This is further analysis of the homelessness and violence issue. As I look back on the title of the White House Executive Disorder as a guy with an interest in rhetoric – I cannot help to notice those elements. What does the title “Ending Crime and Disorder on America’s Streets” suggest? First off – a definitive solution. In other words, if you follow what is in this order that solves the problem – period. Secondly, it suggests that there is crime and disorder that is widely agreed upon. The problem is widespread. Third and implicitly – that the problem was ignored until this administration came along to solve it. Fourth as elaborated in the subsequent text – if you magically eliminate the problems of mental illness, substance use, and homelessness – the problem is solved. Let’s look at the reality versus this rhetoric.
The definitive solution: Per my previous analysis this
order conflates “crime and disorder” with homelessness, mental illness, and
substance use. It further conflates
homelessness with mental illness and substance use. None of the other features of homelessness
noted by the OECD namely youth, the elderly, families, and immigrant status are
mentioned. None of the features noted by the United States Interagency
Council on Homelessness namely non-white minority status, homeless workers
that cannot afford housing, and the fact that housing first options are
effective is mentioned. The only solutions presented are law enforcement and
forced mental health and substance use treatment.
Crime and Disorder are widely agreed upon: Looking at the real
crime rates in the top 100 cities by population in the US shows some
interesting trends. Some cities with
very low crime rates (like New York City) are often held up as examples of
crime being rampant in the US. Other
considerably smaller cities with much higher crime rates are never
mentioned. This selective attention from
the news media and politicians illustrates that the rampant crime problem is
pretty much what somebody decides to say it is - whether there are facts to
back it up or not. That is especially
true because current violent crime rates using the same measure are down by 75% since
1993. Crime in cities is like crime in the homeless populations – it is
localized and most people have no contact with it. Apart from occasional mass
protests – I am not aware of any consistent widespread disorder in American
cities that needs to be addressed. I
don’t think it is too much to consider that hyperbole.
The problem was ignored until this administration came
along: More hyperbole considering
the obvious examples of lawlessness exhibited at the highest levels of
government by this administration. The
January 6th Insurrection was not as result of homelessness, mental
illness, or substance use. Neither was
the pardon of all of those who were convicted.
The strong message in this executive order is that the homeless,
mentally ill, and substance using populations are not above the law and need
both the criminal laws and civil commitment laws enforced against them. That is hypocritical considering the numerous
incidents in this administration giving the strong message that certain people
with many resources are above the law.
The message that nobody in the US is above the law falls apart under
that scrutiny and this administration has no higher moral ground on enforcing
the law than any other. Further – it can
be argued that consistent changes since 1993 have resulted in a major drop in
violent crime in the US and stating otherwise is not historically
accurate.
The magic elimination of the problems: At this point
– I hope that I have illustrated why the title of the executive order is
grossly exaggerated. On that basis alone
eliminating the states problems of homelessness, mental illness and substance
use would be expected to have no impact.
In the previous post, I also examine why the proposed solutions will not
put a dent in a non-system of care that has been rationed for profit by the
same politicians charged with improving it. Massive cuts in health care spending and
research by this administration can only make things much worse rather than
better. President Trump seems to think
that if he orders something and does not provide resources people with either
scramble to provide them for free or law enforcement will solve the problem by
mass incarceration.
That is the rhetoric associated with the current executive
order, but what is the reality. Rhetoric
flows both ways and for a long-time advocates for the mentally ill took the
extreme that there was no violence risk or that it was not any greater than
violence from people with no mental illnesses. As an acute care psychiatrist, one of the
commonest reasons people are admitted to acute care units is violent or
aggressive behavior. I have assessed and treated thousands of those admissions
and know the underlying causes, but have no good data on what it looks like in
the community. As can be imagined that
real world data is difficult to come by because it involves access to
information in a number of databases and a major effort to synthesize all of
it.
That brings me to a recent study that I think was very well
done and could probably not be done in the US (1). The study was registry based and done in
Denmark by a group of researchers with expertise in this problem. The study
cohort was 1,786,433 Danish residents between the ages of 15-42 living in
Denmark at some point during the ten year between January 1, 2001 and December
31, 2021. The primary outcome was any
violent offense leading to conviction as noted in the table below:
The authors used data on multiple registries in Denmark including the Danish Civil Registration System, the Central Criminal Register, the Danish Homeless Register, the Psychiatric Central research Register, the National Patient Register, National Register of Drug Abusers, and the National Register on Treatment with Heroin and Methadone. The substance use registers were available only for a 10-year period and were used as a quality check on the other data. This methodology is also why this kind of study cannot be done in the US. In the US all this data is siloed with respective insurers, managed care companies, pharmacy benefit managers, and pharmacies. It is considered proprietary data that is typically out of the reach of most researchers. The privatization of healthcare in the US has made this kind of research nearly impossible to do. I consider this to be a conflict of interest because the same healthcare companies that profit from rationing healthcare control all the data needed to assess whether they are doing an adequate job.
