If you walk through the Tenderloin neighborhood of San Francisco, Skid Row and Venice Beach of Los Angeles, and the Blade in Seattle, you’ll witness people of all ages and races injecting and smoking meth, cocaine, heroin, and fentanyl on the sidewalk. You’ll see large homeless encampments, prostitution, and violence. In Venice Beach, tent fires are common as is assault and theft. Neighborhoods like these are what Europeans call “open air drug scenes.”

Ending these drug scenes would reduce crime, drug use, and homeless encampments. Fortunately, there are many examples of cities successfully abolishing open air drug scenes. In Amsterdam, police and social workers broke up the open air drug scene in the then-dilapidated neighborhood of Zeedijk by offering social services and enforcing the law. Social workers extended methadone, treatment, and shelter, while police ticketed drug users who were using in groups. When these users did not pay their tickets, they were arrested and given a choice between a drug treatment plan or incarceration. Today, Zeedijk is a beautiful and thriving mixed-income neighborhood. Lisbon, Frankfurt, Vienna, and Zurich also used police and social services to end open air drug scenes.

New York used smarter policing to end the infamous open air drug scene in Times Square in the 1990s, which helped reduce drug-related killings by 90 percent. Increased police presence has been shown to deter crime in a way that longer prison sentences have not. In High Point, North Carolina, police targeted three neighborhoods with open crack cocaine dealing. They sat down with the dealers and showed the extensive evidence they had gathered of the their crimes. The police officers offered job training, tattoo removal, and social services to help the dealers restart their lives as an alternative to jail. These interventions broke up the open drug market in ways previous arrests over decades had not. Philadelphia and Seattle have also had some success in breaking up open air drug scenes.

California needs a new, statewide agency to tackle the problems of homelessness, drug addiction, and untreated severe mental illness. Call it Cal-Psych. Cal-Psych would serve these populations and get them off the streets through new policies and assertive social workers with “whatever it takes” mandates. 

One-third of the homeless have severe mental illness and the severely mentally ill are ten times more likely to be in prison than in state mental hospitals. This is a humanitarian crisis. Cal-Psych would be responsible for procuring the psychiatric beds needed for the severely mentally ill to get treatment. Cal-Psych would also be responsible for implementing an expanded use of assisted outpatient treatment and conservatorship, which mandate medical treatment. Many severely mentally ill individuals require mandatory treatment to be healthy. Cal-Psych caseworkers would have enough funding to provide the support that their clients need. They would know if their clients had stopped taking medication, were back on the street, or had committed a crime. Cal-Psych would have mobile units capable of performing on-the-spot psychiatric evaluations and enrollment in treatment programs. 

Because a large number of the homeless are addicted to drugs, Cal-Psych social workers would coordinate with law enforcement to break up open air drug scenes like those in the Tenderloin and Skid Row. Cal-Psych would secure and manage expanded, on-demand drug treatment. Every time someone has overdosed and survived, Cal-Psych workers would be able to connect that person to treatment. And residential drug treatment would be longer so that people in recovery are not released back into the world right when their cravings are peaking. Addicts who have committed nuisance crimes or crimes to feed their addictions would be offered drug treatment as an alternative to jail, and Cal-Psych would provide case workers who can support people in treatment. 

There are models of effective and humane responses to the mentally ill and street addicts in the U.S. Arizona and Texas have police officers trained to handle mental health calls. They track down people who have violated court orders for treatment. They check in on people. They often have social workers with them. Crucially, their status allows them to handle people who might be in a violent, psychotic state, which social workers are usually not equipped to handle.

Cal-Psych would also manage housing for the homeless. It would be responsible for ensuring every Californian has a right to shelter by buying and building the shelters and housing necessary to get the homeless inside. As part of treatment programs for the severely mentally ill and the drug-addicted, Cal-Psych case workers would be able to offer housing on a contingency basis to their clients, meaning that clients would only receive housing if they met preconditions like taking medication or sobriety. This approach has been shown to be effective at housing individuals and improving their health outcomes. Purchasing residential homes and converting Project Roomkey hotels into contingent housing would be a first step. The governor could issue state-of-emergency declarations to acquire shelters and housing for Cal-Psych.

Cal-Psych would be statewide because many of the homeless are mobile and move across counties. When this happens, they shouldn’t lose their case workers or access to programs. Localities have also widely failed to address the homelessness crisis and the state has more buying power and capacity to implement the needed changes. Californians themselves are so fed up that they now believe that state officials are responsible for solving homelessness as opposed to localities by a 62 to 38 percent margin. However, we would not abandon the current system overnight. We should not repeat the mistakes of the community health advocates of the 50s and 60s who closed mental hospitals without having suitable replacements. Cal-Psych would begin in just a few counties and would expand once it is successful. 

