Tag Archives: mental illness

Plotting Post-Pandemic Recovery

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Photo by Carolyn Torma

In recent years, the development of local or regional recovery plans following major natural disasters has become increasingly common. The Federal Emergency Management Agency has long encouraged such planning, and I led the production of two major FEMA-funded reports from the American Planning Association on the topic—Planning for Post-Disaster Recovery and Reconstruction (PAS 483/484, 1998) and Planning for Post-Disaster Recovery: Next Generation (PAS 576, 2014). I’ve spoken repeatedly on the topic, trained planners, and valued the collective knowledge of the two teams we assembled to make those projects happen. The underlying idea is to help a community assess its losses, reassess its goals, and find the silver lining in the dark cloud of the disaster that will allow it to rebuild better and stronger than before. This is the central concept of community resilience: the capacity to learn from such events, adapt to the changes they require, and move forward.

The idea of natural disasters has generally encompassed those caused primarily by meteorological and geological disturbances, such as storms and earthquakes, though it includes impacts exacerbated by human mistakes in building and planning. Disasters necessarily involve the collision of natural forces with the human and built environment, which has caused some people to question the very use of the word “natural” in connection with disasters. Personally, I am comfortable with the term “natural disaster” so long as we understand that no disaster exists without this interaction.

But there are those disasters where damage to the built environment is a secondary consideration, and the loss of lives is primary. Drought is somewhere in the middle. Damage to structures can occur, but only as the result of the slow, nagging loss of moisture in the air and soil. Heat waves can take hundreds of lives without affecting a single structure, though they can put enormous stress on energy and transportation infrastructure.

Pandemics, however, fall into another category entirely as biological disasters. They occur when bacteria or viruses emerge in the environment and attack humans before we have developed any effective immunity or vaccines. The current COVID-19 crisis fits this mold precisely. It can be far more devastating than a natural disaster simply because it can roam far more freely across the planet, as did the 1918 influenza pandemic, striking down hundreds of thousands if not millions of people. Before the era of modern medicine, pandemics like the bubonic plague in the Middle Ages could kill half of the affected population. Even without vaccines, we at least have the huge advantage of understanding how such microbial threats spread. Our disadvantage in the U.S. has been national leadership, starting with the President, that has been psychologically allergic to scientific advice. The result has been needless loss of life on a colossal scale.

It was a matter of time before some community, even without such federal leadership, applied many of the principles of recovery planning to the coronavirus pandemic. One critical question related to recovery is identifying the point at which the crisis is over, or at least waning. In natural disasters, drought being again the exception, this point becomes clear within a matter of days, or even hours in the case of tornadoes, as the storm passes. However, weather systems such as that which produced the 1993 Midwest floods, can last for weeks or even an entire summer. But at some point, it becomes clear that the emergency is over, and planning for long-term recovery can begin. In the absence of a vaccine, however, it is less clear when we can use the “all clear” signal for a pandemic. Right now, in the U.S., it is painfully clear that the rush to reopen is producing unconscionable and shocking consequences across the South and Southwest, and in a few other locations as well. It is incredibly hard, perhaps even impossible, to plan meaningfully for recovery when you are still stoking the fire by facilitating the spread of the virus.

Nonetheless, some states, notably including New York, much of New England, and Illinois, have fought hard against the odds to bring down infection rates, which are now a fraction of what they were in April or May. Their victory remains tenuous, considering the larger national crisis that remains a growing threat to public health, but Chicago under Mayor Lori Lightfoot has announced a list of states whose residents must quarantine for 14 days upon arrival, notably including Florida, Arizona, and Texas. Later, Iowa was added. By July 17, the Cook County Department of Public Health expanded that quarantine area to include all of suburban Cook County except a handful of suburbs that maintain their own health departments, and 17 states are on the list with new case rates exceeding 15 per 100,000 people per day. While it is nearly impossible to monitor all arrivals, the message is clear: We don’t want to re-create the problems we so recently overcame.

