Losing Kathy: Slow Violence and Social Service Work in New York City

One of my last conversations at Ladders Services was with the Medical Examiner’s office after I heard Kathy had died.* My cubicle was in a cellar with an open floor plan, shared with other cubicles, and my boss and I agreed that I should call the Medical Examiner from a room with a door. Privacy. Sitting in a barren room with dirty white walls, browned floor tiles, and a dated Dell desktop, I called the municipal morgue.

Surprisingly, my voice didn’t shake. “I’m calling from Ladders Services. We heard that one of our clients died but we haven’t been able to confirm. Can you let me know if she’s shown up there?”

I confirmed Kathy’s name and date of birth.

“I can confirm that she is here, and no one has claimed the body.”

Beyond this last conversation, there was my last advocacy effort.  I tried to get the executives of the multi-million-dollar non-profit to pony up some cash so Kathy’s body wouldn’t be dumped, nameless, in a collective grave on potter’s field, located on “Hart Island” – a moniker ironic or brutal or both – off the eastern end of the Bronx.

Since the late nineteenth century nearly a million bodies have been poured into the ground at potter’s field in New York City. These days people caged at one of the warehouses on Rikers Island dig the graves in teams and live with the traumatizing stench for years after – no counseling offered. Given that it is poor people who end up incarcerated at Rikers and poor people who end up buried at potter’s field, it’s always conceivable the burier could have encountered the dead on the outside, when both didn’t have their fates as clearly sealed by the intersecting arms of municipal departments. From capital’s perspective neither the lives of the digger or the dug matter much, though in death, as in life, both will experience “personal responsibility” in a vicious manner. Either could be lost with barely family – biological or chosen – to hold their memories. If a digger holds back his labor, he’ll just be re-caged and replaced.

My direct supervisor and I hoped Kathy wouldn’t be lost on potter’s field. The boss’s boss directed: “Well, see what you can get from Social Services first.” The directive was handed down and I acted accordingly. Making a single call to Social Services took hours on its own, ensuring that Kathy’s body would sit, directionless, for longer. With municipal burial assistance the process of putting Kathy’s skin and bones in the ground would be known as an “indigent burial.”

The city could chip in $900 maximum. Cheap with the dead, the boss’s boss hedged on getting more for her. If charity kicked in and the whole process exceeded $1,700, the city could withdraw funds – burying someone for $1,700 is all but impossible. At $1,701 her body may no longer have met the standard of being indigent-enough for municipal burial aid. The aid process incentivizes the monetarily cheaper type of body disposal, cremation, and lends itself to an under-discussed post-mortem income hierarchy – that of who has access to a grave and who doesn’t. Had Kathy had any assets, Social Services would have subtracted the asset values from the burial grant they gave. Like most other poor people who die so violently, though, she didn’t have anything to her name.

***

I met Kathy my first week on the job with an intensive outpatient mental health team. She was a short and stocky Puerto Rican woman with a familiar city accent and a whirlwind approach to developing relationships. She grew up in New York City. Her dad dealt heroin and she was poor from cradle to morgue. She survived sexual assault by an older cousin. She spent countless nights in the city hospitals. She spent countless nights in municipal shelters. She spent countless nights on city streets. Sometimes, when she was out of touch for days, we would find her lying flat on the concrete in a working-class section of Queens. Outside of Manhattan, homeless outreach workers typically have much more ground to cover with small numbers of staff, and thus they were less likely to bother her, and she could get some relative peace, even lying on concrete.

Kathy got addicted to dope in her twenties and her street-sister, who she’d met during one of many stints in rehab and who was now sober, only trusted her to be around if she wasn’t using. Kathy relied on cocaine to deal with the depression, or when she was on Methadone, or when she was getting high but couldn’t get heroin. She slept on the street when she was using and was open to shelter when sobering up. She had kids, but they were separated from her by the state in their youngest years. She had no known biological family otherwise.

In her last weeks of life, I pieced together her history from social work and mental health assessments in order to argue her need for disability benefits. Reading through voluminous emergency room stays and treatments meant scouring tens of thousands of black and white lines of tragedy and crisis. What was on paper, in her case, was a lot like who she was in person.

