Several top candidates say the city must also expand services for people struggling with mental illness and drug addiction. Although city officials have said 29% of homeless people , that number is likely far .

But the candidates don’t agree on how to deliver the services that would help them.

City Council member wants the city to run its own homeless services agency and withdraw from the Los Angeles Homeless Services Authority, an bureaucracy run jointly by the city and county to manage housing and services for L.A.’s homeless population. Billionaire developer and City Council member want the city to create its own mental health department. U.S. Rep. and City Attorney favor sticking with the county, arguing that pooling resources is better.

Their differences boil down to a deceptively simple question: Can the city do a better job of managing the homelessness crisis by itself?

“It’s a strange model we have in Los Angeles between the county and the city,” said Seth Kurzban, clinical associate professor at the University of Southern California Suzanne Dworak-Peck School of Social Work. “If they create a city model, it has to be something that functions and not what we have now, which is the culmination of decades of bad policy choices.”

The two local governments began working together to coordinate housing and services for homeless people, but as homelessness has gained visibility in parks, along freeways, and on sidewalks, tension has grown between the two, putting the future of the arrangement in doubt.

Voters have also grown increasingly frustrated as they encounter homeless encampments in their neighborhoods. The homeless count in L.A. — to 41,290 — in 2020, the most recent year for which data is available.

The June 7 primary will winnow the field of 12 candidates. The top two vote-getters will face off in the Nov. 8 general election. 

Dr. Jonathan Sherin, director of the county’s mental health department, is encouraged that a handful of are prioritizing behavioral health, despite their disagreement on governance. In the past, he said, behavioral health was treated as “a stepchild that has been neglected for decades.”

Caruso, a longtime , wants the city to establish its own department of mental health and addiction services. Caruso said he would hire 500 mental health and addiction case workers, dispatch mental health workers to respond to 911 calls, and crack down on illegal drug sales.

De León, a Democrat, believes the current patchwork system for dealing with mental health and substance use has failed. He said that creating a city department of mental health would be more efficient because it wouldn’t have to compete for funding with 87 other cities in the county.

De León also wants mental health professionals to be on duty 24/7 within the Los Angeles Police Department and accompany officers on 911 calls.

Bass, a former physician assistant who led a community-based substance use and prevention program in the 1990s, thinks creating a department could take 10 years and divert money away from homeless services. A better strategy, the Democrat said, is to continue partnering with the county to rebuild treatment programs for mental health and substance use disorders that were dismantled because of inadequate funding. She would like to add beds to residential treatment facilities.

Feuer, also a Democrat, agrees with Bass that the biggest problem is lack of resources, not bureaucratic inertia. Both candidates back the creation of a Trieste model, a mental health system named after the northern Italian city where it was pioneered in the early 1960s. The program focused on integrating people with mental illness into the community and providing them with extensive support services, rather than hospitalizing them.

Today, the Los Angeles County Department of Mental Health is in the final stages of setting up a .

“There is a roadmap for the future, and these problems can be fixed,” Feuer said. “But our choices will require political will to implement them.”

The Trieste model didn’t work when it was tried in San Francisco, however. In 2006, the psychiatry department at Zuckerberg San Francisco General Hospital began a collaboration with Trieste’s mental health department to replicate its model but later after determining that differences in the social and economic conditions of the two cities made it impossible.

A new report is adding urgency to the issue in L.A.: Los Angeles County officials found a in the number of drug overdose deaths among homeless people in the 12 months before and after the pandemic began in March 2020.

In recent weeks, the of shirking its responsibility by lowballing the number of beds needed for people who are chronically homeless so it can settle a federal lawsuit brought by downtown residents and business groups. A county commission has called for creating a to direct all county homeless services. And the homeless authority will soon have a leadership vacuum — its chief has announced because of a dispute with the board over staff pay.

In other California cities that have borne the brunt of the state’s homelessness crisis, mayors haven’t focused as much on governance change. But they have begun lobbying for a greater slice of homeless funding.

“Here’s something that most people don’t understand or aren’t aware of: Cities are not homeless service agencies; cities are not health and human services agencies,” Sacramento Mayor Darrell Steinberg said at an April 25 news conference with 10 other mayors. The group urged the state to approve in flexible homeless funds for cities over three years.

“All the mental health money and substance abuse money flows through the counties,” Steinberg said.

