The Street Health Report 2007: Community-based Research on the Health, Health Care Access and Daily Lives of Homeless People in Toronto
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I Homelessness in Toronto
Homelessness is a devastating social problem that affects a large number of people in Toronto. Although the exact number of homeless people living in the city is unknown, approximately 32,000 different people slept in a Toronto homeless shelter in 2002 (1). In 2006, about 6,500 individuals stayed in a shelter on any given night (2).
It is widely recognized that homeless people have much poorer health than the general population. Canadian research and literature reviews confirm homeless people experience a disproportionate burden of chronic and multiple health issues (3, 4) and that mortality rates for homeless people are significantly higher than for the general population (5, 6, 7). Other studies have found that people living in poverty are more likely to die from certain diseases, including cancer, diabetes and respiratory diseases, and particularly cardiovascular disease (8) .
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II Canadian Research on Homeless People's Health
Homeless people are largely excluded from broad-based government health and census surveys, which often depend on people having an address or telephone number. Even when these surveys reach homeless people, they do not address the unique circumstances and needs of this group. As a result, there is a serious lack of comprehensive information on the health status and needs of homeless people.
Fifteen years ago, Street Health, a community-based health agency serving homeless people, decided to conduct a study to explore the health status of homeless people and their ability to access the health care system. In 1992, we published The Street Health Report (9) , a resource on homeless people's health. It was the first of its kind in North America and continues to be used today.
In the 15 years since the 1992 Street Health Report was published, homelessness and housing insecurity has increased in Toronto. The nightly count of people sleeping in homeless shelters has more than tripled, from about 1,900 in 1990 (10) , to about 6,500 in 2006 (2). This increase in homelessness is a reflection of a steady round of funding and program cuts at the federal and provincial levels, coupled with the downloading of responsibility for social programs to the provincial and city levels. These cuts and this downloading have had negative impacts on key social policies and programs. To name just a few changes since 1992: social assistance rates are much lower, rents are higher, and dramatically less social housing is being built. These social policy changes have had a disproportionate impact on low-income people, and have contributed to homelessness. In addition to the important social and political changes that have occurred since The Street Health Report was released in 1992, important new health issues such as tuberculosis and Hepatitis C have emerged in the homeless community.
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III About The Street Health Report 2007
In the winter of 2006/2007 we conducted a survey of 368 homeless adults in downtown Toronto about their health status and access to services: with funding from The Wellesley Institute, United Way of Greater Toronto and the Metcalf Foundation. The project involved extensive collaboration with community, academic and institutional partners, as well as employing a team of peer researchers with lived experience of homelessness. The Street Health Report 2007 (11) presents the results of this study, including findings on the nature of homelessness in Toronto and its root causes, the daily living conditions of homeless people, the physical and mental health status of homeless people, how they use health care services, and the barriers homeless people face when using these services. Based on these findings, we present an action plan consisting of realistic solutions to immediately improve the health of homeless people and to ultimately end homelessness.
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IV Key Findings on Homeless People's Daily Lives
Our study found that for most, homelessness is not a short-term, temporary crisis. Homeless people we interviewed had been homeless an average of 4.7 years, and 78% had been homeless for at least one year. Homeless people become homeless and stay homeless largely because of poverty and the lack of affordable and supportive housing. Thirty-six percent (36%) of those surveyed had a monthly income of $200 or less, and 78% named their economic circumstances as one of the two most important reasons they were homeless. Thirty-three percent (33%) said they became homeless because they could not afford the rent, and 33% said their physical or mental health conditions were preventing them from finding and keeping housing.
Homeless people's daily lives are harsh, difficult and extremely dangerous. Thirty-five percent (35%) of respondents had been physically assaulted, and 12% of all respondents said they had been physically assaulted by police in the past year. Twenty-one percent (21%) of homeless women we interviewed reported being sexually assaulted in the past year. These high rates of experiencing violence have not changed significantly in the past 15 years. Our study also found that homeless people have great difficulty meeting their basic survival needs of shelter and food. Thirty-nine percent (39%) of all homeless people in our survey were unable to get a shelter bed at least once last winter, and 69% said they went hungry at least one day a week.
