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Comment by VonGuard | Hacker News Reader

SF's favorite game is to send ambulances out to a guy sitting on the street, screaming insane things, covered in his own feces and trying to punch people. Ambulance shows, guy says "No!" and so everyone says "Oh, this person is doing just fine, leave them alone." And everyone leaves, and the guy goes back to covering himself in his own filth and shouting at people. Definitely a great outcome for all involved.

If the people advocating for the homeless and mentally ill have a better solution than leaving them on the streets to rot, then I would like ot hear it. Because 100% of the solutions proposed in SF amount to "Leave them alone, they are fine." So fucking sick of it. It is VERY clear when someone needs help, but our society would rather let them suffer in the streets than do anything. Anyone who tries to help or suggests getting them off the streets is a fascist.

Homeless advocacy in the Bay Area amounts to "Maintain the status quo, do nothing to help. Punish those who try to take back their own homes and streets from people covered in filth and perpetually addicted to drugs and violence." SFFD former captain who was beaten senseless this past week in SF is literally in the hospital while 2 of the 3 people who beat him with a crowbar remain on the streets. Even when these people are violent, we do nothing. KRON4 interviewed one of his attackers on TV! Guy's still in his camp on the streets, still angry and dangerous. Attack is even on camera!

We live in a society where those who follow the laws are constantly punished for minor infractions like parking tickets and zoning violations, while people who do not participate in society AND completely flout the laws in every way are not only allowed to do so, there is a huge section of our population that encourages and protects their right to do so.

It is supremely infuriating to watch the Bay Area be so completely backwards and so utterly dogmatic as to ignore problems and constantly attack people for not being progressive enough. We literally have conservatives disassembling democracy across this nation, and the Left's favorite game to play is "Can we castigate more progressives for not passing the acid test."

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> SF's favorite game is to send ambulances out to a guy sitting on the street, screaming insane things, covered in his own feces and trying to punch people. Ambulance shows, guy says "No!" and so everyone says "Oh, this person is doing just fine, leave them alone." And everyone leaves

The flip side of this is forcibly transporting people to hospitals and slapping them with $10-15k bills for a glorified taxi ride.

Homeless can't pay that, so small wonder they're left there. But you or me? No sir, you're unable to make decisions for yourself; we absolutely need to take you in for evaluation.

Your wallet is biopsied on the way to the hospital, where the real fun starts.

Be very afraid of an America with forced medical "care."

There is a public hospital called SF General where people who can’t afford medical care are treated.

I dont know why you are downvoted but bad faith compliance is absolutely a thing. whats to stop city from sending such a patient to nearby private hospital in the name of 'medical necessity'. who decides who needs to forcibly hospitalized? if you fall into a puddle and somebody calls an ambulance would you rely on the ambulance driver's judgement to decide if you need the $10k ride to hospital?

with healthcare you always have to think about bad faith operators because there is zero transparency and no free market there.

> if you fall into a puddle and somebody calls an ambulance would you rely on the ambulance driver's judgement to decide if you need the $10k ride to hospital?

In the US, the fire department shows up first and administers first aid. Private transport to the hospital is arranged after that if needed.

The problem is all the advance-fee bullshit. You're billed $1000 per minute starting with your occupation of a gurney, and that doesn't guarantee you will receive any sort of treatment once you get to the hospital. If you're not destined for a trauma ward, you'll sit in a room for six hours, be discharged without even a diagnosis (or the lolworthy "mild concussion"), and have incurred a debt equal to the cost of a new car for the experience.

These days, you don't even get a bottle of Oxy as a consolation gift-- you get nothing.

It's exploitative even when good faith operators are involved.

>would you rely on the ambulance driver's judgement to decide if you need the $10k ride to hospital?

$10k for an ambulance ride? Is there any documentation for that claim, or is it just hyperbole?

According to the San Francisco Fire Department[0], an ambulance ride is ~$2400 (which includes lifesaving services), plus $46/mile[1.61km].

By my calculation, an ambulance would need to transport a patient ~165 miles (266km) to make an ambulance ride cost $10k.

For some perspective, It's ~160 miles from San Francisco to Fresno[1].

I'd expect that San Francisco EMTs don't deliver patients to Fresno, or even outside the San Francisco city limits[2]. Since San Francisco is 46.9 sq miles (121 sq km) in area, a $10k ambulance ride is incredibly unlikely at best.

N.B: I do not live in the Bay Area. It took less than 30 seconds to confirm the costs above via DDG. Not sure how GP (and others) came up with a number 400% higher.

[0] https://sf-fire.org/services/ambulance-billing

[1] https://www.distancecalculator.net/

[2] https://en.wikipedia.org/wiki/Nota_bene

Edit: Added Nota Bene[2].

This comment is hopelessly obtuse. Most Americans can't even afford a $1000 emergency expense; the $2400 expense you cite is already unaffordable. Add in any ER fees the hospital charges -- which can easily be part of what GP refers to -- and you'll probably get to that $10K figure anyway.

Don't believe me? Here's what happened right here in SF when a bicyclist with a broken arm was taken to the local public hospital, SF General:

"A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that — an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December."