The money for Cal-Psych could come from three sources: California’s failed Mental Health Services Act, which spends little of its money on severe mental illness, Medicaid, and, over time, city and county funding currently sent to unaccountable nonprofit service providers.

Cal-Psych’s care for the homeless that truly meets their needs represents a moral, human, and technological frontier for California. If enacted, it would be arguably the most comprehensive and effective homelessness program in the country. Californians would no longer feel the shame that accompanies seeing someone in a psychotic state on the street, living in tents along the highway, or shooting up fentanyl on the sidewalk because the people who previously struggled under those conditions now have the care, incentives, and resources they need.

Californians see so many homeless individuals sleeping on the sidewalks or in encampments because the state has chosen to not build homeless shelters and instead build permanent supportive housing. This policy choice has made homelessness worse. San Francisco has expanded its permanent supportive housing from over 6,000 units in 2005 to nearly 11,000 in 2019, but saw its unsheltered homeless count rise 95 percent. Today, San Francisco has the greatest quantity of permanent supportive housing units per capita of any major city in the United States. It has twice as much as New York and three times as much as Chicago and Los Angeles, yet it still has the worst homelessness problem in the country.

Refusing to build shelters in favor of permanent supportive housing forces homeless Californians to sleep outside where they are more likely to suffer from violence, addiction, and overdose deaths. Large homeless encampments foster open air drug scenes and general disorder in our cities that hurt the homeless the most. In Venice Beach Los Angeles, fights and fires break out regularly, endangering the lives of the homeless there. And, contrary to what homeless advocates say, the homeless do want shelter. There are frequently long lines outside of shelters in San Francisco.

Housing First is the philosophy guiding San Francisco and California’s homelessness policies. Housing First holds that the only solution to homelessness is to give each homeless person a permanent place to live without preconditions. Housing First advocates believe that shelters divert spending that could be better used on housing.

The evidence does not suggest that Housing First is the best way to end homelessness. In a 14 year study, a team of Harvard researchers found that just 12 percent of the homeless placed in Housing First stayed housed after ten years. In a study widely touted by Housing First advocates, 86 percent of recipients of housing stayed housed for nearly the entire length of the two and a half year study.

But there was a twist. The Housing First intervention did not lower the rate of deaths compared to homeless people who did not have access to housing without preconditions. A study of 249 homeless people in San Francisco found that Housing First did not decrease the number of hospitalizations the homeless experienced. The National Academies of Sciences, Engineering, and Medicine published a review of the scientific literature of Housing First and found that there was little evidence that permanent supportive housing improves health outcomes, other than limited data suggesting it does so for people with HIV/AIDS.

The problem with Housing First stems from the fact that it doesn’t require that people address their mental illness and substance abuse, which are often the underlying causes of homelessness. Several studies have found that people in Housing First-type housing showed no improvement in drug use from when they were first housed. A literature review in 2009 suggested that Housing First’s harm reduction approach may actually worsen addiction. A study in Ottawa found that, while the Housing First group kept people in housing longer, the comparison group saw greater reductions in alcohol consumption, problematic drug use, and greater improvements to mental health, after two years.

The inability of Housing First to improve health and housing outcomes suggests that housing should be offered on a contingency basis, meaning that homeless individuals can only access housing if they meet requirements around drug use and/or medication.

Researchers have found ways to use housing to reduce addiction. Between 1990 and 2006, researchers in Birmingham, Alabama conducted clinical trials of abstinence-contingent housing with 644 homeless people with crack-cocaine addictions. Two-thirds of participants remained abstinent after six months, a very high rate of abstinence, compared to other treatment programs. Other studies found that around 40 percent of homeless people in abstinence-contingent housing maintained their abstinence, housing, and jobs. In a randomized controlled trial, homeless people were given furnished apartments and allowed to keep them unless they failed a drug test, at which point they were sent to stay in a shelter. Sixty-five percent of participants completed the program.

Instead of attempting to guarantee Californians a right to housing, which will likely never be realized, Californians should instead be guaranteed a right to shelter. New York City, a city with over 77,000 homeless people, has sheltered 95 percent of its homeless population. It does not suffer from the same problems of open air drug scenes and homeless encampments. California should also require the homeless to sleep in a shelter bed if they have nowhere else inside to sleep. Cities should not permit the breakdown of public order and adverse health effects of unsheltered homelessness.