Should people in our community die from Hepatitis A, starvation or both? That was the original question that prompted Judge Carter to jumpstart a widespread concern about homeless persons and mental illness. But what does Judge Carter understand about homelessness and mental illness?
There is no medical specialty “Homeless Medicine” nor repository of high quality research on the topic tracking major outcomes. Some “Housing First” studies show communities expend resources more efficiently when homeless persons are housed in permanent housing. In the medical community, homelessness is an endpoint for downward drift – a phenomena common in mental health.
People experiencing mental illness have Psychiatrists. Psychiatrists in the United States use the Diagnostic and Statistical Manual (DSM) first published in 1952 – 66 years ago. Research in Psychiatric treatments tends to be short term (less than 1 year) and only the Psychiatrist gets a vote in evaluating treatment. Family, community, police, the patient, and employers may have a very different opinion on the success of a treatment being researched. The population of people treated under DSM are now reaching the life expectancy of the general population. Yet, life expectancy for people experiencing mental illness or homelessness is best estimated at 40-60 years. Hardly accurate enough to underwrite life, health or disability insurance. Point in time (PIT) counts are the most consistent research on homeless persons. PIT counts are conducted by volunteers instructed to count heads in homeless camps from a distance – for safety reasons – in the dark of night.
In all of this ignorance, many other communities in the United States have claimed “we have solved homelessness.” Highly doubtful. Without a benchmark for life expectancy, it is unclear if interventions for homelessness will increase or decrease life expectancy. Exile has historically been used to remove troublesome homeless persons from some communities. Relocating a homeless person doesn’t solve homelessness – it merely shifts the problem to a new community that must restart a process of trial and error.
Outside the United States there is wide variability in housing quality and no consensus on treatment for mental health. Many European Psychiatrists don’t use the DSM. Pakistan’s High Court has ruled that Schizophrenia isn’t a mental illness. England administers benzodiazepines – highly addictive drugs in the same class as roofies – by intravenous route while in the United States it is administered orally or intramuscularly. There is no published compendium surveying how mental health is viewed, diagnosed, and treated worldwide, comparing and contrasting outcomes. It just doesn’t exist. American medical students are trained that the DSM is the only option and the “standard of care.”
Judge Carter is working with the same information as everyone else, unless some secret repository exists in his chambers. The court orders are forcing action, but in communities that are wrestling with an issue without facts. Firm beliefs exist that the homeless are mostly felons, mostly pedophiles, mostly lazy, mostly illegal immigrants, mostly drug addicts or mostly mentally ill. Yet, it is unclear if the court has maintained a roster of the homeless involved for the purpose of tracking outcomes. The homeless aren’t named in the lawsuit as plaintiffs or defendants. The homeless are subject to the outcome of litigation between charities and governments – forced into a passive role throughout this whole process as the right to provide charity is evaluated.
June 13, 2018 will mark the start of human subject research trials on homeless interventions. Judge Carter has made it clear that outcomes and results are important. Yet, discussions on the Federal “Common Rule” requiring an Institutional Review Board (IRB) for human subject research has not been addressed. The “Common Rule” originated from an ugly history of purposely exposing children to hepatitis, purposely not treating Syphilis in African Americans, purposely exposing pregnant women to radioactive materials, and many similar research programmes to see what would happen. Our version in Orange County, CA is relocating massive amounts of people into close quarters temporary housing and timing the onset of a meningitis outbreak on top of a Hepatitis A outbreak.
If outcomes and results are tracked then each organization involved would need to maintain access to an IRB. In the current climate where conflict trumps cooperation this would mean numerous IRBs – approximately one for each plaintiff and one for each defendant – expending massive amounts of resources. There are also issues involving the Corporate Practice of Medicine, Practicing Medicine without a License, Patient Abandonment, and Medical Malpractice.
Judge Carter has great experience, but what is his motivation? Clearly he is bringing attention to a pressing social issue that has existed for centuries. Is there a more purposeful strategy? Our local governments will start to get sloppy with the tempo of court orders, our local communities will start to get angry for not having a choice. The experience of the homeless will get lost in the news cycle, unless Judge Carter continues photo opportunities. At some point a series of felonies will begin as we explore the fringes of law and medicine. It is highly likely peonage, in some form, has already been discussed and planned by some organization in Orange County.
The discussion about housing is only the beginning. Discussions about security, healthcare, income and relationships come next as we work up Maslow’s hierarchy. Each of these discussions starts with just as much ignorance continuing to just as much conflict. Yet, our community is equivocating on the fundamental American freedoms of association and movement.
Aaron Hand is a Fullerton native and current resident. He graduated from the Medical Doctor / Masters of Business Administration dual degree program at Saint Louis University (Saint Louis, MO) in 2013. Of the 105 or more medical jurisdictions in the United States, Mr. Hand has experienced only three as a provider: Missouri, Kansas, and the Veterans Administration; and only two as a consumer: California and Missouri. Mr. Hand’s major interest is economic development in the mental health community which will require cooperation among healthcare providers, businesses, governments, and families to collect data and generate knowledge.
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