When Julio Perez, a mentally ill convicted felon, shoved Edgar Rivera in front of a subway train in late April, severing the Bronx man's legs, New Yorkers felt a sickening sense of déja vu. Several months earliereven more horriblyAndrew Goldstein, suffering from untreated schizophrenia, had hurled receptionist Kendra Webdale to her death under a city subway train. Perez and Goldstein were the latest versions of a familiar story: seriously mentally ill New Yorkers who kill or maim while not receiving proper psychiatric treatment for their illnesses.
Thirty years ago, if someone as sick as Perez or Goldstein left a New York psychiatric hospital, he did so conditionally. To stay outside, he had to continue treatment, taking whatever medication he needed. But that was before deinstitutionalization, inspired by liberationist psychiatrists R. D. Laing and Thomas Szasz, emptied New York's psychiatric hospitals; before civil libertarian lawyers made mandatory treatment next to impossible; before fiscal conservatives, to save money, began shutting down the now-vacant mental hospitals. Today, after three decades of bad policy, many other unmedicated Julio Perezes and Andrew Goldsteins roam New York's streets and subways. They pose a threat to themselves: the suicide rate for untreated schizophrenia is as high as 15 percent, and many mentally ill people meet pitiable ends living on the street. And they pose a threat to the public: the psychiatrically disabled, less than 1 percent of the U.S. population, commit 1,000 homicides a year4 to 5 percent of the nation's total. Convicted of a host of other misdemeanors and crimes, from disorderly conduct to rape, they crowd our jails and prisons.
Aware of the growing problem, 40 states now have laws that let courts order involuntary hospitalization for the seriously mentally ill who refuse medication. Only backward New York explicitly prohibits mandatory treatment. But Webdale's grisly death prompted state attorney general Eliot Spitzer to propose legislation"Kendra's Law"that would at last establish it in New York. Since then, Governor Pataki and Assembly Speaker Sheldon Silver have introduced slightly different versions of Kendra's Law into the State Legislature. Though the New York dailies have all endorsed some form of the law, the future of the billswhich predictably unleashed apocalyptic rhetoric from New York's civil liberties lobbyremains uncertain.
The truth is, New York City already tried mandatory treatment to deal with a big public health problem a few years back, and it worked wonders. During the late eighties and early nineties, rising homelessness and the AIDS epidemic helped spawn a frightening outbreak of tuberculosis in the city. TB is a scary disease, because it's highly communicable (a Milwaukee homeless man infected 45 people in just six months), and it's often lethal if it goes untreated. Public health officials had long thought they'd conquered TB, so they were unprepared for its sudden resurgence.By 1992 the city confronted three times as many tuberculosis cases as in 1977. In Central Harlem, the infection rate rocketed higher than that of many tuberculosis-plagued Third World countries. More troubling still, fewer than half of the city's tuberculosis patientsoften homeless, AIDS-afflicted, and/or suffering schizophreniacontinued the six- to 24-month treatment until cured, so that the bacteria that survived after partial treatment were tougher and harder to kill than ever in them and in those they infected. By 1991, New York City, with 3 percent of the U.S. population, buckled under 61 percent of the nation's cases of multi-drug-resistant tuberculosisa serious public health crisis.
The city moved to contain the outbreak. To fight the tougher strains, the Department of Health began to mull over legally requiring tuberculosis patients to take their medicine as prescribed. Hong Kong, Singapore, and India had used mandatory treatment to bring tuberculosis under control. Closer to home, Denver, Baltimore, and a few counties in Texas and Mississippi all required it for reluctant tuberculosis patients and were showing signs of success.
But New York City isn't Singapore. At the mere mention of mandatory treatmentno one, remember, was talking about the kind of large-scale quarantine used to contain tuberculosis in the nineteenth centurythe city's professional civil libertarians became indignant. New York Civil Liberties Union lawyer Robert Levy darkly referred to it as "a significant and potentially stigmatizing governmental intrusion on personal privacy and liberty." The civil libertarians found reinforcements in radical AIDS activists, who feared mandatory treatment would slide toward quarantine for AIDS patients. As Jeffrey Levi, then a lobbyist for the AIDS Action Council, hyperbolically asserted, "Tuberculosis provides a handy excuse for people to do with AIDS patients what they have always wanted to do. Get rid of them completely."
