INFIRMARY SERVICES FOR HOMELESS PERSONS IN TORONTO: A CASE STUDY

SUZANNE JEAN ZERGER

A DISSERTATION SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

GARDUATE PROGRAM IN SOCIOLOGY YORK UNIVERSITY TORONTO, ONTARIO

JUNE 2008 Library and Bibliotheque et 1*1 Archives Canada Archives Canada Published Heritage Direction du Branch Patrimoine de I'edition

395 Wellington Street 395, rue Wellington Ottawa ON K1A0N4 Ottawa ON K1A0N4 Canada Canada

Your file Votre reference ISBN: 978-0-494-46024-5 Our file Notre reference ISBN: 978-0-494-46024-5

NOTICE: AVIS: The author has granted a non­ L'auteur a accorde une licence non exclusive exclusive license allowing Library permettant a la Bibliotheque et Archives and Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par telecommunication ou par Plntemet, prefer, telecommunication or on the Internet, distribuer et vendre des theses partout dans loan, distribute and sell theses le monde, a des fins commerciales ou autres, worldwide, for commercial or non­ sur support microforme, papier, electronique commercial purposes, in microform, et/ou autres formats. paper, electronic and/or any other formats.

The author retains copyright L'auteur conserve la propriete du droit d'auteur ownership and moral rights in et des droits moraux qui protege cette these. this thesis. Neither the thesis Ni la these ni des extraits substantiels de nor substantial extracts from it celle-ci ne doivent etre imprimes ou autrement may be printed or otherwise reproduits sans son autorisation. reproduced without the author's permission.

In compliance with the Canadian Conformement a la loi canadienne Privacy Act some supporting sur la protection de la vie privee, forms may have been removed quelques formulaires secondaires from this thesis. ont ete enleves de cette these.

While these forms may be included Bien que ces formulaires in the document page count, aient inclus dans la pagination, their removal does not represent il n'y aura aucun contenu manquant. any loss of content from the thesis. Canada ABSTRACT

Housing, income, and health system reforms driven by a neoliberal agenda have created unprecedented growth of Toronto's homeless population, and enhanced the complexity of their health problems and how they find and receive health care. These reforms have limited the capacity of the universal health care system to address the needs of homeless and underhoused persons, and driven the development of targeted homeless- health care services. By giving voice to the providers who bear the brunt of health care delivery for these individuals, this study enables a rich understanding of the layered meanings of these targeted services within a universal health care system. I argue that while these targeted services are characterized by innovation and sensitivity to the unique needs of the homeless population, they are under-resourced and ultimately reproduce stratifications seen in the broader health care system; the providers are unwittingly entrenching a separate tier of health care for the growing number of persons with needs not met by the universal health care system, and reinforcing the intent of reforms aiming to commodity health care.

My analysis focuses on the tensions the homeless population's unique set of needs cause providers in the hospitals at the point of discharge, and those in the community agencies increasingly burdened with the responsibility to care for them. Under pressure to discharge patients, hospital-based providers struggle to release homeless patients not sick enough to justify a hospital bed, but with nowhere to go to recuperate safely. Many of these patients end up in emergency homeless shelters with aftercare needs shelter-

iv based providers are unable or ill-equipped to provide. A Homeless Infirmary which originated at the onset of Toronto's homeless crisis in 1998 and opened about a decade later in 2007 expressly to alleviate this tension serves as a case study. Using a political- economy framework, this study describes the specific historical-cultural context in which this Infirmary emerged, and how it has developed. Though multiple sources of information are used to understand this context, in-depth interviews with both hospital- and community-based providers best illuminate how this systems-created tension plays out on the frontlines of care.

v ACKNOWLEDGEMENTS

Several people were especially helpful to me throughout the preparation of this dissertation. Dr. Pat Armstrong, my supervisor, provided consistent encouragement and support as well as timely and insightful reviews of numerous drafts. Drs. Tania Das

Gupta, Stephen Longstaff, Isolde Daiski, Karen Anderson and Allan Moscovitch also gave generously of their time and expertise. Audrey Tokiwa and Rhonda Doucette patiently helped me navigate the numerous administrative steps. I was also very privileged to work with Alice Broughton, Pat Larson, and Tracy Warne on this project; these compassionate, intelligent women tirelessly serve persons experiencing homelessness in their community, and are great inspiration to me. These three, along with the many individuals I interviewed for this study, are admirable advocates within systems which too frequently dismiss persons who lack life's basic necessities. My greatest debt of gratitude, though, goes to Robert Teigrob, for his unwavering kindness and support.

vi TABLE OF CONTENTS

Page# INTRODUCTION 1 Background 3 Study Foci 6 The Role of Public Health vs. Medicine in Health Disparities 7 Study Framework and Contributions 15 Outline of Chapters 19

POLITICAL ECONOMY AND HOMELESSNESS, HEALTH, AND 21 HEALTH DELIVERY SYSTEMS The Political Economy of Health Disparities: Neoliberal 22 Globalization Trends The Canadian Context: An Eroding Infrastructure 30 Defining Homelessness: Who's In and Who's Out? 38 Health Care Delivery 48 Housing and Health. 57 Summary 65

METHODS 68 Conceptualizing Homelessness 69 Study Participants 71 Interviews: Content and Approach 75 Other Information Sources 78 Analytical Strategies 83 Advisory Team 85 Summary 86

HOMELESS HEALTH SERVICES IN TORONTO: PROVIDER 88 PERSPECTIVES Overview of Homeless Health Services in Toronto 100 Health Care for Homeless Persons in the Hospital Setting 110 Health Care for Homeless Persons in the Community 124 Funding and Accountability 143 Summary 152

vn TABLE OF CONTENTS, continued

V. THE HOMELESS INFIRMARY 155 Va. Development and Design of Homeless Infirmary Services in 157 Toronto Vb. Referrals to Sherbourne Homeless Infirmary 168 Vc. Clients Served by Sherbourne Homeless Infirmary 178 Vd . Short-Term Impacts of the Homeless Infirmary 184 Ve. Long-Term Impacts: The Role of Targeted Services within a 191 Universal Health Care System Vf. Summary 200

VI. CONCLUDING REMARKS 204

REFERENCES. 210

viii LIST OF TABLES

Table III-1 Interviewee Location, Type and Number 74

Table III-2 Referral Forms: Selected Variables 81

Table V-1 Referrals to Sherbourne Homeless Infirmary 171

Table V-2 Sherbourne Homeless Infirmary Clients 179

ix LIST OF FIGURES

Figure IV-1 Ontario Health Insurance Plan (OHIP) Cards (1990, 1995) 104

x LIST OF APPENDICES

Appendix A) Study Protocol 226 Appendix B) Study Consent Forms 231

XI CHAPTER I

INTRODUCTION

In 1998, leaders of health care associations in Toronto ominously predicted, in a letter to then Health Minister Elizabeth Witmer,

"The medicare principles of universal, accessible, comprehensive and portable health care are a myth for Ontario's homeless population and their situation will worsen significantly... " [cited in (Golden et al. 1999:103)]

Some vivid indications of this prediction becoming a reality a decade later came in the form of some stories relayed by providers caring for homeless persons in Toronto: A manager of a homeless shelter described a naked man, wearing only a hospital bed sheet and a colostomy bag, being dropped of at the door of his shelter upon being discharged from the nearby hospital. A homeless-outreach worker described an acutely suicidal woman with a crack addiction wearing a urostomy being discharged from a hospital in the middle of the night, left to walk through crack alleys to her temporary residence at a downtown women's shelter.

A simultaneous deterioration of the public health and housing infrastructure and of the capacity of the universal health care system has created a gap in care between hospitals and the street; these stories describe what happens when people fall through that gap. Using a political economy framework, this thesis attempts to understand the factors which led to the dire 1998 prediction and to the situation with homeless-health care a

1 decade later. A case study of a program designed to address this gap focuses the

discussion. The providers in hospitals and homeless-targeted agencies who have borne witness to these systems changes throughout the past decade offer their insights into how those changes have affected their ability to care for persons who are homeless in their

community, and how they have navigated the resultant tensions.

Housing, income, and health system reforms driven by a neoliberal agenda have

created unprecedented growth of Toronto's homeless population, and enhanced the

complexity of their health problems and how they find and receive health care. These reforms have limited the capacity of the universal health care system to address the needs

of homeless and underhoused persons, and driven the development of targeted homeless- health care services. By giving voice to the providers who bear the brunt of health care

delivery for these individuals, this study enables a rich understanding of the layered meanings of these targeted services within a universal health care system. I argue that while these targeted services are characterized by innovation and sensitivity to the unique needs of the homeless population, they are under-resourced and ultimately reproduce

stratifications seen in the broader health care system; the providers are unwittingly entrenching a separate tier of health care for the growing number of persons with needs not met by the universal health care system, and reinforcing the intent of reforms aiming to commodify health care.

2 la. Background

Though allopathic biomedicine actually began its dominance in the late 19l century, the medical model on which the health care system is based monopolizes the scene today, virtually unchallenged. That health encompasses far more than health care services, that it is a state defined more broadly than the absence of disease, has paradoxically resulted in health care reforms which further entrench this model

(Armstrong and Armstrong 2003; Coburn 2001). One impact of this emphasis on the medical model, and on the application of market principles to health care, is a crisis for

Canada's homeless population. More people are homeless or vulnerable to homelessness than ever before. And individuals without homes rely heavily on health care services when other determinants of health, like physical, social, and psychological environments, and wealth, are weak or lacking. Mainstream health delivery systems have struggled to adapt to this population's many complex needs, but these struggles are only exacerbated by current trends in the health care marketplace. Shifting patients out of the public system into under or un-fmanced home care, for example, is especially problematic for those without homes to go to, and for those service providers (primarily women) shouldering the burden of their care. Over time, organizations and individuals frustrated with the failures of the mainstream system have gradually developed innovative programs and services. They have usually done so with piecemeal funding in hopes of catching individuals falling through the dwindling safety net. For the most part, these

3 hotchpotch offerings have functioned as a completely separate, distinct health care (non) system.

This thesis examines one of these homeless-targeted health programs in Toronto, the largest city in Canada and the site of some of the country's most aggressive health reforms. This program, the Sherbourne Community Health Centre's Homeless Infirmary, was developed over the past decade as an explicit consequence of- and in direct response to - coinciding changes in Toronto's public safety net and health services.

I first became interested in this topic through my role as research staff for the

National Health Care for the Homeless Council in the United States. The Council is a membership organization of clinics funded by the federal government to provide health care to homeless persons, and of individual clinicians providing that care. Within that role, I became aware of homeless "respite" services, a term equivalent to the Canadian

"infirmary," developed to address acute medical after-care and recuperative needs of homeless persons. I managed a multi-year evaluation often federally-funded homeless respite programs across the US (2000-2004), and participated in the development of a national "Respite Care Providers' Network (RCPN)," a group aiming to support rapidly emerging respite programs through education, networking, and advocacy (1999-present).

I was attending the second formal meeting of this Network in 2001 when I met Toronto's

Homeless Infirmary Director. I moved to Toronto, Ontario, in 2003, though I continued my work with the Council and the RCPN (I currently serve as its Coordinator). As I became engaged with the homeless service community in Toronto, I noted very similar

4 patterns in the experiences and frustrations of providers, and underlying the emergence of and interest in respite/infirmary services for homeless populations. The neoliberal political agenda, both shaping and advanced by globalization, was devastating public safety nets in both countries and increasing the numbers of people at risk of homelessness and literally homeless. In both countries, simultaneous cutbacks in hospitals and in public safety nets were creating a gap in service for homeless persons too well to stay in the hospital but too sick to recover on the streets or in shelters. Respite/infirmary services were a growing need in both locations, though in the US it was not as recent, with targeted homeless-health clinics first opening in the mid-1970s, and the first two respite programs established in the mid-1980s. In Canada, the need for respite (or infirmary) services was not formally articulated until well into the 1990s. But there are other differences as well, not the least of which is Canada's universal health care system which it seemed should have obviated the need for targeted health care services, including a homeless infirmary. Though I originally engaged with this issue from the US perspective, this study is not intended as a comparison of the two national contexts, but rather as an opportunity to explore more deeply the specific historical, political economic factors which have given rise to major changes in the provision of health care for homeless persons in Toronto, including the development of infirmary services.

In this introductory chapter, I explain how the study's political-economy theoretical framework fits into and contributes to broader discussions of health disparities and public health, and outline the content of subsequent chapters.

5 lb. Study Foci

This study focuses primarily on the past decade (1997-2007) because this marks

an important historical moment in health care reform, and homeless health care, in

Ontario. Certainly homelessness existed as a social concern prior to this time period,

and its growth in the 1980s as the number of affordable housing units slowed raised national awareness, but it was in 1999 that Toronto's city council declared homelessness

a national disaster and began in 2000 to generate annual "report cards" on the status of homelessness in the city. The Harris government — marked by the election of Progressive

Conservative Mike Harris as Premier of Ontario in 1995 — and the Harris neoliberal

"Common Sense Revolution" is almost unanimously credited with greatly exacerbating

Toronto's current crisis in homelessness. Among the Harris government's legacies are abrupt halts to affordable housing developments and removal of rent subsidies, merging of hospitals and cutting hospital budgets, slashing welfare rates, introducing a managed competition model to home care, and closing psychiatric beds. Agencies serving homeless and marginally housed populations spun into crisis mode, scrambling to make do; initial anger and retaliation were largely thwarted after a peaceful mass protest at

Queen's Park led to a riot. As one author reflected:

The Harris blitzkrieg hit Ontario like a tornado. Every government service, every right, ...every protection which people had taken for granted [was] either gone or in jeopardy" (Ralph 1997:16).

6 Using a political-economy framework, I revisit the motivations behind those reforms and their subsequent effects, both systemic and personal, as I interrogate the experiences of providers caring for homeless persons in hospitals, clinics, and community agencies.

The Homeless Infirmary, which opened in Spring 2007 in one of Toronto's downtown Community Health Centres, serves as a concrete case example for this study.

The focus will be on the unique intersection, and frequent point of conflict, between hospital and community providers as they attempt to provide care to homeless people.

The tension already exists because homeless people are more likely to be hospitalized, to stay in hospitals longer, and to rely heavily upon emergency services (Hwang 2001;

Eberle Planning and Research 2002; Serge and Ganedinger 2003). Yet it is exacerbated by cutbacks, such as those mentioned, which pressure hospitals to discharge patients quicker and sicker, and which reduce or limit resources in community agencies to take care of them. The Homeless Infirmary is one response to alleviate this tension and to catch persons who would otherwise fall through this gap in service. It also lies at the crux of two perspectives which drive so much health policy and funding: should more energy and resources be put into public health infrastructures, or into medical care? The next section reviews some of the sociological theories which have informed this question, and how they have in turn informed health system policies and reforms.

Ic. The Role of Public Health vs. Medicine in Health Disparities

Discourses on health and health disparities vary according to the socio-political context within which they are produced. They likewise reflect prevailing ideas of what

7 health is, and what causes it to improve or deteriorate (Marmor, Barer and Evans 1994).

Socioeconomic context and political winds are key to understanding how social scientists have thought about health disparities -the research questions raised, the solutions sought

- and have helped to frame health policies and systems.

The weight given medicine and health-care systems relative to public health infrastructures in addressing health disparities, for example, has waxed and waned; with it the definitions of health inherent in both. Once the sweeping, indiscriminate impact of infectious diseases of the 19th century abated, for example, public health struggled to retain its credibility (and funding) in the middle to late 20th century, and medicine gained dominance (Garrett 2000). The postwar economic boom of the 1950s and 60s inspired the leading health policy concern for the developed world to become "how to bring the wonders of modern medical care to all its citizens"; this was consistent with the popular perception of medicine as the "most direct road to health" for all (Marmor et al.

1994:218). Decolonization and liberation struggles in the 1960s led to refocused attention on the effects of social disparities and inequalities on health (Labonte et al.

2005a:6-7). The merging of an increasingly dominant health care system built on a medical model ideology, with a new attentiveness toward social causes of health disparities, sparked concern with "medicalisation." Social scientists played a key role in articulating the varying forms of medical social control and their implications resulting from this institutional dominance, a critique in part reflecting retaliation against Talcott

8 Parsons's structural functionalism, heretofore dominant in sociological scholarship (Illich

1976; Navarro and Muntaner 2004).

Canada's influential LaLonde Report, published in 1974,1 had the arguably unintentional effect of emphasizing the impact of individual lifestyle and behaviours on health, inspiring an entire 'lifestyle behaviour' discourse on health, which stressed

individual-level behaviour changes as the most effective strategy for improving health policy. By individualizing the root and remedies of the problem, the issues of income

and power distribution, which Vincent Navarro and others were raising, were neatly avoided. Social scientists during this era were more interested in the emergence, process and extent to which medicalisation was occurring (where, and in what context) than with its societal impacts. Questions about how and why some groups were more vulnerable to medicalisation that others, or how cultural and structural factors might encourage or discourage medicalisation, were not a significant focus.

Though concerns about the medical model's potential to decontextualize social problems were strongly voiced, the concerns were largely confined to academic, not policy, circles. Critics of the lifestyle approach to health showed how its neglect of the socioeconomic and political context of individuals behaviours resulted in blaming the victim. The political-economic context at this time provided fertile ground for the lifestyle behaviour discourse to emerge and take root, and effectively muffled the critics' cries of concern and alarm. Passage of the North American Free Trade Agreement in

1 This report was named after then-Health Minister, Marc LaLonde. It was considered the first recognition by a major industrialized nation that the wellbeing and health status of individuals and populations are determined by more than biological factors or medical interventions. 9 1992, governing trade between the United States, Canada and Mexico represented unprecedented commitment to market-oriented policies in Canada, the rise of neoliberal parties, and the decline in the relative autonomy of the state, all of which aided in the significant deterioration of the welfare state and with it health and determinants of health

(Coburn 2001:55) . This changing context also coincides with a shift in the kinds of questions being asked. For example, an editorial in the American Journal of Public

Health noted a broad trend in public health research from a focus on health problems of homeless people (proportion of these articles decreased from 77% between 1984-1988 to

41% between 1994-1998) to a focus on personal risk factors for homelessness (increased from 15% to 44%o in those same time periods). They describe the implications of this shift:

In practice, despite the conceptual understanding of the role of structural causes of homelessness, homelessness has been studied as if it were a disease, an outcome defined as residing in the individual (Meyer and Schwartz 2000:1190).

An anthropologist, discussing the medicalisation of homelessness, similarly suggests:

One effect of conceptualizing social problems through a lens of diseased bodies is often a neglect of systemic inequality. Consideration of the material and historical conditions that might contribute to the production of problems is silenced or marginalized by a focus on individual traits and habits (Lyon-Callo 2000:331) [See also (Evans, Barer and Marmor 1994) for a review of criticisms].

2 The Canada-United States Free Trade Agreement, signed in 1988, laid the groundwork for this more comprehensive Agreement a few years later. 10 This criticism, combined with increased awareness that health care access had not

actually reduced inequalities in health between the richest and the poorest, gave rise to an

alternative discourse on 'health promotion' (Robertson 1998).

Characterized by an explicit recognition that health outcomes are affected by

factors external to the health care sector, namely social, physical and psychological

environments and wealth (referred categorically, along with health care, as "social

determinants of health"), public-health strategies called for broad-based changes in the

social and economic environment and a shift away from hospital, physician-based care.

As at least one author has pointed out, this "did not represent so much a new discourse as

a return to the social reformist character of the public health movement of the late 19th

century" (Robertson 1998:156).

Again, however, the political-economic context within which the health- promotions perspective was growing influenced how it became interpreted in practice.

Key to the health-promotions perspective is the fact that health care is just one relatively minor factor determining health; the neoliberals in power interpreted this as a need (or an opportunity) to vastly reduce government contributions to the health-care system, while giving little regard to the linkages between health care and other determinants of health

(Armstrong and Armstrong 2003). In this way, it carried with it some remnants of the

"lifestyle" focus popularized earlier; instead of empowering the individual, the health promoters effectively constructed the individual as a "health consumer" in the model of consumer capitalism (Poland et al. 1998) [See also (Conrad 2005)].

11 One assumption of health promotion is that scientific knowledge can provide a sound basis for individuals to make decisions about their behaviours (e.g. how much to exercise, what and how much to eat), but because scientists cannot agree on which facts comprise that basis, definitions of risk are constantly in flux. Though a detailed discussion of risk and risk governance in health discourse would be tangential here, it is helpful in understanding how health disparities are produced and fostered. For example, a great deal of contradiction exists around what constitutes risk and for whom, and certainly different groups have different interest and capacity to promote their own risk narratives. While the homeless literature links "risky behaviours" - mostly related to drug use - with various diseases and conditions, it stops short of blaming persons surviving on the street and eating at homeless shelters or from dumpsters for smoking cigarettes, making poor nutritional choices, or failing to do cardiovascular exercise. One anthropologist describes how social inequality is embodied in health outcomes, and suggests risk is the primary mechanism by which this occurs; risk is a measure of social violence "capturing how power distributes unevenly down the social ladder" (Nguyen and Peschard 2003:457).

In part because of the reliance on the medical establishment to define risks and protocols for individual health consumers, the health promotion perspective paradoxically reinforces the importance of medical care as a determinant of health, while failing to heed other social determinants. Major changes in the organization of medicine were also

3 For additional discussion on this paradox and its effects in 1990s Canada, see: Armstrong and Armstrong 2003. 12 occurring during this era, with an erosion of medical authority coinciding with a growth

in corporate (e.g. pharmaceutical companies) influence, an increasingly buyer-driven

system (patients acting like consumers) with managed care gaining centrality, and a

general shift in health policy from concerns about access to concerns about cost-

containment (Conrad 2005). In Canada, a net effect of these changes was major

government cutbacks to non-health system determinants of health. These trends became

increasingly entrenched in the 1990s, providing a fertile context for the development of a population health model.

In the early 1990s, health economists Evans and Stoddart from the Canadian

Institute for Advanced Research - a think tank funded from corporate and public sources

- published some highly influential works outlining a model for analyzing the determinants of health of populations, hereafter referred to as "population health."

Dismissing the previously dominant definition of health put forth by the World Health

Organization in 1947 ("health is a state of complete physical, mental and social well- being, and not merely the absence of disease or injury") as operationally unhelpful, these authors adopted a biological definition of health as the absence of illness or injury, of distressing symptoms or impaired capacity (Evans et al. 1994). In agreement with their predecessors, they argue that health care is not the most important determinant of the overall health of populations, and that overspending on health care may actually reduce population health. The perspective diverges, however, when they conclude: invest not in health care, but in greater economic prosperity for all. Japan was a favoured case in point

13 because it experienced extreme economic growth and technology change with a simultaneous growth in life expectancy - all while health care consumed the lowest share of a national budget in the industrial world (Evans et al. 1994:59-60).

Fervent criticisms of the population-health model ensued. Primary complaints were that the model has an unquestioning and uncritical reliance on "science" and "data," assumes knowledge and its production are separate from politics or morality, and neglects how health determinants are created and maintained by economic and social forces. Other criticisms include its value-neutral assertions and failure to acknowledge underlying values and assumptions and that it underestimates the contribution of health care to health and well-being (Poland et al. 1998; Raphael 2001; Robertson 1998). Some have argued reforms based on population-health conclusions — to move resources away from health care ~ were instrumental in creating a subsequent health-care crisis. Current population health theorists agree, asserting that their mantra - health care access in itself will not create healthier people - was co-opted by neoconservative politicians in Canada to advocate capping public health expenditures (Labonte et al. 2005b). They suggest the alignment was unintentional, and in fact undermines a population health approach. Even health promotion advocates, also critical of the overemphasis on health care, found themselves arguing against cuts in funding for health care, acknowledging that removing resources only serves to further penalize those whose health is already compromised by underlying structural inequalities (Robertson 1998:163-164). These arguments became

14 especially salient in the context of cutbacks to public health services and determinants of health.

Id. Study Framework and Contributions

While health promotion and population health perspectives focused attention on inequalities in health, it is the political economy framework which enables a comprehensive understanding of why and how these inequalities are produced and reproduced (Armstrong, Armstrong and Coburn 2001b).4 A political-economy framework is apt for this study because it suggests factors and forces producing and influencing health status within a larger context, such as advanced industrial capitalism, which shape those factors and how they interact with each other. Homeless persons' health inequalities must be addressed within this broader context. Understanding the assumptions underlying Canada's formal health care system will illuminate why those inequalities exist and how they are reinforced. Political economists foster an understanding of the workings of power and provide insights into the contexts within which health inequalities are created and sustained. They encourage meaningful consideration of global political and economic forces, and the distribution of resources between and among populations. As such, this framework is well positioned to help make sense of disturbing trends in homelessness, and in health and health care such as those explored in this study; for example, emergency homeless-shelter staff becoming

4 Population health theorists have acknowledged this critique and are striving to develop a "critical population health" perspective. 15 makeshift health care providers, and motivations for cost-effectiveness dominating health

policy and program development. This framework will allow exploration of these and

related trends for the health needs and services of one of Canada's most vulnerable

populations.

By focusing on homeless-specific health services, and infirmary services in

particular, this study draws attention to the crux of a fundamental tension between public-

health infrastructure and medicine. That is, the need for these services would not exist in

the context of a fully sufficient infrastructure, including appropriate and adequate

housing. By focusing on this tension, this study makes several contributions to current

thinking about health disparities, health service delivery systems, and to homelessness

research.

Research on homelessness is largely separated from research on housed populations. Largely due to methodological constraints, studies rarely even include housed comparison groups. One consequence of this divide, echoed by popular media

images of "the homeless," is reinforcement of the idea that one never becomes the other, that radical differences in health status can be found between someone who is very

impoverished and marginally housed compared to someone temporarily living in a homeless shelter or on the street. Overemphasizing the distinction between housed and homeless populations, or conversely downplaying the importance of housing status to health, are both distortions of reality. This study draws out these distortions, particularly within the context of policy-making and service provision.

16 The knowledge that people experience homelessness and health issues very differently is not typically translated into how specific programs and interventions can and should be designed. Homeless-health services and programs tend to be designed to serve all homeless individuals, as though they comprise a static and homogenous group.

This study will explore how the Infirmary attempted to address needs of Toronto's highly diverse homeless population in the design of their program, and the factors which contribute to and hinder its capacity to engage and care for that population within the current political-economic context.

This study also inserts homeless-specific health care services and providers into broader discussions about health care systems, services, and reforms. A growing body of research is making the connection between housing status and health more overt, showing housing's independent effects on health (Bryant 2004). Yet, as noted earlier, homeless- health care offerings are typically provided outside the "mainstream" system," developed as reactions to needs as they are identified, and thus they remain largely unseen and unknown. This is especially the case in Canada, where the universal health care system ostensibly assures access to health care for all citizens, regardless of housing status. And, although it is these community-based clinicians and homeless-service providers who bear the brunt of health care delivery for homeless persons, a burden expected only to increase, it is rare that their voices and experiences are heard or heeded.5

This study provides an overview of health care services for homeless persons in Toronto,

5 A few anthropological studies have attempted to fill this gap. See, for example: Hopper 2006; Lamphere 2005. 17 and documents providers' perspectives on health policies and delivery systems.

Including providers also ensures that the political economy framework's commitment to action is honoured, as these providers are both ardent advocates and activists.

Typically, scholarly works on homelessness begin with an acknowledgement that structural causes - housing, employment, income, and so on - are responsible for homelessness. Then it usually proceeds to tackle research questions which do not address those causes, but rather concentrate on individual risk factors or efficacy of interventions

- the symptoms of the problem rather than the problem itself (Toro 2007:8-9). This study attempts to explore some of those structural, external causes of homelessness, with a specific focus on health policy and its effects on delivery and access within Canada's universal health care system.

Political economists have been at the forefront of critical analyses of health reforms. These works have focused on the impact of those reforms within the health care system itself and on the persons receiving and providing those services. Many of the conclusions drawn about impacts on the poor and indigent can certainly be extrapolated to encompass homeless persons, even if not explicitly mentioned. Again, however, individuals who are homeless - because of their housing status - have some health issues, health care needs, and service access barriers which are different from those of housed impoverished patients receiving care within the mainstream system. By not explicitly naming those differences, and by focusing solely on traditional health care institutions like hospitals and clinics, we are failing to understand the impacts of health care reforms

18 on the rapidly growing number of people experiencing literal homelessness, or on the providers caring for them. Targeted attention toward this population also raises additional questions. For example, because so much of the impact is borne by community agencies, services, and providers who make up the social support network for these individuals, we are able to ask about what that impact looks like. Is the development of increasingly targeted health services for homeless people within

Canada's universal health care system simply an indication of the failure of the health care system to fulfill its mandates? Or are they an appropriate response to those persons who will require care outside the mainstream system regardless of how comprehensive the mainstream system is? This study will provide greater insight into these missing impacts of health care reforms.

Ie. Outline of Chapters

The subsequent chapters expand on the key elements of the study content briefly reviewed in this one. Chapter 2 provides a context for ensuing discussions, describing how a political-economy framework assists in understanding the forces shaping global health disparities, the volume and nature of homelessness, the relationships between housing and health, and the health care system reforms which have driven the need for homeless-targeted services. Chapter 3 explains and justifies the case study approach, and describes the sources of information used for this study. Findings from the study are presented in Chapters 4 and 5. Chapter 4 is an overview of where homeless people

19 access health services in Toronto, drawing attention to the experiences and frustrations of those providing these services in both hospitals and the various frontline organizations.

The intent here is to better understand how changes in Canada's health system have uniquely affected the providers who are addressing health care needs of homeless persons. Chapter 5 describes the origins of the Homeless Infirmary, the individuals it serves, and the role it plays in the continuum of health care services available for

Toronto's homeless persons described in Chapter 4. Drawing on program data, and interviews with both providers who have referred people to the Infirmary and key informants, the perceived and actual impacts of the infirmary services on individuals caring for homeless persons in both hospital and community settings are explored.6 This chapter also includes an assessment of the pros and cons of targeted homeless services within Canada's universal health care system, and general observations about the future of health care provisions for this population based on the study findings. The final chapter synthesizes the material described in the previous chapters.

6 Throughout this document, the words patient and client are used interchangeably. 20 CHAPTER II

POLITICAL ECONOMY AND HOMELESSNESS, HEALTH, AND HEALTH DELIVERY SYSTEMS

A critical political economy perspective guides this study, funnelling the questions I ask and providing the prism through which I understand the potential responses to those questions. Endorsement of this perspective means I am exploring homelessness and health care as inextricably linked to the political economy, which refers not just to political and economic systems, but also encompasses social, physical, ideological and cultural systems (Armstrong and Armstrong 2003:5). It also enables an analysis of events and phenomena as these systems alter through time (Coburn 2001).

This study focuses specifically on a program in Toronto, Ontario, Canada which provides acute medical care to homeless persons who are too ill to recover on the streets or in an emergency shelter, but are not ill enough to stay in a hospital. Yet this program is responding to a need which has been articulated in just the past decade or so not only in

Toronto, but in communities throughout Canada, the United States, and Europe within a variety of health systems. The specific historical, political-economic context illuminates why this need has surfaced only recently in these countries.

Key to this context is the rise of global capitalism and its attendant neo-liberal ideology, a resolute belief that markets and competition centered on the drive for profit are the best solution to meet all human needs, including health. This translates into

21 health provision where the market sources most services for most people, while those who cannot afford to pay are left to the mercy of ever-diminishing safety nets. This

chapter begins with an overview of global trends and the neoliberal ideas and policies

supporting them, which together are exacerbating health disparities throughout the world by killing impoverished people, eroding social safety nets, and emphasizing cost-

effectiveness and privatization in the health care marketplace (Coburn 2001). Then I

speculate on how some of those trends are influencing the volume and demographics of the homeless population, affecting their health and health service use patterns, driving the

need for infirmary services, and obscuring power dynamics within the provision of health care.

Ha. The Political Economy of Health Disparities: Neoliberal Globalization Trends

Biocommodities and biomarkets - markets for organs and babies - are perhaps the most dramatic and gruesome examples of transnational processes by which impoverished individuals trade in their long-term health to improve that of the wealthy.

But there are many other examples of ways in which neoliberal globalization is harming the poor in pursuit of growth, and of the increased impact of transnational corporations in defining and determining health, leaving the poor in its wake (Conrad 2005; Kim et al.

2000; Nguyen and Peschard 2003; Petchesky 2003). Understanding and describing these trends is an important first step.

22 Several global trends directly affect health care disparities of the world's populations, and are setting the stage for a new wave of theoretical inquiries into how these disparities are produced and sustained, who experiences them and how they can feasibly be diminished. While virtually no consensus exists as to what "globalization" means or includes, most agree significant expansion is underway in the span of social networking and in the complexity and intensity of global interactions - economic, political, military, technological, ecological (Evans 2002:207). While many benefits of globalization are lauded - access to ideas, foods, goods, and technological advances -it is increasingly evident these benefits are not equitably distributed.

