History — How We Got Here

Before there was “homelessness”

For most of American history the word didn’t exist. The very poor lived in county poor farms and almshouses; transient laborers — the men who built the railroads and picked the harvests — wintered in skid rows: dense downtown districts of single-room-occupancy hotels, missions, and cheap cafes. Skid row was bleak, but it was housed bleakness: a man with a few dollars could always buy a lockable room. Spokane, a railroad and mining hub, had one of the West’s classic versions — blocks of SRO hotels downtown serving seasonal workers. Two systems, then: cheap rooms for the poor who could function, and for those who could not, the asylum.

The asylum century

From the 1850s on, states built enormous public mental hospitals — the era’s idea of humane reform, replacing jails and attics with treatment. By 1955 the system peaked at roughly 559,000 people living in state mental hospitals, out of a U.S. population of 166 million — about one American in every 300. Washington’s flagship in the east was Eastern State Hospital at Medical Lake, opened 1891, which peaked near 2,274 residents. The asylums solved the visible problem completely: there was no street population of people in psychiatric crisis, because they were all inside. The cost was everything else — warehousing, neglect, abuse, lobotomy, and lives confiscated wholesale. Both things were true at once. Hold that thought; it’s the pattern of this entire story.

Rosemary

The reform that ended the asylum era has a family story at its center. Rosemary Kennedy — third child of Joseph and Rose, sister of the future president — was born in 1918 with intellectual disabilities. In November 1941, when she was 23 and increasingly volatile, her father arranged a prefrontal lobotomy, then a fashionable procedure. It destroyed her. She spent the remaining 63 years of her life institutionalized, needing care for everything. The family’s grief bent American history: her sister Eunice founded what became the Special Olympics; and her brother, as president, made the mental-health system a personal cause. In February 1963 JFK sent Congress a special message demanding a “bold new approach” — replace the “cold mercy of custodial isolation” with care in the community, and cut the institutional population in half within a generation.

The bold new approach — and the half-built bridge

On October 31, 1963 — three weeks before Dallas — Kennedy signed the Community Mental Health Act, the last bill of his life. The design was coherent: build a national network of roughly 1,500 community mental health centers so people could be treated near family, work, and home. What actually happened is the central tragedy of this history: only about half the centers were ever built, and almost none were fully funded. Federal seed money was designed to taper as states picked up the cost; Vietnam and inflation ate the follow-through; states, delighted to close expensive hospitals, did not redirect the savings. President Carter’s Mental Health Systems Act (1980) tried to repair the structure — and was repealed within a year, folded into a shrunken block grant in 1981. The demolition of the old system was thorough. The construction of the new one never finished. People left hospitals on a bridge that was only half-built, and fell where it ended.

How the hospitals actually emptied

Ideals opened the door; three mechanical forces pushed people through it. Thorazine (1954), the first antipsychotic, made discharge medically imaginable. Medicaid (1965) contained the fateful “IMD exclusion”: federal dollars would not pay for care in large mental institutions — so every patient a state moved out of its hospital converted a 100% state cost into a shared federal one. States responded to the incentive exactly as designed. SSI (1972) gave disabled people a federal income that traveled with them into the community. And the courts did the rest: Lessard (1972) and O’Connor v. Donaldson (1975) established that a person who is not dangerous cannot be confined against their will — Washington codified this in its 1973 Involuntary Treatment Act, the same RCW 71.05 that runs through this map’s ITA lane today. State hospital population: 559,000 (1955) → under 40,000 today. Public psychiatric beds per 100,000 people: ~340 then; roughly 11 in Washington now. Eastern State: 2,274 → ~300.

The arithmetic nobody ran

Here is the calculation that reframes everything. In 1955, one in three hundred Americans lived in a state mental hospital. Apply that same share to today’s population and you get roughly 1.1 million people. The entire U.S. homeless count — everyone, sheltered and unsheltered, for every reason — was about 770,000 in 2024. In other words: the population America once institutionalized is larger than the population America now counts as homeless. That’s not a claim that everyone on the street belongs in a hospital — most homelessness is economic, and most people with mental illness are housed. But it demolishes the idea that today’s crisis is new or inexplicable. The people are not a surprise. They are the same share of humanity every society contains — the difference is that we dismantled the institution that once held them, finished only half its replacement, and then — as the next chapter shows — demolished the cheap housing that was quietly absorbing the difference. The jail became the backstop: Spokane County’s jail, where 60% of inmates have behavioral-health involvement, is now this region’s largest de facto psychiatric facility. The sheriffs of America run the asylums we said we closed.

