COVID-19: Scary Graphics

Posted Posted in Brain Science, Continuing Education, Elder Care, Homestudy, Seminars, Webinars

By Mary O’Brien, M.D.

Quick.  What’s the clinical definition of a “spike”?  You’re not sure, are you.  Don’t feel bad.  No one knows what the clinical definition of a “spike” is.  But the all-knowing bureaucrats and media types toss the word around with abandon.  It serves their purpose, which is to keep as many people as possible afraid and, therefore, controlled, especially in the age of COVID-19.

If you were fortunate enough to have had a good education and some training in critical thinking, you know you must define your terms. It’s the essential starting point for any serious discussion or debate.  You cannot make up terms or definitions on a whim.  This, of course, is distressing to those who worship their notions and emotions. Today, that means millions of people. Reality (or a “spike,”) is whatever people say it is.

Announcing that “the country is seeing a worrisome spike in COVID-19 cases” is misleading.  Defining the terms is not only critical for any measure of professional or intellectual integrity, it is essential for a prudent response.  Sadly, in far too many cases, a lack of intellectual integrity can be easily used to promote paranoia.  Today, nearly anyone can create scary graphics splashed with “worrywart red” ink.  This is done routinely to exaggerate the threat of anything from a virus to a thunderstorm.  Be afraid. Be very, very afraid.

No. Do not be afraid.  Understand what is happening:

  • There is exponentially more testing being done now compared with six weeks ago (as of late June 2020).
  • The criteria for COVID-19 testing have evolved tremendously over the past three months.In March, elderly people with obvious respiratory symptoms were told to stay at home and avoid the emergency room.  They were advised they did not need to be tested.  Today, in much of the country, many people can be tested on demand.
  • Greater numbers of young people are being tested.Naturally, more positive tests will be reported.  Most of these individuals are asymptomatic and will remain so.  Consider this — no one could walk into a clinic or makeshift roadside testing site and simply demand a test for flu, strep, hepatitis, or mono because he or she felt like it.  Medically speaking, what’s going on now is odd.
  • Deaths from COVID-19 have declined by 40% across the U.S. over the last two weeks.This is crucial for understanding what is really happening.  The mortality rate for COVID-19 here is around 0.05% (and probably lower).  Contrast this with what we were told initially.  Italy had a mortality rate around 10-11% and in the U.S. we expected a mortality rate between 3-4%.  That’s quite a difference.
  • Our focus should not be on the number of positive tests, but on hospitalization and mortality rates.There will be regional fluctuations in both.

COVID-19 is new.  Patterns of transmission, virulence, and regional penetrance will change gradually.  Our understanding of the best ways to treat seriously ill patients will change.  This has happened throughout history.  For now, don’t overreact to “worrywart red” on TV graphics.  Steady as she goes, America.  Steady as she goes.

 

Help for the Helpers on the Frontlines of COVID-19

Posted Posted in Brain Science, Continuing Education, Elder Care, Pain, Psychology, Seminars, Webinars

By Dr. Jennifer L. Abel

Many healthcare workers on the COVID-19 frontlines are overwhelmed and traumatized. In addition to putting your lives on the line, many of you are quarantined from your family and some have insufficient PPE. Many are having to make multiple difficult decisions daily and have see an unprecedented number of people suffer and die; sometimes even colleagues.

You are amazing! You are also human! So, it is crucial that you express your emotions: cry in the restroom, cry on the way home, go outside for 10 minutes to shed tears or blow off steam. Angry at a co-worker, administrator, or politician? Pay attention to your driving, but imagine they are in the passenger seat and express your feelings.

Keeping your body relaxed is very important to help with immune function and to survive emotionally.  “How can I possibly relax? I have no time and am way too stressed to relax” are common thoughts on the front lines of COVID-19. Fortunately, relaxation strategies need not take any time at all and can be done without stopping your work activity. Test it out! Because most of you are standing or walking most of the day, stand or walk now while engaging in your favorite strategy simultaneously. Now pretend. Go through the motions of a common work activity while engaging in your strategy. The exception is you can’t do breathing strategies while talking.

It’s easy to get distracted and forget to use your coping strategies. Try to get into the habit of using strategies every time a machine starts beeping, each time you switch rooms, someone calls your name, or when you change tasks. Put up sticky note reminders when possible. Change the wallpaper on your phone or change the ringtone and text-tones. Each time you experience the reminder, engage in your strategy.