Yet despite the fierce early opposition, the Department of Health forged a successful coalition to revise the health code to require mandatory treatment. With their hand strengthened after the press ran several scary stories, city health officials began to mobilize health providers and educate the public. Mainstream AIDS groups, now worried that tuberculosis would strike down vulnerable AIDS patients, offered their help. Then, with the input of Levy and other civil libertarian lawyers, for once showing some common sense, the Department of Health crafted a statute incorporating reasonable due-process protectionssuch as legal representation for poor patientsthat mollified most civil libertarians. Enacted in 1992, the statute has stood impervious to legal challenge.
The city's mandatory treatment program required the enrolled patient to take his medicine as a city health worker watched. Flexibility was key: the patient could take his meds anywhere he wantedhis apartment, a clinic, a street corner, even a crack denas long as a health worker was on hand. To help draw the sick into the program, the city presented it positively, something to remember if New York begins mandatory treatment for the seriously mentally ill. Mandatory treatment, health officials stressed, was first and foremost about helping people take medication, not punishing them for not taking it. Accordingly, the city used graduated incentives. Patients could get $5 to $25 a week in fast-food coupons or transportation tokens if they took their meds under observation. Health officials also combed through public shelters and jails, looking for people sick with tuberculosis.
Even more important than incentives, however, were the threat and the reality of involuntary hospitalization. Under the amended health code, the health commissioner could order a sick person to get outpatient treatment. If he refused, the Health Department could hospitalize him in a secure tuberculosis ward. In the program's first two years, health officials issued 308 orders for forced hospitalization. The majority of the individuals for whom the city ordered hospitalization had a history of substance abuse, homelessness, or both. Most often the threat was enough. Three-quarters of those getting initial warning letters complied with treatment. Paula Fujiwara, director of the Bureau of Tuberculosis Control, explains why: "As patients discovered the city's power to detain, this served as a deterrent measure and allowed the Department of Health to use less restrictive means of ensuring adherence."
Mandatory treatment for tuberculosis has been a rousing success. In 1992, Gotham had 3,811 tuberculosis cases; by 1997 it had 1,730, a 55 percent drop. Drug-resistant cases fell even more dramatically, by 87 percent. (Other cities have had like triumphs, though none quite as dramatic.) Implementing the policy is pricey: the cost for New York's program is some $400 monthly per patient. But hospitalization, at roughly $25,000 per patient each time, is far pricier. Mandatory treatment has been so effective and affordable that 41 states now use it for tuberculosis patients who shun treatment.
Since mandatory treatment defused New York's tuberculosis crisis, why not use it for schizophrenia? The problems the two conditions present are similar, after all: each poses a potential threat to the patient and to others if not treated. Moreover, medication noncompliance rates for both diseases are nearly identicalaround 40 percent one year after regular treatment begins.
Kendra's Law takes a big step in the right direction. But there's a lot of resistance to passing it, and the same forces that oppose it are going to make it hard to implement, even if it does pass.
Civil libertarians head the list of the bill's enemies. Their intractable opposition rests on a welter of confusion. Defending its sacred ideal of individual autonomy, the NYCLU argues (and it has successfully changed state laws to reflect its view) that mandatory treatment shouldn't be used until a mentally ill individual poses a clear "danger to self or others"in other words, after the worst may have happened. But civil libertarians seem unaware that making rational choicesthe only meaning individual autonomy could sensibly haveis impossible if one's brain isn't working. (Half of the seriously psychiatrically disabled don't even know they're sick.) Indeed, rather than robbing the seriously mentally ill of autonomy, mandatory treatmentto the extent that it restores their reason through medicationhelps them achieve autonomy. Herschel Hardin, former director of the British Columbia Civil Liberties Union, understands this point clearly: "Medication can free victims from the Bastille of their psychosesand restore their dignity, their free will, and their ability to engage in a meaningful exercise of their liberties."
