What the Dog Saw and Other Adventures

by Malcolm Gladwell

  “He was like the one constant in an environment that was ever changing,” she went on. “In he would come. He would grin that half-toothless grin. He called me ‘my angel.’ I would walk in the room, and he would smile and say, ‘Oh, my angel, I’m so happy to see you.’ We would joke back and forth, and I would beg him to quit drinking and he would laugh it off. And when time went by and he didn’t come in, I would get worried and call the coroner’s office. When he was sober, we would find out, oh, he’s working someplace, and my husband and I would go and have dinner where he was working. When my husband and I were dating, and we were going to get married, he said, ‘Can I come to the wedding?’ And I almost felt like he should. My joke was ‘If you are sober you can come, because I can’t afford your bar bill.’ When we started a family, he would lay a hand on my pregnant belly and bless the child. He really was this kind of light.”

  In the fall of 2003, the Reno Police Department started an initiative designed to limit panhandling in the downtown core. There were articles in the newspapers, and the police department came under harsh criticism on local talk radio. The crackdown on panhandling amounted to harassment, the critics said. The homeless weren’t an imposition on the city; they were just trying to get by. “One morning, I’m listening to one of the talk shows, and they’re just trashing the police department and going on about how unfair it is,” O’Bryan said. “And I thought, Wow, I’ve never seen any of these critics in one of the alleyways in the middle of the winter looking for bodies.” O’Bryan was angry. In downtown Reno, food for the homeless was plentiful: there was a Gospel kitchen and Catholic Services, and even the local McDonald’s fed the hungry. The panhandling was for liquor, and the liquor was anything but harmless. He and Johns spent at least half their time dealing with people like Murray; they were as much caseworkers as police officers. And they knew they weren’t the only ones involved. When someone passed out on the street, there was a “One down” call to the paramedics. There were four people in an ambulance, and the patient sometimes stayed at the hospital for days, because living on the streets in a state of almost constant intoxication was a reliable way of getting sick. None of that, surely, could be cheap.

  O’Bryan and Johns called someone they knew at an ambulance service and then contacted the local hospitals. “We came up with three names that were some of our chronic inebriates in the downtown area, that got arrested the most often,” O’Bryan said. “We tracked those three individuals through just one of our two hospitals. One of the guys had been in jail previously, so he’d only been on the streets for six months. In those six months, he had accumulated a bill of a hundred thousand dollars — and that’s at the smaller of the two hospitals near downtown Reno. It’s pretty reasonable to assume that the other hospital had an even larger bill. Another individual came from Portland and had been in Reno for three months. In those three months, he had accumulated a bill for sixty-five thousand dollars. The third individual actually had some periods of being sober, and had accumulated a bill of fifty thousand.”

  The first of those people was Murray Barr, and Johns and O’Bryan realized that if you toted up all his hospital bills for the ten years that he had been on the streets — as well as substance-abuse-treatment costs, doctors’ fees, and other expenses — Murray Barr probably ran up a medical bill as large as anyone in the state of Nevada.

  “It cost us one million dollars not to do something about Murray,” O’Bryan said.

  2.

  In the wake of the Rodney King beating, the Los Angeles Police Department was in crisis. It was accused of racial insensitivity and ill discipline and violence, and the assumption was that those problems had spread broadly throughout the rank and file. In the language of statisticians, it was thought that the LAPD’s troubles had a “normal” distribution — that if you graphed them, the result would look like a bell curve, with a small number of officers at one end of the curve, a small number at the other end, and the bulk of the problem situated in the middle. The bell-curve assumption has become so much a part of our mental architecture that we tend to use it to organize experience automatically.