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The situation wasn’t terrifying, as it was in September 2020, when disease swept through the Victorian Post Acute facility in San Francisco and Halperin, a 63-year-old former English as a Second Language teacher, became severely ill with covid. She spent 10 days in the hospital and required supplemental oxygen. Since the pandemic began, 14 residents of the nursing home have died of covid, .

Over time, Victorian Post Acute has gotten better at dealing with the virus, especially its milder omicron form, which accounted for 31 cases as of Jan. 27 but not a single illness serious enough to cause hospitalization, said Dan Kramer, a spokesperson for Victorian Post Acute. But the ongoing safety protocols at this and other nursing homes — including visitor restrictions and frequent testing of staff and residents — can be soul-killing. For the 1.4 million residents of the nation’s roughly 15,000 nursing homes, the rules have led to renewed isolation and separation.

“I’m feeling very restless,” Halperin said. She has Cushing’s syndrome, an autoimmune disease that caused tumors and a spinal fracture that left her mostly wheelchair-bound and unable to live independently. Although she has residual covid symptoms, including headaches and balance problems, Halperin, who has lived in the nursing home for nine years, is usually quite sociable. She volunteers in the dining room, helps other residents with their activities, and shops and runs errands during her frequent forays outside the building.

But covid infections are again spiking at nursing homes around the country. In California, 792 new nursing home cases on Jan. 19, compared with fewer than 11 cases on Dec. 19, 2021. However, the death rates are not nearly as bad as they were during pre-vaccine covid surges. From Dec. 23, 2021, to Jan. 23, 2022, 217 nursing home residents died of covid in California. By contrast, in just the week from Christmas 2020 to New Year’s Day 2021, 555 people died at nursing homes in the state.

Those numbers, and others cited in this article, don’t filter out patients who entered hospitals for treatment of other conditions but — a common occurrence during the omicron wave.

To keep nursing home residents out of overwhelmed hospitals, California public health officials have mandated masking and imposed strict vaccination and testing requirements for visitors and staffers at the homes, said Dr. Zachary Rubin, a medical epidemiologist with the Los Angeles County Department of Public Health. “Our approach is to prevent cases from coming into the facility, stop transmission once it gets into the facility, and to prevent serious outcomes,” he said.

Rubin acknowledged that some of these policies may seem like they’re doing more harm than good — but only temporarily, he hopes.

The omicron surge has created staffing shortages as nurses and aides call in sick, and the strict testing requirements have the effect of limiting visits by friends and relatives who provide crucial care and contact for some residents, bathing and grooming them, overseeing their diets and medications, and making sure they’re not being neglected.

Nationally, a requires all workers in federally funded facilities to be fully vaccinated by Feb. 28. The deadline was extended to March 15 for 24 states that challenged the requirement in court. Last month, California issued a similar order, which also requires nursing home staffers to receive .

However, while vaccination rates for staff members and residents are high in California (96% for staffers and 89% for residents), only 52% of nursing home workers and 68% of their residents in California have received boosters, according to . At Victorian Post Acute, 95% of staff and 92% of residents had been vaccinated with boosters as of Jan. 27, Kramer said.

Across the state, many unvaccinated staff members . Others say they can’t get vaccinated at their workplaces and don’t have time to get shots on their own, said Deborah Pacyna, a spokesperson for the California Association of Health Facilities, which represents the nursing home industry in Sacramento.

“We’re going to have to deal with that as the deadline approaches. If they’re not boosted, does that mean they can’t work?” she asked. “That would be an extraordinary development.”

The state hasn’t indicated how it will enforce mandates, especially for boosters, said Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform.

Most nursing home visitors, as of Jan. 7, must be fully vaccinated — including boosters, if eligible — . Guests also a negative covid test taken within one or two days, depending on the type of test. The federal government is sending four rapid tests to families that request them, and the state of California tests to nursing homes.

That’s “better than nothing,” said Pacyna, but it may not be enough for families that visit several times a week. Some experts think any policy that tends to restrict visitors sets the wrong priority.

“Limiting visitation is bad psychologically,” said , a professor emeritus in social and behavioral sciences at the University of California-San Francisco who has done extensive research on nursing homes. social isolation and loneliness can lead to depression, worsening dementia and cognitive decline, anxiety, a loss of the will to live — and increased risk of mortality from other causes.

Besides, Harrington said, most are caused by infected staffers, who often work multiple jobs because of the low pay.

Maitely Weismann visits her 79-year-old mother, who has dementia and uses a wheelchair, at a Los Angeles residential facility several times a week. Her mother deteriorated considerably during the initial lockdown, and Weismann is doing her best to slow her mother’s decline, she said.

“It’s much harder to do this during the pandemic because there are so many barriers to entry,” said Weismann, co-founder of the advocacy group Essential Caregivers Coalition. “Family caregivers can’t actually tell if a loved one is doing OK through a screen, or a window, or a phone call.”

Responding to the critical health care staff shortages, the CDC issued emergency guidelines in December — California followed suit in January — that who have been exposed to or test positive for covid to return to work if they are asymptomatic.

It’s a short-term, last-resort measure, Rubin said. “It’s just not possible to adequately take care of people and do the daily activities of living if you don’t have a nurse or caregivers. You just can’t operate the place.”

On one recent day alone — Jan. 24 — — which is roughly a tenth of the combined staff in California nursing homes. To deal with the crunch, said Pacyna, “we’re asking people to work extra hours, knowing that the peak is near and this isn’t going to last forever.”

In the meantime, families continue to worry about their loved ones. “When residents are isolated, they become completely dependent on the caregivers in the facility,” Weismann said. “But when staff stops coming to work, the system falls apart.”

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After decades of research, Bredesen had concluded that more than 36 drivers of Alzheimer’s cumulatively contribute to the loss of mental acuity. They range from chronic conditions like heart disease and diabetes to vitamin and hormonal deficiencies, undiagnosed infections and even long-term exposures to toxic substances. Bredesen’s impressive academic credentials lent legitimacy to his approach.

Pan paid $4,000 to a doctor trained in Bredesen’s program for a consultation and a series of extensive laboratory tests, then was referred to another doctor, who devised a stringent regimen of dietary changes that entailed cutting out all sugars, eating a high-fat, low-carbohydrate diet and adhering to a complex regimen of meditation, vigorous daily exercise and about a dozen nutritional supplements each day (at about $200 a month). Pan said she had extensive mold remediation done in her home after the Bredesen doctors told her the substance could be hurting her husband’s brain.

But two years passed, she said, and her husband, Wayne, was steadily declining. To make matters worse, he had lost more than 60 pounds because he didn’t like the food on the diet. In April, he died.

“I imagine it works in some people and doesn’t work in others,” said Pan, who lives in Oakton, Virginia. “But there’s no way to tell ahead of time if it will work for you.”

Bredesen wrote the best-selling 2017 book “” and has promoted his ideas in talks to community groups around the country and in radio and TV appearances like “The Dr. Oz Show.” He has also started his own company, Apollo Health, to market his program and train and provide referrals for practitioners.

Unlike other self-help regimens, Bredesen said, his program is an intensely personalized and scientific approach to counteract each individual’s specific deficits by “optimizing the physical body and understanding the molecular drivers of the disease,” he told KHN in a November phone interview. “The vast majority of people improve” as long as they adhere to the regimen.

Bredesen’s peers acknowledge him as an expert on aging. A former postdoctoral fellow under Nobel laureate Stanley Prusiner at the University of California-San Francisco, Bredesen presided over a well-funded lab at UCLA for more than five years. He has been on the UCLA faculty since 1989 and also founded the Buck Institute for Research on Aging in Marin County. He has written or co-authored more than 200 papers.

But colleagues are critical of what they see as his commercial promotion of a largely unproven and costly regimen. They say he strays from long-established scientific norms by relying on anecdotal reports from patients, rather than providing evidence with rigorous research.

“He’s an exceptional scientist,” said , a neuroscientist at the University of Texas-San Antonio. “But monetizing this is a turnoff.”

“I have seen desperate patients and family members clean out their bank accounts and believe this will help them with every ounce of their being,” said , a neurologist in the Memory and Aging Center at UCSF. “They are clinging to hope.”

Many of the lifestyle changes Bredesen promotes are known to be helpful. “The protocol itself is based on very low-quality data, and I worry that vulnerable patients and family members may not understand that,” said Hellmuth. “He trained here” — at UCSF — “so he knows better.”

