For those on the street or precariously housed, access to care remains an enormous challenge.
By Mark Sampson
They are scenarios that play out in countless emergency departments and health clinics across our province every year. A patient comes in looking for medical aid. Perhaps they don’t have a health card or any other ID on them. They certainly don’t have a fixed address. Maybe they’re in the grips of a mental health crisis or in overt withdrawal from a substance use disorder. Though health care workers will try to help them, they may be dismissed as “frequent flyers” and their underlying illness unrecognized.
For the thousands of Ontarians who are either suffering from absolute homelessness or are precariously housed, access to health care can be problematic. It was a huge issue prior to the pandemic and the fall-out from COVID-19 has only exacerbated their plight. There are many health professionals who dedicate their energy (and careers) to helping these populations: emergency department physicians and “street doctors” who treat and advocate for people experiencing homelessness; hospital leaders who work to embed system improvements for these patients when they come in the door; and scholars who are building an evidence-based body of research to assist with these systemic changes. (To help foster system change, this article will not use the collective noun “the homeless” but instead use “unhoused” or “people experiencing homelessness.” Many understand that these terms help to elevate the humanity of people instead of defining a large group of people with one stigmatizing characteristic).
Hope can feel thin on the ground and there are daily moral injuries that can come from failing to help those with such complex needs. Anyone who has spent time with people experiencing homelessness knows these individuals have suffered some of the most harrowing traumas imaginable, including physical, emotional and sexual violence. They may have grown up in poverty and/or witnessed their elders struggle with substance use or mental health issues. Worse, many people experiencing homelessness have been abandoned by those who are supposed to love them the most: their parents, their children, other family members, and/or the communities to which they belong. The health professionals who work tirelessly to treat and advocate for them refuse to do the same. They keep fighting for the unhoused populations they serve, even on the days — maybe especially on the days — when it feels like a losing battle.
Housing is health care
One of these professionals is Dr. Alex Anawati, an emergency department physician at Health Sciences North in Sudbury and an associate professor at Northern Ontario School of Medicine (NOSM) University. He says he sees at least one person in some state of homelessness on almost every shift in the emergency department. For him, these are not isolated occurrences affecting individual patients, but rather part of larger societal issues that compound marginalization and poor health outcomes for the most vulnerable people living in his community. “You can’t have your eyes open and not see these injustices,” he says. “I’m surprised at how often these cries for help are ignored, to the point where it’s causing me moral injury. How can you ignore it? Homelessness, racism, the ongoing effects of colonialism — that is what walks in the door of the emergency department every single day.”
Dr. Anawati says demonstrating solidarity with unhoused patients requires physicians to think well beyond the usual parameters of patient-centred or even community-centred care. At his hospital, he has championed the notion of socially accountable, defined as the obligation of medical institutions to be accountable care for the health of the communities they serve. Achieving socially accountable care involves, in part, building partnerships with other community organizations and practitioners who help people experiencing homelessness, and to integrate those relationships into the very care that physicians provide. It isn’t easy, as people experiencing homeless can suffer from exceedingly complex personal and medical issues, and have a fragmented relationship with the services designed to help them. Yet, as Dr. Anawati writes in his 2019 call-to-action, “Social Accountability as the Framework for the Moral Obligations of Health Institutions,” emergency departments and their front line staff are uniquely positioned to understand what individuals experiencing homelessness are going through and to be the connecting point between the various organizations that can assist them.
“Health providers who interact with this community have a particular knowledge of their needs,” he says. “They are confronted by the issues that other health and social services fail to address. They have access to the lived experiences of people experiencing homelessness. That is socially constructed knowledge. That’s a source of knowledge that emergency departments can look at more systematically and use to make system improvements.”
But it can often feel like an uphill battle, especially for smaller cities or rural communities in Ontario that don’t have the same resources as larger urban centres, like Toronto, Hamilton or Ottawa. Dr. Anawati can summon statistics at will about his community in Sudbury: with a population of just 180,000, the city has 2,200 people experiencing some level of precarious housing and more than 500 who are suffering from absolute homelessness, according to a 2018 study. About 40 percent of people experiencing homelessness in Sudbury identify as Indigenous (as compared to 10 percent of the population overall) and 60 percent say they have visited the emergency department at least once in the last year.