> came up with a number 400% higher.

A moment with a calculator would show you that the number GP uses is 300% higher, not 400% :)

https://fortune.com/recommends/banking/57-percent-of-america...

https://www.vox.com/policy-and-politics/2019/1/7/18137967/er...

>This comment is hopelessly obtuse. Most Americans can't even afford a $1000 emergency expense; the $2400 expense you cite is already unaffordable. Add in any ER fees the hospital charges -- which can easily be part of what GP refers to -- and you'll probably get to that $10K figure anyway.

I didn't say there weren't problems with the system, or that most folks (let alone homeless folks) could afford such things, but 400% more than the published cost? That's hyperbolic and, more importantly, incredibly imprecise.

I see you disagree with that. I agree that you disagree with me. Have a lovely day.

Edit: removed extraneous text.

> That's hyperbolic and, more importantly, incredibly imprecise.

In common USA English, use of a figure like "10K" suggests imprecision - it's a magnitude of order ballpark, a gesture at the logarithmic scale.

This convention is useful because it's easy to remember a rough ballpark, but precise figures are going to quickly get muddied in details.

It seems strange to complain about imprecision when someone has already clearly indicated that they're talking about a rough estimate.

>In common USA English, use of a figure like "10K" suggests imprecision - it's a magnitude of order ballpark, a gesture at the logarithmic scale.

Really? As a life-long resident of the US, native US English speaker, and the child of a native US English speaker and a long-time resident of the US from another English-speaking country (UK) (both with post-baccalaureate degrees), I never heard that from anyone except you.

Not teachers in primary or secondary school, nor in college. Nor have I seen that in any of the many usage guides I've read over the past half-century or so.

Yes, "Forty days" in the Abrahamic[0] tradition is meant to be imprecise (i.e., meaning "a long time"), but the bible/torah/quran aren't guides to modern English, are they?

Perhaps you could enlighten this American ignoramus as to the correctness of US English idiomatic phrasing in this light. It would be most appreciated.

[0] https://en.wikipedia.org/wiki/Abrahamic_religions

Edit: Clarified prose.

I'm really not clear what you're asking, so all I can say is that nice round numbers are usually a ballpark estimate, while more precise figures suggest some actual calculations were involved. To be a bit technical: if there's only 1 significant figure, then you should take the number with a fair amount of salt.

Unfortunately social rules like this usually aren't well documented. It's mostly a statistics thing: very few calculations produce an exactly even result, so more often than not someone has rounded things off.

If you want to get really fancy you can start using context and tone to further infer whether someone is throwing out a ballpark estimate or a precise number, but that's well beyond the scope of a HN comment

>that's well beyond the scope of a HN comment

Exactly my point. And even if I wanted to, there's wasn't any tone or context to draw on -- just a flat assertion.

I'd add that, at least to me, a "ballpark" figure would be something reasonably close to an actual value e.g., $25 ballpark vs. $27.99. In the case to which I replied, it was more like "ballpark" $25, actual $9.99. Which "ain't the same fuckin' ballpark, it ain't the same league, it ain't even the same fuckin' sport."[0]

[0] with apologies to Quentin Tarantino.

Edit: Added an additional thought and some context.

It's not hyperbolic at all.

Here[1] is an article on the top stories on HN right now where a couple was charged 200k for a rabies shot.

Posted prices here in the US are complete bullshit, as any medical code transcriber could tell you, or indeed anyone who's been to a US hospital and had to pay out of pocket.

I once went to the emergency room at 1am. It was almost empty, no one walking the floors, but still took them 4 hours to get to me.

They never checked my vitals or my weight, the doctor looked down my throat with a wooden stick, gave me one generic 200mg ibuprofen and sent me on my way.

My bill was $3500.

Their reasoning when I fought it? 'we only have very generalized codes and that's how we determine what to charge.

Literally did nothing but waste my time and charged me 3500 for the privilege.

I told them they wouldn't see a dime and I'd happily see them in court over it (no idea if I could even take them to court but I was beyond pissed).

Bill was dropped to 250,which to me was still outrageous for a freaking ibuprofen (dollar store knockoff brand to boot!).

Over one dollar per milligram of OTC medicine.

This was now 15 years ago and the prices have done nothing but increase since.

[1] https://news.ycombinator.com/item?id=35532458

>Bill was dropped to 250,which to me was still outrageous for a freaking ibuprofen (dollar store knockoff brand to boot!).

Yes, medical billing in the US is hopelessly opaque. And I've had an even more egregious experience[0] myself.

However, that $250 wasn't just for the ibuprofen and tongue depressor. It's for the physical plant, infrastructure and other operating expenses as well. Although the largest portion of that is likely the cost for the time of highly-trained personnel (nurses, doctors, etc.).

How much do you earn in an hour? No. Don't tell me. I don't care.

But I'm sure it's more than zero, right? Would you work for zero dollars an hour?

If not, why are you ignoring the costs of paying hospital personnel?

Not sure why you went to an emergency room. Those are for, wait for it...emergencies. Was it an actual emergency? If not, they should have charged you even more.

