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The Street Spirit Interview with Peter Marin
Peter Marin, poet, author, journalist, teacher — and activist. Kim Rierson photo
Street Spirit: You have been involved in homeless activism for nearly 30 years, ever since the massive increase in homelessness in the 1980s. In your experience, is the current level of poverty unprecedented in the United States? And what is your understanding of the relationship between homelessness and poverty?
Peter Marin: Yes, it is unprecedented. But I think homelessness is what happens to people when they fall out of poverty. I think it's very hard for us to understand that, because we do have certain social mechanisms — certain programs like welfare, unemployment and disability insurance — which are actually, in a way, set up to keep people in poverty, right?
You know, welfare is never enough to get you out of poverty. It's enough to keep you continuously in poverty until something goes wrong — and then you fall into homelessness. Homelessness usually occurs when none of the other programs have worked, or when you've come to their end, or when you've violated whatever welfare rules there are, and when your money dries up.
Spirit: Do you expect that the rates of homelessness and poverty will lessen or increase in the foreseeable future?
Marin: If anything, it's going to get worse now than it was in the past few years, because the worst times to be homeless are in economic boom times.
Spirit: Why do boom times make things worse for people living in poverty?
Marin: Because in boom times, rents go up, and gentrification occurs. When new buildings start going up, they start tearing down the old parts of cities. It's when people have more money to spend and invest that the little pockets where the homeless people manage to survive begin to disappear.
Spirit: In boom times, newspapers carry cheerful articles in the real estate and lifestyle sections about how rising housing prices are good news for upper-class homeowners and realtors. Yet, good news for the wealthy is very bad news for poor people who end up evicted due to rising rents and gentrification.
Marin: That's right! And this is a very interesting mechanism that I don't think anybody, including the Obama people, have really started to confront face to face — and that is, as you start to make things better for the middle class, they become worse for the poorest of the poor.
Spirit: It seems counterintuitive because people think a rising economy will lift all boats. Why is it that a rising economy for the rich often sinks the poor?
Marin: Rents begin to go up and people have more money. This happened many years ago in San Francisco, in Santa Barbara, in Chicago and New York. The skid row parts of the city become valuable as real estate because people are going to buy the old buildings, tear them down, and put up housing for the well-to-do. And in good years, or boom times, this process speeds up considerably.
People have more money and they have to invest it somewhere and housing and land are one of the best places to invest it. So they begin to look to those areas for profits — and their profits are really high. But in making those profits, you tear down the parts of the city which belonged to the poor.
Also, when people have more money, they begin to move into buildings in the city, they begin to build lofts, to build apartments. Even in Harlem, in New York, that's going on now. And what you find is that the areas which once belonged to people of different nationalities or ethnic backgrounds for long periods of time, are now subject to invasion from outside.
You can see that in New York, in San Francisco, and in other large cities. All of a sudden, there are posh restaurants where there used to be rundown taverns and places where poor people used to eat or drink, where they used to get haircuts, where they used to play pool, and where they used to live. All of these places vanish completely and cities are quite happy to see them vanish. They encourage this process.
I suppose it's also going on in Oakland, right? This is great for the city, this is great for young people with money, and this is great for the businesses that appeal to young people with money. The only ones who get injured are the poor.
"Scavengers." Oil painting by Christine Hanlon.
Spirit: In Oakland, one writer called it "The Tale of Two Cities," with one city for the rich, and an entirely different city for the poor. The wealthy enjoy an economic upswing and poor renters are evicted and dislocated.
Marin: There are two economies — and this has happened in a way that I think has become almost permanent now. Theoretically, you once could use the school system to rise up out of one class and into another, but that no longer works very well. Charles Murray has written about "the Super Zips" — the zip codes in which the rich live. What happens in those areas is that the rich subsidize their school system with music programs and arts programs and athletic programs. So it turns out, of course, that the children of the rich, when they go to public schools, are getting a totally different education than the children of the poor.
Spirit: Many people first became involved in fighting against the huge increase in homelessness in the early 1980s. It's now 30 years later. Does it surprise you that homelessness has persisted so stubbornly and has only grown larger in the last three decades?
Marin: No, it is not surprising. Look, years ago, I would go out and lecture about homelessness. People would ask me: "What's going to make it better?" I would say, "It's not going to get better."
Spirit: Why such a gloomy prediction?
Marin: Because what it's going to take to make it better is so far outside the usual frames of American political and social reference, that it's just not likely to happen.
Spirit: What are these solutions to homelessness that you feel will not happen?
Marin: Let's start with this: disability. You know how much disability payments are — $800 to $900 a month, maybe, for those who can even qualify. It was that same amount 20 years ago!
Twenty years ago, if you got disabled, the whole purpose of disability benefits was to give you just enough to scrape by on your own because everyone knew you couldn't work. So you would rent a downtown hotel room for $500 a month, and then you would have $300 to $400 left to spend on your needs. You could eat cheaply in diners, and get reasonable medical care if you were impoverished.
But you could get by. Now, 20 years later, disability payments are exactly the same amount that they were back then. But what is the cost of a room, if there are even any rooms? What happened to all the hotel rooms in the Bay Area?
Spirit: The rents skyrocketed in price or the hotels were torn down and gentrified. We've seen a massive number of "evictions for profit."
Marin. Exactly. Exactly. Now, have you heard a local or national politician talk even once about raising disability payments?
Spirit: No, the battle recently has been to cut benefits even more. A few liberals may oppose cutting them too severely, but that's about it.
Marin: Right, and no one says that the purpose of disability was to make it possible for people to survive without being on the streets, so let's raise them to the level it takes to survive.
Spirit: That's right. If rents have tripled and quadrupled, let's triple or quadruple the benefits, just so people have a chance to remain housed.
Marin: Yeah, and this is for people who we know cannot work through no fault of their own! This is for people who may have worked 20 years, and are not able to work now! And also, it's so much harder to get disability because they've tightened all the requirements. Now, even when you deserve it, it's hard to get because they have all these rules.
I have a friend who is a medical adviser to the disability program, so I hear these things all the time. The rules have tightened up, and what's going on with disability is going on everywhere. You know the welfare rules. If you have a man in the house, you don't get welfare!
I don't think anybody really understands that. The first thing I would do is change the welfare rules so that couples could get welfare. But welfare is still mostly only for women. There are a few exceptions in a few states where they have jiggled the system a little.
But does anybody understand that the welfare rules destroy the black family because it drives men out of the house and onto the street just so the women can get money from the government? No, nobody seems to understand that. These things are unconscionable.
When welfare was begun under Franklin Delano Roosevelt, the program was welfare for women, work for men. So we had the work programs of the CCC and the WPA. [The Civilian Conservation Corps and the Works Progress Administration were programs launched under Roosevelt's New Deal to put men back to work during the Depression.]
All the work projects of the 1930s were for men and welfare was for women who they thought at that time should stay in the house. But we don't have work projects any more, even though we know we have an infrastructure crisis going on in America. But has Obama or anyone else talked about a new federal work program for the unemployed and the homeless? No! So what do men get? They get general relief, which is $90 a month.
Spirit: In many areas, they may get general relief or general assistance for only three months out of the year.
Marin: So that's unconscionable! But who confronts any of this? It's true we have an argument about unemployment, but unemployment is not for people at the bottom of the system who have fallen through the cracks of the system.
I don't usually like to use the word hopeless, because I'm not without hope for the future. But this situation is fucking hopeless. And the politicians who are supposed to deal with it are hopeless.
Spirit: In the 1980s, Reagan drastically slashed federal housing programs. Since then, public housing has been cut by every new administration until now it has been decimated. Yet no one is calling for a massive investment in low-income housing.
Marin: Let me give you a local example of that. In Santa Barbara, we have a little bit of affordable housing because they make an attempt to produce it, but I think the minimum it costs is $50,000 a unit. It's not easy to put up affordable housing.
Now, we have countless people living in vehicles and RVs. But we have laws against living in your RV. We don't say, "Well, we know we don't have housing for people, so we know that one of the things poor people can do is live in RVs." Instead, every law on the books says you can't sleep overnight in a vehicle. If you park an RV within 500 feet of a church or a public building or a park, you get a ticket, and if you can't pay the ticket, they will tow your vehicle away.
We build housing, yes, but we know we can't build enough housing for everybody. So now we have the problem of what to do with everybody else, and yet when they say they're going to buy a vehicle and live in it, we tell them they can't.
So all the discussions seem to me absolutely senseless and disingenuous, because we are not really concerned about people getting off the street and sleeping inside something. Because if we were concerned about that, we'd make laws that permit them to sleep in RVs, and we'd make laws that permit them to put a tent over their heads. So I live in a town where we build a small amount of affordable housing, but we forbid people at night from putting a cardboard box or a tent over their heads. And if the police find it, they rip it up or they tear it down.
Spirit: So even though it is not costing the system anything, they won't let people crawl in a tent or sleep under a box. The police raid and destroy every encampment they discover.
Marin: That means the whole debate about housing is an absolute and total lie. It's a lie because the people who are talking about it are not really interested in protecting the poor. They know they're supposed to protect them, but they're not.
We have maybe 4,000 to 6,000 homeless people in Santa Barbara County, and we are happy when we manage to get 200 or 300 people off the streets in a year. But that means all the thousands of others are breaking the law every night they're outside on the street. Now, that's not a rational system. That's a crazy system.