No doubt you’re exhausted. When you experience one of your reminders, ask yourself “do I need all this energy” or “what’s the least amount of energy I can use while doing this procedure? Writing notes? Walking down the hall?” Follow with your favorite word, like soft, loose, or relaxed.

People in helping professions are great at taking care of others, but aren’t nearly as good at taking care of themselves. Now is the time for you to finally ask for what you need, or even want, from others. And take time to self-nurture.

I heard today that people wearing scrubs are being discriminated against out of fear they’re carrying the virus. Some have been mugged or antagonized because they are known to have a job. Please know that the majority of us, not just patients and their families, are very appreciative of your sacrifices.  Know in your heart that having a purpose is a positive predictor of happiness, even though you probably aren’t feeling particularly happy right now. Similarly remember that even when you feel helpless, you are still helping!

Thank you very much for all the help you are providing, especially if you are putting your life at risk and/or isolating from your family to help!


Dr. Jennifer L. Abel is an expert in worry and the author of three books and two card decks including Resistant Anxiety, Worry, & Panic.

COVID-19: Clinical Observations

Posted Posted in Brain Science, Continuing Education, Elder Care, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

Every new illness brings new knowledge. Global experience with COVID-19 is revealing patterns of clinical illness which will guide our approach to treatment. Here are some of those important observations:

  • The illness in 80% of people causes mild symptoms. Many people remain completely asymptomatic. Moderate and severe illness often has two phases. Days 1‒7 are characterized by fever (above 101° F), headache, significant cough, profound fatigue, myalgias, and malaise. Between days 4‒8 some patients have nausea, vomiting, abdominal pain, and/or diarrhea. Some patients lose their sense of taste and smell. Days 8‒21 are characterized (in 15‒20% of patients) by increasingly severe symptoms, including shortness of breath, dyspnea or difficulty breathing, chest pain or tightness, tachycardia and weakness.
  • The mean interval between onset of symptoms and hospitalization is 9.1‒12.5 days. This delay in the progression to serious illness may give us a window of opportunity for treatment.
  • Clinical findings typically include a low oxygen saturation level (O2 sat) on room air. This is a key finding and levels as low as 75‒90% are being seen (95‒100% is normal).
  • Laboratory results also show patterns similar to what was observed with SARS and MERS:

o   ↓ WBC or leukopenia

o   ↓ Platelet count or thrombocytopenia

o   ↑ Liver enzymes, especially LDH around hospital days 5‒8

o   CXR typically shows streaky opacities in both lungs consistent with an atypical pneumonia.

  • Serious complications of COVID-19 include severe viral pneumonia, ARDS (Adult Respiratory Distress Syndrome) respiratory failure, cardiac injury including arrhythmias and CHF. Poor perfusion can lead to hepato-renal syndrome. Neurologic symptoms, delirium, and coma may occur.
  • There is evidence that intubation and mechanical ventilation may be causing more harm than good in some patients. One component of ventilator function, the PEEP setting (positive end-expiratory pressure) may be delivering pressures that are too high for the alveoli or air sacs in the lungs. It appears that some COVID-19 patients in respiratory distress actually need lower levels of PEEP (15‒20) as opposed to levels around 25. Some patients seem to need higher O2 concentrations delivered by face mask, CPAP or BiPAP, and not intubation and mechanical ventilation.
  • According to the CDC, two thirds of the patients who have died from COVID-19 (as of mid-April) had documented serious underlying conditions (heart disease, diabetes, asthma, renal disease, malignancy, immuno-compromise). Obesity has been a significant factor contributing to mortality. 1.9% of patients who have died had no known underlying condition.

We have only scratched the surface here. The next few weeks will reveal new insights about the illness itself and the best treatment protocols. In the meantime, do what is prudent to protect yourself and others. It may not be obvious to everyone, but tremendous progress is being made.

Blessings to all through Passover and Easter.

