Mental health care system in crisis

If you’ve read The Soloist, you are aware of how disabling mental illness can be to lives full of promise. The National Alliance on Mental Illness (NAMI) recently released Grading the States, a report card on the U.S. public mental health care system for adults.

The analysis is based on 65 specific criteria such as access to medicine, housing, family education, and support for National Guard members, and overall the news is not good. The U.S. gets a D, a rating that hasn’t budged since 2006. Across the states, the best grade is B (six states) while there are 18 states with Cs, 21 with Ds and six with Fs. The report includes detailed report cards and recommendations by state.

According to Michael Fitzpatrick, Executive Director of NAMI, “Too many people living with mental illness end up hospitalized, on the street, in jail or dead. We need governors and legislators willing to make investments in change.”

Hopefully, this report, and the imminent release of “The Soloist” movie will generate a national discussion on the need to de-stigmatize mental illness and get people the help they need.

The economy and gender discrimination

Most people are well aware that unemployment continues to rise to its highest levels in 25 years, above 8% nationally and approaching 11% in California. What is less apparent is that this rise is not evenly distributed for men and women. About 14 months ago, men and women had the same level of unemployment (around 4.4%); today 8.8% of men in the labor force are without work, compared to 7.3% of women.

Women appear to be weathering the economic storm slightly better than men. Does this mean that social trends and policies such as affirmative action have reversed gender discrimination in labor markets? As analysts point out, the mostly likely reasons for these trends are that hard-hit sectors such as construction, manufacturing, and financial services tend to be male-dominated; while female-dominated sectors such as healthcare and education have not seen such high levels of job loss. Also, college graduates are half as likely to be unemployed as those who have not gone to college; and more women today are a third more likely than men to have graduated from college.

So, women are doing better than men by some measures, but this doesn’t mean that gender discrimination has disappeared. Despite the gains women have made in education, for example, they still earn less than men on average, even when controlling for hours, occupation, parenthood, and other factors known to affect earnings. In many ways, the proverbial “glass ceiling” still exists. According to Amy Osler from the Chicago Network, which tracks the advancement of women in the workplace, “it’s like climbing straight up an ice mountain.”

So, women, take heart that you’re keeping your jobs at a better rate than men; but watch out for likely budget cuts in education, healthcare, social work…

This is justice?

I recently served on a jury in a civil trial in Los Angeles County. It was the first time I’ve actually gone through the whole process and been selected for a jury, and it was certainly interesting and “good for me” to go through it. It was also frustrating, however, because I couldn’t help but think about how inequality extends even to our legal system (which wasn’t really a surprise, of course).

Here was the case in a nutshell. A woman was walking her dog in her neighborhood a couple years ago when a large dog attacked her and bit her rather severely in her arm and knocked her down a couple times, leading also to problems in her knee and ankle. Perhaps even more significantly, she received significant emotional damage due to the trauma. She sued the owner of the house where the attack occurred. In our deliberations, I and most of my fellow jurors felt the owner of the house bore some responsibility, but in the end we decided unanimously in favor of the defendant due to the narrow scope of the verdict instructions the judge gave us. We had to decide whether the defendant was (1) the owner of the dog or (2) “kept or controlled” the dog. The evidence showed that someone visiting the property at the time was the owner of the dog, and there wasn’t really any evidence that the homeowner had taken responsibility for caring for the dog, so in the end – after clarifying with the judge that we were to consider the defendant as an individual, not as a property owner – it was a simple decision to make.

It was the right decision, but it certainly didn’t feel good. Sure, all of us jurors were inconvenienced for a week and countless public funds went toward supporting the case and trial, but the real victim was this poor woman who in the end received nothing for her troubles. This was not someone looking for a quick way to make a buck; she was a typical hard-working immigrant who came to this country looking to provide a better life for her family. She was victimized by the dog and then by an ambulance-chasing attorney who somehow got this case to go to trial and then proceeded to waste all our time with just atrocious lawyering, leaving numerous holes in almost all aspects of the case.

I couldn’t help but think, if she had the resources to hire a decent lawyer, the result likely would have been different. Yes, the system worked as well as it could in this case, but it still smelled.

Countering discrimination through education

LA Times reporter Corina Knoll provides a touching tale in her article, “Thanking her for opening my eyes,” of how important teachers can be in shaping how we view others and the world. She explains how Iowa schoolteacher Jane Elliot helped her third grade class understand the dynamics and consequences of racism in the wake of the assassination of Martin Luther King, Jr.

With King shot just the day before in Memphis, Elliott encouraged her third-graders to discuss how something so horrible could happen.

“I finally said, ‘Do you kids have any idea how it feels to be something other than white in this country?’ “

The children shook their heads and said they wanted to learn, so Elliott set the rules. Blue-eyed children must use a cup to drink from the fountain. Blue-eyed children must leave late to lunch and to recess. Blue-eyed children were not to speak to brown-eyed children. Blue-eyed children were troublemakers and slow learners.

