Helping Heart

Challenging Health Issues that Unsheltered Individuals Experiencing Homelessness Face On A Daily Basis in Canada

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The End

It’s been amazing being able to learn all of this information regarding the health of individuals experiencing homelessness and teaching everyone reading this blog. It’s great that we’re slowly creating changes to help improve the lives of those facing homelessness, however it is still not enough. In fact, it will never be enough, until there are no longer people experiencing homelessness. The only way to change this problem is by creating affordable housing for EVERYONE to be able to afford a home.

Unfortunately, many people have adopted the not-in-my-backyard (NIMBYism) argument, where they want to support affordable housing, but they don’t want it anywhere near them. The City of Toronto is currently looking into creating supported housing however there needs to be more research done before it is put into effect. Wolff (2008) partnered up with the Dream Team to understand what it would be like to have supportive housing in local communities. The results were that supportive housing would be beneficial in neighbourhoods both economically and socially. It would also reduce issues surrounding crime, tidiness and noise.

(source: Wolff A. (2008). We are neighbours. Wellesley Institute. pp. 1-33)

Check out the story Million Dollar Murray at http://gladwell.com/million-dollar-murray/. In my opinion there are two morals to this story. The first is that those experiencing homelessness are PEOPLE. They deserve to be treated fairly despite their lived experiences. The second moral of this story, which is entirely applicable to the city of Toronto is that it costs us MORE to keep people living in a homeless state rather than fix the situation and improve their quality of life.

Please, please, please keep doing research on this topic, and strive to make a difference in your community. These people have been through enough and it needs to come to an end. They are people too.

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Helping Heart Bag

Helping Heart Bag:

To really help those experiencing homelessness, I recommend that everyone create a Helping Heart Bag with some or all of the items listed below:

·         Naloxone kit

·         Socks

·         Scarfs

·         Blankets

·         Lotion

·         Chapstick

·         Deodorant

·         Comb

·         Wet wipes

·         Tampons/maxi pads

·         Kleenex

·         Soap

·         Mouthwash

·         Toothbrush/toothpaste

·         Mini first aid kit (bandaids, gauze)

·         Light snacks (granola bars, beef jerky, juice, hard candies)

·         Condoms

·         Sunscreen

·         Bus tokens

·         Anything else you can think of that will help!

Give it to anyone that you think needs it. Make more than one if you want. Just make a difference in the world.

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(via 'I wish we could have saved him:' Homeless deaths in Toronto)

Located at the Church of Holy Trinity in downtown Toronto.

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Source: St. Michael’s Hospital/CBC News

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Chronic Illnesses/Diseases & Mortality

My family has a terrible health history. Cancer, and diabetes run on both sides. This terrifies me, especially since there is still no cure for either. It’s comforting however, to know that there are people in my life that would support me through all of it. Someone experiencing homelessness may not have the same thought process.

Those experiencing homelessness are at an increased risk of diabetes, anemia, HIV/AIDS, cancer and many more chronic illnesses/diseases (see more at: http://homelesshub.ca/about-homelessness/health/chronic-illnessesdiseases-and-mortality). When someone experiencing homelessness is diagnosed with such a condition, it is extremely hard for them to get the help that they require since they have a very limited access to adequate health care. In addition to this, many of these chronic illnesses/diseases require prescribed medication which is often costly and therefore unaffordable to those experiencing homelessness. In my opinion, there might also be a lack of motivation to fight the disease upon hearing that they might be dying. As I said previously, it comforts me to know that I would have a support system, however without one, many people might have a lack of motivation to survive.

Recently, Dr. Naheed Dosani has been delivering palliative care for individuals experiencing homelessness. He is both a doctor and an entire social support system for those who are dying. He makes sure that they have a safe and comfortable space to rest in, while providing them with medication such as methadone and hydromorphone to alleviate the pain. He is supported by a program called Palliative Education and Care for the Homeless (PEACH). (See more at: http://www.cbc.ca/news/health/toronto-calgary-homeless-palliative-care-health-end-of-life-1.3937391).

