Exploring the health impact on homelessness

Introduction
More than 75 delegates from several key sectors, including health-care and social services workers, physicians, local and provincial government representatives, and police officials, gathered recently at Toronto's Seaton House, a homeless shelter for men, to attend a one-day workshop on the growing problem of homelessness and its impact on health.

Sponsored by the OMA Committee on Population Health and the University of Toronto department of preventive medicine and biostatistics, the "Dr. Martin J. Bass Day: Workshop on Homelessness and Health" offered various perspectives on the challenges faced by the homeless.

The event focused on the plight of homeless women and children, street youth, and individuals with mental health problems, providing an overview of the various types of homelessness experienced by these groups, and the resulting health issues associated with homelessness.

Structure
Delegates were welcomed to the event by Dr. Verna Mai, chair of the OMA Committee on Population Health, OMA President Dr. Ian Warrack, and Dr. Anthony Miller, chair of the department of preventive medicine and biostatistics at the University of Toronto.

Opening remarks were followed by a tribute to Dr. Martin Bass; an introductory keynote presentation on homelessness and health; and five additional presentations each providing an overview of one aspect of homelessness and its impact on health.

At the conclusion of the final presentation, participants settled into five pre-assigned groups to discuss the health issues resulting from homelessness, the barriers to health care experienced by the homeless, and how the health sector as a whole should deal with these issues. Toward the end of the day, delegates returned to the main meeting area to report on their findings and offer solutions to issues raised in the various groups.

Tribute to Dr. Martin Bass
Keynote speaker and conference co-chair Dr. Chandrakant P. Shah began his presentation with a tribute to Dr. Martin Bass, a family physician, teacher, and humanitarian in whose honor the workshop was dedicated.

A long-time member of the Committee on Population Health, Dr. Bass is director of the Centre for Studies in Family Medicine at the University of Western Ontario, a professor of family medicine and epidemiology, and also holds the prestigious Ian McWhinney Chair of Family Medicine Research.

In his opening remarks, Dr. Shah, a professor in the department of preventive medicine and biostatistics at the University of Toronto and a member of the OMA Population Health Committee, referred to Dr. Bass as a "fine and caring physician" with a "deep sense of social justice and equity.

"His commitment toward underprivileged persons, whether they are poor, unemployed, homeless or from racial and ethnic minorities, has been unwavering," Dr. Shah told delegates.

"It is indeed a rare privilege for me and my colleagues at the OMA and the University of Toronto to honor this outstanding man and dedicate this workshop as Martin Bass Day."

Keynote presentation: an overview of homelessness and health
Following his tribute to Dr. Bass, Dr. Shah delivered the event's keynote address entitled "An Overview of Homelessness and Health."

Dr. Shah provided audience members with a brief summary of the various definitions and categories of homelessness, and reviewed the common health prob- lems faced by homeless persons and the barriers they encounter when seeking health care.

"For many, the term homeless' conjures up an image of middle-aged alcoholic and unemployable males sleeping on park benches, in doorways or under bridges," Dr. Shah told delegates.

"Over the past decade, however, the characteristics of the ever increasing homeless population have altered dramatically," said Dr. Shah. The homeless now include "able-bodied young people lacking marketable skills, runaways, the elderly, urban and rural residents, discharged psychiatric patients, women and children who have fled domestic violence, families and single mothers on social assistance, and the working poor who cannot find adequate and affordable housing."

Dr. Shah provided participants with a definition of the four basic types of homelessness: chronic, periodic, temporary, and relative (the latter referring to homes that do not meet the United Nation's basic standards for a suitable dwelling); and the three major causes of homelessness: a shrinking supply of decent and affordable housing; poverty; and psychological causes such as family breakdown and deinstitutionalization.

Citing several studies and statistics, Dr. Shah then offered an overview of the different health problems faced by various homeless populations.

"Homeless women and men do not have different illnesses than the general population," he told delegates, "however, their living conditions and poverty affect their ability to cope with health problems."

The rate of accidents, injuries, and assault both physical and sexual is much higher among the homeless. In addition, said Dr. Shah, persons with psychiatric disorders are over-represented in the homeless population.

"Overall, the health status of homeless persons is low," he said. To add to the problem, homeless people tend to make less use of preventive health services and more use of emergency health services than the general population, thus adding to emergency room overcrowding and health-care costs.

Despite their health problems and medical needs, many street people report difficulty in accessing health-care services or being denied access to competent, compassionate care and treatment.

"Structural barriers reported by homeless persons include the inability to obtain medical treatment without a health card...and the inability to pay for items not covered by provincial medical insurance, such as crutches," said Dr. Shah.