Kathy had been diagnosed with schizoaffective disorder, which has increasingly become a catch-all diagnosis for poor people who engage mental health providers. Often the diagnosis is adjoined by a primary or secondary substance abuse diagnosis. Invariably when the medical records are closely examined, there are to be found a series of brutally traumatic events recorded by doctors or nurse practitioners as near afterthoughts.  They never account for the structural traumas that can come with surviving racism, or of being deprived of access to housing, or of persistently guarding oneself from sexual assault, or of traveling capitalist circuits impoverished. What is often post-traumatic stress with singular or periodic psychotic symptomology – like hyper-vigilance that may or may not be paranoid, and depression that comes with material desperation – is much of the time diagnosed as schizoaffective disorder.  And an individual’s treatment is subsequently hinged on cessation of drugs they may use to cope and on compliance with psychotropic medications, which may or may not alleviate symptoms and may cause other severe side effects.

In Kathy’s case only one or two doctors, of more than a dozen, had diagnosed her with post-traumatic stress disorder. And once she was diagnosed with schizoaffective disorder, that’s how providers tended to see her. Perhaps things would have been different if providers recognized her as a full human whose trauma seeped down to her toes and into her heart; whose survival was a complicated endeavor of navigating blaming bureaucracies and risk-laden streets. But we all reduced her life to substance use and medication compliance. And we lost her when we did that.

***

When I would meet Kathy in the mornings, I’d buy her a bacon, egg, and cheese with coffee. She always asked me to close the lid of the coffee cup for her. I did it the first few times, and then I gently refused. She continued to ask anyway. Eventually, I went back to tightening the lid each time.

I felt irked about how my co-workers talked about Kathy. There was the paternalism of “she needs us.” And there was the judgmental shock, translated through Christian moral purity, that she had a history of “selling her body,” as if survival sex was an anomaly.

But I was more irked how they talked to her. “Well, I think you should do this,” or “well, anything that stops you from using is probably good,” or some variant of that kind of thing. The fucked-up use of child-talk to a middle-aged woman who had survived decades of abuse and years on the streets without a social worker babying her was painful to watch. I don’t know how it felt to receive that treatment or what it meant for her. I never asked.

After more than a decade in social services, I was confident in the need for strong boundaries and I was particularly bothered at my team’s seeming lack of interest in drawing boundaries about Kathy’s physical contact. She gave lots of unsolicited hugs, which she seemed to want from each person she engaged on the team. I vocalized my discomfort in team meetings, and we all agreed to stop hugging her as a boundary-setting practice.

Since she had no one else in her life for most of the time each week when she was using, this decision meant she lost the last people who she could share a hug with. Since she died soon after, I hold that I started and pushed the conversation that took that last piece of safe human contact from her. I’ve thought about it over and again, and I don’t think I ever asked her what those hugs meant for her. I don’t think any of us did.

One outcome of the team’s judgmental approach was that Kathy was less likely to tell us when she relapsed or missed a dose of methadone or turned a trick.

“Well, you’re doing great – you haven’t used in a week!” my co-worker Andrea would say during the crisis calls that she’d receive. I’d sit in my cubicle listening and think about what it might mean to Kathy to get all these nice comments when she did what the team wanted – when she stopped using, or took psychotropics, or saw the doctor, or went to detox, or went into shelter.  And how it might feel to lose those nice remarks when she inevitably slipped back into using.

“Positive judgment” is what clinicians sometimes call it. It’s often a tool for social service workers to build quick and cheap rapport. It’s dangerous.

Sometimes, at the Ladders office, I’d find adult roaches crawling across my cubicle or smaller ones crawling up my leg, under my jeans. There was no ceiling, just metal bones and rafters; the construction from upstairs caused a mystery dust to fill the air. My asthma flared and I coughed all the time. We were supposed to encourage our clients to stop smoking or reduce their usage. I wondered what the fuck was filling my lungs each day. Since clients would come down to our cellar-offices, I wondered what the fuck was filling their lungs each day too. We were worried about them smoking dope, but god knows what any of us were breathing in. Management told us that they had ensured it was safe. The walls shook from jackhammering upstairs and the white dust randomly fell and dispersed until it disappeared. I began bringing an inhaler.

***

Injecting heroin carries more stigma than smoking it, and to some degree it signifies a deeper dive into getting the drug into the body or deeper engagement in street-level drug use where the risks can pile up. Suspecting that Kathy was using and wanting to talk with her about accessing unused syringes, at one point I had a conversation to try and de-stigmatize injecting. We sat across from each other in one of those barren offices. She said she wasn’t injecting, just smoking.

