her skinny legs to roll backwards in her wheelchair.

On the folding table was a grayscale image of a man’s face printed on a standard sheet of paper. The image was blurry due to the low resolution, but his smile was bright and clear. Next to this image was a large sheet of white butcher paper, along with some pens.

Several dozen people—other people staying in the shelter—had written messages on the butcher paper:

You went too soon, man.

I miss you and hope to see you again in heaven.

I hope it’s better where you are now.

Another person had already taken the bed that this deceased man previously occupied.

She was trying not to cry.

“It’s completely normal to feel sad when one of our [patients] die,” I said. “You were connected to him.”

A small laugh came out of her mouth, and then the tears fell from her eyes.

He wasn’t an old man, but he wasn’t a spring chicken, either. He didn’t like to stay in the shelters; sometimes other men would call him names or make fun of the way he talked. He slept under a bridge, though came into the clinic several times a week. He and I had only met once; he was courteous, made small jokes, and called me “ma’am”. I wished that he would stop smoking methamphetamine. He wished for that, too.

She, his case manager, was hopeful. They talked about his health; they worked on applications to help him get into housing so he didn’t have to stay in a shelter or sleep outside; they talked about how methamphetamine was getting in the way of what he wanted.

“I wasn’t prepared for this sense of loss,” she said, wiping her face. “We talked about his plans. I was hopeful that things would change for him.”

A few weeks prior, he was sitting across from me in that office. She and I now sat there, our sadness filling the room.

I have a friend, also a psychiatrist, who works in a prison. She has commented that these individuals—people living on the streets, people in jails and prisons, people who are part of marginalized and excluded populations—are considered “throwaways”, that people don’t think about them, that they are the forgotten ones.

We only forget about them if we forget that they’re people, just like us.

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Homelessness Lessons Medicine NYC Observations Reflection Seattle

The Kind of Energy We Send Out to the World.

I have been writing; I just haven’t posted anything here. These days, it seems that we cannot escape increasing types of noise and their loud volumes. It’s not all noise, but the signals are overwhelming.

It was a busy teaching week for me: I had the privilege to speak at two community clinics and a public hospital. In all three presentations I commented on the tension between “the system” and our efforts as individuals. When we’re trying to provide care and services to individuals, sometimes the constraints of “the system” interfere with our efforts: Sometimes fiscal concerns reign supreme; sometimes the bureaucracy is inflexible; sometimes the system does not have noble intentions. We grumble, we get angry, we feel helpless.

When we’re trying to design “the system” to provide care and services, sometimes the constraints of people interfere with our efforts: Sometimes there aren’t enough people; sometimes people make mistakes; sometimes people do not have noble intentions. We grumble, we get angry, we feel helpless.

The two, of course, are related: People design systems. People work within systems. People can change systems.

People also have values. Sometimes we find that our values clash with those of the systems we work and live in. That doesn’t mean that we must defer to the values of the system. It takes courage to resist. To show our values to the world without flinching is an act of bravery.

While speaking, I told a story about my first boss when I finally started working as an attending psychiatrist. Our jobs included working with people who were homeless in New York City.

“I want people who don’t have a place to live to get excellent care,” he said, perhaps talking more to himself than to me. “Good care shouldn’t be limited to people who can afford to pay a psychiatrist who works out of a plush office on Park Avenue. People who don’t have money should have access to and get good care, too.”

“These are choices under our control,” I said to the audience yesterday, perhaps talking more to myself than to them. “Even though system pressures are very real, you can choose to give good care to the people who come here for help. You can treat people with dignity and respect, particularly if they are people of color with very low incomes. They might not get dignity or respect elsewhere.”

Perhaps my exhortations sound naive. Perhaps cynicism will triumph over virtue. However, I refuse to embrace cynicism. Cynicism makes for terrible company. Life is already full of challenges; we do not need negative soundtracks to accompany us as we travel through life. What we do affects others. What we say can inspire others.

We have responsibility for the kind of energy we send out to the world.

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Homelessness Nonfiction Policy Systems

How to Prevent All of This?

Some of the people under my care in the jail right now are quite ill. (This statement is always true, but it seems that the intensity of illness is greater now than usual.) As a result, the perennial question seems more urgent now: Is there any way to prevent All of This?

For some of them, it seems that the answer is No. Some of them sought out psychiatric services, attended appointments regularly, and had good working relationships with their physicians and therapists. They shared their concerns with friends and family members; they sought out help when they started feeling overwhelmed. Despite these relationships and support, they allegedly did things that resulted in significant criminal charges. And now they’re in jail.

For some of them, the answer might be Yes. Maybe if they had more people they trusted in their lives; maybe if they had a better connection with the counselor or doctor they saw that one time; maybe if their friends and family had more time and resources to seek help with and for them.

Then again, for some of them, the answer might be No, but for frustrating and sad reasons. Maybe their friends and family did everything they could to help them, but they didn’t want their aid. Maybe they became so fearful for their safety that they withdrew from everyone and, in isolation, their symptoms became worse. Maybe they believe that they are fine; it is the rest of the world that is confused and ill. Maybe their only experience with psychiatrists was involuntary hospitalization: Who wants anything to do with a system that takes away your rights and forces you to accept medication?

Some of these people are so young. To be clear, it’s troubling whenever someone of any age ends up in jail solely because of psychiatric symptoms. But can you imagine being 18, 19, or 20 years of age and landing in jail in the midst of hearing incessant, taunting voices, believing disturbing things that simply aren’t real, and having no visitors because the few people who are in your life are scared of you?

It’s heartbreaking.