So am I surprised that homelessness is increasing? No. The sad part is that we had Franklin Delano Roosevelt and the New Deal, and then we've had crap and bullshit in the 80 years since Roosevelt. That's all it's been.
Spirit: What an indictment! Someone needed to say that! We need to begin here, by telling the truth about how federal officials keep slashing public housing. Do you think the U.S. government should play a massive role in subsidizing low-income housing, like it did during the New Deal?
Marin: Absolutely. One of the government's first responsibilities would be to see that there is adequate housing for all of its citizens. Just as one of the other major requirements would be to provide enough food, and adequate education to allow young people to find an appropriate place in the world as adults.
No one should starve. We know that, right? This is what the government must do. Leave all the war stuff aside, leave the NSA stuff aside, and the billions spent on this by the government. The first thing — the very first thing, beyond everything else — should be housing, damn it. It goes without question.
Spirit: Why is housing the very highest priority of all?
Marin: Because it is so necessary for human survival. Remember back when Abraham Maslow listed the hierarchy of human needs? You begin with what is necessary, and then what is preferable.
We know that food and housing are the necessary things. If government has any responsibility, it's either to see that people have these necessities, or not to interfere with their creating them. In many places, the government has now made so many rules about what kind of housing you can put up. One reason that housing for the poor is so expensive is that it has to satisfy zoning regulations everywhere.
The paintings of Lenny Silverberg confront us with the humanity of homeless people cast out of mainstream society.
Spirit: You said that almost no politician today has enough courage to even raise disability benefits. Are any politicians out there calling on the government to make a massive investment in housing?
Marin: Maybe Bernie Sanders, the independent from Vermont, and maybe Dennis Kucinich when he hopelessly ran for the presidency, and there may be a couple more.
Spirit: So what is the prognosis for the federal government creating a massive new housing program?
Marin: Even Obama, who was supposedly a community organizer — how can someone be a community organizer and not know that housing is absolutely essential? How can he have been a community organizer, and not now insist on housing? I think housing is necessary, and cheap housing is even more necessary. People ought to bend the damn zoning laws to enable cheap, temporary housing, and emergency housing.
Spirit: Along with our nation's failure to house its citizens, it is also failing to educate them. The second-class education given to children in low-income areas often leads to second-rate job opportunities, second-rate colleges, or no colleges.
Marin: The drop-out rates are really scary, although it's very hard to get legitimate figures. California, which used to have a great school system, is now down towards the bottom of the nation in terms of money spent per student, and in terms of results. These things are really scary and we hear noises from politicians about preschools and improving the schools, but I don't think they're getting any better. I just don't see it.
Spirit: Society fails to invest in the lives of poor people at the very beginning when children enter school?
Marin: Yes. Yet, outside of noblesse oblige, why would anybody invest in them? I mean we have enough workers to go around, so it is an interesting situation. We have enough people to go around to staff our industries now. So, if you do a cost-benefit analysis of what you get out of educating people, outside of keeping the social peace, I don't know why anybody would do it. You'd have to do it because you really believe in democracy.
Spirit: Yes, that would be the reason — to create an educated democracy, just as Thomas Jefferson envisioned.
Marin: That's right. But I don't know who believes in that now. People give it lip service but that doesn't count, as we know.
Spirit: Recent research has documented an alarming increase in the extent of poverty in this country. What effect so you think that is having on our democracy?
Marin: We know that poverty is extensive and vast and I believe it's probably underestimated. Also, do we want to count in the poverty rates those middle-class people who become poor as soon as they lose their jobs? They're not impoverished yet, but they live right on its edge.
The question is: How many people feel as if they live in a society stable enough to guarantee them, in some general way, long-term safety between now and death? I don't think anybody has that anymore — outside of the one percent that everybody speaks of. And this is what's scary.
It's hard to imagine anybody even proposing that we ought to have a society like that. I'm not talking about cradle-to-grave social services. I'm just talking about a certain kind of economic and social stability where people can breathe a little easier, and look down the road and think that things will probably be OK.
The loss of that stability is a gigantic loss. And it's been lost now not just to people who live in poverty, but to many people in the middle class. And how you count that number, I don't know.
If I go through my friends one by one, I can see large numbers of them who are trying to save as much money as they can, not for their own use, but to make sure that their children have a modicum of safety in the future. Because I don't think that any of them really believe that 20 years from now, their children are going to be better off, or even safe. Now, living that way is a really scary thing and to have an entire society like that is really troublesome.
Spirit: Many people live with the constant anxiety of being a paycheck or two away from eviction.
Marin: I could start reeling them off, the friends of mine who won't read the newspaper or look at the news any more, because if you do, you're overcome with a set of worries about — not yourself, so much — but the people you love, or the people who will be here after you're dead and gone, and I don't think many people know how to deal with that.
Even when they organize into Occupy or a demonstration or a political movement of one kind or another, I don't know who has the conviction these days that they know how to get us out of this fix.
Spirit: How would you explain to a new visitor to our country — someone who knew nothing about us — why the richest nation in the world has a massive problem of poverty and homelessness?
Marin: You know, I think all of this is fairly explicable in terms of our nation's history, and in terms of the Protestant ethic. It's a country that has always been dominated by a particular elite which sets the rules, and which has access to power in a way that other people do not.
What if we looked at America as if it were a Latin American country? There are countries in which the upper class essentially trades back the presidency every four to eight years, and it makes no difference whether the ruling party is in power, or one of the rival parties. The rich are going to be rich and the poor are going to be poor because it is kept that way intentionally. I think America is exactly like that.
Spirit: In what ways is modern America exactly like that?
Marin: Because both political parties are dominated by people with money. Both parties are dominated by people educated in certain places — Yale, Harvard, the University of Chicago. We have an education system that produces an elite. When the elite people grow up, they may have political differences with one another, and they may argue about a few small things, but they don't argue about turning the system upside down or really changing it.
You know, I taught at those schools as a lecturer or a visitor or a teacher. Even when people in poverty gain access to those schools, I've seen the way these schools take poor young students, and work very hard at making them a part of a particular class to which they're going to belong in the future. And that's the class that maintains power and doesn't rock the boat.
I taught journalism at the University of Southern California, and a student wrote me a paper in her senior year that had to do with her father being a garbage collector. She wrote in the paper, "This is the first time in my four years at USC that I've been willing to tell anybody that my father was a garbage collector." Because everybody knows what's expected of you in that new class. And if you want to make it into that class, then you behave.
Spirit: So you keep your father's employment a hidden, shameful secret.
Marin: Absolutely. I ran into that at several colleges. I was teaching at a college called Warren Wilson College, a little college outside Asheville, North Carolina. In the middle of a talk I was giving — of course, a talk about how the school needed to be changed — a young woman leaped up in tears and said, "I come from around here and I want to tell you that in the three years I've been here, everyone has made me feel like trailer trash."
I think that's one of the ways it feels when you are at one of those good schools without the social background that is required to belong there. I think that goes on all the time in America and nobody notices it. When I went to Swarthmore College, I was led to believe that I was better than other people. I knew we were special, and special, of course, means better. And if you go directly into your profession and become a lawyer or a doctor or a teacher, you become that knowing you are helping people who are your inferiors. No one will ever put it that way, but I don't think you can avoid that feeling
That was back in the days when I got the stuffing knocked out of me because I took freight trains and I suddenly realized there were plenty of people smarter and more courageous than I was who didn't have my education and maybe didn't need it.
Spirit: What led you to begin riding the rails? And what did you learn from the travelers you met on those trains?
Marin: I'm not sure why, but a year or two after college, I started taking freight trains, and rode on them out to California. I was out here in California when seasonal labor was done by marginal or transient or homeless men. The crop-picking was done by laborers who rode up and down the West Coast on freight trains. It was harvest work that was traditionally done by marginal men who traveled on the trains, helped with the crops, and then moved east again following the grain crops and ended up in Chicago for the winter.
Spirit: Did you hop those trains out of restlessness?
Marin: It was restlessness, but there was also something in me that never liked schooling at all. There are personality types like mine where you don't want to learn anything from anyone except from your own direct experience. So that all education which is being translated for you by intermediaries struck me as being unpleasant and authoritarian. I wanted to overcome the sense of being enclosed, the sort of hothouse atmosphere that many very good colleges have.
Spirit: What did you begin learning from your fellow riders on the rails?
Marin: I learned that intelligence, courage, inventiveness, toughness, the capacity to survive, the capacity to take risks, had nothing to do with the class that you come from. Some people learn that in war, of course, because we send our high school students to war, and lo and behold, they turn out to be brave and courageous.
Spirit: In your article, "The Moral Beauty of Acts of Goodness and Justice," you described meeting people in hobo jungles who shared food and clothing. You said it was more inspiring than anything you'd found in great works of art.
Marin: Absolutely. It was de rigueur, right? It was what people did. You were in the jungle with other people and whatever food there was got shared. Whatever bottle there was got passed around. There was no question of it. It was beyond argument. It was automatic. It was what people did.
Spirit: I've seen that exact same thing — the way people who have almost nothing will readily share what little they have with one another, while upper-class people who could share so much, will share very little. Did you ever understand why?
