Last week, a middle-aged man was brought to my hospital in a desperate condition. He had discharged himself from a mental hospital against medical advice three weeks before; arriving home, he had found the prospect of life with his wife no more inviting than that of life in the wards of an asylum. He had taken himself to the center of the city, where he camped out in the open in a small public garden next to a luxury hotel. There he stayed, eating nothing and drinking little, until he was eventually found unconscious and so dehydrated that the blood had thickened and clotted in one of his legs, which was gangrenous and therefore had to be amputated.
What story could better illustrate the supposedly callous indifference and cruel individualism of our society than that of a man left nearly to die in the middle of the city, next to a hotel with rooms at $200 a night, in the full gaze not only of the guests but of thousands of his fellow citizens, all for the lack of a little water?
But other interpretations of the story are possible. Perhaps the thousands of passersby who saw the unfortunate man as he declined slowly toward the verge of death were so accustomed to the idea that the state would (and should) step in that they felt no personal duty to do something on the mans behalf. One does not, after all, pay half ones income in taxes in order to assume individual responsibility for the welfare of ones neighbors. Ones taxes are supposed to ensure not only oneself, but everyone else, against neglect. Just as no one is guilty when everyone is, no one is responsible when everyone is.
Then again, perhaps the passersby thought the man was only exercising his right to live as he chose, as championed by those early advocates for deinstitutionalization of the insane, psychiatrists Thomas Szasz and R. D. Laing. Who are we to judge in a free country how people should live? Apart from a slight measure of untidiness, the man created no public nuisance. Perhaps the passersby thought, as they tolerated him nearly to death, that he was merely doing his own thing, and in the conflict between the imperative to act the good Samaritan and the imperative to respect the autonomy of others, the latter prevailed. In the modern climate, after all, rights always trump duties.
Still, the existence of people who live on the street, or who are of no fixed abode, is generally taken, at least by liberals, as an indication not of our societys commitment to freedom, but of its injustice, inequity, and indifference to human suffering. There is no subject more likely than homelessness to produce calls for the government to intervene to put an end to the scandal; and no subject is better suited to that most pleasurable of human activities, compassionate handwringing.
Yet as is so often the case with social problems, the precise nature and location of the alleged injustice, inequity, and indifference to suffering become unclear when things are looked at close up rather than through the lens of generalizations, either ethical ("no one in an affluent society should be homeless") or statistical ("homelessness rises in times of unemployment").
In the first place, it is far from evident that our society in the abstract is indifferent to homelessness. Indeed, homelessness is the source of employment for not negligible numbers of the middle classes. The poor, wrote a sixteenth-century German bishop, are a gold mine; and so, it turns out, are the homeless.
For example, in one hostel for the homeless that I visited, located in a rather grand but disused and deconsecrated Victorian church, I discovered that there were 91 residents and 41 staff members, only a handful of whom had any direct contact with the objects of their ministrations.
The homeless slept in dormitories in which there was no privacy whatever. There was a rank smell that every doctor recognizes (but never records in the medical notes) as the smell of homelessness. And then, passing along a corridor and through a door with a combination lock to prevent untoward intrusions, one suddenly entered another world: the sanitized, air-conditioned (and airtight) world of the bureaucracy of compassion.
The number of offices, all computerized, was astonishing. The staff, dressed in smart casual clothes, were absorbed in their tasks, earnestly peering into their computer screens, printing documents, and rushing off for urgent consultations with one another. The amount of activity was impressive, the sense of purpose evident; it took some effort to recall the residents I had encountered as I entered the hostel, scattered in what had been the churchyard, who were swaying if upright and snoring if horizontal, surrounded by empty cans and plastic bottles of 9 percent alcohol cider (which permits the highest alcohol-to-dollar ratio available in England at the moment). Nero fiddled while Rome burned, and the hostel administrators made pie charts while the residents drank themselves into oblivion.
There are 27 hostels listed in the yellow pages of our citys telephone directory, and many known to me are unlisted. Some of the hostels are smaller and have fewer staff members than the one I have described; but clearly, some hundreds of peopleand possibly as many as a couple of thousandowe their jobs to the homeless. Besides the employees of the hostels themselves, there are social workers and housing officers for them; there is a special clinic with doctors and nurses for them; and there is a psychiatric team of five, headed by a doctor at a salary of $100,000, that cares for the mentally ill homeless. The doctor is an academic and spends half his time on research; I would personally be prepared to bet quite a lot of money that the scale of the problems of the mentally ill homeless in our city will not decline in proportion to the number of papers he writes or the number of academic conferences he attends.
