Category: Systems

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Observations Seattle Systems

About the CHAZ….

You’ve heard about Seattle’s Capitol Hill Autonomous Zone (CHAZ), right? With free press from President Trump, people both in the US and abroad now know about the “Seattle takeover” and his imperative to “Take back your city NOW”.

Well, dear reader, if you believe that I am reliable narrator, let me share with you my observations of the CHAZ.

First of all, this is how the CHAZ website describes the Capitol Hill Autonomous Zone:

The Capitol Hill Autonomous Zone née “Free Capitol” is a 6 block section around the East Precinct in Seattle, WA. Abandoned by police and left to burn, this area was instead siezed [sic] by anarchists, BLM supporters and other protestors who have since transformed it into a unverisal [sic] community based on mutual aid. Fundamentally, CHAZ is an occupation of Capitol Hill, not an official declaration of independence.

Here’s some context about the Capitol Hill neighborhood where the CHAZ is located: In addition to being the gay mecca of the Pacific Northwest, Capitol Hill is the hip neighborhood of Seattle.[1. Some would comment that Capitol Hill is the hipster, not hip, neighborhood of Seattle.] Bars old and new cater to the spectrum of genders. There’s wood-fired bagel cafe; a bike shop where, after spending time in the physio lab, one can order a Matcha Chicken Avocado Bowl; and a music venue called whose full name includes “Crystal Ball Reading Room”. Two blocks south from the CHAZ is a dealership shared by Ferrari and Maserati. A local cafe offers apricot jam doughnuts for $3.85 each. Rent for a one-bedroom apartment near the CHAZ is around $2000 a month.

Now, onto my observations:

According to the City of Seattle, about 65% of the city population is white and nearly 7% are Black. The vast majority of people (much more than 65%) I saw in the CHAZ were white. Perhaps this was due to the clumps of white tourists who wanted to witness the CHAZ themselves. Maybe white allies had taken upon themselves to “do the work” and use the CHAZ to advocate for Black Lives Matter (BLM) causes and demands. (Of note, I cannot find any comments from the Seattle-King County chapter of BLM about the CHAZ.) Despite the ongoing pandemic, a notable fraction of these white individuals were not wearing face coverings.

While there is a beautiful mural of “Black Lives Matter” physically on Pine Street and references to Black individuals of Seattle and beyond who have been killed by police, the overall vibe of the CHAZ seems more focused on opposing authority. The graffiti on and around the now abandoned police station, the “conversation cafe” stations, and the new community gardens seemed to chiefly cater to white audiences and suggest an anti-establishment philosophy. Black Lives Matter and “a universal community based on mutual aid” are not the same thing, and this is highlighted in the deliberate demands of the Seattle-King County chapter of Black Lives Matter. To be fair, there is overlap between the demands of CHAZ and BLM, though what people do often reveals actual intentions compared to what people say.

In addition to philosophical contrasts, there were physical contrasts within the CHAZ. A man was hugging his adult poodle like a baby, while a crowd of people were nearly running after a man who was yelling at someone about a stolen phone. A white man with what appeared to be a taxidermy weasel draped around his shoulders got into a profane shouting match with a Black man (one of the very few I saw) seated on a bench, a push cart stuffed with belongings next to him.[2. I promise you, dear reader, that there was indeed a man who had draped what appeared to be a taxidermy weasel around his neck. Maybe it was a plush weasel, but the effect was the same.] A (white) man was shoveling wood chips into a new community garden marked with a hand-written sign that read “This garden is for Black and Indigenous folks and their plant allies”. All the doors to the public bathroom were closed and the phrase “shoplift your future back” was scrawled in spray paint on its foundation.

Meanwhile, Seattle Parks and Recreation collected trash from the CHAZ and hauled it away. An employee, wearing a face covering, emerged from a Seattle Public Utilities truck with a clipboard and headed towards the park.

