Parliamentary Research Branch

PRB 99-1E

HEALTH AND HOMELESSNESS

Whether as a cause or a consequence of ill health, homelessness has emerged as a fundamental health issue for Canadians.(1)

The link between health and homelessness is two-fold: ill health can predispose individuals and families to homelessness, while homelessness gives rise to particular health problems. The following sections discuss the health concerns of the homeless, barriers to their good health, and some possible solutions. While much of the focus is on the efforts of municipal and provincial governments, one section deals with the role of the federal government.

As it has moved away from seeing health merely as the absence of disease or infirmity, Canada has over the last three decades achieved international acclaim for its conceptual work in the health area. Beginning with the 1974 report entitled A New Perspective on the Health of Canadians, the federal government has supported the view that health cannot be understood solely in biological or medical terms, but must be seen in a broader social, economic, political and cultural context.(2) "Population health," one of the key conceptual frameworks for current application, focuses on broad determinants of health; in other words, on those factors that make and keep people healthy. These factors are identified as: income and social status, social support networks, education, employment and working conditions, physical environment, biology and genetic endowment, personal health practices and coping skills, healthy child development, and health services. It is not hard to see that many of these health determinants are likely to be absent for the majority of homeless people. Poverty, unemployment, mental illness and geographic dislocation are among the leading causes and results of their condition.

Studies of the homeless suggest that, while their illnesses are not different from those of the general population, they live in conditions that adversely affect their overall short and long-term health status. They exhibit an increased mortality rate; a Toronto study of deaths among homeless people between 1979 and 1990 showed that 71% of the deaths were of people under 70 years of age, compared with 38% of deaths among the housed population.(3) While deaths among the homeless are occasionally due to freezing, they are mainly the result of injury, substance abuse overdoses, and alcoholic liver disease. Climatic conditions, psychological strain and exposure to communicable disease create an overall environment that sustains a range of health problems, including injury from cold, tuberculosis, skin diseases, cardio-respiratory disease, nutritional deficiencies and sleep deprivation. Lengthy periods of homelessness result in chronic health problems including those that are musculoskeletal and dental.

It is obvious that the main barrier to good health among the homeless is their lack of the adequate, safe, accessible and affordable housing that is linked to employability, community support, personal health care and access to health services.

Homelessness renders access to general health care services difficult or impossible. The homeless are unable to obtain medical treatment without a health card (and applying for a health card requires an address); to pay for items not covered by provincial medical or drug insurance plans; to receive adequate treatment in cases where their personal appearance alarms health providers; to make a health appointment, since they lack an address and a telephone; and to receive co-ordinated care when comprehensive medical records are not kept in one location with one provider. Problems continue following treatment or hospitalisation, because the homeless have no place to recuperate and no consistent caregiver.

As a result, health care delivery to homeless individuals is concentrated in emergency departments in the core of large urban centres and in the institutions set up to address their shelter and social lacks. The need to respond to the acute health problems of this population and to redirect attention to preventive health services has led to some innovative studies and potential solutions.

Suggestions for overcoming the absence of a health insurance card (the case for an estimated 30 to 50% cent of people living in Ontario shelters)(4) are currently being discussed in several provinces. They include proposals for more relaxed rules for homeless people who apply for cards, such as allowing photocopies rather than originals of identification documents. For professionals such as nurse practitioners and physicians, who must have a valid health card number for billing the provincial government, a system might be set up to fund their visits to hostels and drop-in centres. Other possibilities would be to move beyond the fee-for-service system that requires patients to present health cards to providers and allow services to be delivered through salaried staff operating in designated community health centres.

A 1998 Toronto study found that men in emergency shelters were more likely to fill drug prescriptions if they had automatic drug benefit coverage through the shelter.(5) The study involved random samples of 80 men in a government agency shelter where drugs were automatically covered by the provincial drug plan and 76 men in a private non-profit organisation shelter where there was no automatic coverage. Of the 100 men receiving prescriptions, only 6% of those who were automatically covered did not fill them, compared to 20% of those without coverage. The primary reasons given for non-compliance were the high cost of the medication or the lack of a provincial drug card.