At least these individuals come to clinical attention. And many get better: They form relationships; they talk with my colleagues and me; they learn how to get along with others; they reflect on what has happened and how to avoid similar consequences in the future; some take medication to help reduce their symptoms.

But then I think about all the people who never encounter law enforcement and never enter the criminal justice system, but they also experience significant symptoms. How do we prevent All of This for:

  • the man who doesn’t tell anyone any personal information and stuffs his tattered clothes with plastic bags to stay warm
  • the woman who won’t move indoors because she believes that the aliens will execute her if she does so
  • the woman who won’t leave her house because she believes her neighbors are cannibals
  • the man who sits all day on the sidewalk across the street from his old employer because he believes that he will get his job back

What about them? How do we help those individuals when the system ignores those who cannot or will not play by the rules?

Many mornings I see the same woman standing near a bus stop. The bus stop is covered, but she never stands underneath the awning. She stands behind the bus stop, even when it’s raining.

You can smell her—a mixture of sweat, dirty socks, and yeast—from several feet away. Pedestrians move around her the way water swirls away from large rocks on the riverbed.

Two black garbage bags sit at her feet. They are full. Plastic zip-lock bags poke out of one of them.

She is a young woman of color. She wears a dark hoodie that is too large for her slender frame, but it’s not zipped up all the way. She’s not wearing anything underneath the hoodie, not even a bra. An unwashed skirt smeared with dirt covers her legs. Her mangled sandals reveal that she has not clipped her toenails in many months.

She talks to an unseen audience and everyone can hear what she says. Her voice is rich and though her sentences do not make sense, she speaks with dignity.

The other morning the rain wasn’t the usual mist that falls from Seattle skies. The droplets were full and heavy, a shower of dark water as the sky was filling with grey light.

No one was standing in the bus shelter. Her clothes were already damp.

“Excuse me?” I asked. She had raised an arm to make a point in her discussion.

She fell silent and blinked a few times.

“Do you want to move so you’re under the bus shelter? So you won’t get wet?”

She turned her head and looked away.

“I can help you move your stuff. It’s raining pretty hard right now.”

She dropped her arm and turned her head further.

“What’s your name? My name is Maria.”

She glanced at me, raised her arm back up, and resumed speaking: “All in all, we must to the left….”

I stood there for a moment, waiting for a sign. None came. I walked away.

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Education Homelessness Medicine Nonfiction Policy Systems

People Get Better.

“What?!” he exclaimed. “Are you serious?”

“Yeah,” I replied, puzzled.

“That’s… amazing.”

“Yeah, it is.” I paused, finally realizing that he had never heard me talk about this before. “It actually happens a lot. People get better. People get better all the time.”

When I first met him, he screamed at me, his face red, spittle flying from his lips. He refused to believe I was a physician.

“Women can’t be doctors! They can’t!”

He did believe, though, that televisions could control his thoughts.

“They know what I think! When they start talking, they control what I think and what I say and what I do!”

He drew a swastika that covered the entire wall of his jail cell.

“Yes, I believe in white supremacy! But I’m not part of a group!”

He accepted medications on his own. First, the yelling stopped. Then, the swastika disappeared. Drawings of cute farm animals took its place. Within a few weeks, he greeted me with a smile.

“Hi, Dr. Yang. How are you doing today? I hope you’re well.”

He invited me to sit at the small table next to the kitchenette in his apartment.

“You want anything to drink?”

“No, thank you. How are you doing?”

“I’m okay. What do you know about the Mediterranean diet? I want to try that. I want to lose some of this weight.”

After discussing the merits of vegetables and lean proteins as they related to heart health, he leaned back in his chair. He then blurted, “It’s been six months since I smoked a cigarette.”

He never smiled when he shared his accomplishments. His condition prevented him from doing so. I smiled for him.

He resumed musing about dietary changes. I mused about how far he had come: Just 18 months ago he was living on the streets, often snarling at strangers and the voices that only he heard. He came to the attention of the police when he chased a young mother pushing her baby in a stroller. He threatened to beat them with the metal pipe in his hand. The police thankfully sent him to the hospital for care.

“Thanks for seeing me,” he said as he walked me to the door. The voices hadn’t completed disappeared, but he could ignore them now. “I like steak and potatoes, but I’ll try the leafy vegetables.”

He used both hands to smear his own feces on his arms, chest, and belly. He applied toothpaste to his elbows and his knees. I asked him why.

“because it’s protection it’s protection against all of you I shouldn’t be here I’m fine I’m not sick you don’t understand who I am they all know who I am you would be scared too if you knew who I am people know me from way back—”

He began howling at the door.

Within days of him receiving medications, all of that stopped. His jail cell was clean. He took showers. He never spoke of what happened. Neither did I.

I was taking a walk a few months later when I heard someone call, “Hey, Dr. Yang!”

I turned around and saw a group of men in uniform working. This man, suited up like his colleagues, waved at me and smiled.

I couldn’t help but smile—this is fanstastic!—but felt a twinge of embarrassment. Did he know that he had called me “doctor”? What would his coworkers think?

First do no harm. I waved back.

“Nice to see you, Doc,” he continued. “I’m doing good.”

“I’m glad to hear that. Take care of yourself.”

“I will, Doc. Thanks.”

People get better. The science hasn’t yet generated interventions that guarantee that everyone will get better. Furthermore, some people who could get better can’t access care due to barriers related to finances, policy, and other systemic factors.

Until then, we must share both stories and data (try this, this, and this) that people get better. It is amazing, but it shouldn’t be surprising.