12 September 2007

All thumbs

Housing and health in Canada

The French have a saying that their heart is on the left while their wallet is on the right (avoir le coeur à gauche et le portefeuille à droite). The Germans remind us that the left hand is the one with the thumb on the right (Links ist, wo der Daumen rechts ist). In Canada, it seems, we're all thumbs.

Thousands of people in this country are homeless on any given night. In 1998, the Toronto Disaster Relief Committee (TDRC), co-founded by Toronto "street nurse" Cathy Crowe, declared homelessness a national disaster. Over the last decade, spanning both Liberal and Conservative governments, the situation has become worse. The health implications of homelessness are obvious to everyone except those who pamper their compassion and need high stimulants to rouse it. An article by Dr. Stephen W. Hwang (St. Michael's Hospital, Toronto), which appeared in the CMAJ nearly seven years ago, warned of the problems caused by homelessness:

Homelessness affects a significant number of Canadians of all ages and is associated with a high burden of illness, yet the health care system may not adequately meet the needs of homeless people. More research is needed to identify better ways to deliver care to this population. Health interventions alone, however, are unlikely to overcome the adverse effects of homelessness and related social ills. The search for long-term solutions to the problem of homelessness itself must remain a key priority.
A report released last August by the Canadian Institute for Health Information (CIHI) sheds some new light on the complex relationship between mental health and homelessness in this country. People who are homeless are more likely to suffer from a mental illness or compromised mental health than the general population. On the other side of the coin, people with severe mental illness generally experience limited housing, employment and income options.

Improving the health of Canadians: mental health and homelessness provides an overview of the latest research, surveys and policy initiatives related to mental health and homelessness and, for the first time, presents data on hospital use by homeless Canadians. According to one startling statistic contained in this document, 52% of the visits to Canadian hospitals by homeless people are due to mental disorders, compared to only 5% among the general population.

People who are homeless tend to report higher stress, lower self-worth, less social support and different coping strategies — factors that are associated with depressive symptoms, substance abuse, suicidal behaviours and poor self-rated health. And the homeless mentally ill inevitably end up in hospital emergency departments.

The troubling relationship between mental illness and homelessness has been known for decades, and ample evidence was brought forth in the CMAJ article quoted above:
The prevalence of mental illness and substance abuse among homeless people is difficult to determine precisely, but consistent patterns have emerged from methodologically rigorous studies conducted in the United States and Canada. Contrary to popular misconceptions, only a small proportion of the homeless population has schizophrenia. The lifetime prevalence of schizophrenia is only 6% among Toronto's homeless population, and US studies have found prevalence rates of 10%–13%. Affective disorders are much more common, with lifetime prevalence rates in the range of 20%–40%.
The research called for in past years has been done. While there is always something else that can be learned through research, the general picture is quite clear. This country has a problem that is not going away. The studies have gone on long enough. To avoid "paralysis through analysis" society must act.

Bill Wilkerson, co-founder of the Global Business and Economic Roundtable on Addiction and Mental Health, expressed his impatience: "We have known for 25 years what this report is telling us yet again," he said. "So it's time for action, not time for more study." Wilkerson was involved in a task force that scrambled to find housing for mentally ill people who were deinstitutionalized in Ontario in the early 1980s. "The only difference, I think, is the problem then was new. Now it's old," he said. (Canadian Press report, 30 Aug 2007)

"The most obvious solution to homelessness is housing," says Tim Aubry of the Centre for Research on Educational and Community Services at the University of Ottawa (quoted in The Globe and Mail, 31 Aug 2007). There are two lengthy reports that confirm this common-sense remark. Housing is good social policy was published in 2004 by the Canadian Policy Research Networks. The authors elucidate further the link between homelessness and physical and mental health deficits. They argue that providing adequate housing is vitally important. "Spending money on housing does not take money out of health care – it reduces the cost of health care." Shelter: homelessness in a growth economy was released in July 2007 by the Calgary-based Sheldon Chumir Foundation for Ethics in Leadership. It claims that Canada's homeless population may be as high as 300,000. These staggering numbers are directly linked to increasing poverty levels. The government's response to homelessness has been "conflicted, sometimes bordering on outright neglect," and "has exacerbated efforts to reduce poverty in Canada." The report concludes:
If neglected, housing insecurity will continue to spread across Canada, fueling the relatively new phenomena of suburban homelessness, accelerating urban decay, and, in the face of record-setting housing prices, ensure the general economic erosion of millions of Canadians.
The Canadian government's new Homelessness Partnering Strategy began on April 1, 2007. It claims to be providing $269.6 million over two years to help communities across Canada combat homelessness. However, there is no housing in it, and it amounts to little more than a homelessness disaster relief program.

What of the response to the growing mental health crisis and its relationship to homelessness? On August 31 Prime Minister Stephen Harper announced the final selection of the Board of Directors for the newly created Mental Health Commission of Canada, which will receive funding of $55 million over five years. The Commission's goal is to help bring into being an integrated mental health system that places people living with mental illness at its centre. Sounds like more expense accounts and meetings, leading to more research.

Canadians are still waiting for an initiative that will include successful social housing as an integrated component of a broader social and economic policy to improve the health and welfare of the disadvantaged. Cathy Crowe of the Toronto Disaster Relief Committee wrote a powerful op ed piece last July about the Canadian housing crisis. She says: "Homelessness is our Katrina, but it wasn't caused by the weather." A public health nurse, Crowe is the author of Dying for a home: homeless activists speak out.

Meanwhile, our government does not see the irony in announcing last July that an American anti-virus software company is "donating security technology and expertise to 450 homeless shelters, which will help to ensure the protection of sensitive information on clients and operations." There are many excellent anti-virus and firewall programs available for free on the Internet. Here is the Canadian government crowing about supporting the work of shelters for the homeless, when all it is really doing is giving free feel-good publicity to a foreign corporation.

How does all this concern me as a librarian? The Diary of a Subversive Librarian highlights this quote from America Gone Wrong: A Slashed Safety Net Turns Libraries into Homeless Shelters:

In a democratic culture, even disturbing information is useful feedback. When the mentally ill whom we have thrown onto the streets haunt our public places, their presence tells us something important about the state of our union, our national character, our priorities, and our capacity to care for one another. That information is no less important than the information we provide through databases and books. The presence of the impoverished mentally ill among us is not an eloquent expression of civil discourse, like a lecture in the library’s auditorium, but it speaks volumes nonetheless.

Only a humanity to whom death has become as indifferent as its members, a humanity that has itself died, can inflict death administratively on innumerable people.

Theodor Adorno, Minima Moralia