Some reported an inability to obtain treatment because they were "unclean and unpresentable," while others reported being sent "home" from the hospital to recuperate when they had nowhere to go and no one to look after them.

"What is needed are public policies and actions on the part of the citizens of Ontario and its government which address the many facets of homelessness and takes remedial action," he concluded. "The health sector should become more cognizant of the plight of the homeless and develop a co-ordinated and comprehensive system to address the health issues in a humane and timely fashion."

Mental illness and the homeless
Following the keynote speech by Dr. Shah, five additional presenters addressed delegates each providing a 10-minute overview of one aspect of homelessness and its impact on health. The first presenter, Dr. Paula Goering, focused on homelessness and mental illness. An experienced clinician, educator and researcher, Dr. Goering is director of a health systems research unit at the Clarke Institute of Psychiatry, where she oversees the work of a core group of interdisciplinary investigators who study mental health service delivery.

"Homelessness has emerged as a major social problem throughout the Western world. And one of the significant contributors to homelessness is thought to be chronic mental illness," Dr. Goering told delegates.

Although it is difficult to determine how many homeless people suffer from some form of mental illness because of the "transient nature of this population and the reluctance to seek assistance," estimates range from 30 to 50 per cent.

In addition, she said, it is also common for people in this group to have more than one disorder mental illness will often be coupled with some form of substance abuse.

With few mental health care resources available to the homeless, this high prevalence of mental illness means that the homeless mentally ill are worse off than the general homeless population.

"They are more often abused and remain homeless for longer periods of time," said Dr. Goering. "They are also more resistant to accepting help from the services that are available to them. In fact, the physical, health and criminal problems are much worse among this subgroup of homeless people than the rest of the homeless population"

Mental illness, coupled with substance abuse and other health problems, makes it particularly difficult to provide effective treatment in this population.

"It's really easy to say that mentally ill homeless people just won't accept our help that they don't want our assistance and that it's just too difficult to help them" said Dr. Goering, "but we can do something to help."

She pointed to data that suggest health-care delivery for this group can be improved by having more "one-on-one" contact between mental health care professionals and homeless people. "What we generally offer these individuals is medication and psychiatric treatment," said Dr. Goering. "What they want is housing and income, which are critical since it's very difficult to follow any kind of treatment regime when you have no place to live and no money."

Dr. Goering also pointed to the need to learn much more about what contributes to homelessness.

"There is a pressing need to understand more fully the pathways into homelessness, both for mentally ill and non-mentally ill people, and to figure out what we can do to prevent it from happening," she concluded.

Homeless women and children
Next on the presenter's podium was Dr. Robert Heyding, who spoke of the barriers to health encountered by homeless women and children.

A former staff physician at South Riverdale Community Health Centre in Toronto, Dr. Heyding has been in private practice since 1987. He has had the opportunity to treat homeless people at several downtown Toronto agencies, including Dixon Hall, the "416" Drop in Centre for Women, Street City and Street Haven Women's Shelter.

Describing the difficulty associated with locating many of his homeless patients for follow-up medical treatment, Dr. Heyding told delegates that, in his opinion, a homeless person can simply be defined as "anyone you can't locate within three or four days because they are so transient. In the last two years, out of the 450 or so people I've treated at Street Haven and 416, about 180 to 190 of them fit my definition of homelessness. I don't know where they are from day to day or week to week."

While homelessness is an obvious barrier to health care, there are many others, observed Dr. Heyding. "One that is difficult to overcome is the reluctance by many homeless people to obtain treatment...some homeless women refuse to be examined by a physician because of a past negative experience, while others may simply fear their belongings will be stolen while they're being examined."

If a person is willing to be examined, the next barrier often involves how to proceed with medical investigations. "If I tell a homeless person to go to a lab to get a blood test, they don't usually make it (to the lab)," said Dr. Heyding. "So we try to perform as many blood and urine tests as we can on-site. This helps ensure that treatment can be administered as quickly as possible."

Dr. Heyding told delegates that another common problem is getting homeless people to take their medication.

"How do I get medications into them? If they don't have a drug card, they can't afford to buy medication; if they're psychotic, they don't want to take medication; and if they're living on the street, they fear they might get robbed. We get around this somewhat by keeping samples of some common medications on-site that we can give to people who don't have drug cards."

Those who are willing to be examined and accept any necessary treatment often face yet another common barrier: access to a valid health card.