The World Health Organization, formerly the conscience of global health, "lost its way in the 1990s," crumbling under lax leadership and rumors of corruption (Garrett

2000:9). The World Bank, among others, stepped in and, by 1997, was the biggest public health funder in the world. It has remained the most powerful institution setting global and national health policy agendas. A detailed account of how these neo-liberal organizations of the international economy are oppressing the poor is beyond the scope of this discussion, but some examples are illustrative. International organizations like the

World Bank and the International Monetary Fund (IMF) impose:

demands that poor countries reduce their social budgets (for instance, draconian cuts in spending on education or health care); bans on government protection of domestic manufacture for export; the weakening of unions and other protections for workers; insistence on instantaneous, electronic flows of speculative capital in and out of countries (often destabilizing smaller economies); agreements permitting transnational

7 For a review of globalization as a contested term, see: Conrad 2005. 23 corporations to sue countries for impeding their pursuit of profit; and so on (Hilfiker 2005:412). 8

The disastrous impacts of the International Monetary Fund's "Structural

Adjustment Programs" (SAPs) on the poorest Third World nations have been especially well-documented. Critics assert these programs "perpetuate and even intensify poverty", eroding social safety nets for education, health, housing, social security and welfare and disproportionately allotting benefits to the wealthiest within the nations' populations

(Evans 2002; Kolko 1999).9 Though gone now, and subsequent attempts have been made to address their fallout, SAPs nonetheless serve as an ominous example of the potential long-term effects of these organizations' methodologies.

Both the WHO and the World Bank allocate health sector spending under the presumption that resources are scarce and allocation must occur within fixed budgetary parameters, presumptions repeatedly challenged by critics of global capitalism who question not only the distribution of resources but the notion of scarcity itself (Bauman

2004; Farmer 2005; Garrett 2000; Gruskin and Tarantola 2001; Petchesky 2003).

Resources are actually less limited than ever before, they assert, but are simply not available for the poor. David Coburn notes, "We are not living in a world of scarcity, but in a world in which resources are radically maldistributed relative to need" (Coburn

2006:67), while Hilfiker is more direct, calling assertions of "limited resources... nothing

8 See also: Price etal. 1999. 9 Petchesky describes methods used to overcome the failure of the SAPs. She also discusses other changes underway in these organizations, some hopeful on the surface, but warns they will continue to perpetuate these same inequalities (Petchesky 2003). 24 more than a euphemism for injustice" (Hilfiker 2005:410). Cost-effectiveness arguments are frequently used to justify inequalities in access to biomedical care. For example, the World Bank touts universal access to basic health services, but champions privatization measures for doing so; that is, it assumes all people but the poorest can pay for services in the market and the rest can rely on a safety net, which in turn is resource- poor and unable to achieve the same standards and benefits for those it serves. Rosalind

Petchesky explains: "Supply and demand, profits or their absence, become the ethic governing distribution, rather than principles of human rights and social inclusion"

(Petchesky 2003:151); but anthropologist/physician Paul Farmer puts it more bluntly:

"Cost-efficiency means it's all right to treat poor people, but only if they can pay for it themselves" (Fanner 2005:25). Reliance on cost-effectiveness and privatization to meet basic health care needs in the absence of mechanisms for public accountability, means there is no way to ensure standards of quality, universal access or nondiscrimination.

Instead, these strategies end up "managing, rather than challenging, inequality" (Farmer

2005:226)[See also (Price, Pollock and Shaoul 1999)].

Transnational corporations have unprecedented control over and impact upon the health of the world's populations. The mounting concentration of capital in private corporations is enormous: "more than half of the world's 100 largest economies are corporate conglomerates, not nation states" (Petchesky 2003:137). As governmental roles

10 As of this writing, soaring food prices have created an unprecedented global food crisis. An article in the Globe and Mail cited an International Monetary Fund managing director Dominique Strauss-Kahn as saying, "If food prices go on as they are today, then the consequences on the population in a large set of countries, including Africa, but not only Africa, will be horrific," though the concern has not translated into pledges for food aid (Carmichael 2008:Al). 25 and responsibilities are delegated more frequently to non-state actors, including health insurance companies, health management organizations, and the pharmaceutical industry, the implications for health inequities can be severe. Of special concern is that

"accountability for what they do, do not do or should do about people's health is poorly defined and inadequately monitored" (Gruskin and Tarantola 2001:17). One author describes the expanding role of multinational corporations in health this way:

multinationals are more than agents of economic change whose decisions are increasingly affecting the distribution of wealth, the fabric of society and the creation of conditions favourable to advancing health; they are also increasingly the institutions called upon by political and social forces to create and operate alternative mechanisms to extend health and social services and to make available new and affordable vaccines and drugs (Gruskin and Tarantola 2001:18).

Pharmaceutical and biotechnology industries have long been associated with medicalisation, but with increased power they are now a driving force. It is now common for these corporations not to simply market their wares, but to market diseases and then sell drugs to treat those diseases (Conrad 2005:6). Male impotence, social and generalized anxiety disorders (SAD and GAD), and attention deficit hyperactivity disorder (ADHD) are among the more well-known examples of this phenomenon.

Sociologist Peter Conrad describes not just biotechnology but also managed care organizations and wealthy consumers as increasingly powerful mechanisms of medicalisation, saying: "the engines of medicalisation have proliferated and are now driven more by commercial and market interests than by professional claims-makers" and warns medicalisation will only increase with globalization (Conrad 2005:10-11).

26 Tuberculosis (TB) provides an especially grim example of how the market fails the poor.

TB is currently one of the leading infectious causes of adult death in the world, and it disproportionately afflicts the poor. Pharmaceutical companies have expressly refused to develop new drugs to combat the disease - the last new treatment is over 30 years old - because they would not recover the costs of drug development (approx. $244 million) from poor countries with few resources and without the property rights laws to prohibit cheaper generic products from entering the market (Farmer 2005:305, footnote 7).

Similar tales can be told for other major diseases disproportionately afflicting those living in poverty. All are indicative of the potential impact these corporations have on creating and exacerbating health disparities among the world's populations.

Linking globalization processes directly with health impacts is complicated, at best, and rife with methodological problems. To name two major ones, there are "lag- time" problems, such as determining whether health gains are a result of previous periods of domestically oriented economic policy, or of their embrace of globalization; and "lead- time" problems, determining how a current embrace of globalization may affect health- related environmental damage. Too, the range of health outcome measures is enormous, historic health data in many countries are weak, and national-level comparisons mask critical sub-national or sub-population health gains and risks.11

What is clear, however, is that world poverty and the gaps between rich and poor within and among countries are persistently increasing (Petchesky 2003:137). As the rich

11 Some of the methodological complexities, and a framework to address them, are described in: Labonte et al. 2005b. 27 get richer, so too are they getting healthier and living longer relative to the poor (Coburn

2001). Some forays into understanding the effects of globalization indicate these patterns

are likely to continue. The Center for Economic and Policy Research presented a globalization scorecard comparing 1960-1980 with the "hyper-globalizing" decades of

1980-2000 and found a clear decline in progress post-1980 in almost all countries both in per capita income growth and standard public health indicators like life expectancy and mortality. Other reports corroborate these findings, citing that some of the poorest countries have experienced not just declines but in some cases reversals in mortality rates. In Zimbabwe, for example, a doubling of maternal mortality was linked to newly imposed user fees for public health services in that country (Petchesky 2003:138-139).

Tony Evans concurs that evidence is mounting that globalization "will lead to greater levels of disease that is preventable and avoidable" and notes the World Health

Organization estimated "nearly a quarter of disease and injury" were directly linked to environmental degradation and decline attributable to globalization (Evans 2002:208).

Over 30 infectious diseases have been seen in humans for the first time in decades as a result of globalization, including HIV/AIDS and sexually transmitted diseases. Diseases thought to have been contained for decades have recurred in epidemic proportions, such as the Peruvian Cholera epidemic in the early 1990s; and, diseases previously known only to specific regions have appeared in distant locations - such as the West Nile virus outbreak in New York in 1999. Without exception, these deleterious impacts on health

12 Evans discusses these ramifications and specific examples in: Evans 2002. For more extensive reporting, see: Farmer 2005; Garrett 2000; Kim et al. 2000. 28 brought on by globalization are both racialized and gendered. Women and visible minorities are not only overrepresented among the world's impoverished, but have less access to income earning opportunities and other resources - thus increasing dependence on others for long-term security. Access to and use of health services are also influenced by cultural and ideological factors, such as low value of health needs of women and girls compared with men and boys in some countries (Pederson and Raphael 2006; Petchesky

2003:139-140; Wermuth 2003:11 Off).

Globalization also has disastrous effects on public health infrastructures to contain and cope with these realities. Several recent books have focused attention here. Laurie

Garret's book Betrayal of Trust documents the harrowing effects when collapsed infrastructures collide with pneumonic plague in India, the Ebola virus in Zaire, tuberculosis in the former Soviet Socialist Republics, and bioterrorism in the United

States. Paul Farmer shares case studies from Chiapas, Guantanamo, and the former

Soviet Union in Pathologies of Power; and Jim Yong Kim and co-authors report on

1 "\

Guatemala, Zaire, and numerous other nations in Dying for Growth. All of these case studies document both the immediate impacts of failing public health infrastructures, and portend dire, long-term and far-reaching implications as well.

One consequence of these global trends is an erosion of collective responsibility.

As boundaries between societies and cultures fade, so too do the clear distinctions

For an interesting exchange about the methodology used in Kim et al. 2000, see: Butt 2002; Irwin et al. 2002. 29 between the public/social and the private/individual. Petchesky comments on the

implication:

... with the demise of that distinction comes, not only the vulnerability of individuals and communities to constant... invasion and scrutiny, but also the converse: the disappearance of ...a sense of public obligations and social rights concerning the health and well-being of people and their environments (Petchesky 2003:136).

Public obligation thus becomes relegated to charity. Janet Poppendieck calls the

"resurgence of charity... at once a symptom and a cause" of society's failure to address inequality, a symptom because it signifies an "abandonment of our hopes for the elimination of poverty" and represents a turn away from prevention to one of damage control [cited in (Farmer 2005:154)]. The public sector is left to tend to the vulnerable populations but with fewer resources (Price et al. 1999).14

lib. The Canadian Context: An Eroding Infrastructure

Esping-Anderson's delineation of countries according to type of welfare states helps to explain national differences in response to these common international pressures

(Coburn 2001:51ff). Internationally, liberal welfare states, including Canada, the United

Kingdom and the United States, are aligned according to the degree to which their welfare states 'decommodified' citizens' relations to the market, the extent to which citizens' access to social resources was not wholly determined according to market criteria. Within liberal welfare states, social policies are "generally designed to

14David Coburn has argued that, in the case of health care and welfare, globalization may be having less of an effect in Canada, which is more affected by its economic dependency on the United States, its dominant bilateral trade partner. See: Coburn 2004. 30 supplement market provision, to reflect participation in the market, or to be targeted or

'means tested' rather than universal in application" (Coburn 2001:55). These countries tend to have lower overall health status than social democratic welfare states, but Canada has been an exception because of its publicly popular, universally accessible health care system. As one author put it, "globalization presented] for Canada a profound challenge to the previously prevailing social consensus" (Shields and Evans 1998:31). Continued neoliberal economic policies, however, have threatened its relatively high international standing in health status both by increasing social and income inequality among and between groups of Canadians, and by undermining social welfare measures such as medicare which may have ameliorated the effects of these inequalities on health status

(Coburn 2001:59).

Cuts to housing at the national level started in earnest when the Progressive

Conservative Mulroney government cut nearly $2 billion from housing funding between

1984-1993; in 1993, all new funding for social housing was cancelled. The Liberals elected in 1993 did not carry through on their promise to fund new social housing, and in

1996 announced plans to download social housing programs to the provinces and territories. This decision made Canada the only developed nation without a national housing plan. As one observer commented on this development:

It was never imagined that a system that had taken 50 years to build up could be dismantled so rapidly. Social housing policy in Canada now consists of a checker-board of 12 provincial and territorial policies, and innumerable local policies. It is truly post-modern (Wolfe 1998:131).

31 Income polarization also rose rapidly in these "hyper-globalization" years in

Canada. The income of the poorest 20% of the nation's population fell over thirty percent from 1984-1993, while income of the wealthiest increased 5.2 percent (Shields and Evans 1998:96). Another sign of growing social deprivation was the fact that food banks, responding to the rapidly growing number of Canadians experiencing hunger, were "one of the fastest growing businesses in the country" through the 1990s (Shields and Evans 1998:96).

These national trends were especially marked in Ontario, where Mike Harris, the

Premier of Ontario from 1995-2002, and his Progressive Conservative government, made particularly aggressive cuts to housing and social services. Harris' neoliberal "Common

Sense Revolution" policy platform espoused reducing taxes, balancing the budget, and shrinking the size and role of the provincial government. It also emphasized individual economic responsibility, typically interpreted as an opposition to government hand-outs.

One author described the rhetoric this way:

In images of the Common Sense Revolution, there are no barriers to access, no predisposing conditions behind poverty, unemployment and crime. The invisible poor or coloured deserve their state because they have not worked hard enough or assimilated (Trickey 1997:114)

Another put it more succinctly when she said, "The Ontario Tories have declared open season on the poor and fired the first shots" (Lalonde 1997:102)

When the Harris government moved to repeal the Employment Equity Act in

1995, just two years after it had been enacted, it withdrew hard-gained support for women, Aboriginals, racial and ethnic minorities, and the disabled to gain representation

32 in the labour force. More importantly, perhaps, it countered the intent and spirit of the previous legislation, which "recognized racism as a systemic rather than individualized component of Ontario society" (Trickey 1997:115).

The Harris government's slashing of affordable and supportive housing is today largely blamed for the rapid growth in the city's homeless population. In 1995, Harris cancelled 17,000 units of co-op and nonprofit housing, which were to house 40,000 people, as well as new funding for social housing (Crowe 2007a). A few years later, in

1998, the "Tenant Protection Act" replaced the Landlord and Tenant Act, the Rent

Regulation Act, and the Rental Housing Protection Act. This new Act effectively eliminated rent controls on vacant private rental units, and threatened security of tenure for many tenants by creating a financial incentive for landlords to encourage lower-rent tenants to move out. In Toronto as elsewhere, this meant sharp rent increases: between

1997-2000, rent for a bachelor apartment rose 23.5% (Mahoney 2001:4). Wage increases generally did not keep pace, and shelter allowances were not increased. In early 2007, the Residential Tenancies Act replaced the Tenant Protection Act, but perpetuates the system of vacancy decontrol. Though the now Act has made some positive improvements, it is "not the panacea or paradigm shift that tenant advocates had hoped"

(Truemner 2007:11).

The impact of these decisions is profound. A "Housing and Homelessness Report

Card" from Toronto, Ontario, declared that: "The housing and homelessness crisis in

Toronto is largely the cumulative result of public policy decisions such as these" (City of

33 Toronto 2003:3). In 2007, approximately a quarter of the city's population lives in poverty, social housing waiting lists span over multiple years, and food bank use and emergency shelter occupancy is at an all-time high (Canadian Public Health Association

1997; Street Health 2007a). A 2007 report showed Torontonians can expect to wait one to five years for a bachelor unit, and up to ten years for a one-to-five bedroom home.

One-fifth (19%) of the Toronto Community Housing Corporation's applicants have been waiting more than five years; as of December 31, 2006, 67,083 households in Toronto were on the wait list for social housing. The nightly count of people sleeping in homeless shelters more than tripled between 1990 and 2006 (Street Health 2007a). 5 The impact is harshest for visible minority groups. For example, decreases to shelter allowance increased the potential for landlords to discriminate against non-white social assistance recipients, and made it easier to ghettoize racial and ethno-cultural groups in subsidized housing.

Ontario also cut social assistance benefits by 21.6% in the mid 1990s, replacing the Family Benefits Act and the General Welfare Assistance Act with the reduced, income/contribution contingent "Ontario Disability Support Program (ODSP)" and

"Ontario Works." This re-crafting of the program marked a "significant reversal of the direction of welfare reform" from the preceding decade (Moscovitch 1997:80). Under the existing federal Canada Assistance Plan (CAP), provinces had not been permitted to

15 As the number of individuals living on the streets and camping in public spaces grew, the response was to "clean up" the city. In 2000, the Ontario Safe Streets Act was passed, prohibiting offences such as begging and subsistence activities (e.g. squeegee kids), and in 2002, residents of a large homeless community called "Tent City" were evicted. For more information, see: Bridgman 2003; Crowe 2007a. 34 make receipt of assistance contingent upon work for employable recipients. Harris overturned CAP's key principles when he introduced obligatory workfare and learnfare programs requiring the "able-bodied" to work or be retrained in return for benefits. In effect these and other changes made many individuals and families ineligible for aid, and cut aid for even more. As one social assistance expert in Canada remarked, "There was no mistaking the government's intention to reduce spending at the expense of the poor"

(Moscovitch 1997:87). These decreased, more narrowly defined funds were also made tougher to apply for and obtain. Currently, the funds available through ODSP are insufficient to cover suitable housing as well as other expenses.16 These initial, massive cuts to housing and income have clearly frayed the public health infrastructure and driven up the number of people struggling to survive. An art exhibit which graphically tracked

Ontario's welfare income for a single person against the number of homeless persons who had died on the streets of Toronto for 1985-2006 shows a marked increase in deaths starting in 1995, a telling indication that not all those affected were managing to survive.

The persistent emphasis, however, is to manage - not challenge - the resulting inequalities. Modifications to the "Special Diet Supplement" to ODSP provide a grim illustration of the continued entrenchment of neoliberal values, which perceive humans as commodities. When it was the Family Benefits program, this supplement provided a

16 The application process is especially problematic for individuals who are homeless, given it requires identification and financial documents, access to health care providers to assist in determining their eligibility, and self-reliance and the capacity to follow-through. See: Street Health 2007b. 17 Several authors have pointed out the irrationality, and negative consequences of, equating health care with other market commodities, subject to the same market discipline forces. See: Armstrong and Armstrong 2003; Williams et al. 2001; Rioux 2006. 35 critical income boost above shelter and basic needs allowances for social assistance recipients requiring a special diet due to a medical condition. Individuals accessed the special diet supplement by having medical practitioners indicate a need for it by checking a box on a form. In late 2006, the requirements for the supplement changed: instead of checking off a box next to a list of special diets, the practitioner must identify the specific medical condition responsible for the dietary need. Each condition is equated with an amount of money; for example, verification of liver or cardiovascular disease is valued at

$10/month. Those with unlisted conditions are ineligible for the funds. Even more harrowing is that the amount one qualifies for is dependent upon the percentage of usual body weight which has been lost due to the medical condition. For example, an individual with HIV/AIDS can qualify for $75-240 per month, with the amount dependent on where he/she fit into categories like "weight loss > 5% and < 10% of usual body weight."18

As social safety net cuts coincided with increases in numbers of people experiencing social exclusion, it was the "third sector" - nonprofit, voluntary organizations serving the public interest - that was expected to pick up the pieces. But rather than bolstering this sector to do so, their capacity to address the need was also greatly diminished. An analysis on the effects of government cutbacks on Toronto's social services agencies revealed not just a pattern of increased demand for services, but agency and program closures and cuts and increased levels of stress (Shields and Evans

Individuals are also required to disclose medical conditions for the first time, including HIV/AIDS. 36 1998:95). For example, in Toronto between 1995-1996, 54 social service agencies were closed down, compared with just seven in the two years prior, and in 1996 nearly four out often were threatened with possible cancellation (Shields and Evans 1998:95). The cuts had the most significant adverse effects on the most vulnerable groups, including women, ethno-cultural groups and low-income families.

As noted earlier, the deleterious effects of globalization are racialized, and

Canada's population, one of the most racially and ethnically diverse among nations, is not immune to those effects. Data released from the 2006 Census reported that the

"visible minority" population in Canada comprised 16.2 percent of the total population, and was expected to increase (Fenlon 2008). This population represents over two- hundred different ethnic groups. Toronto, Ontario, had the highest concentration, with

46.9% of its population comprised of visible minorities. The racial diversity and complexity of Canada, or of Toronto's downtown population, is not reflected by current racial policy and politics, and can be attributed at least in part to neoliberal origins, which has promoted a false universalism, masking underlying racial relations and conflicts, and muffled voices in the dialogue about race (Omi and Winant 1994). For example, one author traced the impact of global capitalism on the ways in which the government legitimated the 1988 Multiculturalism Act, transforming multiculturalism into a national resource in the context of economic competitiveness and prosperity. She notes that "the cultural politics of pluralism. ..make good business sense" and asserts that in the

Canadian context, "the state did not seek to erase difference but rather attempted to

37 institutionalise, constitute, shape, manage, and control difference" (Mackey 1999:68,70.

See also: Antrosio 2005). Another author noted that while Canada embraces globalisation and "romanticizes cultural diversity... persistent expressions of xenophobia and racial marginalisation ... suggest a continuing political and cultural attachment to the concept of a white settler society" (Galabuzi 2001:3).

Research has repeatedly demonstrated that an emphasis on the market as arbiter of societal values and resource allocations fosters income and wealth inequalities, weakens social infrastructure, dissipates social cohesion, and threatens civil society (Doyal and

Pennell 1979; Navarro and Muntaner 2004; Raphael 2006b). These findings have played out vividly in Toronto. More specific impacts on health care delivery and programs serving homeless persons are addressed in chapter 4.

lie. Defining Homelessness: Who's in and Who's Out?

Throughout history, cultural and economic factors, and political mobilization have determined who and what gets expressed as homeless. Definitions reflect dominant ways of thinking about social problems, and efforts of advocates and interest groups to shape public perceptions (Hopper 2003:15). Indeed, one can readily see the wisdom in anthropologist Kim Hopper's suspicion that: "seeking to impose order on the hodgepodge of dislocation, extreme poverty, migrant work, unconventional ways of life, and bureaucratic expediency that have, at one time or another, been labelled homeless, may

38 well be a fool's errand" (Hopper 2003:17-18). Yet order and classification is precisely what is demanded within a capitalist system.

Definitional quandaries plague policies and programs which strive to target and count homeless populations. The mobility of the homeless population, the desire not to be counted or labelled as homeless, and the fluidity of the experience of homelessness which is frequently marked by temporary stays with friends or family, all conspire to make a homeless count nearly impossible (Institute of Medicine 1988; Toro 2007). As a social determinant of health, housing must be characterized as adequate, suitable, and affordable19 (Murdie 2005:2). A definition of homelessness, then, needs to include individuals living in unsafe and temporary housing, and those at-risk of becoming homeless due to violence or an inability to pay rent. This all but assures that counts of homeless populations will fall far short of reality; nevertheless, for a mix of methodological, cultural and political reasons, point-in-time estimates (used to inform policy and funding allocations) and research (relied upon to describe the problem) operationally define homelessness as an experience of those living in public spaces or using targeted homeless services, primarily in metropolitan areas (Fitzgerald, Shelley and

Dail 2001). These popular definitions of homelessness also mask what we know from

19 Canada Mortgage and Housing Corporation (CMHC) identifies these as the three components in its Core Housing Need model. Adequacy refers to the physical quality of the dwelling. Suitability is the appropriateness of the dwelling for the size and type of household. Affordability is the maximum proportion of before-tax income that a household should theoretically spend on shelter. When households fall below a minimum standard of housing as defined by CMHC, and cannot afford to rent housing locally that meets these standards, they said to be in core need (Murdie 2005). 20 The City of Toronto defines homelessness to include these populations: "a condition of people who live outside, stay in emergency shelters, spend most of their income on rent, or live in overcrowded, substandard conditions and are therefore at serious risk of becoming homeless"(City of Toronto 2003). 39 longitudinal studies of homelessness, that it is an episodic and transient experience for the

large majority (Hopper 2003), and that it holds different meaning for different cultural

and ethnic groups (Native Women's Association of Canada 2007:3; Zerger 2004:10). Not

only does this mean we are underestimating the population experiencing housing

problems, it also means our ideas about who is more likely experiencing homelessness

91 and what that looks like are warped.

In Canada, the first attempt to enumerate the homeless population coincided with the 1987 International Year of Shelter for the Homeless, when the Canadian Council on

Social Development conducted a national survey of agencies serving homeless persons.

In 1991, Statistics Canada used an analogous strategy, but later deemed the data to be of

"mediocre quality" and did not publish it (Casavant 1999). The Government of Canada

subsequently told the UN Committee that "the data obtained in these enumeration

attempts were neither reliable nor representative;" indeed, the only information the

federal government shared with the Committee was that just under 26,000 people had used the shelter network in Toronto in 1996 (Casavant 1999).

Public perceptions and policy initiatives focus on those who are "visibly homeless" - sleeping in emergency shelters or unfit public locations, and the implications are profound (Frankish, Hwang and Quantz 2005; Whitzman 2006). A very popular initiative, called Housing First in the US and translated as "Streets to Homes" and

21 The European Federation of National Organizations Working with the Homeless have developed a typology of homelessness which confirms it as a process. The typology includes four categories: 1) Roofless (living "rough" on the streets) 2) "Houseless" (a place to sleep, but temporary - in institutions or shelters) 3) "Insecure Housing" (housing is threatened due to insecure tenancies, eviction, domestic violence) 4) "Inadequate housing" (illegal campsites, unfit housing, extreme overcrowding) 40 "Hostels to Homes" in Toronto, provides a useful example of these implications. This

initiative targets the "chronically" homeless, individuals who have been identified (by a

researcher, using shelter residents as the sample) as high service - that is, costly - users.

The premise behind the initiative is solid: it helps people access and sustain permanent,

affordable housing while receiving services, rather than withholding housing until they

are declared "housing ready." Though relatively new to Canada, this approach in the US

has guided expenditures by the Housing and Urban Development department and other

federal government streams, and over 200 cities to radically re-evaluate their homeless

policies (Gladwell 2006; Pearson et al. 2007). Its popularity is attributable to two factors,

both of which resonate specifically within a capitalist, for-profit system. For one, it

removes visible, unsightly homeless people from view - off the streets and the front

doorsteps of businesses, where their presence and behaviours, like panhandling, are bad

for business. And, targeting the "chronically hard-to-serve homeless" populations, which

are the highest service-users, makes economic sense. The overt Toronto City Council

strategy is to "end street homelessness," so the evaluation of the strategy expressly targets

reduction in use of costly services and increase in use of "appropriate health services",

and reductions in panhandling. Without doubt this is also an appropriate and humane

solution for some individuals, yet the rhetoric supporting the solution is used both to justify the new initiative over existing, effective initiatives and the dismantling of shelter

beds, drop-in services, meal programs, and so on, which serve both immediate and

preventive needs. The money "saved" by this initiative has not been transferred to

41 effective community programs; actually, the reverse has occurred. And, of course, the

cost calculations do not take into account the non-chronic homeless populations who are

not targeted by the program or the vast numbers of "hidden" homeless persons (described

more below), nor do they consider the long-term social costs associated with the

dismantling of the safety net services which are serving those non-chronically homeless populations and preventing persons at-risk from becoming homeless. Most critically, this initiative effectively defines homelessness so narrowly as to isolate it from the issue

of poverty altogether.

Aid discourse in general obscures historically specific, political and economic

interests. A political-economy framework acknowledges that "class, gender and race are not simply indicators of individuals' characteristics as much as markers of the power

individuals within particular groups have within society" (Raphael 2006a: 127). These

are concrete models of hierarchy that greatly influence social determinants of health, and poverty exacerbates every dimension of inequality (Pederson and Raphael 2006; Raphael

2006b). Homeless-specific policy discussions and decisions like the Streets to Homes housing initiative, and the choice to rely upon methodologies known to be inadequate and

flawed, are not neutral or free of subtext. Use of labels like "the homeless" or "clients"

serve both to institutionalize dominant ideas about social relationships and social

22 Drop-in Centers provide social interaction, meals and other basic services that prevent many underhoused individuals from being on the streets. Similarly, meal programs provide much-needed sustenance for individuals barely able to make rent payments from becoming homeless. In Toronto, a range of other concerns have emerged; for example, the short-term funding commitment to the Initiative means many of those individuals who access housing will not receive the level and duration of follow-up services necessary to maintain that housing over time. 42 structure, and to legitimize aid for some while de-legitimizing it for others (Nelson

2005:109). These non-specific references mask, rather than address, specific socioeconomic barriers that women and ethnic minorities face, such as inequitable pay.

"Through this legitimizing effect, aid discourse obscures the interests and intentions of powerful social actors and reinforces the perspective that aid and the need for it are non- political issues" (Nelson 2005:109).

From existing counts and research samples of homeless populations we know males outnumber females by nearly 4:1 in some cases, even though females are more apt to experience poverty (Pederson and Raphael 2006; Toro 2007). A recent

"representative" sample of homeless individuals surveyed in Toronto's homeless shelters and meal programs, for example, included 73% males. A majority of females experiencing homelessness, as well as any dependent children in their care, are "hidden."

Feminists have provided a gendered perspective on homelessness in English-speaking developed countries since the mid 1980s offering reasons for this. For example, women have differences in comfort levels with emergency shelters from men, due primarily to concerns about safety of themselves and their children (Daiski 2007). Homeless women with children in their care may also be unable to find shelters in proximity to schools, or which can accommodate all of their children (e.g. teen boys are not typically allowed in women's shelters). The fact that physical abuse by male partners is a major pathway to women's homelessness also profoundly affects their experiences with homelessness and

43 their options for exiting it. However, it was only recently that the "ready availability of shelters for battered women, coupled with a feminist campaign against tolerance for domestic violence, led to the emergence of a new species of need from behind the scrim of homebound privacy" (Hopper 2003:17). Our understanding of the experience of female homelessness is gradually deepening, to address not only the severe underestimation of the number of homeless women, but the unique emotional, mental, spiritual, and physical impacts of homelessness on their lives (Kappel Ramji Consulting

Group 2002; Whitzman 2006). We also know there are more women among Aboriginal than non-Aboriginal homeless populations, especially those living outdoors homeless, but are only beginning to understand and describe - let alone address - their needs (City of

Ottawa 2005; Native Women's Association of Canada 2007). On the whole, women - and their dependent children - can be counted among those largely ignored within a system prioritizing the visibly homeless.

We have a more limited understanding of the experiences of different racialized groups who are homeless, though clearly racial hierarchies persist through even the most extreme poverty. An international review of homelessness completed in 2007 found that

"everywhere, stigmatized and excluded groups are more likely to become homeless;" samples of homeless persons have consistently found overrepresentation of racial and ethnic minority groups (Shinn 2007:664). The author attributes this to four mechanisms of social exclusion: disparities in employment; historical discrimination in jobs, housing,

Most homeless counts and research samples exclude domestic violence shelters, for example. 44 and credit markets; discrimination in the housing market; and higher incarceration rates

(Shinn 2007:664-667). As noted earlier, a key outcome of this "de-racing" of homelessness in official public discourses signifies a move away from structural, racist structures, "enacting in their place a neoliberal individualization at the level of both explanation and remedy (Kingfisher 2007:102)."

In Toronto, these mechanisms are directly correlated with racial minority groups.

For example, new immigrants and refugees have been formally labelled a "high-risk" subgroup which requires special strategies for homelessness prevention as early as 1992, a notion reiterated in a 1999 report on homelessness (Forum Summary 2003).

Subsequent studies have shown that they comprise large proportions of "hidden homeless" populations. Of those arriving between 1996 and 2001, one-third were identified as being in core housing need by the Canada Mortgage and Housing

Corporation. One author relied upon a variety of data sources to conclude that the racialisisation of poverty is manifest in Canada's large urban centres, and that one aspect of this "creeping economic apartheid" is an increasingly segregated housing market wherein "racialised groups are relegated to substsandard, marginal, and often overpriced housing," which leads to higher health risks, barriers to services, and contact with the criminal justice system (Galabuzi 2001:7) Discriminatory practices based on skin color play an important role in the successful search for rental housing, especially for visible minority groups in a tight rental market in which a landlord can choose from a large number of applicants for a vacant apartment (Murdie 2005; Shinn 2007; Trickey 1997).

45 A summary from a forum on immigrants, refugees and homelessness in Toronto in 2003 noted:

for immigrant, refugee and racially marginalized, diasporic communities, access to stable affordable housing occurs at the nexus of a variety of social, cultural, economic and political factors. These factors represent interlocking forms of oppression based on race, class, gender, sexuality, religion, ability and mental health status (Forum Summary 2003:2).

The large extent of hidden homelessness among these populations was a common theme throughout the forum, and a key recommendation was the need for further research on specific experiences of these groups.

On the other hand, Aboriginal peoples are disproportionately represented in homeless samples in Toronto - and in Canada generally; they comprised 15% of the recent Toronto street sample described above, though they make up just .5% of the

Toronto population (Street Health 2007). Key causal factors for these differences trace to a historical legacy of racist policies such as removal of communities from land occupied by ancestors for thousands of years onto reserves, and loss of language and identity, in part through assimilation policies such as the residential school movement which continued until the early 1980s (City of Ottawa 2005:35; Wente 2000).24 Increasing numbers of Aboriginal persons have migrated from reserves to seek economic opportunities and support in unfamiliar urban centers like Toronto, and for many, seasonal and cyclical migration patterns only compound the instability in their lives (City of Ottawa 2005:3 5; Zerger 2004:10). Among non-reserve Aboriginal people, housing is

24 A review of literature on Aboriginal homelessness identified three features which distinguish Aboriginal from non-Aboriginal homeless groups: third world on-reserve housing, racism and discrimination, and rural-urban cyclical migration. See: City of Ottawa 2005. 46 cited as the most important unmet need, and they are far more likely than the general

Canadian population to be living in crowded housing conditions (especially children under age 14 years), or in housing in need of major repairs (Statistics Canada 2001;

Canadian Public Health Association 1997). The latter can be counted among the hidden homeless population.

