The Guru Is In
Homelessness is Misdiagnosed and Mistreated
By David A. Smith
9 min read
Why this is hell, nor am I out of it. – Doctor Faustus, Christopher Marlowe
Homelessness is not a housing problem; homelessness is a symptom and byproduct of a larger underlying problem—the loss of ability to live independently—whose escalating scale exposes the collapse of an overloaded and anachronistic urban behavioral-health infrastructure.
Half a century of stakeholder selective blindness among those who profit from the current dysfunction has culminated in a massive national failure, now laid bare by COVID. Building the new urban health infrastructure will take disruptive reinvention of the value chains of addictive and behavioral health recovery, a strong vision with a strong leadership consensus, a cross-sectoral collaboration between housing and health heretofore rare, consistency over a decade or more and a potful of money. It is a journey not for policy or political cowards – but the alternative is a plague of downtown San Francisco proportions.
Ever since the Romans invented aqueducts, underground piping, lacus public fountains and cloaca sewerage, urban growth has been constrained by vertical density and by urban infrastructure. Verticality creates wealth, and new infrastructure brings convenience and a dramatic boost to urban healthiness. The resulting city thrives and grows. The speed of its growth and the resulting strain on the new infrastructure often startles the system’s designers due to a combination of:
- Exponential usage growth because the new clean prosperous city attracts urban immigrants;
- Under-maintenance. The new infrastructure’s capital costs are funded by sovereign grants (or the modern equivalent, general-obligation bonds), with user fees to cover operating costs. Usage rises faster than revenues, funding gaps ensue and maintenance is deferred;
- Increased density raises system-component loads. Systems designed to perform within an expected range of load rapidly deteriorate in efficiency when loads rise; and
- Peak-load usage overtaxes the engineering and accelerates obsolescence.
All these forces build up slowly, steadily and often invisibly. The system is patched and adapted, until one bad day, converging stresses cause a sudden collapse:
- London, 1660s. Black Plague leads to a depopulated city, a rise in lawlessness and the 1666 Great London fire;
- London, 1850s. Cholera outbreaks lead to citizen panic and the Great Stink leads to the shutdown of Parliament because its Thames-polluted air is too foul to breathe; and
- Washington DC, 1900s. Rapid Reconstruction-era urbanization and rural-to-urban immigration lead to the explosive growth of alleyway shacks, racial and economic market segregation and alleyway ills that escape into the wider ‘healthy’ city: crime, malnutrition, typhoid and more.
These abrupt implosions were years or decades in the buildup, but it was ignorable because it kept to itself, and ‘those people’ could be confined elsewhere.
Thus, it has been with America’s urban behavioral-health infrastructure, which has steadily degraded over my lifetime until its current moral and social bankruptcy. After World War II, slum clearance and the condemnation of boarding houses (by then known as flophouses) evicted many who were poorly or unsafely housed to become, not better housed but unhoused entirely. The 1950s deinstitutionalization of the mentally ill freed them from the brutish ward into the chaotic street. In response, a well-intentioned 1960s initiative of means-testing rents and adding federal admissions preferences funneled some of them into public or affordable housing. There some newcomers brought behavioral challenges into (among others) elderly housing, slowly expanding the manager’s job into work for which its staff was untrained and uncompensated. While the affordable housing industry, having no choice in the matter, learned and adapted, ‘resident services’ became an unfunded mandate that soon consumed an ever-rising share of Low Income Housing Tax Credit allocations and soft funding sources.
The challenges of urban behavioral health only accelerated with the rapid innovation in pharmaceuticals: crack cocaine (1985), crystal meth (1990s), oxycodone (2000s) and fentanyl (2015). These became available through competing dual channels of distribution: legal, formal and restrictive; and illegal, informal and oh-so-profitable. In this dual-track pharmaceuticals market, the addict-manufacturing value chain for turning independent people into those addicted and dependent ran much faster, cheaper, surer and profitably than did the behavioral recovery value chain offering help to those unwillingly trapped in dependency.
Plague destroys the pretense of normalcy. After the shock and panic wore off, prior catastrophic failures of urban health forced the recognition that the entire urban health infrastructure needed to be rebuilt:
- After the Great Fire, while Charles II and Christopher Wren invented urban renewal, London merchants invented mutual fire insurance companies, and over the ensuing decades developed the business of fire prevention;
- After the Great Stink, chemist Michael Faraday conceived and civil engineer Joseph Bazalgette supervised the building of a comprehensive rerouting of the Thames River basin, with a whole new Embankment, 1,180 miles of underground sewage and a co-located underground railway system, and strategically placed pumping and cleansing stations; and
- After alleyway epidemics, in Teddy Roosevelt’s bully-progressive Washington, DC, former Union Army Surgeon
General George M. Sternberg, ‘the father of American bacteriology,’ secured Congressional authorization to launch the Washington Sanitary Housing Company, the world’s first municipal public housing authority.