Where the cheap rooms went

Deinstitutionalization alone didn’t create street homelessness — for two decades, discharged patients mostly disappeared into the SRO districts. Then we demolished those too. Urban renewal and downtown redevelopment destroyed an estimated one million SRO units nationally through the 1970s and ’80s — New York lost almost 90% of its stock. Spokane’s version has a bittersweet local landmark: Expo ’74, the world’s fair that gave us Riverfront Park, also cleared the skid-row blocks around the rail yards — the beautiful park and the vanished cheap rooms are the same event. Add the third force: the early-1980s federal retreat from housing, when HUD’s budget authority fell by roughly 70%. By 1982, for the first time since the Depression, Americans in every city were sleeping visibly on sidewalks — and a word entered the language: “the homeless.”

The emergency that became permanent

The 1980s response was built as a temporary rescue: church basements, soup kitchens, FEMA food-and-shelter money, armories opened in cold snaps. In 1987 Congress passed the Stewart B. McKinney Homeless Assistance Act — the first (and still foundational) federal homelessness law, creating shelter grants, health care for the homeless, and the programs that evolved into everything in this map’s federal funding column. The fateful assumption was in the framing: this was emergency aid for a temporary crisis. The emergency infrastructure — congregate shelters, meal lines, seasonal beds — hardened into a permanent industry, and forty years later this map still shows its outline: the survival circuit that keeps people alive in place.

The staircase

The 1990s brought the first real system-building: HUD required each region to organize a Continuum of Care — the name still on this map — around a linear “staircase” model: emergency shelter, then transitional housing, then, once a person proved themselves “housing ready” (sober, compliant, employed), permanent housing at the top. It was orderly, intuitive — and for the hardest cases it failed: people with severe mental illness and addiction kept falling off the middle steps, cycling between the street and the bottom stair for years. The staircase worked for people who needed a boost; it lost precisely the people who cost and suffer the most.

Housing First — the inversion

The counter-idea came from practitioners. Tanya Tull’s Beyond Shelter (Los Angeles, 1988) pioneered housing-first for families; then psychologist Sam Tsemberis, working with street-dwelling mentally-ill New Yorkers, founded Pathways to Housing (1992) and inverted the staircase: give the apartment first, unconditionally, then wrap it in voluntary intensive services. The trials stunned the field — 85–88% housing retention for the population the staircase had abandoned. What happened next scrambles today’s politics: the Republican Bush administration nationalized it. Homelessness czar Philip Mangano evangelized cost studies (the “million-dollar Murray” logic this map’s Bill inherits) and pushed 10-year plans targeting chronic homelessness; chronic counts fell measurably. Obama codified: the HEARTH Act (2009) wrote performance into law, Opening Doors (2010) became the first federal strategic plan, and the veterans initiative — HUD-VASH vouchers plus SSVF prevention, run through one accountable by-name system — cut veteran homelessness roughly in half, the strongest proof yet that a coordinated system with a full toolkit actually works. Housing First’s later trouble was scope-creep: a targeted clinical intervention for the chronic few became, in some places, the slogan for everything — while the treatment side of the promise went as underfunded as Kennedy’s centers had. As this map argues throughout: the honest reading of the evidence was always both — housing AND treatment, in combination.

The drugs changed first — a chemistry and logistics revolution

No part of this history is more misunderstood than the drugs themselves — because most people’s mental model of the drug trade is a generation out of date. For a century, the hard-drug economy was agricultural: heroin began in poppy fields, cocaine in coca terraces. Plants need land, seasons, harvests, processing — and above all bulk smuggling: trucks, boats, tunnels, mules. Volume was the trade’s weakness, and interdiction was built to attack it. The opioid era that began in the late 1990s — OxyContin’s aggressive marketing (1996), the pill mills, then the 2010 abuse-deterrent reformulation that pushed a generation of pill users onto cheap heroin — was the last chapter of that old world. What came next abolished it.

