Wednesday, January 19, 2005

Harm Reduction or in Plain English Damage Control

Bare with me folks I’m running on empty. My daughter, Emma (imagine a three-year-old 40 pound Afropolurican with very good lungs) has made a serious attempt on her parent’s lives. She’s waking up three to four times a night screaming, usually with a fashion request like “I need my party shoes.”

So damage control or Harm Reduction is first and foremost in my cloudy mind. The thing about public hospitals is that they’re public. Only sound county policies can fix the medical center, fix Oakland and fix people. That’s the job, the endgame, and the bottom line. That’s where the solutions start, with sick people. Our experts look at budgets, at billing, at politicians, at contracts and studies. No one has spoken to the patients and they especially haven’t talked to the “problem patients” or “frequent flyers.”

You ask any ten homeless people in Oakland what they need, they’ll usually tell you two things: first they will tell you how sick they feel and second they will tell you they are trying to get Disability. By this they mean Social Security Income and Medi-Cal the health benefit that comes with it. You see in Alameda County we have bureaucracies on top of bureaucracies all not managing the poor and sick’s basic problems: healthcare coverage and disability benefits.

Alameda County non-profits, public services, community clinics and private healthcare providers all compete for funding. It’s every agency for itself; they don’t cooperate to get poor disabled people benefits. The very sick and poor (hence very expensive clients) just get bounced around between agencies. County agencies don’t coordinate care and advocate for patients, they compete for Dave Kears’ favor by cutting costs and position themselves for funding. In fact the prison system spends its time knocking people off benefits and then dropping them back into Oakland without a job, an income or a healthcare benefit.

It’s hard to get over that terminal cancer when you have to stand on the corner and sell the Street Sheet Newspaper to get money for yourself and your two young children. Sure you’re dying and certainly you deserve the social security income you paid into for twenty years but in Alameda County we preach the "personal responsibility approach" to getting disability benefits. Yeah, drag your sick self down to the Social Security office and fill out the forms, than fight with all the public agencies that have your medical records to try to make them give them to Social Security. In the mean time live on the street and “hey, if it doesn’t work, it’s not our fault, you have to take some responsibility.“

The good people at The Positive Resource Center, in San Francisco, keep the data on these things and it turns out 90% of claims submitted without an advocate get denied and 30% submitted with an advocate get denied. So clearly the personal responsibility policy is based more on prejudice than on data. See, many people who use county services use drugs, or did use drugs, or have been to prison or have mental illness and the county doesn’t really want to help them. Sure we have a few non-profits, who help the super-sick or special groups, but we have no coordinated plan and worse, we lack a philosophy of compassion and service, and the political leadership to address the problems of our most needy.

So in my little neighborhood in Oakland, the Dimond, we have five to ten people with all sorts of mental and physical illnesses living in parking lots and on the street. We have a clearly schizophrenic woman in urine-soaked clothes, who is sometimes too frightened to stand in line for food. We have a serial defecator who deposits little surprises in shopkeepers doorways, we have a woman with an amputation, and an assortment of men with physical, mental health and substance abuse problems. A local business owner called the county, concerned about the health and welfare of these obvious mentally or physically ill people and was told call the Oakland Police Department.

So, Harm Reduction, it’s a global philosophical approach to dealing with public health problems. It’s a pragmatic approach to substance abuse and high-risk behaviors. The idea is limit the damage. If the public health problem is AIDS, focus on stopping the spread of AIDS; not stopping sex (sex is fun and cheap and therefore very hard to stop). Try to prevent violence, instead of only investing in punishment. It’s a more pragmatic and less Puritanical approach to public health. Besides sticking drug offenders in jail has done little or nothing to slow public health problems.

So as a practical matter what does this mean. Well, in San Francisco, that great city by the Bay. It means all county agencies or agencies funded by the county must work together to get the social security benefits for eligible clients. They can’t dump them on other agencies or send clients chasing down bureaucratic black holes. That’s right, San Francisco plans to put in place performance measures and standards, they’re not just addressing the problem they’re managing the solution. This means merchants, neighbors and police don’t have to watch sick people suffering on their streets, and it means state and federal funds are used to pay for health and income benefits, this saves the county money and keeps public services like hospitals financially viable.

Postscript: Any advice on how to keep Emma "Slave-to-Fashion" Fisher off the catwalk in the wee hours of the night would be deeply appreciated.

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