This column begins on the streets of San Francisco. You won’t need reminding from me that it’s a beautiful city, both in itself and its hinterland. To those on Hog Heights, it’s like Lisbon’s American mirror image. Both are west coast cities. Both were devastated and their entire topography and mentality rearranged by massive earthquakes: Lisbon in 1755 and San Francisco in 1906. Both have hills and cobblestones, wine in the hinterlands and trams that rattle and hum through the streets.

Once upon a time, our visits to San Francisco were consumed by thoughts of art, music and food (all three barely affordable, but that was our problem). No more. At the tail end of summer 2019, what struck one most was the astonishing number of homeless people.

The hustling and entreating was stark: a man with a sign saying “anything helps”; a young woman shooting up right there in an adjacent porch even as the sun was yet to set; a raging man propelling himself along the pavement in a cart; a barefoot young woman swinging a vodka bottle and screaming incoherent abuse at a man in a streetcar queue…

This too was reminiscent of Lisbon, but of over three decades ago, when it and Oporto to the north struggled under the overhang of three generations of fascist rule and the influx of coloniais from Angola and Mozambique, displaced after brutal and bloody wars of independence, many carrying awful injuries and disabilities, physical and mental.

Who would expect a loud echo of those times in what is one of the world’s wealthiest cities, home to the tech mega fauna, their richly rewarded executives and engineers, and their owner billionaires? A city nestled in one of America’s most progressive states?

And yet, so it is. One doesn’t want to overstretch the association. Lisbon is different now. And besides, our streets and, in Dublin’s case, the Liffey boardwalk, are pretty upsetting too. But sometimes seeing something elsewhere brings a new focus to what we see at home.

ACCESS TO STREET BENZOS

San Francisco residents offer various explanations for what is happening. They say, for example, that the weather is kind, so people gravitate there; and that it’s a sanctuary city, so people living on the street aren’t hassled by the police as they would be elsewhere. And they blame drugs of course, heroin, opioids and crystal meth. And then there’s the cost of housing.

Sound familiar?

But to us, the abiding sense was of serious, cumulative mental ill-health. Some of those on the streets, according to their cardboard signs, are veterans. Others have just been fucked over by life. Maybe it was abuse, maybe it was displacement, maybe it was loss. But all have been traumatised in some way.

We need to think about all of this ourselves with clear heads. We need to free ourselves of prejudice – in all sorts of ways. Headlines in our newspapers last week claimed that “Cannabis use by young increases mental health risks”. But it is more the case that mental health risks increase cannabis (ab)use, not to mention opioids, crystal meth, heroin and alcohol. That certainly seems to be the case in San Francisco and it seems highly likely here too.

Vast quantities of illegal drugs are consumed in Ireland. For example, the latest report from the European Monitoring Centre for Drugs and Drug Addiction says that more people in Ireland have used cocaine in the last 12 months than any other country, apart from the UK and Spain.

But legal drugs are also an issue. Irish over-65s are reportedly the highest benzodiazepine consumers in the OECD – and these are prescribed meds.

In a fascinating and very revealing letter to The Irish Times in July, Dr Tom O’Dowd – a GP in the Tallaght area – wrote of his experience when his practice reviewed prescriptions of benzos and the similar Z-drug. They put in supports, consultations and a reducing dosage plan. Six months later, there was little change, except for greater aggro from patients who didn’t want their dosages reduced.

“Older patients are less likely to have access to street benzos and are more dependent on their GP or psychiatrist,” he noted. In his final paragraph, Dr O’Dowd posed a fundamental question: “The broader question is why our western society needs to consume such large quantities of psychoactive substances, be they benzos, opiates or indeed alcohol.”

A BILLION IN TAX

Is anybody at policy level interested in answering that question of demand? Unlikely. Their focus is largely on the supply side. For example, the Government is imposing a minimum unit price on alcohol, despite the grave risk that it will simply displace the consumption of alcohol into cheap illegal alternatives.

We’ve had enough lectures and “guidelines”. For a cash-strapped system, this may be the cheap option. Likewise, devolving responsibility for mental health to over-burdened GPs and hoping for the best.

The people we saw in SF and routinely see on our own streets aren’t at risk, they’re already in full-blown crisis. They don’t need finger-wagging pieties, they need action.

When systems of care are poor and overstretched, troubled people will self-medicate with drugs and alcohol. Deprived of an effective response, they simply find new supply lines or products, one riskier than the next. The only adequate response is a mental health service which is properly and fully resourced.

Building such a service shouldn’t be beyond us. But first we need to stop obsessing about notional or statistical risk. It’s a waste of energy and time. Everyone is at risk. We should instead focus on intervening as early as possible when behaviour begins to pose an active risk to oneself or to others.

Another characteristic of an effective service is that when such a threat becomes active, there is a rapid response. It may cost more at first, but it’s actually more efficient in the long run.

As to funding it, it’s hard to escape the logic of fully legalising, and of course taxing, cannabis – for a start. After all, it’s already available, and very cheap, in every part of the country (as is cocaine). Such a tax would pay for a very significant mental health service. For example Colorado, with a comparable population to Ireland, has raised over a billion in tax since cannabis was legalised there in 2014.

Now that, as they say, would do nicely, wouldn’t it?