 

Novel Coronavirus (COVID-19): Lessons Learned

Posted Posted in Brain Science, Continuing Education, Homestudy, Psychology

We are living in historic times.  A century from now, medical personnel, civil authorities, small business owners, corporate leaders, average investors, and everyday citizens will study the lessons learned from this pandemic.  Here are just a few of the ones we’ve learned already:

  • We should all plan and prepare for crisis, disaster, or catastrophe — especially in good, stable times.  Every family and business needs to build an emergency fund of 3-6 months minimum.
  • It’s important to listen to knowledgeable, wise people (not conspiracy theorists and people on social media).  However, even the most brilliant experts can be wrong.  Predictive models are not crystal balls.  There are unrecognized variables in nearly every situation.
  • Panic never solves problems.  If it did, we wouldn’t have any problems left.  The antidote to fear and panic is perspective.  Every day in the U.S., approximately 8,000 people die from multiple causes.  Each year, we lose between 30-40 thousand people from complications of the flu.  We do not shut down the nation.
  • Bureaucracies often do more harm than good.  Their function is largely based on outdated, territorial group-think, and they cannot change or adapt quickly.  Control freaks almost always create more problems than they solve.
  • All decisions have unintended consequences.Some of them can be disastrous. “Either/or” thinking is often a false choice.  Health, both physical and mental, is heavily dependent on financial stability.  The notion that we must choose between public health or a stable economy is a false choice.  They are mutually dependent.
  • Tunnel vision is usually a mistake.  Rigid adherence to long-held principles of epidemiology can crash an economy and engender other, less obvious medical problems like cardiac events, severe depression, anxiety, sexual abuse, physical abuse, emotional abuse, child abuse, drug abuse, alcohol abuse, suicide, violent crime, and eventually societal breakdown.   It takes discipline and wisdom to see the big picture.
  • “Better safe than sorry” is not always the right choice.It’s understandable in a crisis, but it rarely addresses the root of a problem.   We can protect our most vulnerable people with selective isolation and quarantine and still move forward with life.   Sometimes we must take reasonable risks.
  • Saving a buck by reducing housekeeping staff and standards of cleanliness, especially in public places, can be horribly costly in the long run.  Many hospitals, nursing homes, and medical offices are nowhere near as clean as they were 40 years ago.  Better personal and public hygiene will turn out to be a very good thing in the years to come.
  • Living and working in overcrowded, congested areas has been a problem throughout history.   Smallpox, plague, cholera, yellow fever, malaria, and tuberculosis have taken the lives of millions over the centuries.  Flu pandemics, in many cases, have been even worse.   Perhaps this pandemic will teach us all to be more respectful of everyone’s personal space.
  • We have more everyday heroes than we realize.Celebrities are not heroes.   Nurses, doctors, respiratory therapists, pharmacists, social workers, cafeteria workers, cooks, cleaning people, truck drivers, police officers, firefighters, EMTs, grocery-store clerks, bank tellers, delivery people, postal carriers, farmers, utility crews, and millions of everyday people doing their jobs and looking after others are heroes.  They need to be honored.
  • Politicians should not control the number of hospitals, ICU beds, ventilators, or CT scanners.   Hospitals cannot be run as if they were merely ugly hotels, focused almost solely on occupancy rates.  Surge capacity in beds, staffing, and equipment is essential.   Since 1976, we have seen a 16% decline in the number of ICU beds in our country.  Prudence matters.   It always has.   It always will.

This crisis will end.  We will learn more than we can possibly imagine.  For now, be calm, be kind, be patient.  Your actions may be more heroic than you realize.

homestudy

How To Get Back To Civility

Posted Posted in Brain Science, Continuing Education, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

We all have blind spots about ourselves, but sometimes our self-image can border on delusional.  Seventy-eight percent of people polled believe that there has been a decline in civility during the past decade.  The other 22% were probably in a medically-induced coma.

The real shocker comes next.  Ninety-nine percent of people believe their own level of civility has remained constant.  So who are all those rude people out there?  Perhaps a brief self-assessment is in order.

Do you remember the last time you:

  • Sent a thank-you note (a real handwritten one)?
  • Let someone go ahead of you in a checkout line?
  • Waived another driver ahead of you in busy traffic?
  • Held a door open for someone else? (That’s called manners, not chauvinism.)
  • Offered to help someone struggling with boxes, bags, or packages?
  • Helped someone get his or her luggage in the overhead compartment of an airplane?
  • Helped an older patient in and out of a chair (as opposed to merely standing there and watching him or her struggle)?

