Middle-class families join the homeless

A concerned Toronto doc is stunned by the numbers. As usual, gov'ts throw money at the problem

By Wendy Banks

When Tracy was laid off from her job at the Toronto Levi's factory, her employment insurance cheque wasn't enough to cover the rent on her $1200-a-month apartment in Etobicoke. Soon she wasn't able to afford either the rent or food for her two daughters, Sonia, age six, and Natalie, age 13. When they were evicted two months ago, she went to stay with her family until tensions developed. They're now living in a converted motel room in a shelter in Scarborough. Anxious to keep as much continuity in her children's lives as possible, Tracy has been taking them on a 90-minute commute across town to their old school every day. The subway and bus fare takes the bulk of her daily food allowance.

To Cathy Crowe, Tracy's story is all too familiar. Ms Crowe, one of Toronto's first street nurses and recipient of this year's Atkinson Charitable Foundation Award for Economic Justice, has seen the demographics of homelessness shift over her 15 years as a homeless advocate and nurse practitioner with various Toronto community health centres. "The way we think of homeless people is beginning to change. People are realizing that they're not all addicts; they have nothing in common except that they all need housing," she says. "And across the country, the fastest-growing group of homeless people is families with children."

Dr Stephen Hwang agrees. He's an internist at St Michael's Hospital in Toronto and he's done extensive research on healthcare utilization and health problems among homeless people. "There's a lot of data from the shelter system that shows that the profiles of people using shelters has changed over the last 10 years," he says. "There's been a growth of homeless families in Toronto and a similar change has been observed in Ottawa and also in US cities."

According to Dr Hwang's 2001 national study, Homelessness and Health, published in the Canadian Medical Association Journal in 2001, families occupied 42% of shelter beds in Toronto and 35% in Ottawa, in that year. The Toronto Report Card on Housing and Homelessness in 2003 shows the number of single-parent families using homeless shelters continues to rise steadily, up 200 from 2,001 to approximately 2,300; that figure represents a 51% increase since 1990. A survey of 25 US cities conducted for the 2000 US Conference of Mayors had similar results, showing that families with children accounted for 36% of the homeless populations in major urban centres.

Why is this happening? Dr Hwang thinks it's because of social policy. "There's been a tremendous increase in the number of homeless people in Canadian cities over the last 10 years. In some cities, the number of homeless people has approximately doubled," he points out. "Presumably, this is due to a combination of factors, such as lack of affordable housing, lack of community support for people with mental illness, substance use or other medical issues. So, essentially, these forces cause more people who are living on the margins or right on the edge to fall into homelessness. If you create [the wrong] social situation, you not only increase the number of homeless people but you broaden the types of people who become homeless. Certainly that's true for homeless families. These are people who don't have a tremendous amount of mental illness or substance usage; in fact they tend to be quite healthy families, but they just can't afford to find housing."

The changing face of homelessness has profound implications for healthcare practitioners, and not just those who specialize in street medicine. Dr Hwang predicts that family doctors will be feeling the impact.

"The first indication of this is that practitioners, especially in urban centres, are much more likely to see homeless people in their routine practice," Dr Hwang observes. "It also means that clinicians need to be more sensitive to the unique health issues and social issues that face homeless people, because, for example, a homeless person with diabetes can come to a doctor's office, and one could say, 'Well, you need to adjust your diet and take these medications half an hour before your meals.' But if a person has essentially no control over their diet and eats at a shelter and has trouble accessing their medication, that's obviously not going to do the trick. So there's a whole level of social complexity to these patients' lives that needs to be taken into account."

"Another thing that physicians need to be of aware is that homeless people are not going to necessarily fit the stereotype of the alcoholic man lying on the sidewalk, that someone may come to their office and either be homeless, or at very high risk of becoming homeless, and that may not be obvious unless the clinician takes the time to ask about the patient's social situation."

For Ms Crowe, compassion is key. "As a nurse, I keep hearing from people that one of the most important things for them is their relationship with the doctor — knowing the doctor cares for them."

The question remains: what's being done? The answer is quite a bit, but not enough.

Some of the recent initiatives put in place to help families stay housed seem to be working, according to the Toronto Report Card. Funding is also increasing, at all three levels of government — $15 million from the city of Toronto and the Ontario government. At the federal level, the Ministry of Health committed $1.2 million last September to fund 13 projects "to build research capacity to reduce health disparities in Canada's vulnerable populations," not just the homeless. But of course, the fact remains that none of these efforts, no matter how laudable, addresses the root of the problem." Ms Crowe puts it bluntly: "We have to have a national housing program. That's as important as medicare to people's health."