As the 1666 aftermath of London’s Black Plague was urban fire, the 2022 aftermath of COVID made American urban health collapse too rampant to ignore. Disruptive urban health reinvention is needed now, in which housing will play a part – but not the affordable housing we mainly deliver today in America. Instead, we have to see the current dystopia as two destructive existing value chains, the demand side (addiction) and the supply side (insecure housing tenure), and build new value chains for both the demand side (recovery journey) and the supply side (housing independence journey).
1. Demand side: Acknowledgment of dependency and mutual commitment to a guided-tour course of recovery. With few exceptions, American affordable housing is predicated on the presumption of tenant independence, and yet everyone who has personally known someone with mental health or addiction challenges understands that the addiction never sleeps, it only lurks in waiting. People with severe behavioral health problems are enduring hostages to internal demons: pretending they are independent does them no favors. And like Dante in the inferno, they need guides who are sympathetic, knowledgeable, steadfast and reliable.
2. Supply side: A ladder of rising secure tenures spanning different housing arrangements over the demand-side recovery journey. When it comes to ‘housing the homeless,’ despite the heroic efforts of some homelessness relief entities, our current system treats any individual tenure—emergency room, hospitalization, overnight jail, homeless shelter or the all-too-rare permanent supportive housing—as isolated.
In between lies the unforgiving street, and the undoing of progress.
For virtually everyone seeking a path out, stable affordable housing (which includes family members taking a person in) can be a foundation of a reinvented urban health infrastructure. People who want to change need a medium-term environment (anywhere from a few months to several years) where housing is at the center of a personalized curriculum of behavioral change that crosses multiple state or federal funding sources. This demands a pledge of continuity of tenure even if the individual dwelling needs to change as the person’s independence and agency rise.
It can include way stations in:
- Short-term tenures for immediate post-discharge detoxification;
- Communal living houses where admission and occupancy depend on committing to change and peers helping peers reinforce recovery; and
- Integrated recover-study-work dormitories built around a curriculum of learning and habituating behavioral independence and the means to preserve it once regained.
This urban health recovery and wellness infrastructure does not exist today at anything more than a micro-scale – and it’s an essential part of an urban health recovery infrastructure.
Abandoning a collapsed infrastructure and building a new one in its place requires time (a decade or more), capital in massive quantities and a combination of vision and skill:
- After the Community Reinvestment Act (1977), banks had to plow capital and credit access back into neighborhoods where they took deposits, and over the ensuing decades developed a profitable business of community development lending; and
- After Superfund and the Comprehensive Environmental Response Compensation and Liability Act (1980), chemical companies had to pay to scrub up their toxic spills or their health aftermaths, and over the ensuing decades retooled into cleaner energy and sustainability.
Who will fund these new urban health value chains? Who has profited, knowingly or unknowingly, from the dysfunctional ones?
CRA’s capital inclusivity was funded by the banks that profited handsomely alongside capital exclusion that preceded it. CERCLA’s cleanup was funded by chemical companies that profited handsomely from the rising urban toxicity that preceded it.
The supply side of the new functional urban health recovery infrastructure will require hospitals and Health Care Organizations, along with insurance companies, to collaborate as co-developers alongside nonprofits and other mission entities that are pioneering new hybrid tenure models like those described earlier. This can be done by massaging the Affordable Care Act’s Community Benefit modality.
The demand side of the new functional urban health recovery infrastructure needs to be funded by, and quite probably innovated by, the same pharma companies that profited handsomely alongside not just the disaster response to COVID but also from the system dysfunctionality that pharma’s innovations facilitated and accelerated. This requires a Health Reinvestment Act, with quantitative goals, meaningful slices of revenue and profits, and commitments to internalize recovery work alongside palliation of pain.
Banks fought CRA and learned to live with it. Chemical companies fought CERCLA and learned to live with it. Once pharma’s fierce resistance is overcome and it is enacted, in the ensuing decades pharma will become as adept at averting and recovering from behavioral illness as they have heretofore been adept at deniably enabling it.
Further Reading
Carl Erik Fisher, The Urge
Patrick Keefe, Empire of Pain
Charles Duhigg, The Power of Habit
Gabor Maté, In the Realm of Hungry Ghosts