That is the context in which a large Recovery Task Force the city assembled released a recent report, Forward Together: Building a Stronger Chicago, which examines how Chicago could build a vibrant recovery from the coronavirus experience. Because such reports, especially those involving dozens of contributors and participants, are never crafted overnight, it is worth noting that the effort was launched on April 23, at a time when the outcome was far from clear. Neither the city nor the state could be certain then how long the problem would last or whether the stay-at-home orders and other measures would succeed at all in the near term. As of July 18, Illinois had dramatically increased its testing rate and brought its positivity rate for coronavirus tests down to 2.9 percent, well below most rates elsewhere, although it remains higher in Chicago at 5.4 percent.

So far, the strict measures announced in March have produced measured success, and the task force used that time to look farther down the road to the kind of city that might emerge from this ordeal. Forward Together is, to be clear, not a true recovery plan; it is billed as an “advisory report.” But it is the closest thing to a recovery plan that I have seen so far, and merits scrutiny and consideration for what it offers. (New York Mayor Bill de Blasio promised his own “road map to recovery” on April 26.)

The task force itself was broadly based. Lightfoot co-chaired it with Samuel Skinner, a businessman, lawyer, and political operative who served as both Secretary of Transportation and White House Chief of Staff under President George H.W. Bush. He has a long track record in public affairs. Committee chairs and members included elected officials, among them Cook County Board President Toni Preckwinkle, who was Lightfoot’s run-off opponent in the 2019 mayor election, labor and community representatives, business leaders, academicians, and civic leaders, including some prominent activists. The task force was broadly inclusive, which bodes well for public buy-in on the resulting recommendations. Moreover, the report shows significant evidence of wide community outreach, including a youth forum that tapped the ideas of teens and young adults.

Like all big cities, Chicago has witnessed significant disparities in impacts of the pandemic on specific disadvantaged groups, including the elderly, but also Blacks and Latinx residents. While these two groups each comprise 28 percent of Chicago’s population, they respectively comprise 30 and 48 percent of the cases of coronavirus and 44 and 32 percent of the resulting deaths. This is an important backdrop to the discussion of goals in the report.

The report discusses four specific initiatives to move the city forward and address many of the inequities and vulnerabilities exposed by the coronavirus. Invest South/West aims to bring public and private investment to those neighborhoods in the city that have suffered historic disinvestment, and where COVID-19 rates have generally been highest. Racial and ethnic inequities in coronavirus impact have been notably more severe among both Blacks and Latinx residents, in large part because of lower levels of insurance coverage but also because of differences in job exposures, poverty levels, and living conditions. Solutions Toward Ending Poverty (STEP) is a new program, announced in February by Lightfoot, that is attempting to identify evidence-based metrics that can plot a road map toward reducing urban poverty in Chicago. We Will Chicago—Citywide Plan aims over three years to develop what amounts to a comprehensive plan, something lacking in Chicago until now. The report says We Will Chicago “will encompass all elements of citywide planning.” Finally, Chicago Connected will aim to shrink the digital gap between more affluent and poorer neighborhoods by making broadband more readily available, a need whose urgency has clearly been exposed by the closing of schools and the challenges of assisting children from poorer households with remote learning.

A significant part of the report focuses on the economic development opportunities that Chicago can pursue to restore prosperity as the pandemic recedes. It is clear that certain categories of jobs—food service, retail, administrative, and manufacturing, but also arts and entertainment and personal services—have suffered the brunt of economic displacement from the pandemic. The report notes the opportunity for Chicago, as a result of some economic changes wrought by the pandemic, including shifts to online retail, to focus on transportation, distribution, and logistics (TDL) segments of the economy. These would take advantage of a longstanding Chicago advantage as a transportation hub.

TDL, however, faces its own challenges of inequitable opportunity. Food insecurity represents a serious challenge in “food desert” neighborhoods. Resolving those inequities is the intended purpose of the four initiatives, but it is hardly a challenge that will be resolved overnight. It has taken years of unequal opportunity, to say nothing of deliberate discrimination, to create the current dilemma. Failure to address these problems will slow down or even stagnate Chicago’s recovery from the current crisis.