As mind-boggling as these stats may be, so too are the various impediments that keep individuals experiencing homelessness from getting the care they need. Dr. Anawati puts it succinctly. “For anyone doing work in this area, the number-one barrier is politics,” he says. “We could summarize it like this: housing is health care, full stop. It comes down to political decisions about housing. These people want to be permanently housed. When we secure housing, we see immediate improvements in their health. But I don’t know if the political will is there to address a lack of housing for these populations.”
Life on the street
Indeed, for many who work with people experiencing homelessness, the political will to help these populations seems at best to be lacking and at worse to be going in the wrong direction. An entire body of scholarship focused on homelessness and health, developed both before and during the COVID-19 pandemic, paints a stark picture of where we are today. According to a major study published in Nature in 2021, people experiencing homelessness must overcome tremendous structural barriers to obtain health care and they also contend with competing priorities, such as securing food and shelter, which frequently take precedence over health care. Individuals experiencing homelessness may also avoid care, owing to a mistrust of the health care system and experiences of discrimination from providers. This is having a huge impact on their health. According to a CMAJ article published in 2020, Canadians who experience homelessness now face life expectancies as low as 42 years for men and 52 years for women. Data on the life expectancies among transgender and non-binary individuals experiencing homelessness is missing.
At CPSO, the realities of homelessness in Toronto came into focus earlier this year when we announced our new chosen charity, selected by staff and supported for a three-year term, was Seeds of Hope, an organization that serves homeless populations throughout the GTA. The charity provides food, supportive housing, learning opportunities, spiritual help and much more to people experiencing homelessness, all on an annual operating budget of less than $500,000. One of the reasons Seeds of Hope is such a great fit for CPSO is that it has built relationships with health care professionals who work directly with homeless populations.
One of those professionals is Dr. Jonathan Wong, a family physician at Inner City Health Associates and program lead for Street Clinical Outreach for Unsheltered Torontonians (SCOUT). He is known to everyone at Seeds of Hope — staff, volunteers and the homeless populations he helps — simply as “Doctor Johnny.” Throughout the pandemic, he and the nurses he works with have gone into the tent cities to introduce themselves to the people living there, build relationships with them, and find out what medical and social supports they might need. What Dr. Wong has heard time and time again from these populations is they feel invisible; that people — including those working in the health sector — often look right through them.
“Homeless individuals are stigmatized and dismissed by many on a daily basis,” he says, “sometimes even by health care providers who are meant to support them in what is the never-ending crisis of the homelessness experience. Even though these people are experts of their own lived experience, they can be treated like the concerns and challenges they face to simply survive are illegitimate. A line that I heard from one of my patients that will stay with me forever was: ‘Most people just see right through me. To them, I’m not even a person. I’m not valued.’”
For Dr. Wong, earning the trust of people that he meets and cares for through his street medicine is key. He approaches this work from a place of non-judgment and he understands how important it is to build long-term relationships with individuals experiencing homelessness, even when confronted by the turbulence and trauma of their daily existence. Showing up once at an encampment, asking a few questions and not coming back won’t work.
“We build trust through consistent patient-centered outreach that is free of judgment or any sort of agenda,” he says. “We never go in there saying, ‘You need this.’ Instead, we listen to their needs and priorities, affirm their inherent value as human beings, and ultimately partner with them to reach their goals at their own pace. And honestly, most of their goals tend to be around getting housed, being abstinent from substances, working through past trauma, and then to contribute meaningfully to society and/or reconnect with family.”
