The Homeless Triangle: San Francisco, Los Angeles and Prison

Story Updates

2/3/11

• The Homeless Triangle - PART II: Get on the bus

  This is part two in a three part series. The third and final part will be published tomorrow with the first two sections. See part 1 on The Daily Casserole.

  Each year, for 130,000 Californians, the prison door is unlocked one day and the question now becomes - where do you go? And how do you get there? Do you get any money? If so, how much? It is remarkably hard to find an answer to those basic questions, even if you’re a concerned family member trying to find out.

  Nowhere on the California Department of Corrections and Rehabilitation’s (CDCR) website could I find a description of the release process, or how a destination is chosen, or how much (or little) financial aid or transportation help a prisoner might get upon release. If you are the mother of a son with disabilities, impulse control disorders, and mental illness and you’re trying to find out exactly when he’ll be released – you can’t know. And if you’re trying to find out where he might be headed, or how much money the prison system might give him – you can’t know.   Recently released prisoners often tell me in clinic that they got “nothing.” After 10, or two, or 15 years, the door is unlocked and they take a bus somewhere with no medicine, no appointments, no place to stay and not a penny to their name. After being unable to verify this process on the CDCR website, but finding references in news articles to “$200 and a bus pass,” I decided to call CDCR and find out what was true. Eventually, I spoke to the highly professional and extremely helpful officer Joanne Duroncelet. She was a bit surprised that she couldn’t find the information on the website either. But she proceeded to explain that decisions about what you’re given, and where you can go on release can be highly variable. The maximum someone can get on release is indeed $200 – but you’re not guaranteed it. And there is no adjustment for length of time behind bars. And, if you need a bus ticket, and/or clothes, those come out of that same amount.   But you may indeed arrive in a neighborhood without a penny. There is something called a “parole hold,” which is when a parole officer decides to keep whatever is left of your potential after-bus-ticket-and-clothes money. A parole officer may choose to do that to encourage you to comply with the conditions of your parole (such as checking in). How does a parole hold decision get made? It depends on the parole officer, I was told.   Officer Duroncelet also later sent me the link to the written policy, which is here: http://www.cdcr.ca.gov/Regulations/Adult_Operations/docs/DOM/Ch_8_Printed_Final_DOM.pdf   When it comes to the choice of destination, many prisoners may have contraindications that prevent them from returning to within 35 miles of the place they previously lived. Reasons can include a stay-away order, history of domestic violence, restraining orders or sometimes as a condition of parole. No data exists on where those people go, or how many of them become homeless in a different community’s neighborhoods. But generally speaking, most prisoners are expected to return to their county of incarceration. If you have relationships to rely on, that’s where you are expected to go. Back where it all began.   Set up to fail So you’ve got no food, no place to stay, no money, no pills, no appointment, no health insurance. But you can still work, right?   Unfortunately, many prisoners are released without at least one ingredient crucial to getting hired: an I.D. Forget about skills, or education, or the depressed economy. If you’ve got no driver’s license, no passport and no social security card, you can’t get a job. At least not a legal one.   And if you have nothing to prove who you are, how do you prove who you are?    The bottom-line step that is required to cut through the circular bureaucracy is to obtain a notarized birth certificate. Just being able to figure that out is quite complex – even if you have no issues with literacy, access to technology or a disabling mental illness. Unfortunately, you must go to your county of birth to obtain it. Even after you’ve figured out what is required, without an address, a vehicle, or money, how are you going to achieve that step, the first one required just to be able to start the process of obtaining I.D.?   At Project Homeless Connect in San Francisco, the line in front of the booth for assistance obtaining an I.D. is consistently huge. Lack of identification is a large barrier that many, many people cannot overcome without assistance – particularly for those living on the street.   If there is any division in the entire state that is in an excellent position to certify a prisoner’s identification, it would be the Department of Corrections. They, more than any other, should be able to issue the same state identification to any and all people being released from prison. Not a correctional I.D. – that is a form of identification that would not be acceptable for employment for many reasons - but the very same state identification that the DMV issues. It’s hard to imagine why this isn’t done prior to release, even if you may not be out for long.   The news is full of the overwhelming difficulty finding a job in our current economy. Even for people with highly marketable skills and extensive contacts, unemployment can be prolonged – and can become a semi-permanent state. Add to that backdrop the reality of a felony conviction. Felony convictions render applicants not only undesirable, but also bar them from many types of work, such as getting a contractor’s license.   Added to that is the well-documented fact that felony convictions don’t occur evenly across populations. If you grew up in an environment with poor educational and employment levels, your chances of being incarcerated are higher. Your chances of being employed at any job, once released, without marketable skills or education, are quite small. How do you even look for a job without an address, money, a phone, a change of clothes or transportation? And what are you going to do for food during the time you’re looking for a job?    The brutal fact is, once you’re sent to prison and released, the majority of people don’t stay out of prison. California also has the highest recidivism rate in the nation – 70 percent. Only 25 percent of prison admissions are actually a new prisoner. By far the largest majority of admissions are people sent back to prison for parole violations. And among the group of people returned to prison for what might be called a “fresh felony,” important differences emerge. The types of crimes committed differ between those who are sent to prison for the first time, versus those who were in prison before, and are now being incarcerated for a new felony court commitment.   In 2009, of the more than 63,000 first time prisoners sent to prison, about a third committed crimes against people, about a third committed property crimes, and about a third committed drug-related offenses. But of the 18,000-plus former prisoners who were sent to prison for a new court commitment, only 18 percent committed crimes against people. About 30 percent again were committed for drug offenses. Property crimes rose to approximately 40 percent - of which the largest sub-groups were second-degree burglary and petty theft with a prior. The remaining crimes fell into the category of “other” (12 percent), of which possession of a weapon was by far the highest subgroup. What do these changing numbers tell us? In a best-case scenario, these numbers might imply that prisoners learn something from their imprisonment – and are much less likely afterward to commit violent crimes against people.   A more cynical view might be that, as a group, after release, as time passes, even if they don’t want to re-commit a violent crime, ex-offenders become increasingly economically desperate.   Although a different state, data from Massachusetts supports that interpretation. Researchers did a random-sample survey of 17,565 prisoners to determine their rates of homelessness in the year prior to incarceration. They found that 9 percent of inmates had been homeless – a rate 4 to 6 times the rate in a comparably matched adult population (matched for age, race/ethnicity and gender). They also found that “In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income.”   *** Carried across state lines   Prison erodes and eventually can destroy even the strongest of relationships. Those effects can occur in a relatively short time, but are more likely the longer the term of incarceration. Our recent attempt at cost-cutting the $49,000 per year that California spends on our lowest-level inmates has led to shipping prisoners out of state to private facilities. Given the fact that people who are incarcerated disproportionately come from economically deprived communities, sending prisoners out of state will most often mean that families, even if they wished to, cannot afford to travel to see inmates. Extended time apart, and extensive geographic distances, fracture already strained relationships. California may be saving money in the short run, but sending prisoners out of state may mean we are sentencing a higher number of released prisoners to homelessness when they are returned to us after release. Posted by Spot. Us on 02/03/11
2/2/11

