The Brief

As Dr. Rishi Patel’s street medicine van bounces over dirt roads and empty fields in rural Kern County, he’s looking for a particular patient he knows is overdue for her shot.

The woman, who has schizophrenia and has been living outside for five years, has several goals for herself: Start thinking more clearly, stop using meth and get an ID so she can visit her son in jail. Patel hopes the shot — a long-acting antipsychotic — will help her meet all of them.

Patel, medical director of Akido Street Medicine, is one of many street doctors throughout California using these injections as an increasingly common tool to help combat the state’s intertwined homelessness and mental health crises. Typically administered into a patient’s shoulder muscle, the medication slowly releases into the bloodstream over time, providing relief from symptoms of psychosis for a month or longer. The shots replace a patient’s oral medication — no more taking a pill every day. For people who are homeless and routinely have their pills stolen, can’t make it to a pharmacy for a refill or simply forget to take them, the shots can mean the difference between staying on their medication, or not.

“They’ve been an absolute game-changer,” Patel said.

Street medicine teams bring the shots directly to their patients wherever they are — whether it’s in a tent along Skid Row in Los Angeles, in a dugout in the middle of a field in the Central Valley, or along the bank of a stream in Shasta County. Doctors can diagnose someone, prescribe the medication, get their consent and give the shot within a matter of days — or sometimes even more quickly — and with minimal paperwork and red tape. They don’t need a psychiatrist’s sign-off.

It’s estimated that California is home to more than 180,000 homeless residents. How to help the sickest of them — people with severe, untreated psychosis who might wander into traffic or otherwise put themselves in danger — has become a hot-button issue, with Gov. Gavin Newsom and state lawmakers creating new and sometimes controversial ways to get people into treatment. In a recent UCSF survey of homeless Californians, 12% reported experiencing hallucinations in the past 30 days, and more than a quarter said they’d ever been hospitalized for a mental health condition.

Doctors say the goal of giving an antipsychotic shot to someone living in an encampment is to get them thinking clearly, so that they can start engaging with social workers, sign up for benefits and get on housing waitlists. While Newsom’s new CARE Court allows judges to order people into mental health treatment, and other recent legislation makes it easier to put people with a serious mental illness into conservatorships, doctors administering street injections take a different approach. The treatment is voluntary, and people can get help where they are, instead of in a locked facility.

An Abilify Maintena shot being prepared by the Akido street medicine team at their main office in Bakersfield on May 28, 2024.

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Larry Valenzuela

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CalMatters/CatchLight Local

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Some success stories are dramatic. Doctors talk about patients who one day are babbling incoherently, and a week after a shot, are having conversations.

“It’s been pretty common that that’s the initiation of, ‘We’re going indoors,’” said Dr. Coley King, director of homeless health care for the Venice Family Clinic in Los Angeles. He said he’s seen dozens of patients get off the street after taking these shots.

As with any medication, the shots can have side effects. And while a patient can stop taking a pill and generally put a stop to a negative reaction, once they’ve been given a shot, they have no choice but to wait a month for the drug to wear off.

Despite some street doctors’ rave reviews, injectable antipsychotics still aren’t reaching everyone who experts say they could help. Street medicine teams report having just a handful of patients on these medications at any one time (King’s team in Los Angeles has about two dozen). Some patients don’t want the shots, balking at the idea of having a drug in their system for an entire month, especially if they have feelings of paranoia related to health care.

And street doctors complain that hospitals still seem to prefer discharging patients from temporary psychiatric holds with a bottle of pills they may or may not take – instead of giving them a long-acting shot.

Losing track of patients

One of the biggest challenges street doctors face in administering these shots is following up with patients.

In Kern County, Patel hasn’t seen the woman he’s looking for since his team gave her first antipsychotic shot almost two months ago. Now she’s past due for another dose.

It’s worrying, Patel said, “because I don’t know how she did on it.”

The last place they saw her was at an encampment known as “The Sump” in the Central Valley farming community of Lamont, where she lived in a plywood shack along a muddy ditch behind a farm. But code enforcement recently cleared everyone out of that area, and Patel’s team doesn’t have a phone number or any other way to contact her.

The Akido street medicine team checks for a patient they are looking for in a homeless encampment in a dirt field in Arvin on May 28, 2024.

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Larry Valenzuela

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CalMatters/CatchLight Local

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The first place they look is another encampment known as “the Shrine,” because it once held a shrine to Santa Muerte, a Mexican saint of death often prayed to by drug dealers. The team drives the van through an empty field of dead, yellow grass. Several people are living in room-sized pits they’ve dug into the dirt and covered with tarps and sheets of metal. Next to the vacant land is a vineyard, with rows of vines dotted with small, green grapes.