  But when the LAPD was investigated by a special commission headed by Warren Christopher, a very different picture emerged. Between 1986 and 1990, allegations of excessive force or improper tactics were made against eighteen hundred of the eighty-five hundred officers in the LAPD. The broad middle had scarcely been accused of anything. Furthermore, more than fourteen hundred officers had only one or two allegations made against them — and bear in mind that these were not proven charges, that they happened in a four-year period, and that allegations of excessive force are an inevitable feature of urban police work. (The NYPD receives about three thousand such complaints a year.) A hundred and eighty-three officers, however, had four or more complaints against them, forty-four officers had six or more complaints, sixteen had eight or more, and one had sixteen complaints. If you were to graph the troubles of the LAPD, it wouldn’t look like a bell curve. It would look more like a hockey stick. It would follow what statisticians call a power law distribution — where all the activity is not in the middle but at one extreme.

  The Christopher Commission’s report repeatedly comes back to what it describes as the extreme concentration of problematic officers. One officer had been the subject of thirteen allegations of excessive use of force, five other complaints, twenty-eight “use of force reports” (that is, documented internal accounts of inappropriate behavior), and one shooting. Another had six excessive-force complaints, nineteen other complaints, ten use-of-force reports, and three shootings. A third had twenty-seven use-of-force reports, and a fourth had thirty-five. Another had a file full of complaints for doing things like “striking an arrestee on the back of the neck with the butt of a shotgun for no apparent reason while the arrestee was kneeling and handcuffed,” beating up a thirteen-year-old juvenile, and throwing an arrestee from his chair and kicking him in the back and side of the head while he was handcuffed and lying on his stomach.

  The report gives the strong impression that if you fired those forty-four cops, the LAPD would suddenly become a pretty well-functioning police department. But the report also suggests that the problem is tougher than it seems, because those forty-four bad cops were so bad that the institutional mechanisms in place to get rid of bad apples clearly weren’t working. If you made the mistake of assuming that the department’s troubles fell into a normal distribution, you’d propose solutions that would raise the performance of the middle — like better training or better hiring — when the middle didn’t need help. For those hard-core few who did need help, meanwhile, the medicine that helped the middle wouldn’t be nearly strong enough.

  In the 1980s, when homelessness first surfaced as a national issue, the assumption was that the problem fit a normal distribution: that the vast majority of the homeless were in the same state of semipermanent distress. It was an assumption that bred despair: if there were so many homeless, with so many problems, what could be done to help them? Then, in the early 1990s, a young Boston College graduate student named Dennis Culhane lived in a shelter in Philadelphia for seven weeks as part of the research for his dissertation. A few months later he went back and was surprised to discover that he couldn’t find any of the people he had recently spent so much time with. “It made me realize that most of these people were getting on with their own lives,” he said.

  Culhane then put together a database — the first of its kind — to track who was coming in and out of the shelter system. What he discovered profoundly changed the way homelessness is understood. Homelessness doesn’t have a normal distribution, it turned out. It has a power-law distribution. “We found that eighty percent of the homeless were in and out really quickly,” he said. “In Philadelphia, the most common length of time that someone is homeless is one day. And the second most common length is two days. And they never come back. Anyone who ever has to stay in a shelter involuntarily knows that all you think about is how to
make sure you never come back.”

  The next 10 percent were what Culhane calls episodic users. They would come for three weeks at a time, and return periodically, particularly in the winter. They were quite young, and they were often heavy drug users. It was the last 10 percent — the group at the farthest edge of the curve — that interested Culhane the most. They were the chronically homeless, who lived in the shelters, sometimes for years at a time. They were older. Many were mentally ill or physically disabled, and when we think about homelessness as a social problem — the people sleeping on the sidewalk, aggressively panhandling, lying drunk in doorways, huddled on subway grates and under bridges — it’s this group that we have in mind. In the early 1990s, Culhane’s database suggested that New York City had a quarter of a million people who were homeless at some point in the previous half decade — which was a surprisingly high number. But only about twenty-five hundred were chronically homeless.