It is not always clear how race articulates with other axes of oppression, namely class and gender, in the political arena, given the myriad ways in which they merge and interact. Certainly one key to understanding this would be an uncovering of the factors behind which populations are "hidden" and which have their needs addressed. Because these individuals are hidden, discussions about homelessness and race tend to be overly simplistic and not at all reflective of Toronto's diverse population. Some attention has been paid to the unique barriers faced by "new immigrants" (as a group), and some to the

"Aboriginal" homeless, but these discussions tend to occur in isolation from broader policy discussions about homelessness. For example, city government publications on homelessness - such as the "Toronto Report Cards on Housing and Homelessness"- do not address the issue of race at all either in tracking shelter user, or income, housing and service indicators or in developing strategies to overcome homelessness. This tidily reinforces the notion of homelessness as a homogenous group, and obscures the political and economic forces creating racial differences.

47 Women, visible minorities, and others comprise large "hidden" homeless populations25 - hidden as in out of sight and out of mind - because they exist within an economic system which ensures some populations are more apt to experience poverty than others, and then, because the system defines humans in terms of labour power, makes those same populations disappear from sight and access to resources. This invisibility is not an accident, but a refusal to see. A political economy framework reveals not only the rationale underlying the way homelessness is defined and counted, but also the specific historical, political-economic context for how different groups experience homelessness, and the systemic factors which explain why some groups are

"hidden" and others are not.

lid. Health Care Delivery

The recent history of challenges to medicare in Canada as well as evidence of the declining power of professional medicine are related both directly and indirectly to the increased power of business and a decline in the relative autonomy of the state that have accompanied globalization (Navarro and Muntaner 2004:223).

Just as the existence, volume, and face of homelessness are shaped by political and economic forces, so too are the design of the health industry and the people it most effectively serves (Raphael, Bryant and Rioux 2006:3). There is broad consensus on the

Other "hidden" populations experiencing homeless include those who are living in rural areas, sexual minorities (GLBTQ), adolescents and youth, children, and families. And, as the system gets tighter and more restrictive for those at the bottom rung of the economic ladder, new populations will no doubt arise - such as those becoming homeless for the first time in old age. See, for example, McDonald et al. 2007; Stergiopoulos and Hermann 2003. 26 E.g. absence of health care costs to individual firms at times gave Canada a competitive edge over US corporations. 48 vital importance of social determinants of health, including housing, income, social support networks, education and employment, social and physical environments, gender and culture, on the health of individuals and populations. It is not only researchers who endorse the notion of determinants of health. The World Health Organization, the Public

Health Agency of Canada, and many other institutions recognize their importance and frequently employ rhetoric to that effect in policies and reforms. Nevertheless, the social determinants of health approach remains "subordinate to traditional medical and behavioural health paradigms"; political support for them is largely rhetorical (Raphael

2006b). A 2002 Canadian discussion paper synthesizing provincial and national health care reform reports over the previous five years, for example, noted that without exception the "policy goal was the same: to improve the health status of citizens through mechanisms other than the traditional health care system" (Fooks and Lewis 2002:2).

The authors acknowledge that while the theme is widely embraced in theory, "there has not been a major ... transformation of public sector activities" (Fooks and Lewis 2002:2-

3). As of this writing, "Canada has not integrated these social and economic domains into the modern organization or financing of health" (Feldberg and Vipond 2006:235).

Instead, the Canadian health care system is built on and dominated by allopathic medicine, or a medical model, which emphasizes physician-driven health care in hospital and clinic settings (Armstrong and Armstrong 2003; Feldberg and Vipond 2006). A medical model in the health delivery system is built upon assumptions which have negative impacts on health in myriad ways. It is also incongruent with the integrated care

49 model that research and clinical practice has demonstrated to be more successful in improving health of populations, and is especially at odds with needs of vulnerable persons (City of Ottawa 2005; Brickner et al. 1985; Hay, Varga-Toth and Hines 2006;

Wood 1992).27

As the quote by Navarro and Muntaner above describes, the increased power of business, and the decline in the 'relative autonomy' of the state resulted in radical reductions in government expenditures on the welfare state . Though the onset of this paradigm shift began in the early 1970s, and the introduction of the Canada Health and

Social Transfer Act in the mid-1990s effectively reduced the federal government's ability to enforce the principles of the Canada Health Act (Armstrong 2001a), privatization of health care in Ontario continued during the Harris years with unprecedented zeal. The effects on the health care system were slightly different, however, as it was not as

"radically under fire" as other social welfare measures; different, because health care provided business advantages and served as the site for powerful business interests

(Coburn 2004:237). In part to protect these advantages, and in part due to the immense public popularity of medicare, a "corporate rationalizer" approach was implemented to make it more coordinated, effective and efficient, rather than privatized, at least initially

(Coburn 2001:53; Leduc Browne 2000:7). The medical control of health care was

27 Exposure of the effects of a medical model on health is a key theme of Armstrong and Armstrong 2003. A recurring theme in the homeless health literature is the need to integrate health services, both to reduce access barriers and to provide continuous and coordinated prevention-focused health services. The meaning of the term "integrated" is wide-ranging, however, and includes: interagency coordination; co- locating services; case management approaches; and "holistic" care which is flexible, responsive, and empathetic (Whitzman 2006). 50 deemed a major barrier to this approach, so massive pressures on the medical profession, in the form of hospital reorganizations, expenditure caps, and regulations over health professions, were undertaken and diminished its power (Feldberg and Vipond 2006).

While health reforms have been carried out in the name of the overriding importance of social determinants of health, they have paradoxically reinforced the medical model. They are based on assumptions of the free market: effectiveness, efficiency, and suitability. Indeed, as one author noted, the agenda of macroeconomic market liberalization, free trade, and privatization has become accepted as so universally valid that the term 'reform' itself is used exclusively to refer to policy changes in that direction (Wade 2006:273) Limiting the role of the public sector and defining health care as a private responsibility characterize these reforms. Examples include: putting the burden of payment for health costs on individuals; expanding opportunities in health care delivery to private for-profit health service providers; shifting care from public institutions to community-based organizations and households; applying market rules to health service delivery; and treating health care as a market commodity [paraphrased from: (Armstrong, Amaratunga and Bernier 2001a:2)]. What follows are some examples of how these have played out in Ontario.

Harris's neoliberal provincial government established a Health Services

Restructuring Commission, an arms-length body of experts, to expedite hospital restructuring in Ontario and to address the "changing practices of health care delivery, and the fiscal realities of the late-1990s and early 21st century" (Sinclair 2000:1). This

51 Commission set into motion large-scale mergers, amalgamations, and closings of hospitals and hospital beds across the province, while recommending substantial funding be put into home and community care to compensate for these moves. Though the reinvestment funding continues to fall short of the Commission's estimates, the restructuring recommendations were undertaken rapidly. Province-wide, thirty-one public hospitals, six private and six provincial psychiatric hospital sites were closed, and four hospitals were taken over by hospital corporations (Sinclair 2000). And, between

1990 and 1997 alone, before the final round of hospital closings, the average length of stay dropped from 8 to 6 V2 days, and day surgery went from representing 63% to 69% of all Ontario surgeries (Williams et al. 2001).28 The function of hospitals has been redefined to be exclusively one of acute care, while "acute care has in turn been more and more narrowly defined to include only the most severe and short-term illness or injury"

(Armstrong et al. 2001a:40). This renews emphasis on the medical model. On the face of it, moving patients out of hospital makes logical sense, as many procedures done in hospitals can be carried out just as effectively on an outpatient basis. Convalescing in hospitals is "costly, ineffective, and undesirable" compared to discharging patients to appropriate care settings, yet because "hospital restructuring does not assume that rates of illness or the need for illness care have decreased (indeed, because of an aging population

28 These trends have continued apace nationally: average inpatient days have dropped steadily, and visits to ambulatory care units (clinics, emergency departments, and day surgery) almost doubled between 1976/7 and 1993/4 (from 23 to 41 million), and have progressed in a linear upward trend to over 50 million in 2002/3, indicating a "considerable amount of hospital care was transferred from inpatient to ambulatory services during the period when hospital beds were decreasing." See: Canadian Institute for Health Information 2005. 52 alone one might expect overall needs to increase), access to appropriate care in home and

the community is essential" (Williams et al. 2001:18). These restructurings have

effectively shifted the burden of health care to the home and the community,

externalizing the costs of "subacute and 'daily life care'...to the sphere of the individual, their family, and communities" (Cartier 2003, abstract; Feldberg and Vipond 2006).

The impact will be hardest for individuals who are poor, as they tend to get sick and require hospitalization more frequently than those who are more well-off; in Ontario, hospital admissions are nearly two times greater among poor people (Leduc Browne

2000:13). When individuals from all income levels have equal access to hospital care, this is not a problem, but when "shrinking hospital space forces people to seek care elsewhere, the poor are put at a serious disadvantage" (Leduc Browne 2000:13).

At the same time, Ontario's government engaged in a parallel reform of community-based long-term care. A "managed competition" model was implemented for home care to introduce competitive market forces into the sector to cut costs, achieve cost efficiency and systematize the services (Canadian Institute for Health Information 2005;

Randall and Williams 2006; Williams et al. 2001).30 Government reports stressed the

"quality of life" as well as the economic benefits of the move, remarking that people simply feel and heal better within familiar environments and supported by family and

29 It is hard not to hear echoes of those who warned that deinstitutionalization of mental health care facilities would only succeed with sufficient commensurate support to community providers; though much of the deinstitutionalization occurred prior to these reforms being discussed, it persists as a stated cause of homelessness. See: Canadian Public Health Association 1997. 30 Development of the Community Care Access Centres is an example of a shift in governance to regionalization and decentralization - in the name of effective, cost-efficient care delivery and responsiveness to local needs. Specific impacts of this, and the latest iteration (LINHs), on individuals and agencies providing homeless health care are explored in greater detail in Chapter 4 of this study. 53 friends than they do in institutional settings. Clearly this discourse is based on assumptions about "home" and "family" particular to a privileged middle class and reliant upon an expectation that women will take on the role of caregiver. Joan Anderson has commented on this, urging that the home care movement be understood in the context of "societal and health-care ideologies that stress individual and family responsibility and that are enmeshed in the notion that personal misfortunes (as well as personal successes) are individually produced" (Anderson 2001:7). The effects of home care reforms are only now beginning to be understood; for example, evidence is gathering which shows - counter to the rhetoric - it has resulted in higher per-visit costs, reduced access to services, and exacerbated problems of service provision in rural areas (Evans 1997;

Randall and Williams 2006; Skinner and Rosenberg 2006). When contemplating why the government would persist in implementing a reform failing to achieve its goals, two authors concluded: "the reform did demonstrate the government's determination and capacity to introduce private market forces into health care" (Randall and Williams

2006:1602). Leduc Browne pondered the same question several years earlier and drew a more direct conclusion: "The only answer that makes sense is that privately provided health care generates profits - enormous profits - for the companies that provide it;" governments are acting in the interests of business, not the people they were elected to represent (Leduc Browne 2000:30). Unlike medicare-insured hospitals and physician services, home care was not covered by the Canada Health Act and therefore not subject to the same legislative or political barriers (Randall and Williams 2006). So, while

54 downsizing hospitals ensured a greater portion of individuals requiring community-based care and more intensive and specialized care, the parallel home care reforms ensured a greater portion of care was subject to market competition.

From this perspective, the perverse outcomes experienced in rehabilitation home care, which constituted a relatively minor field not just of home care, but of health care more broadly, could be considered as little more than 'collateral damage" (Randall and Williams 2006:1602).

These authors also suggest that, by placing responsibility for home care with Community

Care Access Centres (CCACs) as intermediary agencies, the provincial government gained a powerful tool for controlling costs. CCAC budgets have had substantial overruns since their first year; the province's reactions have included more restrictive guidelines for determining service eligibility, and reclaiming authority to appoint executive directors, in response to complaints from CCAC Directors across the province that 2001 budget caps compromised their ability to provide service. As will be discussed in greater detail later, one consequence of restrictions on CCAC services and capacities is the decreased likelihood that they will be able to address the needs of individuals who are unstably housed.

In the case of addictions services, the impact of free market principles and neoliberal ideology is especially clear. As with hospital-based services, addictions treatment has undergone a parallel shifting to the community in the name of efficiency, away from residential detox and treatment programs to "daytox" programs, where individuals may receive counselling or medical attention from a hospital while residing at home. Currently, the City of Toronto has the lowest number of detox beds per person,

55 compared to other Canadian cities: 90-100 beds for men, and 30-35 for women (Street

Health 2007a:35). Again, this shift will be of greatest disadvantage to those with limited income and family or community supports, and to those without homes. The demise of

Canada's harm reduction services, however, is driven less by market principles than by ideology: drug dependency is staunchly defined and reacted to in moral and legal terms, not biological ones, despite multi-faceted causes. This predominant view means public policies and treatment services frequently contradict research and the experience of expert practitioners. For example, despite evidence that permanent supportive housing and harm reduction strategies enhance quality of life and save lives, abstinence-based programs predominate. Canada's European-style approach to drugs has long been a holistic one with "four pillars:" including treatment, enforcement, prevention and harm reduction. Currently, however, the Conservative federal government has endorsed a drug strategy which removes funding for harm reduction measures.31 These measures include distribution of clean needles and safe inhalation equipment, which are proven to be key to stemming the spread of HIV, hepatitis C and other infectious diseases. This is just one example of, to paraphrase the lead article's title in the Canadian Harm Reduction

Network's recent newsletter, ideology trumping science, and, again, the consequences for the impoverished will be far more devastating than for those with socioeconomic resources (Canadian Harm Reduction Network 2007).

31 "In-Site", a safe injection site opened in Vancouver, B.C., is the most high profile victim of this turn. 32 The general "war on drugs" approach being endorsed by this government have proven disastrous in the US, but is nevertheless shaping prevention, enforcement, and treatment initiatives in Canada. See: Gordon 2006. 56 Medicare and community-based health care operate under different rules, principles, and pressures. In the next section, I review how housing status and health interrelate and drive specific health care needs, most notably showing the homeless population's increasing reliance upon community-based services for health care. Other examples of health care reforms will be explored in more detail in later sections of this paper, and some of these re-examined in greater detail, as they relate specifically to health care being provided to Toronto's homeless populations.

He. Housing and Health

The political-economy perspective focuses attention not just on health inequalities, but on why some groups have better health than others, and why and how those inequalities are reproduced. The relationship between housing and health is at least three-fold. First, health problems can precede and "causally contribute" to homelessness; including, for example, mental illnesses which affect a person's ability to cope (or the ability of others to cope with the behaviour), alcoholism or drug dependence, or disabling conditions that affect a person's ability to work and pay rent. Health issues also contribute to an increased amount of time spent homeless (Daly 1989; Institute of

Medicine 1988). Second, homelessness increases the risk of developing health problems and transforming minor health problems into serious illness. Individuals and families who are homeless are sicker and die faster than their housed counterparts (Hwang 2001). The

33 Though I do not explore it here, it should be noted that we largely continue to assume common notions of what "home" "health" and "health care" mean across populations. 57 realities of surviving on the streets or in shelters - inadequate access to hygiene and nutrition, exposure to violence and the elements, contact with communicable diseases, fatigue, and so on - are directly correlated with problems such as malnutrition, respiratory problems, dental and periodontal disease, trauma, hypertension, chronic diseases like hepatitis and tuberculosis, and infections related to risky sexual behaviours or drug use (Brickner et al. 1985; Daiski 2007; Daly 1989; Institute of Medicine 1988).

Third, homelessness complicates health care delivery in various ways. Holding on to a health card or other identification cards, for example, is problematic. And, distraction by more immediate survival needs like income, food, or shelter may delay the seeking of health care, as may fear of stigma or institutions (Bierman and Dunn 2006; Wright, Rubin and Devine 1998). Treatment of otherwise manageable conditions, like diabetes or hypertension, can be made nearly impossible by homelessness. Diabetes, for example, can be controlled through daily insulin injections and diet, but homeless persons do not typically have access to refrigeration for insulin, may have syringes stolen (or cause them to be mistaken for an IV drug user), and reliance on food banks and soup kitchens makes a controlled diet impossible (Daiski 2007; Hwang and Bugenja 2000).

Housing conditions also have health consequences. Direct physical effects, such as dampness, mould, or cold housing, for example, are associated with problems like poor respiratory health. Housing also has direct mental health effects. Studies exploring these effects have largely centered on three major themes. First, the impacts of social network disruptions associated with re-housing (even when moving to better quality

58 accommodation). Second, the effects of crowding, while associated with spread of infectious diseases, also enforces social contact and continual presence of others which causes emotional stress (crowding studies have used measures such as the number of rooms and inhabitants, as well as perceptions of crowding). Third, studies on architectural design, which consider negative psychological effects caused by security breaches and unpredictable or uncontrollable noise. Living in poor housing conditions also has indirect mental health consequences, such as hindering the capacity to engage in activities which promote health or reduce the impact of illness (Gill and de Wildt

2003:17-45). Although formal definitions of homelessness acknowledge the problems of individuals living in unstable or unsuitable housing conditions, these health effects caused by poor housing are typically described apart from the homeless literature, once again reinforcing a false dichotomy between homeless and housed, and leaving out of the discussion impacts of housing on the health of hidden and at-risk homeless populations.34

Absent access to social determinants of health, such as housing, food, and income, vulnerable populations tend to be heavily reliant on hospitals to address their health needs. Studies on service utilization patterns of homeless persons certainly confirm this: they are more likely to be hospitalized, to stay in hospitals longer, and to use emergency services for both acute and primary care (Brickner et al. 1985; Canadian Public Health

Association 1997; Eberle Planning and Research 2002; Golden et al. 1999; Hwang 2001;

O'Carroll et al. 2006; O'Connell 1999; Serge and Ganedinger 2003; Smith, McGuckin

34 A few researchers, however, have carefully documented the physical and mental/emotional degradation resulting from sleeping in emergency shelters. See: Hopper 2003; Lyon-Callo 2000. 59 and Knill-Jones 1991; Wood 1992). As one literature review concluded: "...most of the

homeless use hospital emergency rooms for routine care" (Eberle Planning and Research

2002:16). A frequently cited New York City study noted that homeless people are

admitted to hospital up to five times more often than the general population, and stay in

hospital 36% longer than other domiciled patients, even after adjusting for primary

diagnosis, coexisting disease, and demographic variables (Salit et al. 1998). The latter

has been shown to be directly related to lack of housing (McGuire and Mares 2000). A

recent Toronto survey of homeless adults sampled from shelters and meal programs

found over half had used an emergency department in the previous year and one-quarter

had been hospitalized at least one night (Street Health 2007a). One-fifth had used

multiple sources of care, and 59% did not have a family doctor, compared to 9% of the

Toronto population as a whole (Street Health 2007a).

Hospital DischarRes: Infirmary as Home Care for the Homeless?

Increasingly, researchers are calling for the need to understand the impact of

health care reforms on recovery from illness (Armstrong et al. 2001a; Raphael 2006b).

What little we do know about these impacts is discouraging, though not surprising.

Hospital discharge is a period characterized by discontinuity in providers and in location

of care, and by extensive changes in health and therapy. Problems associated with

discharge are related to these gaps in care, and are also attributable to lack of

communication between hospital and community physicians (Forster et al. 2004).

Discharge planning has always been considered an important component of optimal

60 service delivery, and quality of discharge planning has been shown to be predictive of readmission, length of stay, and post-hospital care (Gantt, Cohen and Sainz 1999). A recent study assessed the incidence, severity, preventability, and ameliorability of adverse events (adverse outcomes caused by medical care) in patients discharged from the general internal medical service of a teaching hospital in Ottawa, Ontario, either to their home or to a seniors' residence. Of the study patients, nearly one-quarter (23%) experienced an adverse event following discharge; two-thirds of these caused only symptoms but 12% led to an emergency department visit, 17% to hospital readmission, and 3% resulted in death (Forster et al. 2004). The study authors draw two implications from these findings: the need to follow patients more closely after discharge, and the need to use monitoring strategies which account for frailty (the subjects' average age was 71 years). Both of these needs are especially complicated for homeless patients who are notoriously difficult to follow post-discharge and typically have very frail health due to multiple, complex diagnoses.

Clearly, the impact of hospital-bed closures and shortened lengths of stay is and will be greatest for the most vulnerable populations, including those without homes. The assumption that patients will have access to health care services, a shelter, and support person in which those services can be delivered does not hold for most homeless people

(Edmonton Joint Planning Committee on Housing 2003; Gantt et al. 1999). They are an

35 These authors do not draw the connection I have between earlier discharges and adverse outcomes, nor do they explain why this has been largely unstudied until recently. One New York City study investigated a methodology to track efforts for overcoming impediments standing in the way of a successful discharge planning effort, particularly for the chronically mentally ill. Not surprisingly, they found lack of housing as a significant impediment to an optimal discharge, and associated with readmission (Gantt et al. 1999). 61 uncomfortably visible symbol of the negative impacts of health care reforms, and their visibility raises important questions about the appropriate role of hospitals in primary health care. One author opined in the Canadian Medical Association Journal:

In an era defined by escalating costs, utilization reviews and inpatient lengths of stay, the lodging that hospitals provide to the ill is understood to be incidental, and dispensable. For the most part, this definitional shift, moving in sync with medical progress, has been appropriate and discreet. Occasionally it becomes visible and problematic, as when the discharged patient is homeless and has nowhere to go to recuperate (2001).

Media attention in the US has been paid to a handful of highly visible cases, such as the homeless man dropped off from a hospital van, donning only a hospital gown and a colostomy bag, to Skid Row in Los Angeles, California.36 A follow-up story by CBS television network news program "60 Minutes" brought national attention to the phenomenon. Some medical personnel, clearly feeling backed into a corner, have responded with anger. The CEO of Partners in Care, a managed care association, wrote a scathing letter to the editor of the Hospitals and Health Networks journal, acknowledging these discharges were disturbing, but asserting that hospitals should not be made the scapegoat for a larger societal issue (defined as the 'lack of shelter beds'), and that the problem should not result in "the criminalizing of hospitals and dedicated staff (Simmons 2007:10). Though this study revealed anecdotal evidence of comparably inappropriate discharges of homeless persons from hospitals, the issue in the Canadian media has remained largely confined to medical and public health journals (Bandiera

36 Skid Row in Los Angeles, California, has the nation's highest concentration of homeless persons, thus making it an easy target for scandalous stories about homelessness. The story is not atypical, however, of those I heard from providers across both the US and Canada addressing this precise issue. 62 2003). This can at least partly be attributed to the relative newness and rarity of the problem in Canada.

This issue needs to be examined as one which reflects the neoliberal global economy. In developed countries around the world, concerned citizens and communities are attempting to fill this gap in health care service for homeless persons by developing infirmary (aka medical respite, intermediate, or recuperative) care centers. In Canada, infirmary services are being provided in Ottawa and Toronto, and being developed in many communities, including four additional sites in the Greater Toronto Area. In the

US, over 30 such programs have emerged and many more are in process. Though some of these have been around since the 1980s, recent growth has been astounding, and even

Phil Mangano, the Director of the US Interagency Council on Homelessness has acknowledged it as a growing need in that country (Kelly 2008:1 A). Robert Aldridge, the Director of the European Federation of National Organizations Working with the

Homeless told the audience of a national Health Care for the Homeless Conference in the

US last year that a survey of 100 organizations in 26 countries throughout Europe found

"recuperation care is very poorly managed throughout." Amsterdam and Dublin have begun the process of developing these services for their homeless populations (O'Carroll et al. 2006). This is a contemporary, systems-driven phenomenon. Clearly there are differences within and across these countries which affect the specific features of these aftercare programs, but there is remarkable consistency in the need which has inspired their development, and the roles they must play within diverse systems and environments.

63 Not surprisingly, most of the existing research on these programs is focused on hospitals, specifically the amount of money the programs can save hospitals by reducing hospital visits and the duration of homeless persons' inpatient stays (Buchanan, Doblin and Garcia 2003; Buchanan et al. 2006; Podymow and Turnbull 2006)37. But homeless persons do not receive health care solely in hospitals. As hospitals are offering shorter inpatient stays and becoming more acute-care focussed, the shift represents a role of prevention to one of damage control. It is up to the public sector to provide care for vulnerable populations, with fewer resources. Indeed, a peripheral patchworked non- system of services has been developed by providers in the community who see the health care delivery system failing these individuals. In Canada, as elsewhere, awareness and rudimentary description of these frontline services is only beginning, and remains largely

TO uncontextualized (Hay, Varga-Toth and Hines 2006). An approach which focuses only on hospital and other "mainstream" health care delivery systems, such as that which drives so much health services research, diverts attention from where increasing numbers of vulnerable populations are accessing care.

Equally detrimental is the lack of attention to the providers outside of the hospital setting who are caring for these populations, a gap this study aims to address. The impacts of neoliberalism and economic restructuring are not unidirectional or 37 The Department of Health and Human Resources and Services in the US recently requested a national study assessing the need for and the benefit of medical respite care for homeless persons, but has specifically defined it in terms of cost savings to hospitals via reduced emergency room visits and inpatient stays. 38 By this I mean the opening premise of this report, and of new "Frontline Dialogues" is that these services already exist and should be acknowledged for the work they are doing. No questions are raised about why these services have emerged and grown so rapidly in a relatively short amount of time, or about their role within the broader health care system. 64 deterministic, and the development of homeless-targeted frontline health care services is a clear example of this. Individuals and institutions negotiating conflicts and contradictions encountered by the imposition of a business model on health care has resulted in an immensely innovative mix of community-based health care for homeless individuals within and outside of Canada. This study specifically explores what these negotiations look like in the current political-economic context: how providers accept, resist and create to address issues of need and social justice for individuals without resources in their communities. As such, it is building upon a small body of ethnographic research advocating for more contextualized historical and political-economic analyses of the effects of neo-liberal restructurings of health and welfare systems for impoverished persons (Lamphere 2005; Nelson 2005).

Hf. Summary

This chapter provides an overview of the specific historical, political-economic context within which I am exploring homelessness and health generally, and, more specifically, the emergent need for the development of acute medical after-care for homeless persons in Toronto. This context is characterized by a rise in global capitalism and its attendant neoliberal ideology, centered on a belief that the free market affords the best solution to address people's health. Some of the effects of globalization have included increases in health disparities among the world's populations, weakened public health infrastructures, and an erosion of collective responsibility. Canada (with a focus

65 on Toronto, Ontario) has experienced these effects in the form of unprecedented income polarization, removal of a federal policy on housing (and drastic cuts to affordable housing supplies), and income benefits. Locally, as well as globally, these effects are most devastating to those with lowest socioeconomic status, including women and visible minorities. Although the nation's population, especially in Toronto, is racially diverse, the city's racial policies are geared toward managing and containing racial difference.

These changes correlate closely with a sharp increase in the number of people at- risk of losing their housing and living outdoors. Political-economic forces have shaped our understanding of who and what gets expressed as homelessness. Rather than addressing housing as a social determinant of health, policies and programs narrowly target the small minority who are chronically homeless and most costly to serve. Those most apt to be left out of this focus are women and new immigrants and refugees, whose patterns of homelessness tend to keep them out of public view.

So, too, the design of the health industry and the people it most effectively serves is influenced by the specific, economic-political climate in Toronto. Hospitals are discharging patients "quicker and sicker," Community Care Access Centres, operating under tight budgets and restrictive criteria have limited capacity to provide home care to individuals without homes, Community Health Centres, though technically well-suited to care for homeless persons, also have limited budgets and capacities, and detox and psychiatric beds are closing and shifting burden of cost and care to the community.

Shifts in responsibility of care from hospitals to communities is especially problematic

66 for individuals heavily reliant upon communities for their health care needs. This study specifically focuses on the tensions homeless population's unique set of needs cause providers in hospitals, at the point of negotiating discharge, and those in the community agencies responsible for caring for them. Understanding some of these reforms, especially as outgrowths of globalization and increasingly entrenched neoliberalism, is critical to knowing the context within which this dramatic tension unfolds.

The next chapter describes the specific methodologies used to focus the study and explore questions and issues raised in this one.

67 CHAPTER III

METHODS

In social science, methods cannot be detached from theoretical orientation (Berg

1998). The selection of the case study approach is thus closely married to the political economy theoretical framework described in the previous chapter, a framework intent on assessing social phenomena within the specific historical, political-economic context in which they exist and develop, and on making factors comprising that context transparent.

Services like those provided by the Homeless Infirmary are emerging in several other countries and contexts. The Homeless Infirmary in Toronto is one of only a few which have emerged in Canada, and is the first developed as a "stand-alone" facility. By following the Infirmary from its origins, I can assess those factors which have driven the development of targeted homeless services generally, and this case example specifically, and their short and long-term impacts on the health care system and its providers. What has driven the need for this specific service in Toronto, and what does it mean that it has emerged within the context of Canada's universal health care system? The boundaries between the phenomenon and its context are not clearly evident here, and the case study approach is designed as a guided enquiry to investigate precisely these blurred boundaries

(Yin 1989). In essence, the case study approach affords the depth of exploration necessary to grasp questions of how and why targeted services such as the Infirmary

68 developed in Toronto when they did, and to explore actual and unforeseen impacts. As is

characteristic of case studies, I rely on multiple sources of evidence to mine this depth,

and to corroborate and augment evidence (Yin 1989). These sources include in-person

and telephone interviews, personal observations, program data, and document analysis;

all are described here in some detail. The Human Subjects Review Board of York

University approved this study, including all consent forms and procedures (See

Appendix B).

Ilia. Conceptualizing Homelessness

Research on homelessness is very diverse in terms of classifications and definitions of this population; this negates clean sampling designs, counts, and sure research conclusions, but frequently reflects growing awareness of the heterogeneity and experiences of individuals without homes. For example, "hidden" (as opposed to

"literal") homelessness has broadened our awareness and understanding of women, youth, and people living in rural areas who are homeless. This category includes individuals who are living temporarily with friends or family, at risk of eviction, in households subject to violence, and/or in unsafe or overcrowded households (Kappel

Ramji Consulting Group 2002). The category of "at risk for homelessness" further acknowledges homelessness as a continuum, by including those individuals spending more than half of their total income on housing costs, those residing in prisons, and so on

(Canadian Institute for Health Information 2007:8).

69 Categorization has consequences beyond raising awareness and conducting research, of course, as it influences program designs and funding allocations and decisions. While the categories described are location-based, three common classifications capture variations in the experience of homelessness: temporary (or transitional), episodic (or cyclical), and chronic (Institute of Medicine 1988)(1998).

Though the latter category comprises less than one-quarter of the literal homeless population at any point in time, research drawing attention to their disproportionate use of expensive resources has led to targeted government attention and funding in Canada and the US, diverting attention and resources away from the majority of homeless persons who do not fit that category (Gladwell 2006; Laird 2007; McMurray-Avila 2001).

The homeless individuals discussed and described in this study are those who seek, or are sought out by, services designed expressly for homeless persons; therefore, the "homeless" populations I am referring to are those who find themselves in need of those services at some point in time. This definition thus technically includes individuals who fit all of the categories described above. However, a characteristic of many "hidden" homeless persons, such as those living in domestic violence situations or unstable housing, is that they do not consider themselves "homeless" and would therefore not seek care in homeless services. While the Homeless Infirmary is designed expressly to serve both homeless and "underhoused" persons for precisely this reason, and is the first service of its kind available for women as well as men, it is likely that women and

39To be admitted to the Homeless Infirmary, individuals have to be "homeless or underhoused. This will include people who use shelters, are on the streets and "in the rough," and/or stay in environments, such as many rooming/boarding houses that do not support healing." 70 racial minority groups (who are more apt to be "hidden") are underrepresented in this study. I have attempted to address this oversight by exploring some of these implications with the individuals I interviewed, and will incorporate those discussions in subsequent chapters.

Hlb. Study Participants

Two groups of participants were recruited to be interviewed for this study: providers who referred homeless persons to the Infirmary, and key informants.

Selection and Recruitment

Providers Making Referrals to the Infirmary: Homeless Infirmary staff, again overseen by the senior Case Manager for continuity, tracked information on all referrals made to their program during the study period. Information was collected on one of two forms designed by the Infirmary management team: Community Referrals or Hospital

Referrals. Infirmary staff photocopied each referral form submitted during the study period, blacked out all patient identifying information (name, health number, etc.), and put them into a notebook for me to collect roughly once every two weeks throughout the study period.

I developed and maintained a database with contact information for providers

(name, position, location, telephone number) drawn from the referral forms submitted during the study period. The Infirmary developed more slowly during the study period than initially anticipated, opening just five of their 20 beds for the first month and ending

71 with just seven open beds. The Nurse Practitioner informed me that some providers had become aware of the low number of beds and had begun to telephone her, as the main referral contact, to find out if beds were available before deciding whether to complete a written referral form. Because of this unexpected change to the screening process, I became concerned that by relying solely upon referral forms I was not capturing all of the referrals being made to the Infirmary. Therefore, the Nurse Practitioner agreed to maintain a list of those who were making pre-referral telephone screening calls. I supplemented my database of provider contacts with these additional six individuals.