She’s not there, so the team hands out sack lunches and bottles of water, then gets back in the van and leaves.

“We’ve seen results,” said Kirk McGowan, a street medicine nurse with Akido. “But we’ve seen more failures than successes. That’s just kind of the nature of the situation.”

Who should prescribe antipsychotic injections?

In most cases, the people prescribing and administering antipsychotic shots in homeless encampments are general practice doctors — not specially trained psychiatrists. That’s because despite the growing prevalence of street medicine, street psychiatrists are still rare, according to a recent USC report.

“You look over your shoulder and there’s not a psychiatrist there helping you out,” King said. “And we want to meet the need. We want to take care of these patients. They’re really, really ill, they’re really disorganized, and suffering and dying on the streets.”

There are no legal restrictions preventing a general practice doctor from administering these injections. But some practitioners think the responsibility should be reserved for psychiatric providers.

“These medications are in there for an extended period of time,” said Keri Weinstock, a psychiatric nurse practitioner who practices street medicine in Shasta County. “They do come with risks. There are specialty things that come along with some of these specialty meds, and it’s a lot to learn when you have to know everything else, too.”

Some street doctors who give these shots seek out additional psychiatric training, while others learn on the job — often with a psychiatrist on speed dial, just in case.

“I don’t think it’s rocket science to diagnose schizophrenia, as long as we’ve done it with some thoughtfulness,” King said.

In-the-field diagnoses aren’t always clear-cut, Patel said. Sometimes, people do such a good job of hiding their symptoms that it’s hard to tell they’re dealing with psychosis. Or, instead of experiencing obvious hallucinations or other symptoms commonly associated with schizophrenia, patients experience “negative symptoms,” such as extreme social withdrawal.

When those types of cases arise, Patel calls a psychologist for a second opinion.

While these drugs are generally considered safe, they do come with a risk of side effects that can include dizziness, sedation, stiffness and decreased mobility. Those symptoms might be no big deal for someone living in a house, but for someone on the street, could be catastrophic, said Dr. Shayan Rab, a street psychiatrist with Los Angeles County’s Homeless Outreach and Mobile Engagement team. It could make someone more vulnerable to being attacked or robbed, or prevent them from accessing food or shelter.

“It’s a very serious kind of action that’s being taken and a lot of time needs to be spent before you say, ‘Hey, this individual is safe for a long-acting injection,’” he said.

To make sure a patient doesn’t have an adverse reaction, doctors typically give them an oral dose of the same medication for a few days before administering the shot.

There’s also a risk that after a street doctor gives someone a shot, that patient could later get sent to the hospital on a temporary psychiatric hold. Doctors there might not know the patient already has a long-acting dose of antipsychotic medication in their body, and might give them another dose.

Before giving someone a shot, Dr. Aislinn Bird wants to be 100% sure their symptoms are actually caused by psychotic disorder, such as schizophrenia, and not complex PTSD, major depressive disorder, methamphetamine use, or something else. Overdiagnosis of psychotic disorders is rampant, especially in the African American community, Bird said.

“You have to be sure you really know the correct diagnosis,” said Bird, who serves as director of Integrated Care at Health Care for the Homeless in Alameda County.

But Dr. Susan Partovi, who practices street medicine on Skid Row in Los Angeles, said that’s an “antiquated way of thinking.” When someone is experiencing psychosis, it’s an emergency that needs to be treated as soon as possible, no matter the cause, she said. Her preference is to treat the symptoms first, and then see if the patient wants to work on other issues, such as substance use.

Antipsychotic injectables, such as Abilify and Invega, tend to be most prevalent in street medicine practices. But street doctors also administer long-acting injectable HIV medication, as well as medication for addiction such as Vivitrol — an injectable, long-acting medication that can help reduce cravings for opioids and alcohol, and protect against overdose.

Silencing the voices in his head

Ricardo Fonseca Jr., who goes by “Ricky,” has been homeless for two years, living in a tent behind a Dollar Tree, then in a park in rural Kern County. The 31-year-old said he was working as a welder until he had a sudden mental breakdown and started hearing voices.

The voices said horrible things to him. Sometimes they yelled, and he yelled back, scaring those around him. He used methamphetamine to cope.

“It was getting to the point where I just felt like killing myself,” Fonseca said.

Two months ago, Fonseca started taking a monthly shot of the antipsychotic drug Abilify. Since then, “everything’s changed,” he said.

Now, Fonseca is staying at a friend’s house and considering going to school. He says he’s stopped using meth.