The report makes what strikes me as an honest effort to address social services gaps that, if anything, grew under the previous administration of Mayor Rahm Emanuel, who closed some mental health centers in a bid to reduce budget deficits. The problem is that such reduced access to services only exacerbates problems among those needing such help and may increase other costs as a result. For example, a significant proportion of the inmates at the Cook County Jail (and many others around the nation) suffers from mental illness.

There is an urgent need to restore those services, but more importantly, the report shows that mental health services are far more prevalent on a per-person basis in more affluent, whiter neighborhoods than in poorer areas. For instance, 48 percent of whites with mental illness were receiving services in 2015, but just 31 percent of both Blacks and Latinx with mental illness were doing so. A map toward the end of the report shows differences shows a variation in presence of mental health providers ranging from zero or well below 0.25 per thousand residents in certain poorer areas of the city to well over 2 in predominantly white, middle-class areas and hundreds per thousand in downtown Chicago, a district well-nigh inaccessible to many South Side residents.

This may reflect, among other things, a disproportionate presence of white professionals in mental health and a need to bring more minority psychiatrists and psychologists to those neighborhoods. Reopening clinics in the neediest areas of the city would be a major step forward. As for the connection to coronavirus, the stress induced by greatly increased unemployment, to say nothing of job pressures within health care, can contribute to mental health challenges. Perhaps the most noteworthy proposal in this section of the plan is the recommendation to create a dedicated 211 line whereby residents can access a wide range of social services. It strikes me as essential, also, to reduce pressure on police to respond to personal mental health crises by instead responding to such incidents, to the extent possible, with mental health professionals and social workers.

As I noted, this is framed as an “advisory report.” I strongly suspect, however, given the tenor of the moment, that its recommendations will find widespread support among Chicagoans. What remains to be seen is how well voters and aldermen hold the administration’s feet to the fire to make it all happen. It is not enough to have confidence in a mayor who seems determined to make it happen. Implementation will require broad-based commitment to achieving the goals the report lays out. That includes embedding those goals in the comprehensive planning process that We Will Chicago envisions, and enacting measures to move them forward.

What is important about this effort for the rest of the country is the very idea of mounting such a broad-based effort to produce a forward-looking analysis of how our cities can recover from the coronavirus pandemic. Many may first have to learn how mayors and governors can exert the leadership, and evince the humility to consider the science, necessary to get the virus under control, as many other countries in Europe and Asia have done. These leaders must also be open to hearing from a widely representative cross-section of their citizens in preparing similar reports. Pandemic recovery planning is for all of us an experiment that can build on the foundations of other kinds of recovery plans while recognizing and thoroughly exploring the unique features of this monumental public health challenge. It is no small matter, and should not be treated as such, politics notwithstanding.

Jim Schwab

 

Weak Links in the Chain

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Resilience has become almost a buzzword with regard to how communities handle adversity and disasters, albeit a very useful buzzword. It focuses our attention on how we can better prepare for and cope with such events. The question of the moment is how the concept of resilience applies to our response to coronavirus.

One of many hospitals in Chicago, all of which have visitor restrictions in place due to the coronavirus pandemic.

I am not and never have been a public health expert, though, as an urban planner and adjunct planning professor, I have often worked with such people. I say this because I want to be clear about the prism through which I am viewing the coronavirus pandemic as a public health disaster. What I bring to the task is decades of work, particularly as a research manager, in the subfield of hazards planning. I am known for deep expertise in hazard mitigation and planning for post-disaster recovery. In this article, I am reaching into that toolbox to help identify what we need to learn from the current crisis.

Specifically, part of what has become the standard approach to hazard mitigation planning is vulnerability analysis, the process of identifying what in plain English are weak links in the chain of community capabilities and capacities to manage and recover from a disaster. Every community, every nation has strengths and weaknesses built into its systems, which are really an ecosystem of economic, social, institutional, environmental, governmental, and other elements of the community that comprise the way the community functions in both sunny times and days of turmoil and dysfunction. How well can that community or nation restore itself, rebuild, adapt, and learn from its experiences? One of the most fundamental elements of success, for example, is trust in government and community leadership, something that is being tested right now in the U.S. That leadership can either greatly enable and empower or greatly hinder the capacity for effective response to, and planning for recovery from, a given disaster.