This brought the final list of unduplicated names to a count of 39. Seven of these were not able to be contacted, because they had left their position, declined to participate, or had not included contact information. I contacted each of the remaining 32 providers by telephone, explained the purpose of my study, and invited them to complete a brief interview of 15-20 minutes.40 These providers included social workers, case managers, and clinicians from homeless shelters, drop-in centers, local hospitals, community health centres, and other community organizations. (See Table III-l for specific information about location of these providers.) I encountered difficulty making telephone contact at all, let alone scheduling a brief interview, due primarily to the unpredictability of their schedules and general chaos of their work environments. Though I made multiple attempts to connect with each of the providers, I successfully completed interviews with

These interviews lasted, on average, 30 minutes with a range of 20-60 minutes. The duration of the interview was determined by the interviewee's interest in discussing the questions. One of these interviews was completed in-person upon request. 72 just fifteen who were available and verbally consented to participate (47% response rate).

I recorded their responses on the computer throughout the interview.

Key Informants: The Infirmary management team met to collaboratively identify key informants from Toronto who they considered especially knowledgeable about homelessness and the service needs of homeless individuals in the community. I asked them to include individuals who had participated in the Homeless Reference Group

(convened to develop the Infirmary), hospital administrators, such as Emergency

Department and nursing managers, directors of homeless service agencies (including the other Infirmary), and directors of community health centres and services. Through an interactive process, the management team compiled a list of 30 key informants. I contacted each of the informants by telephone, informing them about the study and requesting a face-to-face interview of approximately one hour in duration.

I chose to complete the interviews in-person to contribute to my awareness and understanding of the various physical contexts within which health services are being provided to this population, and to become familiar with the service community and proximity of services. I completed face-to-face interviews with 28 key informants (93% response rate). I presented each interviewee with a consent form and asked them to review it, then sign it if they still agreed to participate. (See Appendix B for copies of consent forms.) I also asked for permission to audio-record the interview so I would not need to take handwritten notes. All informants consented to participate and to be audiotaped. All but one of the interviews were one-on-one; the exception to this was an

73 interview with two hospital administrators which was voluntarily arranged by an informant.

Table III-l INTERVIEWEE LOCATION, TYPE and NUMBER (N=43) LOCATION TYPE OF INTERVIEW Key Informant Service Provider (In-person) (Telephone) Hospital St. Michael's 2 3 Mt. Sinai 3 1 St. Joseph's 1 1 Toronto Western 1 - Subtotal 7 5 Community and Homeless Health Agencies Sherbourne Health Centre 3 - Homeless Infirmary, Sherbourne Health Centre 4 - Seaton House Infirmary 2 - Parkdale Community Health Centre 1 1 Street Health 1 1 Macewan House "Loft" 1 - Subtotal 12 2 Community Agencies Fontbonne (drop-in/residence) 1 - Counterfeit (harm reduction program) 1 - Community Care Access Centre (CCAC) 2 1 Streets to Homes Project 1 - Community Resources Connections Toronto 1 1 (CRCT) - Hostel Outreach Program for Women Parkdale Activity/Recreation Centre (PARC) 1 - 416 Drop-in for Women 1 - Fred Victor Centre 1 - Community Resources Connections Toronto - 1 (CRCT)-COTA Women's Residence (shelter) - 2 Street Haven - 1 Good Shepherd Centre (shelter) - 1 Evangel Hall (shelter) - 1 Subtotal 9 8 Total 28 15

74 IIIc. Interviews: Content and Approach

My interviews with the community providers who referred clients to the

Infirmary, and with the key informants, served as the primary data source for this study.

The fact that the political economy approach is "historical" means, in part, that "people collectively and individually make their own history....are social, actively formed within particular social locations and relations, rather than pre-existing autonomous individuals"

(Armstrong et al. 2001b:viii). In this study, I located and interviewed individuals who are actively working in and trying to make sense of homeless-health care, and of those factors which have led to its current state. My questions to these individuals explored challenges they faced in their daily work, but also how they made sense of those political- economic influences creating or exacerbating those challenges, and how they navigate the tensions between structure and agency in their work. While I developed interview questions, I allowed these interviewees to affect the direction of the line of questioning, based on their specific context and experience.

I developed a semi-structured interview guide for the telephone interviews with homeless service providers who made referrals to the Infirmary. These interviews captured descriptive information about the providers (e.g. profession, type of institution, length of time working with homeless persons), and centered on three basic content areas: the referrals they had made to the Infirmary; their experiences with addressing health care needs of homeless or underhoused persons and ideas about resolving dilemmas; and their

75 perceptions and opinions of the Homeless Infirmary, including what plans they would have made for the patient (or did make, if the client was not admitted) had the Infirmary been unavailable. Questions were customized according to whether the provider was located in a hospital setting or in a "frontline" community agency.

Interviews with key informants were guided by general, open-ended questions geared more to the "big picture" of homeless health needs and services as they have evolved in Toronto over (roughly) the past decade. Questions about the Homeless

Infirmary, for example, focused more on its place in the continuum of health services for homeless persons, on the pros and cons of homeless-specific health services, and on their perceptions of its impact on the health care system as a whole. I customized questions to fit with the informant's background and area of expertise, and to incorporate learnings from prior interviews as I proceeded. In this way, I was able to "test" themes with subsequent interviewees, and to identify specific policies and content areas to pursue in my secondary research.

What follows is a listing of general study questions which guided the interviews with both the providers making referrals to the Homeless Infirmary, and with key informants.

Referrals Who are these providers? What organizations do they represent? How long have they worked with homeless populations, particularly in Toronto? What were the reasons for referrals?

76 Experiences What are these providers' experiences addressing physical and mental health issues for their homeless clients in Toronto? Have these experiences changed over time? (If so, how?) What (if any) changes have they witnessed in the volume and/or demographic makeup of the homeless population in the Toronto metro area? What (if any) service access barriers have they faced in helping their clients? Do these providers perceive changes in these experiences over the past several years, and if so what are those changes and to what do they attribute them? What (if any) differences do they see in experiences and service access issues of various homeless populations - especially women, sexual minorities, and race and ethnic minority groups? Do they have practical or ethical concerns related to any of the responsibilities they have taken on related to their homeless clients' health needs? Who do they think should be responsible for providing health care for homeless persons, and why? Where should those services be provided?

The Homeless Infirmary How do these providers perceive the services the Homeless Infirmary provides, and the role it plays in the service community for homeless persons? Who do they think it will best serve? Who will not be served? How did they address their homeless clients' aftercare needs before the Infirmary opened? What, if any, concerns do they have about the Infirmary and the development of similarly targeted services?

With both groups of interviewees, I attempted to complete interviews with 100% of those identified in the sample. Although I failed to achieve this response rate with either sample, I completed a sufficient number that I had reached the saturation point, where new themes and facts were no longer emerging during the interviews.

77 Hid. Other Information Sources

Homeless Infirmary Data

Patients: Additional information about patients served by the Infirmary was derived from intake interviews completed at the beginning of the stay, and from data forms designed to capture data during their stay and upon discharge. Because I was working with the Infirmary management team prior to the Infirmary's opening, we were able to collaborate not only on data elements we mutually deemed important, but to develop forms which could capture those elements and be usable for ongoing evaluation if they wished. Forms and processes for data collection were informed by and adapted from those I developed in collaboration with Respite Coordinators and their staff for use in the National Respite Pilot Evaluation often programs across the US. (See Appendix A for a copy of the Study Protocol.) This consistency of key data elements enables the

Infirmary to make some comparisons with patient and program data collected from that study.

All data from and about Homeless Infirmary patients were collected by Infirmary intake staff and clinicians on all clients served between its opening March 20 and July 31,

2007. This time frame was selected to balance time for the program to evolve and to reflect patients served, with acknowledgement of the additional burden of data collection on Infirmary staff. These staff, overseen by the senior Case Manager for continuity, informed all admitted patients about the study, explaining its purpose and asking them to allow an outside researcher to review information collected on them during the course of

78 their stay in the program for descriptive purposes. Patients were assured that data they consented to share with the researcher would be anonymous and non-identifiable.

Infirmary criteria for admittance assured that all patients were "homeless or underhoused" which included individuals using shelters, living on the streets, or staying in environments or houses not supportive to healing. Patients also had to be 18 years of age or older, and capable of providing consent. The number of clients who did not consent for any reason was recorded for an accurate denominator and response rate.

During the study period, 34 clients were accepted for care in the Infirmary; of these, four departed the program before they were informed about the study. Of the remaining 30,

21 consented to share their data for their study (70% response rate).

Infirmary staff tracked data elements on all admitted clients at different points during their stay. These elements included demographic characteristics, referral sources, mental health and substance use status and treatment histories, medical diagnoses, number and type of staff encounters, sources of health care, income and housing, and reasons for the patient's exit. These data provide insight not only into individuals' experiences and outcomes achieved during their stay, but also into which subpopulations are most apt to access, and are most effectively served by, this Infirmary. Following are the general study questions which guided the development of specific data elements collected on homeless patients served by the Infirmary.

Intake Who does the Infirmary serve? What are their demographic characteristics? Do they represent the subgroups defined in the Infirmary's needs assessment as most in need of these services? (e.g. women, refugees, transgendered, young adults, Aboriginal

79 women) How, if at all, do these clients differ from those served by the shelter-based infirmary in the same community?

During Their Stay Once clients are admitted to the Infirmary, are their presenting health conditions resolved or stabilized? Do they obtain access to other supports and services not provided by mainstream health services? Do patients from some demographic groups fare better than others?

Discharge What happens when these patients leave the Infirmary? That is - is the Infirmary simply softening the inevitable landing back to the street or shelter, or are they moving into housing?

Potential Infirmary Patients: Input from 340 homeless persons in the community

(potential Infirmary patients) gathered through 14 focus groups as part of the development of the Infirmary, additionally informed this component of the study and provides some rough baseline data by which to compare the Infirmary client characteristics. These focus groups included diverse groups of homeless persons in various venues, but targeted certain subpopulations including women, refugees,

Aboriginals, mentally challenged, substance users, transgendered, and youth populations.

Referred Patients: In addition to interview data from service providers who had referred patients, data elements from all of the referral forms submitted (n=49) were entered into a statistical software program (SPSS-X) for descriptive analysis. Table III-2 summarizes the variables selected from these referral forms, which varied slightly according to the origin of the referral.

80 Table III-2 REFERRAL FORMS: SELECTED VARIABLES REFERRAL ORIGIN Hospital Community Referral Source: Emergency Referral Source: Health Care Provider, Department or Inpatient Shelter, Drop-In, Self Client Date of Birth Client Date of Birth Current Living Situation: Homeless or Current Living Situation: Homeless or Underhoused; description Underhoused; description Reason for Referral Reason for Referral Primary Medical Diagnosis Presenting Health Issues Current Substance Use: Yes/No, Current Substance Use: Yes/No, preferred preferred substance; pattern of use substance; pattern of use Mental Health or Psychiatric Issues: Mental Health Issues: Yes/No, describe Yes/No, describe symptoms or symptoms or behaviours behaviours Potential Infectious Diseases issues n/a Consequence of Non-Admittance: If Consequence of Non-Admittance: What SHC's Infirmary were not an available might be the consequence if you/your client discharge option, how much longer is not admitted to SHC's Infirmary? would the client remain in hospital?

These forms provide a more comprehensive picture of specific referrals made to the

Infirmary, do not rely on the memory of the individuals making referrals, and provide supplemental information on clients referred but not admitted to the Infirmary.

Personal Observation: I first visited the Homeless Infirmary in 2001 during a visit to Toronto; Sherbourne Community Health Centre had just identified the floor of an old hospital building where it would be built. I had met the Infirmary's Director at a

Respite Care Providers' Network meeting in Boston, Massachusetts a few months prior, and she had informed me about the new facility. From that time, and for the duration of this study, I frequently visited the Infirmary and was able to observe it through the stages of its development, attended pre-opening staff meetings with newly hired employees,

81 attended its Grand Opening (an opportunity to meet many of the key informants and providers I would subsequently interview), and visited informally with Infirmary staff.

Though I did not systematically document my personal observations or visits to the

Infirmary, they affected my opinions and perceptions of its design, purpose, and effectiveness. And, as noted previously, I conducted key informant interviews in-person specifically so I could personally experience homeless services and locations within the

Infirmary's catchment area.

Non-Infirmary Data

To provide some social and historical context to frame and follow-up the interviewees' observations and opinions, I relied on several additional sources. These included, for example, peer-reviewed published research on health systems and services, homelessness and health care; government reports and monographs; newspapers; homelessness surveys and reports from nonprofit organizations; and policy papers.

My experience with the National Health Care for the Homeless Council in the US also served as a point of reference. Within that position, I have frequently interacted with and interviewed clinicians and program administrators who work with homeless persons, including many specifically engaged in respite or infirmary services. While acknowledging the differences between the US and Canadian contexts within which these programs are developing, especially in their health care systems, my interactions with those providers over several years not only inspired my interest in this study topic, but also directed me to focus specifically on their experiences.

82 Hie. Analytic Strategies

As noted previously, the purpose of collecting data from multiple audiences and sources is not only to explore the topic in sufficient depth to address complex "how" and

"why" questions, but to build confidence in the findings and conclusions. This

"triangulation" of evidence, whereby crosschecking of findings occurs over and across sources, also helps by providing multiple measures of the same phenomenon (Yin

1989:97).

I analyzed both quantitative and qualitative data sources for this study. The quantitative data, from patients' program forms and database entries, providers' referral forms, and segments of the interview protocol, were entered into a statistical software program (SPSS-X). Because these data were primarily used for descriptive purposes, I used frequencies and associated statistics, including measures of central tendency and dispersion. Where the sample sizes were sufficient, I additionally employed cross tabulations and associated descriptive statistics such as chi square tests, to test relationships between demographic characteristics, mental health and/or substance use status, and homelessness history on measures related to health and housing.

Analysis of the qualitative data, from interviews with individuals who made referrals and key informants, was conducted in a series of steps, much of it occurring concurrent with data collection. The general analytical approach I took is largely derived from a course on "Interpreting Qualitative Data" I took at the beginning of the study.41

41 This course, instructed by Raymond Garrison, was sponsored by the Institute on Social Research at York University. 83 As I completed individual interviews, I took detailed research notes to document my personal experiences, reflections and reactions. These notes enabled me to reconstruct the evolution of the project and the directions and choices I made along the way, to document my reactions, and to make theoretical reflections. These notes also influenced the next step in the analytical process, which was to organize the data.

I transcribed the audio taped key informant interviews, and then applied source codes to indicate locations of text segments; these codes consisted of a Participant ID number assigned to each interviewee followed by the transcript line number. For the telephone interviews, transcriptions were completed at the time of the interview. For the iterative organizing and coding process, I completed an initial close reading of all transcriptions to recognize emerging themes and patterns, group specific examples, and begin to isolate the data from their specific context. From the initial code book developed, I then reflected on those initial groupings, attempted to relate them to broader research questions, and repeated the process until satisfied they were reflective of the overall dataset sufficiently to begin the next step. I elected not to use computer-assisted qualitative data analysis software, but instead to rely on a manual organizational scheme using a word processor. I put all of the similarly coded data segments, attached to their source codes, into separate file folders, putting them into multiple folders where appropriate. I then separated representative quotes, and wrote up a summary of each folder's content to serve as a basis for writing up the findings.

84 Illf. Advisory Team

An Advisory Team consisting of myself and the Infirmary management team, including the Program Director, the Nurse Practitioner, and the Case Manager oversaw all aspects of this study design and development. These staff have extensive experience working in Toronto's homeless service community in multiple capacities and locations.

Their experience includes, for example, providing clinical practice and program oversight in six different Community Health Centres, a youth outreach program and shelter, two

Addictions and Mental Health programs, and two homeless women's shelters. They have

(and continue to be) advocates for health needs of underserved populations in Toronto through local advocacy groups, City advisory committees and Boards. Two members of this Team were instrumental in all phases of the Infirmary's development from its origins in 1998.

I initially met members of the Advisory Team in my capacity as the Coordinator of the national Respite Care Providers' Network, a U.S-based organization comprised of respite care providers for homeless persons from across the country42. They were seeking resources and information on the various models of medical respite care to consider in the development of their Infirmary. I was project manager of a national multi-method evaluation often respite/infirmary programs in the US, which addressed some of the issues they were interested in, and provided some evaluation tools. Shortly after moving to Toronto in 2003,1 collaborated with this Advisory Team on a study which assessed the

42 In the United States, infirmary services for homeless persons such as those provided in the Homeless Infirmary are referred to as "medical respite care" or "respite." There are currently approximately 350 members of the Respite Care Providers' Network, which was originally created in 1999. 85 health perceptions and needs of women staying at Women's Residence, Toronto's largest women's homeless shelter. In the spirit of the political economy framework and its capacity to stimulate change, I chose to involve this Advisory Team to ensure that this study's findings are not only relevant and useful to the Infirmary and those it served, but to the homeless provider community generally.

Hlg. Summary

The selection of the case study approach to explore the emergence of homeless- targeted aftercare services in Toronto is closely linked to the political economy theoretical framework described in the previous chapter, as it enables me to understand this phenomenon within the specific historical, political-economic context in which it has developed. The Sherbourne Community Health Centre's Homeless Infirmary, opened in

March 2007, serves as the case; this Infirmary both exists because of, and is designed to address, a service gap and tension newly created by systems changes in both the public health infrastructure and the health care system. Key Infirmary staff comprised an

Advisory Team which oversaw the design and methods for the study.

The primary sources used for this case study are face-to-face and telephone interviews with individuals caring for homeless persons in both community and hospital settings. The interviews captured their experiences with the homeless population in

Toronto over the past decade, their perspectives on the development of homeless-targeted health care services during that time, and how they have negotiated this newfound tension

86 with other providers in addressing homeless persons' needs. Forty-three interviews were completed, and included persons with a range of backgrounds and expertise working in four hospitals, six community-based health agencies, and thirteen homeless-targeted community agencies.

Several additional sources are used to provide a clearer picture of whose needs are met by the Infirmary, and what role the program is playing within the broader health care system. For example, the Infirmary is designed to serve underhoused as well as literally homeless persons, but those who do not identity as homeless or seek homeless-targeted services may not be served. To explore the capacity of the Infirmary to address the needs of these "hidden" homeless populations, descriptive information was collected on individuals referred to the Infirmary for a four-month period after the Infirmary opened.

In addition, persons admitted to the Infirmary during that period are also described, including tracking of outcomes the Infirmary aimed to influence.

In the next chapter, I describe why and how homeless-targeted health care services have developed in Toronto, and the experiences of providers working in a variety of settings to care for homeless persons throughout that period.

87 CHAPTER IV

HOMELESS HEALTH SERVICES IN TORONTO: PROVIDER PERSPECTIVES

The political economy framework illuminates the ways in which profit-driven systemic reforms in Toronto have created and defined a large and growing homeless population, changes coinciding with globalization of free-market capitalism, crumbling social infrastructures, and growing health disparities around the world. This chapter examines how Toronto has both embraced challenges derived from neoliberal government decisions to commodify public health care - shrinking and redefining health care services and safety net provisions - and responded to the fallout from those decisions. Individuals who have cared for underserved "vulnerable" populations in

Toronto throughout the past decade have borne witness and struggled from the frontlines to respond to the effects of these systemic changes on individuals on society's margins, and are thus uniquely situated to comment. This chapter briefly describes health care providers' perspectives on changes in the city's homeless populations and on the origins of targeted homeless-health services. It then portrays their experiences caring for the health needs of homeless individuals both within the mainstream health system and in the community, specifically drawing attention to how neoliberal-driven changes to the health care system have uniquely affected those experiences.

88 Description of Providers Interviewed

The providers interviewed for this study, including key informants and providers making referrals to the Infirmary, represent a mix of disciplines in a variety of settings throughout the downtown Toronto area. Their roles included case managers, physicians, nurses, outreach workers, nurse managers, program coordinators, and directors of drop-in centres and shelters. Roughly half (n=20) have medical training, including fourteen nurses or nurse practitioners and six physicians, while the remainder (n=22) work in social services as an outreach worker or case manager (n=10) or in a management role

(n=12). These interviewees were associated with a total often health care settings, including six different community or homeless-health care clinics and four hospitals, and thirteen community agencies, including homeless shelters, mobile vans, residential programs, drop-in centres, and harm reduction programmes. Together, they average over ten years of experience working with homeless or underhoused populations in the

Toronto area, time typically spent in various roles and settings in Toronto.

This study echoes the fact that women are overrepresented among non-physician health care workers, especially those in the community: 71% of the key informants and

87% of community-based providers interviewed for this study were female. Four of the six physicians interviewed were male. Just two of the providers interviewed were from racial or ethnic minority groups.43

43 We cannot have a clear understanding of what is happening in homeless-health care services until we address how race and gender of providers interacts with whether or how individuals seek and/or engage in those services. The lack of diversity among providers interviewed for this study reflects the homeless- healthcare infrastructure as a whole, but does not contribute to a deeper understanding of these issues. 89 The Homelessness Crisis in Toronto

Though the groundwork had clearly begun to be laid prior to the election of

Premier Mike Harris in 1995, these providers unanimously attribute the immense growth of homelessness and the harshness of the homeless experience over those years to changes first implemented with Harris' reign. They describe the wholesale dismantling of the social safety net, including the prompt termination of social housing projects in

1995 (social housing construction grew during the period 1990-1995 under the New

Democratic Party regime) and rent protections. The dissipation of a national policy on housing as authority was downloaded first to provinces; in Ontario it was further downloaded to municipalities in 1999. This was especially disastrous given the escalation of housing prices and a tightening housing market. Massive cuts and restricted eligibility to income benefits were imposed, as was the closing and amalgamation of hospitals and mental health treatment facilities. These decisions, all driven by neoliberal motives behind Harris' "Common Sense Revolution", drove many individuals into unstable housing situations or homelessness. As one informant put it, "People on the margins are the first to lose their housing, because as the pressure builds, landlords and the system reward people who are easy to house" (13-63). The fact that these providers point unanimously to political-economic factors as primary causes of homelessness likely stems from their familiarity with these populations and the systemic barriers that they face.

90 Several of the informants also spoke of deinstitutionalization, beginning earlier in the 1970s-80s, as an important factor in propelling severely mentally ill persons into homelessness within Toronto. Though not displeased with the theory behind having people moved into the community, they note the community supports necessary to enable their survival - let alone their ability to thrive - were simply not put in place before closing the institutions. Several reported seeing clients they had previously served in those institutions now living on the streets: "These were people I'd help get towels for their bath in inpatient in 1987, and here they are on the street, dishevelled and psychotic"

(6-74). Others simply noted the clients who would have been served in those facilities in the past are instead living on the streets or in emergency shelters: "shelters function as essentially a substitute institution for chronic mentally ill people who don't have other supports" (8-36). Deinstitutionalization of psychiatric facilities is analogous to hospital closures, which were made without sufficiently resourcing the community to address its effects, and have displaced many persons in need of physical health care onto the streets or into emergency shelters.

What stands out in these discussions, however, is not observations of what created the homeless phenomenon they have become immersed in, but of how the implementation of these systemic changes and the privatization of the social safety network has cultivated a devastating cruelty, a heartlessness, toward the marginalized individuals they serve, and crippled their ability to provide for them. Providers repeatedly used words like "shocking", "incredible" and "unbelievable" to describe the

91 initial across-the-board cuts to welfare, housing, and their agency budgets. But what some called the "corporatization" of the services left standing was equally devastating.

Many have watched management of social and health services shift to a business model, with business skills and credentials replacing backgrounds and experiences with health care, social work, psychology, and homelessness. They see this general trend toward a business model management approach to social services as translating into increased selectiveness about who they are serving - essentially focusing on the easier to serve (aka

"creaming") and those more apt to produce positive outcomes - leaving most of the homeless population out of the picture. One provider associated this shift happening at a psychiatric facility where she worked, with increased funds taken from pharmaceutical companies:

It really became a research and risk management facility. And these (homeless) clients don't bring in research money. They have treatment resistant illness - severe bipolars, profound personality disorders, addicts, schizophrenics. Your research results aren 't going to be as sexy. Whereas you have a unit with high functioning [clients] who get depressed - they come in, they get better, go back to Bay Street. That looks good on their advertising campaign (6-64).

One consequence of this corporatization is to blur the lines between public and private.

One author commented, "marketization threatens to overturn [the] distinction" between the private sector, where profit is the top priority, and the nonprofit sector, where services are the top priority (Shields and Evans 1998:98).

Coinciding with these changes was an increase in punitive responses to persons living on the streets and in business' doorways. The Safe Streets Act passed in 1999 to

92 prohibit "aggressive" panhandlers and squeegee workers was just one example of the more formalized criminalization of street homelessness these providers began to witness.

Another event which drew media attention in 2002 was the forceful eviction of over 100 homeless persons living in downtown Toronto's largest shantytown, "Tent City".

Security personnel for the property owner, Home Depot, arrived without notice and refused to allow individuals to enter even to collect personal belongings at risk of arrest.4

By definition, these providers are advocates: their jobs are to advocate for clients unable or unwilling to articulate their needs, and to ensure they will be treated with respect and dignity as they navigate a path through the system. But because of their in- depth experience with this increasingly broken system, because they understand the vital role of housing and income to their clients' health, and because they see first-hand the effects of misguided policies on human lives, these providers are also often fierce advocates for systems-level change. So, when Harris' provincial government made massive cuts to housing and safety net services, their initial response was to fight them.

Local advocates campaigned as the "Toronto Disaster Relief Committee" to declare homelessness in Canada a national disaster and a violation of human rights. Their State of Emergency Declaration, presented at a well-publicized public meeting, called for short-term relief as well as University of Toronto professor David Hulchanski's "1 percent solution," calling for all of levels of government to spend an additional 1 percent of their budgets on affordable housing. The efforts garnered national attention to the

44 These tenants were placed in what has been declared a very successful housing intervention. For discussion, see: Crowe 2007. 93 issue, and a Toronto Star journalist was appointed to cover the homelessness file full- time (Crowe 2007a:23). A Federal Minister Responsible for Homelessness was appointed in 1999, and did get some initial funding dedicated to the issue (see discussion on SCPI later in this chapter). But, the Homelessness Minister's office was revoked in

2003, and observers have noted that, on the whole, the federal government has continued to pay only lip service to the issue of homelessness (Forum Summary 2003; Crowe

2007a).

But a great deal of advocacy was stifled. In Summer 2000, approximately 1500 activists from several small coalitions, led by the Ontario Coalition Against Poverty

(known for its direct-action tactics) held a peaceful march at Ontario's Legislature in

Queen's Park to protest the government's cuts and the resulting homeless crisis. The outcome was later termed the "Queen's Park Riot" because protesters were met with police in riot gear, who, depending on the account, either responded to or instigated violence in the crowd. This incident, and the resulting arrests of several activists, muted the voices of many otherwise active advocates for homeless persons. While this is just one incident, it is important to understand it - as well as the reasons for their protests - within the global context. During this same month, for example, anti-poverty protesters were being silenced at the "World Summit for Social Development and Beyond:

Achieving Social Development for All in a Globalizing World" in Geneva, Switzerland

(Petchesky 2003:58).

94 Much of the silencing occurred in less dramatic, more insidious ways, and engendered a culture of fear. Because agencies and agency budgets were being cut, administrators were forced to shift to crisis mode, to scramble for whatever resources they could to serve their clients. This had a paralytic effect on their ability and energy to advocate for change through their organizations when it was most needed. "The message clearly was: keep a low profile, keep off the radar screen, don't talk advocacy" (19-139).

Smaller coalitions and informal networks of providers working with these populations dissipated: "You don't have the time and energy to look at advocacy on the bigger level.

But there's also the fear factor [of more budget cuts]" (19-145). Agencies removed advocacy goals and objectives from their program pamphlets before showing them to the

Ministry. When the downtown Wellesley Hospital was closed, a hospital noted for its services targeted to the growing HIV/AIDs population, providers feared for those patients whom it was assumed could access care in the nearby Catholic hospital, St. Michael's:

You wonder how somebody with HIV who needs an abortion is going to be handled in a Catholic setting. Those were the questions we had at that time. ..Sometimes I felt if you spoke up they would try to destroy you. I wasn 't as bad off as the clients, but I didn 't want to end up homeless too (6-119).

One of the city's most well-known homeless advocates, street nurse Cathy Crowe, described her experiences during this time period in a similar tone:

The day I found myself sneaking into a parked car in a dark alleyway to do a radio interview with the CBC (Canadian Broadcasting Corporation) was the day I realized I was in serious trouble as a nurse if I was going to stay truthful to what I was witnessing (Crowe 2007a: 11).

95 As the number of individuals experiencing homelessness grew, and uncomfortably high-profile cases of individuals dying on the streets reached the media , the City's response was not to replenish housing or income benefits, but to increase reliance on, but not necessarily financial support for, emergency shelters and services.

Stop-gap emergency responses like the "Out of the Cold" program, organized by faith communities and involving opening church basements to homeless persons throughout the Winter, grew exponentially during this period. Out of the Cold began in 1988; in a

2005 newspaper article calling the program a "17-Year Old 'Band-Aid'", one of its organizers complained: "The idea of this was a temporary measure.. .while the community addressed the need for affordable housing. Years later we're still doing it"

(Porter 2005 :C03). In 2003 the City approached Dixon Hall, an established nonprofit agency serving public housing residents and homeless persons, to take over management and oversight of Out of the Cold, effectively entrenching the City's reliance on these temporary beds (often just a blanket and a spot on a concrete floor) to serve as

"shelters". The number of drop-ins doubled, and emergency food programs grew to 84 in 2007. Though the number of meals served at one drop-in rose from 32,000 in 2002 to

100,000 in 2005, and daily attendance increased more than two-fold, there was no increase in drop-in funding during this time period (Ontario Coalition Against Poverty

2006). Tent City, the first squatter settlement in recent history, was begun in 1998 when

45 Twenty-one individuals died in 2000 alone - three were murdered, including a man who had his throat slashed while sleeping in a bus shelter. 46 Controversially, Out of the Cold Programs under the auspices of Dixon Hall employed a registration process which required individuals accessing the temporary shelter to identify themselves, thus potentially affecting their access to welfare benefits. 96 individuals unable or unwilling to access emergency shelters set up camp on some unused (and unsafe) land near the City's waterfront.

The increased availability and accessibility of addictive substances like methamphetamine, opiates, and especially crack cocaine also contributed to the growth of homelessness, made the experience that much harsher, and their addictions that much more complicated. A recent survey reported half (49%) of individuals accessing homeless services in Toronto had regularly used crack cocaine in the previous year, and few drug users use only one substance (Street Health 2007a). Again, the responses, based on a neoliberal agenda emphasizing individual responsibility, essentially dismantled a working system. In addition to reductions in addiction treatment programs and detox beds, there has been a new emphasis on short-term stays with clients visiting treatment programs during the day and going "home" at night, and a move away from harm reduction options proven to curb the spread of HIV and other infectious diseases.47

One harm reduction program manager commented on the multiple meanings, and benefits, of harm reduction:

Harm reduction means different things for different people. For government, harm reduction means spending less money: it's better to have somebody not getting HIV because it costs so much for treatment. These are the wrong reasons, but this is what it means to government. For the user it means buying their drugs cheaper, and not getting beaten up. For women specifically, harm reduction means not relying on abusive partners to shoot them up, to isolate them (5-78).

Research on substance abuse treatment for homeless persons consistently demonstrates the critical importance of housing and long-term treatment periods. There is no evidence that the managed-care trend in substance abuse treatment toward brief interventions can be effective with homeless populations. For a review of the literature, see: Zerger 2002b. 97 Toronto began embracing the Housing First Initiative approach to address homelessness prior to its initial launch of the "Streets to Homes" program in 2005. Phil

Mangano, Executive Director of the US Interagency Council on Homelessness appointed by US President Bush in 2002, has been a vocal proponent of the approach in both US and Canada. In fact, Toronto's recent endorsement of the approach has been criticized primarily for being slow and not aggressive enough. A recent report on homelessness in

Canada asserted:

Mangano leads a charge against homelessness that is still years ahead of Canada. And if American action on homelessness means anything, Canadians can afford to listen closely - even if it means admitting that George Bush's America can teach Canadians something about social justice (Laird2007:74).

The Housing First approach closely follows a business model, evident in its focus on the

"chronically homeless" precisely because they are most costly to the system. In

Mangano's words, "What does business have to do with homelessness? Everything - because the soft social services approach of the past did not work" (Laird 2007:76).

Though a detailed critique of this Initiative is beyond the scope here, it is key to an understanding of how homelessness is being addressed and the political-economic forces behind it.48 Adopting a cost-effectiveness analysis to the phenomenon of homelessness means the emphasis not only ignores long-term preventive solutions (such as housing, food, income), but it effectively masks the link between poverty and homelessness

48 One recent critique of this Initiative, presented at a Homeless Research Symposium, exposed several limitations of the "evidence" which has been used to declare Housing First a success in the US (Kertesz 2008). One of the issues the presenter noted was the need to understand local/political factors, such as availability of services prior to implementation. To date, Housing First programs have only been implemented in resource-rich communities and cities. 98 entirely - despite Mangano's assertion that the goal is to put an end to the "spiritual, social and economic disgrace" which is homelessness (Laird 2007:76). The narrow focus on the chronic homeless population living on the streets, mostly severely mentally ill and/or substance addicted, redefines homelessness to exclude the hidden homeless and persons at risk of homelessness, mostly women and racial minority groups. For example, a report reviewing Housing First programs in the US showed over three-quarters were male (Pearson et al. 2007:44);49 Toronto's first Streets to Homes survey reported 82% of the clients served were male. Streets to Homes reports have also consistently noted an overrepresentation of Aboriginal men and women in the "outdoor" homeless, though no other race or ethnicity categories are described (Toronto Shelter, Support and Housing

Administration 2006; Toronto Shelter, Support and Housing Administration 2007). A recent city policy makes the chronic-homeless emphasis overt: In 2003 the city stipulated that agencies providing high-support street outreach funded by the provincial "Off the

Street, Into Shelter" program could no longer use their funds for "direct survival supports

(e.g. food, clothing, sleeping bags), working with the hidden homeless (e.g. housed but doubled up) or assisting people already in shelters or housed" (Crowe 2007b:3). One street nurse described her experience with this policy: "So you're suddenly hearing from workers - some we've known for ten years plus - feeling terrible, hearing they can no longer on their van give out sleeping bags, hot stew, or warm clothing" (21-13). She also

In the US, the federal Department of Housing and Urban Development has shifted resources from supportive services within housing to only housing, and to Housing First emphases on the chronically homeless. 99 noted that a sleeping bag replacement program had to close down when the demand for

30,000 bags became too great.