[0] A physician to whom I was referred posited (incorrectly) that a skin lesion might be infected with MRSA[1] and insisted that I go to the hospital for testing and immediate IV antibiotics. I reluctantly (as I -- correctly -- believed that wasn't the case) did so. I was in the hospital for three days (the length of time -- at least they claimed it took that long -- to test for MRSA), after which time I was told (shocking...not!) that I was not, in fact, infected with MRSA and discharged. I received a bill for something like $100 and an "explanation of benefits" (EOB) from my insurance company. The "total cost" listed on the EOB was ~$12,000. Out of curiosity, I perused the detail and found that I was being "charged" for being in two hospital rooms at the same time (a neat trick, I wish I could replicate it) as well as having had a Pap smear[2], despite not (ever) having a cervix.

I complained to the insurance company that there was obvious fraud going on. They responded that I shouldn't worry my pretty little head about it because I wasn't paying anyway. That made me even angrier and I demanded that this be investigated and addressed. A few days later, I was involved in a conference call with the insurer and someone from the billing department of the hospital in question. The insurer and the hospital went back and forth (performatively, I soon found) about billing codes, but when I pressed them on how I could possibly have had a pap smear when I don't have a female reproductive system, they finally fessed up and told me that the contract between the hospital and the insurer capped hospital stays/services at $500/day, and that the stuff in the EOB was complete bullshit.

Just as the $3500 on your bill was complete bullshit. But $250 actually seems reasonable for an emergency room visit. Even with health insurance, I'm subject to a $150 co-payment for emergency room visits -- just for walking in the door and signing in.

[1] https://www.mayoclinic.org/diseases-conditions/mrsa/symptoms...

[2] https://www.mayoclinic.org/tests-procedures/pap-smear/about/...

For reference, a bacterial culture cannot be declared negative in less than 72 hours. That's the source of your three-day admission, although that's an odd beast - if you're stable, you can go home on oral antibiotics in most cases with an early followup.

The "rules" of medicine are often quirky and very frequently frustrating (to both patients and doctors) - but they're rarely random.

>For reference, a bacterial culture cannot be declared negative in less than 72 hours. That's the source of your three-day admission, although that's an odd beast - if you're stable, you can go home on oral antibiotics in most cases with an early followup.

Yeah. The doctor who visited this horror on me seems to have been a really bad doctor. Which is also why I changed GPs after this because he recommended this moron.

I'm not a physician, but in 2008 when this was happening, I asked about oral antibiotics and was told they were ineffective for MRSA. That may have been ignorance or a lie. Or, perhaps things have changed in the past 15 years. I have no idea.

Prior to hospitalization, he'd prescribed a topical sulfa drug (which, unknown to me until then I was allergic to) which made things much, much worse. In fact, I have permanent damage and discoloration to the skin on my leg. And I developed hives on the palms of my hands and the soles of my feet. It was a disaster -- but that wasn't the doctor's fault -- I didn't know I was allergic.

After that debacle, I went to see a vascular specialist (the other guy was a "wound care" doctor), who suggested a compression stocking[0]. The lesion was completely healed in five days.

Now I take a much more active approach when I have medical issues, having learned (the hard way) that I need to be my own best counsel when it comes to my health. That includes research, asking questions, making sure I have the relevant information to make appropriate medical decisions for myself.

[0] https://health.clevelandclinic.org/what-you-should-know-abou...

Edit: added the missing link.

Wow I'm sorry that happened to you. Truly.

Yes I am paid for the work I do, but I wouldn't expect to be paid for the work I am supposed to but dont do.

warning this will be a bit graphic/gross

A bit more context on my event: I had an abscess on the upper part of my jaw that had my entire face swollen and a fever of 102+ when I went in. I was shaking all over with chills and sweating like I was in a sauna.

They let me sit there in agony and never checked my vitals. Not my temperature, not my blood pressure- nothing.

I begged them to lance it, anything. Ice for the swelling, even. Nothing.

It was so bad after being in the hospital 4+ hours I went home and the abscess grew so bad it drained out the bottom of my tooth root.

I could very well have died. And they used a fucking tongue depressor and handed me a 200mg ibuprofen.

That was why I was so upset with the bill.

I get it there's doctors and infra to pay for, but not for doing nothing, especially when we had free clinics in that city that could have helped me had it been normal business hours.

I've paid thousands for stiches and complained, but at least I got the stiches, so I shut up and paid. I had slag get in my eye that had to be dug out with a needle. My eye was numbed, they removed the shards (the slag cooled when it hit my tears and shards were embedded in my eye). That cost me a grand total of 750. The penicillin eye drops they prescribed? 500 before I think it was goodrx where they have deals on scripts and I think I got them for 50.

Point being they make this up as they go and there's zero reason for it to ever change.

Edit for more color- the abscesses event was at an ER in a hospital that most definitely had the capability to at least get me to an actual doctor in the hospital side rather than keep me in ER. And this was before the prevalence of these new Emergency centers as I'd have gladly gone to one of those instead.

Wow. That's horrific.

I'm sorry you had to go through that as well.

