In Florida, people are being arrested for giving food to people who are homeless. That’s right, for providing food to malnourished people. The City of Orlando has been targeting Food not Bombs, a community group that, twice a week for the past 5 years, has been providing meals to homeless people in parks. By June 15th of this year, 15 people had been arrested. The penalty for violating the Orlando ordinance is 60 days in jail, a $500 fine, or both. This kind of ridiculous policy and practice raises a couple of issues for me. 



First, we have to address the criminalization of homelessness as a serious problem. Most people don’t consider law enforcement when thinking about our response to homeless. Shelters and day programs are usually what come to mind. But, criminalization of homelessness isn’t just an American issue; we’re equally good at this in Canada. Ontario, for instance, legislated the Safe Streets Act over ten years ago to address panhandling and squeegeeing (many communities across Canada have followed suit), and in Toronto police continue to issue thousands of Safe Streets act tickets (not to mention tickets for other misdemeanors) to people who are homeless and without means to pay the fines. In response to this, there is a growing body of research on ticketing and the use of law enforcement to address homelessness, and the bidirectional relationship between homelessness and prison, that attests to the highly problematic (and unethical) nature of this ‘response’ to homelessness. 



The second issue to consider is the nutritional vulnerability of people who are homeless. While many of us may believe that the nutritional needs of homeless people are met through charitable food services, the reality is quite different. In fact, Val Tarasuk’s research on youth homelessness and nutritional vulnerability shows that it doesn’t matter whether young people get all their food in agencies, or from the proceeds of panhandling, they are quite likely to be malnourished, and this at a time when they are growing and really need appropriate and adequate food. 



A new report from Victoria highlights the link between homelessness and nutritional vulnerability. More than this, the report reminds us that a person’s lack of food isn’t solved once they become housed. In fact, when homeless people do become housed, a large number continue to live in extreme poverty, and after the rent, utilities and other necessities are paid, there is often very little left for food. The use of food banks in Victoria and other communities continues to rise. 



If we want to support people who are homeless in an ethical and humane way, we need to begin by treating them as people. Criminalizing homelessness, and failing to address nutritional needs of particularly vulnerable people is no solution, and this is something no one should be proud of.

Many jurisdictions in Canada have begun to recognize the value of harm reduction and have developed innovative and effective programs to deal with the harms of substance use and addiction.  For example, there are over 30 studies that support the effectiveness of Insite, Vancouver’s supervised injection site, as reducing the harm associated with injection drug use.  Harm reduction works because it gives people choice, counters stigma associated with drug use, acknowledges that drug use is part of our history as a society, and that reducing harms instead of eliminating use can make people and communities safer and healthier.  Recognizing the value of harm reduction can be seen in the inclusion of harm reduction in strategies related to mental health promotion and addictions care as well as public health programs and services oriented to preventing the harms of substance use. However, there has not been much discussion of the role harm reduction plays in ending homelessness. 

Harm reduction is a key principle of Housing First programs.  Housing First separates the right to housing from conditions such as acceptance of treatment or sobriety.  Recently, the Greater Victoria Coalition to End Homelessness contracted Scientists at Centre for Addictions Research of British Columbia to develop a paper that outlines the role of harm reduction as part of a strategic plan to end homelessness.  The cornerstones of this policy framework are social inclusion and the provision of permanent affordable housing.  Permanent housing is essential to reducing the harms of homelessness and substance use. For example, lack of housing increases the harms of substance use including the risk of blood borne diseases and premature death.  The need for permanent affordable housing and policies of client inclusion in the development of policies and programs are complemented by a series of six other strategic directions that outline the necessary elements of a housing and harm reduction strategy. 

This framework recognizes that ‘one size does not fit all’ and that a variety of approaches are needed in the provision of housing and supports.  A housing and harm reduction policy framework includes a range of housing options that place client choice at the center. The proposed policy framework widens the range of housing options to include  low barrier housing where drugs and alcohol are tolerated  to living in buildings where alcohol and drug use is prohibited. Low-barrier housing has the same requirements of tenants in any other rental situation: pay the rent, don’t destroy property and don’t behave in ways that will harm or disturb other tenants. The framework recommends a number of options for integrating housing and harm reduction. For example: the Dr. Peter Centre in Vancouver has  integrated harm reduction philosophy and services such as supervised injection into the provision of housing and supports for people with HIV/AIDS and injecting drug use. Community harm reduction services are important for those living in market housing. 

The strategies recommended in the frame work are consistent with current evidence and have been shown in other cities to reduce the harms of drug use as well as health and social costs. For example, the provision of low barrier housing to people with long term chronic homelessness and alcohol problems significantly reduced, health, policing, social service and justice costs in Seattle. A policy framework is an initial first step and it plays a role in bringing people together around new understandings of what we ought to do. The next step is doing the right things for citizens and communities.

