Is the Reasonable Control of Madness Needed for Prosperity?

Prosperity has many potential definitions. But if we read the concept broadly, as a state of happiness and contentment and not merely as the economic accumulation of things and experiences, then other kinds of ideas and policy concerns might boil to the surface.

I feel I need to say this at the outset because I’ve realized the common thread through this month’s post is madness, a fraught subject not typically associated with urban economics or planning or architecture. But madness is a topic very much associated with social theory. It was the core concern, after all, of Michel Foucalt’s PhD dissertation and first major book. How society treats people with severe mental health problems is also a topic intimately and profoundly associated with the possibility for social and family happiness, as this eloquent webpage from the Early Assessment and Support Alliance suggests. 

But I’m an urban policy guy and a school teacher, not a health care person. So here I’ll be interested in recent coverage of mental health related policy debates that affect cities; in particular, debates about mental illness and homelessness, the fentanyl epidemic, and our disordered national ideation around guns. The common preoccupation here is this: what can be done at the policy level to set boundaries around the negative social effects of madness and the supply of the technologies that can induce it?

CARE Courts – Is There Enough Institutional and Legal Support?

The article that truly got me thinking about madness as a theme was this cover piece for the May 2023 issue of The Atlantic, by Jonathan Rosen. I almost didn’t read the article, because it seemed just too sad, and I’m not going to try to recap it here. Rosen’s writing is too personal. But I’m glad I read the story, and you should read it too. The piece feels as essential as it is melancholic, somehow condensing decades of national debate about mental health into the biography of the author’s brilliant but troubled childhood friend. But this is not merely a history or a winding personal tale. Rosen has an obvious and central policy preoccupation: the question of involuntary treatment (including hospitalization) for the severely mentally ill.

Lurking in the background to this central preoccupation, and probably in the background to The Atlantic’s decision to feature this particular article on the cover, are a variety of new policy initiatives that could give governments more ability to force people into care. Prominent among these is Governor Newsom’s CARE Courts initiative here in California. Rosen mentions CARE Courts multiple times, and assures his readers that this initiative “will bring about only incremental changes.”

Perhaps. Though an admitted non-expert, it sure looks to me like the changes that could be brought about by CARE Courts are a very big deal, even if they are in fact incremental, as Rosen asserts. What are CARE Courts? According to this helpful explainer through Cal Matters, the CARE Court initiative would allow people ranging from family members to first responders to “petition a civil court to create a court-ordered care plan for people who meet specific criteria.” This language seems anodyne on first reading, but consider the meaning of the words. The State is saying that it wants the court system to take direct responsibility to manage certain people’s mental health. 

Meanwhile it’s not at all clear that already overburdened courts and local governments will be up for this responsiblity. Consider this related Cal Matters piece, which states that “there’s a desert of options” for people put on conservatorships in California, which would be one possible result for people pushed into CARE Courts. Does California have a real plan to care for these people, given the well documented potential for conservator abuse? Or consider this long episode of KCRW’s Greater LA podcast on local governments’ race to meet the “staggering” need among homeless mentally ill as CARE Courts roll out. Among the many practical issues raised: where will the lawyers come from to represent mentally ill people in these courts?

But still. Despite the concerns, the need out there is truly staggering. We’ve allowed too many mentally ill people to simply languish on the streets, a good result for no-one. According to this RAND Corporation report, a program analogous to the CARE Courts initiative in Allegheny County, Pennsylvania has resulted in reduced jail costs. While this is seemingly only a technical research finding, it is also a reminder that current hands-off policies toward the unhoused mentally ill have effects too, among them the fact that county jails now serve as mental hospitals of last resort. A non-policy is a policy too.

The Least of Us: A Short Review

In my last post I expressed admiration for a Washington Post article by author Sam Quinones. I admired Quinones’ writing enough, it turns out, to purchase his recent book The Least of Us: True Tales of America in the Time of Fentanyl and Meth.

The book is full of the same kind of punchy prose on display in the Post article. Despite the beautiful writing, however, be prepared. At times the book’s narrative pushes across the tricky boundary between kaleidoscopic and meandering, as this New York Times Review suggests. This lack of narrative focus is too bad, because I think Quinones builds an interesting if implicit background case for a non-trendy policy approach focused on reducing drug supply.

