Yesterday, as I was going about my business in San Francisco, I passed a man lying in the gutter outside the Westfield Centre on Market Street (the swish multilevel shopping complex with some expensive label stores), who was poorly dressed, given the weather (cold) and was clearly having some sort of episodic fit. The street was packed with Sunday shoppers most of whom were well-heeled. I asked the person I was with whether we should ring 000 to get some sort of professional help for the man and he told me that it would be futile because they wouldn’t come out anyway. It was not an isolated incident. Throughout the city the extent of homelessness and the public nature of mental illness is stark. There are choruses of shouts, anguished cries, megaphoned self-dialogues emanating from almost every street corner, doorway, alleyway, train station and whatever. People who should be in care, suffering and crying out. For the richest country in the world to tolerate this degree of human rights violation is almost unimaginable. While the Australian health system is far from perfect, our mentally ill citizens are much better cared for in state facilities and are not left on the street, homeless, suffering from a variety of obvious physical and mental maladies – and basically abandoned by the system. There are some who escape the net and wander the streets of our cities, but, in general, we do not accept that the mentally ill should be left to their own devices. It tells me that any American claim to greatness is a pitiful, self deceit. This is a heartless society where citizens who are most in need of state support are the least able to access it.
Yesterday, I wrote about the myopic nature of fiscal austerity in terms of starving essential public infrastructure of necessary maintenance and improvement funds, which eventually comes back in the form of destructive floods, sewerage collapses, major bridge collapses, and other damaging manifestations.
Fiscal austerity targets public infrastructure because the cuts are less visible to mainstream society and the damage is usually revealed outside the current political cycle where the austerity is imposed.
Governments typically shift blame to past regimes when a serious breakdown in public infrastructure arises due to spending cutbacks in the past.
The lack of transparency of the risks involved in starving essential public infrastructure of necessary maintenance and development funding helps the government hide their culpability and preserve their political position.
In a similar vein, fiscal austerity is also targeted where spending on disenfranchised and powerless minorities is involved.
The mentally ill fall into this category. Most of us are ill equipped to handle a fellow citizen in deep mental crisis shaking and frothing in front of us. It is an incredibly confronting situation that makes most of us deeply uncomfortable.
It is hard to know what to do in a situation like that. Clearly, our responsibility as fellow citizens is to try to get professional help. That used to be a simple matter of ringing 000 or some other well-known number and waiting for the skilled help to arrive.
But when society has reached a point where its professional services are so overstretched through under funding in the name of some celebrated, but irrelevant AAA credit rating, that they won’t respond to emergency calls anyway, the situation becomes chronic and human rights violations occur.
The US is rather forward at exposing so-called human rights abuses elsewhere in the world, especially where there is ideological tension. But in its own borders, in its own large cities, the public health system engages in massive human rights violations every second of every day and the broader public appears powerless to deal with.
It makes the statements that followed the mass murders recently in San Bernardino along the lines that the Republican presidential hopefuls were deep in prayer for the victims appear grossly hypocritical.
These so-called Christians have massive human rights violations staring at them in the main streets, outside the major middle-class shopping malls, and all they can offer is prayers. When programs are put forward in the Congress for funding which would make an important difference they scream lies about the government running out of money.
In their own professional lives as Congress members they have the capacity to approve essential public outlays, which could relatively quickly solve these abuses and provide their fellow, suffering citizens with some dignity and some comfort.
Yet they spend their professional lives lying about the fiscal capacity of the currency-issuing US government and deliberately undermine its ability to act in the best interests of all US citizens.
It is rather mind blowing when the manifestations of the fiscal austerity are so much on public display – and we are not talking here about some degraded infrastructure, which is bad enough – we are talking about fellow humans who are allowed to suffer heinous hardships right before our eyes and the system barely lifts a finger to help because some bastard or another is so ignorant and/or venal that they think or say that the US government will run out of money.
Or at least, that is the smokescreen they set up to con the public into believing that cutbacks are the only way for the nation to remain prosperous, while at the same time they use the state fiscal capacities to bankroll their mates in various financial and other corporate ventures.
The US data is rather stark.
The data on homelessness in the US principally comes from two sources: The US Department of Housing and Urban Development (HUD) and the US Department of Education. The methodology used by each is different but some general trends are discernible.
The National Alliance to End Homelessness summarises the data as follows (Source):
1. “The number of people sleeping on the streets is declining”.
2. “The number of people sleeping in emergency shelters and transitional housing is increasing slightly in some measures and decreasing slightly in others.”
