The Mess that is Healthcare for the Homeless

My primary activity with the London Homelessness Outreach Network is to explore street-level healthcare for people who are experiencing homelessness.  The idea is that we know there is a gap in care in terms of healthcare services that go out to people, rather than requiring them to go to the care.  So, although there are clinics such as InterCommunity and the Centre of Hope FHT, or walk-ins and emerg, these all require that the individual accessing the service goes there, waits, and sees a professional in an examination room.  This often leads to people waiting far too long to access care, and having complications of relatively benign conditions.

Our initial thought is that we should create some kind of community health bus that brings the care to places where people are at, and can also provide some kind of system-wide coordination/communication.  However, in talking with folks around town, we have found that more agencies are continually adding more services, but with little coordination or thought for the big picture.  For example, while we were engaging in our discussions, a local shelter started to host CCAC nurses.  The goal was to pick up patients who would go missing after being rostered to CCAC in emerg, but to also provide minor care and triage for anyone seeking assistance.  In talking with them, they stated their current goal is to get a nurse practitioner or a physician to join them.

So, the problem is, we just keep doing more of everything, without thinking about how, why, who, what, when, and where we should really be doing this.  People who are homeless in London continue to have high morbidity rates and low age of mortality, even though we keep adding more providers into the mix.  Our solution is to host a community summit in the fall to bring together all parties who are currently involved to do some mapping, do some ‘follow the money’ exploration, and see if we could do smarter rather than just doing more.

A Shameful Attempt

I was greatly disappointed watching the documentary called “The Streets of Plenty” that seeks to document the issues surrounding homelessness in Vancouver.  The filmaker inserts himself into the community in the Downtown Eastside with the stated goal of really knowing what homelessness is about, but it comes off as self-absorbed and uninformed.  The first ten minutes were so unpleasant as the filmaker highlighted his biases of victim-blaming, and showed the demeaning ways he attempted to make himself the same as a homeless person.

Points that I particularly objected to:

  1. He stated that panhandling is not embarrassing, rather you simply feel ignored.  I would suggest that feeling invidible is deeply shaming to many.
  2. He shows graphs demonstrating the increase of homelessness along with the increase of social housing, suggesting that social housing is encouraging more homelessness.  Rather, homelessness in increasing, and we are attempting to keep pace with services.
  3. He falsifies how easy it is to get social assistance for a disability.  ODSP claims are in reality much more difficult, and much more frequently rejected.
  4. He presents a philosopher multiple times who repeats the false claime that we are incentivizing homelessness, missing the point that 0% of people who are homeless identify homelessness as their housing status of choice.
  5. He overstates the rate of addiction in homelessness as 100%, versus 30% for those who are temporarily homeless and 66% for those who are chronically homeless.
  6. He concludes with victim-blaming, calling homelessness and addiction “self-imposed slavery”.  The thousands of stories I hear do have a component of the self, but have much more to do with the social determinants of health and structural violence.

There were a few things I appreciated:

  1. He highlighted the historical problems with the mental health system.
  2. He talked about how brutal conditions can be in emergency shelters.
  3. He hinted at the frustrations of having no where to use the washroom.
  4. He touched on the complexities of homelessness.

Interestingly, at the end of the documentary he interviews the Mayor of Vancouver who talks about exactly what the isssues are with homelessness, the primary being the lack of social housing with supports.  This might have been a better place to start the documentary, starting with what we already know.

Political Advocacy

Two weeks ago I had the privilege of attending the All Our Sisters first national conference on women and homelessness (www.alloursister.ca).  Reviewing the poster boards I saw one of the best examples of political advocacy around homelessness that I have seen in a while.  A group called ‘Homeless in Saskatoon‘ created Christmas cards to be sent to their Member of Parliament.  As you can see below, the cards had the tag line “From our home to yours” and featured pictures of rough sleeping accommodations.  A very powerful message, and one we just might have to copy here in London.

Stories in Numbers

There is nothing like an ill child to bring perspective on life. I have been away helping care for #2 son, who I’m pleased to report is doing well now. Until things get settled again, I just wanted to share some statistics from my presentation in the previous post in case you haven’t watched it. I know that stories are more effective than numbers, but I believe there are also a lot of stories in these numbers.

  • Over 70% of homeless youth have experienced abuse in the home.
  • Upwards of 40% of homeless youth identify as LGBTTQ
  • Most youth who become homeless have used little or no substances.
  • Approximately 1/3 of people experiencing homelessness use substances.
  • This number is closer to 2/3 for those who are ‘chronically’ homeless.
  • 2/3 experience a lifetime diagnosis of mental illness, 50% after becoming homeless.
  • 47% of those who are homeless and experiencing a mental illness are not receiving formal care.
  • 55% of those experiencing homelessness have a serious health condition.
  • The average age of death for a homeless person in Canada is 44.5 years.
  • Less than 10% of social housing in London is supportive housing.
  • There is a 9 year waiting list for social housing in London.
  • Approximately 2000 people are homeless in London on any given night.
  • Homelessness costs the city around $10 million annually.
  • Social assistance rates are less than half of any measure of poverty in Canada.
  • In a local study, 0% of homeless people identified homelessness as their ideal housing condition.
  • The U.S. has 4x the rate of homelessness as Canada, Norway has half.

Balancing Cure and Relationship

When feeling drawn to take action on homelessness, many of us fall into a curative stance, that is, we want to fix others.  This is done out of best intentions, the desire to alleviate suffering, but can become pejorative and actually disempowering if it is about ‘us’ giving to ‘them’.  This is particularly common amongst health professionals (myself included), where the whole essence of our profession is helping others.

However, the band-aid cure might actually impair long-term outcomes, rather than enhance them.  This is the same issue that has been debated within international development, that just giving things to people is important in terms of decreasing suffering, but can also become disempowering.  Soup kitchens are essential in terms of ensuring that people have their basic needs for nutrition met, but for every soup kitchen there could be a community garden that allows people to be involved in meeting their own nutritional needs.

I have been exploring models of enhancing street-level health care in London.  The concern is that although people experiencing homelessness have access to a variety of primary care services, they frequently leave concerns far too long because of accessibility to these services.  This would be alleviated to some extent by having health professionals on the street with backpacks and access to resources.  However, a friend has continued to warn me that what homeless people don’t need is more health professionals, but more friends who happen to be health professionals.  It’s about relationship first, living in solidarity with others, and cure comes second.

Poverty Pornography

For the London Homelessness Outreach Network, we have had a couple of wonderful graphic designers helping us with pro bono work.  One of the tasks includes developing a flyer that we can hand out to inform people about what we do.  It has been a bit of a struggle in making this flyer in terms of knowing exactly what images to use.  Interestingly, I was talking with a photographer who works with some international development agencies, and he goes through a lot of the same struggles.

The issue is trying to make a human connection to our work, without peddling poverty pornography.  How can you capture an image that encompasses human suffering, without exploiting that suffering human?  You may notice that on this blog I only use images of places that speak of poverty, not of people.  And, in the only video I have made, I only used images where you could not identify the person.  I want to demonstrate respect for those whom I work with, but also allow others a glimpse into their world.

I’m not sure where the balance is, but for now I err on the side of caution.  I have thought about doing a photovoice project in the future with people experiencing homelessness, so I’m sure this issue will come up again.