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V Key Findings on Homeless People's Health
Homeless people experience high levels of stress, isolation and mental health conditions. One in 10 people we interviewed had attempted suicide in the past year, and 37% said they had no one to help them in an emotional crisis. Fifty-six percent (56%) said they had experienced serious depression in the past year, and 55% had experienced serious anxiety. Sadly, rates of suicidal ideation and attempted suicide among homeless people have not changed substantially since 1992, and remain very high.
The physical health of homeless people is very poor. Seventy-four percent (74%) of people surveyed had at least one chronic or ongoing physical health condition, and 52% had two or more. Fifty-four percent (54%) of survey respondents reported living with extreme fatigue, and 14% said they were usually in severe pain. The homeless population carries a disproportionate burden of many serious physical health conditions compared to the general population. For example, homeless people in our survey were: 29 times as likely to have hepatitis C, 20 times as likely to have epilepsy, 5 times as likely to have heart disease, 4 times as likely to have cancer, 3.5 times as likely to have asthma, 3 times as likely to have arthritis or rheumatism and twice as likely to have diabetes.
Homeless people's mental, physical and general health is much worse than the general population and worse than it was 15 years ago. While the prevalence of some health conditions has remained unchanged, many serious physical health conditions have become even more common, including diabetes, which is 3 times as high, and arthritis and high blood pressure, which are also significantly higher.
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VI Key Findings on Homeless People's Access to Health Care
Despite their poor health, homeless people cannot access the health care they urgently need. Fifty-nine percent (59%) of homeless people we interviewed did not have a family doctor, compared to only 9% of the general population in Toronto. In the past year, 28% were refused health care because they did not have a health card and 40% experienced discrimination from a health care provider. These numbers have risen in the past 15 years.
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VII The Street Health Action Plan
Based on our study findings, The Street Health Report 2007 outlines an action plan consisting of targeted, feasible solutions to improve the health of homeless people and address the root causes of homelessness. These recommendations are directed to all levels of government, as well as other institutions such as hospitals and the police, and fall under four areas:
• To address the poverty and inequality that underlies homelessness;
• To improve access to affordable and appropriate housing;
• To improve immediate living conditions for homeless people; and
• To improve access to health care and support for homeless people
For example, our action plan includes recommendations for increases to the minimum wage and social assistance rates, new investment in affordable and supportive housing, increased funding for accessible primary health care models, and improvements to the shelter and meal program system in Toronto.
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VIII What We Are Doing
We conducted this study because we wanted to create an up-to-date, solid base of sound evidence to strengthen our advocacy efforts and those of other community groups addressing poverty and homelessness. For this reason, broad dissemination of, and advocacy on, our findings and recommendations are a central goal of the study.
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IX Dissemination and Advocacy
Prior to and since the release of our report, we have broadly disseminated and advocated on the report findings and key messages to a wide range of community members, community organizations, coalitions, politicians, policy-makers and the general public, through a variety of methods. We have made many presentations to community groups and organizations, faith groups, hospitals, government staff and managers, university classes and at academic conferences and public forums. We have met with several key politicians and senior policy makers working in health and homelessness at the provincial, municipal and local (i.e. local health integration network) levels, as well as senior hospital managers, to discuss the study findings and its implications for their policy and program areas, and have many more such meetings planned. We have distributed 800 copies of the report so far, as well as having the report and summary available on our website for downloading and in several libraries.
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X Sequencing and Timing: Make it a Public Event
We timed the release of our report to coincide with advocacy initiatives such as liaising with groups organizing all-party debates and demonstrations on poverty issues—aiming to make poverty a key issue in the October 2007 provincial election.
Our report release was a public event that drew a diverse crowd of over 300 community members, media outlets, non-profit and government representatives, and politicians including the Ontario Minister of Health and Long-term Care and the leader of the federal New Democratic Party.
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XI Reach and Ongoing Promotion
The findings from our study have reached the general public through broad coverage by a variety of media outlets. Prior to the public release of the report, select findings were used in several articles and opinion pieces published in the Toronto Star. The Star also covered the report findings and recommendations with a major front-page article on September 19, 2007 (12) , followed by an editorial (13) and several letters to the editor. CBC radio news covered the report release, as did several CBC radio programs through live interviews with study researchers and partners. The Globe and Mail published two articles, including one on their front page, focused on our findings on homeless people's substance use and access to treatment and services (14, 15) . A short film entitled Street Health Stories (16) , produced by the National Film Board of Canada, which weaves together personal stories of health and homelessness with statistics from the report, aired on CBC television a few days after the launch of our report. Our findings were also covered by 24 Hours, several community newsletters and several community radio stations.