• The reality of prison release - Part I

  This is the first in a two-part series on "The Homeless Triangle: San Francisco, Los Angeles and Prison." The full story wiht the second part will be published in full tomorrow on Spot.Us.

  If you work as a doctor in a clinic for the homeless, you see all kinds of simmering panic. There’s the “God, someone’s got to help me” panic of the person who lost their house to foreclosure. There’s the fatalistic panic of a street person with a hard, bone-rattling cough who senses, deep inside, that this might be the infection that kills her.

  But this time, when the man stopped me in the hallway between exam rooms, grabbing my upper arm a little too tightly, there was a different kind of panic in his eyes.
   
  “I don’t know how to find the bathroom,” the man said, terror-stricken. “Curtis,” with salt and pepper hair, was in his late 50s.
   
  “It’s just around the corner - through those doors and to the right.” I hoped to speed-walk past him, but his grip on my arm only tightened.
   
  “I can’t do that,” he said, his voice rising to a near-shout.
   
  His upper lip was shaky with emotion. The only clue that his problem wasn’t some type of unusual neurological defect was the fact that he had way more muscles than you’d expect to see on a man his age. “Just got out of prison?” I said.
   
  He gave a sharp nod. “Twenty years in a cell. I walked down one corridor. That’s all. For over 20 years.” He said it again, this time shouting it: “I can’t find the bathroom.”
   