Research done by Krakowsky, Gofine, Brown, Danziger, and Knowles (2012) suggest that there are four ways in which we can make palliative care more beneficial towards those experiencing homelessness. The first is by creating a positive relationship between the health care system and those experiencing homelessness. The second is by training shelter staff (or any other staff who deals with those facing homelessness) to deal with terminally-ill individuals. This includes being able to comfortably talk about death as well as discuss a plan for each individual person. The third suggestion is to create care for each patient that revolves specifically around their wants and needs. The fourth and final suggestion to create a vast range of ways to deliver palliative care to those experiencing homelessness. Many people have specific ways in how they want to spend their last few months of life – this should be respected and followed to ensure that each individual passes peacefully.

(source: Krakowsky Y., Gofine M., Brown P., Danziger J., Knowles H. (2012). Increasing Access—A Qualitative Study of Homelessness and Palliative Care in a Major Urban Center. American Journal of Hospice& Palliative Medicine. 30(3) 268-270.)

I personally love the idea of palliative care for those experiencing homelessness. Of course it’s heartbreaking that individuals facing homelessness are even in this situation, but some diseases are simply too far advanced for someone to be able to conquer. By providing them with palliative care, it gives them the drugs that they would have previously had no access to, in order to help with the pain. In addition to this, they have a support system who really do care for them, as well as a safe and peaceful environment to spend their last few months of life. Without this, many people would be forced to die alone and on the streets; this is a much better solution.

SOLUTION: 1) Provide EVERYONE with the same health care regardless of their lived experiences and whether or not they have a health card. This would make it much easier to catch certain diseases earlier and even help prevent them or at least maintain them. 2) All of the suggestions made by Krakowsky  et al., (2012) 3) Keep funding palliative care for those experiencing homelessness. Everyone deserves to pass away knowing that someone cares. They are people too.

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Musculoskeletal Conditions & Chronic Pain

We’ve all had occasional pain. Maybe we take an Advil, or wrap up whatever hurts in a tensor bandage. If it gets worse we see a doctor and get referred to a physiotherapist. But what happens when you don’t have access to a doctor who can refer you or even prescribe you pills to make the pain stop? You self-medicate.

Musculoskeletal conditions can include but are not limited to arthritis and rheumatism, arthritis, rheumatism, fibromyalgia and chronic fatigue syndrome (Lightman, Mitchell & Wilson, 2008). Those experiencing homelessness are more at risk of having musculoskeletal conditions from poor sleeping conditions, inaccessibility to prescription medication and rough shelter conditions. There is very little done to help those experiencing homelessness who have chronic pain such as musculoskeletal conditions. This pain does not go away, however some days might be better than others. Although some people facing homelessness may turn to a doctor, many leave untreated.

A study done by Hwang, Wilkins, Chambers, Estrabillo, Berends and MacDonald (2011) found that of the 152 participants experiencing homelessness 48% reported using over-the-counter drugs, 46% used street drugs and 28% used alcohol to treat their pain. Hwang et al., (2011) also interviewed 61 physicians and found that only 51% of them treated the pain of someone experiencing homelessness. Many of them were afraid to prescribe narcotics to someone with a history of substance abuse, or feared that they wouldn’t take their medication properly.

(sources: Lightman, E., Mitchell A., Wilson B. (2008). Poverty is making us sick: A comprehensive survey of income and health in Canada. Community Social Planning Council of Toronto. pp. 1-38. // Hwang S., Wilkins E., Chambers C., Estrabillo E., Berends J., MacDonald., A. (2011). Chronic pain among homeless persons: characteristics, treatment, and barriers to management. BMC Family Practice, 12(73), 1-9)

In my opinion, this is extremely troubling. When you go to the doctors, you are asking for help, and part of you believes that the doctor will do everything in their power to help you feel better – that’s what they’re there for. To hear that a doctor would simply refuse someone the health care that they deserve all because of their lived experiences is disgusting. Especially if you’re treating someone who’s experiencing homelessness – you should understand that they’re going through something that not everyone survives… all the more reason TO HELP THEM. The fact that we are creating situations where people are taking street drugs and even over-dosing to escape their pain is extremely problematic because this is exactly how the stigma surrounding drug users and those experiencing homelessness is creating.