That's awful care. I had a similar situation (not in my mouth, but on the nape of my neck. A sebaceous cyst that was infected and swollen.

This was only a couple years ago and I actually went to one of those "urgent care" centers. They took one look and said "nothing we can do, you should go to the emergency room." For which they charged my insurance company $1800 (of which I was billed ~$200 -- money those assholes will never get, I might add). So those folks aren't necessarily the best choice either.

So I did go to the emergency room and was ushered into an exam room within an hour. They did examine it and me and actually got the on-call resident from the surgery department to open it up and drain it.

It helped a lot, but they did a half-assed job and I had to go back for more cutting/draining. Even now, the sac that the sebaceous cyst grew from was not removed (GRRR!) and I will (probably this year) have it removed and the site closed up properly.

That's much better than your experience, but still not that good.

It was still a few thousand dollars, although my insurance paid most of it.

But whatever hospital you went to should be named and shamed, because they didn't do (provide adequate care) what they were supposed to (and billed for) do. That was awful and you have every right to be angry -- but it's almost certainly not worth legal action -- and more's the pity.

The bigger issue (IMHO) is less about quality of care (although as we've both experienced, that can be quite variable -- and that's certainly an issue) is the business model around health care in the US.

Which makes accessing health care and understanding the costs much more difficult than it should be.

I'm all for a single-payer system or, as they have in Germany (at least IIUC), private insurers that are non-profit by law.

Unfortunately, that's unlikely to happen here -- as the insurance (and healthcare) lobby will push hard to maintain their profits -- sucking resources from the system that could instead be used to provide better care.

And the current model also encourages consolidation, which harms small communities the most (see this joke[0] for context), since there isn't a whole lot of profit to be made, and hospitals have expensive infrastructure requirements.

[0] source: https://motd.ambians.com/quotes.php/name/freebsd_fortunes/to...

   On his first day as a bus driver, Maxey Eckstein handed in receipts of $65.
   The next day his take was $67.  The third day's income was $62.  But on the 
   fourth day, Eckstein emptied no less than $283 on the desk before the 
   cashier.

   "Eckstein!" exclaimed the cashier.  "This is fantastic.  That
   route never brought in money like this!  What happened?"
   "Well, after three days on that cockamamie route, I figured business would 
   never improve, so I drove over to Fourteenth Street and worked there.
   I tell you, that street is a gold mine!"

Edit: Fixed formatting. Removed extraneous text.

That's for services rendered by the SFFD. But there are plenty of private ambulance companies that charge whatever they charge. You don't get to say "no thank you" if you are unconscious.

For example, when my family were involved in a car crash on the freeway in Los Angeles some years ago, even though the local fire department arrived at the scene within minutes, their paramedics did not. My two kids were taken to hospital in separate private ambulances. $6k each.

It would come down to the law to dictate who has the final say in sending someone to a hospital. Or else the people making the decision they shouldn't be making open themselves up to being subject to legal punishment. (Which opens up another question of who can afford to...?)

The free market could incentivize bad faith operators even more because of the greater potential of the profit motive. Free market doesn't necessarily mean greater transparency or ethics.

If someone is punching people, that's a legal issue. That's not really something the medical system has tools to address.

To the rest of your scenario, no one says they're "fine". Just that the person has the right to choose no medical treatment. You also have that right. If a doctor says you will certainly die without treatment, you can say no. The doctor doesn't write in the note that you are fine, just that they offered and you did not want it. It's not a "game", it is the ethical and legal requirements of the role.

You assume your proposed intervention will "help", but what is your basis for that claim? What signals should they be looking at to guide the course of treatment? For doctors, the answer can be vital signs, tests, but those don't help here. Usually, they're looking at patient input.

> If the people advocating for the homeless and mentally ill have a better solution than leaving them on the streets to rot, then I would like ot hear it.

Properly funded, voluntary community treatment. It is possible to design services such that people want them; I've seen it (yes, even people experiencing psychosis). You have to train providers in engagement skills and actually empower the person receiving services. Traumatizing them with regards to health care is not going to help.

Fixing it requires and robust social safety nets at the federal level. A municipality cannot do it alone.

>Just that the person has the right to choose no medical treatment. You also have that right. If a doctor says you will certainly die without treatment, you can say no. The doctor doesn't write in the note that you are fine, just that they offered and you did not want it. It's not a "game", it is the ethical and legal requirements of the role.

The issue is that the people we're talking about don't have the mental faculties to make these decisions. Do you think someone in the state they're in, barely even aware of where they are, unable to even speak or stand up straight, would be allowed to sign a legally binding contract? Of course not, any court would throw out any contract they signed because they're obviously not mentally able to make decisions like that. Same goes for decisions about their health.

>Ambulance shows, guy says "No!" and so everyone says "Oh, this person is doing just fine, leave them alone."

No, no one says 'this person is doing fine'. It's 'we're medical staff and we can't arrest people - they are clearly withholding consent, we can't do anything else'.

I've stayed with distressed homeless people trying to hurt themselves while social worker teams, cops and medical staff came to the scene; if the homeless individual doesn't want help and is not an active danger to others there's very very little that can be done to forcibly detain them.