Within 15 minutes, Elliott says, she observed her brown-eyed students morph into youthful supremacists and blue-eyed children become uncertain and intimidated.

Brown-eyed children “became domineering and arrogant and judgmental and cool,” she says. “And smart! Smart! All of a sudden, disabled readers were reading. I thought, ‘This is not possible, this is my imagination.’ And I watched bright, blue-eyed kids become stupid and frightened and frustrated and angry and resentful and distrustful. It was absolutely the strangest thing I’d ever experienced.”

As Elliot recounts in videos from the Frontline program, “A Class Divided,” she took this rather drastic approach because experience is more valuable than just talk:

I knew it was time to deal with this in a concrete way not just talk about it, because we had talked about racism since the first day of school.

I remember several years ago being asked by a friend who had been active in the civil rights movement and was African American why I, as the proverbial white male, was so concerned about inequality and discrimination. I had to think about it for a little bit. Certainly my most immediate influences of family and faith played important roles, but as I thought about it more, I realized that my education was formative in this regard. I was fortunate to attend public schools in the same state where Jane Elliot taught, with good teachers and a spirit of open-mindedness. I distinctly remember learning in school at an early age about the value of different cultures and race/ethnic groups. One of my earliest heroes I learned about in school, encouraged by my teachers, was Frederick Douglass. That reflection impressed on me the important role that education can play in learning not just about subjects, but also about life and dealing with with complex issues like racism and discrimination.

“The Soloist” on 60 Minutes

In case you need any more encouragement to read “The Soloist” by Steve Lopez, check out the piece Morley Safer did on 60 Minutes this week on the relationship between Mr. Lopez and Mr. Ayers . It’s a nice piece, but trust me, read the book for a more complete story.

Review of “The Soloist” by Steve Lopez

We have a general rule of thumb in our household that before seeing a movie, we try to read the book on which it is based.  (By the way, this has proved to be a great motivator for our son to plow through the Harry Potter books).  You may have recently seen the trailer for a new movie called “The Soloist,” starring Robert Downey Jr. and Jaime Foxx that is slated to be released in theaters on April 24, 2009.

The movie is based on a book by the same name written by Los Angeles Times columnist Steve Lopez, which I had put off reading until very recently.  It wasn’t because I thought I wouldn’t like the book; but rather because the story was so familiar.  The book emerged from a series of Lopez’s columns about the friendship he developed with Nathaniel Ayers, a mentally ill homeless man in Los Angeles.  As a loyal subscriber to the Times, and in particular a regular reader of Lopez’s column, I probably felt the book wouldn’t have much more to offer.  I’m glad I followed our rule of thumb, because I was wrong.  Whether you are familiar with this story or not, I encourage you to read The Soloist, a beautiful account of taking risks, learning, friendship, and personal growth.

Steve Lopez describes himself as a fisherman, constantly casting nets out for interesting stories which hopefully come back once in awhile with hidden gem.  He admits that in an industry that is crumbling by the day, he has a privileged position.  Like his heroes Mike Royko and Jimmy Breslin before him, Lopez plays the role of muckraker and storyteller for a city.  He enjoys “sticking it to the man” (Cardinal Roger Mahoney, LA Mayor Antonio Villaraigosa, and Gov. Arnold Schwarzenegger have been skewered on several occasions for what Lopez believes are both personal and professional transgressions) but also telling the stories of normal everyday people that have larger societal implications. None of his stories has had as much an influence, both to himself or society, as that which began as a chance encounter with the person he first calls Violin Man.

I’m on foot in downtown Los Angeles, hustling back to the office with another deadline looming.  That’s when I see him.  He’s dressed in rags on a busy downtown street corner, playing Beethoven on a battered violin that looks like it’s been pulled from a dumpster.

“That sounded pretty good,” I say when he finishes.

He jumps back three steps, eyeing me with suspicion.

….

I notice while talking to him that someone has scrawled names on the pavement where we’re standing.  Nathaniel says he did it with a rock.

The list includes Babe Ruth, Nancy, Kevin and Craig.

“Whose names are those?” I ask.

Oh, those people, he says.

“Those were my classmates at Juilliard.”

To a curious journalist like Lopez, those last words were a provocation to dig much deeper, and dig he did.  More than just the subject of a column, however, Nathaniel becomes a friend and teacher to Lopez, introducing him to the travails of mental illness, homelessness, and racism and taking him on a journey of self-discovery.

