Homeless Triangle Part One

If you work as a doctor in a clinic for the homeless, you see
all kinds of simmering panic. There’s the God,
someone’s got to help me
panic of the person who lost
their house to foreclosure. There’s the fatalistic panic of a
street person with a hard, bone-rattling cough who senses, deep
inside, that this might be the infection that kills her.

But this time, when the man stopped me in the hallway between
exam rooms, grabbing my upper arm a little too tightly, there was a
different kind of panic in his eyes.

“I don’t know how to find the bathroom,” the
man said, terror-stricken. “Curtis,” with salt and
pepper hair, was in his late 50s.

“It’s just around the corner – through those doors
and to the right.” I hoped to speed-walk past him, but his
grip on my arm only tightened.

“I can’t do that,” he said, his voice rising
to a near-shout.

His upper lip was shaky with emotion. The only clue that his
problem wasn’t some type of unusual neurological defect was
the fact that he had way more muscles than you’d expect to
see on a man his age.

“Just got out of prison?” I said.

He gave a sharp nod. “Twenty years in a cell. I walked
down one corridor. That’s all. For over 20 years.” He
said it again, this time shouting it: “I can’t find the

My mind struggled to grasp his last 20 years. All the changes in
the world. All the ways in which we maneuver through our lives
– simple things that he’d never done. He’d become
a man no longer able to even follow an easy task like going through
the doors and turning right. At his age, to have been so restricted
for so long in prison, he’d undoubtedly committed a truly
vile and violent act against another person.

But now he is, as we say in the healthcare business, ours.

He is a man who is unemployable, with multiple chronic health
problems, and most likely – even without being confronted
with all he cannot do – with serious anger management and
impulse-control issues. He is in our town with nowhere to stay,
nowhere to go and no ability to get there.

“I’ll walk you there,” I said, and wondered,
as we walked the few feet to the bathroom doors, which way he would
go when he left the clinic.

He wasn’t mentally ill. He didn’t have HIV. He had
high blood pressure and diabetes and high cholesterol and prostate
problems that might turn out to be prostate cancer. He had no idea
what tests had been done in prison, or what pills or doses
he’d taken for the last many years. After 20 years in a
prison with years of treatment for chronic health problems, he had
no summary — not even a health card or a discharge print-out.

We did what we could. We picked random pills and doses to start
him on, since he’d been without medicines for several days
already. He had no money for a co-pay so we gave him what we could
out of our medicine closet. We told him to come back in two days so
we could check how he was doing.

But as he left to sleep on a sidewalk in San Francisco, we all
– myself, the nurse, the staff – wondered the same
thing. He had no food, no place, no ties to anyone, no way to get
money. At all. So how long would it be before he hurt someone, just
so he could get back to prison?

Because, odds are, he will.

Prison Churn and Homeless Churn

California incarcerates more of its population than any other
state, with roughly one in
1,000 Californians
sent to prison each year. As of August 2009,
there were 166,569 Californians in prison. And these numbers
exclude jail. Prison is very different from jail. Jail is local,
for smaller offenses, or as a holding place until verdicts are
handed out. Prison is for felons, more serious offenses, and,
generally, for much longer sentences. But our state’s prison
system is far from static. Except for a very tiny minority, every
single prisoner eventually will come back to our neighborhoods.
Generally speaking, more than 100,000 people are released, and more
than 100,000 people are incarcerated every single year. Our prison
system released in excess of 130,000 people into our neighborhoods
in 2009 alone.

The logistics represented by those numbers is mind-boggling.
That’s basically the same number of people as the entire
population of Humboldt County, or the entire city of Concord.
Here’s what getting out is like. You’re not told
exactly when you’ll be able to leave. Your family – if
you still have any relationships left – can’t know
either. No one can know. For security reasons, no one is told,
ever, an exact date of release.

One day, the door is unlocked. Only if you have certain
designated types of mental illness, or have HIV that’s being
treated, are you given any pills when you leave. And even then
you’re only given a 30-day supply as you go.

The California prison system is now the largest provider of
mental health care in the state. Despite that, most studies show
that a large number of seriously mentally ill prisoners are not
diagnosed and treated while incarcerated. But the prisoners who are
being treated for mental illness are now mandated to be given a
case management assessment and an appointment for follow-up prior
to release.
The prison system’s own study
shows that just one visit
from a case manager prior to release is highly effective at
reducing recidivism and increasing compliance with follow-up
appointments. But the very same study also showed that no visits at
all are being done in almost 50 percent of cases, even though staff
were hired to perform them, and it’s mandated by state law.
No one knows why they’re not being done.

The California prison population has aged, with four out of 10
age 40 or over, with one in seven prisoners 50 or older. Many have
multiple health problems. As the healthcare costs for prisoners
have soared, there have been reports of expedited releases for
prisoners with complex medical problems.

But no matter what your age, even if you’re a person with
diabetes requiring insulin, or if you usually take many pills, or
recently had surgery, or are being treated for an infection –
you’re not given even one dose when you leave. You’re
not given any appointments, or even any chance to make an
appointment. Even if you’re a diabetic, you may not be
allowed to eat breakfast. Despite prison health services,
collectively, commanding a $2 billion annual budget, no one, not
even the people with mental illness or HIV, is given even a piece
of paper on release with any medical information on it.

And, of course, when you leave prison, you don’t have
health insurance.

After release, all your health issues will be, without a doubt,
sooner or later the problem of whatever county you’re headed
toward. Why the county? Even if you had a permanent disability, and
federally paid or subsidized Medi-Cal or Medicare coverage for
reasons of poverty or disability, when you are imprisoned, all your
coverage is automatically canceled. Clearly, no one thinks a
prisoner should be drawing benefits while behind bars. The problem,
however, comes when a person is released. There is no automatic
restoration of that same coverage, even for permanent disability.
The county alone will bear the burden of your medical care upon
your release. And, often the county may wind up paying for it
forever more. Having your coverage re-instated is almost always a
long and complex process, requiring multiple visits, and a high
level of literacy and persistence. And the reinstatement process,
it goes without saying, requires an address.

There is no reason why the prison system cannot be as efficient
at reinstating coverage as it is at canceling that same coverage.
If there are doubts about whether qualifying conditions still
exist, there is also no reason why coverage could not be reinstated
upon release for a probationary period of, say, six months. It
would then lapse unless the released prisoner was seen and assessed
by an outside provider. Such a process would be a powerful
incentive for released prisoners to maintain preventive care. And
for counties to be able to provide care instead of post-release
crisis-level, unreimbursed emergency room visits.


Stay tuned for Part II next Tuesday, which looks at options for prisoners on release, and then Part III next Thursday, which reports exclusively the number of homeless prisoners on parole in San Francisco and the Bay Area – which county has the highest proportion of homeless parolees? These three articles were supported by Spot.us. Doc Gurley is a Harvard Medical School graduate and is a practicing board-certified internist, and the creator of the Memoriam app – the first, and only, app to allow disaster-relief workers to speak for the dead. You can follow Doc Gurley on Facebook. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific, effective, affordable tips on how to nurture your joy and grow your personal wellth.

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