  My mind struggled to grasp his last 20 years. All the changes in the world. All the ways in which we maneuver through our lives – simple things that he’d never done. He’d become a man no longer able to even follow an easy task like going through the doors and turning right. At his age, to have been so restricted for so long in prison, he’d undoubtedly committed a truly vile and violent act against another person.
   
  But now he is, as we say in the healthcare business, ours.
   
  He is a man who is unemployable, with multiple chronic health problems, and most likely – even without being confronted with all he cannot do - with serious anger management and impulse-control issues. He is in our town with nowhere to stay, nowhere to go and no ability to get there.
   
  “I’ll walk you there,” I said, and wondered, as we walked the few feet to the bathroom doors, which way he would go when he left the clinic.
   
  He wasn’t mentally ill. He didn’t have HIV. He had high blood pressure and diabetes and high cholesterol and prostate problems that might turn out to be prostate cancer. He had no idea what tests had been done in prison, or what pills or doses he’d taken for the last many years. After 20 years in a prison with years of treatment for chronic health problems, he had no summary -- not even a health card or a discharge print-out.
   
  We did what we could. We picked random pills and doses to start him on, since he’d been without medicines for several days already. He had no money for a co-pay so we gave him what we could out of our medicine closet. We told him to come back in two days so we could check how he was doing.
   
  But as he left to sleep on a sidewalk in San Francisco, we all – myself, the nurse, the staff – wondered the same thing. He had no food, no place, no ties to anyone, no way to get money. At all. So how long would it be before he hurt someone, just so he could get back to prison?
   
  Because, odds are, he will.
   
  Prison Churn and Homeless Churn
   
  California incarcerates more of its population than any other state, with roughly one in 1,000 Californians sent to prison each year. As of August 2009, there were 166,569 Californians in prison. And these numbers exclude jail. Prison is very different from jail. Jail is local, for smaller offenses, or as a holding place until verdicts are handed out. Prison is for felons, more serious offenses, and, generally, for much longer sentences. But our state’s prison system is far from static. Except for a very tiny minority, every single prisoner eventually will come back to our neighborhoods. Generally speaking, more than 100,000 people are released, and more than 100,000 people are incarcerated every single year. Our prison system released in excess of 130,000 people into our neighborhoods in 2009 alone.
   
  The logistics represented by those numbers is mind-boggling. That’s basically the same number of people as the entire population of Humboldt County, or the entire city of Concord. Here’s what getting out is like. You’re not told exactly when you’ll be able to leave. Your family – if you still have any relationships left – can’t know either. No one can know. For security reasons, no one is told, ever, an exact date of release.
   
  One day, the door is unlocked. Only if you have certain designated types of mental illness, or have HIV that’s being treated, are you given any pills when you leave. And even then you’re only given a 30-day supply as you go.
  The California prison system is now the largest provider of mental health care in the state. Despite that, most studies show that a large number of seriously mentally ill prisoners are not diagnosed and treated while incarcerated. But the prisoners who are being treated for mental illness are now mandated to be given a case management assessment and an appointment for follow-up prior to release. The prison system’s own study shows that just one visit from a case manager prior to release is highly effective at reducing recidivism and increasing compliance with follow-up appointments. But the very same study also showed that no visits at all are being done in almost 50 percent of cases, even though staff were hired to perform them, and it’s mandated by state law. No one knows why they’re not being done. 
  The California prison population has aged, with four out of 10 age 40 or over, with one in seven prisoners 50 or older. Many have multiple health problems. As the healthcare costs for prisoners have soared, there have been reports of expedited releases for prisoners with complex medical problems.
   
  But no matter what your age, even if you’re a person with diabetes requiring insulin, or if you usually take many pills, or recently had surgery, or are being treated for an infection - you’re not given even one dose when you leave. You’re not given any appointments, or even any chance to make an appointment. Even if you’re a diabetic, you may not be allowed to eat breakfast. Despite prison health services, collectively, commanding a $2 billion annual budget, no one, not even the people with mental illness or HIV, is given even a piece of paper on release with any medical information on it.
  And, of course, when you leave prison, you don’t have health insurance.
   
