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    Homelessness and Health: Poverty and Human Development

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    Homelessness and Health: Poverty and Human Development

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    Homelessness and Health: Poverty and Human Development

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    Commentary

    Poverty and human development

    Homelessness and health


    Jeffrey Turnbull MD MEd, Wendy Muckle RN MHA, Christina Masters BSc

    DOI:10.1503/cmaj.071294

    omelessness is evolving into a national and international crisis. Within developed countries, homeless
    rates are now believed to approximate 1% of most
    urban populations.1 In the 2001 Canadian census, 14 145 people were counted as living in a shelter. Of note, 1490 (0r 10%)
    people were under the age of 15.2 This is made even more
    worrisome by the fact that these data likely underreport the
    true extent of homelessness because the census data represent the number of people living in a shelter on one day in
    May. This figure does not include the number of people staying in motels, transiently with friends, at a YMCA or a YWCA
    or on the street. This number also does not include people
    who may have recently become homeless and who were enumerated at their previous residence. Furthermore, these figures would have been drastically different if the census had
    been done in January when most shelters are at their capacity.
    In Ottawa in 2006, 1163 children had to stay in an emergency
    family shelter, and in Australia, the 2001 census reported that
    10% of homeless people were children.1
    In 2006, 9010 people in Ottawa spent time in a shelter for
    the homeless.3 This is an increase from 8664 people only 2
    years before.3 In addition to this substantial increase, the
    face of homelessness has changed from single adult male alcoholics to adolescents, single mothers, underemployed
    people, elderly people and recent immigrants.3 Homeless
    people are the unstably housed and the addicted. They are
    also the vulnerable people in our communities who experience a health crisis or a family breakdown. Almost any life
    crisis can precipitate homelessness and shamefully, a large
    proportion of homeless people are children. Raising children in a shelter or on the streets predicts lifelong problems
    and places these children at high risk for homelessness as
    adults.4,5 In addition, young adolescents who find themselves on the street quickly become part of the street culture
    of violence, sexual exploitation and addiction.4,6
    On the surface, homelessness takes its origins from increased urbanization and gaps in the social safety net. The reality of what brings one to the streets and the circumstances
    that lead to chronic homelessness are infinitely more complex. Poverty, lack of social and family support, failed government policy, fetal alcohol syndrome, societal isolation, lack of
    resilience, psychiatric illness, and drug and alcohol addiction
    are all important variables that perpetuate homelessness and
    are resistant to simple solutions.7 Living on the streets of a
    large urban centre is as much about being part of a culture or
    society with different norms and rules as it is about being
    without housing.
    The cost of homelessness to society as a whole and to
    homeless people themselves goes well beyond the nuisance
    of public intoxication and pan handling and the impact on

    Key points of the article


    The face of homelessness has changed from the adult male
    alcoholic to an increasingly diverse population with complex
    medical illnesses
    Despite substantially higher rates of illness, homeless people often lack effective health services
    Like any other complex social phenomena, the solutions will
    require complex, evidence-based integrated strategies that
    will require courage to implement

    tourism.8 Despite our attempts to socially isolate homeless


    people, they are responsible for a disproportionate use of judicial, social and health care resources.9 At the same time,
    they do not materially benefit from this investment as they,
    for example, have similar health indices as those living in underdeveloped countries. Their age-adjusted mortality is 2- to
    8-fold greater than the housed population.10 Those living on
    the streets suffer from the same spectrum of medical illness
    as the housed population, yet the frequency of illness is substantially higher among homeless people. In addition, they
    may suffer from psychiatric disease, mental and physical disability and the consequences of drug and alcohol abuse, including violence, sexual exploitation and infectious diseases
    such as tuberculosis, HIV and hepatitis C. For example, the
    incidence of diseases such as diabetes and HIV in the chronically homeless population are substantially higher than in the
    housed population.1012 A review of the literature shows that
    the incidence of HIV among Canadian youth living on the
    street is 6.1 per 1000, as compared with 0.20 per 1000 in the
    general population.12
    Although actual measures of substance use among homeless people are hard to ascertain, it is estimated that the they
    are 67 times more likely than people in the general population to develop persistent and pervasive alcohol-related problems.13 However, it is important to note that the addiction
    profile among homeless people has shifted from the predominant use of alcohol to polysubstance use, which includes opiates, crack and crystal methamphetamines.12 The
    war on drugs has not curtailed the exploitation of people living in shelters.
    Despite the public perception that the lives of people without homes are responsibility free and that these people
    choose not to have housing, homeless people report increased violence and drug availability, reduced meaningful
    social services and a correspondingly hostile community.

    From Ottawa Inner City Health Inc. and the University of Ottawa, Ottawa, Ont.

    All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.