“I can finally hear the birds and the crickets,” he said. “I couldn’t hear them before.”

As Los Angeles homeowners grapple with the expense of rebuilding after last year’s devastating fires, an L.A. City Councilmember is putting forward an idea that could lower some costs.

Councilmember Traci Park, who represents the Pacific Palisades, has introduced a motion to explore waiving part of the city’s portion of the local sales tax for fire victims who purchase rebuilding materials in the city.

The 1% of the local 9.75% sales tax that goes into the city’s general fund would be given back to consumers under the proposal. The waiver could apply to lumber, appliances and other rebuilding goods purchased within the city.

The motion, introduced Friday by Park and seconded by Councilmember John Lee, says: “The City should do everything within its power to alleviate the financial burden for these residents and businesses in order to facilitate their return and stabilize the Pacific Palisades community.”

Would it make much of a difference? 

Economists told LAist the proposal could help many homeowners mitigate the high cost of rebuilding, but likely wouldn’t tip the scales for under-insured, under-resourced property owners.

“It wouldn't hurt if it's very well designed and easy to use,” said Alexander Meeks, a director at the Santa Monica-based Milken Institute. “But I'm not sure if it's really going to tackle the scale of the financial challenge that survivors are facing.”

Meeks noted that the tax waiver wouldn’t lower up-front costs such as environmental testing, architectural design and permitting. And it may not help homeowners sourcing raw materials from outside the city.

Zhiyun Li, a UCLA Anderson School of Management economist, said the waiver could help some homeowners justify the additional cost of rebuilding more fire-safe structures.

“Homeowners must typically pay out of pocket to upgrade to IBHS+ standards, which are more stringent,” Li said. “The tax waiver could encourage upgrading to IBHS+ standards or investing more in mitigation, thereby reducing future risk and improving the likelihood of maintaining insurance coverage.”

What’s next for the proposal? 

The proposed tax relief would not be available to properties that have been sold since the fires started in January 2025.

The motion has been sent to the City Council’s budget and fire recovery committees. If approved by the full council, it would require the city administrative officer, the Office of Finance and the city attorney to report back to the council within 60 days on options for crafting a tax relief plan.

The motion calls for the report to consider factors such as how to minimize the burden of administering the tax relief, what documentation homeowners would have to submit and what it would cost the city to oversee the program.

Senate and House Republican leadership have resurrected a stalled plan to fund the Department of Homeland Security after a record 47-day funding lapse.

House Speaker Mike Johnson, R-La., and Senate Majority Leader John Thune, R-S.D., said in a joint statement on Wednesday that the House will take up a measure passed by the Senate last week to fund most of DHS except Immigration and Customs Enforcement and Border Patrol through the end of September.

Republicans would then attempt to fund ICE and Border Patrol for three years using a party-line budget reconciliation bill that would not require support from Democrats.

"In following this two-track approach, the Republican Congress will fully reopen the Department, make sure all federal workers are paid, and specifically fund immigration enforcement and border security for the next three years so that those law-enforcement activities can continue uninhibited," Thune and Johnson wrote.

The agreement comes nearly a week after House Republicans dismissed an identical plan, refusing to take up the Senate-passed measure and instead passing a 60-day short term funding bill for all of DHS that had little chance of overcoming Democratic opposition in the Senate.

Johnson called the agreement a "joke" and President Donald Trump declined to publicly endorse the deal. Trump had previously resisted any package that did not include his push to overhaul federal elections known as the Save America Act.

"I think any deal they make, I'm pretty much not happy with it," Trump told reporters last week.

Democrats welcomed the agreement as in line with their pledge not to give ICE any more money without reforms after immigration enforcement agents killed two U.S. citizens in Minneapolis. But the deal does not include any of the policy demands Democrats are pressing for, such as a ban on masks for immigration enforcement officers and requiring warrants issued by a judge, not just the agency, to enter homes.

"For days, Republican divisions derailed a bipartisan agreement, making American families pay the price for their dysfunction," Senate Minority Leader Chuck Schumer, D-N.Y., wrote in a statement Wednesday. "Throughout this fight, Senate Democrats never wavered."

Trump seemed to bless the revived plan earlier Wednesday, writing on social media that he wants a party-line bill to fund immigration enforcement on his desk by June 1.

"We are going to work as fast, and as focused, as possible to replenish funding for our Border and ICE Agents, and the Radical Left Democrats won't be able to stop us," Trump wrote.

Despite the shutdown, ICE has been minimally impacted because Republican lawmakers approved $75 billion for ICE through another party-line budget reconciliation bill last year.