There are countless other examples, especially in this age of narcissism.  Self-absorption is Cause No. 1 of the four major causes of rudeness.  This time of year, people talk about flu epidemics.  But “me, myself, and I syndrome” is a year-round epidemic.  Simply being unaware of other people or their needs is ubiquitous behavior these days.  It speaks to a failure of parenting and education.

That leads to Cause No. 2 of rudeness:  ignorance.  Manners and civility need to be taught, and no participation trophies are not awarded.  Civility is its own reward.

Cause No. 3 of rudeness is lack of character.  We don’t speak much about someone’s character these days.  It’s a serious flaw in our culture.  Character determines how any one of us behaves when no one is watching.  It’s our default mode of behavior.  Eric Hoffer said, “Rudeness is the weak man’s imitation of strength.”  It takes a strong person to be kind, gentle, patient, or polite.

Cause No. 4 of rudeness is simply being in a hurry.  It’s curious, but can you even imagine the spiritual giants of the ages being in a rush?  Granted, people like Moses, Jesus, and Buddha lived a long time ago, but no one could possibly picture their being frantic and frenetic.  As Emerson wrote, “Manners require time, as nothing is more vulgar than haste.”

Self-absorption, ignorance, lack of character, and haste.  These are the major causes of rudeness.  Maybe we could start to “reverse engineer” our way back to civility.  It would surely be worth the effort.

All the Little Warning Signs

Posted Posted in Brain Science, Continuing Education, Elder Care, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

A friend of mine died last week from cancer. She was 52 years old.  Few people knew how seriously ill she was.  She didn’t want pity.  She didn’t even want sympathy.  The only thing she wanted was exuberance in life and dignity in death.  She successfully achieved both.

Sitting in the back of the church and listening to her eulogy, I wondered how many people struggle silently with serious illness and stress.  I suspect every one of us knows people who, despite their poise and polish, suffer tremendous personal anguish that remains hidden from the world.  They function day to day scarcely skipping a beat.  They’re the first ones to lend a hand when someone else is in a jam and they hardly ever grumble or gripe.  Other folks tend to dump extra work in their laps because they’re so good-natured and conscientious.

Then one day, overwhelmed by stress, illness, depression, or exhaustion, these selfless stoics collapse.  Nearly everyone in their sphere of influence is shocked because they failed to notice all the little warning signs.  Somehow it was so easy to overlook the growing fatigue, the waning enthusiasm, or the uncharacteristic irritability.  I’d like to say that doctors are usually expert at recognizing the subtle signs of serious illness and stress.  But the truth is, most of us are not.  Doctors, by and large, are so accustomed to chronic exhaustion in their own lives, they often overlook it completely in others.  There is no laboratory test for stress and no scan will screen for exhaustion.  It takes time and concern and insight to detect the subtle signs of serious stress.  And while many of us may be interested in the well-being of others, few of us take the time to develop true insight into other people’s problems.

Maybe if we all slowed down long enough to notice a friend’s fatigue or a colleague’s quiet mood, we could do something helpful before it is too late.  Maybe if we stopped placing so many unreasonable demands on one another, we wouldn’t be plagued by chronic fatigue and burnout.  Maybe if we made an effort to be more friendly and flexible in our daily encounters, folks would feel free to ask for help when they need it.

It would be wonderful if teachers and preachers and bosses and bureaucrats would promote empathy and compassion as much as they promote rules and regulations.  But until patience and kindness work their way into the culture’s curricula, we’ll have to rely on the insight of individuals.

Do you know someone who’s overwhelmed, worn out, dejected, or depressed?  Be gentle with him or her.  Cut such people some slack.  They may be up against serious stress or illness.  Be kind to them and to everyone you encounter today.  You may not have the chance to be kind to them tomorrow.

Some Timeless Advice

Posted Posted in Brain Science, Continuing Education, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

How’s your bank balance doing these days?  More importantly, how’s your emotional balance doing?  Incessant political nastiness, market swoons, natural disasters, urban decline, violent crime, geo-political tensions, ever-expanding congestion, traffic, and professional pressures are weighing on all of us.  And we haven’t even mentioned the personal stresses of illness, family strife, teenage traumas, aging parents, and relationship struggles.  At least there doesn’t seem to be a massive asteroid threatening our existence.  That was a joke.