Moreover, as psychiatrist and social critic Charles Krauthammer observes, the civil libertarian use of dangerousness as sole criterion for mandatory treatment "is not just unfeeling, it is uncivilized." Krauthammer rightly suggests that the appropriate standard should be helplessness which our current system of mandatory nontreatment utterly ignores.
Though the NYCLU eventually endorsed mandatory treatment for tuberculosis, its refusal to consider it for schizophrenia suggests that the organization embraces the ignorant view that diseases of the brain are somehow essentially different from diseases of the lungs. Just as we once thought that malignant swamp vapors caused tuberculosis, today many still think that malignant mothers or a sick society causes schizophrenia. The first error has passed into historical obscurity, but (especially in Freudian New York City) the second lingers on. Using magnetic resonance imaging and other scientific tools, though, we now know that schizophrenia is a physical disease of the brain, not unlike, say, Parkinson's disease. Even so, for all these reasons, civil liberties lawyersas they have already publicly warnedwill use every weapon in their legal armamentarium to try to overturn Kendra's Law, if it passes, and to stymie its implementation.
The state's mental health professionals are also likely to resist Kendra's Law, if it passes. Ever fearful of being labeled "conservative," the psychiatric community resists using coercion. Arguing against mandatory treatment, Jack Guastaferro, president of the New York Association of Rehabilitative Services, states the party line: "Force is based on fear that is founded upon stigma," he blusters. He downplays Webdale's death and similar tragedies as "isolated incidents of violence." Laura Young, an official of the National Mental Health Association, is equally unyielding. "I'm not insensitive to the plight of caregivers and the families, but we can't sacrifice the rights of people with mental illness," she told the Chicago Tribune. But these advocates are insensitive to society's needs, and of course, the "rights" that they espouse cruelly harm the psychiatrically disabled whose interests they claim to represent. So we can look forward to seeing the psychiatric community resist mandatory treatment by refusing to recommend it when consulted and by taking every opportunity to condemn it.
Finally, Kendra's Law would require mental health officials to accept responsibility for mentally ill patients, and that seems to be the last thing these bureaucrats want. The contrast between New York City's public health officials, who used imaginative incentives to get TB patients to take medication, and New York's budget-obsessed mental health officialswho often look for ways to dump their charges into managed care, or into jails, prisons, and sheltersis glaring. Before he killed Kendra Webdale, Andrew Goldstein had voluntarily signed himself in to mental hospitals 13 times over a two-year period; each timedespite a history of violent attacks on strangers and hospital personnel when he went off his medicationhe was remedicated and cavalierly discharged, usually after a few days, to return to his grim basement apartment with little or no supervision.
Accepting responsibility doesn't mean filling psychiatric hospitals with new patientswith proper medication, taken correctly, the majority of severely mentally ill people can live in the community. But it will require a big shift in institutional culture. Mandatory treatment, by ordering the mental health system to treat the seriously mentally ill rather than disown them, will encourage that shift.
None of these obstacles blocking mandatory treatment is immovable. What may help push them is that psychiatric treatment with some form of coercion has gotten good results elsewhere in the United States. In states that have it, mandatory treatment has decreased psychiatric hospitalizations dramatically. In Ohio, for example, psychiatric hospitalization fell from 1.5 to 0.4 yearly admissions per patient; in Iowa, from 1.3 to 0.3; and in Washington, D.C., from 1.81 to 0.95.
New York State allowed a tiny mandatory-treatment pilot program to set sail in 1995 at Gotham's Bellevue Hospital. The results are promising: among 152 patients treated and discharged, those threatened with mandatory treatment were more likely to take their medicationand they spent 57 percent less time rehospitalizedthan control patients who weren't threatened. Civil libertarians had so gutted the coercive aspects of the pilot program that not a single patient actually wound up rehospitalized for failure to comply with treatment. The experiment worked because participants believed that rehospitalization awaited if they stopped taking their medicine.
Mandatory treatment isn't the whole answer to the problems of the mentally ill. They still suffer inadequate housing and disorganized services. But to help New York avoid more tragedies like those that befell Edgar Rivera and Kendra Webdaleand to help the psychiatrically disabled live better livesKendra's Law is just as crucial as mandatory treatment was in ending the TB epidemic.