> If the people advocating for the homeless and mentally ill have a better solution than leaving them on the streets to rot, then I would like ot hear it.

Fund shelters and support groups well enough that trying to get off the streets and get help doesn't require that you bunk next to someone who has a shiv and is experiencing a massive heroin withdrawl event while you try to sleep. There's a reason homeless people dodge a lot of so called 'help'. It's because the help is often worse than the alternative.

I've befriended and fed a certain individual in south San Jose who would stand on a the corner of Bernal and Santa Theresa and yell at the air. Anyone familiar with the area knows who I am talking about.

He is extremely lucid most of the time. And a very grateful and warm hearted individual. But he cannot for the life of him access any services, food stamps or healthcare or anything. The police can't even help him. They all know him. No one seems to be able to help him. I've fed him and been his friend, I don't know what else I can do.

He has no ID nor way to get ID.

Longtime resident here (15 years). It's easy to become frustrated with the complex and persistent issues of homelessness and mental illness in San Francisco. However, it's important to acknowledge that there are numerous groups and individuals who are passionately working to create positive change in the lives of those affected. They're offering essential services, advocating for policy changes, and developing programs to tackle the systemic issues that contribute to homelessness and mental health challenges. It's simply not true that homeless advocates and organizations just want to maintain the status quo.

Second, it is not a question of punishing those who follow the law, but rather addressing the systemic issues that contribute to homelessness and mental illness. By focusing on parking tickets and zoning violations, you're missing the bigger picture of societal inequality, lack of affordable housing, and inadequate mental health care. This isn't about passing a "progressive acid test", it's about practical solutions that work and are politically feasible.

Lastly, your comment oozes contempt for people who are struggling with addiction and mental health issues. Labeling them as "people covered in filth and perpetually addicted to drugs and violence" is not only dehumanizing but also incredibly counterproductive. We must work together to find compassionate and effective solutions, rather than resorting to name-calling and finger-pointing."

> Because 100% of the solutions proposed in SF amount to "Leave them alone, they are fine."

The mayor actively supports changes to state conservatorship law that would allow authorities to force people into treatment.

https://www.sfgate.com/politics/article/san-francisco-treati...

> SF's favorite game is to send ambulances out to a guy sitting on the street, screaming insane things, covered in his own feces and trying to punch people. Ambulance shows, guy says "No!"

Roughly - without the violence - a friend watched this precise scenario last fall in Spokane, WA. If the person had been within hospital grounds, the paramedics & security could have restrained them under grounds of inability to make choice, given them medications, and maybe helped them some. But, since the person was a block away from the hospital, there was no ability to say, "buddy, you have feces all over you and are laying with flies all over. we're gonna take you in, hose you off, launder the clothes, then see what we can do for your mental state". That would have been the kindest thing to do.

The crux is that certain "out of your mind" states require external intervention, and there is no legal way to apply that in many jurisdictions today. Note that some jurisdictions require a trial-like apparatus for involuntary holds after some 24/36? hour period - I don't that's inappropriate at all. Being able to see a guy laying covered in filth and take him in to help should be legal; at least for 24 hours. The indigent will have their debt forgiven - hospitals know they don't get blood from a turnip.

It is true that some medications don't work for everyone, and some medications produce horrific side effects. So there is some % of people for whom the best medication regimes today do not work. That has to be considered and reflected through. It's also true that there's high correlation with addiction and homelessness. That all has to be considered and addressed.

Considering institutions. As I've had a good friend for a long time with mental illness who has been in wards, the quote from the article is very true.

> I disliked the hospital, but even with its heavy locked door, I knew it wasn’t a branch of the “carceral state” devised by a power‑mad society to torment him.

And this has to be understood by everyone who thinks through this. Mental wards in the United States today are not, conventionally, torture chambers for mad doctors. They are restrictive and often frustrating, for reasons that a little thought should reveal. Aberrant nurses and arrogant & high-handed docs exist there, but they are not, systemically, the norm. It is not a horror movie.

TBQH, I don't think the vast majority of mental health writings online by non-experts touch on severe mental illness in anything approximating a realistic way.

The status quo is really quite unacceptable. My druthers would be to re-institutionalize and keep a very high legal and regulatory scrutiny on the institutions. Other solutions might work well too. But a key cornerstone of improvement will have to come to changing the shape of the law for involuntary holds and medication for people in high crisis.

>The indigent will have their debt forgiven - hospitals know they don't get blood from a turnip.

Lol I was taken involuntarily to the hospital. When they gave up billing me they simply turned it over to collections to let them deal with squeezing the blood from the turnip. (not mental though, fraudulent accusation by federal agents I had drugs up my ass and then dragged there in handcuffs).

> Mental wards in the United States today are not, conventionally, torture chambers for mad doctors.

I've worked on an inpatient psychiatric unit, and while the doctors might not be "mad", it absolutely is torture. The most obvious example is sleep deprivation, which is definitely torture. This is done in the name of "helping" the person (by checking on them), but makes things so much worse.

> My druthers would be to re-institutionalize and keep a very high legal and regulatory scrutiny on the institutions.

