It doesn’t have to be this way: on homelessness, healthcare, and attributes of the city of Sodom

My first elective of my fourth year of medical school will be in pediatric emergency medicine in a poor neighborhood of a big city.  My favorite joke now is that it will be an elective in primary care, American style.  I’m not even sure that I’m joking.

After three years grappling with Israel and Palestine, I feel unprepared for American-style problems, and the inertia and complacency surrounding them.

You know the ragged characters who are a constant presence in American cities, sleeping rough.  Homeless.  In DC, the face of homelessness is black; of course years and decades and centuries of racism contribute to this.  Go to Seattle, the face of homelessness is white, and Asian.  Someone’s always at the bottom and when they fall through the cracks there is very little to catch them.

It doesn’t have to be this way.

You walk down the street, and someone asks you for a dollar.  Maybe they’re the third person to do so that morning.  Your choice is between giving them the dollar, or walking on.  Maybe you’re out of dollar bills, maybe you’re worried that they’ll drink it away, maybe you just want to walk down the street without being asked for money.  Maybe you want a more meaningful interaction than just to give a dollar.  It’s a lousy choice, between giving and withholding the dollar. Of course it helps, but it doesn’t even come close to the changes that need to happen if we want the luxury of walking down the street without being hassled for dollars, or the luxury of sleeping at night while others are cold, unsafe.

Vagrancy is a crime.  That means that wandering around public spaces because you have nowhere to live is a crime.  When my friend Amit, who is not the from the US heard about vagrancy laws, he called them midat Sodom, characteristics of the city of Sodom.  Jewish tradition has a varied list of reasons as to why the city of Sodom was destroyed, it’s not the gay sex so much as raping strangers.  The rabbis add to that other examples of cruelty elevated to an art form: offering a guest a bed, and then, if he is too short for it, stretching his joints with rope until he fits, if he is too tall, chopping off his feet.  And Amit is right: putting people in prison because they have so little their choices are between sleeping in a doorway and sleeping on a park bench, would fit in fine among the other examples.

It doesn’t have to be this way.

They can go to the shelters, where TB is rampant, along with scabies and lice, where the pipes explode on a recurrent basis.  The pipes with *outgoing* sewage.  Yeah.

I’ve spent that last few years living in a country that is poorer than the US, in a poor city in a poor region.  I have seen people making their daily rounds through the dumpsters looking for things to scavenge, I’ve been asked for spare change, but I’ve never seen anyone sleeping rough.  I know it happens here, (especially in Tel Aviv, especially among asylum seekers, whose claims are not considered or are catergorically denied, which gets back to my point about homelessness being a structural problem) but it happens much, much less here.

I just finished my psychiatry rotation.  Not everyone who is homeless in America is mentally ill, but it’s not uncommon.  One of our professors here asked us if we knew what the “psychiatric rehabilitation benefit basket (sal shikum)” was.  “We’re from America,” I told him, “we don’t have those things there.”

He explained that it included a stipend, supportive housing, supportive employment.  My sister worked for a non-profit in Maryland that provided some of those services, and non-profits are part of the patchwork in the US, together with homeless shelters and jails, church basements, doorways, and underpasses.  It isn’t enough.

We can have organized, pro-active, wrap-around services for the mentally ill, options between the street and the psych hospital.  That would be low-hanging fruit, but also a radical change.

We can reduce the gap between what one earns on a minimum wage working full-time, if one is lucky enough to work full time, and the cost of housing in most cities.  It is currently obscene.  Some of the patients I knew at the homeless clinic were mentally ill, others were working as construction workers and at supermarkets and still couldn’t make a go of it.

Meanwhile, maybe ObamaCare will increase peoples’ access to health care other than the emergency rooms.  It will help if doctors don’t refuse to take these patients, because their insurance isn’t “nice” enough, as often happens with Medicaid.  Or we can just go back to agonizing about whether to give a dollar to the guy on the street.  Just, remember that for people on Medicaid, the co-pay for prescriptions is a dollar.


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