The main aggregation of data is illustrated in the first two
tables. During the study period a total
of 55,624 experienced no homelessness and were convicted of their first
violent offense or 55,624/1,771,879 = 3.13% of the sample. 1,460/14,555 = 0.08% of the sample experienced
homelessness and were convicted of their first violent offense. Without considering cultural or geographic
factors that means if you were walking through Denmark about 3.2% of the non-homeless
population over the time course of this study has first time violent
offenses. At the same time, 0.08% of the
total population over this same period are violent first-time offenders who
have also experienced homelessness (1,460/1,771,879). In other words, all things being equal you are
38 times more likely to encounter a violent offender who has not been homeless
than one who has. That hardly seems like
an argument for ending “crime and disorder” by ending homelessness.
A Bayesian (based on prior probabilities) or cultural argument could be made that the first violent offense rate in the homeless is three times higher in that population than the general population and therefore caution should be used in homeless encampments. An extreme argument could be made that this is a reason for removing these camps. But the fact is 90% of those people would not have violent offenses and there are certainly subcultures across any major city where the prevalence of violent crime is as high if not higher. Is it rational policy to excise those neighborhoods from any city? The heat map below is a graphic county by county representation of annual average violent crime rates. The gray areas are unreported. There are clearly high crime areas in the absence of significant homeless populations. The heatmap below plots the number of reported offenses per 100,000 of population. Data is from the FBI’s Uniform Crime Reporting (UCR) Program and violent crime is defined as four offenses: murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault.
The main data analysis in this project involves calculating incidence (defined as cases/10,000) and incidence rate ratios or IRR defined as the incidence in the homeless population/incidence in the non-homeless population. The example below is from Supplementary Table 7a. Association of homelessness and specific violent offences leading to conviction in men (10,623,486 person-years), 2001-2021. For the category “homicide and attempted homicide”.
|
Raw Data |
Incidence |
Incidence
Rate Ratio (IRR) |
|
Homeless cohort: 36 cases/74,706 person-yrs x 10,000 |
4.8 |
4.8/0.4 = 12.2 |
|
Non-homeless cohort: 446 cases/11,144092 person-yrs x
10,000 |
0.4 |
There are also obvious environmental and ecological factors in homelessness that may be associated with violence. Relative to any typical living environment
there is limited privacy and security.
There are far fewer locked doors, security cameras, and alarm systems. Crowding
is a problem that in general is associated with more conflict and
violence. Noise is an additional problem. Poverty is a complicating factor
that can make things worse if there are people getting retirement or disability
checks at specified times or who are known to be carrying food or money.
The neuropsychiatric and psychiatric disability aspects of
homelessness were not explored to any degree in this paper. Many homeless people come to the attention of
law enforcement and end up in jail or transported to local emergency
departments. In both settings
significant psychiatric disorders are noted and may or may not be treated. Severe
psychiatric disorders can lead to many impairments associated with violence including
delusional thoughts, impaired insight and judgement, and overt agitation and
aggression. All of that behavior is worsened by alcohol and substance use which
are also independent risk factors.
The authors conclude for all the problems noted in their paper
that homelessness is a significant public health problem that needs to be
addressed. They have made that
assessment in a Scandinavian country with less income disparity and a more
robust safety and medical network than the US. In
the US we have no definitive research – only a political statement in the form
of an Executive Order that mischaracterizes the problem. That Order also has clear parallels with
previous action by the administration against immigrants because of their purportedly
higher crimes rates, rates of mental illnesses, and substance use. In that case it was shown that native born
use citizens have higher rates of violent crimes, property crimes, and drug
crimes than either legal immigrants or native born citizens (2).
The Executive Order in question has no scientific, rational,
or moral basis. Further – the party that
supports it is long on a states’ rights approach that allows politicians to not
provide needed medical and housing assistance to people in their own states. At a national level – they have severely cut budgets
that will result in the closure of hundreds of facilities (hospitals and substance
use treatment facilities). The idea that
a public health problem can be addressed by removing resources and adding more
law enforcement is pure fantasy - or politics.
George Dawson, MD, DFAPA
References:
1: Nilsson SF,
Laursen TM, Andersen LH, Nordentoft M, Fazel S. Homelessness, psychiatric
disorders, and violence in Denmark: a population-based cohort study. Lancet
Public Health. 2024 Jun;9(6):e376-e385. doi: 10.1016/S2468-2667(24)00096-3.
PMID: 38821684.
2: Light MT, He J,
Robey JP. Comparing crime rates between undocumented immigrants, legal
immigrants, and native-born US citizens in Texas. Proc Natl Acad Sci U S A.
2020 Dec 22;117(51):32340-32347. doi: 10.1073/pnas.2014704117. Epub 2020 Dec 7.
PMID: 33288713; PMCID: PMC7768760.