On the whole, the response from every level of government to the homeless crisis

-which by most accounts played a heavy hand in creating in the first place - has been in the direction of short-term crisis management over long-term strategic investment (Laird

2007). Ironically, this same assertion was a central theme in the Mayor's Task Force on

Homelessness final report in 1999.50 A decade later, systems advocacy efforts continue to be disjointed and relatively ineffectual, for many of the reasons described above, but it remains a critical component of the work being done in providing health care for homeless persons. Many of these informants continue to harbour anger and resentment, others a weary resignation, mixed with fear that the situations they are witnessing are creeping closer and closer to home. It appears those factors which drove the rapid growth and the severity of the homeless situation in Toronto have also set a tone which makes resolution of that situation elusive.

IVa. Overview of Homeless Health Services in Toronto

Closures and merging of public and psychiatric hospitals, mental health and addictions beds and services placed new limits on the number and type of health services homeless and underhoused people were able to access. One emergency department physician-manager said,

This report is also known as "The Golden Report" after its author Ann Golden. 100 My position, and the position of the Emergency Physicians and Nurses of Ontario, is that the pendulum has swung too far. The number of beds that were closed was excessive. We closed about 1/3 of our inpatient beds in the last 10-12 years in Ontario (2-81).

Whereas once the hospital was seen as a place of "respite and asylum," it was rapidly becoming more focused on acute care, its environment and management more corporate. Providers speak wistfully of access to short and long-term hospital, mental health, nursing home and addictions beds now gone, of crisis units, and of physicians with flexible admitting privileges. They reflect fondly on supportive interventions like

"temporary admissions" of 5 days or more to address those patients who came in "with domestic violence, or a social problem, or maybe something as simple as needing to be deloused and this was upsetting for them, maybe they lost their medicine..." (6-27) and on accessible inpatient stays:

Not to say there were revolutionary things happening [in the 1980s], but if someone had a decompensation from a schizophrenic illness they were allowed at least a three month stay, minimum, and often it would be extended beyond that if there were psychosocial issues that had to be sorted out (6-23).

Certainly these changes affect all populations, but homeless populations, compared with their domiciled counterparts, consistently rely most heavily on hospitals for their health care needs (Goering et al. 2004). In turn, it is not a stretch to infer that the providers assisting them in finding the care they need are also disproportionately thwarted in their efforts.

But the reform which most significantly affected homeless persons' health care access, and arguably influenced the growth of targeted homeless health services in

101 Toronto, was the introduction of a new health card and criteria for its use. Individuals must have a valid Ontario Health Insurance Plan (OHIP) health card to prove entitlement to insured medical and hospital services, prescription drugs (for some) and other provincially funded health services and benefits.

In February 1995, the provincial government introduced a photo health card "to protect the integrity of the health care system and to preserve it for the future," a version which substantially increased security features and included an expiry date of coverage

(Ministry of Health and Long-term Care 2007:Section 5, page 4). The conversion to the new photo card, expected to be completed in 2000, remains incomplete: in fact, the 2006

Annual Report of the Office of the Auditor General of Ontario predicted it would take an additional 14 years before the red and white card would be phased out completely

(Ministry of Health and Long-term Care 2006:183). Much of this delay is caused by the introduction of the expiration date. The expiration period implemented was for five years, but the same 2006 Auditor General report identified that 9,700 homeless persons had been registered without all of the required citizenship documents since July 1995, and commented that the Ministry "usually issues cards with a one-year expiry date to such individuals" as a "control measure" (Ministry of Health and Long-term Care

2006:191). (See Figure IV-1 for an illustration of these modifications.) It also implemented several health card validation procedures, justified as a means to reduce health care fraud and administrative costs, though there was question of whether large- scale fraud even existed, let alone the extent of it (Anonymous 1995; Shu 1996:1413). In

102 early 1998, the Ministry ceased the practice of making "good faith payments" to providers when cardholder eligibility could not be determined, a move especially devastating to homeless persons. In 1992, a Street Health survey found over a third

(37%) of homeless persons did not have a valid health card on their person, though nearly all were entitled to one, and seven percent reported they were refused care sometime during their lifetime because they lacked a card. In 2007, after several years of investment in ID and health card replacement and storage programs for homeless people, and in kiosks in hospitals to assist in the process of obtaining a health card, about the same percentage (34%) reported having no health card, and the percentage reporting they had been refused care due to their lack of a card in just the previous year had increased to

28%.51 As authors of the study put it, "It seems that fraud prevention has disproportionately affected people with the highest burden of health problems" (Street

Health 2007a:48).

51 These kiosks were closed down after the Severe Acute Respiratory Syndrome (SARS) outbreak in Toronto in 2003. It is also noteworthy that this survey was conducted only in English, thus very likely missing the experiences of many ethnic minority groups. 103 Figure IV-1 Ontario Health Insurance Plan (OHIP) Cards (1990,1995)5 2

OHIP Card - 1990 Version (red and white)

fH gagBff 6 mmmmimim SHi 1 —•- 0123 456 789 1 "*• 0123 456 789 2- ROBINSON, DANIEL MARTIN • ROBINSON, DANIEL MARTIN '1290 ,87654321 N 4~ -1290 ,87854321 N

1 • Sonic

*• 0123 456 789 ROBINSON, DANIEL MARTIN

00

1 Health number 2 Name 3 OHIP number 4 Expiry date of coverage (month/year) - not on most red and white cards 5 Version code - on replacement cards only 6 Health 65 Indicator - signifies eligibility for Ontario Drug Benefit (available only in Ontario) 7 Date of Birth 8 Sex Cards must be signed. Red and white cards are signed on the back while the photo card is signed on the front.

52 Ministry of Health and Long-term Care 2007: 5-4, 5-5, 5-6. 104 OHIP Card - 1995 Version (photo)

Rainbow Printing a sophisticated printing technique to prevent counterfeiting Trillium Ontario's official ftower Photo- digitized and printed right on the card for added security 3H21 • (»<>4 • 372 • AM "* Health Number and Version. Code- •a unique number for each Ontario resident /l«»Mi • 12 • 05 F

Signature - ITH • 12 • 05 • 2000 » 12 • OS digitized and printed right on the card to prevent counterfeiting r Date of birth Card issue and expiry dates in year-month-day order to show when it m time to renew

^Cart Statement responsibility as the holder of a Health Card S* Magnetic Stripe so health care providers can check that cards am valid Organ donor code for people who wish to donate organs when they dm Holographic overlay

another security feature to prevent counterfeiting Microprinting Is hidden in the card

another security feature to prevent counterfeiting

Bar code so health care providers can check that cards am valid

A new version of the health card was issued in 2007 with additional security features, including a primary photo with holographic overlay as well as a secondary photo and

105 signature, laser engraving of personal health information, and a 2-D barcode (Ministry of

Health and Long-term Care 2007).

In addition to administrative alterations to the health card and its eligibility requirements and processes, the coverage provided by OHIP itself was reduced. Over an eight year period, 22 different services (valued at $ 100 million) were delisted from OHIP coverage.53 All affect vulnerable populations, and those most reliant upon OHIP for preventive health support, the most. One of the most devastating gaps in coverage for homeless persons is that only select dental services - some surgeries done in hospital - are covered by OHIP. The onus is on provincial and municipal governments to provide funding for dental services. No preventive oral health services are covered at all, and tooth extraction is one of the few dental services covered for social assistance recipients in Ontario (Street Health 2007a). This means persons do not seek care for oral health needs until an event has progressed. They end up relying (again) on emergency rooms in hospital for care that is costly, results in prescriptions they cannot fill, and/or they have tooth extractions which compromise their overall health, affect self-esteem, and limit opportunities for employment or career advancement. Again, all of this could be avoided if regular oral-health preventive services were covered.

The requirement that immigrants must reside in Ontario at least three months, and provide assurance they intend to live there over the long-term, before they can access

53 For example, in 2001, audiological services were delisted; in late 2004, the Ministry reduced the number of routine eye exams from annual to biannual for patients aged 20-64 without a known medical or disease condition related to the eyes. Chiropractic and physiotherapy services were delisted for most persons soon thereafter (Leduc Browne 2000:17-18). 106 medical care is yet another example of reforms affecting the most vulnerable. Over half

(55%) of all immigrants to Canada between 1991-2006 settled in Ontario. Meanwhile, the level of poverty amongst racialized communities increased (Ornstein 2006; Galabuzi

2001). Perhaps most exasperating is that the policy has saved less than .01% of the health budget, and ultimately resulted in higher fiscal and social costs -including creation of homeless families among this population - over the long-term. Between 1990 and

2007, the proportion of low-income families in Toronto rose from 16.3% to 28.8%

(Lewington 2007).

As access to fundamental resources for survival - housing, food, income - and to preventive health care dwindled, the complexity and volume of health care needs has grown for impoverished persons.

The Beginning of Targeted Homeless Health Care

In response to concerns about the homelessness crisis, and considerable political pressure, the Minister Responsible for Homelessness (an office no longer in existence) was given responsibility for developing a homelessness strategy, and met with Ministers throughout the country. The end result was a program called the Supporting

Communities Partnership Initiative (SCPI), which made $753 million available over three years - originally targeted to ten Canadian cities. The purpose of the targeted funds was to enhance community capacity to contribute to the reduction of homelessness in Canada, not to provide housing. As one local advocate observed, "The homelessness strategy was designed to make homeless people more comfortable, but it wouldn't make them any less

107 homeless" (Crowe 2007a:26). In Toronto, a portion of these funds were funnelled to three Community Health Centres in Toronto - Regent Park, Parkdale, and Queen West - to either develop a specialized program for homeless clients or to offer the funds to physicians in their communities who were already seeing these clients. Separate, additional funds were targeted for programs and services for homeless Aboriginal people, including to Anishnawbe Health, a Community Health Centre targeting Aboriginal populations (Native Women's Association of Canada 2007:2-3). A key impetus for the funds was to ensure eligible homeless persons had assistance in obtaining their OHIP cards.

On the face of it, Community Health Centres (CHCs) were logical recipients for these funds, given their mandate to serve the underserved in their communities. Yet prior to the arrival of these targeted moneys for homeless persons, CHCs were not focused on serving that population. Indeed, in the late 1980s and early 1990s, CHCs were being harshly criticized by local homeless advocacy groups, like Street Health and the street nurses network, for neglecting to sufficiently serve this marginalized group in their communities. Ideas for how the new funds would best be used created controversy among

CHC personnel. One provider who worked in two of these CHC programs during this era said the CHCs' focus had primarily been on serving low-income working people who lived in the surrounding community, so some personnel bristled at the idea of changing the focus to include persons who were unemployed and/or transient54. Some CHC staff

34 Community Health Centres have historically defined community as "belonging to geographic area or a specific group of people" (Albrecht 1998 vi.). 108 preferred the money be spent for targeted services off-site, in homeless shelters or drop-in programs, and on clinicians doing outreach to encourage clients to use their services on- site; this perspective provoked fears about how to find resources to respond to an expanded client base. Others thought it should simply be spent enhancing what they were already doing, given that many CHC patients were marginally housed. In the end, each of the three CHCs used their homeless funds in very localized ways and embraced divergent models.

Street Health was funded by the provincial government in 1989, when some volunteer nurses caring for homeless persons in local shelters and drop-in centers became busier and more politicized. From the beginning, this group of nurses incorporated advocacy and political action into their work, considering addressing structural issues at least as important as the "bandaid" care they were providing. Their primary advocacy agenda was to ensure hospitals and CHCs were addressing these clients adequately. Yet this small program stood out as a rarity. Very few health services existed expressly for homeless persons. In 1995, Street Health was comprised of four nurses and two HIV workers; in 2007, the multidisciplinary staff totals 25. In the same year Street Health was originally funded, "Street Patrols" was launched by Anishnawbe Health. Street Patrols consisted of a few outreach workers who assisted street-involved Aboriginal persons with survival needs. In 2004, a Trillium grant enabled this program to shift from a "crisis management orientation" to a case management model based on native traditions which has been considered very successful with longtime homeless persons (City of Ottawa

109 2005:34). Today, in downtown Toronto, health care is being provided by clinicians from outreach vans and buses, in homeless drop-in centres and shelters, and in targeted homeless services within Community Health Centres and hospitals. The next sections of this chapter review providers' perspectives on the current realities of providing health care for homeless and underhoused persons in hospitals and in these various community venues, offering a frontline view of the impacts health systems reforms have had on their clients and on their abilities to provide them care.

IVb. Health Care for Homeless Persons in the Hospital Setting

Prevalence rates of chronic and acute illness, of mental health and/or substance use disorders, and mortality rates, are all higher among homeless persons than housed

(Zerger 2002a). One consternating paradox in providing health care for homeless individuals is that they are most apt to rely on hospitals for much of their health care due to a variety of barriers and issues related to their housing status, and to the easy accessibility of its emergency services55, yet hospitals are not well-equipped to care for them, even less so as they become more acute-care focused. Emergency Department physicians are uniquely situated to serve as health advocates for patients, but their

In a joint presentation to the Ontario Ministry of Health and Long Term Care in 2001, by St. Michael's Hospital, Seaton House, Toronto Ambulance, and the Rotary Club of Toronto, the groups presented the following statistics: Number of visits to Toronto Emergency Rooms (ERs) every hour by single men, homeless sometime last year: 9 (79,000/year); proportion of visits for sandwiches, shelter, dressing changes, colds, tension headache, scrape/bruise; left before seen by MD or getting prescription: 24%; proportion of visits mainly because of intoxication: 9%; proportion of visits by ambulance: 15%; proportion of ambulance trips for a sandwich, cold, etc.: 12%. Costs of ER visits by single homeless men: $22.5 million; costs of ER visits including admissions: $38 million; Costs of inappropriate ER visits: $6.7 million. 110 practice environments do not encourage this and staff often feel inadequately prepared to address many health-determinant issues (Bandiera 2003). Pressures to respond rapidly to patient needs, and to discharge patients quickly, leave even less time or opportunity for thoughtful discharge planning, causing frustration for clinicians and other health care providers in both hospital and community care settings.

Mainstream health care settings - the emergency room or inpatient floor of the hospital, the doctor's private office, or walk-in clinics - create difficulties for many homeless persons more than they help them. One of the clash points is that the Canadian health care delivery system is based on a medical model. Elsewhere the problems associated with the key assumptions underlying the medical model have been exposed, as well as how they hinder the capacity of the health care system to improve health

(Armstrong and Armstrong 2003). Some aspects of the medical model of care, though, are especially problematic when housing status enters the picture.

Separating the biological illness from social context, for example, is especially incongruous when someone has no home or other basic necessities of life. Safe housing

(not to mention food, income, social interaction, and so on) is directly linked to one's health. Its absence creates health problems, exacerbates existing ones, and creates barriers to health care access. (See Chapter 2 for more detail.) And medical training

56 A recent article named several challenges to effective discharge planning for homeless populations, including: lack of time, failure to name one person as directly accountable for the quality and success of the discharge plan, and absence of a separate payment mechanism for discharge planning (Backer, Howard and Moran 2007). Another named impediments to "effective health advocacy" in emergency departments, including long patient waiting times, multiple simultaneous time demands, and lack of ongoing contact with patients (Bandiera 2003:337). Ill which emphasizes compartmentalization of the human body and skill in isolating single curable illness to resolve is of little use when clients present with multiple' complex, often severe, health concerns. One physician remarked,

It's difficult to really drill down with them clinically and isolate what is really wrong with them because it's often really a multitude of things. It's not just that there's a leg ulcer that's MRSA positive, but they 've also got nutritional issues, some chronic illness that's never been diagnosed or managed... it's problematic (2-9). Another noted the increase in complexity of cases arriving in Emergency Rooms: "Our pressure is in the Emergency Room. People are coming with greater acuity, greater degrees of crisis" (1-263).

Care Compliance

A number of factors contribute to a homeless person's inability and/or unwillingness to comply with clinical treatment and advice, severely compromising continuity of care and encouraging fragmentation and duplication of service. Reasons most frequently documented include mistrust of large institutions based on negative experiences, intimidation by hospitals or doctors, fear of negative provider attitudes, lack of income or transportation, and lack of awareness of how to access services (McMurray-

Avila 2001). Homeless or underhoused visible minorities and women are especially likely to resist these settings due to lack of trust and fear of negative attitudes (Kappel

Ramji Consulting Group 2002; Native Women's Association of Canada 2007; Whitzman

2006).

Procedures clinicians in hospital or clinic settings are typically able to take for granted are thwarted when a client does not have housing. Adding a substance use

112 disorder and/or a mental illness means some are simply unworkable. Obtaining medical history and records, for example, is complicated for individuals who have accessed a variety of clinicians in several settings and are unable to retain or organize their own records. Requiring a patient to wait for long periods of time in an institutional setting is untenable for many persons, but for those with mental illness or addiction issues, it can be the difference between obtaining care and leaving unassisted. Keeping appointments for follow-up care can be hindered by lack of transportation or a telephone, and conflict with schedules for food or shelter lines (Whitzman 2006). Profit-driven political decisions like cuts to public transportation57, cuts to shelter beds and meal programs, and policies which limit the number of "no-shows" before a client is uninvited to return to a clinic, all compound these barriers.

As clients are permitted shorter inpatient stays, clinical instructions for follow-up care become more critical to the individual's ability to heal. Yet directives to, for example, keep one's weight off of a fractured leg, complete dressing changes, follow a specific diet or eat food prepared in a special way, get bed rest, obtain and take medications, and so on - are all virtually impossible for a person living in an emergency shelter or on the street and relying on food programs or dumpsters for their nutrition

(Hwang and Bugenja 2000). One physician describes the challenge of providing care to homeless patients this way:

57 Though price hikes are underway, concerns are not just about price but also accessibility. WheelTrans, for example, is a specialized paratransit service in Toronto, but trip confirmations are routinely made by telephone or internet which is not feasible for many homeless persons. It also uses a rigorous screening process, and a numerical rating system that does not allow for the fluctuating needs associated with many disabilities. It also penalizes customers for cancellations and "no-shows" by suspending service. 113 As a physician you 're trained to identify a problem and come up with a solution. The understanding is that once you 've identified the solution, the patient will follow the instructions and do it, and the problem will be solved. Probably the biggest challenge is to let go of that (23-399).

If equipment, such as a walker or wheelchair, is required, a shelter or transitional residence may not have space to keep it for the client, and there is the potential for theft.

The act of prescribing medication creates special dilemmas. Knowing what to prescribe, for example, is affected by reliance and comprehensiveness of medical records. As one provider noted, "It's hard because they might have gone to another doctor. We don't know what to prescribe, and there's always the possibility of an overdose" (7-52).

Ensuring the ability to purchase and fill a prescription is not possible if the client is not known to be homeless, or if he/she does not have a current, valid OHIP card. Prescribing narcotics is fraught with ethical concerns, largely because many have street value and the client may sell them or have them stolen. Providers are faced with decisions like whether it is appropriate to deprive a person of pain medications or limit the quantity simply because of their circumstance. And, providing care to clients who are unwilling to participate in their care - due to conflicting priorities, mistrust of authority, mental illness, etc. - can be particularly frustrating. One hospital-based social worker spent several days completing an application and convincing a nursing home to accept a homeless client, only to learn he was evicted the day after he was admitted. "I don't do any less for them than I would anyone else. However, when I go to all that work and they don't follow-through, it makes it hard to go to those lengths the next time"(13-A5).

114 Another dilemma for clinicians caring for homeless persons in a hospital or clinic setting is how to do so most effectively without treating them fundamentally differently from other patients. Paradoxically, providers are trained under an ethos which encourages them to treat people alike, to accept patients as they are and not discriminate, but then are asked to provide care within a health care system which increasingly functions under an oppositional business philosophy. Caring and curing are based on conflicting assumptions; caring for a patient not only does not fit neatly in the dominant medical model, but frequently runs counter to it (Armstrong and Armstrong 2003). A business model places limits on the flexibility providers have to do their job, and clients who are homeless profoundly challenge this limitation. One physician provides an example of this, demonstrating how the system itself can encourage a different - lower - standard of care for homeless clients. A man visited this physician for a fracture of the humerus; his usual medical procedure would be to put it in a partial cast, ask the patient to watch it and return in a week to determine whether it would heal without doing surgery. The physician realized this would not work for this patient, whom he knew to be living on the streets and highly unlikely to return for follow-up. The physician found himself advocating for the patient to have the operation done on his arm at that time rather than waiting to determine whether it was appropriate to do so. When the response was that he should treat the individual like he would anyone else, he realized while he usually argued that homeless people should not be treated differently, in this case he was

115 doing the opposite to achieve an equitable outcome. Understanding the rationale behind differential treatment is critical to this issue of delivering health care to homeless individuals within a mainstream system, as it is so closely linked to the social determinants of health dismissed by the medical model approach. Judge Rosalie Abella addressed this rationale when she coined the term "employment equity" in 1984:

It is not that individuals in the designated groups are inherently unable to achieve equality on their own, it is that the obstacles in their way are so formidable and self-perpetuating that they cannot be overcome without intervention. It is both intolerable and insensitive if we simply wait and hope that the barriers will disappear with time (Abella 1984: preface).

Specific contexts and histories are also key to appropriate health care. As one author stated it in relation to women's health care, "treating people the same is often not good enough. Indeed, it may be quite inappropriate for care" (Armstrong 2001b: 129). Equity of health care for homeless persons must involve recognition of differences in terms of their context, capacity and power, but the free market approach runs counter to this.

Mental disorders are not mere symptoms of broader social conditions, "poverty, lack of security, violence, the lack of healthy family relationships during childhood, and trauma or significant losses.. .are crucial factors for mental illness" [cited in (Wermuth

2003:120)]. Homelessness and unsafe or crowded housing are thus not surprisingly highly correlated with numerous mental illness diagnoses. Homeless women, for example, have prevalence rates of trauma and post-traumatic stress disorder that near

100% (Bassuk et al. 1998). When mentally ill individuals, and/or those with substance

58 In the US, clinicians working with homeless persons have developed alternative clinical guidelines on disease entities like diabetes mellitus, asthma, chlamydial or gonococcal infections, otitis media, HIV/AIDS, reproductive health care and cardiovascular illness. (Reviewed in: Montauk 2006.) 116 use disorders or addictions, in need of health care encounter a hospital setting and providers not conducive to their needs, the result can be inadequate resolution of the health care problem or even catastrophe. Several providers commented on the discomfort associated with some of these patients: "Often around the fact that they were dishevelled and smelly and intoxicated, and might be swearing, maybe not presenting as the nicest people" (23-8). "Nobody likes to be sworn at, nobody likes people who are abusive" (23-

399). As with empathy, general knowledge and training around mental health are inconsistently distributed across clinicians. Many community providers shared their frustration with this, as in the following comment: "It's the luck of the draw. It's so much down to the individual doctor, their interpretation of the mental health act, their sympathy - or lack thereof - to your clientele" (19-275). As psychiatric hospitals and beds have closed, however, hospitals are seeing increasing numbers of these patients.59

The Centre for Addictions and Mental Health is in the process of moving toward a tertiary care role, reserving already limited beds for tertiary specialized services. Part of this process is encouraging emergency departments to absorb more of the care of mental health patients. As one Emergency Room manager noted: "pushing all regular-type mental health patients out is very overwhelming for places that aren't set up for it" (12-

120). In the past, hospital personnel at least had more flexibility in terms of keeping patients in their care:

59 Globally, mental illness is expected to increase, especially "depression, anxiety, and compulsive disorders" among societies where there is high income inequality. An aging population is expected to contribute to higher incidence of dementia, and violence and poverty will make the population more susceptive to mental disturbances. For discussion, see: Wermuth 2003. 117 It used to be they [the Ministry] didn 't worry about it. Then it was down to 10 days. And believe it or not we did have patients longer than 10 days -patients who were autistic, behavioural issues, what do you do? So we had them living in Emergency. But now the Ministry is saying you can't have anyone longer than 3 days. But sometimes it takes you longer than 3 days to sort patients out... (12-100)

And, as noted previously, addiction treatment services are not only shrinking but are trending toward non-residential day treatments and away from a continuum of care approach which encompasses harm reduction, factors with disproportionately negative effects for impoverished and homeless persons.60 Again, however, providers without sufficient training will see increasing numbers of patients with substance use disorders in hospitals and clinics. "Medical education generally doesn't prepare doctors to deal with addiction, disease, infection, and mental illness all in the same client" (Hay et al.

2006:34).

Admission to Care

Some hospitals and physicians simply avoid caring for patients known to be homeless by standing in the way at the front end, disallowing admission into care. All of the providers I spoke with, including those working in hospitals and clinics, shared experiences with this block to admission. One physician, for example, described a male homeless client who had been arrested under the Mental Health Act north of the city:

"They stopped at five hospitals along the way and they wouldn't take him - they said 'we

The current national drug policy in Canada mirrors the US "war on drugs" approach, despite substantial evidence that it has increased the number of unemployed (primarily minority) men and caused a dramatic swelling of the prison population (Wermuth 2003). The associations between the criminal justice system, homelessness, and health are too great to address here, but many of the discharge issues discussed as relevant to hospitals are also directly relevant to prisons and jails. For an overview, see: McBride 2004. 118 don't do that kind of work' or, 'this is beyond our expertise'" (20-132). Eventually a public hospital downtown accepted the patient, a hospital with a specific mandate to care for the underserved. Another provider commented more generally: "Hospitals are not as open to taking patients. They say they are, but they're not, in reality" (4-226). One in five of homeless persons surveyed in Toronto last year reported negative experiences with hospital security, the personnel most apt to be charged with behaviour management in waiting areas. Physicians also frequently balk at seeing homeless patients in their private practices or community drop-in clinics, for many of the reasons already discussed plus the fact that they, like others in the general population, may harbour stereotypes and stigmas about poverty and homelessness. During interviews, the names of just a few physicians kept coming up as those rare providers actively engaged and skilled in serving this population. All of this means the pool of providers already considered insufficient for the general population is even smaller for those most in need.

The fee-for-service payment arrangement is unworkable for physicians who serve this population, in large part because many homeless persons do not bear the valid health cards necessary for reimbursement. If the venue is the Emergency Department where the provider is legally required to provide care, this is not technically a problem. (Though at least anecdotally by providers' and homeless persons' accounts, refusals do occur in emergency rooms.) On the other hand, primary care providers and doctors seeing non­ emergency patients in ambulatory practices are within their rights, and in fact are directed to, demand payment up front for patients who cannot provide OHIP coverage when they

119 present for services. The fee-for-service system has worked so efficiently that doctors have been trained to expect payment for every patient they see and every service they perform. "The idea that you would provide free service for someone who's either uninsured or poor and uninsured is still a foreign concept for most physicians" (8-218).

In addition to difficulties obtaining payment for services rendered, though, the fee-for- service payment is also problematic because it incentivizes curative treatment and high volume care. Following is one physician's description of why the fee-for-service payment plan does not work for homeless clients:

Where it is an issue is that our clients uniformly have complex health problems because they are dealing with issues of social determinants of health. We don't see high volumes in a day. And a fee-for-service system doesn 't remunerate you based on what you have actually done for a client, or time, it just says is this a minor, intermediate, or complete assessment. ...So I spend two minutes saying yeah I've looked at your throat and listened to your chest and say you have a cold -1 bill for an intermediate assessment. I spend 45 minutes talking about your depression, your housing, your diabetes -1 still get paid the same amount of money (23- 94).

In effect, the fee-for-payment system encourages short and costly visits and discourages preventive care. One of the responses - again, rather than fixing the problem upstream - has been to put money into programs which assist individuals in obtaining and storing their health cards. These programs are overwhelmed and under-resourced, but are attempts to address the gap in the existing system. In community settings, alternate payment plans have been developed for physicians to compensate services they provide to individuals without health cards. These are discussed in greater detail below.

120 Discharge: Where Community and Hospital Providers Meet

Treating homeless persons in hospital settings can be demanding, unpleasant, and rife with ethical quandaries, but the true dilemma is at the moment of discharge, when providers must send patients home to recuperate when that patient has no home to go.

The homeless patients get caught in the crossfire between the provider preparing them for discharge, and the provider in the community called upon to tend to their recovery.

Providers in both environments have ample horror stories to share. Providers on both sides of the situation label it atrocious, but despite some awareness of the systemic causes for the dilemma, animosity can be found in both camps.

Hospital discharge planners under pressure to get the patient out the door may be unable to find a safe and appropriate place for him/her to go, unaware of his/her capacity to follow-up on a treatment plan and sufficiently heal, or possibly unaware of the patient's housing situation at all. Following are comments from hospital administrators who oversee and manage emergency department staff:

I've been here 25 years. Certainly the pressure to discharge is very significantly increasing all the time because of both scarcity of inpatient resources, as well as system philosophy. The system philosophy is towards treating people out of hospitals as much as possible (2-9).

When beds are really tight and ER 's are really hopping, there are not thoughtful discharges going on (12-100).

Homeless people often don't come unless there's something very wrong. And they often don't come of their own accord. The stretch for a lot of staff, ethically, is that these people need medical care, yet they often refuse to stay in hospital. So they 're discharging these patients out the door and really they're falling off the edge of the cliff as they step out the door. Because we never know if they're going to fill a prescription, take

121 medication, follow-up with their treatment plan. And so that's a really uncomfortable position where you 're a health care worker in the business of helping people, and the system doesn 'tfeel like it's there to support these people (2-9).

We can arrange to bring patients back, and we do all the time. But if they 've given an address, or we 've gotten wrong information - that's where it's dangerous. We had a patient with pneumonia come in, we gave them IV antibiotics and discharged them thinking they were going home to a place where they could rest and get better. And they weren 't (12-10).

It should be noted that although these predicaments certainly affect and frustrate physicians, who are ultimately responsible for a patient's discharge plan, it is frequently nurses and social workers - primarily women — who bear the brunt of planning after-care arrangements and patients' discharges.

Community providers on the receiving end of seemingly thoughtless or even heartless dumping of humans on their doorsteps, frequently lack the ability or resources to care for them. Following are examples of discharges that nurses and social workers in the community have witnessed and struggled to understand:

One woman had a urostomy, a horrible apparatus tapped into her kidney. Acutely suicidal, crack-addicted, with some psychotic features. I managed to get her in there (ER) and was told they 'd keep her at least overnight. I left at six, and later learned she was sent home before midnight. She was living at a (homeless women's shelter). You couldn 't get more pathetic, more downtrodden, and she's sent home in the middle of the night. Just the fact that she had to walk through crack alleys to get home. It's discouraging. ... she tried to kill herself (6-93).

I've had guys dropped off here (shelter) wrapped in a hospital bedsheet and a colostomy bag with no way of changing it, and us with no way to do that. And we don't know how. Literally. They took care of immediate health needs, I suppose, and everything else fell outside their bailiwick (10-190).

122 They '11 discharge them with an IV, and they 're supposed to come back every day to get their IV. However with drug users you 'vejust given an open vein to use drugs. It's just baffling (7-149).

People get discharged and 24 hours they 're back to the street - they 're less trusting, they 're more traumatized. That's not a win for anybody (18- 90).

Responses vary to the witnessing of these events, but most feel on some level that their hospital-based colleagues must simply not care: "They don't care. They don't care. I don't know if there's a way to make them care" (16-268). The reality of all of these providers' work lives is that they have less time than ever to do more time-consuming, complex care than ever, so it is no wonder that reactions to the needs of those caught in the middle are not as thoughtful as they could be.

Although the general consensus is that homeless persons are not best cared for in a hospital emergency room, that hospitals exist for acute, not preventive or long-term, care, and that the real issue is appropriate housing, hospitals remain a major source of care for this population whose numbers and needs are growing. Their responses have varied. Two of the downtown Catholic hospitals, who include service to the

"disenfranchised and disadvantaged" in their institutional mission and value statements, have created isolated crisis areas within their emergency departments where individuals can shower, eat and rest after treatment; employ social workers to address client needs in the waiting rooms; and provide clean used clothing. One has recently developed a bridging program to ensure care is provided in the interim until home care can be provided. As the individual describing this noted, though: "For some that will probably

123 be the difference between readmission versus none. Of course, if they funded

Community Care Access Centres adequately in the first place, it wouldn't be needed"

(13-321). Other hospitals in the area have developed community panels and committees to dialogue about needs and strategies and to raise awareness, or developed lists of community resources for discharge planners. A Homeless Discharge Tool-Kit was developed to assist hospitals in these efforts, but it ultimately had minimal impact due to lack of input from hospital personnel in its development. The question for hospitals administration, though, is what is the incentive for them to improve upon their care for this population? Increasingly operating in a business model, hospital administrators see the issue as one of market-share, not one based in values. "If they have any mode of decency they'll see that's not the way you treat people. But instead it's a money thing"

(4-226).6i Even those two hospitals which stand out for their mandate to serve the impoverished, no longer consider it their mandate to provide primary health care for homeless people; that is falling to the community.

