An Old City Seeks a New Model
Far more important is the added treatment capacity. The waiting list for outpatient counseling--which is least in demand--has dropped to zero. Waits for methadone and inpatient programs, which account for two-thirds of slots, still range from about a week for some clinics to as much as a month for others. (Despite the citywide referral line, many people still contact programs directly.) When Beilenson makes the case for more slots, he always returns to the bottom line: The cost of treatment ranges from $3,500 a year for a methadone slot to about $35,000 a year for an inpatient slot (with a twenty-eight-day program, this would serve twelve people). Meanwhile, a drug user supporting a $50 habit might easily need to steal $300 worth of property each day. (Baltimore police estimate that fenced goods sell for one-sixth of their retail value.) That, plus the costs ranging from broken car windows to security guards to AIDS treatment to prison cells, adds up. In a finding that has been repeated elsewhere, the California Department of Health under Governor Pete Wilson followed addicts before, during and after treatment and found that every dollar spent on treatment yielded seven dollars in savings.
Which is not to say that treatment yields permanent abstinence--from either drugs or crime. University of Maryland studies have found that people in outpatient treatment programs commit crimes, on average, forty-one days a year, which seems high until it's compared with the addict population not in treatment--for whom the average is 248 days.
Schmoke says he now prefers the word "medicalization" to "decriminalization" but that his goal is still to treat "drug abuse primarily as a public health problem and not primarily as a criminal justice problem." And the refrain of the city's police commissioner, Thomas Frazier, is that "we can't arrest our way out of this problem." Still, Baltimore police have hardly laid down their arms. From 1988 to 1998, Maryland's prison population climbed from about 13,000 to more than 22,000; a significant percentage of the increase was the result of drug arrests in Baltimore. Last year city police made 90,000 arrests, 85 percent of which were for drug possession, sales or some offshoot of the drug trade.
Hundreds of those arrests came near the corner of Monroe and Fayette in West Baltimore--a corner made infamous by the recent book The Corner by David Simon and Edward Burns. A city-run needle-exchange van comes to Monroe and Fayette each week. When Beilenson took me to visit the program, we met a woman who embodied his wish for drug treatment--and his frustration. Wearing a vacant look and moving in jerk-steps, she pushed a handful of needles into a canister and picked up a package of new ones. I followed her onto the street, where Beilenson joined us. Jackie, who wanted to be known only by her first name, is 37 years old and looks twenty years older. She has five children and uses between $50 and $200 worth of heroin and cocaine a day. She's been in jail five times, for soliciting prostitution and for "boosting" (shoplifting). She spoke with evident anguish about this--about the jobs she had lost, about "what I put my parents through."
"Have you thought about getting into treatment?" I asked.
"Oh yes," she said. "If I could right this minute, yes I would. Yes I would. Next time I get the chance to get into treatment..." She trailed off. The meaning of "right this minute" was clear enough. At that moment, Jackie was in withdrawal--the low point of the addiction cycle and a time when treatment referrals can be most successful. Beilenson gave her a phone number to call, but her interest in treatment seemed unlikely to last beyond the next score.
As we drove away, Beilenson made his diagnosis: "This is the typical addict in Baltimore. In and out of jobs. Boosting. Prostituting. Did you see the yellow in her eyes? She has serious liver issues--and if she doesn't get taken care of she's going to end up very sick. What I would have liked to do is say, 'Look, we've got treatment for you. Right now. This afternoon. Here's where to go, and here's a token for a cab.'" But Baltimore can't even offer immediate care to people who are begging for treatment. Despite shorter wait lists, psychiatric hospitals report that addicts regularly feign threats of suicide or violence to gain entry. When the city added a twenty-four-hour staff to its treatment hotline, it turned out that 80 percent of after-hours calls came between 7:30 and 8 am. The morning's slots are dispensed beginning at 8 am, and the callers were trying to be first in line.
People who already want treatment, Beilenson argues, shouldn't have to compete for slots. Everyone benefits if they get off the streets as quickly as possible. But the real advantage with immediate treatment would apply to people like Jackie--people who struggle with an addiction but, in the five or ten or thirty days it takes for a slot to open, are likely to have a change of heart, switch addresses, lose their phone or even land in jail. And an ideal treatment system would go even further, cajoling people who might be amenable to treatment but who would never seek it out.