What the Dog Saw: And Other Adventures

shelter just those twenty-five hundred hard-core homeless. “It costs twenty-four thousand dollars a year for one of these shelter beds,” Culhane said. “We’re talking about a cot eighteen inches away from the next cot.” Boston Health Care for the Homeless Program, a leading service group for the homeless in Boston, recently tracked the medical expenses of a hundred and nineteen chronically homeless people. In the course of five years, thirty-three people died and seven more were sent to nursing homes, and the group still accounted for 18,834 emergency-room visits – at a minimum cost of $1,000 a visit. The University of California, San Diego, Medical Center followed fifteen chronically homeless inebriates and found that over eighteen months, those fifteen people were treated at the hospital’s emergency room 417 times, and ran up bills that averaged $100,000 each. One person – San Diego’s counterpart to Murray Barr – came to the emergency room eighty-seven times.

“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 endlessly and invest in results that actually end homelessness.”

Mangano is a history buff, a man who sometimes falls asleep listening to old Malcolm X speeches, and who peppers his remarks with references to the civil-rights movement and the Berlin Wall and, most of all, the fight against slavery. “I am an abolitionist,” he says. “My office in Boston was opposite the monument to the 54th Regiment on the Boston Common, up the street from the Park Street Church, where William Lloyd Garrison called for immediate abolition, and around the corner from where Frederick Douglass gave that famous speech at the Tremont Temple. It is very much ingrained in me that you do not manage a social wrong. You should be ending it.”

3.

The old YMCA in downtown Denver is on Sixteenth Street, just east of the central business district. The main building is a handsome six-story stone structure that was erected in 1906, and next door is an annex that was added in the 1950s. On the ground floor are a gym and exercise rooms. On the upper floors there are several hundred apartments – brightly painted one bedrooms, efficiencies, and SRO-style rooms with microwaves and refrigerators and central air-conditioning – and for the past several years those apartments have been owned and managed by the Colorado Coalition for the Homeless.

Even by big-city standards, Denver has a serious homelessness problem. The winters are relatively mild, and the summers aren’t nearly as hot as those of neighboring New Mexico or Utah, which has made the city a magnet for the indigent. By the city’s estimates, it has roughly a thousand chronically homeless people, of whom three hundred spend their time downtown, along the central Sixteenth Street shopping corridor or in nearby Civic Center Park. Many of the merchants downtown worry that the presence of the homeless is scaring away customers. A few blocks north, near the hospital, a modest, low-slung detox center handles twenty-eight thousand admissions a year, many of them homeless people who have passed out on the streets, either from liquor or – as is increasingly the case – from mouthwash. “Dr. -, Dr. Tich, they call it – is the brand of mouthwash they use,” says Roxane White, the manager of the city’s social services. “You can imagine what that does to your gut.”

Eighteen months ago the city signed up with Mangano. With a mixture of federal and local funds, the CCH inaugurated a new program that has so far enrolled 106 people. It is aimed at the Murray Barrs of Denver, the people costing the system the most. CCH went after the people who had been on the streets the longest, who had a criminal record, who had a problem with substance abuse or mental illness. “We have one individual in her early sixties, but looking at her you’d think she’s eighty,” Rachel Post, the director of substance treatment at the CCH, said. (Post changed some details about her clients in order to protect their identity.) “She’s a chronic alcoholic. A typical day for her is, she gets up and tries to find whatever she’s going to drink that day. She falls down a lot. There’s another person who came in during the first week. He was on methadone maintenance. He’d had psychiatric treatment. He was incarcerated for eleven years, and lived on the streets for three years after that, and, if that’s not enough, he had a hole in his heart.”

The recruitment strategy was as simple as the one that Mangano had laid out in St. Louis: Would you like a free apartment? The enrollees got either an efficiency at the YMCA or an apartment rented for them in a building somewhere else in the city, provided they agreed to work within the rules of the program. In the basement of the Y, where the racquetball courts used to be, the coalition built a command center, staffed with ten caseworkers. Five days a week, between eight-thirty and ten in the morning, the caseworkers meet and painstakingly review the status of everyone in the program. On the wall around the conference table are several large whiteboards, with lists of doctor’s appointments and court dates and medication schedules. “We need a staffing ratio of one to ten to make it work,” Post said. “You go out there and you find people and assess how they’re doing in their residence. Sometimes we’re in contact with someone every day. Ideally, we want to be in contact every couple of days. We’ve got about fifteen people we’re really worried about now.”

The cost of services comes to about $10,000 per homeless client per year. An efficiency apartment in Denver averages $376 a month, or just over $4,500 a year, which means that you can house and care for a chronically homeless person for at most $15,000, or about a third of what he or she would cost on the street. The idea is that once the people in the program get stabilized, they will find jobs, and start to pick up more and more of their own rent, which would bring someone’s annual cost to the program closer to $6,000 dollars. As of today, seventy-five supportive housing slots have already been added, and the city’s homeless plan calls for eight hundred more over the next ten years.