Lopez is fascinated with the story of how this talented musician, who overcame all sorts of odds as an African American male during the 1970s to attend Julliard, ended up on the streets of Los Angeles. He learns how quickly an illness such as paranoid schizophrenia can take someone with such promise and even family support down a path toward extreme poverty and homelessness.  Lopez begins to care about Nathaniel, learns about his past, develops a common appreciation for classical music, provides him with new violins and cellos that have been donated by reader of his columns, and ultimately tries to get him the care and housing he needs.  He struggles with the fine line between being a journalist and friend, whether by helping his new friend he’s putting him at risk:

Every time the phone rings at night, my stomach does a flip.  I’m always sure it’s the police, calling to say Nathaniel is hanging on by a thread after a mugging, and nice going Mr. Columnist.

In his columns, Lopez can at times come off as arrogant and condescending.  In this book, he bares his soul a bit more, detailing the ethical and personal dilemmas he faced in trying to help his new friend.  Is he exploiting Nathaniel for his own ends?  How can he help someone who so often expresses a distaste for wanting to be helped? Recounting the experience of receiving an award from the National Alliance on Mental Illness for his role in educating the public about mental illness, Lopez expresses his own inadequacies:

I don’t feel as though I’ve done much more than write about what people at the conference already know, and as I look at a crowd that is standing and applauding, I’m tempted to grab the microphone and ask if anyone out there can tell me what to do next.

It is clear to Lopez that Nathaniel needs psychiatric care and a place to live, and he tries numerous ways to entice his friend into both, usually involving using Nathaniel’s passion for music as bait.  He works with LAMP Community on Skid Row to create space for Nathaniel to practice his music.  He enlists musicians from the Los Angeles Philharmonic to provide lessons for Nathaniel.  He gets LAMP to reserve a room for Nathaniel to live in and bangs his head against the wall trying to get Nathaniel to stay there.

Ultimately, however, Lopez learns that this journey is not about himself.  Their relationship goes through many ups and downs, and it is after one of the particularly stressful times, when Lopez seem to almost have given up hope that Nathaniel makes the choice on his own to spend the night in the apartment.  Lopez recounts how he found out while driving around the streets looking for his friend and talking on the phone with LAMP staffer Stuart Robinson:

“Do you have any idea where he was?” I ask.

“Yes,” Robinson says. “He spent the night in his apartment.”

He what?

I pull the car over to avoid driving up on a curb.  Almost exactly one year after our first encounter, he did it.

Yes, he did it and thus begins a long process of recovery that continues to this day.  The two remain close and appear to be doing well.

I saw them at the launch of the Nathaniel Anthony Ayers Foundation, which was founded by Nathaniel’s sister to support programs for the artistically gifted mentally ill several months ago.  Mr. Ayers – as Lopez turns to calling him near the end of the book – played his cello as a surprise guest at the event, and the affection and respect toward each other was evident.  I have heard some question whether Lopez’s views on homelessness and mental illness are too colored by his own savior complex and relationship with Nathaniel Ayers, and whether he would have shown any interest in this person if he did not have a unique musical talent.  It’s a fair challenge, but one that I think Lopez is open to struggling with.  In the end, I think anyone can see that he has played a very important role in educating all of us through his writings.

About a quarter of homeless persons in the U.S. have a serious mental illness such as chronic depression, bipolar disorder, schizophrenia, and severe personality disorders.  That means there are about 165,000 people on our streets every day struggling with a serious mental illness.  What will it take for us to mobilize the dedication and patience to ensure that all of these people get the care and housing they need and deserve?

Hopefully the movie will be a great success and will generate a national, and even international, discussion to remove the stigma associated with mental illness and homelessness.  But, even more hopefully, people will read this book and wrestle with the challenges and hope it provides.

The Soloist: A Lost Dream, an Unlikely Friendship, and the Redemptive Power of Music. Steve Lopez.  G.P. Putnam’s Sons, New York NY.  2008. 273 pp. ISBN 978-0-399-15506-2

Health, Wealth and History

One of the most poignant moments in the most recent presidential campaign came during the second debate in discussing health care. The town hall format debate was full of the usual equivocating and double-speak of presidential debates and the campaign in general, and both candidates offered vague, stump-speech responses to an audience member’s question about whether health care should be “treated as a commodity.” But, when pressed by Tom Brokaw on whether health care is a “privilege, right or responsibility,” each candidate clarified his perspective. John McCain declared “I think it’s a responsibility” while Barack Obama asserted “I think it should be a right for every American.” For a populace mired in the midst of an economic meltdown looking for assurances that the new President would work to secure access to such a basic need as health care, Obama’s direct response seemed to connect better and propel him to victory in the election.

Access to health care to address all sorts of diseases is indeed a fundamental concern for millions of Americans and the source of household stress. What is often lost given current debates is the astounding progress made by modern medicine in addressing many – though not all – formerly incurable diseases. My father (currently retired after a long career in academic medicine and research) recently published a book highlighting these advances, as well as remaining challenges, in medicine.