Since our city is in no way untypical and contains approximately 2 percent of the British population, it is a fair assumption that not far short of 50,000 people earn their living from the homeless in these islands. This may be a sign of inefficiency, of incompetence, and even of profligacy, but scarcely of indifference in the liberals sense of the word; and compassion for some is undoubtedly a good career move.
Still, it might be argued that all this activity is but a Band-Aid to a fracture or aspirin to malaria. By the work of charitable and governmental agencies, society assuages its conscience and turns a blind eye to the fundamental causes of the plight of the homeless.
It is accepted as axiomatic, of course, that the plight of the homeless is a desperate one. Who can look at the physical surroundings of most hostels without revulsion, or contemplate the food from their soup kitchens without nausea? Does it not follow that those who spend their lives in these conditions are the most hapless of beings and ought to be rescued?
As a child, whenever I saw a gentleman of the road who dressed a little like Tolstoy playing at peasantry, with his tangled gray beard, muttering his imprecations and calling down his curses upon the world, I did not pity him, but on the contrary thought of him as a superior kind of being, a little like God of the Old Testament, in fact, or at least like His prophets. These men were schizophrenic, no doubt, and I soon enough lost the preposterous idea that their strange behavior was the consequence of esoteric wisdom available to them but not, say, to my parents. And even in these days of community care, so called, of the mad, the schizophrenic make up only a minority of the homeless; but I have learned by another route that the homeless are not merely to be pitied, like injured hedgehogs or birds with broken wings, to be healed by a little well-meaning intervention by professional helpers, de haut en bas. The homeless suffer, all right, but not always in the way or for the reasons we imagine.
A 55-year-old man who had spent half a lifetime traveling from hostel to hostel round the country was admitted to my ward suffering from delirium tremens. His condition then was indeed pitiable; he was terrified of the small animals that he saw crawling from the bedclothes and the walls, his tremor was so profound that he could not stand, for him to hold a cup or cutlery was out of the question, and looking at his bed one might have supposed that a prolonged and serious earthquake was taking place. He was incontinent of urine and had to have a catheter inserted; sweat poured from him as rain drips from the foliage of a rain forest. It took a week of baths to clear him of the smell of homelessness and a week of tranquilizers to calm him. Surely, you would have thought, any way of life was preferable to the way of life that led to this.
Once restored to health, however, he was by no means the pitiful creature he had been only shortly before. On the contrary: he was a man of intelligence, wit, and charm. There was a roguish twinkle in his eye. Nor had he emerged from the kind of family background commonly (but erroneously) supposed to necessitate a dismal future without prospects: his sister was a senior nurse, and his brother was a director of a large public company. He himself had done well at school but had insisted upon leaving at the earliest opportunity, running away to sea. After an early marriage, the birth of a son, and the irksome assumption of a mortgage, he longed for the restoration of his premarital freedom and rediscovered the joys of irresponsibility: he deserted his wife and child and worked no more but rather spent his days drinking.
Before long, he had descended the housing scale from apartment to rented room to hostel bed. But he regretted nothing: he said his life had been fuller of incident, interest, and amusement than if he had kept to the narrow path of virtue that leads straight to a pension. I asked him when he was fully recovered to write a short article describing an incident from his past, and he chose his first night ever at a hostel. It was raining hard, and a line of bums waited outside the Salvation Army for admittance. A fight broke out, and one man pulled another by the hair. There was a ripping sound, and the assailant was left holding his victims scalp.
Far from so appalling him that he resolved at once to reform, my patient was intrigued. His temperament was that of a sensation seeker; he hated boredom, routine, and being ruled by others. He joined the large fraternity of wanderers who live on the margins of the law, ride trains without tickets, taunt the burghers of small towns with their outrageous behavior, infuriate magistrates by confronting them with their own impotence, and frequently wake a couple of hundred miles from where they started out in the evening, without any recollection of how they got there. In short, the life of the chronic homeless is one of ups as well as downs.
Of course, the longer it is lived, the harder it is to give up, not only because of habit, but because it grows progressively more difficult for the person who lives it to reinsert himself into normal society. A 55-year-old man might have some difficulty explaining to a prospective employer what he had been doing for the last 27 years. With age, however, the physical hardships of the existence grow more difficult to sustain, and my patient said to me that he thought that unless he gave up the wandering, he might not have very long to live. I agreed with him.
I found him a hostel for alcoholics who had dried out and who had undertaken not to drink again. At first, he did very well: he kept his appointments with me and was neatly turned out. He even appeared happy and contented. He was surprisingly well-read, and we had pleasant literary conversations together.