The core of this implicit argument, at least as I piece it out from the books’ disparate threads, is as follows. We have a giant new mental health (and criminal justice) problem connected to a drug of addiction that, says Quinones, “can stifle our most basic instinct for survival.” This drug, fentanyl, was invented in the 1960s by brilliant Belgian chemist Paul Janssen, a man who also invented scores or other crucial drugs, from antifungals (ketoconazole) to antipsychotics (haloperidol), to antidiarrheals (loperamide). According to Quinones, Janssen “knew fentanyl’s potential for abuse,” and “would allow fentanyl to be provided only to anesthesiologists, only in liquid supply, and only as liquid sealed in glass vials.”  The drug right away made heart surgery much safer and less painful. It is widely and safely used for a variety of purposes in hospital settings today.

But, as we all know, fentanyl is used in non-regulated settings as well. Fast forward to the 1970s and, according to Quinones, Janssen Pharmaceutica had already transferred the technology to make fentanyl to China. Fast forward again to the 2010s, and Quinones states that a single Shanghai based firm under the online name “Gordon Jin” was able to transfer “kilograms of fentanyl, its analogues, and other synthetic drugs—of its own manufacture—through the mail to two dozen countries and thirty-five American states.” People began to die in large numbers as drug dealers mixed the new drug in “Magic Bullet” blenders, catering to people already addicted to opioids like Oxycontin through years of aggressive, largely unregulated, marketing by US drug companies, especially Purdue Pharma and the Sackler family. Mexican drug cartels got in on the fentanyl action. So did others. Fast forward again to 2020 and even an Orange County twenty-something named Wyatt Pasek was able to sell enough candy colored pills laced with fentanyl to drive a Rolls Royce, “hobnob with celebrities he won’t name,” and post Instagram photos of “himself bathing in a tub of cash.”

In other words, Quinones seems to be telling us, we have an enormously addictive drug that is cheap to make, given the right know-how. We have malign criminal actors happy to exploit the situation even as people die in escalating numbers, and foreign governments willing to wink at these criminal actors, much as the US government once winked at Purdue. Add to this the fact that the world has never had a shortage of profoundly selfish individuals like the aforementioned Wyatt Pasek, now “doing seventeen years in federal prison,” Quinones tells us, and we have a true disaster on our hands.

As I mentioned in my previous post, Quinones would love to somehow interdict chemical ingredients for fentanyl from China before they enter Mexican ports, disrupting fentanyl supply at the source. Whether this is even possible I have no idea. I have my doubts, although clearly I’m attracted to the notion. A place in me would like to believe the US and Mexican governments could one day work together that effectively, and that supply-side approaches to dealing with the collective madness of fentanyl addiction could work effectively along with demand-side programs such as as Hawaii’s Opportunity Probation with Enforcement initiative.

Guns and Other Ambient Madnesses

We see madness in many domains of life, not just in drug addicts or people living with severe mental illness on the streets. With the abandonment of faith in government and civic institutions, it feels like the generalized sense of madness in society is increasing. Regular readers will know that I believe our national thinking on firearms so disordered in the US as to constitute a kind of collective mental illness. When I walked out of the house yesterday, I encountered the police scene on display in the photograph below. A troubled man was holed up in a pleasant home, possibly with an AR-15, the police thought. They had reason to think so. Such monstrous weapons are everywhere. I am with Washington Post columnist Christine Emba on questioning why anyone would need such a weapon for protection, except perhaps, as a gun loving friend of mine one told me, for protection for the time when the government comes to take away the guns. This kind of thinking is circular, of course. It is apocalyptic. It is so distrustful of democratic institutions as to amount to little more than nihilism. It is straight up crazy. It is everywhere.

To sum up I want to return to the conceptual frame of supply and demand. I’m attracted to Quinones’ “supply side” analysis of the fentanyl crisis, as I tried to explain at length above. The fentanyl issue truly strikes me as analogous to the absurd oversupply of firearms in US society, where we now face a situation in which there are more guns than people. Supply itself is creating contagion around both synthetic drugs and guns.

By contrast, inadequate supply of public services is a concern when it comes to topic I started with, CARE Courts. Whether the State and counties are able to provide adequate legal representation for people affected by severe mental illness, much less an adequate supply of trained mental health professionals, is an open question. This will remain a crucial policy issue over the next year or more as CARE Courts roll out across California.