Whom the Gods Love Die Young explores the history of disease and medical care through the lives and deaths of ten famous people who passed away before the age of 40. Most of the people are from the arts (Robert Burns, Lord Byron, Charlotte Brönte, Stephen Crane, Rudolph Valentino, Jean Harlow, and Mario Lanza), but also from politics (Princess Charlotte and Eva Perón) and sports (Lou Gehrig). It is part biography, part medicine 101, and part medical prognosis. Though I am not unbiased in this case, I found the book engaging and well-written (not surprising given that the author corrected my grammar countless times at the dinner table as I was growing up).

In nearly all of the cases in the book, if these persons were alive today they very likely would live much longer due to advances in modern medicine (the possible exception being Lou Gehrig, as ALS continues to confound researchers). That is, of course, if they lived in the developed world or had financial resources to ensure access to the best health care. As highlighted in the book, deaths from diseases such as malaria (Lord Byron), tuberculosis (Stephen Crane), cervical cancer (Eva Perón) and death in childbirth (Princess Charlotte) have plummeted in the U.S. and much of the world but continue to plague poor countries and people.

For example, maternal mortality declined more than 99% over the last half of the 20th century, but rates in developing countries can be more than 150 times that in the U.S. Cervical cancer rates in the U.S. fell by two-thirds over the last 50 years due to improved screening (and hopefully helped recently by a promising new vaccine); but these interventions are much less readily available to the poor in our world. The advances of modern medicine have undoubtedly saved lives and improved the quality of life overall, but if health care is a right, we should strive to made this progress more universal.

Whom the Gods Love Die Young: A Modern Medical Perspective on Illnesses that Caused the Early Death of Famous People. Roy Macbeth Pitkin, M.D. RoseDog Books, Pittsburgh PA. 2008. 183 pp. ISBN 978-1-4349-9199-7

Progress in Addressing Homelessness in Los Angeles?

“Los Angeles” is often thought of as synonymous with “dysfunctional” when it comes to addressing homelessness. In a post for the Funders Together: Homelessness Ends Here Blog I highlight the quiet, but significant, systemic changes being made toward ending homelessness in Los Angeles County. We still have a long way to go, but it is important to acknowledge and celebrate success where we can find it.

Homeless children: a national disgrace

The National Center on Family Homelessness NCFH today released a report outlining the extent of homelessness among children in the U.S. In America’s Youngest Outcasts: State Report Card on Child Homelessness, NCFH researchers found:

  • More than 1.5 million children are homeless annually in the United States—one in every 50 American children.
  • 42 percent of homeless children are younger than age 6.
  • Homeless children have twice the rate of moderate to severe health conditions compared to middle class children, and twice the emotional problems.
  • More than 1 in 7 homeless children have moderate to severe health conditions, such as asthma.
  • Homeless children struggle in school, with an average 16% lower proficiency in math and reading, and an estimated graduation rate below 25%.

The report includes data for all 50 states along four major domains (extent of child homelessness; child well-being; risk for child homelessness; and state policy and planning efforts) and rankings by state, as well as a policy platform to address the problem of child homelessness.

There is a wealth of information on the report and the Campaign to End Child Homelessness at http://www.homelesschildrenamerica.org

The Great Disruption

As economic indicators continue to worsen, people from all walks of life are personally feeling the effects of the recession. Unemployment continues to rise as layoffs spread and businesses fail. Public resources continue to be thrown at corporations deemed too-intertwined with our financial system to collapse. Retirement accounts shrink as the stock market plunges. Demand at local food banks, shelters and other safety net systems continues to rise.

The poor are used to struggling and worrying every day about the precariousness of their financial position; today many more of us are in the same boat. As a result, news and discussions tend to focus on the here and now. Few are asking the “big questions” about what this current situation means for our future.

Thomas Friedman, author of The World is Flat and Hot, Flat and Crowded, is one who likes to explore the big questions about our economy and society. In a provocative N.Y. Times Op-Ed, he contends that the current crisis may be much more than just a hiccup, but rather may serve as an indictment of our economic growth model:

Let’s today step out of the normal boundaries of analysis of our economic crisis and ask a radical question: What if the crisis of 2008 represents something much more fundamental than a deep recession? What if it’s telling us that the whole growth model we created over the last 50 years is simply unsustainable economically and ecologically and that 2008 was when we hit the wall — when Mother Nature and the market both said: “No more.”

We have created a system for growth that depended on our building more and more stores to sell more and more stuff made in more and more factories in China, powered by more and more coal that would cause more and more climate change but earn China more and more dollars to buy more and more U.S. T-bills so America would have more and more money to build more and more stores and sell more and more stuff that would employ more and more Chinese …

We can’t do this anymore.

I fear that unless we restructure our economy along the lines that Frideman contends need to be “smarter, more efficient, more responsible,” we may all feel ourselves being in a constant state of precariousness.