Recognising that health care professionals must learn to provide a more welcoming and supportive environment, Toronto’s Wellesley Hospital found a way to provide more compassionate care and decrease repeat visits to its emergency department. In a randomised controlled trial, it found fewer return visits when persons with no fixed address were approached by a volunteer and offered a chance to discuss their health than when similar homeless people received regular care from emergency department staff.(6)

Increasingly assertive interventions for improving the health of the homeless include street patrols, mobile health vans, and outreach programs that involve an integrated, one-stop health and social service contact.

The health of the homeless, like that of the general population, is influenced by multiple variables, including age, gender, and ethnicity, as well as socio-economic status, and geographic location.

Abused youth have been identified as being at high risk for homelessness. A 1994 study of homeless youth in Calgary found that more than half had gone through the child welfare system, having experienced abuse at home and problems in school.(7) A 1992 survey of Ottawa street youth noted that 92% had attempted suicide.(8) Once on the street or without a home, youth can experience a range of physical, psychological and emotional health problems.(9) These are related to unsanitary and precarious living conditions, inadequate nutrition, violence, alcohol and drug use, risky sexual behaviours, low self-esteem and ongoing societal rejection, and economic marginalization.

Ongoing work is needed to identify the different life patterns and resulting needs of young people. For example, a 1996 survey in Ottawa revealed extremely limited use of soup kitchens, shelters and addiction treatment facilities by street youth.(10) Accordingly, interventions need to focus on the whole situation of the individual youth, avoiding a "one size fits all" solution or one aimed only at an immediate health problem.(11) In addition, there must be inter-agency co-ordination and co-operation across health and social spheres with flexible design and delivery for food, shelter, and counselling services as well as life skills training, education, and treatment.

Officials at Adsum House, an emergency shelter for homeless women and children in Halifax, point out that the profile of homeless women is diverse, including pregnant teens and elderly women, women in conflict with the law, women victimised by eviction, fire or flood, and women who are mentally ill or addicted.(12) Single mothers and battered wives are among the women viewed as most at risk for homelessness. Often suffering from depression because of increased vulnerability, economic strain and social isolation, such women also face the same physical hazards as other homeless women, stemming from poor nutrition, inadequate protection against conception or sexually transmitted diseases, proximity to infectious diseases, and physical violence.(13) As the Canadian Public Health Association reported, the health of the children of these women is also affected by the cycle of low income and tenuous hold on stable shelter: "Welfare motels and hostels are available…however, studies of children housed in such facilities report increasing frequencies of acute illness, chronic illness and developmental slowing or delay."(14)

Perhaps because women are still a minority of the homeless, there is little material assessing the effectiveness of interventions aimed at the various subgroups of the homeless female population. The primary need for all appears to be affordable, accessible, secure housing in combination with social support programs and appropriate health services. These could include access to counselling on nutrition, sexual activity, and substance use as well as pregnancy and parenting programs.

Since the late 1960s, services for persons with mental disorders have shifted away from being predominately institutional or hospital-based to being community-based. In Canada, resources have shifted from psychiatric hospitals to psychiatric units in general hospitals. Data show that between 1960 and 1976 the number of beds in Canadian mental hospitals decreased from 47,633 to 15,011, while bed capacity in general hospital psychiatric units rose from 844 to 5,836.(15) Factors contributing to this shift included: increasing use of psychotropic drugs, growing criticisms of psychiatric institutions, awareness of the community psychiatry movement in the United States, and the exclusion of provincial psychiatric hospitals from the federal-provincial hospital insurance program introduced in 1958.(16) Critics have argued that delivery of mental health services has been seriously fragmented, with negative consequences for those with serious and chronic mental illnesses who reside in the community. In 1994, it was estimated that between 20 to 30% of the homeless in Canada were mentally ill and in need of treatment.(17)

Individuals who are homeless or who have rejected traditional social and mental health services require prevention as well as crisis intervention services. Because mental health professionals typically work in community mental health centres, hospitals, or in private practice, mobilizing and co-ordinating their services for the mentally ill and homeless can be difficult. Active outreach programs that assist such individuals whenever and wherever the need arises can alleviate their periods of dysfunction and prevent some of the costly hospitalizations, or even incarcerations.