SOLUTION: 1) We need to develop a policy that gives those experiencing homelessness access to prescribed medication for a very low cost. There are ways to tell if someone is truly hurting, give them the drugs they need. 2) We need to be able to specifically treat those experiencing homelessness. We cannot simply exclude them from proper health care simply because of their lived experiences. They are people too.

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Dental & Oral Care

Teeth! We brush them every morning and night, we floss, we get braces, we do everything in our power to make sure our smile is perfect. In my opinion, not having proper dental care is destructive. I remember one time I avoided getting a cavity filled which resulted in me getting a root canal because the nerve was so badly damaged. Before the root canal, I remember that tooth being extremely painful; it was sensitive to just about everything - hot, cold and even the air. For those experiencing homelessness, there is nothing to smile about due to the lack of adequate dental care provided to them.

Lightman, Mitchell, and Wilson (2008) found that there are four types of private health insurance (dental, prescription, eyeglasses, hospital) which are highly linked with income. Therefore those with higher incomes are more likely to benefit from these types of insurances meanwhile folks with a low income may not experience any benefits from it. This means that those experiencing homelessness may not be able to access dental care due to their minimal income.

(source: Lightman, E., Mitchell A., Wilson B. (2008). Poverty is making us sick: A comprehensive survey of income and health in Canada. Community Social Planning Council of Toronto. pp. 1-38.)

The City of Toronto is now offering FREE dental care, which covers:

·         Examinations

·         X-rays

·         Fillings

·         Cleaning

·         Some root canal treatments

·         Extractions

·         Emergency and urgent dental care to treat issues like dental pain or cavities

However there are a few limitations. Folks are only eligible to this service if they are between 0-17 years old or over 65 years old. Adults in between 17-65 must be enrolled in a Toronto Public Health program and must meet other eligibilities (which are not listed on their website). For more information see, http://www1.toronto.ca/wps/portal/contentonly?vgnextoid=51b74485d1210410VgnVCM10000071d60f89RCRD.

It seems to me that poor dental care is linked to hunger and nutrition. For instance, if someone experiencing homelessness has a sore tooth they may not be able to eat any hard food – such as apples, bagels, granola bars, etc. The inability to eat anything given to them, means that they are at an increased risk of malnutrition since they now need to find food that they are able to eat that is ALSO nutritious.

SOLUTION: There needs to be free dental care for ANYONE who is below a certain income level. This minimum income level needs to be much higher than the living wage because many people prioritize basic survival over dental needs. They are people too.

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(via Homeless women craft makeshift sanitary products due to high prices)

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Menstrual Care

Every month, for approximately a week, women bleed. Every woman. Not just the women who have a roof over their head. Not just the women who can afford to buy pads/tampons every month. And not just the women who can lie in bed all day while her cramps are the most painful they have ever been. Every single woman. I think that many people often forget that women experiencing homelessness go through these types of monthly situations, because a majority of rough sleepers (people who sleep on the streets) are men. Many women choose to stay in shelters or drop-in centres, especially those who have their kids with them.

For those who experience a monthly period, it is often the worst time of the month, a real downer. For women experiencing homelessness, it is so much worse. While this is a natural experience, many women are unable to access what they need to stay hygienic during this time of the month.

Toronto Star writer, Emily Mathieu, did an amazing job investigating how women experiencing homelessness deal with their monthly menstrual cycle. (The following information is from the article, see more here, https://www.thestar.com/news/gta/2017/01/23/periods-an-extra-hardship-for-homeless-women.html).

Much like condoms, menstrual supplies are not an option if it means choosing it over food or transportation. Many women are forced to make their own form of tampons every month when they cannot access real ones. This is often done with just about anything they can get their hands on such as cotton balls, Kleenex and even newspaper. This can lead to a variety of infections or even cause Toxic Shock Syndrome (from leaving a tampon in too long) which is quite severe and can cause death.