    CMAJ October 23, 2007 177(9)


    2007 Canadian Medical Association or its licensors

    1065

    Commentary

    They are discouraged by a system that works for others but


    that works against them. For example, negotiating a complex
    health care system is almost impossible for many. Despite
    their heavy burden of illness, they lack access primary or preventive health services.5,7,1012 In addition, transportation to
    and from medical appointments is often impossible because
    of timing and expense. Health cards, prescriptions and integrated health services are not usually within their grasp, although health and social policy dictates that they are entitled
    to these benefits. As a consequence, often the only health care
    homeless people receive is through the emergency department, which is costly and ineffective.9,11 These problems are
    not unique to health care: they apply equally to the housing,
    judicial and social systems.
    Despite the many challenges, there is hope. There is now
    an emerging body of evidence identifying cost-effective approaches to address many of the root causes of homelessness
    and the associated health and social consequences.5,10 These
    strategies include affordable and supportive housing, enhanced social inclusion, harm-reduction strategies, individual and community empowerment, community mental health
    services and poverty-reduction strategies.14
    Unfortunately, effective strategies run counter to the ideologies, beliefs and expectations of citizen groups and political parties. In addition, our elected representatives often seek
    politically expedient, simple and short-term solutions to
    complex social and health problems. The controversy surrounding strategies like social housing and harm reduction
    are filled with emotion and strong positions. However, like
    all complex social issues, they are seldom explained in a short
    sound bite or within the mandate of a political party despite
    their best intentions. Successful models such as housing
    first require a long-term integrated strategy that is not solely
    driven by short-term cost savings.
    In order to stem this crisis, first we must identify eradication of homelessness as a major social problem that deserves
    meaningful government funding. Community engagement
    and leadership are key to making this metastatic social cancer
    a front-and-centre priority. Second, every effort should be
    made to depoliticize the problem of homelessness. This
    may be achieved by focused dialogue involving stakeholders
    from different backgrounds, ideologies and political colours.
    Third, strategic investments and energy should largely be fo-

    1066

    cused on evidence-based programs, so that we invest in programs that work rather than in ideologic solutions. We do not
    believe in a radical departure from the past, but rather in enhanced leadership, collaboration and targeted evidence-based
    investments. There is no shortage of great ideas, and effective
    solutions are well within our reach.
    This article has been peer reviewed.
    Competing interests: None declared for Wendy Muckle and Christina Masters.
    Jeffery Turnbull has received honoraria from Ottawa Inner City Health Inc.
    Contributors: All of the authors contributed to the conception and design of
    the manuscript, drafted the article and revised it critically for important intellectual content. All of the authors approved the final version for publication.

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    Rebeccas Community. Homeless Statistics. Australia: The Community. Available:


    www.homeless.org.au/statistics/ (accessed 2007 Sept 25).
    Statistics Canada. 2001 Census analysis series: collective dwellings. Ottawa: Statistics Canada: 2002. Available: www12.statcan.ca/english/census01/Products
    /Analytic/companion/coll/pdf/96F0030XIE2001004.pdf (accessed 2007 Sept 26).
    Alliance to End Homelessness. Experiencing homelessness: third report card on
    ending homelessness in Ottawa. Ottawa: The Alliance; 2006. Available: www
    .endhomelessnessottawa.ca/documents/ReportCardonEndingHomelessnessin
    OttawaJan-Dec2006webemail.pdf (accessed 2007 Aug 20).
    Haley N, Roy E, Leclerc P, et al. HIV risk profile of male street youth involved in
    survival sex. Sex Transm Infect 2004;80:526-30.
    Kidd SA, Davidson L. Youth homelessness: a call for partnerships between research and policy. Can J Public Health 2006;97:445-7.
    Roy E, Boudreau JF, Leclerc P, et al. Trends in injection drug use behaviors over 10
    years among street youth. Drug Alcohol Depend 2007;89:170-5.
    Lee BA, Price-Spratlen T, Kanan JW. Determinants of homelessness in metropolitan areas. Journal of Urban Affairs 2003;25:335-56.
    Dunford JV, Castillo EM, Chan TC, et al. Impact of the San Diego Serial Inebriate
    Program on use of emergency medical resources. Ann Emerg Med 2006;47:328-36.
    Nosyk B, Li X, Sun H, et al. The effect of homelessness on hospitalization of patients with HIV/AIDS. AIDS Care 2007;19:546-53.
    Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario.
    JAMA 2000;283:2152-7.
    Schanzer B, Dominques B, Shrout P, et al. Homelessness, health status and health
    care use. Am J Public Health 2007;97:464-9.
    Boivin JF, Roy E, Haley N, et al. The health of street youth: a Canadian perspective.
    Can J Public Health 2005;96:432-7.
    Fischer PJ, Breakey WR. The epidemiology of alcohol, drug and mental disorders
    among homeless persons. Am Psychol 2001;46:1115-28.
    Padget DK, Gulcur L, Tsemberis S. Housing First services for people who are
    homeless with co-occurring serious mental illness and substance abuse. Res Soc
    Work Pract 2006;16:74-83.

    Correspondence to: Dr. Jeffrey Turnbull, Ottawa Inner City Health


    Inc., Unit G, 500 Old St. Patrick St., Ottawa ON K1N 9G4;
    fax 613 562 4505; turnbull@ottawahospital.on.ca

    CMAJ October 23, 2007 177(9)

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