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
Nonfiction Seattle

Blue of the Sky.

Photo by Johann Piber

The bus stop is at 145th Street and Aurora Avenue. There was a city bus there; if I run the two blocks fast enough, I thought, maybe I can catch it.

Then I noticed the two law enforcement vehicles, sturdy vans with red and blue lights flashing from the windows. One was parked directly in front of the bus; the other was in the driveway of a nearby storefront.

The bus remained at the stop as a third law enforcement vehicle made an assertive U-turn in the middle of the street to join the other two.

I stopped walking. I took a few steps forward, then stopped again.

“No, this doesn’t seem right… I can catch the bus at the next stop,” I muttered out loud.

It was a few minutes after 11am on Tuesday, November 8th, in the year of our Lord 2022.


There is essentially no sidewalk on the west side of Aurora Avenue. I reached the bus stop at 135th Street on Aurora; no bus was coming. I kept walking, squeezing myself between the parked cars and the businesses along the street. I had faith that a sidewalk would soon appear.

I heard the rumbling first. A bulky black box with thick treads on its large wheels approached. A man wearing a helmet and sunglasses inside the armored vehicle glanced out the open window. The red and blue lights in the front and on top of the vehicle were not on. The white “SWAT” lettering on its side gleamed in the late morning sunlight.

A few minutes later, a second armored SWAT vehicle rumbled past.

“What is happening?” I asked.


A photo of the 14-year-old was distributed to all Seattle police and an officer located the two teens on a Metro bus at North 145th Street and Aurora Avenue North at 11:02 a.m., the charges say.

Seattle Times: What prosecutors say happened at Ingraham High before the fatal shooting

I had to cut through a car dealership on Aurora because there still wasn’t a sidewalk. Despite the sun floating in the blue of the sky, I put the black beanie back on my head. Underneath my black wool winter coat was a black puffer jacket; a grey scarf was knotted around my neck. I continued to look for a sidewalk. I was apparently unwilling to cross the street.

The young women already knew that there is no sidewalk on Aurora, so they stood in the street. Their hands, adorned with colorful fingernails, tossed their shiny, long hair over their shoulders. Their shorts and skirts stopped just past the curvature of their hips, exposing the bare skin of their legs to the gaze of drivers and the cold morning air. The cropped jackets covered their arms, but not their cleavage. Their eyelashes looked like small, dark butterflies on their cheeks. Shades of red, pink, and purple were on their lips.

They weren’t yet waving at cars passing by.

One of them waved at me as I approached and called, “Hey!”

We made eye contact; she grinned. “What do you call those big cats that live in the hills?”

I reflexively smiled back at her, though did not stop walking. “Mountain lions?” I guessed.

Her rosy lips bloomed into a satisfied smile. She nodded, pointed at me, and said, “I like that.”

I shrugged and kept walking. I wished she and her peers weren’t standing out there. I wondered what their circumstances were. I prayed for their health and safety. I thought about why she asked me this peculiar question. (I only learned about REST, real escape from sex trafficking, after this conversation.)

I continued to look for a sidewalk.


About a week later, I boarded the light rail at the most northern stop. It was another sunny and cold day.

Many young people were on the train. Some of them had signs. I couldn’t read all of them; I spied one that was upside down that included the word “GUNS”.

They poured out of the train at Pioneer Square. Many of them had traveled over 130 blocks to join other students at Seattle City Hall to

[call] for better mental health support, more restrictions on gun access and more training for security staff in the wake of a shooting Tuesday at Ingraham High that left one student dead.

Seattle Times: At rally, Seattle students demand more mental health resources, gun safety measures

I looked up, shielded my eyes from the sun, and squinted at the blue of the sky, white of the snow, and grey of the mountains.

Categories
Consult-Liaison Nonfiction Public health psychiatry Seattle

Constraining Choice Sets.

The rains have finally returned to Seattle, though the wildfires continue to burn:

Wildfires from Google Maps as of the morning of 2022 Oct 24.

That map does not include the entirety of Washington State (there are more fires outside the boundaries of that image), or the fires burning in neighboring Idaho and Oregon.

While we did not experience the blood red skies that San Francisco experienced from the wildfires of the summer of 2020, the air was looked and smelled thick. Each whiff contained fragrant notes of Douglas Fir and perhaps Western Red Cedar, all overwhelmed by charred carbon. Landmarks disappeared into a gritty haze of grey. The evenings featured a crimson sun sinking into ashy layers of peach, pink, and coral.

By October 19th, Seattle had the worst air quality on the planet:

Conditions did not improve the next day. The Space Needle has a webcam (more precisely a “panocam”, as it provides a 360-degree view). Go take a look at it now; this is the grey pall that we embrace for much of the year. Despite this pewter drape, one can still see the surrounding buildings, lakes, and trees. Compare this to the view on October 20th:

(“Is the Mountain Out?” refers to glorious Mt. Rainier, the 14,410-foot tall stratovolcano that looms over the region.)

The rain finally arrived on October 21 and displaced the smoke:

Unfortunately, it did not extinguish the wildfires. Our neighbors to the east have yet to escape the smoke.

In addition to headaches, congestion, and watery eyes, people also experience psychological effects due to wildfires. I came across this paper in Nature Human Behavior from July 2022 that reports on one aspect of this: Exposures and behavioural responses to wildfire smoke (no paywall as of this writing). While the paper doesn’t quite answer the question I want to answer, it did report:

… during large wildfire smoke events, individuals in wealthy locations increasingly search for information about air quality and health protection, stay at home more and are unhappier. Residents of lower-income neighbourhoods exhibit similar patterns in searches for air quality information but not for health protection, spend less time at home and have more muted sentiment responses.

(For those who consider how your digital data gets used, the data for this paper came from Twitter, Google searches, and a real-time air quality monitor called PurpleAir, along with geographic income data.)

As we also have seen during the pandemic, people with lower incomes have less choices, even if they have access to similar information (emphasis mine):

Why do wealthier locations respond differently to smoke exposure? The measured differences do not appear to reflect differences in exposure information or in overall internet activity, given the consistent response of air-quality-related searches across income groups. Rather, the responses are consistent with lower incomes constraining choice sets and behaviours, including less flexibility in working from home, fewer resources with which to consider purchasing protective technology and (regarding the sentiment results) having other more pressing matters to worry about.

The Seattle Times published an article on October 20th that highlighted “constraining choice sets”. The King County Regional Homelessness Authority opened a “smoke shelter“, though few people used it. Why?

“The long-term effects of breathing in smoke is not going to be like the most highest of priority,” said an outreach worker. This is consistent with the findings from the article: While people living outside may have access to the internet, they likely are not seeking air quality monitors or information about filtration, as they do not have their own windows to close or own spaces to filter.

One of the conclusions of the article about wildfires could very well be applied to the pandemic: a “policy approach of promoting private provision of protection could be biased against disadvantaged groups”. I also suspect that the unhappiness the wealthier respondents reported as a result of wildfire smoke is not dissimilar from the ongoing unhappiness we all are seeing as a result of the pandemic and its social consequences. (It is likely that people who are poor are also experiencing unhappiness; they simply may not have the time, energy, or resources to feel it.)

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.