Most of us know that the American way of managing homelessness is ineffectual. What is less well known is how expensively ineffectual it is. What we spend on our way (calling it a “system” is laughable)) could provide for a system that works better, many times over, in both cost and efficacy, but for a counterproductive application of excessive morality. One example tells us why:

I got to know a homeless man named Michael Grace in my work as a street medic. I’d get him as a patient twice a month, or so. That’s just me, just one medic of many. When he passed away, it appeared in our productivity statistics. Each paramedic call costs over two grand. Mostly, a fire engine is sent, which costs the tax payers another grand. Expensively ineffectual: three grand, twice a month, just me, just for transport to the Emergency Department (ED), where they often found things wrong with him, mostly related to his being homeless. His homelessness was largely caused by his drunkenness, which was intertwined with his mental illness, which was exacerbated by his living on the street, which exacerbated his drinking, which exacerbated his mental illness, which sent him to the ED.

That cost does not include that of the poor schmo who has a “true” medical emergency and can’t get the right help because the EMS units are expensively and ineffectually tending to hundreds of homeless. Or to patients that dwindle to danger as the ED staff wrangles its many Mikes.

Michael Grace was from Ireland, with a brogue that was his main charming device and his other survival tool (panhandling) apart from going to the hospital. Imagine Emmet Kelly the clown, but skinnier. He had the gift of gab, but also the curse of lip, for which he was beat-down regularly. I had him once where he had a shaved head and a crescent of surgical staples across the side of his skull from a bad one. That fractured skull/concussion alone probably cost taxpayers a hundred thousand dollars. Which was almost certainly never correctly treated, so add TBI to his smorgasbord of problems. The rate I learned, of a community’s liability to pay for trauma, is a hundred thousand dollars per bullet wound.

All Mike would have to do was lay down on the sidewalk, and a ubiquitous bystander would call on a ubiquitous cell phone, and we would get the call as “Unconscious, man down.” We and a fire engine would go out. Bystanders would film our every move. Forcing him to stay on the street when he declares an emergency is considered patient abandonment, career-ending, and sometimes criminal, so to the ED we’d go.

Mike had seizures from alcohol withdrawals, but also from his head trauma habit. Imagine what’s involved in keeping a drunk, homeless man with scrambled brains, twice-daily current with seizure meds. So we’d get him as a seizure quite often, too.

In a microcosm for our whole war on drugs, there was an incident where Mike drew his nemesis-nurse, who took away his vodka pint, and ceremoniously dumped it down the drain. “Oh, now ya done it!” He said. He started seizing a few hours after that. God only knows if it was withdrawals from his flushed bottle. Gone are the days when a wise doctor could just hand him a pint and sit him in a corner. Mike seized and seized, had to be chemically paralyzed, had to go on a ventilator, and went up to the ICU for a few days. So that makes more tens of thousand of dollars. All for the cost of a 4 dollar pint of Georgi vodka.

So, just in the scope of my experience, Mike might have cost the taxpayers upwards of a quarter million dollars. I always gave him money for his ‘lil pint after that.

Mike was well aware drinking too much was naughty, he heard about it from everyone since he was a teen. He gave his life to it. Obviously, for some, the lesson just doesn’t “take.” For these, asking them to just stop drinking, so they can get into a shelter, so they can get their chronic medical problems stabilized, and stabilize their mental illness (which is lots of why they drink and are homeless), is like asking an amputee to tap-dance.

Mike passed in mid-April, but I had him in March, where someone called for him because he lay across the sidewalk. We found him, dusted with snow he didn’t even bother to wipe off. He said he “had it,” and he was right. That was the last I saw him. He was 47 years old. In my opinion, what really killed him was when his ma, back in Ireland, passed. A collection went out, to get him his airfare back for her funeral. Of course, he mucked that up, probably over the stress of facing the rest of his family. He drank the money, played big-man to his friends. The shame ate him to death, albeit two years later.

Defining what works for people like Mike must include redefining our moralizing. A person whose alcoholism is mitigated by (say) a “wet shelter,” but remains a drunk, is not a failure when we compare it with what it costs to process him in an endless loop of jail, homelessness, and hospital ED. Maybe we can rehab them off alcohol from that stable place. I’ve had homeless tell me they drink from the boredom of homelessness “and you’d do it too.” If Mike just had seizures, we would not fault him, or dare deny him his medication. Add in the disease of alcoholism, and the enforcement of morality (totally ineffectual anyway), costs us upwards of a quarter of a million dollars. Portugal applies medical ethics to the medical problem of addiction using the model of mitigation and harm-reduction, and enjoys breathtaking success. The lesson applies just as well to our opioid epidemic, which is now killing more of our countrymen than motor vehicle accidents.

I will, in subsequent posts, examine the institutional silos of power that would need to change to make something like a wet shelter, with alcoholism treated as a disease, possible. Another will explore how our moralizing in the housing markets brought about similar unintended, expensively distorted, results.

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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