Category: Homelessness

Categories
COVID-19 Homelessness Medicine Nonfiction Observations Policy Seattle

The Space Between Us.

I am one of the few people walking through downtown Seattle these days. Most of the people outside are people who slept outside the night before. Sometimes they are still sleeping in sleeping bags or tattered boxes when I walk past. They’ve always been there, but now that there are much fewer people outside, they seem to be everywhere.

The other people walking through downtown in the morning fall into two groups: People going to work, like me, and people walking their dogs. The people out and about in the morning are much more likely to wear face masks. The evening crowd seems to be younger and they are much less likely to wear face masks.

I see the magnolia trees bloom. Their pastel petals are already falling off to make room for new leaves. The soft pink cherry blossoms are already gone; the tree limbs are already full of fresh green leaves.

The offices now have bottles of liquid hand sanitizer from local distilleries. The hand sanitizer coming out of the wall dispensers have floral and chemical notes.

Every staff person should have their own set of cloth face masks. There are two in a bag. Volunteers sewed and packaged them. One of mine is dark blue with intersecting white lines. The other is light blue with a large pattern that is reminiscent of paisley.

Several people staying in our shelters have tested positive for coronavirus. There haven’t been “clusters” of cases yet, just one here, another one there. Staff show up to work, don their cloth face masks, put on gloves, and wipe down surfaces with disinfectant when they can. Some people staying in shelters cough and sneeze. Most put on the surgical face masks that staff give to them and try to stay away from other people, but where are they to go? A few are unable or unwilling to wear face masks. Staff continue to don their cloth face masks, put on gloves, and wipe down surfaces.

People are moving from congregate shelter settings into motel and hotel rooms. What will happen when people have their own private spaces? Their own bathrooms, their own beds, their own doors that they can lock? This reduces the likelihood of disease transmission. What else does this reduce? Hypervigilance? Paranoia? Pain? Substance use? (Or maybe it increases all of those things?)

The nurses are amazing. They try to assess for respiratory symptoms from six feet away, a subtle dance that we’ve all had to learn how to do quickly. Maybe it’s a chronic cough. Maybe it’s flu-like symptoms. Maybe it’s coronavirus.

The internal coronavirus team is amazing. They organize the waterfall of data and quickly refer people to the county isolation and quarantine sites. The system has started to move faster, but it’s not fast enough. And what are we to do when the isolation and quarantine sites won’t accept our referrals? Who holds the balance between liability and public health? What will the emergency departments say when it is the fear of acute withdrawal, not the actual withdrawal itself, that results in a visit from someone with coronavirus?

When I start feeling angry, I pause and realize that my colleagues in hospitals have even more reasons to feel anger. I’m not misreading the guidance: Following a high risk exposure to someone with confirmed coronavirus, staff should continue to work even if asymptomatic. Of course, I know why: The system needs health care workers to work during this pandemic. But what is the message this sends to individual workers? You might get sick, you might contribute to asymptomatic spread at work. The people who live with you might get sick. Despite this worry for yourself and those around you, please continue to work. And because we don’t have enough tests right now, we won’t test you until you start to demonstrate symptoms.

(What about the grocery store workers and farm workers? Do their employers provide face masks? Are they part of unions? Do they have health insurance?)

You are essential, you are a critical worker, you are immune to worry and anxiety. Right? This is no time to worry about yourself because we also don’t have time to worry about you.

I see the pairs of police officers leaning against their cars on Pike and Pine, their arms crossed. The sun stretches its warm rays across the sound and the new leaves rustle in the spring breeze. My cloth mask is mildly damp from the humidified air moving in and out of my lungs. I make brief eye contact with the person approaching me. We make time to worry about each other and the physical space between us grows.

Categories
COVID-19 Homelessness Medicine Seattle

Some Notes Related to COVID-19.

Some notes:[1. Personal notes that reflect my own opinions, not those of my employer!]

To my knowledge, as of this writing, no individual staying in our shelter or housing programs has tested positive for COVID-19. (Note: Only a fraction of them have been tested.) This continues to boggle my mind. There may come a time very soon when I will look back on this post and think, “Well, that was quaint.”

I received a phone call from a medical epidemiologist this afternoon. Among other things, he said that his job is “to get swabs into people’s noses”. I won’t lie: I had to stifle a laugh.

The medical epidemiologist also shared that there is apparently a shortage of “viral media”, though he didn’t want to “get into the sordid details” about that. My secret source commented that the cause of the shortage of viral media is a shortage of bovine serum albumin. Holy cow.

I haven’t talked so much about nasal anatomy and swabs in my life, even as a medical student learning anatomy. The FDA has apparently approved self-swabs for COVID-19 testing, which include sampling from the anterior nares (nose picking) and mid-turbinates, both of which are easier to access than the nasopharyngeal region (the experience of which has been described as “brain tickling” or a “brain biopsy”). Supplies are limited, though, and we don’t know how to access them.

Homeless shelters and other congregate settings are the lowest priority to receive personal protective equipment (PPE). The only way these settings rise in priority is if there is a confirmed case. Thus, volunteers have made cloth face masks for PPE. It’s wonderful and terrible at the same time.

With Washington State’s “stay home, stay healthy” order, most of the people now on the streets are pushing overflowing carts, wearing soiled blankets, carrying stuffed trash bags, and carrying broken backpacks because they have no homes in which to stay. It is hard to witness this.

I appreciated Ed Yong’s article about How the Pandemic Will End. You may, too.

Categories
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.

Categories
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.

Categories
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.