A woman sat cross-legged on concrete in Anchorage's Fairview neighborhood, lit by a streetlight. She wore dirty red sweatpants, sneakers and layers of shirts in the biting cold. Her head lolled right and left.
An ambulance and fire engine pulled up, sirens bawling. A call for help had come into dispatch: 13th and Hyder. Chest pains. Was it a heart attack?
In the early winter darkness, five firefighters approached the woman.
"How are you doing?" a paramedic asked.
The woman squinted through puffy eyelids.
"I'm drunk," she said.
That interaction began a night in which the woman cycled through an ambulance, a hospital emergency room and a van to the city sleep-off center. Each step cost the city and the health care system, but left her no better off than before.
Most of Anchorage's homeless are not alcoholics.
But a large proportion — about 20 percent, according to a "point in time" study that surveyed the city on a single night in January 2014 — exists at the confluence of chronic homelessness and addiction. The group that city officials call "chronic public inebriates" fluctuates in size, but doesn't top 400 people.
Social service agencies and police refer to a core group of 200 "top users" that represent the most prolific consumers of public services, gripped by a lifestyle of compounding health problems and increasing risk of death.
Similar versions of the interaction at 13th Avenue and Hyder Street — a drunk person, an emergency response, transportation to an emergency medical or drunk facility — happen dozens of times each day in Anchorage, according to police, firefighters, doctors and social workers.
The endless loop represents an expensive problem that has vexed Alaska's largest city for generations. Private and public agencies have poured studies and committees, plans and money on the situation. While the efforts suggest protecting the health and welfare of the most vulnerable people remains a community priority, it's hard to pinpoint what has been accomplished.
By measures of human misery and mounting costs to the public, the situation is as bad now as it ever has been, and in some ways worse.
Anchorage Safety Center, the city's emergency sleep-off shelter, had more visits in 2013 — the most recent data available — than in any year before. The most frequent visitor spent 275 nights of the year there.
Those visits came with a cost.
In 2014, the city spent a record $1.97 million on a year-long contract to run the center and Anchorage Safety Patrol, a van service exclusively devoted to transporting drunk people in public places to the sleep-off center. The center and patrol are not designed to help people get better. They're purely a humanitarian Band-Aid meant to keep people from dying in snowdrifts.
The scope of the problem is staggering, and some say it appears to be growing worse.
On some days in 2014, demand for the safety patrol to pick up public drunks outstripped demand for all other emergency services, including vehicle accidents, medical problems and fires, according to data supplied by the Anchorage Fire Department.
The busiest fire station in the city, Station 1, serves downtown and the Ship Creek area, the heart of the city. In 2014, firefighters there answered more calls to just one address — Brother Francis Shelter — than the quietest station in the city, in the Rabbit Creek neighborhood, saw in total. It is the only station that must have its staff supplemented by rotations, fire officials say, because firefighters aren't voluntarily bidding to work there. It struggles to keep a full complement of paramedics, due in large part to burnout from dealing with a population whose problems appear self-inflicted and who can be hostile to people charged with caring for them, firefighters say.
Police evict an endless loop of "party campers" from tents around the city's vacant lots and forests. They say toothless laws mean there are no real penalties for street drinkers beyond fines that usually go unpaid.
"The problem is far worse than I've ever seen it," said Anchorage Police Department Lt. Gary Gilliam, who heads a special team charged, in part, with policing homeless alcoholics.
All the while, homeless drinkers continue to die. Some die outdoors and make the news, like a woman found dead in a tent in the Ship Creek area in December, or a man whose body was found under an overpass near Dimond Boulevard in November. But people who work in the field say many more die in hospital beds from acute alcoholism.
For more than two months, Alaska Dispatch News rode along as paramedics responded to "man down" calls, spent time at the sleep-off center and followed the cops as they dismantled camps. We spoke with people who were drinking in city parks and panhandling, and with some of the few who left the streets for sobriety and apartments.
Firefighters circled the woman at 13th Avenue and Hyder Street and lifted her to her feet.
She wobbled. Something was wrong with her heart, she said: "The rhythm's not beating right."
The firefighters led her to a stretcher and loaded her into the ambulance. Over the next 45 minutes, they took her to a hospital, completed paperwork and cleaned up. During that time, the crew and ambulance were unavailable for anyone else. There are only nine ambulances on duty at any given time in the Anchorage Bowl. It doesn't take much — a bad car accident or two — for all of them to be called into service at the same time, firefighters say.