Later that week when my boss saw track marks on her legs, it became clear that we hadn’t earned her trust enough for her to feel safe telling us. Or it wasn’t useful, from her perspective, for us to know.  Maybe Kathy knew all she needed to about unused needles and didn’t need another formulaic harm reduction conversation. I’ve sometimes found that people who use drugs find typical harm reduction conversations less useful than the workers who begin them.

***

Kathy and I spent her last weekend alive together. She was found passed out at rehab and ended up in a private hospital in Brooklyn. My supervisor called me from her vacation home, and I went to the hospital. “Tell them to do a tox screen!” was what they always asked when clients were hospitalized – getting drug screens was seen as a way to get information from clients on what they were putting in their bodies for future conversations, though it always felt underhanded and uncomfortable to me. Because Kathy had passed out, the assumption was that she had used and overdosed. Accordingly, the detox wanted to kick her out, meaning she’d lose her transitional bed and have nowhere to return to upon discharge.

I had little in the way of authority as a social worker walking into an emergency room to advocate for Kathy after the doctor had determined she was simply a “user.” Substance users are seen as less-than, and typically treated with disdain, negligence, and disregard by doctors and often many nurses as well. Working class solidarity quickly meets its limits when stigma enters the picture.

After she came to, the doctor wanted me to get Kathy out of the hospital. But Kathy was open to staying, and that seemed the healthiest move. More than anything, she wanted a bacon, egg, and cheese with coffee and a lot of sugar, which folks recently having used methadone often crave. So, I prioritized the sandwich – which, when it is nearing midnight, even in New York City, is difficult to come by. Some blocks later I found one. I rushed back, put it on Kathy’s bed, and then begged a doctor to let her stay. They gave her one night. An expected and over-generous ‘thank you’ quickly flew from my lips to the doctor who allowed a single night for Kathy to recover and then be pushed back onto the streets.

With the nurse’s aide, I transported Kathy to the in-patient unit, where she shared a room. Kathy apologized to me for demanding the bacon, egg, and cheese – she said she hadn’t realized it was already near midnight. When her roommate asked her what she was sick with, Kathy said she had diabetes and that she was on “mind medications.” I sat with her for a while. Then I went home. The next morning upon awaking, I went straight back to the hospital.

Kathy was ready to be discharged, but the computers were down. She loudly whined. “I want to leave. I’m gonna leave!” A risk in these situations is that someone walks out against medical advice, as they might miss out on actually-useful information or discharge prescriptions. I bought Kathy another breakfast sandwich, which in turn bought us some time. When the student doctor and her supervisors came to discharge Kathy, they told her she had diabetes, which Kathy said she knew. Kathy had never told this to me or others on my team, partially, as I understood it, because she didn’t want to hear commentary about her diet. Since engaging with service providers means being under surveillance much of the time, there was sense in this.

It looked like she was hospitalized as a result of uncontrolled diabetes, though her tox screen also came back positive, though not for cocaine or heroin. Eventually she was discharged. My boss convinced the detox to take her back. So, we took a cab back to the detox facility.

As a white social worker, I didn’t need to go through the metal detector. She did. Then the two of us, along with other folks getting treatment, each of whom went through the metal detector, all went up in the elevator together. I left her upstairs and went home. She tried to hug me on my way out. I refused.

Kathy was dead just a few days later. When she was found, in a vacant drug den uptown, she was surrounded by crack and heroin supplies, lying lifeless on the floor. The most likely explanation was that since the detox she had not realized how much her tolerance for dope had been reduced and she overdid it upon using again.

Or she intentionally killed herself, which she had tried repeatedly in the past.

***

Kathy died anonymously. Her life, like that of so many poor people’s lives, has no record of note. Medical and social service records will be destroyed in a few years, and that will take the last traces of her. Databases will eventually delete her name. Vital Statistics will keep her birth certificate that no one will ever request. She had no possessions.

At the end of the year, a local organizing group held a memorial service for all the homeless people who died in these preceding months. I dropped her name and memory in that space. It made me feel like she was a little less disposable to the world. Disposable probably sounds harsh. But it’s precise. A poor person’s life comes with a quicker death, and sometimes with no memory of a life lived. I remember Kathy. Her street-sister does too. I don’t know who else does. And I left Ladders Services soon after.