But my focus here is on what a vulnerability analysis of our response to COVID-19, the disease caused by the novel coronavirus, might include. I say “might” because I do not pretend that what follows is comprehensive. It is merely suggestive. A more comprehensive list would best emerge from a summit of leaders and experts when it is time to decide on the lessons learned from this disaster. For now, leaders are rightly focused on using existing authorities and capacities to control the spread of the disease.

The main point of a vulnerability assessment is to identify potential points of failure relative to the hazard under consideration. For instance, with hurricanes or floods, we would want to know what roads or bridges would collapse or become impassable. We would also want to know the locations of substandard housing that might suffer damage or destruction or endanger its occupants. There are dozens of other examples of potential points of failure that I could list here, but presumably, you get the idea.

With the novel coronavirus, we are dealing with an invisible hazard that inflicts suffering and death on people, not buildings or structures, and—most importantly—for which there is not yet an identified cure or vaccine. Most people do not die, and many suffer only mild symptoms, but the spread of the disease is of radical concern in part through the slow rollout of testing kits in the U.S., which exacerbates an existing inability to know precisely who is infected, especially since many people test positive who are asymptomatic, that is, not exhibiting clear symptoms of the disease. Vulnerability depends on various factors, most notably, but not exclusively, age. Respiratory and other existing conditions can elevate that vulnerability, while some older people may be tough enough physically to weather the assault. Thus, identifying and classifying real and potential victims is a business fraught with uncertainty.

Given all that, where are the weak links in our communities? Many can be readily identified from the more routine aspects of vulnerability assessments, starting with governmental capacity:

  • To what extent has the city, state, or the federal government prepared and established capacity for anticipating the problem and quickly enabling the appropriate responses? It is perfectly logical to expect that greater capacity should exist at higher levels of government that have greater resources at their disposal.
  • What is the level of political maturity among the electorate, and the political will for undertaking and enforcing difficult but necessary decisions in a crisis?

The biggest questions surrounding coronavirus seem to relate to institutional capacity, some of which can obviously be enhanced or supported through governmental capacity, for example, in procuring and distributing the personal protective equipment, ventilators, and temporary hospital beds needed by the regional “hot spots” for virus outbreaks, which at the moment include New York, but also a frightening spike in confirmed cases and deaths in the last few days in Louisiana, possibly tied to the huge crowds attending Mardi Gras in New Orleans. These have led to Gov. Jon Bel Edwards issuing a stay-in-place order similar to those in effect in California, Illinois, and New York. Among obvious questions in a vulnerability assessment going forward:

  • What hospital capacity exists for treating large increases in numbers of patients in a future pandemic? This includes emergency room capacity, intensive care units, and other essential elements of the treatment process, as well as the ability to expand access to protective gear. It also involves the adequacy of skilled professionals to work with this increased patient load.
  • What capacity exists to monitor, work with, and even thin the population of crowded jails and prisons, where social distancing is effectively an oxymoron, and the potential for rapid spread of disease can amount to a death sentence for those confined behind bars?
  • What are the sanitary and patient care conditions in local nursing homes, and how effectively are they regulated? Nursing homes and similar facilities for elderly medical care have in some cases become virtual incubators for the spread of coronavirus, leading to situations where relatives can no longer visit.

Many of these questions also lead us to questions of economic vulnerability, which also pertain to social equity. Restaurants in states that have instituted closures of public places where people normally congregate in large numbers have laid off thousands, possibly millions of workers—the numbers change by the day—who often work for hourly wages and need every hour to pay the rent. Workers in the gig economy, the tourist economy, and the travel industry are all similarly vulnerable in varying ways. One result, even under normal circumstances, is that many of these workers, some of whom are also undocumented immigrants, are reluctant to take sick days because they have no paid sick leave. Often, they also have no paid health insurance, or cannot afford it.

