Special report / Document

Impact on health care adds to the social cost of homelessness, MDs say

Fran Lowry

Canadian Medical Association Journal 1996; 155: 1737-1739

[en bref]

Fran Lowry is a freelance writer living in Toronto.

© 1996 Fran Lowry

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In brief

Homelessness has become a visible part of Canada's urban landscape, affecting adult men and women, youths and families with children alike, and the issue becomes particularly serious as winter approaches. During a workshop in Toronto earlier this year, physicians, researchers and social workers examined the effects of homelessness on health, identifying many of the unique health needs of this vulnerable segment of society.

En bref

 En nombre croissant, les sans-abri font partie du paysage urbain au Canada. Les sans-abri sont aussi bien des hommes et des femmes adultes que des jeunes et des familles avec enfants. À un atelier tenu récemment à Toronto, médecins, chercheurs et travailleurs sociaux ont relevé les problèmes de santé uniques auxquels sont exposés les sans-abri.
The homeless have always been with us. There have always been what sociologists call the chronically homeless, the skid-row bums and rummies who live "on the Main." Until recently, they had their own part of town in most urban Canadian centres and stayed in it, largely out of sight.

Today, the situation is different. The number of homeless Canadians has grown consistently since the 1980s, reaching unprecedented levels in 1996. In 1995, about 27 000 Torontonians used the city's hostel system. Recent estimates indicate that 3600 people, including single adults, youths aged 18 years and younger as well as families with children, use Toronto's emergency shelters every day.

"We don't visualize women and children as homeless," says Dr. Chandrakant Shah, professor in the University of Toronto's Department of Preventive Medicine and Biostatistics. "We forget about them because the usual perception of a homeless person is of a down-and-out drunk male, the kind that has always existed. The big difference now is that we are starting to see an increase in the number of women and children turning up in emergency shelters.

"In Toronto, in just a short period, the number of homeless families has risen from 800 to 1800," he told a workshop on homelessness and health, jointly sponsored by the U of T and the Ontario Medical Association and held earlier this year. "It's an epidemic."

Some believe the epidemic was precipitated by Ontario's recent cuts in welfare payments, which lopped 21.6% off monthly welfare cheques. Since the main cause of homelessness is a lack of affordable housing, community workers were not surprised that the substantial reduction in welfare payments left some people with nowhere to go but the street. The huge majority of those who end up on there are young -- only 12% are over 50.

The illnesses of homeless women and men are not different from the general population's, but their living conditions and poverty affect their ability to cope with health problems as they appear.

Mental illness

The homeless are more likely to have chronic and psychiatric illnesses than the general population. Studies in various Canadian cities indicate that the proportion of homeless people with psychiatric disorders may be as high as 35%.

Shah suggested it is common to have more than one disorder, and the most common combination is mental disorder and substance abuse. In one study, more than one-third of emergency shelter users were alcohol abusers, 15% were drug abusers and 20% were current or former psychiatric patients. Many homeless people have a combination of problems that make them very difficult to treat.

Which comes first, the mental illness or the homelessness? Shah says this question is still being debated. "Does the homelessness lead to higher prevalence of disorders or does having a condition predispose people to homelessness? The answer is that both are true. For example, being homeless can lead to depression and depression can cause work disability, leading to poverty that results in homelessness. A follow-up study of homeless persons in California found that although 45% of respondents had no medical or psychiatric impairment when they first became homeless, these healthy respondents were likely to develop some type of disorder after being homeless for 6 months."

Street kids

The health problems of street kids, distinct from those of older homeless Canadians, are uniquely related to their age and erratic lifestyle. Like all the homeless, they fall prey to poor hygiene, inadequate diet and exposure to the elements. But because they are younger and still growing, said Dr. Noni MacDonald, professor of pediatrics and microbiology at the University of Ottawa, they are more vulnerable to these deprivations and to the violence, drugs, alcohol, sexually transmitted diseases and mental-health problems that pervade their world. (One survey of Toronto street people under age 25 found that over 70% had left home because of physical and/or sexual abuse.)

According to MacDonald, the needs of Canada's street kids cannot be addressed at Salvation Army-type facilities that were set up to help older, usually alcoholic, men. Street kids simply won't go there.

"When you are 15 years old it's hard to line up with the winos and drunks, so kids don't use soup kitchens. The needs of a 45-year-old alcoholic are so different from those of a 14-year-old girl. If you don't have a place to keep your clothes because if you take them off they'll get stolen, then you can't shower. Where can you wash?"

There has been an increase in intravenous drug use, hepatitis and HIV infection among street youth who, despite being very sexually active -- many work as prostitutes -- usually have unprotected sex. An interview of 100 Ottawa street kids aged 15 to 19 found that 25% had had at least four different sex partners within the last month, yet only 27% of the boys and 8% of the girls always used condoms. About 16% of the girls were infected with chlamydia and had never been treated.

"STDs are a big problem in these kids," MacDonald said. "We need resources and interventions that are designed specifically for them. Right now, there are no centres just for this population, and the kids won't go to the drug and alcohol centres that exist because they don't meet their needs."

Why do people become homeless?

People do not become homeless because of individual decisions, drug or alcohol addictions, or mental and physical disabilities, a man who has worked on poverty issues in Third World countries, including Bangladesh, told the workshop. They end up on the street because of inadequate income, not enough affordable, supportive housing and a lack of adequate social services.

"Social-service employees and other caregivers often mouth the most common myths, that the homeless just made the wrong choices in life," said Beric German. "If you don't have enough money, it's your fault. If you are an addict, 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 a hundred different circumstances. It is quite a different matter to be making decisions from a managerial level, receiving a good income, than to be making a decision when your income, and thus your options, are very limited."

| CMAJ December 15, 1996 (vol 155, no 12)  /  JAMC le 15 décembre 1996 (vol 155, no 12) |