Access to health care is a human right. In Canada, we enjoy a system of universal health insurance and yet, many Canadians are left without services other Canadians can access with relative ease. For individuals experiencing homelessness, the ability to maintain one's health can be compromised by the impact of deteriorating health and obstacles, which often prevent them from getting the critical help they need.
Health & Poverty
In Canada, our publicly funded health care service is a cornerstone of our society -- it is central to the health and well-being of the general population. According to Statistics Canada, 85.1% of Canadians have a family doctor and 59% cite their health as very good or excellent. On the other hand, for individuals experiencing extreme forms of poverty and marginalization, including homelessness, maintaining a healthy life and accessing health care services is a considerable challenge. This is a major problem as these marginalized individuals face the largest likelihood of illness.
Canada Without Poverty provides us with a helpful snapshot by demonstrating the link between poverty and health:
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The World Health Organization finds that poverty is the single largest determinant of health.
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Poverty is correlated with illness and in turn, illness increases one’s likelihood of poverty.
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A lack of income can entail inadequate access to nutritious food as well as safe and stable shelter - all working to negatively impact health. On the flip side, illness leads to poverty by reducing household savings, overall productivity, and quality of life for individuals and families.
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Poverty causes serious health problems such as significantly increasing one's chance of developing diabetes and complications such as blindness and cardiovascular disease.
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The increase in illness that derives from poverty bears a significant economic burden, where the cost of poverty on the Canadian health care system is approximately $7.6 billion.
Health & Homelessness
Considering the points provided above, it is obvious that poverty is strongly correlated with poor health and increased health care costs overall. What sort of impact, then, would extreme forms of poverty such as homelessness have on the health of this population? The COH defines homelessness as an extreme form of poverty characterized by the instability of housing and the inadequacy of income, health care supports and social supports. These instabilities that characterize homelessness has a profound impact on one's health that include:
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The longer an individual experiences homelessness, the more their health deteriorates.
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Individuals experiencing homelessness face higher mortality rates, higher rates of infectious disease and chronic illness and long-term physical health conditions than their housed counterparts.
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Common health problems among this population include hypertension, arthritis and other musculoskeletal disorders, obstructive lung disease, tuberculosis, respiratory tract infections, human immunodeficiency virus, hepatitis, peripheral vascular disease, digestive tract disease, poor dental health, visual impairment, exposure-related skin diseases, as well as malnutrition and traumatic injuries.
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For youth experiencing homelessness, malnutrition is found to exacerbate underlying medical conditions common among this population such as tuberculosis, hepatitis B infection, HIV and other STIs.
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Approximately 30% of those experiencing homelessness suffer from at least 2 medical conditions. This likelihood doubles in individuals aged 50 and over.
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Women who are pregnant and experiencing homelessness often are at great risk of poor health due to a lack of access to prenatal care, poor nutrition, and exposure to violence.
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One study found that women experiencing homelessness in general often face sexual victimization and may engage in sex work to earn an income, putting them at risk of contracting HIV/AIDS and other sexually transmitted diseases.
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Indigenous populations disproportionately experience homelessness. One study found precarious accommodations on reserve are commonly overcrowded implying that houses will have poor ventilation, poor sanitation/waste management and unsafe water supplies - all resulting in poorer health for this population.
Hospital Emergency Care & Homelessness
The information provided above makes it clear that there is a strong link between homelessness and the exacerbation of poor health. And yet, this population faces considerable gaps in getting the help that they need. Considering a lack of access to transportation to attend healthcare appointments, missing health cards, an inability to afford prescriptions and due to the 24-hour accessibility, emergency rooms are often the primary source of care for individuals experiencing homelessness. In fact, nearly 50% of individuals experiencing homelessness do not have a family doctor.
Even in accessing emergency rooms, however, homelessness significantly impacts the ability for individuals to get the care they need. This is due to prejudice, stigma and discrimination on the part of health care providers against individuals experiencing homelessness (particularly those with addictions, who are racialized and/or LGBTQ2S), long wait times and overall negative experiences that result in an interruption of treatment plans.
Coupled with this, use of hospital emergency care is a costly expense. One study found that out of 1,190 homeless individuals surveyed between 2004 to 2005, 77.3% had utilized an emergency department with a rate of 2.1 visits per person, where each person costs $1,462. Moreover, the average monthly cost associated with housing an individual while they are homeless in a hospital bed is $10,900. Ultimately, addressing homelessness via an emergency response framework, which includes emergency room over utilization, has cost Canadians over $7 billion per year.
Considerations
To curb the costly expense of emergency room utilization as the primary source of health care for individuals experiencing homelessness, a variety of innovative initiatives are making great strides in breaking down barriers, making healthcare more accessible to those who need it desperately.
For instance, there are “street medicine teams” that work to bring health care directly to the visibly homeless, rather than waiting for them to visit emergency rooms. This is a great method considering that postponing treatment is a common occurrence among this population.
In Toronto, Street Health is a non-profit agency operating around the intersection of Dundas St. and Sherbourne St., the largest concentration of homeless shelters and drop-in centres in Canada. Street Health works to remove barriers to treatment and provide client-centered, flexible and responsive care. Through this crucially needed initiative, Street Health states that on an average day, 115 clients come through their doors and they are able to assist 40,000 individuals a year.
In addition to the street health initiatives, approaching homelessness via preventative framework is the most effective way to reduce the unnecessary illnesses experienced by this population. It also cuts down the massive costs associated with poverty.
There is strong evidence demonstrating Housing First can reduce illnesses associated with homelessness through providing housing without being contingent upon “readiness” or sobriety. One study following a cohort of previously unhoused individuals placed in stable accommodations found a reduced rate of emergency room utilization, in addition to increased overall health. These findings are consistent across multiple studies, including a Toronto-based study that provided individuals with stable housing, resulting in previously homeless individuals finally able to pursue treatment, attend appointments and fully implement treatment plans. Additionally, according to 7 Cities in Alberta, from 2008 to 2012 their Housing First clients reported 64% fewer days in hospital, 60% fewer interactions with Emergency Medical Services and 60% fewer emergency room visits.
As a fundamental human right, individuals experiencing homelessness are entitled to the universal health care the general population of Canada is able to obtain. And considering the health and monetary benefits associated with Housing First, a preventative approach to ending homelessness just makes sense.