This does not and can not work for reasons outlined in my original comment. The system claims to be helping but shuts down any feedback mechanism that would suggest otherwise. There's just no way to square that circle.

> I've worked on an inpatient psychiatric unit, and while the doctors might not be "mad", it absolutely is torture. The most obvious example is sleep deprivation, which is definitely torture. This is done in the name of "helping" the person (by checking on them), but makes things so much worse.

Checking on them how often?

Is it worse than a normal hospital?

You might benefit from looking at personal experiences of what a psych ward is like. There's a furry comic called Fresh Meat about the partially fictionalized experiences of a teenaged girl in for attempted suicide, where one of the beginning sections she is forced out of bed from a dead sleep in order to be transferred to another ward by being shoved out of bed and then when she's asked not to be touched the nurse tells her there's much worse that can be done to her besides touching. She is also withheld food and water until she signs a consent form that allows her to be kept indefinitely, but also she cannot leave the facility on her own will because she's in a psychiatric hold.

Thanks for sharing that. Great comic - read it straight through. :)

I am sympathetic to stories like those, and I don't doubt that bad things happen, but it's important to recognize that people suffering from serious mental illness are often unreliable narrators. It's a difficult situation.

Question: if a non-psychotic psychiatric patient cannot be trusted to perform first-hand accounts of their own abuse, and psychiatric wards are tightly controlled such that lawyers and patient advocates can only be allowed in when deemed reasonable by the hospital, how does a sexually assaulted patient navigate reporting their abuse?

Believing that all patients, regardless of their exact illness, cannot be trusted to accurately describe abuse done to them is precisely what enables abuse in the first place. Suicidal thoughts is not a condition where you cannot tell if you're being taken out of bed in the middle of sleep. Suicidal thoughts is not a condition where you cannot understand someone is threatening you.

I really don't know.

With the caveat that this is just an anecdote, one of my family members is an extremely intelligent and highly accomplished man. He graduated from Yale law, worked at a very high level in the executive branch, and during his professional career, I don't know anyone who questioned his character. Retired, he is now suffering from severe intractible depression.

Last month, I drove my relative to a doctor's appointment, and due to his own mistake, he showed up at the wrong time. And on the wrong day. Since I had walked him into the office, I heard his conversation with the receptionist, and then with his doctor, who came out to calm things down.

On the ride back to his house, my relative phoned another member of my family and angrily explained what had happened. He blamed everything on the doctor, and made baseless accusations against the doctor and receptionist. My relative's account of the situation wasn't based in reality. And he related his account right in front of me. He truly believed every word he was saying. But it wasn't true. I saw what had happened with my own eyes. I heard it with my own ears. I, fortunately, am well.

It wasn't the doctor's fault, nor was it the receptionist's fault. Quite the opposite, my relative had made a mistake. His illness, however, — depression — blinded him to that reality. And his reaction was to sling baseless accusations at his doctor.

Like I wrote before, this is a really difficult problem. I don't have a solution. I wish I did.

Figure every 15 minute someone looks through the door to make sure you didn't harm yourself. Mileage might vary by ward and illness.

Some wards are noisier than others.

I've heard of a camera in-room as well. Better for disturbance, worse for privacy.

Note that these people in acute inpatient wards are in a serious crisis: attendants _have_ to make sure they aren't hurting themselves.

>We live in a society where those who follow the laws are constantly punished for minor infractions like parking tickets and zoning violations, while people who do not participate in society AND completely flout the laws in every way are not only allowed to do so, there is a huge section of our population that encourages and protects their right to do so.

At the end of the day it's inconvenient to punish homeless for crimes. They have no money, they're often infected with disease, and they are often unpleasant to deal with. Meanwhile when I did absolutely nothing wrong, federal officers bragged to me what a great vacation it was to drag me to the hospital for the better part of a day on a fraudulent and fabricated search for "drugs" because they said it was better than doing their normal beat, and it paid great overtime. People say you should be polite to law enforcement, but the fact is being unpleasant/unpolite/filthy works.

Like most humans, a frightening amount of law enforcement boils down to they did it because it was easiest. Dealing with mentally ill people at their worst moments is not easy, extorting a well to do professional for going 5 over the limit is much easier.

> We literally have conservatives disassembling democracy across this nation, and the Left's favorite game to play is "Can we castigate more progressives for not passing the acid test."

I have to say, a rant like that about how things are in SF ending on that note caught me off guard. You explained in detail all of these problems and closed out that you’re worried about conservatives?

I have to ask…why?

The point of SF's progressive movement is to fight back against conservative policies with an example of what progressive politics can accomplish. It's not exactly working out now is it? SF itself is the city where all of the beautiful progressive ideas come together in harmony and make a heavenly place. It is absolutely incorrect in that assessment of itself. Spend 5 minutes at a city council meeting and you will see exactly what I mean. Same thing happens in Oakland. The city spends an awful lot of time commenting on what's going on in conservative areas and passing rules and laws that seemingly address those things but are really just talk. And then they continue to ignore the real problems of crime and homelessness. Oakland and SF love passing support statements for people having issues in other states, but can't get their own Police Departments to even show up to do their jobs. Priorities are entirely wrong.

