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
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.