While many shelters do give out menstrual supplies, it is not enough for women to stock up on them. Depending on how heavy a woman’s flow is, those supplies may not even last a day much less a week. Organizations such as the Period Project, gather supplies and distribute them to women on a monthly basis to help women stay as hygienic as possible (see here, https://www.periodprojecttoronto.com/).

The reality is that prices of women’s menstrual supplies are far too expensive, especially for those facing homelessness. This is a basic need for women, and it is simply ridiculous that not every woman has access to them!

SOLUTION: Make women’s menstrual supplies more accessible, lower the cost, or even make them free. No woman chose to have her period; it is a natural process that women should not have to pay the price for. They are people too.

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Street youth pregnancies: A study conducted in 1997-98 by the Hospital for Sick Children and the Shout Clinic among 93 street-involved females found that an alarming number of street youth have pregnancies. There was a total of 118 pregnancies among the women. The study found that: 59% reported having been or currently were pregnant. The average age of first pregnancy was 16.7 years. At the time of the first pregnancy 29% of youth were living on the street 27% in shelters, and 43% with friends or family. 32% of all pregnancies were miscarried 22% were terminated electively 34% delivered and 12% were still pregnant.

Covenant House http://www.covenanthousetoronto.ca/homeless-youth/facts-and-stats

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Sexual Health

We’ve all heard someone say use condoms for safer sex. It’s everywhere. Everyone tells you it – teachers, doctors, friends. But what if condoms are inaccessible to you? What if you can’t afford birth control? And what if you have to have sex in order to survive? I don’t think that many people think about those experiencing homelessness as people who have sex. The reality is, they DO – just many other people.

Many people experiencing homelessness are more at risk for sexually transmitted diseases as they are likely to have multiple sexual partners, take part in sex work, or be sexually assaulted. That sounds harsh but that is the reality. The problem is condoms are simply inaccessible. They are not cheap for someone who has a limited amount of money, and some people may not even consider it a necessity; you can still have sex even if you don’t have a condom. Another problem is, you may not even know that you have an infectious disease that can be sexually transmitted. As someone experiencing homelessness, they may not have sufficient access to health care and simply may have never gotten tested. Hwang (2001) states that many people experiencing homelessness are at risk for the spread of HIV/AIDS, gonorrhea, and chlamydia.

Pregnancy is another issue that is a reality for those experiencing homelessness. Without the use of condoms, women facing homelessness are not only likely to get a sexually transmitted disease, but also end up pregnant. Birth control is an effective way to prevent pregnancy however once again, without an adequate access to health care, women are unable to get birth control since they must have a prescription from a doctor to access it. In addition to this, birth control is expensive, and even low-costing birth control may not be in the budget of many women experiencing homelessness. Even if a women ends up pregnant, she may not even know until later on in the pregnancy, because she may not be able to afford a pregnancy test. This could lead to serious malnutrition and have harmful complications for the fetus.

When interviewed, one woman stated that since she was experiencing homelessness and pregnant, she experienced a lot of judgement and constantly feared that she would have her child taken away (Patterson, Markey & Somers, 2012).

Recently, there has been an effort to provide everyone with the sexual health care that they need through the Toronto Sexual Health Clinic. They provide free condoms, free or low-cost birth control, Plan B, STI testing and free treatment, HIV testing, pregnancy testing and relationship councilling (see more at: http://www1.toronto.ca/wps/portal/contentonly?vgnextoid=30865e67bbee0410VgnVCM10000071d60f89RCRD). The best part of this clinic is that you don’t need OHIP coverage to visit the clinic.The problem with these types of clinics are that they aren’t dispersed evenly throughout the city, and aren’t widely talked about, so not many people are aware of them. In addition to this, they are only open for a limited amount of time, and many of them operate on a first come first serve basis, therefore there are still many people that could be turned away until the next day.

Watson (2011) describes survival sex as the exchange of sexual favours for material goods. Women that Watson (2011) interviewed for her study stated that they needed to stay with a certain person to survive, or that they ignored the abuse the received since they were still being given the materials the needed to survive – one girl stated that she had sex just to avoid being raped. In addition to this, it has changed the way that these women view intimate relationships. It is alarming that we as a country are forcing women and men who are experiencing homelessness to turn to such a harmful and dangerous method of survival.