That, in itself, needs eventually to be recognized by the United States as a source of pandemic at worst, or a threat to public health, at best. Take, for example, the story of a McDonald’s worker who shared the news that he went to work ill, vomited when he ran to the restroom, but was afraid to call in sick because a missed paycheck was a threat to his economic security. How often does that happen, and how reassuring can it possibly be to customers who even think about the potential consequences? Is anyone attempting to gather data on this problem? A worker rights organization, Arise Chicago, has been fighting for better protection for workers on this front for several years, and won passage of a Cook County ordinance in 2016, but the battle continues. At the moment, these workers either are laid off because of restaurant closures, or are adapting to the temporary new world in which their employers can sell takeout, drive-out through, or delivery.

But whether it is hotel, restaurant, or transportation workers (such as taxi and Uber drivers), among others, the vulnerability lies in the harsh facts that drive them to show up for work despite illness because of their lack of paid sick leave or medical coverage. Nowhere in America can an honest vulnerability assessment of future pandemics ignore these socioeconomic imperatives. Economic facts drive health impacts, which in turn drive at least some of the questions surrounding health care capacity. In this sense, one can see how identifying all the weak links in the chain of vulnerability means recognizing the interrelationships between the various categories of vulnerability I listed initially.

This description of the process could go on for many more pages, but it may be more important to let the complexity and interdependence of it all inspire further thought. With that in mind, let me offer a few other items for consideration:

  • Given the inability of some parts of the population to accept the necessity of temporary restrictions, how well prepared are we to control the wayward behavior of the few, even as the majority of our citizens show adequate consideration for others around them? What are we prepared to do about them?
  • In the event of a lockdown, what are we prepared to do for victims of domestic abuse who are suddenly trapped inside their homes with abusive partners, parents, or relatives? Do we have institutional capacity to remove them to safer quarters and the ability to answer their calls for help? Sheltering in place is hardly likely to make an abuser more sympathetic.
  • How well are we positioned to assist those suffering from mental illness, for whom isolation may increase propensity for depression and suicide?
  • In what ways can we respond to the needs of homeless people, for whom the spread of a pandemic disease may increase due to proximity and unhealthy circumstances?

There are some very hopeful signs of creative thinking on these issues in local and state governments, if not in the White House. For example, the City of Chicago has reached agreement with several hotels to use hotel rooms as isolation rooms for victims of COVID-19, with the city paying for the capacity in advance. This relieves hospital capacity, to some degree, but it also provides some employment for hotel workers who would otherwise be idling at home because of the shutdown of the hospitality industry as both leisure travel and conventions grind to a halt. The workers will provide food in the kitchens and undertake other safe duties, while trained public health personnel deal directly with the quarantined patients. The hotels stay open, some workers stay employed, and some strain is removed from medical facilities. Some members of the Chicago City Council are now calling for the use of vacant public housing units for the same purposes.

Likewise, some otherwise closed YMCA facilities will begin accommodating the homeless while providing necessary social distancing. All of these are creative solutions that can emerge from identifying the weak links in the chain, and can provide cornerstones for sound planning for resilience in the face of future public health emergencies.

In short, let’s all keep our thinking caps on. We’re going to need them not just this time, but for the future as well.

Jim Schwab

Incident below the 606

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The 606 is, if anything, ordinarily a very safe, quiet space full of people enjoying the outdoors. This photo is from opening day in June 2015.

The 606 is, if anything, ordinarily a very safe, quiet space full of people enjoying the outdoors. This photo is from opening day in June 2015.

One of the more disquieting aspects of urban life is an occasional confrontation with the irrational. I have debated telling this story, but I decided that enough other people either have had or will share such experiences that sharing it may have great value. One must be prepared somehow to handle these unexpected situations.

In my very last post a week ago, I noted my workouts with a trainer at XSport Fitness. One of those occurred yesterday, Saturday morning, at 8 a.m., after which I walked home with my gym bag, stopping for a snack and coffee at McDonald’s, after which I crossed Western Avenue by going up the ramp on one side to the 606 Trail, about which I have written more than once, and crossing to the other side. It is when I came down I encountered trouble, in broad daylight in the middle of a sunny, beautiful morning.

I was heading down the sidewalk to my home when a young man stood in front of me and demanded to know where I was going. “I’m going home,” I said in a matter-of-fact voice that was intended to suggest that the rest was no one else’s business. Nothing about his manner suggested that this was a friendly question.

