Most vulnerable

So-called right-to-life activists -- opponents of abortion and advocates for keeping terminally ill people without cerebral cortexes metabolizing by means of artificial life support -- are fond of saying that "Society is judged by how it treats its most vulnerable citizens." Okay, if that's what y'all believe, consider this.

The Center for Studying Health Systems Change, with funding from the Robert Wood Johnson Foundation, has been conducting the Community Tracking Study since 1996. This is a largely qualitative, longitudinal study of 12 local health care markets around the U.S. Results of their latest round of interviews, site visits and data aggregation are reported in Health Affairs by Robert Hurley, Hoangmai PHam, and Gary Claxton, and this one is free. (

There is a lot in here that ought to trouble us, but I'll just focus on mental health. As our readers know, I'm a skeptic about a lot of the diagnostic labelling in psychiatry, its reductionist approaches to treatment, and the confusion between individual pathology and social injustice. Nevertheless, there really are people with really real mental illnesses that render them largely helpless and cause great suffering. According to Hurley, et al:

Public mental health services have been severely affected by state budget distress, since so much of this care is funded by state funds and federal block grants that have not increased to meet growing costs. In virtually every site, observers portray public mental health systems’ ability to care for people with chronic mental illnesses as being in serious decline and disarray. Homeless shelters and local jails are characterized as the twenty-first-century versions of the state mental hospital of fifty years ago. Many general hospitals have phased out inpatient psychiatric units because, they contend, they lose too much money serving publicly or unsponsored patients.

There is also a severe shortage of emergency mental health services, and community mental health providers are unable to meet the need and must turn away all but the most severely mentally ill. Let's not forget that Mr. Bush took office promising to "reform" the mental health system. He was actually talking about screening 100% of the population for mental disorders and he appointed the so-called "New Freedom Commission" to recommend ways of providing integrated, comprehensive mental health services to everyone who needs them. As we now know, this was really just part of an effort to sell more psych-meds, but it didn't even accomplish that because they never had any intention of actually spending money to do something about the problem.

Of course, we are wasting public money, not saving it, by warehousing mentally ill people in prisons and cycling severely ill people in and out of acute care hospitals. But it's not about money anyway. It's about whether we want to live in a decent, ethical society.