Marin: Well, I will tell you one thing. I believe that people who are on the margins of life or who have to exist hand-to-mouth, something of subsistence and tribal nature persist and will come to the surface. It is natural to share. The question is not why they do it, the question is why the rest of us don't. Somehow, they had removed from themselves the talons of bourgeois culture, and therefore the way they naturally thought was different from the way the rest of us think because that's the way we're taught to think.
Also, they had no destinies to protect. They weren't like the rest of us who have to put money in the bank against the future. It didn't make any difference to them what they had the next day, so they could share what they have today. They were not acquisitive, and all hope of acquiring enough or saving enough had just disappeared. Or maybe, they didn't have that nature to start with — which is why they were on the road in the first place, and then sharing comes naturally.
Spirit: In every homeless encampment I've ever witnessed, I've seen the same thing — sharing comes naturally.
Marin: It's very hard to take a freight train with someone, or to be in a hobo jungle with someone, and say, "Oh, I'm going to eat my sandwich, and watch someone else go hungry." People just naturally say, "Hey bud, do you want part of my sandwich?" When you're on the trains or in the hobo jungles and free of the oppressive order of society, some aspect of human nature, hitherto not put to use, comes up to the surface. So this sharing is not special — it's part of human nature.
That's what I like to think. I have never heard a report of a tribe where only some people died of hunger. They may kill an animal, and the chief gets the first choice, and then it goes down the line. But people at the end of the line still get something to eat. It's sort of automatic.
That's what people do when they're in small groups. They learn something about community and they learn something about freedom. They learn that you can function without authority. And that's what you see in the hobo jungles and on the trains. You see people figuring out how to function without authority.
Now, there are always sociopaths and there are always drunks, and if you're in a group with two or three drunks, it's a problem because they get hostile and angry and out of control. But barring these excesses, people manage to live together.
Spirit: You could be describing the community that has formed out on the landfill at the Albany Bulb. Strangers moved to a dumping ground, set up tents and homes, and learned to live in community. They began looking out for each other — in freedom and without authority.
Marin: What we have to remember is that just as violence probably comes naturally to us in certain circumstances, so does cooperation. That was the argument the anarchists like Kropotkin and Bakunin made long ago. And there's a lot of power in those arguments. Now such things work best in small groups and relatively stress-free environments, maybe not so well on the level of an entire nation.
Spirit: Cities cannot enact segregation laws against any minority in our society, except one — homeless people. Why is it still acceptable for politicians to banish people merely for being homeless?
Marin: First of all, you can see historically that the definition of poverty and the attitude towards poverty is intrinsic to the reformist movement that you find in England and America at the end of the 19th century. You see that the poor back then were described as public nuisances and dangers. Their living areas were seen as breeding grounds for vice and disease. They are associated with everything that bourgeois culture hopes to eradicate.
When I taught at the university here [UC Santa Barbara] and I would have my students go out and spend time with the homeless, they would return and talk about the way the homeless smelled, and how they scared them. Remember, these are people who are like outlaws. We look at them and we know they are not living according to any of the rules the rest of us observe.
It's very hard to get people to accept homeless people as being "us" because they look differently and they live differently. People are really afraid of them. They walk by them or they see them camping in their neighborhood, and everybody is nervous about them. They actually make us nervous because they exist in a different reality. When people are reduced to living on the streets, they become "other."
Homeless people marched from Santa Barbara, California, across the entire country to join the Housing Now protest in Washington, D.C., in 1989. Pictured in back with the march sign is Peter Marin. Eve Fowler photo
And it may just be visual. But there's also this: The notion of homelessness as a punishment runs through Christianity. Adam and Eve violate the law and they are kicked out of Eden. Same with Cain and Abel. The punishment for disobedience is exile. And I think there is something still deep in our psyches that associates homelessness with the breaking of law and punishment. I don't know why that is, but it's very difficult for people to understand the homeless as being of the same race they come from.
If you go back to the 17th century and the enclosure laws, when groups of people began to wander the countryside, laws were posted not letting people come off the roads into the towns. Wanderers had historically and culturally been seen as invaders and threats and for some reason that has never changed.
People who live in large cities begin to see homeless people as nuisances. Merchants don't like them. People don't like being asked for money. They don't like seeing people who are pulling carts around laden with their goods. It's aesthetically upsetting to people. I think the aesthetic response turns into a moral response. They just want people to go far away so they don't have to look at them anymore. That's the sense that I get in my town, Santa Barbara. The attempt to control the homeless is really an attempt to preserve the aesthetic beauty of the town, to keep the town pretty and to keep themselves safe. Yet it is deeply immoral.
Spirit: Why do you say it is deeply immoral?
Marin: Because if you look at it clearly, treating people as if they were exiles, worthless, and animals, is immoral. To not help them immediately is immoral. From my point of view, the deepest immorality is that if you're not going to help people, you have absolutely no right to punish them for finding their own way to live among us. So when you talk about the Albany Bulb, that is the lowest, the most immoral. The cruelest thing you can do is to deprive people of the right to take care of themselves when you have already decided not to take care of them on your own.
Spirit: Homeless people in Albany were pushed around and told by police they must go live on a dumping ground. So they created a life for themselves with no help from anyone. Now, Albany officials want to forbid them from taking care of themselves and evict them altogether.
Marin: Yes, and this happens everywhere. Everywhere there are sets of rules that make it impossible, or at least very difficult for the homeless to care for themselves. And that is outrageous. It is unforgivable. As you know, I've seen those laws made by Republicans and by Democrats. It doesn't mater who is in power. They make these stupid laws so that people can't take care of themselves.
Spirit: Politicians try to deny the class system in this country, yet it's clearly visible all around us. We've created a society where tens of millions are poor, but, instead of trying to reduce poverty, the economic elite continue to slash their benefits and criminalize the poor.
Marin: Where Marx was right was about class consciousness. I think it's pretty clear that the class you come from determines the way that you think. I think it's almost built into the class system that people will be unable to think of the poor and the homeless in different ways. I remember asking my students at UCSB when was the last time their families had been poor. Many of them had to go and ask their parents. But the fact is, none of these students knew they'd ever been poor. Do you see what a difference that makes?
The second part of what I found is that the people who were the most sympathetic to the homeless were Catholics. Not Protestants, but Catholics. The Catholics often came from very large families, and in the large families, they always had sinful, screw-up uncles, etc. So they knew people like the homeless, right? The other kids came from tiny families, often just one parent and one or two siblings, and they had no experience of human variation, no knowledge of poverty, and no one to tell them, "We were poor once."
This was a big thing if you were raised Jewish, as I was. This is what you heard all the time: "We were poor, we were poor, we were poor." So be nice to poor people. I knew I'd come from peasant stock, so I knew the people on the street who had nothing were not unlike my grandfather. I knew that in my bones, so there was not an abyss between me and the poor.
Spirit: Well, that brings up a crucial point. Nearly all elected officials in the U.S. are well-off or outright rich. Do you think that helps explain their lack of compassion? Is it one reason why they pass laws that banish the poorest citizens?
Marin: What class consciousness really means is that there is an abyss between you and people unlike you.
There are several levels to this. One is that there are people who don't want our help, or we think they don't want our help, because they are drunks and don't want to be sober, or they are homeless and they don't want to apply for housing, or they are ex-veterans who can't talk to social workers because that schoolteacher tone of voice which you sometimes hear from social workers drives them up the wall, so they stalk out of the office. Some veterans have seen too much of death to really partake in the niggling, exhausting, bureaucratic rigmarole that you have to go through to get any kind of help.
One of the arguments is that they don't want help and yet, if we just leave them alone, we will be encouraging them in their bad behavior. So the argument is that if we don't destroy those homeless camps, we will be "enabling" them to go on being homeless. We should banish the word "enabling" from the language.
So let's do everyone a favor, and if we destroy their camps, then they will have no place to go and they will have to come in and talk to social workers and go into recovery programs. That's one theory.
The second one is the aesthetic notion. In my town, the little town of Santa Barbara, the argument is that we can't afford to have homeless people on the streets because we don't want them to frighten the tourists away. We want to be this perfect little shopping center of a town where people come for its ease and beauty. We don't want anything of poverty or suffering or homelessness to be visible because that will drive away the people from whom we're going to make our living. And this concern overrides all others.
If I go talk to City Council members, even liberal City Council members, they will tell me that they can't do certain things because they feel so much pressure from the merchants, and they don't want to jeopardize their own political careers.
Spirit: These laws are nearly always driven by merchants who use the aesthetic argument to say the city must have a clean, attractive downtown with really cool shops, but really it's an anti-homeless crackdown for economic reasons.
Marin: Yes!
Spirit: Merchants want higher profits, and city managers want higher sales tax revenues and a thriving business economy. Is that a major reason for anti-homeless crackdowns, in your experience?
Marin: I make this argument in my town all the time, and I'm sort of an anathema to merchants. But I also want to be fair, and I understand that on our main street, we have a lot of small, local businesses, and they have genuinely had hard times the last five or ten years. Now, they haven't had hard times because there are homeless people in the streets.
But their own hard times, caused by other reasons, make them very nervous about anything that might affect their business. I don't think the homeless affect their business, but they are nervous about their futures and their livelihoods, because life is not so easy for them either. They are small businessmen. They are not giant corporations. I don't want to defend them, but my point is that it's the politicians who give in to them who are the distressing factor.