In addition to informing and supporting our own advocacy work, The Street Health Report 2007 has been used extensively by other community advocates, and to contribute to a broader strategy to address poverty. Prior to our report release, our appalling findings on homeless people's experiences of violence and assault, as well as their lack of access to shelter beds and low incomes, were used by the Toronto Disaster Relief Committee (TDRC), Street Health advocates and the Wellesley Institute to do media advocacy; to respond to current events in the news; and to create a backgrounder on these issues. Since our report was released, several academics, community activists and health care providers have cited the report findings in their writing, presentations and media work on poverty and homelessness issues.
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XII Keys to Our Success
Our success with media coverage of our findings can be attributed to three key factors, as well as good luck.
1. Ongoing media relations efforts and nurturing relationships;
2. Our long-standing reputation as a source of information and opinion on social issues related to homelessness; and
3. Extensive outreach to key reporters leading up to the launch of our report, offering exclusive advance access to the report, resulting in commitments from CBC radio news and the Toronto Star to cover the report findings on the date of its release.
In addition, we had been building up to the report release for several months, by mentioning it in dealings on other issues with our key media contacts, and by releasing some key statistics to the media on homeless people's experiences of violence and access to emergency services in response to current events up to four months prior to the launch.
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XIII What Can Health Promoters and Practitioners Do?
1. Make homeless, underhoused and marginalized people a priority in all health promotion initiatives, by considering and including the unique needs and barriers of these populations within all planning and strategies.
2. Advocate, wherever possible, for changes to social and health policies and programs, to ensure these policies and programs adequately address people's need for adequate incomes, housing, quality health care and access to services.
3. Make a start now and let the McGuinty government know that you want to see real action on poverty reduction in Ontario. Send an email to Premier Dalton McGuinty (dmcguinty.mpp.co@liberal.ola.org), Minister Deb Matthews (dmatthews.mpp@liberal.ola.org), who has been charged with heading up the government's efforts on poverty reduction and your MPP, letting them know that you will be watching the upcoming Ontario Throne Speech (on November 29th) for more details on their Poverty Reduction Strategy. For more information and a sample email message please contact Dana Milne, Provincial Organizer, Income Security Advocacy Centre at: milned@lao.on.ca.
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XIV Conclusion
As we move forward, we will continue to try to engage politicians and policy-makers, and to follow up with those we have already reached, to continue to advocate for changes that will address homelessness and improve homeless people's lives. We also hope that other advocates will continue to use our report as a tool to conduct their own advocacy on homelessness and poverty issues.
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XV References
1 City of Toronto. 2003. The Toronto Report Card on Homelessness and Housing 2003. Toronto: City of Toronto.
2 Shapcott M. TO's "sheltered" homeless: Up or down? Toronto: The Wellesley Institute. Available at: http://wellesleyinstitute.com/files/tohomelessupdatesept2006.pdf.
3 Hwang SW. 2001. Homelessness and health. Canadian Medical Association Journal. 164(2): 229-33.
4 Frankish CJ, Hwang SW, Quantz D. 2005. Homelessness and health in Canada: research lessons and priorities. Canadian Journal of Public Health. 96(Supplement 2):S23-S29.
5 Hwang SW. 2000. Mortality among men using homeless shelters in Toronto, Ontario. Journal of the American Medical Association. 283(16):2152-2157.
6 Cheung AM, Hwang SW. 2004. Risk of death among homeless women: a cohort study and review of the literature. Canadian Medical Association Journal. 170(8):1243-1247.
7 Roy E, Boivin JF, Haley N, Lemire N. 1998. Mortality among street youth. Lancet. 352:32.
8 Raphael D. 2002. Social Justice is Good for Our Hearts: Why Societal Factors - Not Lifestyles - are Major Causes of Heart Disease in Canada and Elsewhere. Toronto: CSJ Foundation for Research and Education.
9 Ambrosio E, Baker D, Crowe C, Hardill K. 1992. The Street Health Report. Toronto: Street Health. Available at: http://www.tdrc.net/Crowe-Resources.htm.
10 Golden A, Currie WH, Griaves E, Latimer EJ. 1999. Taking responsibility for homelessness: an action plan for Toronto. Report of the Mayor's Homelessness Action Taskforce. Toronto: City of Toronto.
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