3. “The number of people living doubled up, considered homeless by some agencies but not by others, has grown substantially over the last several years.”
The latest report – The 2014 Annual Homeless Assessment Report (AHAR) to Congress – published by the US Department of Housing and Urban Development in October 30, 2015 provides comprehensive coverage of the extent of the problem in the US.
1. On average, “there were 578,424 persons experiencing homelessness on a single night in 2014 … an overall 10 percent reduction … since 2010, the year the Obama Administration launched Opening Doors, the nation’s first comprehensive strategy to prevent and end homelessness.”
2. “32 percent … were found in unsheltered locations”.
3. “Nearly one-quarter of all homeless people were children under the age of 18”.
4. “Homelessness declined by 2 percent (or 13,344 people) between 2013 and 2014 and by 11 percent (or 72,718) since 2007.”
5. Between 2007 and 2014, homelessness has increased by 28.7 per cent in New York State, 40.4 per cent in Massachusetts, 45.6 per cent in the District of Columbia, 14.4 per cent in Minnesota, and by 16.6 per cent in Missouri.
Reductions occurred in California (-18 per cent), Texas (-28.4 per cent), Florida (-13.6 per cent), New Jersey (-32.6 per cent), Oregon (-30.9 per cent).
There is a plethora of data available, which I will not summarise here. My main focus was on investigating the link between mental illness and homelessness.
A few years ago I completed a major research project in partnership with an Australian mental health facility investigating the effectiveness of early intervention programs with paid work opportunities for the prospects of use with psychotic disorders.
We found that for this cohort it was critical to intervene before the onset of the illness destroyed the individuals prospects to complete an adequate level of formal education. We also found that with properly designed jobs, which included flexibility to cope with the episodic nature of their illnesses and clinical support available within the workplace, severely ill young people could still make a significant and product is contribution via paid work.
Related research found that the likelihood of dropout and the descent into homelessness and chronic illness was reduced if early intervention and job provision was available.
Our research results were consistent with other studies in the US and elsewhere and provide very little scope for dispute. The issue is to convince austerity-obsessed governments that investing in a set of interlinked initiatives to target mental illness, joblessness, and homelessness is a superior use of real resources.
There is bi-directional causality. In other words, untreated mental illness lead to joblessness and often homelessness. But equally, the loss of a job set off a sequence of damaging events which took a person into a state of diminished mental health, which then, often, lead to family breakdown and homelessness.
It is thus critical to ensure that there are sufficient jobs available that are capable of being performed by the least skilled workers in the population. It is also critical to ensure that the onset of mental disability is treated adequately without delay.
In our final report we recommended a modified version of the Job Guarantee, tailored to the specific cohort with psychotic disabilities as one effective intervention available to public policy officials. The pilot job creation program run by the specific mental health institution in question was incredibly effective.
According to the March 2011 report from the US National Alliance on Mental Illness – State Mental Health Cuts: A National Crisis – “One in 17 people in America lives with a serious mental illnesses such as schizophrenia, major depression, or bipolar disorder … About one in 10 children live with a serious mental disorder”.
The report found that:
In recent years, the worst recession in the U.S. since the Great Depression has dramatically impacted an already inadequate public mental health system. From 2009 to 2011, massive cuts to non-Medicaid state mental health spending totaled more than $1.8 billion dollars. And, deeper cuts are projected in 2011 and 2012. States have cut vital services for tens of thousands of youth and adults living with the most serious mental illness. These services include community and hospital based psychiatric care, housing and access to medications.
This is a glaring example of the myopia (and heartlessness) of fiscal austerity.
We learn that “Communities pay a high price for cuts of this magnitude. Rather than saving states and communities money, these cuts to services simply shift financial responsibility to emergency rooms, community hospitals, law enforcement agencies, correctional facilities and homeless shelters.”
The HUD estimate that in 2015, around 20 per cent of the total homeless people in the US are Severely Mentally Ill. Other studies have this ratio up around 25 per cent.
In the population at large the SMI ratio is about 6 per cent. In other words, this cohort is disproportionately represented among the homeless.
As the US Today study writes:
They’re gripped by schizophrenia, bipolar disorder or severe depression — all manageable with the right medication and counseling but debilitating if left untreated. In the absence of such care, their plight costs the federal government millions of dollars a year in housing and services and prolongs their disorders.