IVc. Health Care for Homeless Persons in the Community

All mainstream services are dedicated towards people who are housed (10-232).

There... needs to be a broader acknowledgement that frontline health services will be needed more and more if action is not taken to address the underlying social causes of many of the health problems faced by the people living on Canada 'sfrontlines (Hay et al. 2006:vii).

61 Ironically, the reality is that the care they are providing their homeless clients is actually very costly given the frequency of readmissions. 124 The rapid development of health services in Toronto specifically for homeless and underhoused persons over the past decade or so has been reactionary, fragmented, and piecemeal. As one provider put it, "it was a reaction to what was an obvious need. ... it arose out of a people's sense that we needed to do something, rather than out of a strategic plan" (8-50). Today, these services comprise a semi-cohesive informal system which operates largely outside of the mainstream. They are typically small or medium- sized, under- and insecurely-resourced nonprofit agencies, most at least partially reliant upon volunteers. The author of a recent descriptive report on "frontline" services such as these noted: "in a real sense, these services are 'marginalized' like the people they serve"

(Hay et al. 2006:32).

These community-based providers feel shut out of the mainstream; most feel unacknowledged, unappreciated, and at times disrespected. Mostly, though, they feel hopeless in the face of the battle they see their clients up against to achieve health - via housing, employment, nutrition, income - knowing they are usually only able to provide stop-gap, bandaid solutions which manage the problem but do not resolve it. "What we see is a very sick system, not a very sick client" (10-297). Their palpable sense of futility is reflected in comments about their work, such as: "it's like peeing in an ocean" (6-315),

"it feels like an uphill battle to nowhere"(7-238), "it's like beating your head on the wall"

(19-120), and "we're just lemonade stands in the refugee camp" (9-282).

Little research has focused on the physical or psycho-social impacts of providers working on the frontlines, but close examination of their environments and

125 responsibilities, and comments such as these, indicate high levels of stress involved with their work. These providers spend much more time with patients and generally have a more holistic approach to health care; this conflicts with the medical model approach they are trained for and operating within (Armstrong and Armstrong 2003:95). They are also heavily reliant upon hospital staff to communicate with them about their mutual clients, and to respect their role in the clients' care. To this end, they spend a great deal of time educating mainstream staff about homelessness and poverty, mental health, and substance use disorders, and advocating on their homeless clients' behalf. Though personalities occasionally play a role in the communication breakdown, the system itself can be blamed for the limited time and flexibility either parties have for this vital function. Ultimately, however, communication between these colleagues is very poor, and can have grave consequences for homeless clients. The following comment is from a community-based physician frustrated with hospital-based providers who work with her homeless clients.

I'm not your dumping ground while you 're the expert. That sort of perspective is not about my ego, it's about a lack of respect for the work being done in the community, and ultimately a lack of respect for the client. .. As a provider it's dehumanizing, it's discouraging, and in terms of concern for what it does to our clients, it's devastating (16-151).

Community Health Centres and Community Care Access Centres

Community Health Centres (CHC) are nonprofit or government-sponsored organizations which offer a range of services to promote health in the community, including interdisciplinary teams of care providers who are remunerated by salary (not

126 OHIP). Though they typically focus services on a geographic catchment area, their aim is to serve individuals and families who face barriers in accessing mainstream systems.

As noted earlier, three downtown CHCs in Toronto were the first recipients of targeted homeless-health care funding, which they used in various ways according to their organizational interests and community politics and needs. While today many hospital- based providers assume a referral for a homeless client to a CHC will result in assistance, those in the community are more aware of the limits of CHCs: long waiting lists and crowded drop-ins. The reality is closer to this statement from the Toronto's Right to

Health Care Coalition's recent report: "CHCs receive some funding from the Ontario government to provide care to noninsured patients, but are overwhelmed with demand and typically unable to open service for those in need" (Right to Healthcare Coalition

2007:3). [See also (Goering et al. 2004:22)]. In 2002, for example, 80% of the CHCs were closed to new clients (Kappel Ramji Consulting Group 2002:78). A study of homeless women in Toronto noted these constraints on CHCs to be responsive is especially problematic for women without a health card, who seek CHCs as their first option to obtain primary health care (Kappel Ramji Consulting Group 2002:78).

Another issue is that homeless persons, especially those with mental illnesses and/or long histories of homelessness, tend to be mistrustful of the institutional environment. One manager distinguished his homeless drop-in center from the neighborhood's community health centre along these lines: "We're really a seat of the pants organization, sort of whatever comes through the door is what we do, compared to the CHCs which are very

127 structured and organized. So there's a real culture clash" (13-115). A physician within one CHC noted when the Centre moved into a brand new facility, the homeless and underhoused clients in the neighborhood felt less welcomed and stopped coming.

Finally, CHCs which get engaged in caring for homeless persons remain rare. Just the originally funded CHCs were ever mentioned when I asked about homeless services, and at least one of these has cut back on its outreach services.

In 1996, 43 Community Care Access Centres (CCACs) were set up to coordinate those discharged from hospitals and provide clinical home care to individuals in the community, a vitally important service as health services have increased reliance upon individuals and families in the community. However, unlike physician and hospital care, it is not covered by the Canada Health Act. The importance of these services was duly noted by commissioner Roy Romanow in his 2002 report on the future of Canadian health care. In addition to devoting an entire chapter to home care, he specifically recommended that three priority areas of home care services be covered by the Canada

Health Act (mental health, post-acute care, and palliative care) because they substitute for services that previously would have been covered in hospital (Romanow 2002:181).

Nevertheless, home care services not only remain uncovered by the Act, but the introduction of managed competition to CCACs, combined with rapidly rising demands due to health reforms and an aging population, has been disastrous for families and providers. The managed competition mechanism in essence turns CCACs into "brokers" responsible for tendering home care services - receiving and responding to bids from all

128 agencies and organizations (old or new, non or for-profit), and managing the competition

(Leduc Browne 2000:25). Because CCACs have no obligation to take patients, those most difficult to serve are the ones most apt to be left out of home care. When budgets were frozen in 2001, representatives complained: "We just don't have the funds. When you have so many needy people you have to draw the line somewhere" (Yelaja

2001 :A01). Clearly, providing services for the homeless population through the CCAC is a challenge because the eligibility criteria stipulate that the individual (at minimum) has evidence of three months residency, lives in a suitable home where care can be provided, and has a health insurance card (Romanow 2002:173). Yet the CCAC in charge of inner-city Toronto sees a disproportionate number of clients who are homeless or underhoused, have a mental illness, are HIV-positive or have AIDS, are disabled or elderly and living alone (Leduc Browne 2000). In response, this CCAC has formulated partnerships with organizations in the community which serve homeless people, including homeless shelters, drop-ins, Out-of-the-Cold, and infirmaries (Kappel Ramji

Consulting Group 2002). In most cases, they simply provide those organizations with some nursing hours to provide home care to individuals residing there. Conflicting perspectives on whether and/or to what extent CCACs accept patients without OHIP abound. They are, however, funded on a per diem basis, and are ultimately making decisions based on money. This tends to conflict with their philosophy of providing support for the health of the community. CCACs have also become less involved in

62 Also prior to that year, the provincial government had paid off any debt CCACs had accrued at the end of the fiscal year, but this ceased with newly introduced accountability legislation (Williams et al. 2001). 129 providing mental health services, even service coordination, as the business model becomes increasingly entrenched and their resources restricted. The continuity of care so critical to building trust is also seriously undermined by the managed competition model because different providers win contracts as they come open: "a relationship is impossible to establish and maintain when a client-driven system is converted into a funding-driven competitive system (Leduc Browne 2000:26). One provider commented,

"You're lucky if you see the same nurse twice" (24-3). (See additional discussion on

Ontario CCACs in Chapter 2).

Homeless Shelters and Drop-ins

The impact of more rapid hospital discharge practices on homeless shelters and drop-in centers has been the most dramatic, given their role as a first access point for persons without homes. They began seeing not only many more people on their doorsteps63, but also persons with more complex health needs. As pressures on hospitals increased, discharge workers typically sought help from homeless shelters for those patients with no fixed address. Indeed, discharge planning was identified as a key need by the Mayor's Homelessness Task Force (1999) and generated a workgroup on the topic. All these years later little or no progress is evident. Hospitals continue to discharge homeless clients to shelters, and the consequences are dire.

Not only are shelter staff ill-equipped to respond to these health needs, frequently putting them in inappropriate and dicey ethical situations ["When the nurse is gone, we

63 The number of different people using emergency shelters rose 21% (from 26,529 to 31,985) between 1990 and 2002 (City of Toronto 2003). 130 don't know what the hell we're doing!" (9-B12)], but shelter facilities themselves are not conducive to healing. They were not built or staffed for anything other than temporary residence, and this clashes strongly and dangerously with their newfound role. Most shelters, for example, are closed during daytime hours - the idea being that residents should be out seeking employment - so there is no option for bed rest. One large shelter has 100 residents but only three staff on after 4pm, so "it's hard to even keep [a resident] safe" (12-C7) let alone provide close monitoring. Residents must be mobile to live in a shelter. Only a handful of shelters have elevators, with heavy restrictions on their use, and few have wheelchair accessible toilets and showers, or storage for personal equipment or assistive devices. Shelters have very little control over the amount or quality of the food they are able to provide, or the capacity to be flexible in special food preparation or access. For example, one drop-in which provided 100,000 meals last year did so with City funding amounting to about ten cents per meal. Because these shelters serve individuals nobody else will, some residents have behavioural issues, addictions, mental illness, and/or criminal backgrounds. This means shelters impose rules and restrictions to all residents' freedom, and it can be difficult for a small staff to assure safety to its residents. This is especially a barrier for women, who frequently avoid shelters for precisely this reason (Bridgman 2003; Daiski 2007; Kappel Ramji Consulting

Group 2002; Williams 2003). Access to illegal drugs is also difficult to control. And, the large volume of residents means privacy is nearly impossible to provide, let alone silence.

Shelters are not conducive to sleep. Extreme fatigue is common among persons living

131 without homes, and has important impacts on physical and psychological health and well- being (Street Health 2007a). A recent study of the perspectives of homeless people on their health affirms all of the negative effects of shelters reported here. However, this

author's recommendation that shelters "relax some of the restrictive rules that impinge on human dignity, such as early curfews" may be difficult to achieve given the diversity of populations and needs these shelters are expected to address while maintaining safety

(Daiski 2007:279). Many of the factors which make homeless shelters non-conducive to

healing are also commonly found in crowded rooming houses.

Close quarters and compromised immune systems make these environments

superb for ill health and the spread of infections. As one informant put it, "We've created the perfect service delivery system for a virus. You've got people wandering around for

food here, picking up donated clothing there, to shelter over there..." (13-255).

Tuberculosis remains disproportionately high among homeless populations, as it is primarily a disease of poverty and crowding (Haddad and Wilson 2005). When the

Severe Acute Respiratory Syndrome (SARS) outbreak occurred in Toronto in 2003, the public health system infrastructure had decayed to the point of almost complete

incapacity. Hospitals shut their doors, the Centre for Mental Health and Addictions shut

its doors, and awareness grew of the dangers associated with failing to consider homeless populations in emergency planning. Support workers were not allowed to go into

apartments to check on people because of potential for infestation, and telephones were relied upon for reporting. One drop-in centre became aware of an individual who was

132 asked to quarantine himself. "We thought it was a joke at first; there was no way to actually follow-up and see if he did, or to see where he went" (13-275). Another physician who works with homeless clients remarked, "Exactly what would happen in the shelters if pandemic flu hit the city is probably not that well thought out, and I suspect it would collapse into chaos" (8-341). Approximately five years ago, bedbugs appeared in Toronto and have since become a huge problem. Because they do not spread disease, they are considered a personal - not a public health - problem. Bed bugs make people incredibly uncomfortable and cause untold suffering, however, and are not surprisingly an especially big problem for homeless people and people in substandard housing. As one nurse in a homeless drop-in put it, "Some people are in houses, but live on the streets because their houses have bed bugs" (7-196). A 2005 study on the bed bug phenomenon reported bed bug infestation reports from 31% of Toronto's (then) 65 homeless shelters in 2003. The number of shelters with active infestations increased steadily from spring

2001 to winter 2003 (Hwang et al. 2005).64

It is not surprising that episodically homeless persons, women, refugees, youth, families with children, and other whole groups of individuals will avoid shelter environments to the extent possible (Bragg 1996; Daiski 2007). One agency surveyed its clients about why they did not want to stay in homeless shelters, and the responses were: noise, light, violence, and bed bugs (22-73). Shelters tailored to unique needs of various ethnic minorities do exist, but are rare. A 2007 study on Aboriginal women, for example,

64 Six of the infested shelters made substantial building repairs, and two increased laundry demands on residents. Costs averaged $3,085 for each of the shelters but ranged to $15,000 (Hwang et al. 2005), 133 reported that Aboriginal shelters in Canadian urban centers are inadequate to the need,

and that shelters funded through Indian and Northern Affairs Canada have received lower rates of support than those funded by other sources, thus hindering their viability (Native

Women's Association of Canada 2007:2). The same report says a problem for many

Aboriginal women is that most public shelters "approach issues of family violence and homelessness through a 'justice' lens that does not accommodate a First Nations emphasis on healing" (Native Women's Association of Canada 2007:2). Thus, the fact that many of the frontline health services for homeless persons are geared toward shelter- based individuals thus only addresses a subset of the homeless population. Shelter per diem rates are set provincially, with a municipal supplement provided in Toronto. These rates vary somewhat according to the type of facility and who it serves; for example, rates for youth shelters are highest, and facilities with additional services receive higher rates.

Some advocates have pointed out that although emergency hostels serve many persons with moderate to serious psychiatric, mental health and addictions issues, they do not necessarily receive sufficient funds to coyer counselling and support services (Goering et al. 2004; Kappel Ramji Consulting Group 2002:76).

Shelters remain the only option for many, though, and to address the needs of their clients, the shelter system has taken several initiatives: creating partnerships with mainstream providers to make regular shelter visits, making referrals to providers willing to see their clients, and creating shelter-based medical clinics and medical beds. In 2004, as shelter service costs skyrocketed, the City initiated a review of the health care issues as

134 they related to shelters, to better understand how health care needs (including physical and mental health, and addictions) for this population could best be met. The report found that over 70% of clients were receiving health services on or off-site at more than half of the homeless shelters. The proportion of clients receiving health services increased at 52% of the shelters just between 2001 and 2002 (Goering et al. 2004:8).

One-third of shelter providers reported changing dressings or bandages for residents, the majority store medications and remind residents to take them, and many spend increasing amounts of time travelling with clients or arranging their transport to hospitals and medical appointments. Frontline staff spent 30% of their time per shift dealing with health care, especially mental health, behaviour management, and harm reduction issues.

Despite the prevalence, though, shelter staff are not health care providers, and lack training to accommodate the level of care they are asked to provide. Making matters worse, only a few of the shelters surveyed reported receiving formal instructions directly from hospitals at the time of discharge. All of the informants I spoke to commented that hospitals discharging patients directly to shelters without consultation happens frequently, and that hospital staff often downplay the gravity or complexity of the patients' health status to gain access to shelter beds. Perhaps most disturbing is that shelters are also becoming substitute institutions for chronic mentally ill people who do not have other supports. Long-term care is virtually unattainable, particularly for aging homeless persons with any mental illness and/or substance use disorder. Many nursing home beds have become privatized and far more selective about the individuals they

135 serve, leaving those clients least likely to pay and hardest to serve to reside in emergency shelters (Leduc Browne 2000). Homeless persons also age much more rapidly than housed persons due to the harsh reality of daily living, so are often younger than other nursing home residents and do not fit well into the environment. Palliative care for homeless persons has garnered increasing concern and attention in the frontline service community; just two shelters have palliative care components (Crowe 2007a). Recent forums on the issue have been overflowing, and research studies are beginning to examine it (Podymow, Turnbull and Coyle 2006).

The shelter system is maladapting to meet the needs of persons not accessing services, becoming the new asylum. No longer are shelters providing the traditional

"three hots and a cot;" instead, they are morphing to address a new population with new needs the best they can with limited resources. Almost nobody who runs or works in a homeless shelter or drop-in centre, or who work in hospitals for that matter, believes shelters are an appropriate place for people to recuperate from illness or try to heal.

Community providers also noted, though, that few hospital staff have ever even visited the homeless shelters they frequently discharge clients to, and thus are not likely to truly grasp the capacity (or incapacity) of the shelter to care for them. As one community provider said, "We shouldn't be doing it, but somebody needs to be doing it" (10-48).

Yet few believe either that the hospitals are the appropriate venue of this care, for many of the reasons previously discussed. Herein lies the dilemma. Political-economic factors have driven the rise of homeless populations, eroded the public health infrastructure and

136 safety net, privatized health care services, and created a gap between hospitals and the community. Homeless shelters have begun bearing much of the responsibility for filling this need, putting their thumb in the proverbial dike of need which has overflowed through their doors, while the causes of the overflow remain unaddressed. In the words of one provider, "You can fund all the health care you want in these shelters - if you have no appropriate housing, all you'll have is people who are healthy in shelters" (20-63).

Homeless Outreach

In addition to homeless health services cropping up in various nonprofit agencies and homeless shelters, some outreach services geared toward individuals living on the street or in other public spaces have also developed. As more community agencies become privatized and embrace the medical model, turning people away because of mental health and/or addictions issues, these case management outreach services have grown considerably. All employ mulfidisciplinary teams and use an intensive case management model. A mobile health van (the Health Bus) is operated through the

Sherbourne Community Health Centre to provide health care at various locations throughout the city. The number of clients they have seen has increased from 2-

3,000/year ten years ago, to 22-24,000/year today (25-33). The Centre for Mental Health and Addictions employs five "Shared Care Teams" comprised of nurses, outreach workers and (consulting) physicians and psychiatrists to address severely mentally ill homeless persons in nine locations throughout the city. The Hostel Outreach Program began in 1988 to serve homeless women with serious mental health issues who were

137 living in one of four women's shelters. Over time this program broadened its referral base, and its volume, considerably and began doing outreach in additional sites and on the street. Assertive Community Treatment (ACT) teams also operate in various locations. Most recently, a single Multidisciplinary Outreach Program (MDOT) has been funded primarily to provide support for those housed through the Streets to Homes project, but they too take referrals from throughout the community. The advantage of these approaches is that they provide comprehensive care, and they bring the service to the client rather than relying upon the client to negotiate the systems and find care on their own. Yet all of these outreach efforts in a sense entrench individuals into a lower tier system for homeless persons because outreach workers operate off-site and have little capacity to connect clients back to mainstream services. For example, a Shared Care

Team may get to know a schizophrenic patient in a shelter, get him/her started on treatment and set up treatment follow-up, but because that service is tied to the shelter and not the individual, once the client leaves he/she no longer receives that care. The continuity of care thus becomes severely undermined. The range of salaries varies across providers, even within the same discipline, and providers have to be generalists to a degree which frequently exceeds their training. Pitting each of these programs against each other for the same pot of money is also a good way to ensure coordination and collaboration are kept to a minimum. Complaints of one program "dumping" clients on others unfortunately occurs with growing frequency as demands increase. Comments included, for example: "When ACT teams get tired of their clients, we get them all" (10-

138 178), and, "Streets to Homes workers dump patients on us all the time - to keep their numbers looking good" (15-20).

Homeless Health Care and Hidden Homelessness

The homeless-health care services currently available are serving individuals who are literally homeless, usually those who are "street-involved" or at least accessing homeless shelters or drop-ins. They are more limited in regards to serving those I have been calling the hidden homeless, including women and new immigrants and refugee groups. These providers reported on some of the factors that contribute to the fact that these groups are least likely to have their needs addressed within the existing homeless- targeted services. As one physician in a downtown Toronto hospital commented, "I work with the best-served [homeless] sector, which is the single male population" (8-246).

Experiences with violence and trauma pervade the lives of women who are homeless: it frequently precedes their homelessness, defines their lives while they are homeless, and serves as an impediment to getting out of it. Women with drug use problems or addictions are almost guaranteed to be involved in the sex trade, and are especially difficult to serve. One program manager talked about trying to engage women in a harm reduction program:

We 've been trying to get funding for women-specific programs. We need them everywhere, not just here. The number of women accessing the program is only about 30% at best, and that doesn 't reflect the number of women who are using. There are more than that. I'm not sure what we're doing wrong. There is the sex trade stuff of course. There's privacy stuff. The important thing is child care. You see women's children used against them - by jilted lovers, neighbours, parents, everyone. So if a woman is using and has a child ...one of the big problems is Children's Aid Society.

139 They think women aren 't able to care for their child because of their drug use and that's not true. The problem is poverty, not the drug use. So a lot of women are afraid to come to programs like this because they '11 be identified as drug users. That's one big problem. (5-187)

With women, the sex trade piece is inherent - if they 're using and homeless, then they 're going to be sex trade involved. Even on the street, there's sexism. The pecking order continues. ... Many of these women have numerous pregnancies, children taken away. If you weren 't crazy before, you 're going to be crazy after you 've had four kids taken away (6- 178).

There seems to be an increase in homeless women. The specific challenges for that population is that by and large homelessness is male, and many women avoid going to services primarily because of ...well, there seems to be a fair amount of aggression (14-182).

One provider who has spent most of her years in homeless services working with women comments on what makes them unique:

/ can't think of a single woman I've worked with where there wasn 't at least some indication of violence either in their upbringing or as a woman in poverty or homeless. Usually multiple. Lots of violence of sex workers, or in combination with substance use -from dealers or as dealers. [Iget] a very strong message from the women around getting re-victimized in the system, being homeless and living in shelters, by workers generally by us - around issues of control, wanting to have control/authority over life, not having that or perceiving it. Some women do choose to combine spaces with men, absolutely, get protection that way. But there are also women who live on the street. I knew women mostly connected through the shelter system (willing to go into shelters), but there are a lot who live on the street would not go to shelters. Lot of women I knew would prefer to stay in a coffee shop all night rather than go to shelter. I knew someone who slept outside the police station for protection (26-12).

The Sherbourne Community Health Centre's mobile outreach van (the Health Bus) recently added a stop to their routes which will cater specifically to women engaged in sex trade, though the hours of service makes it challenging. Though it takes time to

140 establish a new regular van stop, staff reported responding to a huge need within the first month. One staff person from the mobile van reported some of the difficulties posed by serving women in that venue:

For women- [homelessness is] always unsafe. Especially if they don't have someone sheltering them, watching out for them - a girlfriend or someone. Sometimes they come to the Bus with their partner (pimp), and you can see they are in unhealthy relationships. You ask her a question and he answers. We try to separate them, give her privacy - or just ignore him and talk to her directly - but it's tough because she's obviously depending on him. And for those who aren 't we see lots of assaults (25- 113).

It is less clear how and where new immigrants and refugees experiencing homelessness are accessing health services. Though some targeted services exist for these populations, they are not always widely known, and even then are often overcapacity. As of the end of 2005, just 11 percent of clients (not necessarily homeless) registered at the Sherbourne

Community Health Centre were classified as newcomers/immigrants; this compares with the 49% of these individuals residing in the catchment area (Sherbourne Community

Health Centre 2006:19). While research has started to document the barriers for new immigrants in accessing affordable housing, we still know little about how to improve their pathways to and engagement with primary health services.

These providers also speculated about why Aboriginals, especially women, are underserved by homeless-health services.

If I had to identify any group, I would say it's the native continuum. That's where things really fall apart. For my money, that's the group I feel oftentimes ... it's absolutely horrifying what they 've been through. ...I've seen women who have been physically, sexually, emotionally abused,

141 cultural genocide. So fragmented and compartmentalized. If anything's a priority, it's the Native piece (6-301).

The Aboriginal community is an issue. We don't see a full load of First Nations folks. I wish we had more onsite to offer that's culturally appropriate. I tend to see mainly white people -born and raised Canadians (16-302).

All of these providers noted they strive to collaborate with services targeted for

Aboriginal persons when possible, but many expressed frustration with their inability to do so meaningfully. This frustration is not unique to providers in Toronto. For example, their comments converge with those of providers working in non-Aboriginal homeless services in Ottawa, Ontario. These Ottawa providers, similarly frustrated at their inability to address the needs of Aboriginal homeless persons, commented that

Aboriginal clients tended to be more socially isolated and harder to serve (City of Ottawa

2005). In Romanow's report for the Commission on the Future of Health Care in Canada in 2002, he dedicated a chapter to Aboriginal health care, noting that Natives get trapped in the middle of mixed funding and shifting responsibilities for health care. This, added to discrimination and a lack of culturally appropriate services, means this population is underserved in the mainstream system; these homeless-health care providers concur that these factors hold true in the homeless care system as well. One program manager put it this way:

There are a lot of politics in the field as far as First Nations providers that don't have the best relationships getting along with each other, governance issues, organizational issues. That has meant Aboriginal people living on the street are not getting the best service, by any means. Lot of internal politics among Aboriginal agencies that provide services. I'm sure they 're complex, and I don't really understand. We talk about it

142 amongst ourselves about why aren 't we doing more?... We 're not doing enough here to address the issue (18-199).

IVd. Funding and Accountability

In the early 1990s, government funders began to shift from providing funding to organizations for services to contracting with organizations to provide specific services.

The profound negative impacts this shift has had on nonprofit organizations that deliver services for the government, including those providing housing, food and health care services for homeless people, have been well-documented (Eakin 2007). The cumulative administrative burden on applicant agencies is overwhelming, and funding agreements and compliance requirements restrict flexibility and innovation critical to an agency's capability to respond in a timely and effective manner to community needs as they arise.

These and other failures of the funding process are problematic for all nonprofit community agencies, but only those unique to homeless service agencies are reviewed here. The original targeted homeless funding for homeless services, the National

Homelessness Initiative - Supporting Community Partnership Initiatives (SCPI) in 1999, completed its second round of three-year funding in spring, 2006 to cease at the end of that year. After enormous advocacy efforts, funding was extended again to Spring 2007.

One administrator and advocate commented, "We got it back, but it was very tentative.

It's up in March, then we'll have another big fight on our hands" (22-220). When funding was finally handed down (technically April, but the Call for Proposals had not been available as of August), it was morphed into a two-year "Homeless Partnership

143 Strategy" with a heavy focus on the "housing first initiative" described earlier, and on accountability.

Funding for most homeless-targeted programs is project-focused and short-term.

The temporary availability of these moneys creates a great deal of instability for small programs and makes any long-range planning nearly impossible. One provider commented,

A lot of the agencies that care for the homeless are small, nonprofit organizations that depend on project funding. They don't have stable funding, so it's impossible to plan. And any effort and energy they have is expended on securing funding as opposed to programming -just applying for the next funding proposal (20-224).

Recruiting staff to work with homeless persons is already challenging, and the lack of stability and salary options for them makes it more so. Because large amounts of staff time are required to fulfill reporting requirements for the funding, there is less flexibility for creativity and innovation, less time to carry out important but time- consuming duties like accompanying clients to medical appointments, and less time for collaboration with partnering agencies. Nearly all of the informants expressed a strong desire and need to improve collaboration efforts with partnering agencies, and saw the negative effects of failing to do so. Yet they also felt stymied by lack of time or resources, as these comments by administrators reflect: "There's no incentive for us to work together, other than our belief that it's beneficial" (9-282). "[Coordinating services] takes somebody, or a group, some time and resources to set aside and be willing to do

144 this" (22-189). These comments echo those from interviews with providers of services for Aboriginal homeless persons in Ottawa, who also expressed a strong desire to collaborate with other homeless-targeted agencies, but named a lack of longer-term funding as the primary hindrance to their programs' capacity to do so (City of Ottawa

2005:17).

Measures of productivity are problematic largely because homeless clients tend to have multiple, complex needs which take time to address. Engaging a person in outreach to draw him/her into a service system can take years of effort. The longer the person has been disconnected, the longer this process can take, yet it is essential to engaging that person in care. Capturing and counting numbers of clients seen and served makes some sense in an appointment-driven clinic setting, but far less in a drop-in centre or transitional shelter for a highly mobile population. Yet only numbers are used to justify services now, providing zero opportunity for nuance in description or difference:

We used to have an officer we could speak to. Now it's us sending in statistics a few times a year through the computer showing yes, we serve this many clients, and that's why our agency is needed (7-95).

These numbers are key to obtaining funding for much-needed service, and are expected to take on even greater importance with the advent of the newest governance structure, the Local Health Integration Network (LHIN), which was put in place in 2006 and enacted in April 2007. LHINs represents the regionalization of health services in

Ontario - a health reform strategy touted to improve coordination and integration of

65 A Toronto Drop-In Network, comprised of 45 drop-in centers for homeless, marginally housed, or socially isolated individuals is a hopeful exception. As with other projects, though, its unstable funding may limit its capacity. 145 health care delivery, control expenditure, and increase the effectiveness of health services by enabling more local input and responsiveness to localized needs. When implemented in other provinces, research and experience have challenged and in some cases refuted all of these claims, but not sufficiently to sway the political endorsement of it as a strategy in

Ontario years later (Church and Barker 1998). As one critic wryly noted, "politically astute action is not the same as sound public policy" (Church and Barker 1998:482).

Over two-thirds of the budget previously managed by the Ministry of Health and Long-

Term Care was given over to LHINs, along with responsibility for oversight of planning, funding and integrating local health services. The Ministry, in turn, has become far less involved in the actual delivery of health care than ever, instead playing a leadership or guardian role. The Sherbroune Homeless Infirmary, as well as all of the agencies included in this study, resides in the Toronto Central Local Health Integration Network.

This is the only entirely urban LHIN: it covers one of the largest populations (approx.

1,100,000 persons) and has a higher proportion of new immigrants and visible minorities when compared with the rest of the province. The Toronto Central LHIN also contains the highest concentration of health providers in Ontario, encompassing 26 hospital sites,

17 Community Health Centres, 34 long-term care facilities, and over 100 community agencies (Sherbourne Community Health Centre 2006:21-23).

Although a detailed discussion of the LHIN structure would be out of place here, the reactions of these providers to this latest development reveal much about how they are perceived within the broader health care system. While all of them agreed that the

146 true impact of the LHIN structure on their homeless service agencies or clinics would not be known for some time, they nonetheless expressed scepticism which ranged from cautious optimism to outright distrust.

One of the primary thrusts of the LHIN is the call for partnership between public and private sector organizations to avoid duplication of services.

We 're being told how there's no money-you have to come to the table, and tell us how to fix the system. That's the spin. Integrate! Coordinate! So everyone 'sjust trying to create strategic plans that fit with their Integrated Health Service plans - trying to present as being on top of it. Ultimately I don't know what it means. To me it doesn 'tfeel like good news - it feels like moving the system to more of a managed care thing. ... The messaging is, essentially, you have to figure out how to fix the system yourself. Without any resources... just by integrating (19-220).

Many find it ironic, given the extent to which they are integrated and coordinated with a wide range of community services within and outside of the health system to serve the needs of their clients. They strongly endorse the principle of developing partnerships and reducing duplication of services, but it is typically discussed and implemented in a manner more appropriate to insular agencies where a client comes in for a single purpose and a formalized intake is conducted. One outreach coordinator commented:

We 're integrated and coordinated with community centers, with drop-ins, shelters, food banks with all kinds of places -the guy who runs the corner shop - there are these other systems that work outside this framework. They may not be formal, may not have these MO As [Memorandums of Agreement]. You 're not just coordinating mental health services - you have to be coordinated with a lot of services - these are human beings with lots of different needs (19-350).

At the core of their concern, perhaps, is acknowledgement that partnerships are themselves a form of privatization and have the capacity to shift the balance of power.

147 Partnerships can push voluntary or public agencies to conform to for-profit practices, as the partners with the most resources are likely to end up with more power. And, "this more powerful partner is more likely to be a for-profit organization, especially in the context of a business paradigm" (Armstrong et al. 2001a:30).

The greatest frustration is with the lack of commitment to the social determinants of health, which would serve homeless persons far better.

... as much as I see them talking about social determinants of health I don't see them making any kinds of overtures or directions to wanting to take on the health housing issue, for example (7-20).

A key theme in these providers' responses is the lack of transparency in the process, and the lack of opportunity to voice concerns directly with those in higher-level positions. To date, it appears opportunities to get involved in the development of the LHIN have been limited, confined to few invited positions on topic-specific councils. While exclusion of these professionals simply reproduces and reinforces extant power relations, inclusion in the form of these councils will not necessarily rebalance power relations. They may deliberately choose not to share concerns they feel deeply about - like structural, systemic inequalities - for fear they might lose support for other more immediate issues.

As one outreach program manager put it,

Some of us have managed to land on their councils - seniors council, addictions council - if you have a link to those you have a little better access. But even if you 're on the council - the message is, again, how are you going to solve the system? I'm on the health council -I'm one of two community people, the rest are hospital, not at the same level - so much on nursing shortages, staff are unionizing. I'm supposed to bring some of the issues from the community forward, but I'm such a small potato in the

148 bigger scheme. So there really isn 't anyone to speak to directly. I think everyone's getting a little leery around getting too vocal (19-220).