Most of us have learned that taking only withdrawals from a bank account does not work well.  Sooner or later we need to make some deposits.  The same principle applies to our emotional balance.  The stresses we face in everyday life represent withdrawals from our emotional reserve.  We need to balance those withdrawals with some regular deposits.  And that, unfortunately, is not always so easy or obvious.

Emotional depletion has consequences.  Eventually it can compromise our immune, neuroendocrine, and cardiovascular systems.  Since millions of us are experiencing emotional depletion, we need to be intentional about restoring our emotional account balance.  Here are a few ideas:

  • Take a deep breath and slow down long enough to realize you’re running on empty.
  • Disconnect from your devices, social media, and TV for several hours. If this causes undue stress, you know you’re emotionally depleted.
  • Spend at least 15-20 minutes each day in a natural setting. Remember nature?
  • Let go of anger, resentment, and criticism. No one can experience love, joy, or peace when he or she is consumed with negative thoughts and emotions.
  • Do something physical and useful. Clean out a closet, spruce up the yard, bake cookies, wash the car.  As long as it gets you up and moving and has tangible results (not staring at a screen), it will help.
  • Call or visit with a sympathetic person who will truly listen and encourage you. Texting doesn’t count.
  • Do something thoughtful and unexpected for another person.
  • Forgive everyone.

If all else fails, remember some timeless advice from Abraham Lincoln, “This too shall pass.”  It always does.

Patriot Day

Posted Posted in Brain Science, Continuing Education, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

It’s hard to believe, but it happened 18 years ago.  The horrific events of Sept. 11, 2001 (9/11), shocked the nation and the rest of the civilized world.  We now have an entire generation of young people who know of 9/11 only through video images.  They have no actual memories of that day.  Those of us who do will never be the same.

This coming Wednesday, 9/11, is Patriot Day. Many people across the nation are honoring those who sacrificed themselves for others by performing an act of kindness.  Wouldn’t it be great if kindness became our second nature, our default mode?  We would wake up thinking, “Whom could I help today?”  Sadly, we do not think this way.

Instead, we are focused on getting “likes” on Facebook and/or other forms of social media.  As a result, far too many people are literally addicted to attention.  Getting “likes” on Facebook actually stimulate dopamine release in the reward pathways of the brain.   However, did you know performing or witnessing an act of kindness also stimulates release of serotonin and boosts “Immunoglobulin A” (IgA) production?  IgA is our first line of defense against infection.  It is most concentrated in tears, nasal secretions, and saliva.  This could be helpful as we head into cold and flu season.  And, heaven knows, millions of us are worried sick about horrible headlines and hurricanes.

Given this reality, performing acts of kindness truly becomes therapeutic.  Maybe this year on 9/11 we could:

  • Take the time and interest to compliment someone — especially someone who probably hasn’t received a compliment lately.
  • Pay for the driver in the car behind us at a toll booth or drive-thru.
  • Donate clothes or household items in good condition to Goodwill, the Salvation Army, or a shelter.
  • Take a box of donuts, muffins, or chocolates to the people at the bank, pharmacy, fire station, or police station.
  • Leave a basket of treats on the doorstep of a single mother or elderly neighbor.
  • Send a greeting card (a real one) to someone who has had a rough year.
  • Donate blood.
  • Send flowers anonymously to someone in a nursing home.
  • Give a donation to the American Red Cross for disaster relief.

There has been a battle between good and evil since the beginning of time.  Two thousand years ago someone told us to overcome evil with good.  So far, no one has come up with a better plan.

A Precious, Healing Balm

Posted Posted in Brain Science, Continuing Education, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

It’s not on Amazon.com.  None of the brick and mortar stores have it.  You won’t find it in a catalogue.  It’s not available at a bank or hospital.  This elixir is so rare and valuable you couldn’t even talk your doctor into giving you a prescription for it.  That’s just as well because no pharmacist would know how to fill it.  This vanishing and precious healing balm is silence.

We are addicted to noise.  It’s nearly impossible to escape.  Incessant noise bombards us in the workplace, the grocery store, the drug store, airports, waiting rooms, and neighborhoods.  People bring their own noise with them everywhere they go — just in case there might not be enough ambient noise.  People can’t even go for a walk without portable noise.  Years ago, Max Picard wrote, “Nothing has changed the nature of man so much as the loss of silence.”