Here are my questions:

Is the Capitol Hill Autonomous Zone a distraction from Black Lives Matter? If yes, what are the consequences of that distraction at local, state, and federal levels, now that President Trump has condemned this “occupation of Capitol Hill”? What are the consequences to BLM if it is conflated with the CHAZ?

Could an Autonomous Zone exist anywhere else in Seattle? Does it matter that this part of Capitol Hill is young, trendy, and expensive? Could the Autonomous Zone exist in a Seattle neighborhood with more Black lives, such as the Central District or Rainier Valley? Even if the Autonomous Zone could exist in another neighborhood, would it exist? Would protestors want that? Would the neighborhood support that?

Has the local chapter of BLM made a statement about CHAZ? If yes, why is it difficult to find? If no, what worries or hopes does BLM have about doing so? The Seattle-King County BLM chapter has demonstrated great thoughtfulness about its activities in the midst of this pandemic, including specific rules about their protest. Their silent march drew around 60,000 protestors despite the rain. I look forward to learning more about and supporting their perspectives.

Will the CHAZ protestors vote? Some argue that the only way to change the system is to join it. Others insist that change can only come from the outside, as there are too many conflicting interests from within. Voting applies in either scenario.

Will the CHAZ protestors follow the lead of BLM? Sometimes the urge to “do something” is overwhelming, when the most productive and helpful action is to wait and follow. Before people congratulate themselves on the actions they are taking, it is prudent to ensure that these actions are in the service of the goal that will both change and improve the system.

How will the CHAZ end? Will the protestors leave of their own accord? Will they stay until forced to leave? Will there be non-violent negotiations, or will we witness more violence? How much effort will Seattle Police put into returning to their precinct building? What is the Mayor’s strategy about this, now that she is the target of antagonizing messages from both Seattle residents and the President of the United States?

When will the CHAZ end? With unemployment rates high in Seattle, as in the rest of the nation, some people may choose to remain in the CHAZ because the economy continues its slump. There is a Presidential election in November and if the President continues to give his attention to the CHAZ, that may reinforce their desire to remain. If Seattle sees a spike in coronavirus cases, will the city recruit Public Health to help assess the safety of the encampments and gatherings and then ask people to leave?

If you live in the Seattle-King County area and are able, please donate money to the Seattle-King County chapter of Black Lives Matter. Whether you live in Seattle or elsewhere, please also participate in the US Census and make sure you vote in the upcoming elections. Please continue to ask questions, engage your mind, and exercise critical thinking. Change will take all of us.

Categories
Consult-Liaison Medicine Nonfiction Reflection Systems

Mental Health Awareness Month During a Pandemic.

It’s been Mental Health Awareness Month during a pandemic.

When we look back at this time, people will have different memories of their experiences: Some will remember changes in job duties and extra time for leisure. Others will remember intense pressure and stress as essential workers. Still others will remember the despair due to unemployment and financial worries. We all will remember how the COVID-19 pandemic disrupted our routines and affected our mental well-being: It impeded our freedom to go outside, abilities to pursue the activities we want to do, and usual opportunities to express ourselves.

Wearing a face covering may mask the expressions of displeasure and anxiety on our faces, but it does not diminish the discomfort and worry we feel within. As many in our community try to avoid illness, some will fall ill and and others will succumb to death. There are reasons to grieve.

Because discomfort and anxiety are internal experiences, our culture often frames these reactions as a personal problem—a disorder of one individual mind. However, this pandemic has had adverse effects on everyone. Many of us are feeling the same emotions. These are unsurprising reactions to an unexpected and (hopefully) once-in-a-lifetime situation.

We must avoid medicalizing these reactions. Individuals receive psychiatric diagnoses within specific contexts. Our reactions as a result of the the pandemic are collective experiences within the same context. It is unfair to argue that all people experiencing distress during this pandemic have psychiatric disorders. This argument also undermines opportunities for communities to support their own members who are suffering.

