A prison, an asylum, or both?

Why are there so many homeless people in the US, so often suffering from mental illness? Because we closed the asylums, of course! That Q&A has become canon. But what would happen if we opened large psychiatric institutions again?

Fort Lyon. Photo (c) The Pueblo Chieftan

NPR has a piece on such a proposal: Colorado Weighs Reopening Psychiatric Hospitals for Homeless (including a short audio segment from All Things Considered). Though much of the impetus seemed to come from creating jobs and reusing an existing campus — Fort Lyon, which was once a veterans’ psychiatric hospital and then a prison — the plan would bus up to 300 of Colorado’s homeless people to the Fort, which would serve as a rehabilitation and transitional housing facility. At the end of the week, the bill to make this happen was shot down, but it will be added as an amendment to another bill.

Improving the plight of mentally ill homeless people should just be a matter of balancing cost/benefit of allowing things to continue as they are or bringing back the institutions, right?  The solution is not a simple binary (and neither was the problem, I’d argue, though that has become the prevalent discourse). Even if we imagine a Utopian care and rehabilitation facility and not a dumping ground like Vita, is the best option to remove homeless people from the community, sweep them out of sight, and hope that budget priorities don’t empty them onto the streets en masse again?

Sam Tsemberis of Pathways to Housing is quoted in the NPR piece. “Having someone in transitional housing teaches people how to manage living in transitional housing.”  I’ve heard a bit about the Pathways to Housing model in the past: it provides housing first — immediately taking homelessness out of the situation — and then adds needed counseling and treatment. (The website is very broken in Chrome; I didn’t check other browsers.) PBS NOW did a half-hour piece about the success of this approach, despite the obvious concerns it raises. [Watch video.]

The head of Colorado’s Coalition for the Homeless, John Parvensky, sees a need for both approaches to reach the range of people who find themselves long-term homeless.

“It’s not really a question of either-or: Should the state support community-based options or should they support Fort Lyon?” says Parvensky. “They really should be doing both, but historically they’ve been doing neither.”

Reading a number of Colorado news articles, it quickly became clear that what’s being debated is not the question of what’s best for homeless people. It’s about budget and jobs and veterans (an earlier proposal had Fort Lyon as transitional housing explicitly for homeless veterans). It’s about the corollary to the American Dream that says that everyone should pull himself up by his bootstraps and take personal responsibility for improving his life.

I’m not convinced that large inpatient institutions are the solution — my personal opinion is that they cause new problems without solving anything but how to hide inconvenient people — but it’s hard to argue that ignoring the problem is better for anyone involved. On my future reading pile: a list of psychology/psychiatry and social work studies on the Housing First approach (anyone have a good anthropological study to recommend on this?) The claimed cost savings of it soothe my fiscal conservative side, while a humanistic method that treats those on the streets as people first — not as junkies or crazies — appeals to my inner anthropologist. The phenomenological experience of being treated worthy of shelter must be so different than that of trying to get clean, find work, or stay on a psychiatric regimen while homeless in order to be considered for a housing program.

The homeless guy in the apartment next door

by Jonathan Bartlett for LA Weekly

William had been homeless for about 20 years when he received a $200,000 legal settlement. One of his first actions was to do what many would applaud: he got off the streets and out of the broken-down hotels of Los Angeles and rented an apartment.  What he did not do was bathe, wash his hair, change his clothing, wear shoes, or alter his lifestyle of keeping all of his possessions in shopping bags.

The very day he moved in, the leasing agent left soap, shampoo, towels, and a change of clothing in his apartment.  William was insulted and disgusted that his home had been “contaminated.”  By the next week, neighbors were making complaints about the foul odor they said was seeping from his unit.  A veritable battlefield of potpourri and deodorizers was laid out between his door and the next and eviction threats began.

Read the full story on the LA Weekly site: The Man Who Smelled Too Much

I couldn’t help think of a piece by Bourgeois (From Jibaro to Crack Dealer: Confronting the Restructuring of Capitalism in El Barrio) that we read in Anthropology Theory this week.  The “common sense” of the other residents of the nice apartment building is foreign to William.  If the problem is the odor leaving his home, then fine: he squirts some peppermint soap under the door and calls it good.  His neighbors, the building management, and the eventual jury he faces can’t comprehend why he doesn’t simply bathe, put on shoes, and change his clothes.  The foreman is baffled why William won’t cut his hair, since “it grows back.”  There is some victim-blaming going on, but what about the rights of his neighbors?  The comments on the article make for an interesting read, as well.

What isn’t an epidemic?

Ben’s post on violence, and my response, have got me thinking about one of the (many) questions we raised in class but never really answered: does it always make sense to think of health concerns driven by behavior (rather than, say, microbes) as epidemics? We see this all the time in the media and in the academic literature: the obesity and tobacco epidemics, most famously.  And then there are a host of “epidemics” of behaviors that have been medicalized or psychopathologized to fit into the disease model, but I’m pretty sure it would have sounded absurd to refer to them as epidemics until fairly recently: sex addiction, for example.

What are the problems with using the label “epidemic”? Should the term be potentially applied to any set of behaviors that lead to adverse health consequences, or are there limits? We have discussed some examples where it seems more productive to think of behavior in terms of epidemics even when we may find that behavior abhorrent: needle exchange programs have been very successful in limiting the spread of AIDS and hepatitis, for example, even if some feel that they condone illegal behavior.  The term is also a useful way of undermining the medical tendency to blame the patient: as we know, behavior occurs within a socioeconomic context (cf. structural violence), pretty much every disease results from a complex interaction between behavior and pathogens, and many forms of behavior have a genetic component.  Maybe there are good reasons to use the blanket term “epidemic” to erase the distinction between passive (victim) and active (deviant or unsanitary citizen) when we talk about health.

But there are political consequences of the “epidemic” label as well: to use a current example, Bloomberg has been using the term to justify his attack on soft drinks in New York.  Whether we agree with the soft drink ban or not, it raises the question of how far government control of the behavior of its citizens should extend in the name of addressing a public health concern… and has some uncomfortable resonances with the state-of-exception, war-on-terror rhetoric used to justify the erosion of civil liberties post-9/11.  If violence is an epidemic, should we get rid of the Second Amendment in order to reduce the virulence of the disease?

Thoughts? Can you think of a recent “epidemic” that you don’t think merits the name? This one, maybe? Where and why do you draw the line?

Supervised drug injection center

Micah shared in May: We touched on Merrill Singer’s work in class, and the ethical quandary vs. the epidemiological common sense of trying to make sure IV drug users aren’t infecting themselves.  Needle exchange programs in the states are highly controversial, but apparently Canada is way ahead of us.  At what point, if ever, does it make sense to “blame the victim”?  Vancouver’s Supervised Drug Injection Center: How Does It Work?