He was right.  Silence gives rise to the very rhythm and harmony of life.  Without silence, there is no calm, comforting stability.  Chaos is, by its very nature, noisy.  Consider the floor of any stock exchange.  Everything is noisy and chaotic, and yet markets crave stability.  Most people crave stability whether they recognize it or not.  Perhaps we use noise to avoid facing the deepest truths about ourselves.

Many of us are familiar with Henry David Thoreau’s quote, “Most men lead lives of quiet desperation.”  The American writer James Thurber tweaked that sentiment in 1956, writing, “Most men lead lives of noisy desperation.”  Given our current culture, that’s probably more accurate.  Anyone who has lost electrical power for even 20 minutes knows that feeling of desperate frustration.  We want our gadgets to function.  We want our noise.

Oddly enough, when we’re sick or in pain, we usually want peace and quiet.  Could it be that silence is therapeutic?  That concept seems foreign to many people today, but it’s worth considering.  Silence is indeed a precious, healing balm.  It lies at both the center of the universe and the human heart.  Maybe, one day we’ll catch on.

We Can Do Better

Posted Posted in Brain Science, Continuing Education, Homestudy, Psychology, Seminars, Webinars

By Mary O’Brien, M.D.

The pendulum has swung too far.  Fifty years ago there were psychiatric hospitals full of mentally ill patients who were poorly treated and even abused.  “One Flew Over the Cuckoo’s Nest” was required reading.  National outrage peaked and psychiatric hospitals closed leaving thousands of patients unequipped to face the outside world.  Alcoholism, drug addiction, and homelessness began to spiral out of control.

Today major cities like New York, Seattle, Portland, Los Angeles, San Francisco, and others have homeless populations overwhelming local resources.  Los Angeles County now has over 60,000 homeless people, and San Francisco publishes a map to help visitors avoid piles of human feces and used syringes.  Police officers are becoming ill as a result of contact with infected people.  Tuberculosis, Typhus, Typhoid fever, Hepatitis A, and scabies are only a few of the conditions smoldering on the streets.  Rape and violent assault are routine.  California now accounts for one-fifth of the homeless population of the entire country.

The two largest contributors to homelessness are mental illness and addiction.  Most cities have laws against sleeping on the streets, but often those laws are not enforced.  Decriminalizing bad or problematic behavior does not make it go away, and permitting squalor is not compassionate.  Homeless people do not represent a big voting block, but government officials have a responsibility to protect public health and safety.  Experience over the last 40 years has taught me something about caring for homeless patients and starting free clinics, so here are a few thoughts:

  • Commit to addressing the problem. If inaction, complacency, and blame solved problems, we wouldn’t have any problems left.
  • Enforce existing laws and give the police the support and back up they need. That is not being “mean.”
  • Triage people in tent cities. Most need help from social services, many need treatment for addiction and mental illness, some may respond to help from church organizations, and some probably need to be arrested.
  • Organize a volunteer force (the local equivalent of the Peace Corps or the Job Corps). Those not in need of acute treatment for mental illness or addiction might be salvaged with a program that teaches basic living skills.  Such programs already exist in some areas.  College and graduate students could volunteer and earn “credits” toward paying off some school loans.  Colleges and universities would need to cooperate, but at some point you have to put your money where your mouth is.  Tax credits could be given to non-student volunteers.
  • Organize mobile free clinics to vaccinate, screen for infectious diseases, and begin basic treatment. Invite nursing and medical students as well as retired professionals to help.  Sometimes people simply need to be asked.  They would need legal protection from malpractice.  Non-controlled drug samples and old medical equipment could be donated.  I know whereof I speak here.
  • Create transitional housing facilities (like senior life care in reverse). Old warehouses and military style barracks could be refitted. California has the largest percentage of billionaires in the country.  Ask them for help.  No one becomes massively successful because he or she has a dearth of ideas.

Fifty years ago some people were abused in mental hospitals.  Now we allow them to abuse themselves and one another on the streets.  This is a massive, complex, and expensive problem.  But failing to address it will have catastrophic consequences for everyone.  We can do better.