I'd guess that the idea is that left wing politics in a lot of places has gotten bogged down in ridiculous notions of "just do whatever you want, everyone has kindness within them" and lets that override the normal concerns about cohesion and wellbeing in society.

You can have socialism, redistribution, a progressive society etc., whilst also recognising that no, you can't just park your tent wherever you want and bother people.

You can support the fact that people might have unorthodox sex lives in private whilst also believing that people who parade the fact that they "have multiple genders" are attention seekers.

The best way that I can describe the feeling I have is that effectively, there's no "upper bound" for compassion/empathy in the modern left-wing framework and that crashes and burns when it hits the real world.

The "left" as practiced in SF fails to get anything done and lets things fester and worsen through neglect.

But... the evangelical/nationalistic right, on the other hand, comes out and says exactly all the things they want. Less healthcare, less regulation of the powerful, more cops for the less well-off, more weapons, less sexuality that they don't like, etc. "Fixing mental health" isn't in that list. "Building more housing" isn't even on that list. There are a LOT of people with good reason to be scared of those moves.

Tell me which of these I should think is more feasible:

1) Working with democrats to add some practicality to how to get to the desired outcomes I support?

2) Trying to convince the right that they should change almost all of their goals?

I might be accused (by some) of being on the right.

It's not that I don't want to "fix mental health". Who wouldn't want to wave that magic wand and be able to justifiably claim to be the savior of what I sometimes read is as high as 20-40% of the population of our country?

That said, I feel like it's a problem that can't reasonably be solved by anyone. Not because they're unwilling or incompetent, but that the science just isn't there. Everyone today wants to solve infectious disease, after all. And we actually manage (sometimes) to accomplish that. But if the year were 800AD and you complained that those in charge weren't solving the perplexing miasmas and dark humors that were making people sick with the black death...

You'd have been a fool. No one knew how to deal with those things then. And no one knows how to do something about mental health now. There seem to be medications that sometimes help some people, but when they don't work (or when they do!) no one can give a straight explanation why. The psychologists fail to give us a working theory of the human mind such that we can (even hypothetically) understand why someone is schizo. Or depressed. Or has OCD.

Don't get me wrong. I am not blaming the left for not fixing this. It's just intractable. Everything I see suggests it's likely to remain so into the indefinite future.

Both sides should stick to "building more housing" if you ask me.

There are a lot of people on the left who have never ever liked conservatives or republicans but who are extremely frustrated at what the left is doing. They seem to be failing on a lot of things, and conservatives seem to be succeeding, but whenever we criticize the left or suggest something other than what the current thing is in progressive circles, we’re called fascists.

More importantly though, it kinda sucks you focused on the tribal aspect of the comment because it was full of other things to engage with.

It was simply the part that surprised me the most. I’ve heard so much of the rest of the topic that the poster’s mindset was the newest information from my perspective.

You worry about conservatives destroying Democracy but all of the most desirable places to live for people who aren't rich enough to afford private segregation are conservative areas. Are there any liberal areas where it's actually nice to live if you are poor or of moderate income? As in not wealthy enough to afford, doormen, gated communities and private schools?

It's hard to answer this question if we don't have any examples of what you think of as conservative "nice places to live." The affordability bar varies wildly even in red states, and you also have red state/blue city stuff going on a lot.

So I'll turn the question back like this: what do you think are nice places to live that have demonstrated effective solutions to affordability and mental health problems at scale in a relatively dense city with high property prices from high demand?

In my experience, the way this is "fixed" in a city like Phoenix is a combination of: "be able to sprawl outward further and further without yet getting completely blocked by geography so there's always somewhere to put new construction to keep costs down" and "have inclement weather that pushes the homeless out so we don't have to be the bad guys ourselves as much" - but these are basically the opposite of the most common proposed "if only the government could get it together" fixes for SF: denser construction and confinement. Those tools are likely necessary for a city like SF, but it's not like there are Republican cities showing how to get it done.

Massachusetts (and most of New England) is great. I own a large house with a mortgage that's cheaper than a shared studio in San Francisco and I never worry about locking the door.

Neighbors are all friendly, well behaved kids roam the street unsupervised, it feels the same way it did 30 years ago here. It's deep blue territory. The weather is terrible and the Red Sox have gone off the rails, but you can't have everything.

Ok, so can you be more specific that's a large reason, but my understanding was it's very expensive there? So what is an average home price like, and is there any significant diversity diversity? Massachusetts as a whole looks to be as much as 80% white.

There is a huge range, parts of Boston and the NYC suburbs that extend into CT might compete with San Francisco on astronomical prices (and real estate market absurdities) and parts of Maine will compete with anywhere in the US for cheapness.

The average is not as meaningful here because there are places all along the scale (except in Boston, again, kind of crazy there, but there are commutable suburbs with fairly reasonable prices).

No place is going to have the same diversity, fun, or nice weather like San Francisco. Certainly not in New England. That why it sounds like studios are going for $2500 or more there and I have a 3bed2br house for less than half that here.