***

2020: A COVID-19 Postscript

The COVID-19 crisis has smashed through New York City and it’s been impossible not to think about Kathy through it, along with dozens of other homeless people I’ve worked with who have died alone over the past decade. Two months since the city was shuttered, more than 175,000 people have been known to be infected (the number is undoubtedly astronomically larger), with at least 20,000 dead at the time I write this. More than a month ago The New York Times reported, “The coronavirus is killing black and Latino people in New York City at twice the rate that it is killing white people.”

Millions lost their jobs nationally, and the city’s unemployment rates have soared. Local unemployment claims hit a State-run benefits system so disinvested that its decades-old technology couldn’t handle the demand and collapsed early into the crash. Thousands couldn’t make their claims, thousands didn’t get their benefits. Governor Andrew Cuomo saw opportunity. He held a late-night vote where elected officials from across New York granted him vast emergency powers. And with the state budget due on April 1^st, just as the crisis overwhelmed working class lives and community organizing groups, the governor declared an austerity budget and spending cuts. Along with a newly emergent discourse of acute austerity came renewed discussions of deservingness, terrifyingly transparent government assessments of disposability, and a shifting terrain of class composition. As the current crisis has developed, far-right police and white supremacist organizing efforts, coupled with a reactionary and politically active and powerful middle class, have gained significant wins that were unexpected just months ago.

As those inside and outside carceral facilities warned that congregate settings like jails and prisons were going to become concentrated spaces of infection and death, the governor sought to rollback progressive bail reforms – which had eliminated cash bail for many crimes, and limited the ability of judges to use discretion in setting bail – that had been put into effect just months prior. White supremacists and police organizations, assisted by right-wing tabloids, succeeded in empowering the governor to plow through legislative changes, allowing judges to cage more working-class people. No one seriously doubts that the intent is to cage people of color at Rikers and in other tightly surveilled spaces. But it is also about directing a generalized fear of a largely unknown virus away from government neglect, and toward the racialized panic and endemic racism that contextualizes so much of the daily experiences of low-income black and brown people. An April strike by those inside the cages at Rikers, coupled with relentless lawsuits to release some prisoners, has led to some decreases in the municipal jail population. Those in New York State prisons have been met with inhumane blasé by the governor, with the infection rates and death tolls growing. But austerity discourse and racialized blame-shifting efforts by the state, buttressed by right-wing organizing and liberal ambivalence, have already had the successful impact of ensuring policies that will further exacerbate policing, criminalization and punishment.

Following the governor’s austerity announcement, Mayor de Blasio subsequently declared his own cuts – almostacross the board. The first major cut was an end to the city’s summer youth employment program (SYEP), which has functioned for decades as a lifeline for families with little income. The NYPD, however, were in the clear in the city’s budget proposal. The ‘progressive’ Speaker of the City Council had in fact more-than acquiesced in early austerity negotiations (at the time of writing the municipal budget is not done yet). He cut deals with the mayor and the municipal Office of Management and Budget, as he repeatedly has, that buttress his public image as a progressive politician while privately supporting deep concessions and few material gains for working class people, particularly those with the lowest or no incomes. In this case, it appears the administration agreed to take the public hits in the PR cycle about the SYEP cuts, allowing for the Speaker to move through the news looking like a hero as he began to lead the way to stop cuts that he’d actually negotiated into play.

Seeking votes for his long-ago announced mayoral run, the same Speaker who championed a push to “close Rikers” last year did little but grandstand about his bonafides and publicly say positive things about the cops. Simultaneously, Rikers became the most dangerous place in the United States in COVID terms. He and other politicians feigned deep concern, but that’s about as far as interventions went. Public policy discussions increasingly pose the possibility that Rikers may not close, after all.

Racialized austerity discourse and right-wing organizing have driven government responses to much of the crisis. As government officials told everyone to “shelter in place”, the city and state’s abandonment of more than 70,000 unhoused people – largely people of color – became transparent. With tens of thousands sleeping in tightly packed congregate shelters, the shelter system became grounds for viral spread across workers and residents. The more than 5,000 people living on the streets are also at high-risk of catching the virus and dying on the concrete without access to safe housing, and many already have.

