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No simple solutions

The problem of homelessness involves much more than a lack of housing

No simple solutions

HUD Secretary Ben Carson participates in a roundtable discussion at Stella apartment homes in San Diego, Calif. (Howard Lipin/The San Diego Union-Tribune via AP)

Last week, U.S. Housing and Urban Development (HUD) Secretary Ben Carson came to my city to discuss Los Angeles’ homelessness crisis with Mayor Eric Garcetti. While in L.A., Carson bused down to South L.A. to visit an accessory dwelling unit (secondary housing in a single-family unit’s backyard) as one possible solution. The Trump administration has criticized California for having excessive red tape that makes it harder to develop new housing but hasn’t offered many strategies to address California’s housing and homeless crisis other than to remove regulatory barriers. 

Carson is not wrong about the cumbersome regulations—and it’s something many California politicians are working on—but to get a clearer understanding of why it’s so hard to solve homelessness, it would also be worth the secretary’s time to sit with a street outreach team and observe the cases they deal with on a regular basis. 

That’s what I did one morning. I visited the Echo Park branch of Homeless Health Care Los Angeles (HHCLA), a nonprofit clinic that treats the most impoverished population in L.A., to join a medical outreach team composed of a physician and two nurses. Because of patient confidentiality laws, I can’t provide the names of the patients, but here are three typical cases that show why helping the homeless involves more than offering them shelter, treatment, or housing. 

Let’s start with an elderly woman, whom I’ll call April. April has a bad injury on her leg. It’s so bad that the flesh is stripped off, leaving a red, infected gash. The infection has seeped into her leg and is now dissolving her bones. The last time she agreed to see a doctor, the doctor said she needed surgery soon or she would lose that leg. 

The infection is getting worse and worse, but April still has not been admitted into a hospital for surgery. Partly, it’s because many specialized surgeons in the area don’t take Medi-Cal and thus refuse to operate on her. But mostly, it’s because April herself has refused to go. She says she’s unwilling to leave her belongings. 

That’s something many people don’t realize about chronically homeless folks: The stuff they have piled high on a cart that they push around all day? Those things may look like stinky, rotting junk to you, but to them, it’s their entire economy. It’s their life. April’s case is complicated by her undiagnosed mental illness. She picks up random stuff from the streets to hoard, and they’ve become as valuable to her as high-priced items are to a collector. Something in her mind finds enough security and comfort from these seemingly worthless belongings that she’d rather hobble in pain than give them up. 

Over the last few weeks, the outreach team went to visit her regularly, trying to convince her to go to the hospital. It almost worked twice—the pain was so excruciating that April let the nurses accompany her to the ER. But the wait at the ER takes as long as 12 hours, and during that time, the woman began worrying about her belongings, and so left. The nurses can’t force her to stay, so they let her go and tried again the next day. 

The physician suggested giving April some psychiatric medicine, which might alleviate her hoarding symptoms. Legally, they cannot force her to take medication against her will unless she’s a danger to herself and others or is gravely disabled. April’s injury and lack of housing do not make her gravely disabled under state law. She is willing to take medication, but few people living on the streets are capable of taking medication consistently and regularly. Without constant monitoring, many of them lose their medication or completely forget about it.

The day I visited the outreach team, April finally seemed ready to go to the hospital. The nurses recommended that she divide her belongings into three categories: One pile for “must haves,” another for “maybes,” and the other for “throw outs.” She agreed to do it, because she said she couldn’t bear the pain anymore.

The outreach team hurrahed, but as soon as they got together to discuss the situation, they scrunched their eyebrows with worry: Now, where were they going to put her belongings while she’s in surgery? April has two carts packed with things, and it was highly unlikely that she would be willing to part with more than half of those things. And after her discharge, where will she go? After working so hard to convince patients to seek treatment, the outreach team now has to scramble to make that happen, and it’s not easy. 

“That’s the hardest thing about this,” one nurse sighed. “She’s finally willing to go to the hospital, and we need to strike while the iron’s hot, but we can’t just snap our fingers and make it happen for her.” 

The nurse calls a program in L.A. that helps with housing, employment, education, and mental health services to the homeless. They say they may be able to get her a motel voucher to store her belongings, but it could take a week to get one. Unfortunately, April doesn’t have much time. She might have a flash of rationality to seek treatment now, but in a week she might lose that resolve. Worse, if she waits any longer, the doctors would have to amputate her leg, or she might become really sick from the infection. 

Later, the team talks about another patient. Let’s call him Adam. Adam also has a mental illness. He has delusions that cause him to wrap wire around himself to “protect” himself from outside forces. Those wires cut deep into his skin and are very painful and potentially dangerous. Adam has a housing voucher, but housing won’t do him much good when he’s constantly psychotic and refuses to take medication for his mental illness. Again, doctors cannot legally force medication on him unless he meets specific criteria for involuntary treatment—and even with his delusions, Adam is well-versed enough about his “civil rights” to insist on living his life the way he wants to live it. 

One more case: an old woman who sits at the bus stop all day, wrapped in layers of coats and sleeping bags. People can’t tell if she’s blind, but she wears thick sunglasses and crumples newspaper between her eyes and the glasses. Passers-by became concerned—a heavily bundled old woman sitting exposed to the blazing sun for hours could suffer from heat stroke. So they called the police, but when the police tried to take her to the hospital, she flipped out. “You have no right to take me!” she screamed. “I have rights! I know my rights! You have no right!” The police officers stepped away, knowing how it looks to the public for a poor old lady to be screaming about her rights at the cops in L.A. 

The physician turned to look at me: “See? Not so easy as it seems, huh? So many barriers!” 