The intersectionality of homelessness
No discussion of homelessness is complete without looking at the intersectionality of race, ethnicity, gender diversity, language and other aspects of a patient’s identity (or, more accurately, identities) that affect access to care. Indeed, the demographics of homelessness in Canada have been shifting in recent decades: according to homelesshub.ca, a web-based research library and information centre, 28.2 percent of those experiencing homelessness are members of racialized groups, compared to the Canadian average of 19.1 percent. Indigenous Peoples make up only 4.3 percent of the overall Canadian population but comprise 30.6 percent of the youth homelessness population. In previous issues of Dialogue, we’ve examined topics such as anti-Black racism, treating trans patients and Indigenous health, but adding homelessness to the equation lends a whole other dimension to the care these populations receive — or don’t — from the health system.
Someone who knows a lot about this is Dr. Alex Abramovich, PhD, an independent scientist with the Institute for Mental Health Policy Research at CAMH, and an assistant professor at the Dalla Lana School of Public Health and Department of Psychiatry at the University of Toronto. He has dedicated a great deal of his research to looking at social inequities impacting 2SLGBTQ+ health and homelessness. He says roughly 30 to 40 percent of youth experiencing homelessness in Canada identify as 2SLGBTQ+ and family conflict is the leading cause of homelessness among this population.
“The stress and the stigma of not having a safe place to call home can’t be overstated,” he says. “It has such a negative impact on your health. We see higher rates of anxiety, depression, suicide, etc., among this population, and they often don’t get the help they need.”
Dr. Abramovich says that those who have multiple marginalized identities, such as racialized 2SLGBTQ+ homeless youth, are continuing to encounter multiple discriminations. In terms of their day-to-day living, these populations often need to choose between two or more unsafe situations. “They’ll say: ‘Will I sleep in a shelter tonight where I might get a meal and a shower, or will I sleep outside where I’ll have less chance of being harassed?” he says. Indeed, a lot of 2SLGBTQ+ youth experiencing homelessness encounter harassment from other homeless people at tent cities and encampments, and this forces them into even more transience — such as sleeping in cemeteries — where doctors performing street medicine may not even find them.
Their encounters with traditional health care can also be harrowing. “Unfortunately, the system is not created to support everyone,” says Dr. Abramovich. “It’s a system that takes a one-size-fits-all approach and the sort of person my research looks at is someone who doesn’t fit into that system.” He gives an example: a teen who is transgender, Indigenous, homeless, battling substance addiction and identifies as gay will encounter multiple intersecting obstacles to receiving adequate care at the emergency room, walk-in clinic or other medical settings.
But how do we break the bias against patients who are homeless and work to improve the care they receive? In terms of treating those who identify as 2SLGBTQ+, Dr. Abramovich says there is a lot of free or affordable training for health practitioners online, and updating intake forms with more inclusive language around gender and having all-gender washrooms in your setting are small changes you can make immediately. But these are low-hanging fruit. The bigger change, the harder work, is attitudinal. “All of this boils down to human decency and treating all patients with respect,” he says. “It sounds simple and it really can be, but people often complicate these issues. Health care providers need to understand that these populations often experience trauma. In many cases, 2SLGBTQ+ youth and young adults have been rejected by the people who are supposed to love them the most. And they experience violence on a daily basis in public and institutional settings.” We all owe it to these populations to change our thinking, he says, to ensure they are and feel safe during encounters with the system.
Dr. Anawati, in Sudbury, agrees. Like Dr. Wong in Toronto, he cares for his patients who are homeless from a mindset of non-judgment, of recognizing that it is the system more than anything else that routinely comes up short for these people. “I don’t know if you’ve spent time in an emergency department, but you can see all the failings of society right there,” he says.
Still, Dr. Anawati is hopeful that he, the team at Health Sciences North, and the Nurse Practitioners Clinics in Sudbury will continue improving the lives of patients who are homeless and he remains committed to the principles of social accountability in medicine. “If I wasn’t hopeful, I wouldn’t still be here,” he says. “The health institution I work in and the health providers I work with recognize the importance of social accountability. The emergency department keeps social accountability as part of its departmental meeting’s agenda, opening the door to discuss the impact of homelessness. I work very closely with a nurse practitioner group who are on site in a homeless shelter. I get hope from being in contact and working with all of these amazing people.”