Merchants are always going to do what these merchants do. It comes with the territory. But what I don't understand are the liberal politicians who are so politically ambitious that they will not jeopardize their careers by taking any stand because it's the right one to take. That's the part that drives me crazy, and I deal with that all the time, and I've dealt with that for 25 years. Mostly, it's liberal politicians in my town, not conservative politicians.
"Faux Street Revisited." The viewpoint of a homeless woman at ground level, as passers-by hurry past and ignore her. Oil painting by Christine Hanlon.
Spirit: Almost all the anti-homeless laws in the Bay Area have been passed by liberals who want the public to vote them back into office. They believe the public disdains the homeless, so they go against all their principles just to get re-elected.
Marin: That's right. Even the liberals are just unspeakably awful because they worry more about their careers than they do about the poor.
Spirit: These are the city officials who refuse to bend zoning laws to build housing, then they arrest and banish the poor.
Marin: In my town, we have, every two weeks, a big symposium or discussion or conference about homelessness and how to fix it. And this is the scary part. This is the part that really disturbs me as an advocate. I cannot get the affordable housing people, or the recovery program people, to oppose the laws that criminalize sleeping in a tent or a park. Do you understand that?
Spirit: No, I can't understand why service providers won't oppose the anti-homeless laws. It's exactly the same thing here in the Bay Area. Most of the affordable housing groups and recovery programs would not take a stand with the activists in fighting the Berkeley ballot measure to criminalize homeless people for sitting on the sidewalk. It was such a sell-out. How do you understand it?
Marin: Well, basically, they are now government-financed service providers. Here's the distinction: They are against homelessness as a problem or a social crisis, but they are not for individual homeless people. Do you see the distinction?
Spirit: Why would service providers not be more concerned about the real people on the streets whose rights are trampled by discriminatory laws?
Marin: Because they don't know any of the homeless people. They know them only because they sit across the desk from them as social workers and service providers. They have a program to which people have to apply and they have hoops through which people have to jump. But they're not out on the streets living with people or helping them day by day. They're not advocates for the person; they're advocates for the program, and that's a very different thing.
Spirit: But even so, why do they refuse to take a public stand against the inhumanity of laws that criminalize the poor?
Marin: Because they're part of the class that we're talking about, that's why. They are good members of the privileged class. They don't identify with the poor. That's a different thing altogether.
Sometimes, you do run into great social workers who identify with the poor. We have them in my town. Sometimes they're vets, and they see guys on the streets who they fought with, and they understand that these are guys just like them. They were their buddies. And they fight for them in a different way than the professional social workers.
We have, in my town, two or three people who work with homeless people on the street and bring them food and bring them clothes and help them as best they can survive in the way they are. And those are terrific people — they're like saints — but we only have two or three of them, and the others are gone now.
This close-up portrait of the face of a homeless man by artist Lenny Silverberg shows the damage, hardships and suffering caused by many years of living outside in the harsh weather.
Spirit: It seems that the dedicated activists who cared about homeless persons, and worked with them as equals, are being replaced by a new breed of career-oriented social workers who lay down endless rules for the poor, with very little understanding of their lives.
Marin: "Tough love" — that's another phrase we should ban from the language. I have a story about this for you. We have a jail seven miles out of town, and because of budget problems and overcrowding, the jail releases about one-fourth of its released prisoners after the buses stop running for the night. My Committee for Social Justice runs a ride program, so if people call after they're let out at 3:00 in the morning, they don't have to walk seven miles back to town through the rain and cold. They get a cab ride.
Now I have been trying to fund this program for several years, because I can't do it myself forever. But when I go to my fellow advocates and say we need a ride program, they will say let's give rides to the drinkers who are willing to go into a recovery program, but not to the people who won't go into a program. These are advocates saying this!
Spirit: Why would they be opposed to helping someone stranded seven miles out of town in the middle of the night?
Marin: Because they want to force the drinkers into recovery. Or they want to punish them for not going into recovery.
We have nights where it goes down below 30 degrees, and when you get cold, icy rains, people are forced to walk seven miles back to town. You know, you ask certain questions, like why they don't support this, and I don't have an answer. In Brooklyn, we would have said, "They don't do it because they're assholes." There isn't another reason!
Spirit: The lives of the poor must be very cheap to them, and ex-prisoners must not count at all.
Marin: And drinkers especially — the lives of drunks are worthless to them.
Spirit: In your essay, "Helping and Hating the Homeless," you looked at why so many homeless people cling strongly to their freedom and their familiar outdoor spaces, and avoid the shelters that service providers offer them. Most people do not understand why they have such a great dislike for the shelter system.
Marin: They won't go near shelters because of the rules. In Santa Barbara County, a few years ago, four people in a 10-day span froze to death outside, We had one guy die in a wheelchair. So at that point, a doctor friend of mine and I went to the Board of Supervisors, and for three years, they had been developing what they called a protocol for emergency warming centers. We said, "Look we know you've been taking three years. We can do this in a month and a half. Just give us the money."
Two weeks later, we went back with 20 people, and two weeks after that, we went back with 200 people. And the County gave us enough money to start these emergency warming centers. That was four years ago, and they're still operating. They're allowed to open when it's going to rain or when the temperature is going to drop below 35 degrees at night. We have mats and people provide food. They're pretty nice operations.
What I found was that these warming centers were called, in social science parlance, "low-demand shelters." So people just come in, and they can come in drunk. They can come in and go out and come back in again. They don't have the same rules as most shelters, and the rules are why people don't go to those shelters.
What you see in shelters — and you know this as well as I do — is a continuous process of infantilization, which is impossible for certain men, and especially veterans, to accommodate themselves to. So they won't go near shelters because they are treated like orphans and children.
Spirit: They're regimented like prisoners in some of the shelters.
Marin: Absolutely. I used to stay in shelters when I traveled on freight trains. They take your clothes, give you pajamas, turn the lights out at 8 at night. At 6 in the morning, you get up and no matter what the weather is, you have to go back outside for the day, even if it's pouring down rain — and that's it. So I know something about those shelters and I would rather have slept under a tree than go to one of them, if I had a choice.
Spirit: So a large part of the resistance to living in shelters has to do with the fear that they will lose their freedom?
Marin: We have a culture which has largely lost any sense of the value of freedom, or being left alone, or living life on your own terms. People do not treat this as if it is a good in itself. So they don't understand that certain people, among them many of the homeless, actually factor in the value of being left alone, or living life on your own terms, as opposed to help at the price of institutionalization.
It is astonishing that people don't understand this need for freedom. That's the part that's really strange to me. But, and here's the key to it, the people who are dealing with the homeless are people who have probably thrived in institutions, loved institutions and never lived outside of institutions since their childhood. Nowadays, if you're a child, you live in institutions from the word go. You're never on your own.
But these are guys who have a desire to be on their own. And once you get a taste of it, it is almost impossible to give it up. If you hang out with friends at the Albany Bulb, and then they shut down the Bulb, and you start going to a social worker's office or to a shelter, and you're sitting across a desk from someone who is using that schoolteacher's voice and telling what you should do and should not do, you're out of there!
Spirit: People who value their freedom can't stand the indignity of being talked down to and ordered around by social workers imposing rigid rules.
Marin: There are people who can't tolerate that. And the people who can tolerate it, and who even like it, have no way of understanding the people who can't tolerate it. They have absolutely no way of crossing that divide and understanding those who value freedom.
Almost everything in these shelter institutions is artificial. The requirements are artificial. The distribution of power and submission is artificial. It's not only artificial, but it's arbitrary. People with any minimal sense of freedom or independence are right not to put up with it. They are in the right. They are preserving some human values which all the rest of us should congratulate them for preserving. But of course we don't. Because by preserving the values of freedom and independence, they're a threat to the rest of us who want to lead simple and institutional existences.
Spirit: It is strange that in a nation that supposedly enshrines freedom as the highest value, there is such disdain for freedom in real life, and an unwillingness to accept people who want to live in freedom.
Marin: Well, here's the great irony. The people who defend freedom — God help us! — are the weird, reactionary, gun-toting guys who want to live in the mountains and kill their own food [laughing]. It's very strange that there is an anarchical streak in Americans, but this often manifests itself as conservatism, because there's a hatred of government and law.
Spirit: We've also lost the very idea of a frontier where people can still seek freedom, like Thoreau at Walden pond or Huck Finn on the Mississippi. We're eradicating the last few places where people can live in freedom — vacant lots, parks, hobo jungles, places like the Albany Bulb where people can set up camps.
Marin: We are indeed eradicating these areas. We are eliminating all unmanaged space and behavior.
In the religious tradition, there is a contemplative tradition, which is an adventurous, inward tradition. I think that some homeless people have more of that than we recognize. It's one of the things you sometimes find in their company. They may be a little strange and have a skewed way of seeing things, but many of them see the world on their own terms, as if they were seeing it for the very first time.
The point is that they preserve something that the rest of us don't have and there is something terrifying in the fact that the rest of us don't understand that. They preserve life as it is freely lived, outside of institutions.