Congress is on a two-week recess, but the Senate and House could move to fund all of DHS except ICE and CBP as early as Thursday using a procedure known as unanimous consent that allows the chambers to circumvent formal voting as long as no member objects.

Even during a recess when most members are not in Washington, this could be unpredictable, especially in the House, where many hard-line conservatives oppose a deal that does not fully fund DHS.

"Let's make this simple: caving to Democrats and not paying CBP and ICE is agreeing to defund Law Enforcement and leaving our borders wide open again," Rep. Scott Perry, R-Pa., a member of the ultra-conservative House Freedom Caucus, wrote on X. "If that's the vote, I'm a NO."

If a member does object, that could require waiting for another vote when all members are back from recess.

Claudia Grisales contributed reporting.
Copyright 2026 NPR

California clocked its second-worst snowpack on record Wednesday, a potentially troubling signal ahead for fire season.

It’s an alarming end to a winter that saw abnormally dry conditions briefly wiped from California’s drought map in January, for the first time in a quarter-century.

Though precipitation to date has been near average, much of it fell as rain rather than snow. Then March’s record-breaking heat melted most of the snow that remains. The state’s major reservoirs are nevertheless brimming above historic averages and are flirting with capacity, and a smattering of snow, rain and thunderstorms are dousing last month’s heat wave.

But experts now warn that California’s case of the missing snowpack could herald an early fire season in the mountains.

On Wednesday, state engineers conducting the symbolic April 1 snowpack measurement at Phillips Station south of Lake Tahoe found no measurable snow in patches of white dotting the grassy field.

“I want to welcome you call to probably one of the quickest snow surveys we’ve had — maybe one where people could actually use an umbrella,” joked Karla Nemeth, director of the California Department of Water Resources. “We’re getting a lot of questions about are we heading into a hydrologic drought? The answer is, I don’t know.”

State data reports that California’s snowpack is closing out the season at an alarming 18% of average statewide, and an even more abysmal 6% of average in the northern mountains that feed California’s major reservoirs.

Only the extreme drought year of 2015 beat this year’s snowpack for the worst on record, measuring in at just 5% of average on April 1st, when the snow historically is at its deepest.

“I think everyone's anticipating that it will be a long, busy fire season,” said Lenya Quinn-Davidson, director of the UC Division of Agriculture and Natural Resources Fire Network.

“Without a snowpack, and with an early spring, it just means that there’s much more time for something like that to happen.”

‘It’s pretty bizarre up here’ 

In the city of South Lake Tahoe, which survived the massive Caldor Fire in the fall of 2021 without losing any structures, fire chief Jim Drennan said his department is already ramping up prevention efforts.

“It's pretty bizarre up here right now. It really seems like June conditions more than March,” Drennan said. “People are already turning the sprinklers on for their lawns.”

Without more precipitation, an early spring may complicate prescribed burning efforts. But Drennan said fire agencies in the Tahoe basin can start mechanically clearing fuels from forest areas earlier than usual.

“That means we can get more work done,” he said.

It also means homeowners need to start hardening their homes now, said Martin Goldberg, battalion chief and fuels management officer for the Lake Valley Fire Protection District, which protects unincorporated communities in the Lake Tahoe Basin’s south shore.

Goldberg urges residents to scour their yards for burnable materials, create defensible space and reach out to local fire departments with questions. The risks are widespread — from firewood, wooden fences, gas cans, plants, pine needles — even lawn furniture stacked against a house.

“In years past, I wouldn't even think of raking and clearing until May,” Goldberg said. “But my yard's completely cleared of snowpack, and it has been for a couple weeks now.”

‘A haystack fire’

Battalion chief David Acuña, a spokesperson for Cal Fire, said fire season is shaped by more than just one year’s snowpack.

Climate change has been remaking California’s fire seasons into fire years. And California’s recent average to abundant water years have fueled what Acuña called “bumper crops of vegetation and brush.”

“Most of California is like a haystack. And if you’ve ever seen a haystack fire, they burn very intensely because there's layers of fuel,” Acuña said.

Like Quinn-Davidson, Acuña wasn’t ready to make specific predictions about fires to come.

But John Abatzoglou, a professor of climatology at UC Merced, said the temperatures and snowpack conditions this year offer a glimpse of California in the latter decades of this century, as fossil fuel use continues to drive global temperatures higher.

How this year’s fires will play out will depend on when, where and how wind, heat, fuel and ignitions combine. But it foreshadows the consequences of a warmer California for water and fire under climate change.

“This,” Abatzoglou said, “is yet another stress test for the future in the state.”

This article was originally published on CalMatters and was republished under the Creative Commons Attribution-NonCommercial-NoDerivatives license.