Tuesday, November 16, 2010

The Cost

A small NH town has a dump man named Ed. Now, I know Ed, because he was for many years a resident of the state psychiatric hospital, where I have worked for over 30 years. Ed originally came from this town, and when the hospital was trying to place him years ago, the social worker decided to move away from the usual plan of finding an SRO or a little apartment in town, setting him up with the local mental health center, and gradually teaching him to live in the world he had left in the early 60's. She contacted the town selectman - that's a singular - and asked if anyone might have a place for someone that came from there but they had probably forgotten.

Forgotten young Ed? How old would he be now? Of course we remember Ed. He was in my sister's class at school. His father used to have a little shop in town. Ed needs a place? Let me get back to you. Let's see what we can do. I will point out that no one from the town had ever visited Ed or sent him a card in 25 years, but that's NH. They didn't want to embarrass him by having people see him in the state hospital, probably.

The selectman got back to her a few days later. There was a woman glad to have Ed in, and the town had even arranged a job for him, as the assistant dump guy. A few years later the regular dump guy retired, and Ed became the dump guy. He's still delusional - tells the townspeople all kinds of crazy stories - but it doesn't interfere with his work much. A local PCP follows his meds - no psychiatrist or interfering human services people to clutter up the joint.

In the same town there's a retired guy with a truck. For $1 a bag, he'll pick up your trash Tuesday or Thursday and bring it to the dump. Leave the dollar attached to each bag. If you can't get out, he'll come into your house by prearrangement and take the trash out himself. He probably should have some sort of license and meet some state or federal standards that folks suspect exist but no one wants to look into it. So the sweet old guy makes another $200/week, and everyone's happy.

It is the ideal solution everyone is thinking about in the back of their minds when they are setting policy. This is the way life should be. This is how communities should act. It is the thought behind Tolkien's anarcho-monarchism, the idea behind the libertarians's love of small, naturalised, spontaneous solutions, the force behind all the liberal programs to teach job skills, develop natural networks of support, and have self-determination.

Wouldn't it be nice if.

It's 90% fantasy.

Y'see, Ed's not violent, and he shows up to work everyday. He stays on his medication, he's not addicted to drugs, and because years back he belonged to some independent Baptist sect, he's never had a drop of alcohol. But more than all that, it's only one guy. What's the town going to do if they have another Ed, or three, even if he's one of the easier ones to figure out. And then next sweet old retired guy with a truck has to figure out some other scheme as well. When you think of it, there are already retired people in town who don't have the health to pick up bags - but they didn't come into the story.

How would you replicate this solution in Boston? Hell, how would you replicate it in Concord? There are many, many more people out there, all of them with added difficulties - some of their own making, but many not. Making a life for all of them is an expensive proposition. In fact, it is furiously more expensive than any of you imagine. To do this right, to provide the services that people need to have a life, is well beyond our ability to fund. Well beyond. We might hope for technological solutions to bail us out over time: medications with fewer side effects, or gene manipulation to pull some of the developmental and psychiatric problems out of the equation. Better methods of incentive and persuasion to keep people in the treatment they need. New communication technologies that allow people to work without having their oddness and lack of social or employment skills show.

But for now, we have these people, and they are real people, and they are just difficult and expensive.

Conservatives and liberals have their separate ways of screwing this up. Small-government types entertain the fantasy that a lot of this would work itself out if people were more self-reliant - if individuals and families stepped up and made these natural solutions happen. They have a point, of course. I am very reluctant to apply for disability benefits for young people, knowing that this dooms them to a rather meager, helpless life in many cases. A lot of people could indeed smarten up and fly right if they had to. The risk of that is, some people can't, even with significant family support, or can't quite, and pushing them out into the world is merely kicking them when they are down. And let me assure you, you don't know which one's are which.

Liberals feel your pain, and in their kind-heartedness think we could do what is necessary if we would just try harder. They also have no idea how extensive the problems are. But you can see how they sense it at a distance, because a lot of them move into parts of the human-services bureaucracy where they are no longer providing services. They set up information clearinghouses, in order to connect people to services that already exist. They go into advocacy, trying to get this miserly, uncaring society to see how much we need to increase our support and grow new programs. They believe that if we all just pull together, dammit, we could make this pretty good. And so human service bureaucracies, and non-profits supported by government money, become about 50% people not doing anything that actually provides services. They go to meetings a lot.

They move into these positions to avoid despair. And it keeps the fantasy alive that if we would just be a good society like oh, all of Europe, they think, that this is manageable. Yes we can.

No we can't. Sooner or later liberals are going to have to face the despair, and deal with it emotionally. Their emotion drives their politics, and their hatred of people who won't do what they just know is important is a hatred of that despair. A hatred of reality. There is the hope that the pain of others will go away, and we can be free of it. Say, rather, that everyone picks their place along the line of pain, and endures from there. We're pretty good at that, actually.

No one wants this reality. In a fallen world, this will always be here. But facing the despair, and deciding what is my part in this, is a task of adulthood. There will be no comity until everyone faces a little more of the truth.

And hey, this is just mental health, developmental delays, autism, and substance abuse. I haven't even touched on physical problems, crime, or a dozen other things I know little about.


Ymar said...

"To do this right, to provide the services that people need to have a life, is well beyond our ability to fund. "

What would be required is a self-regenerating system that gets more funds the more services it puts out.

Essentially a business. If you can find a way to make helping such people profitable, you have in essence solved the question of sustainability and feasibility. It can be sustainable forever because what you put in is less than what you get out.

But if you put in more than you get out, then it's called a hole. A sink hole. It'll last awhile while it is good. And then it won't.

Ben Wyman said...

The solution, clearly, is that everyone should move to small New England towns.

Sponge-headed ScienceMan said...

Two great reads for further exploring this topic: The Great Good Place by Ray Oldenburg and Robert D. Putnam's Bowling Alone. From Oldenburg:

Beyond those aforementioned conditions that kept the local citizens pretty much confined to the immediate locale and encouraged people to get out of their houses, the character of the third place association in River Park owed much to the size of the community. The town was within the range of population size and physical space that many experts considered ideal. Among adults, everyone knew everyone on sight, by voice, by reputation, and by the reputation of the individual’s family. The size of the community was compatible with the limits of human memory.