Federal and provincial jurisdictional boundaries are seen as a major impediment to the delivery of health and other services for the various Aboriginal groups.(18) Aboriginal people who are homeless can be Indian (status or non-status), Inuit, or Metis and can live in remote rural areas or large urban centres. Although approximately half of all Aboriginal people are status or registered Indians, and therefore eligible for federal benefits such as health care and housing, a large portion of the responsibility for Aboriginal people who live off reserve falls to provincial governments. While federally funded non-insured health benefits are theoretically available for status Indians, regardless of residency, access to them is difficult for status Indians who are homeless.

Aboriginal people living on reserves may reside in crowded and dilapidated buildings; in Canada’s cities, they may face similar inadequate housing or be without shelter. As the Royal Commission on Aboriginal Peoples noted, inadequate housing contributes to the significantly higher rates among Aboriginal people of tuberculosis, pneumonia and other upper and lower respiratory tract infections, gastrointestinal diseases, skin infections, cancer due to second-hand smoking and deaths due to fire.(19) In addition to facing racism, homeless Aboriginal people may be unable to discuss their health problems with medical staff because of language barriers; they may lack access to trained Aboriginal health care professionals or medical interpreters; and they may find the available health programs to be culturally inappropriate.(20) Mental health issues, including suicide, substance abuse and family violence, are repeatedly identified as key concerns among this population. It is essential that they have access to safe, communal housing that is alcohol and drug-free and to readily available and culturally sensitive programs and services.

In the late fall of 1998, both the premier of Ontario and the mayor of Toronto suggested that homelessness was a national issue and called on the federal government for assistance in addressing it.(21) One article noted that the federal government had already provided funding of $300,000 for a task force on homelessness and $50,000 for a summit meeting on this issue.(22)

The federal government’s role in relation to the health of Canada’s homeless is not clear. Constitutionally, there is no precise division of power on health matters as distinct from health care. The provincial governments have wide powers to regulate local health matters, particularly the delivery of health care services; specifically, they have the authority to make laws concerning the establishment, maintenance, and management of hospitals, asylums, and charitable institutions. The federal government gains its authority in health matters through general powers, namely those pertaining to criminal law, spending, and peace, order and good government. In addition, it has specific authority for groups such as First Nations people on reserves, veterans, military personnel, the RCMP, and individuals within federal correctional services and its institutions.

Interpreted broadly, the federal government has seen its key roles in the health of Canadians as being protection of their health and promotion of strategies to improve it, in addition to support of the health care system they need. In relation to the homeless, the federal government can follow several avenues for identifying and meeting their health needs. It can:

• Work in partnership with provincial and territorial governments to foster national approaches to health programs and services for the homeless;

• Respond to the health needs of those homeless who are members of those groups that fall within its specific authority (First Nations, veterans, etc.);

• Monitor and administer the Canada Health Act and its five principles – accessibility, portability, comprehensiveness, public administration, universality- in a manner that encompasses the needs of the homeless;

• Direct spending to specific programs and initiatives through clearly delineated strategies for helping the homeless;

• Provide funding for research and evaluation initiatives focused on the homeless within such bodies as the Medical Research Council and the Social Sciences and Humanities Research Council.

As noted earlier, major urban centres across the country have begun to develop a wide range of interventions across numerous policy areas using an interdisciplinary approach. A similar effort supportive of these intersectoral endeavours to address the health of the homeless could be made at the federal level. Any interventions would have to pull together the often separate policy spheres of income and social status, education, employment and working conditions, and physical environment. They would have to involve not only health professionals but economists, educators, environmentalists, and employment and social services specialists, as well as family, friends and community members. The aim would be to develop a comprehensive and integrated framework within which the federal government could develop strategies for alleviating homelessness.

Thus, while there is room for a co-ordinated, co-operative multi-jurisdictional effort, there is also work to be done among the federal ministries focused on health, employment, and housing. Responding to the housing and health needs of groups, such as First Nations and veterans, that are under federal jurisdictional responsibility will first require some careful collection of data about who they are, where they reside and what health problems they are likely to face. Critics have noted that the five principles in the Canada Health Act have little relevance to the homeless, who cannot meet provincial criteria for health cards or for accessing services. Recognising that the federal government has in recent years moved away from strategies directed to specific sub-groups of the Canadian population, advocates for the homeless assert that new health initiatives, such as pharmacare or homecare, must include some focus on this group. In addition, focused research studies funded by the major federal research councils could provide valuable insights and contribute to a fuller assessment of what the federal government does (or does not do) to protect the health of homeless people in Canada.