  It turns out, furthermore, that this group costs the health-care and social-services systems far more than anyone had ever anticipated. Culhane estimates that in New York at least $62 million was being spent annually to shelter just those twenty-five hundred hard-core homeless. “It costs twenty-four thousand dollars a year for one of these shelter beds,” Culhane said. “We’re talking about a cot eighteen inches away from the next cot.” Boston Health Care for the Homeless Program, a leading service group for the homeless in Boston, recently tracked the medical expenses of a hundred and nineteen chronically homeless people. In the course of five years, thirty-three people died and seven more were sent to nursing homes, and the group still accounted for 18,834 emergency-room visits — at a minimum cost of $1,000 a visit. The University of California, San Diego, Medical Center followed fifteen chronically homeless inebriates and found that over eighteen months, those fifteen people were treated at the hospital’s emergency room 417 times, and ran up bills that averaged $100,000 each. One person — San Diego’s counterpart to Murray Barr — came to the emergency room eighty-seven times.

  “If it’s a medical admission, it’s likely to be the guys with the really complex pneumonia,” James Dunford, the city of San Diego’s emergency medical director and the author of the observational study, said. “They are drunk and they aspirate and get vomit in their lungs and develop a lung abscess, and they get hypothermia on top of that, because they’re out in the rain. They end up in the intensive-care unit with these very complicated medical infections. These are the guys who typically get hit by cars and buses and trucks. They often have a neurosurgical catastrophe as well. So they are very prone to just falling down and cracking their head and getting a subdural hematoma, which, if not drained, could kill them, and it’s the guy who falls down and hits his head who ends up costing you at least fifty thousand dollars. Meanwhile, they are going through alcohol withdrawal and have devastating liver disease that only adds to their inability to fight infections. There is no end to the issues. We do this huge drill. We run up big lab fees, and the nurses want to quit, because they see the same guys come in over and over, and all we’re doing is making them capable of walking down the block.”

  The homelessness problem is like the LAPD’s bad-cop problem. It’s a matter of a few hard cases, and that’s good news, because when a problem is that concentrated you can wrap your arms around it and think about solving it. The bad news is that those few hard cases are hard. They are falling-down drunks with liver disease and complex infections and mental illness. They need time and attention and lots of money. But enormous sums of money are already being spent on the chronically homeless, and Culhane saw that the kind of money it would take to solve the homeless problem could well be less than the kind of money it took to ignore it. Murray Barr used more health-care dollars, after all, than almost anyone in the state of Nevada. It would probably have been cheaper to give him a full-time nurse and his own apartment.

  The leading exponent for the power-law theory of homelessness is Philip Mangano, who, since he was appointed by President Bush in 2002, has been the executive director of the US Interagency Council on Homelessness, a group that oversees the programs of twenty federal agencies. Mangano is a slender man, with a mane of white hair and a magnetic presence, who got his start as an advocate for the homeless in Massachusetts. He is on the road constantly, crisscrossing the United States, educating local mayors and city councils about the real shape of the homelessness curve. Simply running soup kitchens and shelters, he argues, allows the chronically homeless to remain chronically homeless. You build a shelter and a soup kitchen if you think that homelessness is a problem with a broad and unmanageable middle. But if it’s a problem at the fringe it can be solved. So far, Mangano has convinced more than two hundred cities to radically reevaluate their policy for dealing with the homeless.

  “I was in St. Louis recently,” Mangano said, back in June, when he dropped by New York on his way to Boise, Idaho. “I spoke with people doing services there. They had a very difficult group of people they couldn’t reach no matter what they offered. So I said, ‘Take some of your money and rent some apartments and go out to those people, and literally go out there with the key and say to them, “This is the key to an apartment. If you come with me right now I am going to give it to you, and you are going to have that apartment.” ’ And so they did. And one by one those people were coming in. Our intent is to take homeless policy from the old idea of funding programs that serve homeless people endlessly and invest in results that actually end homelessness.”

