What the Dog Saw [77]
“If it’s a medical admission, it’s likely to be the guys with the really complex pneumonia,” James Dunford, the city of San Diego’s emergency medical director and the author of the observational study, said. “They are drunk and they aspirate and get vomit in their lungs and develop a lung abscess, and they get hypothermia on top of that, because they’re out in the rain. They end up in the intensive-care unit with these very complicated medical infections. These are the guys who typically get hit by cars and buses and trucks. They often have a neurosurgical catastrophe as well. So they are very prone to just falling down and cracking their head and getting a subdural hematoma, which, if not drained, could kill them, and it’s the guy who falls down and hits his head who ends up costing you at least fifty thousand dollars. Meanwhile, they are going through alcohol withdrawal and have devastating liver disease that only adds to their inability to fight infections. There is no end to the issues. We do this huge drill. We run up big lab fees, and the nurses want to quit, because they see the same guys come in over and over, and all we’re doing is making them capable of walking down the block.”
The homelessness problem is like the LAPD’s bad-cop problem. It’s a matter of a few hard cases, and that’s good news, because when a problem is that concentrated you can wrap your arms around it and think about solving it. The bad news is that those few hard cases are hard. They are falling-down drunks with liver disease and complex infections and mental illness. They need time and attention and lots of money. But enormous sums of money are already being spent on the chronically homeless, and Culhane saw that the kind of money it would take to solve the homeless problem could well be less than the kind of money it took to ignore it. Murray Barr used more health-care dollars, after all, than almost anyone in the state of Nevada. It would probably have been cheaper to give him a full-time nurse and his own apartment.
The leading exponent for the power-law theory of homelessness is Philip Mangano, who, since he was appointed by President Bush in 2002, has been the executive director of the US Interagency Council on Homelessness, a group that oversees the programs of twenty federal agencies. Mangano is a slender man, with a mane of white hair and a magnetic presence, who got his start as an advocate for the homeless in Massachusetts. He is on the road constantly, crisscrossing the United States, educating local mayors and city councils about the real shape of the homelessness curve. Simply running soup kitchens and shelters, he argues, allows the chronically homeless to remain chronically homeless. You build a shelter and a soup kitchen if you think that homelessness is a problem with a broad and unmanageable middle. But if it’s a problem at the fringe it can be solved. So far, Mangano has convinced more than two hundred cities to radically reevaluate their policy for dealing with the homeless.
“I was in St. Louis recently,” Mangano said, back in June, when he dropped by New York on his way to Boise, Idaho. “I spoke with people doing services there. They had a very difficult group of people they couldn’t reach no matter what they offered. So I said, ‘Take some of your money and rent some apartments and go out to those people, and literally go out there with the key and say to them, “This is the key to an apartment. If you come with me right now I am going to give it to you, and you are going to have that apartment.” ’ And so they did. And one by one those people were coming in. Our intent is to take homeless policy from the old idea of funding programs that serve homeless people