“This is my neighborhood,” he asserted, “and I don’t know you.”

“It doesn’t matter,” I said, and began to move down the sidewalk. But he moved to block my path. I moved out toward the street to pass him, and he moved again. He reasserted that he did not know who I was, and I made clear that was irrelevant to my right to continue on my way home. But he would not get out of the way, prompting me to ask, with increasing exasperation, “What is your problem?”

I had both the gym bag and a mostly full cup of coffee in my hands. Before I could truly absorb just how determined he was, I saw his punch coming toward my jaw. I moved back just as quickly, so that his swing only barely connected with my cheek, but now he had really angered me. I threw the coffee at him, and it splattered across his shirt. But I lost my footing and fell backwards, landing on my rump on the planter strip below the trail 16 feet above. He picked up the gym bag and threw it at me while I was down. I quickly got back up, but it was clear this confrontation was not over, and I might just have to throw a few punches of my own if he continued.

But by then, something else happened that I think is one of the redeeming glories of the 606. A small crowd of witnesses to the scuffle had gathered above, and it was very clear to all of them that he was the aggressor. Some began to try to talk him down, threatening to dial 911 for the police. I would have done that myself, except that it was a rare trip in which I had not brought my cell phone. “Do it,” I yelled to them, signaling, I suppose, that I did not have a phone with me. At that moment, I would have liked nothing better than to see a squad car show up. But it did not happen.

What did happen is that one of the men on the trail had made his way down the ramp to usher me away from the confrontation while the young man watched. Amazingly, considering all the witnesses to what had happened, he loudly protested that I had thrown my coffee at him, to which I replied, “Yes, after you took a damned swing at me!” In effect, I retreated at the other man’s urging, continuing further down the trail and then circling back to my home. Equally interesting, though, someone came out of the nearby building and ushered the young man inside. It was over; no one was hurt.

I subsequently made a police report at the station, cycling there after I got home. As soon as I told my story, the officer behind the desk indicated they knew who it probably was, showed me a picture, and I verified him as the individual who had assaulted me. They told me he was mentally ill. I know his name but will not share it. I know where he lives and will not share it. I have learned from detectives shortly after originally posting this that they are still looking for him. This was not the first time he had accosted someone. Moreover, they said it was consistent with his “M.O.”

One important feature of this story is that it highlights a problem we all know exists, but that our society does a remarkably poor job of confronting: the management of the mentally ill, including, in his case, the apparently violent mentally ill. I do not profess to be an expert in this area. There are social workers and psychologists who are much more conversant with all the issues and bureaucratic complications of a system that copes poorly, in part because most of us do not want to spend much time thinking about such people, let alone funding programs to treat them. Our jails and prisons are full of them. Many of the homeless are victims of mental illness. Yet, in Illinois, we have a governor more focused on union-busting than on funding needed social services, despite persistent pleadings from churches and social service agencies, and a legislature that is more focused on re-election than on finding solutions to our fiscal mess. We are at a standstill.

I am not saying, of course, that there is any foolproof solution that would prevent encounters such as mine. Mental illness is a fact of human life that may never disappear no matter how many medicines we invent. There will always be the problem of someone who needs those medicines not being willing to take them. There will always be those who slip between the cracks. It will fall to those of us with enough poise, enough mental stability, and enough judgment to try to defuse these situations. In this particular case, I am enormously grateful to all those people on the trail because, in their absence, I am not sure what else might have transpired. It was a somewhat unnerving incident in part because, rational creature that I am, it took a minute or two for me to grasp that this individual was simply not operating with the same set of perceptions that were part of my universe. In my universe, the street belongs to anyone who wants to use it, and other people’s rights end at the beginning of my nose, as they say, or in this case at the edge of my jaw. In his universe, I constituted some sort of threat merely by trying to walk past him.

If I had been more elderly than my 66 years, less physically fit, or a mother with a child, the incident could have been terrifying, and I suspect it has happened and may yet happen again. And in the process sometimes, we end up with even more of the walking wounded among us. It is a sobering thought on an otherwise sunny Sunday morning.

 

Jim Schwab