Multiply these cases by hundreds and thousands. Currently, California has more 150,000 people experiencing homelessness. Officially, about one-third of them suffer from a mental illness, but people who deal with the homeless on the streets tell me the percentage of those with mental illness is much higher. 

That’s why even as I get frustrated with my state and local leaders for not solving the homeless crisis quickly enough, when I look at how homelessness looks on street level, I get it: It’s not easy. It will never be easy. If there’s one thing I learned from reporting on homelessness, it’s this: Fellow citizens, be wary of anyone who tries to present simple solutions to this mind-numbingly complex issue, because there is none.


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  • Ceelynn
    Posted: Thu, 02/20/2020 06:40 pm

    Questions I have... for April, it seems like there could be a network of Christians willing to step in and help by watching her belongings during her surgery and post-op.  I'm not sure how far a volunteer would go in possibly giving her a place to stay during recovery or maybe they would at least help her with the motel voucher?  For Adam, sounds like he is a danger to himself.  Wouldn't he then qualify for involutary medictaion giving?  Homelessness is a multi-faceted problem that can be helped one person at a time, but they will always be with us.  I don't believe it can be eradicated, but hopefully reduced.  Oh, and where's the 3rd case?

  • CJ
    Posted: Fri, 02/21/2020 03:07 pm

    April, Adam, unnamed old woman wrapped in coats at a bus stop. 

  • Bob R
    Posted: Fri, 02/21/2020 01:22 pm

    Few people seem to understand the genesis of this problem.  We used to have vagrancy laws in this country.  We also had the ability to compel medical intervention for those who were not simply a “danger”, to themselves, but actually unable to care for their most basic needs.  Many of these people (yes, they ARE people, not mere “homeless”) are less able to care for themselves than a six-year-old child left to fend for himself on the streets.  And we would never willingly condone such heartlessness!  In an effort to be “charitable”, we’ve caused this problem ourselves. 

    One glaring omission in this story is the problem of addiction, which goes hand-in-hand with mental illness.  "Mayor Pete" has been preaching that addiction should be dealt with through treatment, not incarceration.  One question Mr. Mayor; how do you get people into treatment who aren’t mentally capable of making such a choice voluntarily?  The ability to first take them into custody is an essential part of the equation. 

    I’m convinced that many if not most of these tragic lives are salvageable.  What’s needed is a change of heart (not to mention mind) among the American people, so they would enact common sense changes to our legal system.  First, the police need to be given the tools to detain anyone living on the streets.  Second, those so detained would be evaluated.  Those unable to care for their basic needs (all three of the cases cited in this article) should be given legal counsel and brought before a judge to prevent abuses by overzealous administrators. Treatment may include anything from involuntary commitment to a mental facility, or drug treatment (again, involuntary), to some kind of group-home/halfway house setting where they could learn basic life-skills. 

    Those who are able to take care of themselves should be offered the choice of job training/placement, or incarceration. 

    I know all the arguments.  It’s cruel, a heartless a violation of civil rights, etc.  One problem with thinking with our hearts rather than our heads is that we tend to overlook the unintended consequences.  And the real victims here are the people on the streets.  Unfortunately, they are being used as political pawns to further an agenda.

    Some will argue it’s too expensive.  To save these tragic lives, returning many of them to a useful, self-fulfilling purpose, really?  And just from a purely economic standpoint, are we really so economically ignorant as to not understand that wealth is in effect, the sum total of all the “stuff” people create!  The more people producing, the greater the wealth of a nation.  This is borne out by the dramatic increase in the economy.  When anti-business government regulations were replaced with business-friendly ones, more people began producing, and, shocker, total wealth increased!

    I have no hope that such common sense suggestions will ever be implemented.  “Progressives”, both in and outside the legal system would never permit it.  The nation has been taught to feel rather than think.  So, I pray for revival in this country as the only hope of change.  I suspect things will only have to get horribly difficult before we repent.

  • Kelstel
    Posted: Thu, 02/27/2020 09:40 am

    Thank you for reminding us that there are no simple solutions.  I am still trying to educate myself as to how we got here.  I found a helpful article (along with the comments that followed) that has given me more to think about. Here it is:

    The deinstitutionalization of the mentally ill (beginning in California then extended federally) seems to be a part of the problem.  But, how do we go back?  How do we love our neighbor when they won't consent to care?  NO easy answers...may the LORD grant us wisdom.

  • Bob R
    Posted: Tue, 03/03/2020 03:01 pm

    As I said in my earlier comments, no one would consent to allowing a six-year-old child to fend for himself on the street, yet many of the mentally ill or drug addicted are no more able to care for themselves than a child.  Not allowing the police to have tools to take such people into custody represents the real lack of care for them.  I'm not talking about prison but involuntary mental health / drug treatment programs.  Virtually no hope of ever seeing this accomplished though, due to the inability of the American public to think rationally about unintended consequences.

  • VolunteerBB
    Posted: Fri, 03/06/2020 02:13 pm

    I'm sure Dr. Carson knows about people like these.  He is addressing one issue out of the many that could help.  As you state there are no one size fits all, easy solutions.  The problems are many, and the solutions will be many.  

    When I read these stories I always wonder why the problem has gotten so much worse than it used to be.  I am thinking one reason could be how hard it is to get people such as these into "involuntary" places they can live and be forced to take their medications and be taken care of humanely.  Yes, the homes of old were closed down because of inhumane situations (think, One Flew Over the Cuckoo's Nest), but just because we did it poorly then doesn't mean we just give up on that idea and not try to do it better.  To leave people on the streets like this just because they "know their rights" does not mean we are any more humane than before when they were forced into facilities for their own good.