"Staff at 416 and Street Haven work very hard to obtain health numbers for homeless patients, but it can be very difficult," said Dr. Heyding. "Sometimes, I'll submit a health card number that the Ministry of Health later discovers is invalid. That means that I don't get paid, the lab doesn't get paid, and the specialist that I may have referred the person to doesn't get paid. That's a big barrier."

While some homeless people are reluctant to see a doctor, others may visit several different physicians and health facilities. "They might see me one day, go to emergency the next day, and a walk-in clinic the day after that," said Dr. Heyding. "And then, when I see them again, they have a bag full of medicines from several different physicians.

"It's difficult for me, as a physician, to treat someone who sees a whole lot of other doctors since I don't know what treatment the patient is being offered. My way around that is to try and establish a single doctor for each patient. If that patient continues to see several doctors, and I know about it, I'll inform the others that the patient is already being seen by me."

Preventive medicine is another area that is very difficult to address in the homeless population. "We attempt to get everybody vaccinated during flu season, we monitor blood pressure and administer treatment when necessary," said Dr. Heyding, "but it's very difficult to practise preventive care in this group."

Chronic homelessness
Chronic homelessness was the topic addressed by the next presenter, Beric German.

An outreach worker with 16 years experience helping the homeless in downtown Toronto, Mr. German has been with Street Health since 1989. Homeless for a brief time as a youth, he is currently involved in research on how to prevent AIDS transmission in the homeless population.

Mr. German told delegates that chronic homelessness is usually the result of one or several of the following factors: "lack of income, employment, affordable and adequate housing, and appropriate affordable social services.

"The most common myth among social service workers and other caregivers is that people living on the street have simply made the wrong choices in life," he said. "If you don't have enough money, or are unemployed, then it is your own fault. If you're an addict, then you just have to make another decision and all will be well.

"What this mythology doesn't explain is that different people are making decisions from different positions in society and under different circumstances. You don't become homeless because of individual decisions, addictions, or mental or physical disabilities," he stressed.

According to Mr. German, hostels are a poor solution to the problem of chronic homelessness.

"There is a wealth of literature on the need for supportive housing for people who have mental illnesses, he said. "As you can imagine, long-term hostel stays are not appropriate support.

"Homeless people travel from one group of strangers to another, and from one unknown, homeless, purposeless, and frightening situation to another. It's easy to lose yourself or your mental health in the shelter system because it's difficult to take guidance or comfort from people you don't know."

The feeling of hopelessness that exists in most shelters, coupled with a general lack of "purpose" experienced by many homeless people, often makes a poor situation even worse.

"The routine in shelters does not lead to development or maintenance of the life skills necessary to survive in our modern society and to fulfil daily tasks it breaks them down," Mr. German told delegates.

"Furthermore, if the people arriving at a hostel didn't have a drug-use problem when they came, then many might develop such problems under the conditions I've just described! The endemic stress produced, and complete sense of hope- lessness, can lead to addictions and a deterioration of existing illnesses or conditions."

Mr. German then provided delegates with a look at the other side of the addictions argument. Stating that substance abuse in adults may be a habit that cannot ever be fully "reversed," he argued that "we cannot refuse hostels or housing to people because of addictions.

"Barring (an addicted homeless person) from housing or hostels doesn't deal with an addiction...and can unwittingly become a death sentence for the homeless person," he said. "Placing homeless people who are long-term drug or alcohol abusers in dry' houses (i.e. where no drugs or alcohol are allowed) is a situation which is set up to fail. There have to be wet' houses and wet hostels. If drinking or drug use is to be regulated, then let it be so."

The solutions to the problem of homelessness are often "old solutions," concluded Mr. German. "We are being told in essence that we cannot afford to be a complex and caring society. The attitude that the state should not intervene' is the solution of the 1930s. We need not repeat that experience."

Street youth
The next presenter, Dr. Noni MacDonald, continued the argument for improved hostel and shelter facilities to help meet the needs of a specific homeless group in this case, street youth. A professor of pediatrics and microbiology at the University of Ottawa, and chief of the division of infectious disease at the Children's Hospital of Eastern Ontario, Dr. MacDonald provided delegates with an overview of the problems faced by street youth. "Street youth are a non-homogeneous and ever-changing group of adolescents and young adults who spend most of their time on city streets," said Dr. MacDonald.

"They're found on the streets of all major cities in Ontario and across the country and, to a lot lesser extent which a lot of people don't want to acknowledge in our small villages and communities."

Dr. MacDonald told delegates that the majority of street youth have run away from home because of major family conflict, physical or sexual abuse, or disillusionment with parental or community values.

"In general," she said, "street kids tend to be more males than females and, much to everybody's surprise, 50 per cent come from middle and upper class homes."