But I don't want to romanticize homelessness. I think a lot of what we're talking about is a part of a tremendous suffering, a tremendous unhappiness where people are reduced, pushed out of society almost like animals. But part of our animal nature is this attachment to being left alone. Wouldn't it be ironic if some of the homeless people had preserved more of their humanity — just in terms of these reflexes for freedom, and their capacity for cooperation — than the rest of us have?
Spirit: Even though all the economic trends and housing shortages lead nearly everyone to predict that homelessness will remain a massive problem, is there any sign of hope on the horizon, in terms of movements for change? We just saw an Occupy movement that did talk about economic justice in populist terms.
Marin: I think the Occupy movement was a good effort, although they seem to be hibernating now. But in terms of homelessness, maybe not so good. We had some homeless people who went to their demonstrations and joined with them, but in general, it seems sort of like a throwback to the 1960s with young people involved and engaged. But I don't know if it was sort of a spontaneous combustion that disappeared or whether it will come back stronger than before.
My own feeling is that 20 years ago, the homeless people seemed to be better organized themselves than they are now, at least in the areas that I know about.
Spirit: There's also been 20 years of social decay, poverty and economic downturns. That's 20 years of people on the streets being depressed and the economy being depressed.
Marin: And dying. Every spokesperson in my town is gone. They lived down in the hobo jungle outside Santa Barbara, but of course we've destroyed the hobo jungle so they have no place to live anymore. Leaving that aside, a lot of the drinkers were guys who stood up and argued for their rights, alongside advocates who were arguing for human rights.
And now, every one of those guys I knew, except for one, is dead. And the advocates are retired and silent. Their place has been taken by service providers, which may be inevitable. They are all talking about providing services and not protecting rights — and there is a big difference between them.
Spirit: What is the difference between protecting rights and providing services?
Marin: Did you ever read the famous book by Jacob Riis, How the Other Half Lives? He was an influence on Teddy Roosevelt, and he wrote a book about the homeless where he describes them as vice-ridden immigrants who we have to get rid of by improving. We couldn't kill them so we had to educate them and clean them up.
Spirit: He must be the patron saint of all social workers who are so judgmental of the people who come to them for help.
Marin: I know! And when you read the book, it's like a racist tract. It's about Irish immigrants and Jewish immigrants and the way their apartments smell. It's fascinating. It is sympathetic, but it's denunciatory at the same time, which is the nature of the reformist tradition.
Spirit: So he really is the model for the modern professional service provider.
Marin: He is! The same people who built the sewer systems were the ones who wanted to clean up the slums, and they wanted to do it for the same reasons: It was hygienic, it was modern and it was sensible. Whether they did it out of any real sympathy for the poor is another question entirely. I would say the distinction between providing services and protecting rights is this: Service providers are dealing with social problems and the freedom-fighters are dealing with individuals.
Spirit: So the people trying to protect human rights are dealing with the individual person — the soul, not just the statistics.
Marin: Yes, that's just what I think. I think that's always the case. I think that was the case with the Freedom Riders in the South during the Civil Rights era. When they were doing the Freedom Rides, what they had on their minds were their sisters and mothers and fathers and brothers. They were thinking of people.
So I think true advocates are speaking for their friends. And I think service providers are the people who sit across the desk from you, whether they work for the state or a private agency.
Spirit: You have often warned against lumping millions of people into the one catch-all category of homelessness because very different kinds of people run into entirely different kinds of problems that have led to homelessness. In your experience, what are some of the main triggers of homelessness?
Marin: It's one of the strangest things in the world to be in a room full of homeless people, and to see that whatever you are saying about homelessness applies at any point only to some of them. For instance, the people living at the Albany Bulb are only a particular segment of the homeless population — the freedom-lovers or whatever we want to call them.
First of all, there's women with kids. The welfare rules are such that women with kids and immigrant families very often run afoul of the welfare rules and end up on the street. Or their housing is so tenuous that even with welfare, they end up homeless, and have to go through the whole cycle again of trying to find new housing — which gets harder all the time.
Second are the elderly, who find themselves in old age left without sufficient money to pay what it costs to live. These are people with small pensions, these are widows whose husband died, these are people on Social Security who can't stretch it far enough to make ends meet, and others become disabled in old age and end up homeless.
So that brings us to the large numbers of physically disabled people, of all ages. Their disability payments are simply not sufficient to cover the cost of housing where they live. It increasingly takes more competence and tenacity to navigate the systems required to get off the street and find shelter. So you simply get large numbers of people who are exhausted and helpless so that they can't do what they are required to do on their own. That's why people miss welfare payments.
In Santa Barbara, we have a list for subsidized housing that is now six years long, but if you don't renew your application three times a year, they drop you off the list. And they do that so that the list doesn't get even longer than it is. But how many people who are on the street, or who are old, or disabled or mentally challenged, are going to be able to do that?
Then there are the mentally disabled. My county happens to have a particularly unsuccessful and failed mental health department, so we have large numbers of people on the street who don't receive any kind of mental-health attention or aid. As it is now, in my town, the budgets are so overstressed that they will only respond to a call for help involving a person on the street if they are an immediate threat to themselves or others. Otherwise, if they're just hungry or ill-clothed or destitute on the streets, they don't necessarily come with assistance. So they're on the streets, more and more.
Then, of course, we have military veterans, which is perhaps the biggest group. The number of vets on the streets varies from time to time depending where we are in relation to various wars. Also, they tend to die in their 50s, so all of the Second World War vets are gone, many of the Korean vets are gone, and we're beginning to lose some of the Vietnam vets now. Now, we're beginning to get the vets coming back from Iraq and some of them are ending up on the streets.
Spirit: That's the point where the war overseas becomes the war at home.
Marin: At one point, I remember seeing the figures from our area that, in the general population, one out of every nine males has seen service in a war, and on the streets, one out of every two men have seen service in a war. So that's rather an astonishing figure showing that wars, and what we now call post-traumatic stress, drive people into the streets.
We have many fewer services for men than for women, and also the shelter services for men require such a level of humiliation that men just say, "screw it," and don't accept the help that they're offered because of the form in which it comes. So we have men who receive less help than women, men who come from broken marriages, who have lost their jobs, who are no good at satisfying bosses, so you get a lot of them on the streets.
These are guys who may be badly socialized. Some are high school drop-outs, social drop-outs of all kinds, and a certain number of men for whom the German word "wanderlust" applies. That's people who can't stay in one place or stick to one job for a long period of time. I know a lot of guys like that. They are very hard workers, but they can work for a week and that's it. And they're out the door because they can't do the same job over and over again.
So there are those guys. And then there are what in my town we call "the travelers." The young kids who are still out there who just sort of take off, and you see them downtown near our City Hall in small groups, playing the guitar or asking for money. They just move from town to town.
A lot of them are the result of the foster care system, because they come out of that system and there's no place to go and they're not fit for doing anything, and nobody really prepared them for anything.
And then there are the drunks, God help them. The drunks sort of cut across all categories, but there are people who are just alcoholic and they lose jobs, or can't get jobs, or don't want jobs, and just end up alcoholics and addicts who live on the street. There's a sort of familiar curve which ends badly.


Comfortable home with the option of a master on the first floor or the second floor. both with direct access to full baths. Vaulted Great Room, with gas fireplace and ceiling fan.Eat-in Kitchen opens to the deck that was added less than 2 years ago. There privacy fencing was completed around the same time frame.Convenient laundry room off the kitchen. Kitchen has built in stainless steel appliances, a neutral back splash & Pantry. Neutral carpet and paint throughout less than 5 years old. Unfinished storage room over the garage is a bonus, accessed from the upstairs master bedroom.Average LG&E bill $185/mo. Avg. Louisville Water & Sewer $70 per month.Close proximity to shopping, interstate, restaurants, movie theaters & more!!! Move In Ready!!


I'm really enjoying sharing these kid-friendly handmade Christmas ornaments with you! And my latest favorite are these sweet little rustic-style sleds.
This ornament was inspired by the book The Animals' Merry Christmas by Richard Scarry, so it'd be a fun craft to do after reading the book with the kids. But even if you don't have the book, the kids' imaginations can imagine their own stories about these cute sleds. No matter how you approach the project, though, making these ornaments is sure to be a treasured memory for years. Have fun and enjoy this fun craft with your kids.


Last edited by P'ter; Jan 16 2009 at 05:39 PM.
Golden angel on top of the Victoria statue in The Mall, London, UK.
Floriade, Commonwealth Park, Canberra, Australia.
Vis Island at Stinava, Croatia.
Roof of the Gents' in the town Solesmes, France.
Melbourne Central Shopping Mall, Australia.
Henrhyd Falls in the Swansea Valley, South Wales, UK.
Selsed House, Lutherville, Maryland, USA.
ESO hotel @ Paranal, Atacama, Chile.
Pont Vessy over the Arve (connecting the communes of Geneva and Veyrie), Canton of Geneva, Switzerland.
"People of Alföld", Hortobágy, Hungary.
China Pavillion @ World Expo '88 in Brisbane, Australia.
Statue of Sacajawea in the National Statuary Hall, in Washington, DC.
Rock and Roll Hall of Fame, Cleveland, Ohio.
Forge Mill Needle Museum, Redditch, Worcestershire, UK.
Moelfre, Anglesey, North Wales, UK.
Pea Soup Beach, Victoria, Australia.
Round tower at Glendalough, County Wicklow, Ireland.
