This week our PM, Malcolm Turnbull, was admonished when he gave $5 to a homeless man in Melbourne. He was sorry if people thought he should not have done this. He said, “I felt sorry for the guy”….”there but for the grace of God go I.”
George Orwell wrote after being ‘down and out’ in Paris and London, “Still I can point to one or two things. I have definitely learned by being hard up. I shall never again think that all tramps are drunken scoundrels, nor expect a beggar to be grateful when I give him a penny, nor be surprised if men out of work lack energy, nor subscribe to the Salvation Army, nor pawn my clothes, nor refuse a handbill, nor enjoy a meal at a smart restaurant. That is a beginning.“
The cities my wife Jan and I visited in the US, Alaska and Canada on a recent holiday were clean, ordered and visually appealing. The people were courteous. They had it all together, it seemed. But there were strangers. On street corners, rootless wanderers, disordered and begging were homeless mentally ill people. Most with black faces. The courtesy extended to us was not extended to them. No ‘panhandlers’ here – one shop window notice said, “Don’t give money to the panhandlers – donate to the Glory Hole.”
I vividly recall an emaciated, disheveled young man, oblivious to trousers around his knees, as he weaved across a busy intersection and, beyond, two rangers shepherding a gesticulating man out of the main park in downtown Seattle. And the shouts from an agitated man as security edged him on to the pavement outside the prestigious Nordstrom shopping mall in central Vancouver.
At the same time as seeing the homeless in the west coast American cities, 49 people were shot dead and 56 injured in the Almedo massacre in the US. Not blamed on the ubiquity of the gun or its romance but on mental illness. Mass shooters must be mentally ill – not angry, hostile, resentful, aggrieved, hate-filled.
Let’s assume, for the moment, that gun deaths in the US, higher than in comparable countries, are due to mental illness, there’s surely a case for investing in services to reach the mentally ill. Judged by the visible numbers of street-living mentally ill people, the efforts of this wealthy nation are grossly inadequate.
Street scenes like this occur in Australia, probably less frequently. We have our own difficulties in reaching the severely mentally ill, especially the long-term homeless.
Over a period of 30 years, in a free clinic at the Matthew Talbot Hostel for the homeless, Woolloomooloo in central Sydney, I have often asked mentally ill homeless people where they would prefer to be? In an asylum (when asylums existed) or on the street? The answer was always – anything but the asylum. Homeless people have a pervasive fear of being labelled as mad and therefore shun mental health services.
Given the manifold needs and complexity of the problems, how can those who could benefit get access to support and appropriate treatment?
- Health services need to be accessible in the environments frequented by homeless people, be free at the point of delivery and be able to respond comprehensively to their needs.
- Social, accommodation and health agencies in contact with homeless people, have to work together to ensure that one agency’s service dovetails with the services provided by another. The homeless person must not be shunted from one service to another, through the “revolving door”; once known as the ‘bum’s rush’.
- Difficult problems need to be shared as the worker or clinician at the end of the line does not want to be “dumped on“ with dilemmas he or she cannot handle alone.
- Health and social services should have ‘open door’ and ‘no wrong door’ policies; people are commonly excluded because they have too many problems for the agency to deal with.
- Further, such marginalised people need assertive follow-up to overcome their reticence in seeking help. As with other continuing health problems an effective ‘chain of care’ needs to be established.
The primary health networks currently being funded by government, offer an unique opportunity to construct different models of primary care for special ‘high risk’ populations such as, the homeless mentally ill.
Even the most disenfranchised person can accept from time-to-time that they need first-aid or immediate medical help. This initial contact, in the context of trust, can be the conduit through which appropriate specialised services, which may alter the course of their lives, can be assessed. For unless there are creative approaches along these lines, impaired people will continue to fall through the cracks into destitution and homelessness.
Ian Webster is Emeritus Professor of Public Health and Community Medicine, UNSW.