My instructor in inpatient medicine seemed to be obsessed with anemia. Whenever a patient in the hospital had a low red blood cell count, he would write in his notes, “w/u anemia” (for “work-up anemia”) It was such a common occurrence that one year the residents bought him a rubber stamp with “w/u anemia” on it so he wouldn’t have to write it anymore!
Anemia does require a medical work-up. The single abnormality of a low red blood cell count can have many different causes, each with a different treatment. Sometimes anemia is due to a single episode of blood loss and a transfusion is all that is needed. Other times, such as with bleeding ulcers, the bleeding must be stopped so the anemia can be treated, repeated transfusions make no sense. Other times anemia is a sign of another disease that needs to be treated. Alcoholism, vitamin deficiencies, kidney disease, cancers and infections can all suppress blood cell production in the bone marrow and lead to anemia. Fixing the blood count requires the physician to address the underlying cause.
Given the long list of possible causes, the word “anemia” used in isolation, is near meaningless. More information is needed to understand the word and devise treatment. There is no single solution to the problem. A doctor who orders iron tablets for every anemia is a very bad doctor.
Homelessness and anemia have this in common. All homelessness involves people living on the streets, but not all homelessness is the same. There are many different causes of homelessness, and treating the problem will require varied approaches
Some homeless people want to participate in society and have the ability to work, but need some help rejoining the workforce. Others are so damaged mentally and emotionally that participation in society is impossible. They lack the personal and mental skills needed to hold a job, handle money and relate to others. Many, perhaps the majority, could participate in society if they wanted to, but don’t want to. The causes are varied, and the solutions must vary as well.
The “capable homeless”, those who want to work and provide for themselves are perhaps the easiest to help. These unfortunate souls often find themselves on the street due to a combination of poor planning and bad luck and on occasion, burned bridges. They may be hardworking people who were barely getting by, living paycheck to paycheck until a health crisis, loss of transportation, or lost job left them with no place to go. Whether due to pride or social isolation, they have no friends or family to turn to. For these people a homeless shelter, some free meals and some financial assistance (perhaps affordable housing) could turn their lives around. When it comes to the problem of homelessness, these people seem to be in the minority.
The mentally ill pose a unique problem. People who suffer from psychotic disorders may never be able to participate in society. Delusional thinking, hallucinations, lack of interpersonal skills and inability to handle complex tasks may render them incapable of holding down a job or managing their finances. Mental illness can also make it impossible for them to comply with medication regimens, trapping them in a cycle of isolation. Our society decades ago decided it was immoral to force these individuals into institutions, is so doing ignoring the reality that a life on the streets trapped in delusions is an even crueler existence. Temporary shelters may provide a brief respite for those suffering from severe mental illness, but like blood transfusions for a bleeding man they do nothing to solve the underlying problem.
The most numerous and most troubling segment of the homeless population are those who have (or had) the ability to work and participate in society but choose not to. The stress of normal life, of waking up on time, going to a boring job, answering to a boss, and paying bills is more than they care to handle. Some escape from the stresses of life via needle or bottle, living from one high to the next. There are others who are simply antisocial. They do not care at all about other people or how their actions impact others. They want what they want, when they want, how they want, refusing to answer to anyone. Paradoxically, these people act as if the world owes them everything and that they owe the world nothing.
This last category may be the largest. They know help is available, know there is a way they could rejoin society, but have no interest in such help. They prefer a life on the streets to a life of responsibility. They will take food and financial assistance when offered but will intentionally avoid such help if it requires them to change their behavior. It is difficult for others to understand, but to these people a life of “freedom” on the streets is superior to a life of responsibility.
Just as the treatment of anemia is dependent on the underlying cause, the treatment of homelessness must also take root causes into consideration. There is no single response to the homeless problem that will work for all. If the problem of homelessness is to be addressed multiple solutions will need to be pursued. As obvious as this truth is, it seems to not be understood by the judges who hand down rulings demanding more shelters or the politicians who make our laws. Our government leaders seem to think the solution is to provide everyone with a place to live and food to eat. While this may work for the small subset of unfortunate individuals who want to work and rejoin society, it will do nothing to address the root causes for the majority of those living on the street.
The mentally ill are often unable to access help on their own and thus will need hospitalization, institutionalization, or ongoing supervised care. They need to be in settings where there are people to make sure they take their medications appropriately, counselors to help them understand the world, and structure to keep them safe from their bad judgment and destructive behaviors. Our society needs to let go of the belief that such arrangements violate the rights of the insane. If we do not change our approach, there plight will not change. They will remain on the streets.
The anti-social, drug addicted and alcoholic homeless present a different problem. As long as they are given the option of living outside of the rules of society, most will choose it. They will refuse shelter and services when offered. Those that accept shelter will not typically stay long, leaving when they realize they cannot use drugs or drink. Getting these people off of the streets will require a firm and decisive response from society. Instead of building shelters with swinging doors and no obligations, we will need to develop a path to reenter society. We will need programs, camps or facilities to provide these people with opportunities to get sober, receive psychiatric care, life counseling and job training. These able bodied homeless will need to be given a clear choice, enroll in a reentry program and become someone who contributes to society, or go to jail and contribute to society via a supervised work problem. Returning to the streets cannot be an option. If it is, they will choose it.
I have little hope that these approaches will ever be implemented, for they will require us to accept hard truths about human nature and to change our way of thinking. Simple solutions, though destined to fail, are more politically and socially palatable.
Bart