  After release, all your health issues will be, without a doubt, sooner or later the problem of whatever county you’re headed toward. Why the county? Even if you had a permanent disability, and federally paid or subsidized Medi-Cal or Medicare coverage for reasons of poverty or disability, when you are imprisoned, all your coverage is automatically canceled. Clearly, no one thinks a prisoner should be drawing benefits while behind bars. The problem, however, comes when a person is released. There is no automatic restoration of that same coverage, even for permanent disability. The county alone will bear the burden of your medical care upon your release. And, often the county may wind up paying for it forever more. Having your coverage re-instated is almost always a long and complex process, requiring multiple visits, and a high level of literacy and persistence. And the reinstatement process, it goes without saying, requires an address.
  There is no reason why the prison system cannot be as efficient at reinstating coverage as it is at canceling that same coverage. If there are doubts about whether qualifying conditions still exist, there is also no reason why coverage could not be reinstated upon release for a probationary period of, say, six months. It would then lapse unless the released prisoner was seen and assessed by an outside provider. Such a process would be a powerful incentive for released prisoners to maintain preventive care. And for counties to be able to provide care instead of post-release crisis-level, unreimbursed emergency room visits.
  Posted by Spot. Us on 02/02/11
12/5/10

• Homeless Coverage

  As part of the background and research for this piece I have also been covering homelessness and health in my City Brights column at sfgate.com, the online portal for the SF Chronicle and on my own site, docgurley.com. These articles are about a very similar topic and there is considerable overlap - and much of my research is doing double duty there. Some of the articles are universal in what they say and are very applicable to my Spot.Us story. Here is a quick summary. Given the season, the Homeless Gift Guide is a particularly interesting one right now.

   

  Looking for death on the streets and finding it

  @DocGurley, @SFGate

  Gunpowder on the Street

  @DocGurley, @SFGate

  Saving Your Health When Losing Your Home

  @DocGurley

  Will Losing Your Home Kill You?

  @DocGurley, @SFGate

  Hidden In Plain Sight: Dying and Homelessness

  @DocGurley, @SFGate

  Be selfish, Give a gift to a homeless person

  @DocGurley, @SFGate

   

   

   

  Posted by R. Jan Gurley on 12/05/10
11/4/10

• Caring for homeless people and prisoners

  As part of the research for this story I have been talking with a range of professionals associated with homelessness and the prison system. In this short video clip I highlight a very short segment from Dr. Doug Price-Hansen of the Tom Waddell clinic in San Francisco. Dr. Price-Hansen is an unusual and very highly qualified combination of board certified internist and psychiatrist. He has been working with homeless and prison populations for his whole career. Here he talks just a little about working with both populations.

  The goal for this story is to look at the links between homelessness, prison and our major California cities with a strong focus on data that can show what the relationships really are. If you are interested in hearing more about this important and under reported topic that affects everyone. If so, please donate now.

  Posted by R. Jan Gurley on 11/04/10
10/12/10

• The link between mental health, incarceration and homelessness

  As part of the research for this project I got to interview Panya Weisheit of the San Francisco Mental Health Court extensively. Here is a short snippet of that interview where she talks a little bit about the relationship between homelessness, incarceration and mental health.

  Posted by R. Jan Gurley on 10/12/10
9/11/10

• Why care about prisoners' health?

  

  It was a discouraging week for those of us working on the topic of prisoners, health and homelessness. The latest report-card on the prison system's healthcare delivery gave them very poor marks. I participated in the BlogTalkRadio live call-in show hosted by the Annenberg center's Reporting on Health where reporter Julie Small discussed her work on this important topic (listen to the great show here). Prisons are seemingly incapable of just handing out pills, or even making sure a medical record goes with a person. And these aren't just trivial tasks - a 21 year old died purely because no one would give him his inhaler (all because his records were "lost" in transfer).

  Here’s the exact language of the report – “nearly all prisons were ineffective at ensuring that inmates receive their medications. Sixteen of the 17 institutions either failed to timely administer, provide or deliver medications or failed to document that they had done so. The 17 prisons’ average score of 58 percent in medication management was significantly below the minimum score for moderate adherence.”

  “Numerous prisons were significantly noncompliant in the following medication management tasks: delivering sick call medications (new orders) to inmates; providing chronic care medications; providing medications to inmates within one day of arrival at the prison; delivering medications to inmates upon discharge from an outside hospital; and administering tuberculosis medications.”