  Mangano is a history buff, a man who sometimes falls asleep listening to old Malcolm X speeches, and who peppers his remarks with references to the civil-rights movement and the Berlin Wall and, most of all, the fight against slavery. “I am an abolitionist,” he says. “My office in Boston was opposite the monument to the 54th Regiment on the Boston Common, up the street from the Park Street Church, where William Lloyd Garrison called for immediate abolition, and around the corner from where Frederick Douglass gave that famous speech at the Tremont Temple. It is very much ingrained in me that you do not manage a social wrong. You should be ending it.”

  3.

  The old YMCA in downtown Denver is on Sixteenth Street, just east of the central business district. The main building is a handsome six-story stone structure that was erected in 1906, and next door is an annex that was added in the 1950s. On the ground floor are a gym and exercise rooms. On the upper floors there are several hundred apartments — brightly painted one bedrooms, efficiencies, and SRO-style rooms with microwaves and refrigerators and central air-conditioning — and for the past several years those apartments have been owned and managed by the Colorado Coalition for the Homeless.

  Even by big-city standards, Denver has a serious homelessness problem. The winters are relatively mild, and the summers aren’t nearly as hot as those of neighboring New Mexico or Utah, which has made the city a magnet for the indigent. By the city’s estimates, it has roughly a thousand chronically homeless people, of whom three hundred spend their time downtown, along the central Sixteenth Street shopping corridor or in nearby Civic Center Park. Many of the merchants downtown worry that the presence of the homeless is scaring away customers. A few blocks north, near the hospital, a modest, low-slung detox center handles twenty-eight thousand admissions a year, many of them homeless people who have passed out on the streets, either from liquor or — as is increasingly the case — from mouthwash. “Dr. —, Dr. Tich, they call it — is the brand of mouthwash they use,” says Roxane White, the manager of the city’s social services. “You can imagine what that does to your gut.”

  Eighteen months ago the city signed up with Mangano. With a mixture of federal and local funds, the CCH inaugurated a new program that has so far enrolled 106 people. It is aimed at the Murray Barrs of Denver, the people costing the system the most. CCH went after the people who had been on the streets the longest, who had a criminal record, who had a problem with substance abuse or mental illness. “We have one individual in her e
arly sixties, but looking at her you’d think she’s eighty,” Rachel Post, the director of substance treatment at the CCH, said. (Post changed some details about her clients in order to protect their identity.) “She’s a chronic alcoholic. A typical day for her is, she gets up and tries to find whatever she’s going to drink that day. She falls down a lot. There’s another person who came in during the first week. He was on methadone maintenance. He’d had psychiatric treatment. He was incarcerated for eleven years, and lived on the streets for three years after that, and, if that’s not enough, he had a hole in his heart.”

  The recruitment strategy was as simple as the one that Mangano had laid out in St. Louis: Would you like a free apartment? The enrollees got either an efficiency at the YMCA or an apartment rented for them in a building somewhere else in the city, provided they agreed to work within the rules of the program. In the basement of the Y, where the racquetball courts used to be, the coalition built a command center, staffed with ten caseworkers. Five days a week, between eight-thirty and ten in the morning, the caseworkers meet and painstakingly review the status of everyone in the program. On the wall around the conference table are several large whiteboards, with lists of doctor’s appointments and court dates and medication schedules. “We need a staffing ratio of one to ten to make it work,” Post said. “You go out there and you find people and assess how they’re doing in their residence. Sometimes we’re in contact with someone every day. Ideally, we want to be in contact every couple of days. We’ve got about fifteen people we’re really worried about now.”

  The cost of services comes to about $10,000 per homeless client per year. An efficiency apartment in Denver averages $376 a month, or just over $4,500 a year, which means that you can house and care for a chronically homeless person for at most $15,000, or about a third of what he or she would cost on the street. The idea is that once the people in the program get stabilized, they will find jobs, and start to pick up more and more of their own rent, which would bring someone’s annual cost to the program closer to $6,000 dollars. As of today, seventy-five supportive housing slots have already been added, and the city’s homeless plan calls for eight hundred more over the next ten years.