The evidence is quite clear that outreach programs that are well funded and well targeted are very effective. The claim by many neo-liberals that this cohort do not wish to live in homes and are incapable of living in adequate domestic circumstances is not consistent with the evidence.
Is this one of those myths that pervade the economic policy debate to justify cutting spending in these very
And in case some defunct economist comes out and says that fiscal policy is ineffective, they should be reminded that since 2010, there has been a decline in homelessness in the US as a result of the federal government – Opening Doors – program, which is touted as “the nation’s first comprehensive Federal strategy to prevent and end homelessness”.
The Program recognises that:
1. “Homelessness is expensive; it is better to invest in solutions”.
2. “Homelessness is solvable”.
3. “Homelessness can be prevented”.
In my professional life I have sat in rooms with representatives from multilateral institutions, who were well-paid, have fancy mobile phones and in some cases, expensive jewelry (and that comment is not gender specific – I perhaps should have used the word bling), pull up to meetings in fancy cars – and then wax lyrical about how complex the problems of homelessness and unemployment are and then descend into a vacuous set of motherhood statements about the good intent of their organisations etc.
At one meeting, I just got so sick of listening to this nonsense that I informed one of these characters that the solution to unemployment was a simple as a government creating a job. The look on their face was quite something else. Fancy that! Solving unemployment by creating a job.
Similarly, the expansion of Medicaid in the US under the Affordable Care Act has clearly helped to reduce homelessness in general and for those with serious mental illness in particular. See, for example, the October 2014 Report on the Permanent Support Housing (PSH) initiative – Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices from the Field.
The evidence is clear. There are intervention strategies that are extremely effective in helping those with mental illness into secure and stable housing.
The so-called ‘Housing First’ or ‘Rapid re-housing’ strategies treats the mental illness after solving the housing problem. Clinical support accompanies the housing provision. These programs shift the mentally ill citizens off the streets immediately and provide long-term medical and psychiatric support.
Here is some evidence on Rapid re-housing initiatives in the US.
The problem is that these types of strategies are chronically underfunded.
The US Today investigation (August 27, 2014) – Mental disorders keep thousands of homeless on streets noted that in 2014:
President Obama requested a $301 million housing budget increase that would create 37,000 more permanent-supportive housing units and potentially wipe out chronic homelessness in America … That request stalled in Congress.
A more politically popular request for an increase in supportive housing for military veterans passed overwhelmingly and could eradicate veteran homelessness in the USA by next year
It is no surprise to learn (according to data from the AHAR Report cited above) that:
Between 2013 and 2014, homelessness among veterans declined by 11 percent … Homelessness among veterans declined by
33 percent (or 24,117) between 2009 and 2014.
Where there is cash outlaid, goals are achieved.
The evidence is very clear that outreach programs combined with housing first-type strategies, access to on-going treatment and drug provision, skill development and well-designed job opportunities – provide a very effective suite of interventions that not only achieves residential stability but also reduces the symptomatic nature of the mental disability and allows an individual’s material circumstances to improve out of sight.
In May 2015, the Republicans in the US Congress forced through legislation that deliberately cut public funding for affordable housing for low income American households (National Trust Fund).
The Republicans also have publicly opposed the Affordable Care Act, despite evidence that it is an effective support for homelessness.
I read a recent report that made me laugh. On November 21, 2015, the article – Republican Reeling As ObamaCare Opposition Is Crumbling In Red States – reported that “opposition to ObamaCare expansion is falling apart in the GOP stronghold.”
The reason? The report says that “the program has not caused the apocalypse that Republicans predicted” and that the program actually delivers significant benefits to targeted cohorts.
While some public policy problems are not readily solvable through increased outlays, the problem of homelessness, especially the over representation by mentally ill citizens in this cohort is readily remedied with extra funding and properly coordinated policy interventions.
Even in a narrow sense, leaving a significant proportion of our nation’s population to endure massive hardships on the streets is a total waste of productive resources.
It continually amazes me how so-called conservatives who believe in enterprise and all the other buzzwords they use standby and allow millions of people to remain unemployed for extended periods of time in destructive and unproductive states.
Whichever way one wants to construct the issue – the lack of funding for the mentally ill and the homeless in general – is another example of fiscal myopia.
Ultimately, the real costs of leaving this problem to sort itself out (the free market solution) are so large that the short-run ‘saving’ by public departments engaged in austerity become dwarfed by having to deal with a much larger problem in the future.
And then there is the question of humanity and human rights.
That is enough for today!
(c) Copyright 2016 William Mitchell. All Rights Reserved.