Left organizers have demanded 30,000 of the city’s 100,000 vacant hotel rooms be opened for the safety of homeless people and they have evidenced that there is even federal money to pay for it. But the mayor has doubled-down on the classic neoliberal perspective on homelessness – it is a matter of an individual’s health or that “something went very wrong” in their individual life – and has refused to open individual hotel rooms for individual use (as opposed to shared rooms). More recently he relied even more on basic neoliberal tactics of governance, pitting those without homes against other working class people in an austerity-driven deservingness contest: “There seems to be, in my humble opinion, an over-focus on the hotels…The hotels are being put on a pedestal that’s just not the reality”, de Blasio said in reference to demands for the city to provide hotels for the homeless.

In a major win for rightist upper middle class and business groups who want the homeless out of sight, the city has expanded and intensified its “sweeps” of people on the street, with reports of late-night wakeups by the NYPD, belongings tossed into the garbage, and mandates that people go into municipal shelters. But those same people have expressed terror: going inside a congregate shelter means a higher likelihood of infection. The mayor has responded to criticism that these sweeps are harmful, particularly during the COVID crisis, and raged against public encampments. He has declared that the primary reason someone would be sleeping outside right now is due to a never-defined “mental illness” that keeps them from making reasoned choices. In the process, the mayor has rewritten history to justify his policy choices, repeatedly arguing that, unlike former mayors, he will “not tolerate” encampments – a claim belied by the vast police violence and re-displacement that those on the street have faced for decades in New York. Pathologization and policing intersect closely in managing people in this crisis.

State violence against homeless people reached significantly heightened proportions this month as overnight subway service was shut down between 1am and 5am for system-wide “scrubbing,” which first and foremost meant the removal of homeless people. The mayor and governor both salivated at the idea that this could mean the permanent removal of homeless people from the overnight trains (without providing any additional permanent housing). Reports from witnesses who have been monitoring the impact of the closures have painted the predictable – and predicted – picture of a police-centered mass bullying effort that withdrew a basic survival resource (overnight trains) and left people on the streets and in the cold, to wander with nowhere to go until early morning hours.

The Transit Workers Union (TWU), suffering devastating losses among its rank and file, decided to punch-down instead of up, siding with the Metropolitan Transit Authority (MTA) who run the trains, in a campaign to shift blame for deaths among rank and file workers to homeless people. It was in fact the governor, mayor and MTA who refused to announce the need for public sector workers to wear personal protective equipment (PPE) or to supply needed PPE until well-into this crisis. But the TWU leadership – supported by some outspoken members –has opted not to channel anger toward the State, but rather to co-lead a propaganda campaign with the MTA, supported and popularized by local right-wing tabloids, to reduce homeless people to merely transmitters of the virus.

Focusing blame on homeless people has been a remarkably successful effort, channeling workers’ anger away from bosses and toward those lower on the wage-hierarchy and without the basic resource of housing. And once the governor obtained front-page coverage by declaring their presence on subway cars “disgusting”, homeless folks spending overnights on the trains were all but destined for increased police violence and the cold concrete outdoors. Which is just what has happened.

Pushing homeless people out of the most basic spaces they rely on for their survival has a vast array of violent impacts. Increased death tolls are just one prominent effect. No one will know just how many people living on the street died from this horrible virus and the government neglect that accompanied and facilitated its spread; they often won’t be recorded as COVID deaths. Their bodies will go nameless, dumped on Hart Island, along with many others unable to afford a different burial. At this point there are so many dead that the city has stopped using the labor of prisoners to dig graves on potter’s field and has hired outside contractors. The term “mass grave” – accompanied by photos published by the AP – has re-entered public discourse, this time in reference to that little island off the Bronx.

In April, for the first time in many years, a City Council member publicly challenged the paltry amount provided to the poor for burial aid, the same issue I experienced with Kathy. According to one local organizing group, city officials had requested an increase from the state in burial aid early into the crisis. State officials refused to allow it, because the body count wasn’t yet high enough. City administrators agreed enough not to press the matter until it was deemed necessary, but by then it was already too late for families facing the inability to bury their loved ones. Only recently was an “emergency rule” put into effect to raise the maximum death benefit expenditure, and only for 60 days.

The COVID crisis is a heavy reminder that Kathy’s story is that of countless people. And this crisis has laid bare the routine processes of structural violence that Kathy faced. The politics of disposability – the triage of who must be prioritized for survival and whose survival is up for debate or relegation – are in full display. What that all means in terms of the possibility for liberatory struggles, however, remains to be seen. If one is to take the examples of wins by rightist forces and unions organized against homeless people as a lens into current terrain, the future doesn’t bode well for our side.

*Names and identifying and various other details changed to protect Kathy’s confidentiality.