Once on the street, most fall into one of the following categories: the unemployed, young offenders, the homeless, those with serious drug and alcohol problems, and the sex industry workers.

Major sources of income for homeless youth include: agencies, family members (which may include receiving money from family members or selling family possessions), panhandling, crime, and sex for money. Some hold full- or part-time jobs "which are almost always menial and almost always short-lived, since it's really hard to get and keep a job if you don't have a place to live and no alarm clock to wake you to go to work, or if you have dirty clothes and no shoes," Dr. MacDonald observed.

The use of soup kitchens, shelters and addiction treatment facilities by street youth is very limited, she said. A recent survey of street youth in the Ottawa area shows that only 10 per cent of males and four per cent of females use soup kitchens regularly.

"Soup kitchens are not a major source of food for most street youth," Dr. MacDonald told delegates. "The problem is that it's very hard when you're 15-years-old to line up with the drunks, druggies and violent people' when you really don't know how to defend yourself and you're feeling very vulnerable."

A few centres have put together special soup kitchens specifically for street youth, "but we don't have enough of them," she said. "There's still not enough appreciation that the needs of a 45-year-old alcoholic are not the same as the needs of a 14-year-old girl."

Drug and alcohol use is also a common problem among street youth. "Again, unfortunately, there are very few drug and alcohol treatment centres designed for these kids," said Dr. MacDonald.

"The 13, 14, and 18-year-olds have to go to the same centre as the 45-year-old addict but it isn't the same problem or same type of issue."

The same can be said for shelters and hostels: "Kids won't go because it doesn't meet their needs," she said. Echoing the comments of the speakers before her, Dr. MacDonald stressed that the lack of housing leads to many of the other problems commonly experienced by street people.

"Many of our street youth lead very erratic lifestyles, which result in poor hygiene, inadequate diet, irregular sleeping patterns, exposure to the elements, street violence and sexual violence, drug and alcohol abuse, sexually transmitted diseases, and major mental health problems."

Street youth who turn to the sex trade not only suffer from a higher incidence of physical and sexual abuse, they also contract far more sexually transmitted diseases, which, due to the lack of regular condom use, they pass on to members of the general population.

"Most street youth are at very high risk for STDs," Dr. MacDonald told delegates, "and most have higher depression and suicide problems much higher than the average population."

Street youth face all of the same risks as the rest of the homeless population, Dr. MacDonald observed, "however, these problems are all just a little different if you're 14, compared to being 24, 34 or 64," she concluded. "And that's the take-home message we've got to have resources and interventions that are designed specifically for these kids if we hope to solve these problems."

Relative homelessness
The final presentation of the day was delivered by Mr. Jim Morris, deputy grand chief of Nishnawbe-Aski Nation, on the topic of relative homelessness.

Relative homelessness is said to occur when a home falls short of the minimum standards for dwellings established by the United Nations. These standards are summarized as follows: a home must provide adequate protection from the elements; access to safe water and sanitation; secure tenure and personal safety; and access to employment, education and health care. Moreover, to be considered a "home" by UN standards, a dwelling must "not cost more than people can really afford."

In his address, Mr. Morris recounted stories and presented slides which showed that many natives living on reserves are existing in conditions of relative homelessness, and have been for many years.

"Our people are locked inside federal reserves, living in houses that were designed by people living in Ottawa. These houses are often overcrowded, inadequate, and they do not suit the environment," Mr. Morris told delegates.

"When these houses were designed and built in the 1960s, they were wired for electricity and they also had rooms where the bathrooms were supposed to go but to this day, many of those homes are not connected to hydro and a large percentage don't have running water."

Most of the problems encountered by the homeless populations mentioned in earlier presentations are also shared by members of the relative homeless population.

"Many of these people have very great health problems and psycho-social problems related to living in this environment under these conditions," said Mr. Morris.

Among the problems encountered on reserves are increased drug and alcohol use, physical and sexual abuse, poor nutrition, crime, and serious medical and mental health problems. Natives living on reserves also experience a much higher suicide rate, particularly among the large youth population.

"Of the 29,000 people living in treaty nine, two-thirds are 30 and younger," he observed. "And these communities keep growing as more and more people are moving back to their roots."

Suitable housing with reasonable access to employment, health care, social services, and educational facilities, would go a long way in helping the relative homeless to overcome many of the difficulties typically associated with the homeless population.

Moreover, in the case of natives living on reserves, Mr. Morris told delegates that "helping these people regain their inherent right to the land, and all the resources that belong on that land" would be a major step toward eliminating the problems associated with relative homelessness.

