#40: The City of Palliative Care
Where the rational drug addict goes to die
I recently read a sad story about a mother moving to San Francisco to rescue her fentanyl-addicted daughter. But the daughter ultimately wouldn’t leave. This is the money quote:
“The city is way too easy for people with nothing to get by,” she said. “That’s why I’m still here nine years later. You get by with doing drugs and suffer no consequences. I like it here.”
The bitter joke of the story is that in San Francisco, the mother works full-time, drains her savings, but still can’t make ends meet and is forced to move away.1 Meanwhile, her daughter has lived on the streets for nine years – in an ironically carefree and stable state.
The stability of being homeless in California, particularly in San Francisco, is remarkable. The quality of social safety nets lets the homeless get by, but those same social programs appear ineffective at actually getting the homeless off the streets – which is very frequently intertwined with getting them off drugs. The article mentioned that “of the 4,000 homeless people who lived in hotels at any point during the pandemic, only 10 moved into residential drug treatment programs”.2
San Francisco now has a billion-dollar budget for servicing the homeless – over $100,000 per person – but it appears unable to actually remedy the situation. For all the money spent, the city is woefully missing success stories, lives turned around, evidence that the approach works.
The fentanyl-addicted daughter of the story suggests a reason why: actually, her life is… okay. Not good, but it’s stable. Most critically, it is obvious that any change would be for the worse. This is what some economists call rational addiction. Drugs feel good, there’s not really any further to fall, and getting clean from hard drugs is awful. Especially given the unspeakably horrible ordeal of overcoming withdrawal from meth or fentanyl, there has to be a serious incentive to get clean – the other side of life has to look much better, otherwise it just isn’t worth it.
But frankly, the other side of life doesn’t look a great deal better. Consider the mother: working very, very hard in menial, unstable jobs, and still not making ends meet. The idea of slaving away all day, seven days a week, just to barely make rent for forty years, is horrendously unappealing. Trying to live in San Francisco as an honest citizen, flipping burgers or whatever to scrape by, is a game that is just not worth playing. Especially as a decade-plus drug addict with zero marketable skills or experience, I get why the daughter of the story doesn’t even bother. There’s little incentive to get clean, but there’s also little existential pressure: between city programs and shoplifting, she’s mostly taken care of.
And so the homeless accumulate in San Francisco, living day-to-day in an unfortunate, but stable state. It is not a truly stable state, of course: there are thousands of overdoses, and over a hundred die every year. It is a stable, managed, slow death.
In that sense, the great tragedy of the Californian homeless system is that it’s palliative care. The intentions may be noble, but it is effectively end-of-life comfort. The daughter of the article has lived on the streets as a drug addict for nine years. On average, over the past nine years, she has received $632,000 of care.3 A staggering sum. And she will obviously die in the next few years. By her own account, she estimated having overdosed fifty times.4 She likely has sepsis on her leg, and she is refusing to go to the hospital. The level of human and financial waste here is beyond words, and it is all the more tragic because everyone knows where this person is going to go. Dare I say it: if $632,000 hasn’t fixed the problem, more money won’t help.
San Francisco runs the world’s most expensive palliative care program:5 move here. We will spend unthinkable sums of money supporting the collective fiction that you are “getting better” while you are slowly, inevitably, circling the drain. Don’t get me wrong – I am not condemning the humanitarian efforts or intentions of the government of San Francisco. I am pointing out that the government has inadvertently created a thing of immense cruelty: this is a system that takes in people and slowly, but surely, kills them. That’s it. It appears largely unsuccessful at rehabilitation. You may argue that all the spend enables these people to live longer, but enabling a few years of survival on the streets while addicted to fentanyl is a (delayed) death sentence all the same. To quote the story one more time:
“People don’t come here to live. They come here to die.”
This essay first appeared on my website. Follow me on Twitter.
Rephrased for brevity.
To get to this number, I averaged the number of annual homeless in San Francisco since 2013, which is 6,864, and averaged the city’s homeless budgets from 2016 through 2023 (I could not find prior budgets), which is $486 million per year. That’s $632,000 per homeless person per year.
There’s a great part of the article where she describes the bliss of a near-fatal overdose. It underscores the tragedy of the stable state: the introduction of Narcan and other medical aides to mitigate an overdose have made larger, more powerful highs… safer. Addicts now need to practice even less caution. While Narcan & co are obviously saving lives and cannot be rescinded, it feels like there’s something perverse about these emergency solutions further enabling the problem.
It’s actually reminiscent of regular American healthcare, where end-of-life care has similar ballooning, crazy expenses: tens of thousands of dollars to extend a life by just another day. And people pay them unquestioningly. (This is absurd, of course: you should retire one day earlier and live that day in good health, rather than trying to tack on the pitiful last day at the very end, “living” in misery wired up to IVs.)