They asked questions: Had she been sick? Coughing? Did she have an ID? Take any medications?
As they fished through the woman's polka-dot purse for identification, a nearly empty plastic fifth of Monarch Vodka tumbled out. Abruptly, the woman turned belligerent.
"You think?" she sneered to every question.
"Frickin' jerk," she said to a medic trying to determine whether she had any injuries. "Trying to get my frickin' clothes off."
The medic kept asking questions. The exam showed no acute problem, aside from drunkenness.
He asked which hospital the woman used.
"Every one," she said.
The medics took her to the emergency department at Alaska Regional Hospital.
Privacy laws forbid longtime emergency room doctor Gil Dickie from discussing patients, but virtually every overnight shift he works includes a few people who are there solely because they are drunk. Sometimes they come in as "man down" calls. Other times patients are too drunk even for medics to determine whether a serious problem exists. To rule out serious conditions, doctors perform tests. One CT scan of the head can cost $2,230, a heart EKG $674, a drug screening $588, according to the hospital. A blood alcohol test is $295.
If the person can't pay and doesn't have insurance, the cost usually ends up going into an "uncompensated care" account, said Kjerstin Lastufka, an Alaska Regional Hospital spokeswoman. The hospital eats the loss, which ultimately translates into higher rates for paying hospital customers.
Often, all those tests show the person is simply drunk. But not always: Dickie remembers a habitually drunken man who fell off a barstool. A scan revealed massive bleeding in his brain.
"The danger is to blow these people off," he said. "They do suck up a lot of our time and resources. But what's always been my feeling is that's what the emergency room is there for. We're a safety net for a lot of society."
Dickie, like paramedics, police and the safety patrol, sees some of the same people night after night. He, like medics and cops, gets to know their names, families and stories.
While many don't need emergency care for what they came to the hospital for, almost all have a complex set of pre-existing medical conditions, exacerbated by addiction and homelessness.
Severe alcoholism can cause a host of associated ailments, ranging from liver cirrhosis to brain atrophy and seizures, Dickie said. Homelessness exposes people to trauma from assaults and falls and to cold exposure injuries such as frostbite. At least a quarter of homeless people nationally suffer from a severe form of mental illness, according to the federal Substance Abuse and Mental Health Services Administration.
People living on the street who come drunk to the ER time and time again don't always lack a home.
Dickie thinks of one patient, a man in his 40s, brought in repeatedly with injuries from assaults or on "man down" calls.
"His mom picks him up every time," he said.
'A big cycle'
Later that night, medics from Station 1 were called to the busy sleep-off center, where dangerously intoxicated people sleep inside in a long, narrow room tucked behind the jail near Ship Creek.
A man in his 30s was so drunk that staff members decided he needed to be taken to the hospital.
The man was agitated and yelling. In the ambulance, medics put him in "soft restraints": Velcro straps that held his wrists to the gurney. He tried to hit a medic riding in the back. He asked for a diaper.
Before the ambulance arrived at the emergency room, medic Adam Peterson asked the man how much he'd had to drink.
Two fifths of whiskey, he answered. Same as every day.
After he was wheeled into the hospital, firefighter Rick Erickson stayed back, cleaning the gurney, spraying disinfectant and mopping. Some shifts, every run is like this one, he said.
The number of emergency responses to Brother Francis Shelter and the adjacent Bean's Cafe, the nucleus of a homeless crowd that includes many street drinkers, illustrates the outsized impact a small population can have on a public resource.
In 2014, firefighters were called to Brother Francis Shelter 848 times and Bean's Cafe 508 times.
No other addresses in the city garnered anywhere near that many calls. The closest runner-up, Stevens International Airport, had 238.
"Here's the crux of it: Uninsured, homeless, public inebriates are using 911 as their primary source of health care," said AFD deputy chief John Drozdowski.
Increasingly, some of the most frequent callers have learned how to manipulate the system to get an ambulance ride to the hospital instead of a van trip to the sleep-off shelter, using phrases like "chest pains" or "head injury."