Small group sessions
Following the presentations, delegates gathered into five pre-assigned groups to discuss the health issues resulting from homelessness, the barriers to health care experienced by the homeless, and how health professionals and the health sector as a whole should deal with these issues.

Each group included one facilitator charged with keeping the discussion focused and within the allotted time; a recorder assigned to chronicle the group's discussion on a flip-chart; and a reporter to present the group's findings.

In a final gathering at the conclusion of the workshop, each of the five group reporters briefly presented their findings to the rest of the delegates. Highlights of the issues/barriers and strategies identified by each group follow:

Group 1: Individuals with mental health problems

Issues: Poor attitudes toward the homeless (blaming the homeless person for his or her plight); poor access to health-care professionals by the homeless; lack of co-ordination and teamwork among health professionals, government agencies and other facilities in providing services to the homeless; poor training of staff who work with the homeless regarding their needs and how to assist them.

Strategies: Change attitudes toward homeless by improving training and education to front-line workers and health-care professionals, improving public policy, and educating the public; improve access to Ministry of Health expertise in areas such as case management; improve links between ministry facilities and other health-care services/ providers to exchange information; implement and/or improve government support systems to help prevent family breakdown which may lead to homelessness; improve access to affordable housing.

Group 2: Women and children

Issues: Lack of commitment by government regarding the welfare of children; poor employment opportunities; lack of money to address mental health issues; too little transitional housing for homeless women and children; poor access to prescription drugs to treat medical conditions in the homeless.

Strategies: Ensuring universal health care to the homeless by making access to health care easier for this population; implement agricultural policies to reduce food wastage and improve co-ordination of food donations to shelters and food banks; encourage government to provide incentives to create low-income housing; improve transitional housing to better meet needs of homeless women and children by providing greater access to counselling and teaching transitional skills needed to find and maintain employment; make better use of the media to educate the public and improve support for the homeless; organizations like the OMA should use their influence to address needs of the homeless.

Group 3: Chronic homelessness

Issues: lack of recognition of homelessness as a major barrier to health; lack of knowledge among health professionals regarding the unique health needs of the homeless, particularly with regard to addictions; lack of understanding of the effect of crowded living conditions (i.e. shelters, hostels) on morale of the homeless; lack of "wet" shelters where those who choose to drink can do so safely.

Strategies: provide a forum in which the homeless can participate in defining issues and needs of homeless people; allow homeless to participate in policy discussions; lobby to reinstate for- mer level of social assistance; relax rules regarding ID required to obtain health cards for homeless people; create more community health centres that will see clients without health cards; make politicians aware of the cost of not providing certain services to the homeless; implement strategies to better identify people at risk of homelessness.

Group 4: Street youth

Issues: homeless minors may have difficulty obtaining care; no strategies in place to deal with difficult youths who "don't fit" in current education system and opt to drop out; justice system hardens young offenders, making some potentially more dangerous; lack of opportunities for full and sustained employment for youths who quit school; lack of support services to help prevent family breakdown that may force children out of the home.

Strategies: ensure any reforms to health-care system take homeless population into account; provide more financial support for the integration of, and improved co-operation among, health, social service and justice systems; improve education strategies to ensure that youths who "don't fit" in the traditional education system somehow receive adequate education; implement peer counselling among homeless youth; recognize and implement child rights; improve flexibility in the justice system to allow for different solutions to different problems regarding youths and the law; create addiction, abuse and shelter services specifically designed to deal with homeless youths and their problems.

Group 5: Relative homelessness on reserves

Issues: poor living conditions homes lack basic necessities such as hydro and running water; displaced individuals move back and forth between reserves and cities; lack of recognition of relative homelessness as a health issue; lack of recognition that the impact of relative homelessness on people is similar to impact of other types of homelessness; lack of adequate support services to address issues of abuse and depression on reserves; lack of understanding by government that homes must be improved to meet and exceed standards set out by the United Nations.

Strategies: improve funding to reserves and allow members of these communities to determine the best way to apply funding to meet their needs; place housing under the umbrella of health policy; recognize and encourage traditional healing practices; provide more money to help natives improve their living conditions; government must clarify status of natives in Canada return land to natives so that they can determine their own future.

Where do we go from here?

Following the conclusion of the group presentations, Dr. Lynn Noseworthy, medical officer of health for Hastings and Prince Edward Counties Health Unit, and a member of the OMA Committee on Population Health, provided delegates with a brief summary of the day's events.

Noting that the workshop gave "credibility and legitimacy" to the issue of homelessness, Dr. Noseworthy outlined the common themes presented throughout the day, including: