No simple solutions

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.