Not all distress reaches the threshold for a clinical diagnosis, especially during extraordinary times. While mental health professionals can help people who feel anxiety and sadness, that doesn’t mean that increasing the number of mental health professionals and their services is the primary solution during this pandemic. Most people feeling worry and anguish now will not need specialized services. Support from people from the same culture or context can and will help people tolerate and then grow from these emotional experiences. Relationships, stemming from faith traditions, hobbies, cultural groups, and friendships, are invaluable during these times of stress, loss, and grief. Providing education and resources to the community at large, such as through programs like Mental Health First Aid,[1. You can learn more about Mental Health First Aid here. I have no affiliation with them.] can help ensure that those in our community receive attention and emotional support. Communities can also provide support through other concrete means, such as financial donations, food assistance, and employment opportunities. Though individuals should remain six feet apart, the distance does not dilute the healing power of relationships.

To be clear, some individuals do experience levels of distress due to the pandemic that warrant professional mental health intervention and support. This does not mean that they have meaningless relationships or are “weak”. We often do not know the struggles people endure. Complications from the pandemic can overwhelm already strained internal and external resources.

We are living through an extraordinary time in history. We are all experiencing psychological stress, though perhaps at different frequencies and intensities. There is nothing routine about our external circumstances, so there is nothing routine about our internal experiences, either. The pandemic has demonstrated how interconnected we are. Let us focus not on individual distress, but focus instead on how we can all help each other during this difficult time. This will not only bolster the mental well-being of others, but will help our mental health, 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
Education Seattle Systems

Recommendations to other physicians from Washington re: COVID-19.

This post isn’t polished, but (a) it seems important to get this information out and (b) it also helps me feel like I have some control over something:

I work as the medical director for a non-profit agency that serves people who are currently or formerly homeless.[1. This post is NOT on behalf of my employer! I am writing as a private citizen who has opinions.] I am trained as a psychiatrist and have previously worked in local government. I live in the county in Washington State where people have died from COVID-19.

Here are my recommendations for other physician leaders in other regions, particularly those who work in outpatient, non-profit settings. I hope this information can help you if once COVID-19 arrives in your area.

Start talking with other physician leaders that intersect with your work now. Talk about how you all will coordinate together. How can your teams all work together to ensure that only people who need ED-level services are sent there? What sort of screening will you all do? If people who don’t have homes need to self-isolate, where can they go? Establish a communication system now because when COVID-19 arrives, you don’t want to fumble through that. If you haven’t met these other people yet, meet them now.

Start talking with physicians who work in your local government. My observations thus far are that physicians in government haven’t been active in planning for systemwide medical issues, and not because they’re not interested, but rather because they are overwhelmed and there’s not enough of them. Start asking questions like: if people who are homeless need quarantine, where should they go? has the city or county started talking with the hospitals to determine a system of where people with COVID-like symptoms should go? who will get tested? is there a centralized phone number clinics can call to alert county authorities of outbreaks? what sort of communication is the city or county having with the state?.

Keep up the advocacy with state and local partners with questions related to system processes. The state and local partners likely won’t have answers, particularly if you serve underserved patients. Since COVID-19 is affecting everyone, governments are thinking about the majority of people, many of whom are the “worried well”, can self-isolate, can go see their own doctors, etc. People without the same resources can’t do the same prevention and early intervention activities, so it is vital to keep following up with government partners so they don’t forget about these underserved populations. (This also includes populations that may not seek health care services, like immigrant and refugee populations.) If you can keep up the questions to your physician partners in government, they will feel empowered to keep asking their partners (e.g., state and federal agencies) for information.

Start teaching stuff to your non-medical partners. Sometimes physicians and nurses forget what we know; we think everyone knows what we know. Agencies that serve homeless populations often don’t have medical staff, so their leadership and line staff may have questions like, “Will an air purifier eliminate COVID-19?” or “Will hydrogen peroxide kill COVID-19?” People may not know HOW to wash their hands. Advocate with your agency leadership to get hygiene supplies now (because most of the suppliers locally are sold out) and make it easy for your staff to practice good hygiene. And don’t make assumptions that people know how to do hygiene stuff.