Chinese tea room in the Luisenpark in Mannheim, Germany.
'Anonymus', by sculptor Miklós Ligeti, Vajdahunyad Castle, Budapest, Hungary.
Downtown Roanoke (with Wachovia Tower), Virginia, USA.
Shopping window display in Bourke St. Mall, Melbourne, Australia.
Old Bell Inn (now museum), Montgomery, Wales, UK.
Herzogsburg, Perchtoldsdorf near Vienna, Austria.
Chand Baori stepwell in the village of Abhaneri, nr Jaipur, India.
"Seed" sculpture @ Eden Garden Project, Cornwall, UK.
Former East High School (now an apartment building), in Wausau, WI, USA.
Stuart Hall Shool for Girls (including Anne McCaffrey), Staunton, Virginia, USA.
Les Pyramides d'Euseigne, Val d'Hérens, Switzerland.


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Open access peer-reviewed chapter
The Biology and Clinical Relevance of Sentinel Lymph Nodes in Melanoma
By Brian Parrett, Lilly Fadaki, Jennifer Y. Rhee and Stanley P.L. Leong
Submitted: November 14th 2010Reviewed: April 19th 2011Published: August 23rd 2011
DOI: 10.5772/21530
Home > Books > Melanoma in the Clinic - Diagnosis, Management and Complications of Malignancy
chapter and author info
Brian Parrett*
Center for Melanoma Research & Treatment and Department of Surgery California Pacific Medical Center and Research InstituteSan Franciso, CA, USA
Lilly Fadaki
Jennifer Y. Rhee
Stanley P.L. Leong
*Address all correspondence to:
From the Edited Volume
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Melanoma in the ClinicDiagnosis, Management and Complications of MalignancyEdited by Mandi Murph
Melanoma in the Clinic - Diagnosis, Management and Complications of Malignancy
Edited by Prof. Mandi Murph
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The initial route of metastases in most patients with melanoma is through lymphatics to the regional nodes (Morton et al., 1992) [Fig.1]. However, routine lymphadenectomy for patients with early stage melanoma is unwarranted because most of these patients (~80%) do not have nodal metastases, are unlikely to benefit from the operation, and may suffer complications including lymphedema, seroma, infection and wound breakdown. However, a significant portion of patients with melanoma, predicted by primary tumor factors, harbor clinically undetectable regionally lymph node metastases at time of presentation. Delay of elective lymph node dissection until the presence of palpable nodes may allow the spread of melanoma to other nodes and distant sites with a decrease in long-term survival (Morton et al., 2006). The key to solving this clinical dilemma is to provide a minimally invasive method to selecting the relevant "sentinel lymph node" (SLN) in a specific basin to determine nodal micrometastasis (Morton et al., 1992). The SLN is accordingly the first lymph node(s) receiving direct afferent drainage from the primary tumor and thus is most likely to contain metastatic disease if any regional lymph nodes are involved. The technique of SLN biopsy is best named selective sentinel lymph node dissection (SLND) and allows surgeons to determine the spread of melanoma through lymphatic channels from the primary tumor; it has substantially impacted the way cutaneous melanoma is staged and managed.
The relatively orderly fashion of melanoma metastasis from the primary site to the SLNs and then to the non-SLNs prior to systemic sites is supportive of the spectrum theory of cancer spread (Hellman, 1994; Leong, 2004) [Fig. 1]. This theory states that for a given malignant lesion, development of nodal and systemic metastasis from localized disease is a genetically driven process of progression within the tumor microenvironment to distant body sites, most often through the "gateway" of the SLN(s). Selective SLND is an ideal procedure because it is minimally invasive, yet powerful enough to select the relevant lymph node of the nodal basin, without a complete node dissection. It is now widely accepted that the SLN status is the most important factor in predicting outcomes and determining further treatment for melanoma and this is the focus of the chapter (Leong, 2004).
The figure depicts progression of melanoma from the primary site to the SLN, then to non-SLN or regional nodes and distant sites. Occasionally, cancer cells may bypass the lymph nodes and spread to distant sites through vascular channels. In the majority of the cases (approximately 80%), the SLN is the gateway for cancer spread (bold arrow pathway in figure).
2. The sentinel lymph node in melanoma
2.1. History and rationale
In 1977, Cabanas described an approach to staging penile carcinoma after using lymphangiograms in patients to determine the lymphatic anatomy of the penis. He hypothesized that if penile carcinoma metastasized, it would do so to a node that was located medially and superiorly to the saphenofemoral junction in each groin (Cabanas, 1977). The term sentinel node, first coined by Gould in 1966 for parotid cancer (Gould et al., 1966), was used to describe the first node in this drainage pathway; if this was found to have metastatic disease, the patient required a lymphadenectomy. Conversely, when the SLN was negative for disease, the likelihood of metastatic disease in the groin was low and lymphadenectomy was unnecessary. The idea that a primary tumor would preferentially drain through the lymphatics to a specific lymph node, and that the status of that node would reflect the tumor status of the regional lymphatic basin, was revolutionary. However, the lymphatic drainage of solid tumors might vary from patient to patient and not necessarily be fixed to an anatomic location (Wong et al., 1991). To accurately identify the SLN, intraoperative techniques were needed to define the lymphatic drainage of a given primary tumor site rather than utilize an operative approach that was dependent upon the defined anatomy.
Thus, in 1992, Morton introduced the concept of identifying and selectively harvesting the SLN from the draining basin of a primary melanoma to identify patients with clinically occult lymph node disease (Morton et al., 1992). This was performed with intradermal injection of vital blue dye around the primary melanoma and then exploration of the regional lymphatic basin to identify blue stained node(s). This technique was based on the observation that when a blue dye such as isosulfan blue is injected around the primary melanoma, it drains into the SLN. With meticulous dissection, the dermal lymphatics could be visualized and utilized to map the lymphatic drainage of the skin to a SLN. In this study, metastases were present in 18% of SLNs, while non-sentinel nodes were the sole site of metastases in only two of 3079 nodes from 194 lymphadenectomy specimens that had an identifiable SLN, resulting in a false-negative (FN) rate of less than 1% (Morton et al., 1992). Therefore, this technique identifies, with a high degree of accuracy, patients with early stage melanoma without nodal metastases who can be spared from a morbid radical lymphadenectomy. Several confirmatory studies, including prospective randomized trials, have provided a wealth of information regarding the SLN, including accuracy, prognostic value and candidate selection (Ross et al., 2011).
However, intraoperative lymphatic mapping with blue dye alone is technically difficult with prolonged learning curves to acquire satisfactory outcomes. Thus, radioguided techniques were sought to provide a simpler method to identify and harvest the SLN while minimizing the extent of the surgical dissection. In 1993, Alex and Krag reported on the use of an intra-operative hand-held gamma probe to identify regional nodes that had taken up technetium labeled sulfur colloid (Alex & Krag, 1993). Additionally, the development of a number of radiopharmaceuticals with appropriate particle size provided the opportunity for the development of cutaneous lymphoscintigraphy, developed by Robinson, Morton and associates in the 1970s (Robinson et al., 1977). Cutaneous lymphoscintigraphy was especially important given the recognition that the dermal lymphatics, particularly in trunk melanomas (Leong et al., 1999), could have substantial variability; this allowed surgeons to define the regional lymphatic basins that were at risk for harboring metastatic disease prior to selective SLND (Fig. 2). Preoperative lymphoscintigraphy to define the SLN from the primary site in combination with the gamma probe could direct the surgical incisions and make the procedure less invasive than the blue dye procedure. Also, selective SLND using lymphoscintigraphy allows the identification of affected lymph nodes that would not be routinely evaluated during an elective nodal dissection such as in-transit lymph nodes and lymph nodes in minor nodal basins (e.g., popliteal and epitrochlear regions) [Sumner et al., 2002]. Lymphoscintigraphy is also essential for selective SLND in head and neck melanomas as these have complex and less predictable lymphatic drainage patterns, resulting in lower SLN identification rates and higher FN rates (Klop et al., 2011; Leong et al., 1999). For these reasons, cutaneous lymphoscintigraphy has become a routine component of the management of most melanoma patients.
2.2. Accuracy and false-negative rate
The SLN concept has been supported by high accuracy rates and low false-negative (FN) rates in melanoma. The immediate FN rate, defined as the percentage of nodal basins that harbor nodal metastases in nodes other than the SLN as determined by synchronous elective lymph node dissection after a negative SLN biopsy, has been reported to be less than 5% in several studies (Gershenwald et al., 1999; Morton et al., 1992; Nowecki et al., 2003, 2006; Reintgen et al., 1994; Thompson et al., 1995; Uren et al., 1994). In the Multicenter Selective Lymphadenectomy Trial I (MSLT-I) [Morton et al., 2006], 2,001 patients with cutaneous melanoma were randomized to: (1) wide local excision alone with observation only and subsequent lymphadenectomy if nodal relapse occurred, or (2) wide local excision and selective SLND with lymphadenectomy if metastases were found in the SLN.