Fentanyl is not a stronger heroin; it is a different industry. A fully synthetic opioid — roughly 50 times the potency of heroin, 100 times morphine, with analogs like carfentanil (an elephant tranquilizer) running orders of magnitude beyond that — it needs no field, no season, no country: only precursor chemicals and a recipe. And the logistics inverted overnight. Potency is compression: a kilogram of fentanyl replaces a truckload of heroin, so supply that once moved in semi-trailers now fits in parcel post. Precursors — many of them legal industrial chemicals when shipped separately — are ordered online, mailed in unremarkable packages, and combined with instructions a video can teach. When China scheduled finished fentanyl (2019), production simply re-routed: precursors to Mexican labs, synthesis at industrial scale, then northward as powder and as billions of counterfeit “M30” pills pressed to look like prescription oxycodone — the pale-blue “blues” that now define the Northwest street. The economics did the rest: a pill that sold for $30 fell below a dollar. Interdiction built for bulk faces a product with almost no bulk at all. There has never been a cheaper, more potent, more portable intoxicant in human history — and it is also, gram for gram, the most lethal.

Methamphetamine ran a parallel revolution. The old meth — biker labs and kitchen “shake-and-bake” — was cooked from ephedrine and pseudoephedrine, which is why the 2006 Combat Methamphetamine Act put cold medicine behind the pharmacy counter. It worked: domestic labs collapsed. But the trade responded with chemistry, not surrender: cartel super-labs adopted the P2P method (phenyl-2-propanone), built from a rotating cast of cheap, swappable industrial precursors that no pharmacy rule can touch. P2P meth is vastly cheaper, essentially unlimited in supply — and, in the consistent testimony of clinicians and longtime users alike, different in kind: faster descent into paranoia, hallucination, and profound disorganization. Journalist Sam Quinones’ reporting connected the dots many street workers had already drawn — the arrival of P2P meth tracks the explosion of tents, of untreated psychosis in public, of people no shelter can safely hold. Today the two drugs travel together: fentanyl for the down, meth for the up, each masking and compounding the other, smoked rather than injected — which lowered the entry barrier further still.

In Spokane, the game changed almost exactly with COVID — and we have not recovered. The Northwest ran a few years behind the East Coast on fentanyl; the blues arrived here in force around 2020, into a city whose services were locked down and whose isolated residents were newly alone. The overdose curve tells the story with brutal clarity: 80 deaths in 2019 → 346 in 2024 — more than a four-fold increase in five years, carrying this county to #2 among America’s large jurisdictions in overdose death rate (12 months ending September 2025). Every legacy assumption of the response system was calibrated to the slower drug era this history just described: outreach models that wait patiently for “readiness” (fentanyl compresses the interval between crisis and death from years to months); detox protocols designed for heroin and alcohol (fentanyl withdrawal is harder to manage and complicates medication starts); low-barrier hospitality models built when a meal and a cot could stabilize someone (see the low-barrier services review in the Hard Questions); even drug-court timelines and jail-release planning. The chemistry moved faster than the system — that mismatch, as much as any policy choice, is how the present crisis got its shape.

The street changes

Around 2015 the ground shifted. West Coast rents exploded past wages; unsheltered counts climbed; and the drug supply completed the transformation the previous section described — fentanyl and P2P meth remaking the street itself. The law swung too: Martin v. Boise (9th Circuit, 2018) barred cities from punishing sleeping outside when no shelter existed — shaping every West Coast camping policy — until Grants Pass v. Johnson (Supreme Court, 2024) reversed it and returned enforcement discretion to cities. Washington added its own convulsions: the Blake decision (2021) briefly decriminalized drug possession statewide; Trueblood forced competency-restoration reform; Ricky’s Law (2016) created secure withdrawal beds. And Spokane lived the national story in miniature: Camp Hope (2021–23), the state’s largest encampment, then the TRAC mega-shelter, then its closure, then the scattered-site pivot, the 2024 Proposition 1 camping law, and the 2025 enforcement ordinance. Every experiment the nation ran, this county ran in fast-forward.