(sources: Hwang S. (2001). Homelessness and health. CMAJ, 164(2), 229-233. // Watson J. (2011). Understanding survival sex: young women, homelessness and intimate relationships. Journal of Youth Studies, 14(6), 639-655). )

Solution: 1) We need more sexual health clinics dispersed evenly throughout the city. Maybe by integrating sexual health clinics and harm reduction centers we would be able to help a much wider range of people. Sexual Health Clinics should also be open for longer hours that way they’ll be able to see more patients. 2) We need to make condoms and birth control more accessible to EVERYONE as well as offer them for free in many more locations. There are too many people having sex for condoms to not be a necessity. They should also be put in place where people can just take them – no questions asked. 3) Clinics respecting everyone’s lived experiences and making them feel as though their opinion is relevant – whether they are young, old, experiencing homelessness, or even pregnant. They are people too.

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Skin, Respiratory & Foot Care

If you live in Toronto, at some point you’ve probably complained about how unstable the weather is. One week you’re wearing shorts and a tank top, then next week you’re back in your winter jacket. By living in unsheltered conditions people experiencing homelessness do not have the privilege or bundling up when it gets really cold or showering often when it’s really hot outside. Situations like this expose those experiencing homelessness to a range of skin diseases, which when left untreated are life altering.

Those experiencing homelessness are more likely to get skin conditions or diseases such as cellulitis, impetigo, venous stasis disease, scabies and body lice (Hwang, 2001). If that’s not enough, it’s likely that they will get these conditions more than once, depending on how long they live on the streets. Many of these diseases are treatable however without a health card those experiencing homelessness are likely to be turned away from our “health care” system. On top of this, if they are treated, treatments may cost more than they can afford to pay, so they may have no option but to skip the treatment altogether.

Living in unsheltered environments also puts those experiencing homelessness at risk for specific respiratory diseases such as chronic obstructive pulmonary disease, emphysema, bronchitis and many more (http://homelesshub.ca/blog/what-are-top-10-health-issues-homeless-people-face).

I think foot care is the most overlooked out of all of these issues. It’s something not many people consider, just because it’s never really talked about. Growing up I went through dozens of shoes. Even now, I replace shoes constantly because they’re either uncomfortable or more often just worn down. Unfortunately, those experiencing homelessness cannot replace shoes as much as they’d like and as a result, they are forced to wear the same shoes day in and day out. This results in foot disorders such as onychomycosis, tinea pedis, corns and callouses, and immersion foot (Hwang, 2001). In addition to this, those who experience homelessness live in harsher conditions therefore they must walk or stand for longer periods of time and experience moist socks or shoes for hours or even days with nothing to change into.

(source: Hwang S. (2001). Homelessness and health. CMAJ, 164(2), 229-233.)

Solution: 1) I think that there needs to be more of an effort to donate skin care products as well as foot care products. These products are more often over looked, but needed the most. Something as simple as moisturizing everyday can help an individual’s skin A LOT. 2) We need a health care system that is willing to support the needs of those experiencing homelessness. If someone does not have their health card on them, is that really a reason to turn them away instead of giving them the help that they clearly need? They are people too.

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taken from: https://www.ontario.ca/page/get-naloxone-kits-free 

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Infectious Diseases

Many folks experiencing homelessness have been forced to turn to drug-use as a way to self-medicate in replacement of adequate health care. As a result of this, those experiencing homelessness open themselves up to a range of infectious diseases such as hepatitis A, B and C, tuberculosis (TB), HIV/AIDS.

First let’s look at how serious these diseases are. The following information was produced by the http://www.mayoclinic.org/

Hepatitis A: a virus which causes a contagious liver infection.