This is not to say that hegemonic systems and relations are unchallengeable or unchangeable, but that "the ways of accomplishing that [may be] far more complicated and convoluted than we might first assume" (Nelson 2005:117).

These providers fear the potential of the LHIN structure to endanger their precious resources. With merging of dollars heretofore separated, such as mental health and addictions, all agencies will be in competition with each other regardless of size.

Homeless agencies are most at risk - they 're all scrambling to have projects to show they 're emptying out Emergencies because that's considered value-added (12-270).

...with LHIN coming in, all the addictions and mental health dollars will be thrown into one pot so everybody's going to be fighting for the same money. ...a little tiny agency like us competing for dollars against some big agency, I mean, who's going to win? (7-90)

Several of these providers declared outright that the LHIN is simply the latest in the trending toward devolution of government responsibility and shifting responsibilities to the community sector.

/ think people are very sceptical. Everybody fears this may be one way of cutting costs and blaming the community, or shifting responsibility to the community (20-203).

I think it's really just a way of the government to devolve its responsibility. And have someone else take the egg on the face. They 're very very corporate. Everyone's gone to the Schulich School of Business. The whole social service world has been taken over by MBAs -it's really remarkable (19-178).

149 Alternative Payment Plans

As noted earlier, the fee-for-service method of payment is not entirely workable for health providers working with homeless persons. In response to a few physicians' lobbying efforts, and a dose of serendipity, the Ministry has enacted some alternative payment plans (APPs). There are variations of APPs, but those addressing physician care for homeless populations essentially fund physicians on an hourly rate. Major advantages to this system are that it covers both indirect and direct care, and it covers people in Ontario who are undocumented workers, are refugee claimants, or are for another reason without a valid health card. However, it is short-sighted in many respects as well. For example, the funding is only for physicians, which is a much more costly and less appropriate approach than multidisciplinary teams. More importantly, this solution may simply serve to entrench a lower-tier approach to health care because it is paying physicians already serving these populations, not providing an incentive for new providers to serve them. As one physician described it, "The pay is not great - you still have to want to work with this population, but at least it's not a disincentive"(20-226). It is also applicable only in those venues already targeted for specialized services to these underserved populations, such as selected community health centres, mobile units, drop- in centers and emergency shelters.

Features of Homeless Health Care Services

These community-based health services for homeless people have several features in common, all designed to address needs not met in the mainstream system. For

150 example, they provide services with minimal if any eligibility criteria and offer flexible drop-in hours or transportation to medical appointments to counter difficulty with making and keeping appointments. Providers strive to address the immediate needs clients may prioritize over their health, such as access to housing and income. These services offer flexibility, providing care where the patient lives or spends time rather than requiring him/her to travel to a clinic, accepting and accommodating deviant behaviours, relieving the patient of the onus of service coordination, and providing a multidisciplinary and holistic approach to health care. They also attempt to be more sensitized and responsive to, and experienced with, issues related to mental health and/or substance use disorders.

As the current federal government strives to eliminate harm reduction from the nation's approach to substance abuse treatment, for example, these services' capacity to accommodate individuals at a stage in recovery not yet conducive to abstinence becomes even more critical for saving lives and preventing spread of infections. That is, the innovation and flexibility inherent to these community-based health care services is key to caring for individuals otherwise not served by the universal health care system. Yet they exist, and have developed and grown, because the public health infrastructure has crumbled while the capacity of medicare to be truly universal has shrunk, thus opening a broad gap for society's most vulnerable to fall through.

The growth of the homeless-health care infrastructure has recently been recognized, along with other nonprofit organizations responding to the needs of individuals not otherwise served by the universal health care system. The focus of a

151 roundtable discussion on frontline services, the "Frontline Dialogues", hosted in Ottawa in 2007 is a formal example of this acknowledgement. While they are playing a vital role in persons' lives who would otherwise not have their needs met, these organizations are unwittingly becoming institutionalized extensions of the public welfare system. They are acting as voluntary back-up to a safety net that is no longer functioning adequately. This has some parallels to the community's reaction to create food banks in response to hunger. Shields and Evans note that, by becoming this institutionalized extension of the welfare system, "food banks can assist the state in the depoliticisation of hunger, in that they enable governments to look the other way and deny the right to food" (Shields and

Evans 1998:97) 6. Similarly, homeless-health programs, are unintentionally buoying up neoliberal policies and letting the governments off the hook.

IVe. Summary

This chapter provided a brief synopsis of the political-economic factors behind the development of homeless-targeted health services in Toronto, namely the simultaneous deterioration in the public health infrastructure and the narrowing capacity of the medicare system to care for all Canadian citizens. Much of this decline has occurred over the past decade; the election of Ontario Premier Mike Harris in 1995 and embrace of his neoliberal "Common Sense Revolution" platform is credited with

66 When a group of respite providers asked a US federal government official in Fall 2007 for advice about how to obtain sustainable federal funding for homeless respite care, he responded by warning them not to follow the path that food banks had taken and become too effective at filling the gap at low cost before arguing for the need for funding. 152 expediting it and creating what many consider a homelessness crisis. The main thrust of the governmental response at all levels has been to narrowly focus on the subset of homeless persons who are most costly to the system, and to increase reliance upon emergency and stop-gap measures. These changes are largely described from the perspective of those persons responsible for providing care to homeless persons in both hospital and community settings, with an emphasis on how they have experienced those systems failures in their roles on the frontlines.

While homeless persons rely heavily upon hospitals and emergency rooms for their health care, these institutions are ill-equipped to address their needs. Health care reforms have dissolved the ability of providers in these settings to be flexible and provide equitable treatment to homeless persons, an ability already challenged when patients are not able and/or willing to comply to treatment directives due to their housing status. As pressure to discharge patients more quickly increases, these providers experience a major dilemma when their patients have no home to go to for recuperation. Many of these homeless patients end up at homeless shelters or drop-ins, which do not have the trained staff, facilities, resources, or mandate to take care of their health needs. Demands on providers in both settings severely limits their capacity to communicate or coordinate care for these patients.

This point of discharge from hospitals is precisely where homeless persons are caught in the crossfire. Providers who work with homeless persons (primarily in community settings) have responded by building frontline services and enhancing the

153 capacity of existing community agencies to address these health care needs. The resulting infrastructure is piecemeal, having grown organically in response to needs as they arose. These efforts are characterized by innovation and sensitivity to unique needs of the homeless population. Yet these programs and services are under-resourced, usually with short-term and insecure funding not conducive to long-term planning, reliant upon volunteer staff or staff working for compensation below private sector levels, and especially vulnerable to governing structures built on a business model which runs directly counter to the needs of homeless persons. And their capacity to serve women,

Aboriginals, and visible minority populations is also limited, thereby reproducing stratification seen in the broader health care system as a whole. One consequence of this infrastructure appears to be that it unwittingly entrenches a lower-tier of health care for the growing number of persons unable to access medicare, and reinforces the intents of reforms aiming to commodify health care.

The next chapter looks more closely at one of these targeted frontline programs, the Sherbourne Community Health Centre Homeless Infirmary, which was designed specifically to serve homeless persons with nowhere to go upon discharge from the hospital. By focusing on this Infirmary, I can explore in greater depth the perceived and actual impacts of the infirmary services, and the pros and cons of these targeted homeless services within Canada's universal health care system.

154 CHAPTER V

THE HOMELESS INFIRMARY

Awareness of the need for convalescent or infirmary beds for homeless people who were still sick when they were discharged from hospitals was first officially suggested in Toronto in what has since become known as the "Ann Golden" report, named for the Chair of the Mayor's Homelessness Action Task Force established in

January 1998.67 The Task Force was charged with developing solutions to the "growing problem of homelessness" in the city. One of the three work groups established as a result of this report was an "Infirmary Working Group;" this group in turn produced a report in 2001 which recommended a Homeless Infirmary be developed and implemented immediately (Infirmary Working Group 2001). In addition to more detailed planning, the next five years was devoted to the selection and building of the facility. Several factors led to the building of the Sherbourne Community Health Centre in 2003 as the site for the new Homeless Infirmary, and room for the Infirmary would not be available until that Centre moved into a nearby abandoned hospital building, completed in 2006.

As recorded in earlier chapters of this study, though, the "problem of homelessness" only

Previously, recommendations addressing this discharging dilemma focused on discharge guidelines and lengths of stay in institutions. One example of this can be found in the Coroner's jury report from the inquest into the death of Drina Joubert in 1986 (Coroner, Province of Ontario 1986). 68 The other working groups established included one on Harm Reduction and one on Discharge Planning - the latter developed discharge planning guidelines, which have not been implemented by hospitals. 155 grew in volume and complexity in those intervening years, and certainly by the time the

Homeless Infirmary officially opened its doors in March, 2007.

This chapter explores how the design and development of the Infirmary and its services responded to the changing homeless population, and describes issues faced in taking referrals and caring for homeless clients within the current political-economic context. This is done in part by comparing and contrasting the Sherbourne Homeless

Infirmary with another Infirmary developed during the same time frame in a nearby homeless men's shelter, Seaton House. These two Infirmaries are not competing or duplicating services, although some clients could well be served by either program, but are targeting different persons and actively communicating about who is most suited to their respective programs and services and how best to separately serve them.

Throughout this chapter, I refer to these programs in shorthand as "Sherbourne

Infirmary" and "Seaton Infirmary". This close examination of the Sherbourne Infirmary enables a clearer understanding of how targeted health services evolve within this context, and the factors which affect its capacity to respond to individual and community needs in both the short and longer term. This chapter closes with a discussion of the role of targeted homeless-health care services generally, and the Sherbourne Infirmary specifically, within the universal health care system. As noted in a previous chapter, the providers interviewed for this study represent a mix of disciplines in a variety of settings throughout the downtown Toronto area, and have, on average, over a decade of experience working with homeless persons.

156 Va. Development and Design of Homeless Infirmary Services in Toronto

Sherbourne Community Health Centre Homeless Infirmary

The individuals developing the Sherbourne Infirmary had to be responsive to the vast changes in the homeless populations and their health needs, and the health care system and its services, which occurred subsequent to the Golden Report recommendation in 1998. Most fundamentally, the vision of the need for infirmary beds shifted from one of a "quiet, comfortable place to rest" when recovering from illness, to one which would require a much greater emphasis on medical care (Golden et al. 1999).

Even in 2001, the Infirmary Working Group's vision was exemplified as "health care, bedrest, good meals and close proximity to washrooms. [For example], if they have the flu and just need a healing environment to recuperate" (Infirmary Working Group

2001:1). As one of those involved in the Infirmary's development from the beginning put it, "people didn't anticipate patients would be so sick" (29-85). This shift was also reflected in negotiations for funding. Because this was an undefined model of care, the

Ministry of Health looked at nursing homes and other long-term care rates to estimate costs. The facts that an Infirmary would have much quicker turnaround of clients, who were coming in with acute medical issues and multiple, complex psychosocial concerns, and that nursing homes themselves were grossly underfunded, meant these cost projections were mostly unrealistic. "There's no way we could have run it with the

Ministry's original projections of costs" (29-85). The original model envisioned for the

157 Sherbourne Infirmary in 1998- essentially a place to rest - was no longer sufficient to address the needs posed a decade later.

Around the time of the Golden Report, long-time health care providers serving homeless persons in the community changed their advocacy stance. Whereas they had been strongly opposing development of an Infirmary in favour of better accommodation for homeless and marginally housed persons within the existing mainstream system, they were now acknowledging it as an unavoidable need. The original resistance to the

Infirmary was a more broad-based fight against a lower-tier health care system for the impoverished, and the grudging collapse of the resistance came only in the face of overwhelming and unmet needs for these individuals. This underlying concern about what an Infirmary might stand for - the entrenchment of a lower-tier of health care within a supposed universal health care system - dominated conversations throughout the development of the Infirmary and continues to define its efforts.

We tried to be thoughtful about ...how we develop it in a way that doesn 't further marginalize people. But in a sense our whole being is about the fact that this is a marginalized group who may be getting second class

health care or may not be getting as much access to health care (28-317).

A drop-in manager put it succinctly: "It's always a struggle of whether we are really entrenching a two-tier system. Really that's what an Infirmary is. .."(13-181). The multifaceted character of this marginalization is well-illustrated by a series of 14 focus groups with 340 homeless persons from various underserved populations which was undertaken to inform the design of the Infirmary in 2002-2003. Unique concerns arose in these discussions, such as women's safety and privacy concerns, refugees' lack of health 158 care knowledge upon arrival in Canada, and discrimination faced by gay, lesbian, bisexual, transsexual and questioning (GLBTQ) youth, same-sex couples, and Aboriginal populations in both the shelter and health care systems (Miles 2003). The recurring concern shared by all groups, though, was with follow-up, with whether the Infirmary would resolve their one common issue - their homelessness - during their stay there. If not, these participants remarked, it would still be a helpful resource in a crisis, but would essentially be no different or better than any other band-aid solution. They and the developers saw the potential of the Infirmary to end homelessness, to heal and house clients. To fail to capitalize on that potential, it would simply be a better temporary alternative for recovery, a "softer landing" when leaving the hospital, than could be found in a homeless shelter bed or on the street.

Seaton House Infirmary

In late 1997, just prior to the Golden Report, the Annex Harm Reduction Program opened in downtown Toronto's large (currently 580-bed) homeless men's shelter, Seaton

House, in direct response to the recommendations made by the Coroner's jury into the inquest of three homeless men's freezing deaths the previous winter. The Program is a

"wet shelter," where shelter staff distribute and manage alcohol consumption for alcoholic residents. It began as a 24-bed "safe haven" for men addicted to alcohol, and has since expanded to nearly 150 beds. In 1997, St. Michael's Hospital provided medical

69 This Program and its origins are well-described in Tomislav Svoboda's dissertation (Svoboda 2005). There, he documents that although the recommendation clearly called for a wet shelter, the City was against this approach. Seaton House personnel (along with Dr. Svoboda) nevertheless developed this into a wet shelter program, and have since documented its effectiveness. Other cities in Canada have contemplated replicating this model (McKeen 2007). 159 care as part of the Annex' staff team. The physician sent from St. Michael's was a medical student completing his residency, and although he had trained at large public hospitals in the same neighbourhood, he was appalled at the lack of supports available for these men in the shelter, who were "by the far the sickest [he] had ever seen" (8-128).

His ability as a clinician to communicate with hospital staff and administration about what he was seeing prompted the beginning of a fruitful relationship previously unattainable to shelter staff:

[As] as shelter manager screaming at the hospital administration that...what is happening to these people is wrong and needs to be fixed, I could scream from the top of City Hall and not be heard. I could get a physician who was affiliated with the hospital - a student no less - whispering how long does this need to go on before we fix it, and get all kinds of traction (10-105).

This cultural conflict between medical and community providers clearly affects not only homeless persons, but the individuals building programs and providing services as well.

Over the ensuing years, Seaton House has gradually formalized relationships with St.

Michael's Hospital, which have been formative in the development of an Infirmary within the shelter. In 2001, an Infirmary was opened just down the hall from the Annex

Program. That same year, it was designated a Teaching Infirmary and became a mandatory rotation for medical residents at St. Michael's.

As was true for the Sherbourne Infirmary, Seaton House staff fretted considerably in the development phases about providing separate health services for homeless persons.

They feared development of an Infirmary would alleviate hospitals of addressing homeless persons' needs and entrench a lower-tier of health care for their clients. In the

160 end, they developed the services for the same reason: supportive housing, mental health and addictions treatment, and other necessary services simply did not exist in the community and people were dying as a result.

Because both the Sherbourne and Seaton Infirmaries address the same gap in services, and were developed in roughly the same time period and political-economic environment, some comparisons help to illuminate key issues and concerns related to homeless infirmary services in Toronto's downtown core. In interviews, the Seaton

House Infirmary was repeatedly raised as a reference point for discussion about the new

Sherbourne Infirmary, and when it was not, I expressly asked them to compare and contrast the two. While the two Infirmaries are not competing for clients or duplicating services, they are engaged in discussions about who is best suited to their programs and what services can best address their needs.

One of the concrete differences between these two is that the Seaton Infirmary serves only single adult men, while the Sherbourne Infirmary serves persons of all genders ages 16 and older. Although technically both Infirmaries accept referrals from any individual or agency in the community, the Seaton Infirmary is perceived as exclusively available for St. Michael's Hospital referrals due to its origins. Seaton

Infirmary has 14 beds and Sherbourne has 20. Both provide multidisciplinary care, with teams of physicians, nurses, social workers, and case managers, and operate with a harm reduction philosophy. Ancillary services are available for clients at both - including laundry, food, and help with benefits and housing. Sherbourne can serve higher level of

161 acuity, as it has medical staff available 24/7 while Seaton Infirmary does not have a regulated health care provider overnight.

The facilities themselves are strikingly different. Seaton Infirmary beds are semi- private bunk beds separated by curtains on a floor in the men's shelter, just down the hall from the Annex Harm Reduction Program where alcohol is distributed. Exam rooms are small, and little room is available for expansion in its current location. Sherbourne

Infirmary is a brand-new facility designed expressly for Infirmary services. The nearly

3,000 square foot floor of a renovated hospital is accessible by elevator, and includes private rooms clustered around lounges with televisions, with separate pods for women and men. Exam rooms are juxtaposed to the private rooms. Other services solely for

Sherbourne Infirmary client use include a large kitchen and cafeteria accessible at all hours, a room equipped for physical therapy and exercise, laundry facilities, and a small room dedicated for private meditation or worship. Sherbourne's environment is generally more conducive to controlling infection, monitoring and serving clients, and healing.

Interviewees frequently focused on the environmental differences between the

Infirmaries. Typical comments include: "The Seaton [Infirmary] is dark and dingy and not a very happy place. The people don't really want to go there.. ."(18-177); and,

"Partly because of its location in the shelter, it is generally not viewed as a desirable place to be by people who are not already there"(8-141). Discharge planners frequently encounter resistance from clients about going to the Seaton Infirmary, especially those who have not previously stayed there, due to concerns about safety, proximity to alcohol

162 and other drugs, and its "institutional" feel. Homeless men who participated in the focus group discussions described earlier concurred that they did not like to use the Seaton

Infirmary for these same reasons.

More importantly for this discussion, however, is how these two models of care have evolved, and how that evolution has affected those developing them to perceive their role within the broader universal health care system. As noted earlier, creators of both of these Infirmaries shared concerns that their infirmary programs would be entrenching a lower-tier of health care for homeless and impoverished persons. The decisions to move ahead with the programs were made only when it became clear that too many individuals were not able to access the services they required to be healthy. [As one put it, "People were dying, they were disappearing, and there wasn't any way of treating them" (10-149).]

St. Michael's Hospital looms large in the Seaton Infirmary. Its personnel were involved in providing health care in the shelter from the beginning and have become even more intensively involved; and, it continues to be perceived in the community as the sole referral source for the Seaton Infirmary. ["So many people in the community have seen it as a resource between Seaton and St. Mike's, and that people outside don't get much chance to access it" (28-340).] Funding came from the City of Toronto for shelter staff and services, and from OHIP for physicians. In 2000, St. Michael's researchers published a paper in the Canadian Medical Association Journal which revealed the very low wages physicians were being paid for their work with Seaton House clients when relying solely

163 upon OHIP (Hwang et al. 2000). The City initially responded to the problem with a stipend and an hourly fee for the Medical Director position; as funding constraints became more intense, the City had concerns about the potential for physicians to "double- dip" by charging OHIP and getting a stipend. Seaton staff responded by showing how much care was not being paid for at all. Persistence, time, and luck on the part of

Seaton's staff have only recently resulted in securing a pioneering alternative payment plan for its physicians from the Ministry, but St. Michael's does not provide substantive additional funding for the program. Staff are nevertheless keenly aware that the work they do is not only helping their clients, but is preventing hospital readmissions, emergency room visits, and saving hospitals money as a result. As one Seaton staff person put it,

We 're diverting people from the hospital. Robbing Peter to pay Paul, you always get Paul's support. The relationship is very one-sided. If we're saving you all of this grief and work and money, what are you doing to help us? (10-207).

(This issue of cost-savings to hospitals is returned to later in this chapter.) The

Sherbourne Infirmary, on the other hand, accepts referrals from any of the area hospitals, but perceives itself as a resource to community agencies and providers as much as to any specific hospital. Community providers shared concerns that this Infirmary will become a "dumping ground for hospitals" (16-215) but also optimism that its existence will bridge gaps between the hospitals and communities: "as hospitals grow to rely on them they'll have to learn more and respect what they're doing" (16-314). The Sherbourne

164 Infirmary is funded by the Ministry of Health and Long-Term Care, and does not have plans or interest to seek funding from any hospitals.

The location of the Infirmary beds informs the philosophy of care, including the program's role within the health care system. Seaton Infirmary is a shelter-based model.

Clients who access the Seaton Infirmary are primarily residents who require a more intensive level of monitoring or care. Non-Seaton residents referred there are assessed by non-clinician shelter personnel and must become residents of the Seaton House before accessing Infirmary services. The concern with this process is that individuals would be institutionalized in a shelter setting, required to reside in a homeless shelter to have their needs met. As one physician emphatically retorted, "People shouldn't have to seek access to a shelter system in order to access recuperative care" (1-18). Seaton Infirmary staff, however, assert they are actually doing the opposite. Roughly one-tenth of the men in Seaton House are long-term residents, averaging 10-15 years in residence.70 For these men, Infirmary providers sever ties from all other health care providers and consolidate their medical records, becoming their primary health care source. ["That's not the model we want. We want them housed, but given a system that doesn't care about these people, we do what we need to do" (8-128).] For the remainder of the men served, the majority, staff strive to integrate their care seamlessly with St. Michael's hospital and meaningfully address primary and mental health needs "in front of the disaster" (10-83). Because clients are most often discharged back to their shelter beds, there is an opportunity for

70 This is one example of the changing role of homeless shelters from emergency, transitional housing to long-term care facilities. Reasons for this shift are described in earlier chapters of this study. 165 continuity of care and long-term care provision, and few leave against medical advice.

"Here there is a continuous loop. So when the health needs are met and stable, residentially there's no disconnection" (10-244). Though their residence remains constant, however, moving them between Infirmary and shelter beds means staff

"constantly kind of pull people out by the roots" (8-128). A benefit of the shelter-based model is the capacity for providers to develop trusting relationships with clients over time. One Seaton Infirmary provider compared this with a community-based clinic,

"You can have an excellent primary care clinic devoted to this population - they'll come in, you'll see them, do an excellent workup, and never see them again" (8-128). Input from shelter staff, who have even more time to develop these relationships and can sit with clients during health visits, can greatly enhance the ability of clinicians to provide quality care. Infirmary clients who develop relationships with the doctors are able to return to them even after they leave the shelter, and a handful do, but generally physicians encourage them to find a family doctor in the community. As one doctor put it, "most people would find it odd and undesirable to go to a shelter for their primary care when they're no longer living there" (1-18).

The Sherbourne Infirmary, by contrast, is located within a community health centre, and emphasizes the acute-care focus of their services. Length of stay is a maximum of three weeks. One difference from the shelter model is that individuals who are underhoused may be prevented from homelessness by obtaining care in the Infirmary, rather than required to give up that housing and live in a shelter to obtain the care. As

166 one Seaton House staff said, "You can be saved from losing your home by going to the

[Sherbourne] Infirmary, but by going to Seaton House [Infirmary] you've lost your home" (8-128). On the other hand, the potential for contributing to already fragmented care is more prevalent in the Sherbourne model, where staff have only a short amount of time to build a relationship with the client and learn their medical histories and needs.

The referral process for the Sherbourne Infirmary includes completion of a one-page application form, followed by a verbal, sometimes face-to-face, pre-screening assessment with an Infirmary clinician to determine the suitability of the match. Sherbourne

Infirmary staff defined the admission criteria and referral processes with the overt intent to:

get the message back to the community agencies and hospitals that they have to do their jobs with these clients. ... What we insist on is that there be apian in place - we might be a good part of the plan, but we 're not going to be the plan (23-395).

Hospital discharge planners, for example, must provide assurance that the client has a place to go upon discharge from the Infirmary. Community providers such as shelter or outreach workers must agree to continue working with the client post-discharge.

Infirmary staff strive to make connections to housing, income sources, and meet other client needs during their short stay, but ultimately the onus is upon the person making the referral to follow-through with the client's care.

In the next section, I review some of the issues these staff have faced so far with screening referrals and addressing client needs - from their perspective, as well as the

167 perspectives from providers making referrals - to better understand the role this Infirmary is playing in the broader health care system.

Vb. Referrals to Sherbourne Homeless Infirmary

A slight majority (56%) of the referrals to the Sherbourne Infirmary during the four-month study period came from area hospitals. Although hospital referrals during the study period came from providers at eight different Toronto hospitals, two-thirds (n=18 or 66%) originated at St. Michael's.71 Over three-quarters (78%) were from inpatient units at the hospitals, and 15% from emergency departments. (The remainder were unknown.) Community-based referrals originated in 14 locations, including women's outreach and shelter programs (n=7), homeless and other community health clinics (n=5), homeless shelters (n=3), community health centres (n=3), a mobile van (n=T), and a community care access centre (n=l). (One source was unidentified.) The volume and diversity of referral sources reflects both the level of awareness of the Infirmary as well as the range of need for Infirmary services in the area. All but one of the providers making referrals to the Infirmary during this time period had learned about the Infirmary from a colleague.

Description of Clients Referred (See Table V-l)

At the time of this study, Infirmary Program referral forms unfortunately did not capture demographic information on clients, other than date of birth. Although this

71 Ironically, the first two referrals made to the Sherbourne Infirmary were clients who resided at Seaton House and could have received infirmary care there. This was likely a result of lack of understanding on the part of some hospital staff, and has not happened since. 168 decision was made in the interest of keeping the amount of time required to complete the

referral forms at a minimum, this oversight greatly limits the Infirmary's capacity to track

who is most in need of their services, who they are most apt to serve, and where there are

gaps in care. For example, if the majority of clients referred to them are older white

males, who also have access to the Seaton Infirmary, the Sherbourne Infirmary staff may

decide to more actively recruit clients from sites serving women and/or new immigrants

to better accommodate the needs of those groups. From four-fifths of the forms,

however, I was able to extract information about the individual's gender based on

descriptions of the reasons for referrals (e.g. pregnancy, or use of "he" or "she") or of the

referral source (e.g. men-only shelters). Through this process, I determined gender for

four-fifths (81%) of the clients referred to the Sherbourne Infirmary; of these, 36% (29%

of the total sample) were female. Without any information on the client's race or

ethnicity, I could not draw comparisons to clients served by the Infirmary. No persons

were referred from a program targeting specific groups, such as Aboriginals or refugees.

Just over half of those referred were between 30 and 49 years of age, with an average of

46 lA years. Individuals referred from community agencies or providers were slightly more apt to be female and younger. Approximately seven out often of these referred

clients were identified as homeless, but nearly one-quarter were underhoused. Their most common living situations included homeless shelters (35%), the street (25%), or rooming houses (19%). Approximately half (46%) noted they had mental health and/or

Chi square tests revealed no gender differences for any of these variables. 169 substance use issues. The most common substance of choice among users was crack- cocaine (31%).

All of those referred had multiple medical conditions, many of them in addition to mental health and/or substance use issues. Primary medical diagnoses or presenting health issues for these homeless persons included one or more of the following: fractures or injuries, diabetes, cellulites/infections (including HIV+), respiratory problems, heart disease, surgery recovery (above knee amputation, perforated bowel, broken pelvis, punctured lung), and cancer treatment.

170 Table V-l

REFERRALS TO SHERBOURNE HOMELESS INFIRMARY* (N=48) Hospital Community Total N=27 N=21 N=48 Gender Male 56% (15) 48% (10) 52%(25) Female 22% (6) 38% (8) 29%(14) Unknown 22% (6) 14% (3) 19% (9) Age 20-29 years 4% (1) 14% (3) 8% (4) 30-39 years 22% (6) 24% (5) 23% (11) 40-49 years 26% (7) 38% (8) 31% (15) 50-59 years 15% (4) 9% (2) 13% (6) 60-69 years 22% (6) 9% (2) 17% (8) 70-79 years 4% (1) 5% (1) 4% (2) Unknown 7% (2) 4% (2) Mean Age 48.8 years 44.2 years 46.5 years Client Housing Homeless 70% (9) 67% (14) 69% (33) Underhoused 26% (7) 19% (4) 23% (11) Unknown 4% (1) 14% (3) 8% (4) Living Situation Street 26% (7) 24% (5) 25%(12) Shelter 30% (8) 43% (9) 35%(17) Rooming House/Apt 18% (5) 19% (4) 19% (9) Family/Shared 11% (3) 6% (3) Awaiting housing 4% (1) 2% (1) Hotel 4% (1) 2% (1) Unknown 7% (2) 14% (3) 10% (5) Mental Health Yes 48% (13) 43% (9) 46% (22) Current Substance Yes 52% (14) 38% (8) 46% (22) Use Substance of Choice** Alcohol 18% (5) 5%(1) 13% (6) Marijuana 7% (2) 4% (2) Crack Cocaine 33% (9) 29% (6) 31% (15) Heroin 11% (3) 6% (3) Other 4% (1) 10% (2) 6% (3) * Data sources include referral forms and interviews. ** Indicates multiple responses were accepted.

Hospital vs. Community Referrals

Community providers were asked to indicate on the referral form what the likely

outcome would be for the client should he/she not be admitted to the Infirmary. Of those

who responded (n=19), nearly half (n=9 or 47%) specifically noted that the client's 171 condition (cellulites, wound, illness) would deteriorate rapidly, and seven (37%) feared risk of infection to him/herself or to others given the client's living situation on the street or in a shelter. Others noted risk of depression, compromised dignity, and return to substance use as plausible outcomes. One indicated the client would not be able to have a surgical procedure and/or would risk post-operation complications that could not be addressed. Providers referring from hospitals were asked to indicate how much longer the client would be able to stay at the hospital should he/she not be admitted to the

Infirmary. Approximately half of those who responded indicated they would keep the client until the condition was stabilized or resolved, while the other half said the client would be discharged within a couple of days. Several of these providers specifically expressed concern about infectious diseases, such as hepatitis and MRSA (skin infection).73

To supplement the information provided on these referral forms, I interviewed a subset of 15 individuals making referrals - six within hospital settings (inpatient and emergency departments) and nine from community agencies (drop-ins, community health centres, shelters, homeless clinics). These providers averaged ten years of experience working with homeless persons in the community, and two-thirds worked exclusively with homeless persons in their daily work. In addition to questions reported elsewhere about these experiences, I asked them to discuss specific referrals they had made to the

73 Community-Associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA), has emerged as a major cause of skin infection in the hospital setting. Higher rates of hospitalization, HIV infection, and injection drug use, as well as crowded living conditions and/or poor hygiene place homeless people at higher risk for acquisition and transmission of CA-MRSA. For more detailed discussions, see: Charlebois etal. 2002; Pan etal. 2005. 172 Infirmary, and what would have happened had their client not been admitted. These cases further highlight the situations both these providers and their clients face in the current health care climate. The large majority of their cases resulted in admittance to the

Infirmary, because the few whose referrals were rejected said they had been able to find their client help elsewhere and/or acknowledged the referral was not a fitting match to the

Infirmary. A recurring theme in these cases is the lack of sufficient and appropriate staffing to address the level of need their clients have.

Several of the interviewees had referred homeless women to the Infirmary who were either pregnant or had recently given birth. In most cases, the infants were taken into custody by Child and Family Services immediately after birth. These women were referred due primarily to concerns about post-partum psychosis, emotional distress, and potential for infection. While support is available during pregnancy, and for women whose babies have been adopted or are deceased, there is limited support in the city for those grieving in this situation. A nurse in a homeless women's shelter described the critical need for the Infirmary for both the women and the providers:

Ninety-nine percent of our women lose the baby (to custody). How do you assess post-partum depression? They spend a few days to recuperate physically after having the baby - they may or may not follow-up with their doctor. Some may be active prostitutes and pimps have them out on the street real fast. Post-partum and infection are big concerns (12-B3).

A discharge planner from a Family Birthing Center in a large downtown hospital had referred several women in this circumstance. Asked what she would have done had the

Infirmary been unavailable, she remarked:

173 I would have given her brochures on baby blues andpost-partum psychosis, and explored the kinds of counselling she could get. We have 3500 births a year. The sheer volume of clients means I can't stay involved. She would be an outpatient. The average stay is 24 hours for vaginal births, 3 days for C-section. It would be opening the issues and throwing a band-aid on it. The Infirmary would be able to assess her needs in greater depth. I can't avail myself of aftercare. My role is transition (1-B3).

She would have relied on the shelter system, though she acknowledged shelters would

"not be the best" place for these women to recuperate (1-B3).

Many of the referrals made to the Infirmary are due to mobility issues, and to the lack of staff to monitor clients with ongoing health issues. For example, a health care coordinator in a shelter had made several referrals of individuals unable to navigate the large number of stairs in the shelter:

We can tough it out for a few days, but not if they need longer. We 're charitably based, so we depend on volunteers. Some of the volunteers are kids, so we can't have clients in the building unsupervised (3-B3).

Similarly, a case manager in a community mental health program described a woman in her 70s who lived in the "best housing program available" but was unable to climb the fourteen stairs to her room due to severe cellulites. "She needed help changing her dressing. At the housing program, there are two staff for 21 residents so they can't give a lot of attention" (7-B2).