Two coasts, two crises

Before Spokane’s own chapter, one structural fact explains why the West’s streets look nothing like the East’s. In 1979, a New York court case — Callahan v. Carey — produced a consent decree establishing a legal right to shelter: New York City must provide a bed to anyone who asks. Massachusetts followed with a right for families (1983); Washington, D.C. added winter guarantees. The result is a paradox most people never notice: the East has enormous homelessness — New York’s count dwarfs most states — but it is overwhelmingly sheltered, indoors, and invisible; unsheltered shares run in the single digits. The West took the opposite path: no right to shelter anywhere, the nation’s highest housing costs, and winters people can survive outside. California’s homeless population is roughly two-thirds unsheltered; Washington and Oregon run far above eastern norms. So the same national crisis produced two different visible realities — and two different politics. Street camping, encampment sweeps, Martin v. Boise, Grants Pass, the “protect the rights-of-way” question that opens this map — these are western battles, fought where homelessness lives outdoors. When Spokane compares itself to peer cities, the honest peer group is western: cities with our legal structure, our drug supply, and our sidewalks as the default shelter of last resort.

Spokane’s own chapter — Camp Hope, the scattered-site bet, and a downtown in the balance

Spokane’s visible street crisis built through the late 2010s, but its defining event began in December 2021, when a protest encampment outside City Hall relocated to state-owned land in East Central and became Camp Hope — at its peak the largest homeless encampment in Washington, 600+ residents on a WSDOT parcel, with its own governance battles, service tents, National Guard census, and a two-year fight among city, county, sheriff, and state over whose problem it was. Roughly $24M in state Right-of-Way money flowed here; the camp closed in June 2023, its residents moved to the Catalyst building, the TRAC shelter, and points unknown. The official story was resolution. The fuller story — the one this history exists to tell honestly — is more uncomfortable: Camp Hope, for all its genuine dangers and indignities, functioned as containment. It concentrated hundreds of the region’s highest-need people in one place — where outreach could find them daily, and where downtown’s sidewalks were not the default. What Spokane never built was the thing to catch them after.

The next two experiments came fast. TRAC, the ARPA-funded mega-congregate shelter on Trent (opened 2022), absorbed the overflow at ~$20M over its final two years — then closed October 2024, criticized from every direction: too big, too chaotic, too warehouse-like, too expensive. The replacement philosophy — the scattered-site model — spread smaller shelters across sites with the Bridge Center as day-use hub, promising dignity, neighborhood-scale operations, and better linkage. The theory has real merit; COVID had already pushed the whole country away from mass congregate dormitories toward smaller and non-congregate settings, and the evidence for small-format shelter is genuinely better on safety and engagement. But the honest ledger after a year and a half is this: the scattered-site system has not been up to the task at its funded scale. Total beds fell short of displaced demand; coordination overhead multiplied; and the unsheltered count — the number that measures sidewalks — rose from 443 (2024) to 617 (2025) to 643 (2026) even as the total count declined. The congregate-versus-scattered debate, it turns out, was partly a distraction: form factor matters less than capacity and linkage. A big shelter without treatment connections warehouses people; small shelters without enough beds disperse them. Spokane managed to demonstrate both failure modes in three years.

Downtown absorbed the consequence. With Camp Hope gone, TRAC gone, and scattered capacity short, the region’s unsheltered population defaulted to the urban core — doorways, alleys, the skywalk level, the transit plaza. The commercial numbers now read like the cautionary tables in this map’s Urban Core memo: storefront vacancy estimated at 30–40%, assessed values and foot traffic sliding, anchor tenants gone or wavering, and — for the first time in living memory — serious people asking whether downtown Spokane remains viable at all. This is the same downtown that Expo ’74 built and that a century of civic effort sustained; the Urban Core research elsewhere on this map documents what happens to entire regions when cores like it fail. That — not aesthetics, not politics — is what’s at stake in the enforcement-plus-offramps bargain this map’s bookends describe: the streets are currently functioning as the region’s largest shelter, and downtown is paying the rent.