"We take them to the hospital, they release them, they go to Anchorage Safety Patrol and they just sober up to get out and go do this again," says Matt Eckart, a medic at Station 1. "It's just a big cycle."
Rhett Paulson, a medic who was subbing at Station 1 for a shift earlier this winter, says he can see the attraction of the emergency room.
"If you go to the hospital, a lot of times there's free food. It's a much nicer bed," he said. "It's a softer bed. You're up off the floor."
Half of the calls he'd responded to that day were alcohol-related.
The medics at the station fight a daily battle against growing hard. In emergency medicine, cynicism can be dangerous: Severe intoxication and a head injury look similar. The last thing anyone wants, they said, is to miss a genuine emergency because a patient has cried wolf so many times before.
"Everyone who got into this job got into this job to help people," Paulson said. "After a while, if you run enough of those calls and it feels like you're not helping people but that you're enabling people … You have to watch yourself to make sure you're not getting a bad attitude about what you're doing, and that you're still providing high-level care to everyone."
Sometimes the paramedics feel they're in real danger.
Days after the call to 13th and Hyder, an ambulance responded to Dimond Boulevard for a "man down."
Before the ambulance arrived, medics realized the man was one of their "frequent flyers," a panhandler with a history of making threats to firemen. He had been transported by ambulance more than 40 times in 2014, said Mike Crotty, the AFD Emergency Medical Services battalion chief.
The firefighters now require that the police join them before they will approach the man.
'They call it home'
The white, windowless vans of the Anchorage Safety Patrol run 24 hours a day.
Calls are unceasing: Drivers are so busy they eat on the fly during their eight-hour shifts, if at all.
Safety patrol employees work in teams.
The team always approaches "clients" the same way: With blue gloves on, an EMT examines the person to determine whether the destination should be the hospital or sleep-off. Some won't go voluntarily and must be coaxed or even carried into the back of a van.
City officials didn't see the full picture of just how often the service was being called upon until June 2013, when the safety patrol began receiving all of its calls through the city's 911 dispatch center. The change was aimed at eliminating situations in which a police patrol car, ambulance and safety patrol van would all be summoned to the same drunk person.
The change revealed the true scope of demand: In 2014, Anchorage emergency dispatchers fielded an average of 68 calls per day for a person drunk in public, compared to 86 per day for every other type of non-police emergency.
The city has run a sobering-up center and pick-up service, in one form or another, since 1989.
The idea is simple: Anchorage's subarctic climate means that drunk people who do not find shelter could freeze or succumb to a host of other hazards. The sleep-off center is supposed to keep them safe until they are sober enough to navigate on their own. Alaska law gives the city legal authority to pick up people deemed dangerous to themselves or others and hold them at the sleep-off shelter up to 12 hours.
On one midweek evening in early winter, a safety patrol van picked up a man sitting with his head between his knees outside the Hotel Captain Cook, flanked by unhappy-looking security guards.
They peeled a younger guy from the asphalt outside City Hall.
They carried an incoherent man off the sidewalk in front of Brother Francis Shelter while bystanders screamed obscenities at them.
"I've been hurt a couple times," said Britney Gilmer, a 27-year-old who has worked as a safety patrol driver for the past two years. "I've been scratched. I've been punched. I've been tackled. I think everybody knows it comes with the job."
People accuse the safety patrol of enabling drunks, Gilmer said. She sees her job as making sure people live to see another day.
"I've picked up a lady who was face-down in the dirt and she was very close to not being able to breathe," she said.
Use of the emergency center has risen dramatically.
In 2013, the safety center recorded 26,518 admissions, an increase of 17 percent from 2009.
That year, Anchorage's sleep-off center saw 20 percent more arrivals than downtown Seattle's Dutch Shisler Sobering Support Center, which runs on a similar model. The Anchorage shelter was nearly seven times busier than San Francisco's Mission Street Medical Respite and Sobering Center, where ambulances can take drunk people rather than clogging hospital emergency rooms.
The Anchorage center is a long and narrow room that smells like gym mats, infrequently washed bodies and disinfectant. People stagger in and collapse on the mats. Men and women stay in separate sections. Often, someone is yelling. Boxes of absorbent medical pads are on hand for people who urinate on themselves. A windowless, concrete cell by the entrance where violent or disruptive people are held is called "the quiet room." People who are too out of control to remain are taken next door to the jail, where they are considered "non-criminal holds."
