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Why Are Insane Asylums the Model for Human Services?

We're stuck in a 19th-century model that costs too much and doesn't serve anybody well. Rather than cut, cut, cut, we need to redefine the way we deliver services to bring them into the 21st century.

Abandoned psychiatric hospital in New York. Human services emerged in their current forms early in the 19th century. (Photo: Shutterstock)
The three intertwined crises we now face — the coronavirus pandemic, the conflict over racial equity and the plummeting economy — have exposed our public institutions, ranging from education to health care to nursing homes, as outdated and inadequate to the present challenges. With government revenues plunging across the country, most see their only choice as cutting programs — with little if any fat left to cut — which will only exacerbate these other crises.

There is an alternative. And that is to rethink how the public sector delivers human services, which account for roughly two-thirds of public spending at all levels of government. The only way state and local governments will survive the current challenge is not to slash programs, but rather to redefine their entire human-services model for the 21st century. Those that do the most in this regard, and do it the quickest, will be the ones that do the best.

In large part, the problem is our reliance on large physical institutions for the delivery of almost all public services. Virtually all institutional settings have been implicated in and contributed to the current crises. For example:

• The first major hot spots for the spread of the coronavirus were nursing homes, which continue to be epicenters of the outbreak.

• Hospitals, of course, have become major disease vectors themselves and are now taxed to capacity in areas experiencing the most virulent outbreaks, such as Phoenix and Miami.

• Schools were shut down almost immediately across the country, and we are now engaged in a great nationwide debate as to if, when and how they can reopen.

• Offenders are being released from prisons across the country to stop the uncontrolled spread of the virus within their walls.

Most such institutions also are highly implicated in the debate over racial equity:

• Public education has always has been inequitably provided and funded, and racial disparities have worsened dramatically with the sudden shift to distance learning. High-speed internet access is essential if your entire education has been moved online, but roughly one-seventh of households with school-age children lack such a connection, and that share rises to one in three for the 40 percent of such households with incomes below $50,000. It's even higher for poorer families, African Americans, Latinos and those in rural areas. Such families also are likely to lack a home computer adequate to the task of online learning.

• Health disparities and access to medical care, including in emergency settings, are strongly correlated to race, as the higher death rates from COVID-19 among African Americans have laid bare. Similar racial disparities are prevalent in every other area of human services, from child care and early childhood education to nursing homes.

• There is, of course, one area where people of color are treated to far higher levels of government attention: the criminal justice system. Those subject to the wildfire spread of the virus in confinement are disproportionately Black.

And now the economic downturn is coming for all such services like the grim reaper. State governments are looking at severe revenue losses — and, inevitably, budget cuts — in the neighborhood of 25 percent for the 2020-21 fiscal year. North Carolina's public university system is looking at budget cuts as deep as 50 percent. Local governments and school districts will be slightly insulated at first because property taxes lag other revenue declines, but by next year they will be in severe distress as well.

And what is the general governmental response to these looming deficits? To cut services, of course. Even state funding for primary and secondary schools, usually an untouchable even in such crises, is beginning to be slashed, and how could it be otherwise? We have spent decades hollowing out most public services: What is left to eliminate?

What's important to realize is that all these services emerged in their current forms early in the 19th century. It started with the "insane asylum," which at the time was actually conceived as a humane advance over prior systems of neglect. This became the model for the treatment of all social maladies, from violent offending to simply being poor or left an orphan. The solution to every ill turned out to be to construct an imposing and dehumanizing building, cram as many people inside it for as long as possible, ruin their lives and then release them into society. (When I have given talks on this subject, the teachers in the audience invariably interject that this applies to schools as well.) The basis of how we address crime, mental and physical health, poverty, child welfare, schooling and even the warehousing of our elderly is, then, literally insanity.

The asylum model itself — as well as poorhouses, orphanages and prisons — was derived in turn from that dominant institution of the era: the factory. But thinking of people as factory inputs and outputs is inherently dehumanizing.

It is also outdated. We now know better how to address these challenges and achieve better outcomes for people. The literature in all of these separate fields, developed independently, reads remarkably similarly: In all cases, we know that individually tailored efforts work better than one-size-fits-all; that real-world integration works better than cloistered institutionalization; that continued support and "aftercare" work better than simply dropping people at some predetermined end-point; that sticks are rarely effective without carrots; and that, as your grandmother might have told you, an ounce of prevention is worth a pound of cure. The dispersed and ubiquitous technologies that define our age make all of this — from community corrections to urgent-care centers, and from hybrid learning to home care for the elderly — much more practicable and effective.

And here's the irony: Doing virtually everything we ask government to do better would also mean doing it cheaper. We don't need to be cutting public services: We need to be modernizing them.

As I've written before, everything from how we handle criminal corrections to how we serve the children in our midst most in need would be improved if we invested in individualized solutions, more modern and competitive systems, and preventing crime and recidivism, poverty, ignorance, family disintegration, mental illness and chronic health disparities, instead of simply mopping up after them — if not, indeed, sweeping them under the rug.

This would also better address the multiple threats now facing our state, local and — if anyone there were paying attention — federal governments: an abandoned public health infrastructure, a shuttered education system, the isolation of our seniors, breakdowns in public order and a collapse of public resources in which a further turn to austerity will only worsen all the other problems.

How do we solve this spiraling free-fall of public budgets and public services? Not by cutting government spending. Not by bloating it. But by fundamentally rethinking it and bringing it into the 21st century, and doing so as soon as possible.

Governing's opinion columns reflect the views of their authors and not necessarily those of Governing's editors or management.

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