The cool thing is I'm 15 minutes from downtown Worcester, 45-60 to Boston and Providence, and 2.5 hours to NYC. I find that I get out in one city or another about as often as people who live there, but am also able to take more trips internationally because I'm not spending a fortune on housing. But if you're the kind of person who really is taking full advantage of what a place like San Francisco has to offer then it probably does make sense to live there.

> Are there any liberal areas where it's actually nice to live if you are poor or of moderate income?

Lots of the Great Lakes Region. I live in a liberal area where the average house price is ~150-200k and I rent a 2 bedroom, ~1000 sq. ft. apartment in the middle of the city within walking distance to things for $950.

Ok, that realistically is the kind of answer I am looking for. Thanks, can you give any more specifics because great lakes region is pretty large.

Though I also think you may benefit from a bit of the weather being inhospitable to most of the poor and homeless.

Also what is the diversity like?

Mid sized cities in the region are very habitable, diverse, and reasonably priced. Indianapolis, Columbus, Cincinnati, Lansing, Green Bay, Springfield, etc. The big cities are harder but still better than the coasts, $$ wise. I think Milwaukee is reasonable, though.

Diversity will vary a lot. The manufacturing cities are pretty diverse: My city is about 60 percent white and 40 percent POC.

They do lean more towards 'working class' liberal than 'professional' liberal. More 'rah rah unions' and less Ibram Kendi. Though if you're in a university city or capital, both are decently represented. If you meant other than racial, I haven't had a problem being gay in any of those areas since the mid-00s and a lot of those cities have small but thriving immigrant populations and the cities are small enough that there is political diversity coming in from the burbs/rural areas.

I feel like those areas are more diverse than the big big cities I have lived in. (Boston, Seattle, Vancouver).

Maine, Georgia, Michigan (anywhere but greater Detroit)

Hint: all of these places are solidly purple (but voted blue in 2020 so I counted them). It's like having actual political competition is a good thing!

> If the people advocating for the homeless and mentally ill have a better solution than leaving them on the streets to rot

The comment you are replying to put forward exactly such a solution: that treatment should be helpful enough and sufficiently respectful of users' rights, that people who need it don't refuse it.

You can't reason the person smearing shit on themselves and screaming at people into treatment.

The eagerness to reason from the headline anecdata on this topic is a signal that it is not just the mentally ill who exhibit severe thinking problems.

No, you can't reason with that one person at that moment. Get them sedated, cleaned up, new clothes and a haircut, and then ask them what is going on with them.

For each one like that there are another 10,000 people in various forms of quiet desperation.

> Get them sedated

Kind of tough to get them to that first step willingly. Got any other ideas?

<del>Willingly was your idea.</del> As for other ideas, some are in the comment.

What about the 10,000 who might be willing if society offered them treatment options even a sane person would accept?

EDIT: because sibling comments are willfully ignoring my point

EDIT2: public disturbances are frequently halted with police arrest, not whatever willingness could be brought about ahead of time with better systems in place

Willingly wasn't necessarily their idea, that's the whole point of this thread - getting people into treatment by their own choice vs. forcing them:

> > > ... treatment should be helpful enough and sufficiently respectful of users' rights, that people who need it don't refuse it

The list of people who need help is so much longer than any one causing an event that makes it into the newspapers or anecdotes.

Why is it such a fantasy that treatment options should be appealing to the people committing themselves to them?

presumably, in order to obtain consent. non-consensually committing someone raises issues that must be addressed to prevent abuse.

I live in a state with 72 hour minimum emergency involuntary committal. (further requires a court order) this is a compromise that addresses the above concern. ideally it is enough for the patient to get on a routine of taking meds and making sure there aren't adverse reactions from them.

We used to fairly easily commit people to asylums. There was lots of abuse of this power. Mental institutions were very bad places (see One Flew Over the Cuckoo's Nest). Finally the pendulum started swinging the other direction starting in about the 50s (in the 60s JFK called for reform) and culminating in the 80s when Reagan effectively emptied the mental institutions (but more for budgetary reasons than any concern for the mentally ill). And now we've reached the other extreme where we're too afraid to violate the civil rights of the mentally ill so we let them stay on the streets because that's what they "want" to do.

I think too many basically sane people are close enough to losing their minds at all times that they would fear for their own civil rights. The mentally ill on the streets are only a small sample of a spectrum.

I understand the history well enough to note that a wide swath of (also) expensive alternatives have not been tried yet, or the basically sane people mentioned above would be willing to undergo treatment that works.

> culminating in the 80s when Reagan effectively emptied the mental institutions (but more for budgetary reasons than any concern for the mentally ill).

“Reagan” getting credit or blame for this is largely misleading. There were a number of drivers..

Deinstitutionalizations was an important goal of the Community Mental Health Act of 1963.

Subsequently, a series of federal court rulings in the 1970s which restricted involuntary commitment and required paying patients federal minimum wage for doing work in and for institutions (like the prisons, mental institutions were slave institutions – on top of their myriad other problems – in all but name) undercut both the pipeline and the financial underpinnings of the system of institutionalization.

That’s…not a solution. That’s a goal.

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