The pendulum, today

Now the federal pendulum is swinging again: 2025–26 executive orders and the HUD NOFO overhaul move money and mandate toward treatment, accountability, and public order — Tier-1 renewal protection cut from 90% to 30%, exactly as documented in this map’s NOFO memos. Whatever one thinks of the particulars, the historical read is sobering: every 15 years or so, America reverses doctrine, defunds the last era’s infrastructure mid-construction, and starts over — asylum to community (half-built), staircase to Housing First (half-implemented), and now Housing First to treatment-first (contested). Communities that survive the pendulum are the ones with their own plan, their own governance, and their own regional commitment — able to take each federal era’s money without being whiplashed by it. That is precisely the case for the unified regional structure this map recommends.

What the history teaches

Four lessons, offered in the spirit of bringing people together rather than assigning blame. First: intentions have been overwhelmingly good. The asylum was a reform. Deinstitutionalization was a liberation. The shelters were rescue; the staircase was order; Housing First was evidence; today’s treatment pivot answers real failures. Nobody in this story set out to produce the streets of 2026 — and the people working in today’s system deserve the same presumption of good faith. Second: the failures were almost never failures of compassion — they were failures of follow-through and handoff. The community centers weren’t built; the savings weren’t redirected; the services weren’t attached; the systems never learned to talk to each other. Seventy years later, the Safe & Healthy Task Force’s central finding — Spokane is “losing far too many” in the gaps between systems — is the same diagnosis at local scale. History’s verdict is this map’s thesis: the crisis lives in the seams. Third: the arithmetic is stable even when the doctrine isn’t. Roughly the same fraction of our neighbors will always need profound help. The only question any generation answers is where they will be — hospital, housing, jail, or sidewalk — and how humanely and how expensively. And fourth: improvement is always available. Every turn of this story someone looked at inherited failure and built better. That’s the invitation of the whole map: not to relitigate seventy years, but to be the community — finally — that finishes the bridge.

And the moment is now. Spokane stands at a real pivot point. If we hope to save our downtown — and if we hope to save the vulnerable lives we are watching end in overdose or waste away on our streets — then this history has one final instruction: look hard at where we’ve been, and then act. Decisively, together, and now. Every era in this story that hesitated at its pivot point — that half-built its bridge, half-funded its plan, half-kept its promise — handed the bill to the next generation with interest. The next chapter of this history is the only one we get to write. It should be the one where Spokane didn’t hesitate.

Capsule timeline

• 1891
  Eastern State Hospital opens at Medical Lake.
• 1941
  Rosemary Kennedy’s lobotomy.
• 1954–55
  Thorazine; state hospitals peak at ~559,000 (1 in 300 Americans).
• 1963
  JFK signs the Community Mental Health Act — his last bill.
• 1965–72
  Medicaid (IMD exclusion) and SSI accelerate discharge.
• 1973–75
  WA Involuntary Treatment Act; O’Connor v. Donaldson.
• 1974
  Expo ’74 clears Spokane’s skid row; Section 8 created.
• 1981
  Mental Health Systems Act repealed; HUD retreat begins.
• 1987
  McKinney Act — first federal homelessness law.
• 1990s
  Continuum of Care “staircase” era.
• 1992
  Tsemberis founds Pathways to Housing — Housing First.
• 2003–10
  Bush chronic initiative → HEARTH Act → Opening Doors; veteran homelessness halved.
• 1996–2010
  OxyContin era: pill boom, then reformulation pushes users to heroin.
• 2006
  Combat Meth Act kills domestic ephedrine labs; cartels answer with P2P.
• 2013+
  Fentanyl era begins; West Coast unsheltered surge.
• ≈2020
  The game changes in Spokane: counterfeit-M30 fentanyl and P2P meth arrive in force alongside COVID; OD deaths 80 (2019) → 346 (2024).
• 2018–24
  Martin v. Boise → Grants Pass reversal; Blake; Camp Hope; TRAC opens & closes.
• 2024–26
  TRAC closes; scattered-site model falls short of displaced demand; unsheltered 443 → 643; downtown vacancy hits ≈30–40%.
• 2023–26
  Measure 1 fails → Safe & Healthy Task Force → June 2026 Recommendations; federal NOFO pivot; this map.

A general history, deliberately compressed — the full literature runs to thousands of pages. Key sources: E. Fuller Torrey, American Psychosis; Kim Hopper, Reckoning with Homelessness; HUD/USICH program histories; Tsemberis’ published trials; state hospital census series; local reporting archived throughout this map’s Sources tabs. Corrections welcome — see Help us get this right.