To access the full policy framework, see: Housing and Harm Reduction: A Policy Framework for Greater Victoria

Bernie Pauly RN, Ph.D is an Associate Professor in the School of Nursing and a Scientist in the Centre for Addictions Research of BC at the University of Victoria.

By Stephen Hwang & Emily Holton

For the first time in Canada, we have the numbers to show that people who are vulnerably housed face the same severe health problems - and danger of assault - as people who are homeless. This means that the number of people experiencing the devastating health outcomes associated with inadequate housing could be staggering. There are about 17,000 shelter beds available across Canada every night, but almost 400,000 Canadians are vulnerably housed. This means that for each person who is homeless in Canada, there are more than 20 other low-income individuals who are vulnerably housed - paying more than half of their monthly income for rent, and living with substantial risk of becoming homeless. We’ve shed light on a hidden emergency.

For the Health and Housing in Transition (HHiT) study, we interviewed 1200 vulnerably housed and homeless single adults in Vancouver, Toronto, and Ottawa. The results were disturbing. People who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless - are at high risk of serious physical and mental health problems and major problems accessing the health care they need. Many end up hospitalized or in the emergency department. Almost half (40%) of people who don’t have a healthy place to live have been assaulted at least once in the past year, and 1 in 3 (33%) have trouble getting enough to eat.

Check out the report on our early findings here: Housing Vulnerability and Health: Canada’s Hidden Emergency. We’re presenting it today at National Housing Day in Ottawa. Over the next two years, the HHiT study will continue to track the health and housing status of our participants. The results will help us better understand how changes in housing status can affect health. They will also help us to identify factors that help people achieve stable, healthy housing.

Having a roof over one’s head is not enough. The HHiT results showed us that the real gulf in health outcomes doesn’t lie between people who are homeless and people who aren’t homeless. It’s between those who have continued access to healthy housing, and those who don’t. To support health, housing must be decent (i.e. good quality), stable (i.e. affordable), and appropriate to its residents’ needs. We’re calling for the federal government to respond by setting national housing standards that ensure universal, timely access to healthy housing. The need is overwhelming.

Stephen Hwang's primary appointment is in the Department of Medicine at the University of Toronto, with cross-appointments in the Departments of Public Health Sciences and Health Policy, Management and Evaluation. His research focuses on deepening our understanding of the relationship between homelessness, housing, and health through epidemiologic studies, health services research, and longitudinal cohort studies. His current research projects include a study of predictors of health care utilization in a representative sample of 1,200 homeless men, women, and families in Toronto, a study of the barriers to the management of chronic pain among homeless people, and an evaluation of the effects of a supportive housing program on health and health care utilization among homeless and hard-to-house individuals.

Emily Holton is a research writer and knowledge transfer specialist at the Centre for Research on Inner City Health, St. Michael's Hospital.

When you hear the word “homelessness,” what comes to mind? If you are like most people, you probably think of the men who sleep on the hot-air grates in downtown Toronto. That is the image that so often accompanies media stories about homelessness.

Several things about that image hide the reality of homelessness for many Canadians. The first part is the person’s gender and age. There are many homeless women and children too, although in their case it seldom takes the form of sleeping on the street. That is another problem with the image – it equates homelessness with street life. In reality, homelessness can take multiple forms, including moving from shelter to shelter or “couch-surfing” (that is, staying with friends when one loses one’s own home).

The image usually features a solitary figure, which obscures the fact that entire families may become homeless. Indeed, some of those who appear to be alone may simply be separated from their families by homelessness. Finally, the setting (downtown in a big city) is a cliché. Homelessness exists in towns and cities of all sizes, in the suburbs and in rural areas, and in all the provinces of Canada.

Last year, I helped edit an online book collecting the best Canadian research available on homelessness. The thirty chapters encompassed the experiences of women and their children, Aboriginal people, frail seniors, youth, immigrants (some of whom become homeless shortly after arriving in Canada). They included research on food insecurity, social stigma, moneymaking strategies, child custody, the physical and mental health problems of homeless people, and the intersection of homelessness and crime, as well as promising efforts to reduce homelessness or alleviate some of its effects.

Did we cover the full spectrum of the problem? Not even close. This week we added another ten chapters to fill the many gaps.

One important new chapter is about homelessness among women in Canada’s North, a particularly urgent issue. Yukon, Northwest Territories, and Nunavut share a high cost of living, limited employment opportunities, underdeveloped infrastructure, and a shortage of social services. Women who lose their housing have few places to turn. Yet we hear very little about their plight in the rest of Canada.

Another chapter deals with homelessness among Aboriginal peoples in the Prairie provinces. This group spends a lot of time on the move, and many go back and forth between urban centres that offer work, services, and a wider range of housing options, and their home communities, which offer a connection to family and traditions. Yet in neither place are these people completely at home.

A third chapter looks at homeless women in small cities and towns in Ontario, social isolation, low-quality social services, and weak public transit infrastructure create barriers to seeking help.