Pre-operative lymphoscintigraphy demonstrates varying lymphatic channel patterns in patients with primary melanoma. (A) Drainage of a single channel from the right upper arm leading to one SLN in the right axilla. (B) Drainage of a single channel from a posterior midline neck lesion to multiple contiguous nodes in the right posterior neck. (C) Confluent channels drain from the upper back to a single SLN in the left axilla. (D) Multiple channels from the left upper back draining to a single SLN in the left axilla. (E) Single primary site drainage source from the right arm, diverting into several channels and leading to a single SLN in the right axilla. (F) Changing of drainage patterns from a lesion in the left anterior chest wall to one SLN in the left axilla. (G) Parallel simple channels from the right lower extremity, each draining to a single SLN, each in the same basin in the right groin. (H) Multiple channels from the midline back draining to multiple SLN(s) in different basins, the right and left axilla. This figure has been previously published by our group in Clinical Nuclear Medicine 30(3):150-158, 2005.
Results from 1,269 patients with intermediate-thickness primary melanoma (1.2 mm to 3.5 mm in this study) showed that 16% percent of SLNs had micrometastases, while 3.4% of those with "negative" SLNs developed nodal metastases, which is consistent with the accepted FN rates of the procedure.
Additional evidence that regional node metastasis constitutes an orderly, nonrandom event was provided from a study that examined 105 lymphadenectomy specimens in patients with at least one positive SLN (Gershenwald et al., 1998). They found that the SLN was the only node involved in 83 (79%) of the basins, with microscopic nodal metastasis identified in an additional 21% of the lymphadenectomy specimens. In 92% of patients who had at least one positive SLN and were mapped with blue dye and radiocolloid, lymphatic metastases were identified in the SLN that contained the greatest radiotracer uptake.
2.3. Current indications for selective SLND
In our practice, patients chosen for selective SLND have the following: (1) a Breslow thickness of 1 mm or greater; (2) a Breslow thickness less than 1 mm, but with high risk features such as lymphatic invasion, regression, ulceration, increased mitotic figures, or Clarks level IV; or (3) a shave biopsy that resulted in a Breslow thickness of less than 1 mm. Patients who are not recommended to undergo selective SLND have one of the following features: (1) known lymphatic or metastatic disease; (2) melanoma-in-situ; or (3) a Breslow thickness less than 1 mm with no high risk features. These are the most current indications for selective SLND and what most melanoma centers follow. Given this criteria, the positive SLN rate has been documented to be between 14-21% in most studies (Kapteijn et al., 1997; Leong et al., 2005; Morton et al., 1992, 2006; Thompson et al., 2005). Despite these guidelines, population based studies have shown that only 50% of patients with stage IB and II who met the criteria for selective SLND actually undergo selective SLND (Bilimoria et al., 2009; Cormier et al., 2005). The factors for this are likely multi-factorial including insurance, geographic area, socioeconomic factors, and age. This signifies the need for better education, access to health care, and melanoma multidisciplinary centers for patient referral.
3. Technique and evaluation of SLN
3.1. Pre-operative lymphatic mapping
The SLN is now reproducibly defined by lymphoscintigraphy and lymphatic mapping performed by the injection of Technetium-99m (Tc 99m) sulfur colloid radiotracer, a vital blue dye, or a combination of both around the melanoma site. Isosulfan blue (Lymphazurin 1%, Hirsch Industries, Inc., Richmond, VA) is the most commonly used blue dye in the United States and is the only dye approved by the Food and Drug Administration for lymphatic mapping. Regarding radiotracer, a more selective agent, Technetium-99m-labeled Tilmanocept, is a mannose receptor–targeted molecule that is being developed for identification of SLNs ( Leong et al., 2011 ) and will likely be used in the near future.
A summary of the numerous studies using the blue dye technique, radiotracer mapping by a hand-held gamma probe, or a combination of both techniques is shown in Table 1. The success rate of harvesting the SLN by blue dye alone is less than that of radiotracer alone or the combination of blue dye and radiotracer, both of which now approach 100% (Table 1). Given this data, the use of radiotracer is the most commonly use technique now. With greater surgical experience, the use of blue dye is not essential as radiotracer has a higher sensitivity than blue dye alone and this can avoid reported allergic reactions seen with the injection of blue dye (Leong et al., 2000; Liu et al., 2011).
For this technique, filtered Tc99m sulfur colloid is injected intradermally at the primary melanoma site. Dynamic imaging is performed to follow the lymphatic collecting vessels until they reach the draining SLNs. An image should be acquired as the lymphatics reach the nodal basin so that SLN(s) directly receiving the channels can be identified and distinguished from any second tier nodes that may be seen. This phase of the study usually takes 10-20 minutes. Delayed scans are performed 2–2.5 hours later, at which time all regions that possibly drain the primary melanoma site are examined with 5-10 minute static images. The surface location of all SLN(s) is marked on the overlying skin. Close communication between the nuclear medicine physician and surgeon is invaluable, especially in cases where there are unusual draining patterns. Importantly, the SLN is not just the first node seen on dynamic imaging, since there may be multiple separate lymph channels that have different rates of lymph flow. If they drain to different nodes, these are all SLNs, regardless of the time taken for the lymph containing the radiocolloid to reach them (Fig. 2). The SLN is also not necessarily the closest node to the primary site. Lymphatic vessels can bypass many nodes and even whole node fields before reaching a SLN. Therefore, the best way to identify a SLN on lymphoscintigraphy is to see the lymphatic collecting vessel on dynamic imaging as it drains directly to the SLN (Fig. 2).
Author Year of Patients Blue Dye Alone Radiotracer Both
Morton et al. 1992 223 82% (basins) - -
Krag et al. 1995 121 91% (patients) 98% (patients) -
Glass et al. 1996 148 60% (nodes) 80% (nodes) 97% (nodes)
Albertini et al. 1996 106 70% (nodes) 84% (nodes) 96% (basins)
Kapteijn et al. 1997 110 84% (nodes) 99.5% (nodes) 99.5% (nodes)
Leong et al. 1997 163 74% 98% -
Pijpers et al. 1997 135 86% (nodes) 85% (basins) 100% (nodes) 100% (basins) -
Gershenwald et al. 1998 626 87% - 99%
Gennari et al. 2000 133 80.8% (nodes) 97.1% 99%
Nowecki et al. 2003 726 91.6% - 97.3%
Reporting of success rates is not standardized. Percentages are indicated in patients, nodal basins or SLNs.Success Rates of Melanoma Sentinel Lymph Node Identification Techniques in Studies with >100 patients*.
3.2 Intra-operative identification of the SLN(s)
After lymphoscintigraphy, the patient is transferred to the operating room and no further injection of radiotracer is necessary, but Lymphazurin (1-2 mL) may be injected intradermally prior to the procedure. The surgical sites are prepared and general anesthesia is most often used. Intraoperative mapping of the SLNs is achieved using a hand-held gamma probe (Neoprobe 2000, Neoprobe Corporation, Dublin, OH). A small incision is made over the marked area of greatest activity as detected by pre-operative lymphoscintigraphy and confirmed by the hand-held gamma probe. The incision is carried down through the subcutaneous fat and the fascia is incised as the lymph nodes usually reside beneath the fascia. Using the gamma probe, the SLNs can be located by detecting increased radioactivity in counts per second or blue dye within node. After the removal of the SLN, the gamma probe is used to search the resection bed to make sure that no residual elevated radioactivity remains. Theoretically, the single SLN with the highest radioactive count ("hottest" SLN) or the blue node is most likely to harbor tumor cells and is removed during biopsy. However, literature describes FN rates for SLN biopsy if only the single, "hottest" SLN is removed and the other nodes are left in place (McMasters et al., 2001). Thus, we and others use the 10% rule (Liu et al., 2011; McMasters et al., 2001): the gamma probe is applied and any SLNs that assessed ≥ 10% of the ex vivo radioactive count of "hottest" SLN are removed, including any blue nodes or suspicious nodes by digital palpation.
After selective SLND, the wound is closed in layers. On a side table we dissect the SLN(s) from the non-SLN(s) or lymphatic tissue within the resected specimen using the gamma probe so that each lymph node is correctly labeled with its respective radioactive counts for pathologic evaluation.
3.3. Pathologic assessment of the SLN
The standard histological technique for evaluating a nodal dissection specimen involves evaluating representative sections from each identified lymph node using hematoxylin and eosin (H&E). In actuality, given the large size of the nodal dissection specimen, <1% of the whole specimen is routinely evaluated (Ross et al., 2011; Sondak et al., 2007). With a smaller sample from a selective SLND, the SLN can be evaluated more intensively with multiple sections using a combination of H&E and immunohistochemistry (IHC) to stain for melanoma associated antigens such as S-100 and HMB-45 (Fig. 3).
Figure shows staining of melanoma micrometastasis within a SLN.
Therefore, despite the less invasive nature of selective SLND, the staging data is likely more accurate than an elective lymph node dissection.
Selective SLND is a safe procedure with a very low complication rate. Additionally, the risk of radiation has been studied in physicians injecting the radiotracer as well as the surgeons removing the nodes. The maximum recorded dose of radiation recorded was 1900 times smaller than the current 1 year dose limit recommended by the International Commission on Radiological Protection, and no limitations are needed in the number of surgical interventions performed yearly (Nejc et al., 2006; Sera et al, 2003).