(1) Canadian Public Health Association, "Homelessness and Health: Position Paper," Ottawa, 1997, available on www.cpha.ca, October 1998.

(2) Marc Lalonde, Minister of National Health and Welfare, A New Perspective on the Health of Canadians: A Working Document, Ottawa, April 1974. This support continued to be expressed in documents such as Jake Epp, Minister of National Health and Welfare, Achieving Health for All: A Framework for Health Promotion, Ottawa, 1986 and Federal, Provincial and Territorial Advisory Committee on Population Health, Strategies for Population Health: Investing in the Health of Canadians, Report for the Meeting of Ministers of Health, Ottawa, September 1994.

(3) Canadian Public Health Association, "1997 Position Paper on Homelessness and Health," available at web site www.cpha. ca, October 1998.

(4) Margaret Philip, "Homeless without Health Cards Likely to Go without Care," Globe and Mail (Toronto), 2 March 1998, A8.

(5) Gillian Wansborough, "Homeless Men’s Drug Compliance Varies," The Medical Post, 13 October 1998, p.23.

(6) D.A. Redelmeier, J.P. Molin, R.J. Tibshirani, "A Randomised Trial of Compassionate Care for the Homeless in an Emergency Department," Lancet, 345, 6 May 1995, pp.1131-1134.

(7) Allison Bray, "Net Failing Street Kids, Expert Says," Winnipeg Free Press, 21 October 1995, A7.

(8) Canadian Public Health Association, "1997 Position Paper on Homelessness and Health," available at web site www.cpha.ca, October 1998.

(9) Tullio Caputo and Katherine Kelly, "Improving the Health of Street/Homeless Youth," Determinants of Health: Children and Youth, Volume 1, Papers commissioned by the National Forum on Health, Editions MultiMondes, Sainte-Foy, Que., 1998, p.408-441.

(10) Ontario Medical Association, "Exploring the Health Impact of Homelessness," available on web site www.oma.org, December 1998.

(11) Jim Anderson, A Study of "Out-Of-The-Mainstream" Youth in Halifax: Nova Scotia Technical Report, Supply and Services Canada, Ottawa, January 1993.

(12) Adsum House (an emergency shelter for homeless women and children), "Profile of Homeless Women," available at web site navnet.net/~mic/adsum, January 1999.

(13) Sylvia Nocav, Joyce Brown, Carmen Bourbonnais, No Room of Her Own: A Literature Review on Women and Homelessness, CMHC, Ottawa, p.31-36.

(14) Canadian Public Health Association, "1997 Position Paper on Homelessness and Health," web site www.cpha.ca, October 1998.

(15) Health Systems Research Unit, Clarke Institute of Psychiatry, Best Practices in Mental Health Reform: Discussion Paper, Prepared for the Federal, Provincial, Territorial Advisory Network on Mental Health, Health Canada, Ottawa, 1997, p.1.

(16) Health Canada, The Mentally Ill and the Criminal Justice System: Innovative Community-Based Programs 1995, Report prepared by Carol Milstone, Supply and Services Canada, Ottawa, 1995, p.9.

(17) Ibid., p.14.

(18) House of Commons Standing Committee on Health, Towards Holistic Wellness: the Aboriginal Peoples, Ottawa, July 1995.

(19) Royal Commission on Aboriginal Peoples, Gathering Strength: Report, Volume 3, Canada Communication Group, Ottawa, 1996, Chapter 3 on Health and Healing and Chapter 4 on Housing.

(20) City of Calgary, "Community Action Plan: Aboriginal Services," available at web site www.gov.calgary.ab.ca, December 1998.

(21) Various stories in the Toronto Star and Globe and Mail (Toronto), in the first week of November 1998.

(22) William Walker, "Lastman Begs for Homeless," Toronto Star, 5 November 1998.