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It’s a slow, sad parade. the domestic-violence case, the petty assault in a food lineup on Granville, the drunken phone calls to a onetime “girlfriend” met in a shelter and now an enemy with a no-contact order.Then the shoplifters, in varying states of mental distress. Jason Phillips, who stole $33 worth of chocolate bars, just wants to plead guilty and get it over with. “I stopped a 16-year-old girl being raped…so I’m a public hero, right?” he says, somewhat tangentially. Susan Foulks, charged with stealing $200 worth of fragrances from Sephora. It’s her third shoplifting charge in three months — she has 13 convictions since 1999 — and her lawyer recites a familiar story: lives at the London Hotel, bipolar diagnosis, “long-term poly-substance abuse.” Judge Elizabeth Burgess is dubious about handing her yet another pass. “What assurance can you possibly give me?” Foulks, dressed this chilly winter day in a bomber jacket, denim capris, and flip-flops, sounds genuinely confused: “I promise you I won’t do it again. I didn’t understand before. I can go to Kingsgate Mall to do my shopping.”So unrolls yet another day at Vancouver’s Downtown Community Court, this groundbreaking city experiment aimed at doing something more with the mentally ill and drug-addicted than just cycling them through jail. What’s newer is happening a floor above, where a group struggles with what to do for the core offenders — the 10 percent who are bipolar, schizophrenic, have PTSD, with heroin, meth, crack, or prescription drugs possibly thrown in. Today, two probation officers, two nurses, a social worker, and team leaders from the health system and the justice system sit with psychiatrist Bill MacEwan to assess a dozen of those most in need of urgent help.Foulks has been on this list, but not today — she is already, as they say, case-managed. The goal for the others when they leave the Gore Street courtroom? To make sure they stay in the housing the team has found them, go to the recommended counselling, do the community work they’ve been sentenced to, take their prescribed anti-psychotic, anti-depressant, anti-mental-illness drugs.It sounds so simple: health and court workers conferring on the most complex cases. Yet it took months of negotiation back in 2008 between Vancouver Coastal Health and the justice system to secure the agreement that allows the agencies to share information at community court. Only this July did VCH rejig its court team to include real psychiatrists and nurses rather than clerical staff making referrals to already overloaded clinics. “Before that, it was a zoo,” says MacEwan. People kept out of jail by the court judge would be sent to their slum hotels with no coordination to make sure they were getting treatment. Of course some broke down, hurt others or themselves, before the system found them again. While stakeholders struggled to contain the chaos, a mental-health emergency worsened.Anne Mcnabb started as a nurse in the Downtown Eastside decades ago, working in clinics, visiting hotel rooms. She is now officially Director at Mental Health and Addictions Services, Inner City, but her real role is DTES Crisis Manager. Only in the last few months has the public heard that such a crisis — hundreds of mentally ill people using illegal drugs in combinations undreamed of only a decade ago — looms, as the police chief and mayor publicized statistics and stories of rampant violence and self-harm: 26 attacked by violent, mentally ill people in 15 months; mental illness a factor in 21 percent of police reports; 43 percent more people with mental-health issues in the St. Paul’s emergency room in the past three years. Researchers chimed in about the link between Downtown Eastsiders with psychiatric problems (74 percent) and addiction problems (95 percent) in the city’s residential hotels, the sizable overlap telling. The province responded in November with promises to invest an additional $20 million in treatment for those suffering the most from mental health/addiction illnesses, but for frontline workers like MacEwan, none of this is new: they’ve seen the storm clouds building for years.Vancouver Coastal Health and its affiliated nonprofits did a near-miraculous job of bringing overdose deaths down and halting the spread of HIV in the late ’90s, but with unforeseen consequences. “The needs are different,” McNabb explains. “Then, it was a public-health crisis about HIV. Now, there’s lots more chronic disease. People are living longer, and the population has a great deal more variety in the substances it uses.” For VCH, the two crises have meant trying to turn a cumbersome bureaucracy away from the standard model that still works for many in the city — call a medical service, make an appointment, show up, get treatment — but not for the next generation of mentally ill, dirt-poor people on a combination of booze, downers, and uppers.The health authority’s effort to adapt has meant a dispersed system designed for frustration, communication breakdowns, and confusion. A recently commissioned set of internal reports stated unequivocally that VCH’s biggest problem is “the absence of a clear, cohesive mission that staff can act on to address widely acknowledged gaps in care.” Managers feel disempowered. Nonprofits compete fiercely with each other for funding. The agency can’t seem to get moving on the simplest innovations that everyone agrees are needed — like a methadone service that can accommodate the fact that sometimes its clients are going to break the rules.Whatever 2.0 is settled on in the coming year, McNabb will be responsible for getting it to work at street level. She says the new model is all about going where people in the Downtown Eastside are: their hotels, the streets, wherever. To that end, she’s been putting groups in place for a new kind of medical SWAT response: this year’s Downtown Community Court team is only the latest in a drive that began six years ago when she sent a POS team (that’s Primary Outreach Services, in the acronym-laden language health agencies adore) including a doctor, nurse, case manager, mental-health specialist, and addictions pro to cover a defined set of hotels. Two more were added in 2009. More recently, Assertive Community Treatment teams are tracking particular people rather than covering designated hotels.There are other changes. McNabb has negotiated groundbreaking information-sharing agreements between police and the health system, similar to the one at community court. She’s planning to station POS teams out of the big, difficult social-housing projects that Housing Minister Rich Coleman insisted on building the last three years to take in the city’s homeless. Just as important, she’s emphasizing the need to collect evidence about what impact different health services actually have. One of the more startling discoveries about the Downtown Eastside is that many health groups know how many patients they’ve seen, shots they’ve given, needles they’ve distributed, tests they’ve administered — but very few can provide any robust information on the difference they’ve made to anyone’s health in the long term.Vancouver Coastal Health spends $66 million a year in the 40-some blocks of the DTES. That doesn’t include money spent on the hundreds of people from the neighbourhood who use the E.R. or psychiatric beds at St. Paul’s, and it’s separate from the cash delivered for area housing, courts, and policing. Nearly half goes to a long, baffling list of nonprofits. It seems like a lot — about $15 million to housing operations alone — until weighed against the never-sated demands. “Part of our limitations — there is no new money,” says McNabb, whose health-care team has depended, at points, on private donors. (Goldcorp funded one.) That shift has been painful. In November, five nonprofits were to lose hundreds of thousands of dollars in funding.”It was a huge shock and devastating to our organization,” says Adrianne Fitch, executive director of one, the West Coast Mental Health Network. “We were keeping people out of the hospital.” More unsettling changes will come. McNabb says her group has started assessing the exact level of help needed by the 4,600 people who use VCH’s mental-health services in the Downtown Eastside. The group has determined that about 500 Level 1 people don’t need intensive services. “That should create some capacity and flow to reach higher-needs clients,” says McNabb. “But we have to do a major culture shift.”Not everyone plans to shift alongside. Susan Giles and Evanna Brennan have worked as nurse partners in the Downtown Eastside for 30 years. They pioneered the concept of bringing health care to clients wherever they could find them, making their way through some of the city’s grottiest hotels, back alleys, and unplotted hangouts — classic examples of the dedicated missionaries the area, and the health system, attracts. Along the way, they won several awards. McNabb’s POS teams are an update of the approach that Giles and Brennan developed.But the two don’t work for VCH anymore. Faced with increasing demands to spend time entering information into the agency’s cumbersome computer system, dismayed when their boss told them they’d be split up, ground down by the Sisyphean task they face — that VCH also faces — they chose to retire. They now spend a couple days a week working for nonprofit housing agencies.On one recent Tuesday, they hit Bridge Housing, the women’s residence on Columbia, where Brennan rubs cream onto the burned-looking legs (the result of collapsed veins) of a woman while Giles asks about her cancer pain. Then they’re on to a shelter on Alexander Street, where they operate out of what looks like closet. One woman, 44, wanders in to ask if the bruises from the beating she got the other day are normal. She excitedly tells the nurses she is on her way to live in Surrey, with a group called Servants Anonymous, for survivors of the sex trade.The two companionably get her history and offer encouragement. “What’s your methadone dose?” asks Giles. “A hundred,” she says proudly. “Down from 160. When I was at 160, I was doing a lot of crack. Now I’m clean for three weeks.” “Good for you,” Giles says, as she searches for ibuprofen to hand out. “You’re making good progress, which is great,” Brennan adds. The woman, obviously hungry to talk, praises the work they do. When she leaves, there are two others hovering outside the door.Giles and Brennan carry on, a few pills handed out, notes taken. It’s an endless job, one where people get a little bit better — but maybe not. Where they get off the street — into an abusive relationship. Off one drug — and onto another. They keep on trying, though, and try to run in harness together while they do it. Sometimes it works. Bill MacEwan tries to make change from inside. Sometimes it doesn’t. People keep pouring over the walls no matter what.