A small minority of people will do things you won’t like. There are people calling health care agencies pretending that they are the WHO or CDC and are asking for financial information so they can steal money. Supplies, like face masks, may suddenly go missing. Prepare for these sort of disappointing behaviors.

You can’t overcommunicate. In the face of uncertainty, frustration arises. Don’t lie, either; tell people what you know and don’t know. That way, they will be more likely to trust you when you do have recommendations.

Support your staff. You can’t rely on your staff to take care of other people if your staff don’t think you are taking care of them. We heard a comment today during a phone call that an estimated 40% of staff will be out of the office due to illness. Some may also call out because of fear. We can appeal to the better natures of our teams, but they won’t rise to the challenge if they think we don’t care about them. And if they don’t think we don’t care about them, then they won’t have the emotional and cognitive capacity to care for patients. (This applies to local government, too: They must take care of the agencies that provide services on their behalf, or otherwise the agencies will feel unsupported and may not extend themselves.)

People are expressing and demonstrating anxiety, which is fine—there are reasons to worry. But there are things we can do as leaders to acknowledge and mitigate that anxiety. Start now.

Categories
Nonfiction Reflection Systems

The AirBnB Listing.

Had the AirBnB listing included more details about the neighborhood, we probably would’ve stayed elsewhere.

It was lovely: It was a cabin off of a gravel road in a rural area. Fragrant trees towered over the hot tub surrounded by manicured gardens bursting with blossoms of red, peach, and violet. Chirping crickets lulled us to sleep and the songs of warblers and sparrows heralded the rising sun.

The AirBnB listing didn’t advertise the faded truck driving through the neighborhood, a red, white, and blue flag the size of a queen-size sheet flapping from its bed: “STOP THE BULLSHIT: TRUMP PENCE 2020”.

The AirBnB listing didn’t highlight the hand-painted signs leaning against the campers that faced the highway:

     Trump is
   bRinging
     United states back to real
   aMerican
     People

The AirBnB listing didn’t describe the tree farm down the street. The scarecrows guarding the short saplings wore plain white robes adorned with white hoods. Were we reading too much into that?

When we saw the roadside diner, we kept driving because we saw that the first letter of the three words in the name were all K. Maybe locals called it the “Triple K”; maybe it was just meant to be “kute”. Maybe we were reading too much into it.

Nonetheless, we felt like we were in the minority, that we were outnumbered, that we didn’t belong there.

Though we speak impeccable American English, we made a point of greeting people first so they could hear that we were Americans, even if some people don’t think we look like them. We said please and thank you, we smiled and deferred, we were demure. We were model minorities.

Why did we do that? Why did we assume that all people in regions that support Trump would not want us there? Is it fair to assume that all people who support Trump hold racist beliefs? That they believe that we Asians eat dogs, can’t drive, and are socially incapable? Did we think that, if we tried hard enough, we could change their minds?

The AirBnB hosts saw my profile photo when I requested to stay in the lovely cabin. I am obviously Asian. They could have rejected my request, but did not. When we met our hosts—an older white couple, one a military veteran—they were courteous and civil. Even though there was a firearm depot down the road, the hosts had posted signs on their property stating that guns were prohibited. Didn’t these data points reassure us?

And yet: What did they really think of us? Were they simply willing to take our money, even if they thought we didn’t belong here?

Such is the creeping toxicity of racism: You don’t actually know when you should be worried, so you always worry. Even worse for those with darker skin, if you can’t be sure when your life is in danger, then you always feel like your life is in danger.

The toxicity of racism creeps in both directions: Those white individuals who fear that people of color will outnumber, replace, or dominate them also carry this chronic cognitive cargo, even when surrounded only by white people.

Despite climbing mountains bursting with wild flowers, admiring snowy peaks of nearby volcanoes, and appreciating the shade of pine and spruce, we never fully escaped the worry about racism or the worry that we were reading too much into things.

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