About one in 10 people walks into the center on his or her own, like the prim-looking older woman who on one winter night strolled through the door with her ID in hand, took a breath test and lay down on a mat, wrapped in her coat.
When people sober up, a staff member measures their breath alcohol content before they are free to walk out. Just before midnight on a recent night, a half-dozen people took breath tests and gathered their belongings from lockers in preparation to leave together in a group.
As they shrugged on coats, another group staggered inside, fresh from the van. The two groups greeted each other warmly.
The most depressing, van driver Gilmer said, is when families come into sleep-off together.
"Fathers and sons, mothers and daughters," she said.
She's heard people refer to the sleep-off center as "home."
As in, "We're going home."
''It's like digging in sand''
The sprawling camp in a thicket of woods near 46th Avenue and Bering Street in Midtown included bikes, tents and, improbably, a hospital gurney.
Anchorage police officer Sally Jones was there to post a sign warning the camp's inhabitants that they had 15 days to pack up and leave, or the camp would be torn down.
For Anchorage law enforcement, policing homeless alcoholics is an exercise in frustration.
"We just chase them around in the woods," Jones said.
As with some firefighters, police on the Community Action Policing team spend their shifts on a steady stream of drunk calls — about six a day on average, according to Mark Karstetter, an officer with the CAP team.
Break up one camp, police say, and another takes its place.
"It's like digging in sand," Karstetter said.
After settling a 2011 lawsuit with the ACLU, police began clearing the majority of the hundreds of homeless camps in the city.
Today, they are in a "maintenance phase" and down to a fraction of the active camps that once existed, with perhaps 50 hardcore campers living outside during the winter, according to Jones.
Recently, police worked with a private landowner to remove brush from a sloping lot near Brother Francis Shelter on East Third Avenue that attracted partying campers.
But some of the campers moved to a much more visible location, the sidewalks at Third Avenue and Karluk Street, between the jail and the shelter. A congregation of tents and tarps has sprouted there in recent months.
Alaska is one of just a few states in which being drunk in public is not a crime and the law directs police to help, not arrest, people incapacitated by alcohol.
Police contend that with donated tents, free food at soup kitchens, a sleep-off center for cold nights and weak laws governing public drinking, being a homeless alcoholic can be a viable lifestyle.
"We make it easy for them to be chronic public inebriates," Officer Jones said. "There's no one holding their feet to the fire."
The harshest penalties available now, she says, are pouring out a person's bottle of booze and sending them to the sleep-off center.
Social services exist to help homeless alcoholics, she says. Her job is different.
"I do get this a lot, 'Where do you want me to go? I can't camp anywhere.' And the short of the answer is I don't know … I mean, who is responsible for you? That's where the tough love comes in and it's like, if you get a caseworker, do step one, step two, you will get off the streets."
Gilliam and other members of the CAP team would like to see the rules get tougher, with the "top 50" users involuntarily committed to treatment.
Later, Jones arrived at a vacant, privately-owned lot near the Moose's Tooth restaurant in Midtown. Inside a tent she found a man, a woman and empty bottles.
The campers were squatting on private land. Jones told them they needed to move immediately.
The woman said the two were working with a social service agency to get off the streets.
Jones gave the couple until the following morning to leave.
But she knew it was likely she'd see them in another tent, somewhere else, again.
At 1:15 a.m., the same woman in red sweatpants that firefighters picked up at 13th and Hyder a few hours earlier sat on a bus stop bench in front of the Brother Francis Shelter. Emergency Medical Services Battalion Chief Mike Crotty was driving by. He stopped to talk to her.
Earlier, the woman said, staff at the hospital called the safety patrol to pick her up. The patrol delivered her to the sleep-off center. She was not drunk enough to warrant sleeping at the facility overnight.
She walked to Brother Francis Shelter, she said, but it was far too late to be let in for the night.
That's how she got to the bench.
She'd been heaving, and a stream of vomit led from the sidewalk in front of her to the street. She said she feared she was throwing up blood.
Crotty looked at the vomit and figured she was probably right. He offered to call for medics again, but she refused.
There was nothing left for her to do but wait for morning.
Editor's note: These stories were produced as a project for the National Health Journalism Fellowship, a program of the USC Annenberg School for Communication and Journalism.