Chapter X: Solving Homelessness: A Physician’s Reflection on a Broken System and the Hope to Rebuild

It may trigger you when you pass someone sprawled on the sidewalk, face hollow, skin breaking down, muttering into a void no one else can see. The frustration, the helplessness, and the anger rev up something in your moral compass. “Why can’t we just get this person help?” you think. “Why are we letting people live like this?”

If you’re a physician, a first responder, a social worker, or someone who just walks the streets of your city every day, you’ve likely felt this deep discomfort. The tragedy isn’t just visible. It’s visceral.

And the more you learn, the more painful the picture becomes.

The Reality Behind the Tent

Contrary to common belief, most people living on the street didn’t choose this life. They didn’t “fail” in the way society often assumes. Many are survivors of trauma, poverty, childhood neglect, psychiatric illness, and addiction. But the system doesn’t work like a net, it works like a maze. And it leaves people behind.

Addiction, for instance, is not a failure of character. It’s a chronic brain disease, one that rewires decision-making and dismantles impulse control. But in our system, if someone with this condition says "no" to help, even while clearly spiraling. We conveniently step back and call it “choice.”

The Gray Zone: Between Freedom and Survival

We talk a lot about liberty in this country. And rightly so. But liberty, without safety, becomes abandonment. And in the world of homelessness and addiction, we’ve built a system that protects autonomy to the point of moral paralysis.

Legally, someone can live in a tent under a bridge, covered in infected sores, using meth daily, hallucinating, and refusing food and still be deemed to have capacity. Because they can say their name. Because they can answer questions. Because, technically, they “chose” that spot on the concrete.

But anyone who’s worked with addiction knows: executive function is gone. This isn’t freedom. It’s collapse. It’s what neurologists and psychiatrists would recognize as profound impairment masquerading as autonomy.

Why the System Fails And Why It’s Not Just a “Homelessness Issue”

Homelessness is often talked about as a housing issue. And housing is crucial but what we’re really seeing is a public health crisis.

It’s a crisis of untreated mental illness, unmanaged addiction, and unmet medical needs colliding with broken systems.

Right now, someone can:

• Be too sick to live independently,

• Not sick enough to meet legal thresholds for involuntary care,

• Not criminal enough to be jailed,

• And not lucky enough to have family or resources to intervene.

They live and die in the gray zone.

The Revolving Door We All Know

Here's the cycle:

1. A person overdoses or causes a public disturbance.

2. They’re taken to an ER or jail and briefly stabilized.

3. They’re offered voluntary treatment but often refused.

4. They’re discharged or released "against medical advice" (AMA)

5. They return to the street.

Clinicians call it the "revolving door.” Outreach workers call it burnout. Families call it despair.

And the human "being"? They call it survival.

Is There Another Way?

Yes. Some cities and states are trying to build something better, humane systems of protective care that intervene before someone dies, but without resorting to criminalization.

Examples of emerging models:

• CARE Courts (California): Court-mandated treatment plans for people with severe mental illness or addiction, combining accountability with housing and medical care.

• Assisted Outpatient Treatment (AOT): Allows courts to order treatment while the person remains in the community, often with intensive wraparound support.

• Medical Respite and Stabilization Units: Low-barrier facilities that provide weeks or months of medical, psychiatric, and addiction care — not just overnight shelter.

• Expanded Conservatorships: Some counties are pushing to redefine “grave disability” to include repeated, dangerous self-neglect.

These models aren’t perfect. But they’re real attempts to solve what many of us feel in our bones: People should not be free to die slowly in public while the system stands by.

Why the Medical Voice Matters

As physicians and healthcare workers, we’re often the only ones who see these patients at their worst and yet, with our hands tied.

But we also have power:

• To document dangerous self-neglect clearly and compassionately.

• To advocate for expanded criteria for care.

• To work across systems — with courts, housing programs, mental health teams — and create bridges.

• To lead with both evidence and empathy.

We are not powerless. But we are often too siloed. (multiple well-intended organizations locked into grant funding criteria)

So, What Does “Solving Homelessness” Actually Look Like?

Let’s be clear: there’s no silver bullet. But here’s what the most successful models have in common:

1. Housing First — but not housing only.

2. Integrated Care — medical, psychiatric, addiction, and social services in one place.

3. Low Barrier, High Support — accepting people as they are, but helping them move forward.

4. Structured Compassion — not punitive, but not passive either.

5. Accountability with dignity — court-backed when needed, voluntary when possible, always humane.

In Houston, San Antonio, and even cities abroad like Helsinki, this model has been proven to work. It’s not theory. It’s policy backed by willpower and outcomes.

A Final Ethical Reckoning

One colleague once said, “We have a structured system for stray animals. But for human beings who are addicted, psychotic, and dying in public we call it freedom.”

That’s not just heartbreaking. It’s ethically untenable.

No, we shouldn’t build “human pounds.” But we can and must build humane protective systems where care is the goal, not control. Where rights are respected, but harm is not ignored. Where people can rebuild not just survive.

Because the real tragedy isn’t that people are “too far gone.”

It’s that our system is too far behind.

Closing Thought

To solve homelessness, we must stop seeing it as a single issue and start treating it as the complex, systemic failure it is. And more than that: as the moral test of our time.

We have the knowledge. We have the models. What we need now is the will to act before one more person dies “free” on a sidewalk. As a learn and walk this journey, I am being redefineD, first by asking questions. Join me as we help serve and create solutions to love our neighbors as God loved us.