We also consider the ethics of research into homelessness. It is important to understand and communicate the experiences of people who often have no voice in society, but it is equally important not to appropriate their voices. Many of the chapters contain the words of homeless people, men and women, young and old, describing their stories and tryng to make sense of an arduous life in a hostile world.

In presenting these diverse perspectives on homelessness, we hope to remind Canadians that homeless has not disappeared, even though the recent economic downturn has meant that many people are too worried about their own futures to pay attention to the plight of those even less fortunate.

At the same time, we stress that although homelessness affects a diverse group of people, it is not a complex problem. Yes, you read that correctly: it is not a complex problem.

After all these years of research and policy analysis and documenting the lived experience of those affected and those who provide support services, we know what the causes of the problem are. That means we know what the solutions are.

When individuals or families run into serious difficulty in one or more of the three key areas that support a decent standard of living, they may find themselves unhoused and potentially on a downward spiral. The three areas are: housing, income, and support services. Groups already facing inequities, discrimination, and violence are often the first to face difficulties in these areas when the economic tide changes.

An adequate standard of living means not only that good-quality health care is available to everyone, but also access to adequate housing, employment at a living wage, and essential support services must also be available for everyone, not just those who can afford them – and that systemic inequities are addressed in social policy.

We know what we need. We need social protections that prevent people from becoming unhoused. We need programs that ensure that no one will be unhoused for more than a very brief period should a crisis of some sort arise. We need policies that correct historic and systemic inequities, and that provide adequate, affordable and secure housing, an adequate income or income support when needed, and adequate support services if these are required (for addictions, mental health, and so on). Only then will we begin to solve the problem of homelessness.

J. David Hulchanski is Associate Director, Research, for the Cities Centre and Professor in the Faculty of Social Work at the University of Toronto, and co-editor of an electronic book on homelessness, Finding Home, available on the Homeless Hub, www.homelesshub.ca/FindingHome.

Are Canadians who are experiencing homelessness getting the health care that they need?  The average person might assume that the answer to this question must be “yes,” because Canada has a system of universal health insurance.  In fact, almost all previous studies of unmet needs for health care among homeless people have been done in the US, where more than half of people who are homeless do not have any health insurance. These studies have (not surprisingly) found that lack of health insurance greatly increases the risk of unmet needs for care.  Amazingly, almost no studies have looked at this issue in countries that ensure that its citizens and residents have universal health insurance.

We recently published a study in the American Journal of Public Health that looked at unmet needs for health care among homeless people in Toronto, Canada.  We surveyed a representative sample of 1169 homeless individuals at shelters and meal programs and asked them if within the last year they had needed health care but been unable to get it.  Fully 17% of homeless individuals -- about one in six – reported unmet needs for care.  Mothers with children who were living in family shelters were more than twice as likely to have unmet needs for care than the average mother with children living in Toronto.  Among the homeless people that we interviewed, those who were younger and those who had been a victim of physical assault in the past year were more likely to have unmet needs.

These findings show us that homeless people still have substantial unmet health care needs within Canada’s system of universal health insurance.  However, it’s important to realize two things.  First, this finding should not be misinterpreted to mean that our system of universal health insurance is “broken” or “doesn’t work.”  In fact, another recent study asked almost the same question that we did of homeless people across the US and found that 32% had been unable to obtain needed medical or surgical care in the past year.  So, the rate of unmet needs among homeless people in the Canadian system is about half that of homeless people in the US.  Universal health insurance works! 

Second, our study underscores the importance of understanding the difference between a health insurance system and a health care delivery system.  When people are disadvantaged and marginalized, it’s not enough to say that that their health care will be paid for, so there’s nothing to worry about.  We need to realize that there can be many other barriers to obtaining needed care, such as not having a family physician, not having transportation to the clinic or doctor’s office, not understanding when it’s important to seek health care, or being reluctant to seek care because of previous bad experiences with health care providers.  All of these factors, and more, come into play when a person is homeless.

We need to continue to design health care delivery systems that meet the needs of people who are homeless.  Some of the most promising strategies include having teams of health care providers work in outreach settings such as shelters, drop-in centres, and mobile health units; enhancing the capacity of our many outstanding community health centres to provide comprehensive care for homeless patients; integrating the delivery of care for physical health, mental health, and addictions; and educating and empowering individuals who are homeless to help improve their own health.

Stephen Hwang's primary appointment is in the Department of Medicine at the University of Toronto, with cross-appointments in the Departments of Public Health Sciences and Health Policy, Management and Evaluation. His research focuses on deepening our understanding of the relationship between homelessness, housing, and health through epidemiologic studies, health services research, and longitudinal cohort studies. His current research projects include a study of predictors of health care utilization in a representative sample of 1,200 homeless men, women, and families in Toronto, a study of the barriers to the management of chronic pain among homeless people, and an evaluation of the effects of a supportive housing program on health and health care utilization among homeless and hard-to-house individuals.