  Which begs the question - if this is how poorly prisons are doing with patients who are literally locked in place, then how can anyone expect better care for those they're sending out to the streets? If you can't get a prison system to send its OWN records with an inmate, then how can you expect them to send a copy on release? And why should you and I care, especially when so many of us can't get any pills or appointments ourselves?

  Here's my take on this complex issue, from an article I wrote in response to Julie Small's work:

  "So what does this have to do with you and me? Other than the looming issue of widespread pan-resistant tuberculosis being spread around the state, that is? See, the danger when it comes to prison healthcare, or to prisoners in general, is that we’re all so overwhelmed with badness in the news, and with struggling to just make ends meet, that we’re already tapped-out, sympathy-wise. For many of us, the gut response to this kind of news is that we kind of just wish it would all go away. Hey, we all know people in prison have done some bad things. Probably some skin-crawlingly bad things. But so often, with so many people incarcerated for not-so-horrible crimes, lock ‘em up and throw away the key is not just a revenge-response, it’s also a symbol of our collective, profound, compassion-exhaustion.

  The fact is, however, that none of those people in prison will just go away. All those people who are so often addicted, brain-damaged, developmentally delayed, many with poor impulse control – we’ve got no plan for them, nowhere we expect them to be, no way for them to live. Even among the many staggering thousands upon thousands of Californians who are very functional and are in prison purely because of drug and non-violent offenses, prison still becomes (with a recidivism rate of 70%) a truly revolving door experience. Even if we want to think of prisoners as some type of “Other” category of person, all ex-prisoners are people who will end up in our homes, our healthcare systems, our neighborhoods, and, in many, if not most cases, lying on our sidewalks. They don’t just go away. They can’t.

  When we decimate the lives, and health, of a significant group of ourselves, these same people do, inevitably, come back home to us. Even if, after years of prison, we’ve rendered them homeless, we are still the place to which they return. Poorly-treated tuberculosis won’t just go away either. It stays and breeds and simmers. And spreads. Kind of like rage. Or despair.

  So what can any of us do? I personally believe it’s past time to ask ourselves whether a prison culture – particularly one which has been given, for many, many years, an essentially unlimited financial windfall with minimal accountability – can ever render basic, non-lethal healthcare. Keep in mind, if a government-funded clinic or hospital was unable to deliver doses of medication in a consistent, reasonable manner, their license would be yanked so fast, heads would spin so rapidly there’d be a state-wide epidemic of vertigo.

  And don’t even start on the topic of psych medication dosing and diagnosis. Right now our prison system is the state’s largest provider of mental health care services – and funds are being tidal-waved into building more and more expanding prison-mental-health (is that an oxymoron?) facilities. This expansion is occurring even as line-item budgets are X-ing out those same services to the non-incarcerated general population. And the expansion is continuing to occur even as the track record of prison healthcare just gets more and more littered with bodies. Back in the 1960′s, when we closed our locked psych wards, did we really, as a society, deliberately choose to replace Nurse Ratchet, with Guard Nick-with-a-nightstick?

  

  CDRC website image: Grand grand-breaking of the first of many new prison mental health facilities.

  There is something deeply, deeply wrong with this picture. It’s time for someone to point out that, when it comes to healthcare, our Prison Emperor has no clothes."

  Until we're willing to demand more accountabliity from one of our most well-funded divisions of government, all of us, collectively, on our city streets and in our neighborhoods, will bear the consequences.

  "One simple, important thing we can all do is spread the word. Talk about, email, share or tweet this topic. It’s time we all began discussing what we’re paying for, medically – behind locked cell doors."

  Posted by R. Jan Gurley on 09/11/10
8/21/10

• When The Devil Is In The Details

  Check in with this week's update to find out just how hard it can be to get your identity back after being in prison. And find out more about how willing the California Department of Corrections and Rehabilitation can be when it comes to clarifying or providing its data. Sometimes, the devil really is in the details.

  Posted by R. Jan Gurley on 08/21/10
8/6/10

• California Prisons Data Diving

  The first report for the Homeless Triangle pitch. Sometimes what's most interesting is not what's in the data but what's missing. In the first week I find quite a lot of extensive data online at the California Dept of Corrections and Rehabilitation website.

  Posted by R. Jan Gurley on 08/06/10