Working as a paramedic, I’ve seen systemic failures in our way of managing homeless that combine ineffectuality with breathtaking expense. I’ve known individual homeless people whose use of the emergency services have cost the taxpayers hundreds of thousands of dollars each, and I’ve known dozens them.

How does this happen? Much of the explanation lies in fact that the institutions (standing apart, like silos) responsible for the care of the homeless don’t cooperate. Worse, they duel.

To understand the analogy of dueling silos, let’s look from the vantage point of the typical situation for the typical homeless person I routinely see: he is a mentally ill alcoholic with a criminal record. He (almost always a he) cannot get a job to pay for a home because of his criminal record (that’s the over-incarceration silo). He cannot get into public housing because of that criminal record(ditto). He cannot get into a homeless shelter if he is drunk (the shelter silo). Drunkenness/drug addiction and homelessness aggravate his mental illness (the psychiatric care silo).

When the healthcare system encounters people like this, we have to treat them as many times as their problems present. Which, for homeless drunkenness, can be every single day. Healthcare workers are vulnerable to lawsuits because we are responsible for the problem, but we have no power over it, and the perpetual treating of these chronic problems as emergencies is ineffectual and expensive. That’s the defensive medicine silo needed for defense against the litigation industry silo.

The interests of the silos are not aligned: the healthcare industry, shelters and psychiatric care institutions want to help them, the jails not as much. Try to take public money from the jails to give to the others, and the duel for funding will bring the lion’s share to the politically connected. Which, in incarceration-happy New York City, is not the mental health silo.

The rise in homelessness should also be seen as a decrease in their options. It’s an unintended consequence of our decades of criminalizing our approach to mental illness and addiction. Add in “broken windows, zero tolerance,” types of policing (lots of which is still related to drunkenness and mental illness), and the outcome is that vast numbers of Americans, disproportionately minorities, have a criminal record. Which cripples their ability to earn money, and which puts them at risk for homelessness (and also makes them unable to provide for families, BTW). Our diligence in implementing these incarceration policies was never accompanied with an exploration into the question: “will people with criminal records just disappear?”

On the homeless shelter silo end: denying drunks access to the shelter system is not a bad policy, in and of itself. Those in recovery would be triggered, and a shelter full of drunks would quickly degrade into a gin mill. Forget mixing drunk, often criminal, often psychotic, men with women. Despair at having them near battered women. Panic at the thought of having them near sheltered women with children. Imagine the policing nightmare of wrangling a shelter full of drunk, psychotic people. Realize the liability fault-line that is just a flight of steps in a place like that, much less the bendered, semi-conscious drunkards the place would rapidly fill with (the lawsuit-happy legal industry silo).

On the other hand, as George Carlin once said: “asking an addict to just say no, is like asking a depressive to just cheer up.” Variants of failure, using a moralistic model for coping with substance abuse, go back millenia. Obviously, if the idea worked, it would have done so by now, some time, somewhere, in cultures religious, traditional, modern, authoritarian, orderly, free (etc). The modern twist to the problem is, now, everyone is responsible to pay for the care of the drunkard, and it’s open-ended. You are paying now, already, you will continue to pay. It’s just a question of: how much? What results do we buy?

To get to a financially stable, medically ethical goal of treating the sufferer of homelessness, we need to mitigate the cycle (there is no “cure”), which is better defined as a “syndrome,” which is: untreated mental illness; often correlated to criminality; co-morbid with addiction; leading to homelessness; which exacerbates the others; which inevitably cause bad health outcomes; which need expensive emergency care; the deliverers of which are helpless to resolve the chronic causes of the acute presentations. In order to do those things, we need to reform the most powerful interests in the country, in the interests of the least of us (the homeless), and for the benefit of the most of us (the taxpayers).

We’ve painted ourselves into this corner: a politician, juggling the silos needed to make a collation powerful enough to be a successful politician, must sell to a neighborhood (the NIMBY silo) a place for crazy, drunken ex-cons to live, so they won’t burden the healthcare system, which the taxpayers (too diffuse for their own silo) pay so expensively for. Which is a microcosm of why Americans pay the highest percentage of our GDP on healthcare, double the next highest spender on the list, and gets middling results.

Can we expect this feat of integrated reform from a political system torn asunder by the completely undefinable (what racism is, among many others)? Better get out your checkbooks (again).

Subsequent parts of this series of articles will be explorations into how other nations have untangled the syndrome, and fantasies of what changes we might make had we the political functionality.

Eugene Darden Nicholas

About Eugene Darden Nicholas

Eugene Darden (Ed) Nicholas is from Flushing Queens, where he grew up sheltered from the hard world, learning the true things after graduating college and becoming a paramedic in Harlem. School continues to inform and entertain in all its true, Shakespearean glory. It's a lot of fun, really. In that career, dozens of people walk the earth now who would not be otherwise. (The number depends on how literally or figuratively you choose to add). He added a beloved wife to his little family, which is healthy. He is also well blessed in friends and colleagues.


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