Causes: Eating food handled by someone with the virus who doesn't thoroughly wash their hands, drinking contaminated water, eating raw shellfish from water polluted with sewage, being in close contact with a person who's infected — even if that person has no signs or symptoms, having sex with someone who has the virus Treatment: practice good hygiene, rest, cope with nausea (keep eating), stop using drugs and alcohol

*there is currently no cure for hepatitis A, people must simply learn to deal with its symptoms

Hepatitis B: a virus (HPV) which causes a serious and contagious liver infection

Causes: sexual contact, sharing of needles, accidental needle sticks Treatment: anti-viral medications, Interferon alfa-2b (Intron A), a liver transplant, have safe sex, don’t share needles, toothbrushes, razor blades

Hepatitis C: a virus (HCV) which causes liver inflammation and can lead to serious liver damage

Causes: being exposed to the blood of someone who carries the HCV virus Treatment: vaccines, anti-viral medications, a liver transplant

Tuberculosis (TB): serious contagious disease that affects your lungs

Causes:  bacteria that spread from person to person through microscopic droplets released into the air Treatment: Isoniazid, Rifampin (Rifadin, Rimactane), Ethambutol (Myambutol), Pyrazinamide, Bedaquiline, Linezolid

HIV/AIDS: an immunodeficiency virus (HIV) which causes immunodeficiency syndrome (AIDS) which is a chronic, life-threatening condition – this interferes with the body’s ability to fight diseases

Causes: having sex, sharing needles, blood transfusions Treatment: there is currently no cure for HIV/AIDS however certain drugs can help control the virus

As you can see, all of these diseases are contagious and can be spread through the sharing of needles and poor hygiene practices. In addition to this, many treatments which involve drugs can be costly. Other treatments which require users to stop drinking or using drugs are seemingly impossible without the help of rehab plans which takes months for those experiencing homelessness to gain access to.

Places such as The Works, on Victoria Street specialize in Harm Reduction by:

·         The needle exchange program

·         Supplying users with harm reduction kits (to take drugs safely) on location & mobile outreach

·         Opioid substitution clinic (methadone & suboxone) – counselling & support

·         POINT program – trains individuals on how to recognize and prevent overdoses as well as how to use take-home nasal-spray Naloxone kits in cases of overdose (without needing to show your health card)

·         Testing and vaccination – tests for HIV (anonymous & Rapid testing available), Hepatitis C, Hepatitis B and Syphilis and free vaccines for Hepatitis A and B, Tetanus, Pneumococcal and Influenza.

·         Supervised Injection Sites (to use drugs in a safe environment)

(see more here, http://www1.toronto.ca/wps/portal/contentonly?vgnextoid=3732be9b82e0b410VgnVCM10000071d60f89RCRD)

Now at participating pharmacies like the ones in Shoppers Drug Mart have implemented programs such as the POINT program where they teach users or friends/families of users on how to recognize and prevent an overdose. They now provide FREE injectable naloxone kits however you need to provide an Ontario Health Card (see more at: https://www.ontario.ca/page/get-naloxone-kits-free). This is of course problematic since many people experiencing homelessness do not carry or have lost their health card. In addition to this, it is also problematic to have these programs in such public places since there is a lot of stigma surrounding drug users therefore not many users would feel comfortable walking into such a public place for help (Smye, Browne, Varcoe and Josewski, 2011).

(source: Smye V., Browne A., Varcoe, C., Josewski (2011). Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context. Harm Reduction Journal. 8(17), 1-12.)

FYI: Naloxone temporarily reverses the effects of an overdose caused by opioids such as fentanyl, morphine, heroin, methadone and oxycodone.

Solution: 1) We need more community-based organizations such as The Works, distributed across Canada where users feel safe. 2) If pharmacies want to help they need to primarily erase the stigma surrounding drug users. Then and only then, pharmacies should create more programs similar to The Works, however they need to stop requiring health cards as a way to access these programs because in reality it is a barrier for those experiencing homelessness. 3) There needs to be a program set up to provide free or low-cost treatment to those experiencing homelessness with infectious diseases since many of these diseases are fatal without the proper treatment. Smye et al., (2011) suggest integrating harm reduction into our primary health care to acknowledge that people have different lived experiences and our health system can support any lifestyle. This would eliminate the stigma and allow users to feel comfortable asking for help in any environment. They are people too.