The Bredesen package doesn’t come cheap. He has built a network of practitioner-followers by training them in his protocol — at $1,800 a pop — in seminars sponsored by the Institute for Functional Medicine, which emphasizes alternative approaches to managing disease. Apollo Health also offers two-week training sessions for a $1,500 fee.

Once trained in , medical professionals charge patients upward of $300 for a consultation and as much as $10,500 for eight- to 15-month treatment packages. For the ReCODE protocol, aimed at people already suffering from early-stage Alzheimer’s disease or mild cognitive decline, Apollo Health charges an initial $1,399 fee for a referral to a local practitioner that includes an assessment and extensive laboratory tests. Apollo then offers $75-per-month subscriptions that provide cognitive games and online support, and links to another company that offers dietary supplements for an additional $150 to $450 a month. Insurance generally covers little of these costs.

Apollo Health, founded in 2017 and headquartered in Burlingame, California, also offers a protocol geared toward those who have a family history of dementia or want to prevent cognitive decline.

Bredesen estimates that about 5,000 people have done the ReCODE program. The fees are a bargain, Bredesen said, if they slow decline enough to prevent someone from being placed in a nursing home, where yearly costs can climb past $100,000 annually.

Bredesen and his company are tapping into the desperation that has grown out of the failure of a decades-long scientific quest for effective Alzheimer’s treatments. Much of the research money in the field has narrowly focused on amyloid — the barnacle-like gunk that collects outside nerve cells and interferes with the brain’s signaling system — as the main culprits behind cognitive decline. Drugmakers have tried repeatedly, and thus far without much success, to invent a trillion-dollar anti-amyloid drug. There’s been less emphasis in the field on the lifestyle choices that Bredesen stresses.

“Amyloids sucked up all the air in the room,” said Dr. , an Alzheimer’s researcher and a professor of psychiatry and behavioral sciences at the Keck School of Medicine at USC.

Growing evidence shows lifestyle changes help delay the progress of the mind-robbing disease. An exhaustive in August identified a long list of risk factors for dementia, including excessive drinking, exposure to air pollution, obesity, loss of hearing, smoking, depression, lack of exercise and social isolation. Controlling these factors — which can be done on the cheap — could delay or even prevent up to 40% of dementia cases, according to the report.

Bredesen’s program involves all these practices, with personalized bells and whistles like intermittent fasting, meditation and supplements. Bredesen’s scientific peers question whether data supports his micromanaged approach over plain-vanilla healthy living.

Bredesen has positive results in many patients following his approach, but critics say he has fallen short of proving his method’s effectiveness.

The papers lack details on which protocol elements were followed, or the treatment duration, UCSF’s Hellmuth said. Nor do they explain how cognitive tests were conducted or evaluated, so it’s difficult to gauge whether improvements were due to the intervention, to chance variations in performance or an assortment of other variables, she said.

Bredesen shrugs off the criticism: “We want things to be in an open-access journal so everybody can read it. These are still peer-reviewed journals. So what’s the problem?”

Another problem raised about Bredesen’s enterprise is the lack of quality control, which he acknowledges. Apollo-trained “certified practitioners” can include everyone from nurses and dietitians to chiropractors and health coaches. Practitioners with varying degrees of training and competence can take his classes and hang out a shingle. That’s a painful fact for some who buy the package.

“I had the impression these practitioners were certified, but I realize they all had just taken a two-week course,” said a Virginia man who requested anonymity to protect his wife’s privacy. He said that he had spent more than $15,000 on tests and treatments for his ailing spouse and that six months into the program, earlier this year, she had failed to improve.

Bredesen said he and his staff were reviewing “who’s getting the best results and who’s getting the worst results,” and intended to cut poor performers out of the network. “We’ll make it so that you can only see the people getting the best results,” he said.

Colleagues say that to test whether Bredesen’s method works it needs to be subjected to a placebo-controlled study, the gold standard of medical research, in which half the participants get the treatment while the other half don’t.

In the absence of rigorous studies, said USC’s Schneider, a co-author of the Lancet report, “saying you can ‘end Alzheimer’s now and this is how you do it’ is overpromising and oversimplifying. And a lot of it is just common sense.”

Bredesen no longer says his method can end Alzheimer’s, despite the title of his book. still makes that claim, however.

This story was produced by , which publishes , an editorially independent service of the .

[Correction: This story was updated at 5:15 p.m. ET on Jan. 6, 2021, to correct the year that Apollo Health was founded.]

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