After about three months of this stable existence, my patient confessed that he was growing restless again. Yes, he was happy, and yes, he felt physically wellmuch better, in fact, than he had felt in years. But something was missing from his life. It was the excitement: the chases down the street by policemen, the appearances in the magistrates courts, the sheer warmth and companionship of the barroom. He even missed that important question with which he used to wake each morning: Where am I? Waking in the same place each day was not nearly as much fun.
And sure enough, he missed his next appointment, and I never saw him again.
This is not by any means an isolated case: far from it. People like this patient are the most numerous category among the hostel dwellers. At least two of them are admitted to my ward each week. Today, for example, I spoke to a 45-year-old man who had once held a responsible job as a store manager but who was admitted a couple of days ago in delirium tremens. He agreed that his wandering life, now of 12 years duration, had not been an entirely miserable one. The patient, who drank as much as any patient I have ever encountered, was proud of the fact that he had not been in trouble with the police for the past seven years, though not for lack of breaking the law. His social security check was totally inadequate to his consumption of spirits, and he had become a practiced thief, "though only for what I need, Doctor." It was evident that the craft of stealing without getting caught gave him much pleasure. He admitted that he wasnt driven to theft by necessity: he told me that he was an accomplished portraitist and could earn enough money in a few hours by his skill to keep himself drunk for a week.
"Ive had plenty of money in my time, Doctor. Moneys no problem to me. I could get plenty again. But the more I get, the longer I binge."
This patient, too, knew that he would return to the life he had been leading, whatever we did for him, whatever we offered him.
These homeless men, then, have made a choice, which one might even dignify as an existential one. The life they have chosen is not without its compensations. Once they have overcome their initial revulsion at the physical conditions in which they have decided to live, they find themselves secure: more secure, in fact, than most of the population engaged in a struggle to maintain its standard of living and by no means guaranteed of success. These men know, for example, that there are hostels everywhere, in every town and city, that will take them in, feed them, and keep them warm, whatever may happen and whether the market is bullish or bearish. They have no fear of failure and are utterly without the constraint of routine: their only daily task is to appear on time for a meal, and their only weekly task is to collect their social security. Moreover, they are automatically part of a fraternityquarrelsome and occasionally violent, perhaps, but also tolerant and often amusing. Illness goes with the territory, but a general hospital is never far away, and treatment is free.
It is difficult for most of us to accept that this way of life, so unattractive on the surface, is freely chosen. Surely, we think, there must be something wrong with those who choose to live like this. Surely they must be suffering from some disease or mental abnormality that accounts for their choice, and therefore we should pity them. Or else, as the social workers who arrive periodically in the hostels believe, all who lodge there are by definition the victims of misfortune not of their own making and quite beyond their control. Society, as represented by social workers, must therefore rescue them. Accordingly, the social workers select a few of the longest-standing residents for what they call rehabilitation, meaning rehousing, complete with grants of several hundred dollars to buy those consumer durables the lack of which nowadays is accounted poverty. The results are not hard to imagine: a month later, the rent of the apartment remains unpaid and the grant has been spent, but not on refrigerators or microwave ovens. Some of the most experienced among the homeless have been rehabilitated three or four times, securing them brief but glorious periods of extreme popularity in the pub at taxpayers expense.
To say, however, that a choice is a free one is not to endorse it as good or wise. There is no doubt that these men live entirely parasitically, contributing nothing to the general good and presuming upon societys tolerance of them. When hungry, they have only to appear at a hostel kitchen; when ill, at a hospital. They are profoundly antisocial.
And to say that their choice is a free one is not to deny that it is without influences from outside. A significant part of the social context of these homeless men is a society prepared to demand nothing of them. It is, in fact, prepared to subsidize them to drink themselves into oblivion, even to death. And all of them, without exception, consider it part of the natural and immutable order of things that society should do so; they all, without exception, call collecting their social security "getting paid."
These gentlemen of the road are being joined in their homelessness by increasing numbers of young people, fleeing their disastrous homes, where illegitimacy, a succession of abusive stepfathers, and a complete absence of authority is the norm. We are constantly told by those liberals whose nostrums of the past have contributed so richly to this wretched situation that society (by which is meant government) should do yet more for such pitiable people. But is not homelessness, at least in modern-day society, a special instance of a law first enunciated by a British medical colleague of mine, namely, that misery increases to meet the means available for its alleviation? And does not antisocial behavior increase in proportion to the excuses that intellectuals make for it?