I ended up using public transport for most of my stay in San Francisco last week. If you wander through life with a car and a middle-class income, it is damned easy to lose touch with the most ordinary of day-to-day rituals.

Losing touch, dramatised to presidential proportions, was a turning point in George Bush Senior’s demise in the 1992 election. A young woman at a town hall meeting asked the leader of the free world how the spiralling national debt, which created real-life challenges for herself and her friends, affected his own life, personally. He could not answer.

As I booted around on bus and train, what I noticed most was the amount of emotionally disturbed people who seemed to populate public spaces and, most notably, public transport.

I witnessed people in what I assume to be advanced stages of paranoia, dementia, schizophrenia and general psychosis. They had adapted to the boundaries of their lives: ranting on one train for ten minutes, stepping off only to occupy the same seat in the following train.

And for the most part, they were ignored completely.

This is a phenomenon I notice with parents of young children. The whale-pitch screams of three-year-olds have no effect on them, and their calm conversation continues, whilst I experience elevated heart activity and worry about the state of my furniture.

‘Do they take care of people with mental illness in this country?’, I asked my friend.

It was a big question. And I understand that the answer is complex and, perhaps, even unfathomable.

One Asian woman stays with me still. She had the gait and demeanour of a down-and-out immigrant, carrying bags. She boarded our bus and sat behind us.

In her own world, she began to play out conversations. I do not know if they were riffs on soap operas, or from her own life. What was noteworthy is that she exactly conjured several voices; at times she modulated to a New York gamine perhaps 30 years her junior. At times, she spoke with the authority of an eloquent manager explaining why things must be as they must be.

After one minute of dialogue, a giant, guttural whooping sound came from within her body.

Over the course of ten minutes, this created a Pavlovian dread in me. Whooping was a signal to return to the beginning, and her same conversation played out again. Within it, the agony of her condition lay.

Throughout this extraordinary theatre, the travelling public stared ahead. It was getting late. I did not judge them. I too wished she were not there. I too said nothing.

I was prompted to think about this again because John Oliver, in his excellent polemic ‘Last Week Tonight’, has recently taken America’s broken prison system to task.

Apparently, prison is a likely place for this lady to end up. America’s growing prison population numbers 2,000,000; one in every one hundred adults. The breakdown in the care of the mentally ill is one of its many growth drivers.

I took up the theme of the paradoxes in America with a good friend, as we ate a leisurely lunch on my last day in the Bay Area. We are both avowed lovers of what America has to offer.

I remarked on another casual observation – the omnipresence of instruction in the urban landscape: signs telling me what to do and what not to do, announcements demanding that I keep here and not place a foot there.

‘The land of the free is a police state, isn’t it?’ I ventured, only half in jest.

He thought about it, acknowledging , for example, the bossy and arrogant approach of most American border-control experiences.

‘Yes’, he said, ‘it too is part of the American experience. But America is built on paradox. It is that tension that gives it its vital energy’.

Soon after, I grabbed a shuttle bus to the airport. Being full of well-healed tourists, a pointed silence was held throughout the journey.

Brian McIntyre. © 2014