There have been reports of adverse allergic reactions to blue dye (Leong et al., 2000) which can range from a mild allergic reaction to anaphylaxis associated with hypotension, pulmonary edema, and/or cardiovascular collapse. It is hypothesized that prior exposure to common household products is responsible for patient sensitization to blue dye. Single institution case studies quote allergic reaction rates of 0.7 to 2% for melanoma. A multi-institutional survey by our group of 14,800 melanoma patients treated with blue dye in over 185 institutions revealed a 0.4% rate of adverse blue dye reactions, most of which are mild. Despite this low rate, it is important to be aware of any adverse reactions such as urticaria, respiratory and hemodynamic changes which usually occur in the first 10 to 20 minutes. We recommend that the anesthesiologist and nursing team are made aware of the use of blue dye prior to its injection, an intravenous line always be inserted, and that the proper medications, including epinephrine and corticosteroids, be readily available. If blue dye is to be used, we suggest that the surgeon use as little blue dye as needed; we have found reliable results in head and neck melanoma using less than 1 cc per injection. Additionally, blue dye is not essential as we demonstrated in a recent study that using the 10% radioactivity rule (McMasters et al., 2001) with blue dye does not significantly decrease the Miss Rate when compared to the 10% radioactivity rule with technitium alone (Liu et al., 2011).
5. Clinical relevance of sentinel lymph node
Further support for the SLN concept stems from research that clearly shows that SLN status is the most significant prognostic factor with respect to disease-free and overall survival as shown in Table 2. Selective SLND is an excellent staging technique and can be used to identify patients who would or would not benefit from a complete lymphadenectomy and is also necessary for inclusion in clinical trials.
5.1. Positive node
As shown in Table 2, patients with a positive SLN have a significantly decreased overall 5-year survival compared to patients with a negative SLN. Therefore, for patients with a positive SLN, therapeutic decisions should be made and most often a regional lymphadenectomy is recommended. However, the survival benefit of selective SLND followed by completion lymph node dissection (CLND) is still controversial and many groups have attempted to study this by comparing melanoma patients after CLND after positive sentinel node biopsy and after therapeutic lymph node dissection for clinically detected regional lymph node metastases. In the MSLT-1 trial (Morton et al., 2006), among patients with nodal metastases (primary melanomas ranging from 1.2 to 3.5 mm), the 5-year melanoma specific survival rate of those who underwent selective SLND with immediate lymphadenectomy (72.3%) for a positive SLN was significantly higher than those in the observation group who had lymphadenectomy only when there was clinically evident nodal disease (52.4%; p =.004). However, no overall survival advantage was seen when comparing the entire cohort of patients randomized to selective SLND with those patients who had wide excision only and nodal observation. Other data from meta-analysis of 6 studies showed a significantly higher risk of death for patients who only underwent elective lymph node dissection after clinically evident nodal metastasis versus patients who underwent SLN-guided CLND (Pasquali et al., 2010). However, this is a complex topic and survival benefit is also likely related to other factors including age, primary tumor characteristics, and features of the nodal metastases. Additionally, these studies tend to be underpowered because of a low percentage of patients with positive SLN(s) who could potentially benefit from CLND (Ross et al., 2011).
5.2. Negative node
When SLNs are negative for micrometastasis, the remainder of the lymph node basin is usually negative (Morton et al., 1992; Reintgen et al., 1994; Albertini et al., 1996; Krag et al., 1995; Ross et al., 1993; Thompson et al., 1994) with FN rates under 5%. This is good evidence to conclude that melanoma metastases are most often spread in an orderly pattern (Fig.1). In general, if the SLNs are negative, there is no need to proceed with a more morbid regional lymph node dissection; selective SLN mapping replaces the more extensive lymph node dissection if SLNs are found to contain no metastasis.
Patients with a negative SLN have an overall 5 year survival of 84 to 92%, significantly better than positive node patients. Despite better survival results, a negative SLN is not an absolute predictor of survival. Recurrence and death in SLN negative patients may be related to FN SLN results or a pure hematogenous spread (Leong et al., 2004, 2011 ; Ross et al., 2011). In particular, head and neck melanomas have a higher FN rate, over 12% in some studies (Klop et al., 2011); this is likely due to a complex lymphatic drainage pattern with multiple basins in the head and neck ( Leong, 2011 ). FN results for selective SLND may result from failed preoperative lymphoscintigraphy, including injection techniques and interpretation of the lymphoscintigraphy, failed intraoperative lymphatic mapping, failed pathologic identification of microscopic disease, and "skip" metastasis (Leong, 2004). Predictors of relapse and death in SLN negative patients include increasing tumor thickness and ulceration (Ross et al., 2011).
Author Year of Patients 5-Year Overall Survival
Negative Node Positive Node p-value
Nowecki ZI 2003 726 84% 40% <0.001
Leong SP 2005 363 85.6% 61.5% <0.0001
Morton DL 2006 1269 90% 72% <0.001
Cascinelli N 2006 1108 90.6% 75.4% <0.0001
Mandalà M 2009 1251 88.7% 42.9% <.0001
Kunter C 2010 1049 90% 58% <0.001
Ellis MC 2010 397 92% 73% 0.0001
Overall Survival in Relation To Sentinel Lymph Node Status.
6. Biology and clinical impact of micrometastasis in SLN(s)
The dimensions and "amount" of micrometastasis in the SLN gives important prognostic data. According to the Rotterdam criteria for SLN tumor burden (van Akkooi et al., 2006, 2008), the maximum diameter of the largest focus of a positive SLN(s) is used as the measurement of record. There were 388 melanoma patients with positive SLNs from three European centers analyzed by this method with a median follow-up of 36 months. Three groups of patients were defined: (1) submicrometastasis with at least 10 cells but less than 0.1 mm (10%); (2) micrometastasis between 0.1 and 1.0 mm (35%); and (3) micrometastasis greater than 1.0 mm (55%). Patients with sub-micrometastasis (<0.1 mm) were identical to the SLN-negative group with an excellent survival rate. Tumor burden in SLNs increased with T-stage. Both T4 and SLN tumor burden were the most important factors for overall survival.
Similarly, 63 melanoma patients with positive SLNs from the UCSF melanoma SLN database with a median follow-up of 8 years were analyzed (Baehner et al., 2011). SLN micrometastasis was recorded for size, number of foci and anatomic location by H&E. Fourteen of 63 patients had positive non-SLNs. Using the log-rank test, maximum metastatic size and primary melanoma thickness were correlated with progression-free survival and overall survival. Neither number of metastatic foci nor microscopic location was statistically significant. Multivariate analysis showed that the maximum metastatic size and primary melanoma thickness were the most important prognostic factors for progression-free survival and overall survival. As a continuous variable, every 5.0 mm increase in maximum metastatic size was predictive of progression-free survival. The estimated 5-year overall survival rate was 90% in patients with maximum metastatic size <0.6 mm, 52% with maximum metastatic size from 0.6 to 5.5 mm, and 55% with maximum metastatic size >5.5 mm. When stratified by thickness, the estimated 5-year progression-free survival rates were 95% for patients with maximum metastatic size <1.6 mm, 70% between 1.6 and 4.5 mm, and 45% >4.5 mm; the overall survival were 82%, 52%, and 5%. Both primary melanoma thickness and maximum metastatic size were independently prognostic of progression-free survival and overall survival in melanoma patients (Baehner et al., 2011). Other studies have also demonstrated that the incidence of SLN metastases correlates directly
with increasing tumor thickness (Gershenwald et al., 1998; Ross, 2011) as well as other factors including ulceration, lymphatic invasion, mitotic rate, Clark level, and anatomic site (Ross, 2011).
The overall challenge in melanoma is to identify patients with truly localized disease versus patients with metastasis to nodal and/or systemic sites, as early detection remains key to successful eradication. With this in mind, selective SLND was introduced 20 years ago and has become essential in the care of patients with cutaneous melanoma, with a multitude of publications validating the importance of the SLN. Selective SLND provides a minimally invasive standard of care (Morton et al, 2008), that allows accurate staging, gives significant prognostic information, facilitates therapeutic lymphadenectomy with regional disease control, avoids unnecessary elective lymph node dissection, and may improve survival in node-positive patients. However, in a minority situations (~20% of the time), cancer cells may spread through the vascular system to distant sites, bypassing the SLNs ( Leong et al., 2011 ). Therefore, it is important that all patients with melanoma be followed closely after their diagnosis.
2.The sentinel lymph node in melanoma
3.Technique and evaluation of SLN
3.2Intra-operative identification of the SLN(s)
4.Safety
5.Clinical relevance of sentinel lymph node
6.Biology and clinical impact of micrometastasis in SLN(s)
7.Conclusion
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Brian Parrett, Lilly Fadaki, Jennifer Y. Rhee and Stanley P.L. Leong (August 23rd 2011). The Biology and Clinical Relevance of Sentinel Lymph Nodes in Melanoma, Melanoma in the Clinic - Diagnosis, Management and Complications of Malignancy, Prof. Mandi Murph, IntechOpen, DOI: 10.5772/21530. Available from:
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Pandora, the music recommendation site that rivals Last.fm, has started testing audio ads - they're not going down too well. Pandora has been running on-screen ads for a while, and users seemed to accept them as a necessary part of the service. But over the last few days, some listeners have started to notice ads in the audio stream itself - in particular, 9 second ads for the McDonald's Dollar Value menu. Every post I've seen so far has been negative.
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