Were the Infirmary not available, the primary option open to providers would have been to find a shelter bed or, for those clients who had "burned bridges" in the shelter system or were unwilling to go to a shelter, leave them to recover on the street,

This provider also noted that there is financial pressure for clients without OHIP, as the cost to stay is $1000/day. 174 alternatives which would have exacerbated their health problems. A drop-in manager who had referred a homeless man with chest problems and flu symptoms commented that if the Infirmary were not available, "It would have been very tricky. He would have been

sleeping outside on a blanket with a fever. I look at the Infirmary as a life-saving thing"

(9-B5). Taking clients back to the Emergency Room is another undesirable option. The case manager said she would have tried to take the elderly woman back to the hospital:

/ would have had to take her back to the ER and fight with them there. It was the only option even after she fell. The best the housing program could offer was to put her on a couch. She had been to the ER about five times and was on a 10-day run of antibiotics without effect (7-BS).

Given the complexity and volume of need for infirmary services, and their broad referral base, Sherbourne Infirmary staff work hard to do thorough pre-screenings of each client they admit to determine the closeness of fit to their program's mandate. One staff person, a clinician well-known and respected in the community, does the vast majority of these screenings. As noted previously, the onus for the client's long-term plan after he/she is discharged from the Infirmary is on the individual who made the referral. Some of the most common issues Infirmary staff have already faced, and which again highlight the program's unique role in the health care system, are summarized as follows.

Referrals from hospitals, while clinically tend to be very challenging, are generally more predictable and thus easier on Infirmary staff. Many clients are admitted post-operatively, and in an increasing number of cases the client can come to the

Infirmary pre-operation to meet staff and visit the facility, and be scheduled for a post-op stay before they even prep for or have the operation. Medical records and medications

175 are readily obtained from the hospital, and hospital staff have a good sense of how long the visit will or should be. These referrals also, however, tend to be extremely hard work for staff as they require a lot of clinical and personal care and oversight.

Referrals from communities, on the other hand, tend to be less predictable, and their match for the Infirmary harder to discern. Scheduling is more complicated because community agencies rarely have the staff to transport the client to the Infirmary after admittance. This means they are more apt to be no-shows. "You give people chances.

But it's hard when you hold beds and then they don't show up. We have limited beds"

(29-160). While both parties want to take advantage of the small window of opportunity when a client, whose health is deteriorating, is ready and willing to get involved in his/her health, capturing this window can be a moving target given the chaos of their lives. For those using crack-cocaine, this is especially tricky, as they may simply want a place to crash. By admitting those individuals, Infirmary staff would be in a position they do not want to be in. Accessing medical records and medications can also be more difficult, especially if they do not have a provider already.75

This Infirmary was designed and developed by, with, and for community providers to address the gap in service they were seeing for their homeless clients. As a shelter-based nurse commented, "During the planning we urged the need was more community than hospital" (12-B11). At the same time, the shift from hospital to home- care meant hospital staff working with homeless clients were also feeling pressure. The

75 Clients referred to the Infirmary who do not have a regular health care provider are taken on by Sherbourne Health Centre physicians. 176 Infirmary is thus in the process of trying to fulfill the need for both entities, situated awkwardly in the middle. The reality that community-based referrals are more "muddy" and frequently more emotionally difficult for staff than referrals made directly from the hospitals, places strain on this already vulnerable position and has the potential to pull them more one way than another. The question is whether the Infirmary has the ability to maintain this unwieldy balance. One administrator commented,

I'm worried that Infirmary staff will think the community referrals are not worth taking the risks, so they won't be as flexible or patient with them.. ... You don't want to not honour those [community] referrals. But the hospital referrals are way easier (29-225).76

One of the biggest challenges is management of discharges from the Infirmary.

As noted earlier, admittance staff ensure a plan for the client's care is in place upon discharge, but the Infirmary is a unique environment for persons accustomed to being in

"high survival mode" (26-134). Its clean, comfortable, new facilities, combined with providers and staff who treat them with dignity, understanding, and respect, affords them a chance to rest many have not had in years. "I think it's nice to be somewhere where people are nice to you, where you're being looked after, where you don't have to fight for your existence and deal with people's attitudes" (23-243). This environment was intentionally created to provide this opportunity, but in some ways its success in doing so creates unforeseen needs. A key benefit to this respite is that individuals are able to

76 Interestingly, a social worker from a homeless agency suggested this would likely result once the Infirmary became more established. During her interview, when asked which homeless subpopulations might be best served by the Infirmary, she said, "[The Infirmary is] most likely to help those being discharged from the hospital. I don't know if that's a good thing or a bad thing, but it's most straightforward" (10-B13). 177 reassess their lives and situations. Thus, though they may say they are happy where they are - with a preference to go back to the street or to the shelter - at the time of intake, their time in the Infirmary may inspire them to want to improve their housing situation.

The reality, of course, is that the maximum amount of time for staff to assist them in taking advantage of such newfound motivation is very brief (three week maximum), and within a context of very limited housing or supportive services, so Infirmary staff struggle with the challenges of balancing expectations with reality. Staff come from a wide range of training and experiences, and do not always agree on what "compassion" for a client might mean.77 The persons responsible for making the decisions for final discharge are put in an ethical quandary. "It's really tough. It's draining emotionally.

It's one of the worst parts of this" (28-395). "It's really sad because often the client thinks they will find a room in a week, and have often been in shelters for a long period of time, and it's just not going to happen. It's sad, but that's the way it is" (29-160).

Vc. Clients Served by Sherbourne Homeless Infirmary (See Table V-2)

During the first four months of operation, Infirmary staff documented information on admitted clients at intake and again at discharge. Demographic characteristics are highly comparable to those of all referred clients: they are the same age (46.5 years), and are as likely to be homeless (73% vs. 69%). Fewer of the admitted clients were females

(14% vs. 29%o of all referred clients), but these ratios may be closer if gender was known

77 They work as a team to discuss and reach consensus on individual clients, a practice which has been especially challenging for physicians who are accustomed to giving rather than heeding direction. 178 for all of the referred clients. While we know the majority (59%) of the admitted clients self-identified as "white" (usually listed as "Caucasian"), no comparison is possible with referred clients because race was not recorded on referral forms. The majority (n=19 or

85%) of the admitted clients were Canadian citizens, and one each fell into the category of landed immigrant, refugee claimant, and undocumented. Over one-quarter (n=6 or

27%) reported they needed help with legal issues, but just one of these had a legal worker helping them at the time of admission. Over one-third (n=8 or 36%) said they had religious or spiritual practices, and all of them identified several activities they enjoyed doing for fun and relaxation.

Table V-2 SHERBOURNE HOMELESS INFIRMARY CLIENTS (N=22) Gender Male 86% (19) Female 14% (3) Age 20-29 years 4% (1) 30-39 years 18% (4) 40-49 years 45% (10) 50-59 years 9% (2) 60-69 years 14% (3) Mean Age 46.5 years Race White 50% (11) White - European 9% (2) Black (Somali, Caribbean) 14% (3) Metis 14% (3) East Indian 4% (1) Unknown 9% (2) Time Spent <1 year 36% (8) Homeless (This 1 -4 years 41% (9) Episode) 5 or more years 4% (3) Unknown 9% (2)

179 Table V-2, continued SHERBOURNE HOMELESS INFIRMARY CLIENTS (N=22) At At Admission Discharge Client Housing Homeless 73% (16) -- Housed 27% (6) 82% (18) Unknown — 18% (4) Housed Only (N=6) (N=18) Living Situation Rented apartment 0 7 Shelter 0 3 Rooming House 0 2 Family/Shared 3 2 Unsuitable housing (bed bugs, unsafe) 2 0 Hotel 1 2 Palliative care 0 1 Transitional housing 0 1 Client Income No 23% (5) 9% (2) Yes 77% (17) 91% (20) With Income Only (N=17) (N=20) Income Source Ontario Works (OW) 5 6 Ontario Disability (ODSP) 7 10 Employment 1 1 Workplace Safety and Insurance 1 1 Board (WSIB) Old Age Security (OAS) 1 1 Canada Pension Plan (CPP) 1 2 Other 1 3 Health Care Regular Source of Primary — 17 (77%) Care Has OHIP Card — 17(77%) Has information to maintain — 95% (21) self-care

The length of time these clients had been homeless ranged from one day (a woman had left her violent partner) to 20 years. Just over one-third (36%) had been homeless less than one year at the time of intake. This statistic masks the fact that all but one of those who had been homeless less than one year had been homeless multiple times 180 prior to this episode. In fact, all but one of these clients for whom this information was known matched the US federal definition of "chronically homeless" - a definition adapted in Canada recently to target services.78 That is, the Infirmary did not, during these first few months of operation, serve individuals who were newly at-risk or newly homeless.

The primary outcome measures recorded for each client at intake and discharge were health status, housing status, and income sources. The latter two outcomes do not reflect upon the mandate of the program, but rather are indicators of the connections the

Infirmary staff try to make for clients in addition to addressing their acute health care needs. The overall pattern on all outcomes for those clients admitted to the Infirmary was one of marked improvement.

Diagnoses were recorded in three different categories: primary presenting diagnosis, additional diagnoses noted at intake, and new diagnoses identified during the client's stay. Severity rates were recorded on all of these diagnoses at both intake and discharge; these ratings ranged from 0 (asymptomatic, no treatment needed at this time) to 4 (symptoms poorly controlled, history of re-hospitalizations). On the whole, all diagnoses improved an entire severity rating during their stay. Presenting diagnoses rated

2.3 (2=symptoms controlled with difficulty) at admission fell to a 1.2 (symptoms well controlled with current treatment) rating at discharge. For all but one client, who left

78 The US federal definition of "chronic homelessness" - the basis of support for the Housing First initiatives described earlier, is "an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more, or has had at least four episodes of homelessness in the past three years" (Department of Housing and Urban Development). 181 against medical advice, the primary clinician noted h/she had information needed to maintain his/her health in regards to the presenting illness. And over three-quarters had an OHIP card and a primary care physician when they left the Infirmary.

Admitted clients had improved housing situations: one-quarter (27%) were housed at intake, and this rose to four-fifths (82%) at discharge. Though housing situations varied, seven of these individuals moved from the Infirmary into rented apartments, and one each was discharged to palliative care center and to a transitional housing program for women. Nine out often (91%) clients had income sources at the time of discharge, compared to 77% at intake. These statistics do not reflect additional applications submitted for housing and/or income benefits during the Infirmary stay which were still pending at the time of discharge.

Some Descriptive Comparisons of Infirmary Clients

As noted in the methods chapter of this thesis, the forms used to capture information about clients served by the Sherbourne Infirmary were adapted from those developed by infirmary (respite) care providers in the US for an evaluation often respite programs. While comparisons between Sherbourne Infirmary client data and those from

US-based programs provide helpful descriptive information about who is using the services, and draw out patterns of interest for future research, they should be interpreted with caution.

Demographically, the clients look remarkably similar. More than three-quarters of those served in both samples were male (78% US sample of 1,349; 86% Sherbourne

182 sample of 22), with an average age nearing 50 years (48 years US, 46.5 years

Sherbourne). All of the programs serve disproportionate numbers of individuals from visible minority groups, though those groups are somewhat different in the US than in

Canada. For example, African Americans were overrepresented in the US programs,

7Q while Aboriginals were in the Sherbourne sample. Nearly nine out ten (88%) of the US clients listed US as their country of origin, while 85% of the Sherbourne clients were

Canadian citizens. The experiences with homelessness also look similar: 45% of the

Sherbourne clients had been homeless in the current episode for one or more years, compared with 43% of the US program clients.

The largest differences, though they cannot be tested statistically, occur where expected - in safety net measures. Over half (53%) of the US clients had no access to any income when they were admitted to the respite program, and 44% still had none upon discharge. This compares with less than one-quarter (23%) of Sherbourne's patients who had no income source upon admission, and just 9% who were discharged with none.

Access to sources of primary care and health insurance also differ. Upon discharge from the US programs, just half (49%) of the clients had a regular source of primary care, 44% had no health insurance source, and 28% received Medicaid (US government national

A study of an infirmary in a men's shelter in Ottawa had very similar characteristics to those served in the Sherbourne Infirmary: the average age in the Ottawa sample of 140 men was 48 years; 83% were White and 14% Aboriginal (Podymow and Turnbull 2006:380). Interestingly, the sample of the shelter-based infirmary in Amsterdam was also similar: 77% of the 142 clients were male with an average age of 47 years (van Laere et al. 2002:9-10). 183 insurance for low-income individuals) . All of these percentages were even higher at intake. For Sherbourne Infirmary clients, over three-quarters (77%) had access to both a regular source of primary care and a Ontario Health Insurance Plan card upon discharge.

To look at patterns in referrals to infirmary/respite programs, I used a more recent national study of 522 referrals made to 24 US respite programs (Zerger, Doblin and

Thompson 2008). In both of these samples, just over half (53% US sample; 56%

Sherbourne sample) of the referrals came from hospitals. And the list of most frequent admitting diagnoses of referred clients are identical: fractures/injuries, diabetes, cellulites and infections, respiratory problems, heart disease, surgical recovery, and cancer treatment.

Vd. Short-Term Impacts Of The Homeless Infirmary

Beginning this study immediately after the Infirmary officially opened had the distinct advantage of capturing providers' opinions and predictions about its short-term impacts before they were influenced by experience. That is, rather than imagine what the impacts might have been, they could instead speculate on what they would be. In this section, I review themes recurring throughout these speculations, and then look at the research literature for short-term impacts of existing infirmary services.

These percentages reflect national statistics. Among homeless persons accessing federally funded "Health Care for the Homeless" clinics in the US, during 2005, just 22% were enrolled in Medicaid and 70% had no medical care resources (Health Resources and Services Administration 2007:7). Some of the reasons for this low enrollment are addressed in: Post 2001. 184 Nearly all of the interviewees expressed great relief and delight that the Infirmary was now available for their homeless clients. They perceived it as filling a very important niche, a need that had gone unaddressed for too long. Homeless agency

(shelter and drop-in) providers were greatly relieved to be able to send clients for a level of care they themselves could not provide. Three noted that hospital emergency room staff were more willing to take clients when they included a referral to the Infirmary for aftercare. Infirmary staffs experience working with homeless populations, and their openness to the harm reduction model, were considered key to its value. Some typical comments were: "They're just so on track with what the patients actually need" (12-

224); and,

The [staff] have the understanding of the issues around homelessness and mental health in particular. They are prepared to work with these folks. There's a general acceptance of these people and their unique challenges

(5-C7).

Those who had toured the Infirmary additionally commented on the general beauty of the facility, the lack of the "institutional" feel, and the warmth of the reception staff to clients. On the whole, they agreed with this person's comment: "It will save people's lives, and it will improve their quality of life" (16-318). Hospital staff concurred that the

Infirmary is targeting a need they had witnessed or experienced, though administrators tended to see it as serving the community more than the hospital.

Many interviewees also shared concerns. Several, for example, expressed fear that the Infirmary would rapidly be inundated with referrals and that this would affect their current admission criteria. For example: "Sometimes there's a lot of good 185 intentions around this kind of service, but once it gets up and running the criteria tighten, the rules tighten. There's potential for that I think" (22-127). And, "Everybody's going to want to access it. They're going to have to pick and choose who gets in. And that's hard"(7-C7). Others similarly feared that hospitals would take advantage of the

Infirmary's services and change its practices accordingly. For example, "There's concern they'll be a dumping ground for hospitals On the one hand you want to meet the existing need. On the other hand you don't want to do it so well that you obviate the need" (16-222). And, "I fear that hospitals will discharge patients even earlier. The other fear is that the ER will send them to the Infirmary instead of admitting them to the hospital" (12-C7). Both of these fears can be seen as components of the broader concern shared by many from the outset: that the Infirmary is ultimately yet another band-aid solution to the real problem of a lack of affordable and suitable housing. "Are we using this as a stop-gap because we don't have housing?" (6-B12). One informant saw this as a potential reality, but said it depends on the purpose:

If it's to support someone who's in housing who may fall victim to eviction problems because of their health problems, that's one thing. It's a homeless prevention motive. If you have somebody leaving a shelter, going to the hospital, only to be discharged to an Infirmary, to be sent back to the shelter ~~ what we 're doing is fragmenting care at this point. You become part of the problem (10-244).

These concerns about the Infirmary's role likely bespeak the relative newness of homeless-specific health care services, as these seasoned providers have been watching them grow over the past decade(s) despite their strong convictions that the system needs

186 to be fixed. One long-time community provider expressed this sense of defeat in her comment about the short-term impact of the Infirmary:

// '11 make things a little less bad. It's going to make really bad situations a little bit better. And that's a lot of what we do. It's great to have it there. It's going to be hard for them. It's not going to turn clients' lives around, just make things a little less shitty (10-C7).

These preliminary findings support these providers' predictions of the Infirmary's short-term impacts, both their praise and their concerns. All of the persons referred to the

Infirmary during its initial months had multiple, complex health needs, and many additionally had mental health and/or substance use issues. Yet all of the clients admitted to the Infirmary had their acute medical needs addressed, and most additionally showed positive improvements in engaging with primary health care, in their housing situations, and in their access to income. The Infirmary is also fulfilling an important niche for homeless women who have previously not had aftercare options. And, all of the providers making referrals to the program during these initial months reported that without the

Infirmary, the health and lives of the persons they were referring would deteriorate significantly, and their own jobs would have been considerably more difficult.

The concerns, too, are supported by this study. Although the Infirmary attempts to address the needs of hospitals and communities equally, this balance may be jeopardized by the reality that referrals from hospitals are more predictable and less complicated. And, while the model of care was carefully designed not to (further) entrench a lower tier of health care for impoverished persons but rather to "push back" to existing resources by placing the onus of follow-up care on the provider making the

187 referral, it is also true that resources are limited for or simply unavailable regardless of setting. In this sense, the Sherbourne Infirmary is playing more of a"band-aid" role than one of homelessness prevention.

Elements of the Infirmary model suggest it has the potential to build its prevention capacity, such as to serve underhoused as well as chronically homeless populations, given sufficient resources. For example, its positioning as an integral component of a Community Health Centre rather than a shelter affords a unique ability to engage persons into a range of services without requiring them to identify as homeless.

The alternative payment plan in place for physicians also enables it to provide health care for individuals regardless of whether they have a OHIP card, thus offering individuals preventive health care services who might not otherwise receive them and potentially prevent a health care crisis leading to homelessness. And, if it builds trust of local hospitals it will be able to serve underhoused individuals who might otherwise not be able to receive certain surgeries or procedures at all. Again, though, with the volume of demand to address immediate needs of chronically homeless persons so great, this capacity cannot be met without additional resources.

The Value of Infirmary Services

Infirmary services attempting to fill this same gap in service between the hospital and the street or shelter are operating in locations other than Toronto. The only other known infirmary in Canada is a 20-bed men's shelter-based unit in Ottawa, though several others are at least in the discussion stage of development. Medical respite or

188 recuperative care programs have developed in nearly 40 cities across the US, and in a

Q 1

handful of cities in Europe including Amsterdam and Dublin. Published studies on

infirmary programs are sparse, but include assessments of shelter-based as well as stand­

alone facilities (Buchanan et al. 2003; Buchanan et al. 2006; Kertesz et al. 2004;

McGuire and Mares 2000; Podymow and Turnbull 2006; van Laere, Buster and Janssen

2002). Regardless of program model, the clients served are very similar in terms of age,

gender, and diagnoses to those of the Sherbourne infirmary. All of these studies

conclude the programs are suitable and effective solutions to essentially the same

dilemma. Though many of the studies refer to benefits such as clients' improved health

and connections to care, all of them ultimately draw this conclusion about effectiveness by examining measures related to hospital utilization of homeless populations - prevention of early readmissions, reduced hospitalization and emergency department visits, shorter lengths of stay - and the potential, therefore, of cost savings to the health care system. The emphasis on cost savings is likely one of necessity, as all of these programs are under-resourced and thus, ironically, need to document their monetary worth so they can try to claw back from the health care system which drove them into existence in the first place.

There are several problems with focusing on cost as the primary value of homeless infirmary care. For one, it is likely that if an infirmary program is run the way it should be run, and serving a broad range of homeless and underhoused persons, it will 811 refer to all of these programs as "infirmary" services or programs because that is the common usage in Canada. In other locations, however, they are labelled variously as medical respite, recuperative care, intermediary care centres, etc. 189 not result in cost savings. If the infirmary targets extremely high service users (like

dually-diagnosed chronically homeless persons) and operates on a minimal budget, it can

save costs; this is the case for most of the programs studied to date . This does not mean

infirmary programs are not cost-effective, particularly if measured as disability-adjusted

life-years gained, or as months or years of homelessness averted, but they may not save

money. And, as this study has shown, while these infirmary programs exist to address

the shift in care from hospitals to communities, they are arguably an even more urgent

and vital service for other community agencies currently in the position of responding to the need without sufficient resources, than they are to the hospitals themselves. Focusing

only on the value these programs have for hospitals masks both the significant impact they have on community-based homeless agencies, and the role that changes in hospital

services have had on the need for these programs in the first place. Finally, it is problematic that the question of cost is raised at all. As one key informant put it,

"the idea that you 're going to save money by doing good is a dangerous one to promote It's like asking whether sending your children to school saves money. Is that the way you want to think about it? " (8-420)

This issue of who cares for society's most impoverished and how well they are supported to do it, falls more appropriately under the realm of collective responsibility. Framing it as one of money saved, a tactic wholly consistent with the neoliberal approach, severely bounds the solutions available to respond to it.

82 The one exception to this is a study of a stand-alone 24/7 medical care respite facility in the US, which the Sherbourne Infirmary is modeled after in part. These authors could only show that the costs of the respite program were comparable to those that would be provided in a nursing home facility (Kertesz et al. 2004:159). 190 Ve. Long-Term Impacts: The Role of Targeted Services within a Universal Health Care System

Health care providers and administrators who work with homeless populations in

"frontline" or homeless-targeted service agencies are concerned about the role of these agencies within the broader health care system. They are caught between the proverbial rock and a hard place. On the one hand, they are not alone in contributing to what is already essentially a multi-tier system of health care in Canada, their work fulfills a specialized need that the current system is not and arguably cannot meet, and to ignore the need would be unethical. On the other hand, in addressing this need, and fighting for dollars to grow their services, they are aiding in the construction of a burgeoning (albeit fragmented) homeless health care infrastructure, an outcome they oppose.

Brian Day, the president of the Canadian Medical Association, created a stir just a few months after his controversial election to the office when he "publicly confessed to something Canadians have long suspected: It's sometimes who you know, not necessarily how sick you are, that gets you quicker access to medical care" (Walton 2007:A15). Dr.

Day, an outspoken advocate of health-care privatization, had used his inside connections and clout to obtain health care services for himself and his family more rapidly than a

Canadian without such attributes could have. Though his neoliberal view that more differential access would improve medicare remain controversial, the rapid development of "frontline" services and a new national dialogue on "frontline health" are but

83 "The contest has been portrayed as a showdown between a staunch supporter of private for-profit care (Dr. Day) and a passionate defender of medicare (Dr. Burak) - a watershed moment for the CMA, which has backed the idea of publicly funded health care for 75 years" (Picard 2006: A5). 191 indicators of the reality that over 30% of the Canadian population is currently unserved or underserved within the mainstream system, and that without a two or more-tiered health

system this population would be ignored entirely. As one key informant said, "As much

as we say we have universal access and care, we don't. We have a multi-tiered system

already. .. .We don't have a system that accommodates to people whose lives are chaotic, whether they're homeless or not"(23-306). Others noted that:

Fundamentally, our biggest concern was the reality that there already is a two-tiered system. People who have means will probably be able to navigate the system and get their needs met. ... There's absolutely going to be this other tier of health care for people who are, if not outright homeless, at least precariously housed. I don't see how we 're not going to have that. Because you can't turn this around tomorrow (13-77).

If you look at what's happened in Toronto over the past ten years, clearly what's happened is development of specialized health care for homeless people, rather than mainstream health care, even in a setting where at least theoretically everyone has health insurance (8-50).

In this sense, discussion of "tiers" within any public system intended to be universally accessible is moot as long as class differences exist. But the rapid development of specialized health care for homeless people is new, and cannot be entirely attributable to fundamental class differences, though the growing gap between the rich and the poor is one part of the story. What these providers are concerned about seems to be less about their role in creating a new tier of health care, for they are accustomed to finding innovative ways to help clients who lack equitable access to many mainstream systems, and more about the increasing vulnerability and powerlessness they feel as the capacity of those systems weaken further. Over just the past ten years or so, as

192 a direct result of political-economic factors, the safety net as their clients have known it has diminished, fundamental tools of survival are simply unavailable to growing numbers of people: income benefits, work opportunities, health care services, housing or shelter, food. As the numbers of individuals living on the streets and in homeless shelters has grown, so has the harshness of that experience, and the unlikelihood that they will escape it soon or unscathed. These providers are extremely well-versed in the labyrinth of services and resources available in their community, and innovative in accessing them for their clients and making them work. They are accustomed to creating life-rafts, so if that is in the form of specialized health care so be it, but given the current political-economic climate, this familiar exercise feels more and more futile. Put differently - multiple-tiers of access and quality already exist within Canada's universal health care system, and these providers are generally resigned to that - their concern is less about the effect a new tier will have than about the erosion of the existing system, and its capacity to take care of people. Will the volume of clients in need of care outside of that system continue to grow? Which leads to the question: in providing health care for homeless persons, to what extent should the focus be on the need for specialized services, and to what extent should it be on "fixing" the existing system.

Specialized health care for homeless persons is typically provided in spaces not occupied by housed persons: on the streets or in encampments, in doorways or under bridges, in homeless shelters or drop-in centres. This happens out of necessity for that subpopulation of homeless persons unable and/or unwilling to access health care services.

193 Paradoxically, however, it both addresses a unique need and entrenches a separate system of care. As one mental health provider put it,

The tiered part is worrying, but there's also a specialty in it. ...you don't want to pretend that the person who's been beaten up 50 times, has been a sex trade worker, is a crack addict ~ has the very same needs of somebody who goes home to the suburbs. Yet [separating homeless people] always seems a little primitive to me. It seems ghettoizing ( 6-229).

These providers are balancing, on the one hand, the reality that a subset of the homeless population will never be well-served (or at all) by the mainstream health care system and therefore need alternative help, with, on the other hand, the strong desire to avoid creating a separate homeless-health care infrastructure when the existing system is accountable and funded to provide services. They acknowledge the need for both specialized health care services for some homeless persons and the need for mainstream health care services to be responsive to homeless persons generally, but struggle with reining in development of specialized services before they become a full-blown homeless-health care infrastructure. Following are typical comments about this dilemma:

I'm really pissed off that we as a society are moving down this road. I know some examples of really good [infirmary] care [in the US] - that only entrenches the separation between free and available access for all. Maybe I can be convinced that free and available access means it's going to have to be differently available for people with different challenges and different needs, but I don't know (13-359).

I think there's a delicate balance between providing targeted homeless services but not segregating homeless people (16-46).

In principle it would be better to have mainstrearning, but in reality a lot of mainstream services don't meet the real needs of homeless people, particularly the most vulnerable or unwell.... I think there's a subset of the homeless population that it's never going to work well for. And to insist

194 the existing mainstream system should be their source of care is doomed to failure, at least for that subset of homeless people. It's sort of wishy- washy, but I think the answer is that we need both (8-99).

The fear, expressed specifically toward the Homeless Infirmary but applicable generally, is that these targeted services will become a dumping ground for hospitals which are increasingly shifting services to the community. There is general agreement, among providers within and outside of hospitals, that homeless-specific services are better for this target population than a hospital is able to provide. Following are some comments that reflect this:

I think we provide better care than hospitals in certain situations... (9-

305)

I don't think traditional models of health care work for most homeless people. We 're the best equipped, we 've been doing it the longest, we work in a multidisciplinary individualized model, we have a lot of supportive services on-site and we 're connected to other community agencies that matter. To me that makes hospitals out of the question. Completely off limits to any homeless person in their right mind... (16-46)

Yet providers still worry about whether its separation means it is "really a stop-gap measure. Is it really designed in a sense to keep clients out?" (28-103) This concern is reflected in the desire of the Sherbourne Infirmary to emphasize connecting clients with primary health clinics and providers in the community, urging accountability from referring agencies, and avoiding the role of discharging clients to the streets.

As discussed in the previous chapter, a central issue in caring for homeless persons is acknowledging and respecting the differences in their context and needs. As

Judge Rosalie Abella described the paradox in striving for employment equity,

195 "sometimes [equality] means treating [people] as equals by accommodating their

differences. .. .Equality.. .does not, and cannot be allowed to, mean the same treatment

for all" (Abella 1984:3,13). As the capacity of the universal health care system to

provide equitable access narrows, it is those individuals at the bottom of the

socioeconomic ladder who are most apt to get bumped off. The hidden homeless

population - especially women and visible minorities, who are more apt to be

underhoused and/or at imminent risk of losing housing, and those eligible for services but

not able to produce a health card or other required identification - fall into this category.

But for a small subset of homeless persons who will not access that system or have too

many needs that cannot be met within it, specialized services may be the appropriate

answer. The political economic framework points to the specific context within which

the need for this balance to achieve equity is exposed, but these providers are

experiencing the daily efforts and struggles involved in negotiating it.

These frontline providers also strive to achieve another balancing act: between

systems-level and individual-level advocacy. While advocating for clients within the

existing system - helping them navigate services, complete applications and forms, meet

benefits requirements, and so on - they are also advocating for the prevention of

homelessness and avenues for ending it, in the form of affordable housing, income and jobs. While addressing the symptoms (the cancer victim, if you will) they are seeking the

cure for the ill (the cancer). In the Sherbourne Community Health Centre's Family

196 Health Team business plan, this is described as an "uneasy ethical dilemma" for those providers caring for homeless people:

As we work to prevent illness, alleviate symptoms and minimize suffering, our helplessness in influencing the fundamental determinants of health - which include housing - inevitably haunts and outrages us (Sherbourne Community Health Centre 2006:20).

The Centre's vision for homeless clients expressly states that advocacy will occur both individually with clients, and systemically to end homelessness (Sherbourne Community

Health Centre 2006:21).

A primer on organizing health care services for homeless people in the US describes what sets federally-funded "Health Care for the Homeless (HCH)" clinics apart as "the philosophy that their ultimate goal is to help people escape homelessness"

(McMurray-Avila 2001:38).8 The key informants interviewed forthis study echoed a similar philosophy, though, ironically, presented it as a way of preventing - not typifying

- a homeless health care infrastructure like the one in the US. One provider put it this way,

as long as we have the vision of ending homelessness, we 11 be okay. I think we 're straddling something. We 're doing a bit of a balancing act. But I have faith that as long as we have that model in mind - ultimately getting them to the community - and that we 're orienting ourselves that way, then we 're not just saying this is homeless programming. If you say that, then you 're saying it's part of a homeless service industry and that's wrong, there shouldn 't be a homeless service industry. You have to be an activist the whole time. The whole time you need to be saying this is a

In that country, the homeless health care infrastructure has ballooned from 19 targeted clinics in 1987 to 192 (plus over 300 subcontractors and 64 government and private agencies) twenty years later, with federal funding more than doubling in the last decade to the current allocation of nearly $200 million (Health Resources and Services Administration 2007). 197 stop-gap measure as we try to patch things in the community, and 3A of our effort is in the community (9-330).

Most of these providers perceive the Sherbourne Infirmary, and other specialized services for homeless persons, as an indication that the system is broken, that "if we were doing it right, the Infirmary wouldn't exist" (10-297). They see the systemic causes (lack of housing primary among them), and resent the need for separate health care services, but at the same time feel the need to address immediate needs. The following comments illustrate their struggle to balance both issues and concerns simultaneously.

It's not either-or. It's a worthy cause to look at health care for the homeless, but I would rather put my dollars at the other end of the river and have a housing policy. ...But...you need to have something in the interim to manage what their health needs are. You can't leave it go (2- 139).

The ideal would be to have housing. ...Homelessness causes huge health and social issues. Get these people into mainstream instead of creating another infrastructure. I think it 'sfine to develop these support services in the short term because you need to do something... However, it would be nice at the three levels of government for some strategic planning to be done (14-135).

I think you need to be trying to meet the reality that things aren 't going to change instantly. ...At the same time there has to be the fight for housing. Trying to move at the same time toward integrating people into mainstream society (16-242).

If we had a system that accommodated to the needs of everyone, then I would argue that we shouldn 't have specialized services to the homeless or anyone else. But because we don't have a system that is accommodating in equal manner to people's needs, nor does it recognize those needs, I think we have to... if we 're going to be a compassionate society (23-306).

198 They are trying to make the existing system work better, to "reorient mainstream services

(20-184)", build public awareness and acceptance, to fight for housing and generally fight against homelessness (22-77), while addressing the immediate crises coming to their doors85.

A few authors have commented on this paradox, that frontline workers' resistance to the broken system they are operating within - their ability to "work the system" - has unintended benefits to that system (Hopper 2006; Lamphere 2005). Their resistance takes on many forms - such as expanding the scope of clinical work when ancillary services (e.g. case management) are disallowed by managed care, 'creative coding' to make health conditions reimbursable that otherwise would not be, bending admission criteria, and so on - within various settings and roles (Hopper 2006:223). Yet by working the system compassionately on behalf of those whose needs are not being met, their opposition serves to redeem, not undermine, the system. By filling this gap, managing increased workloads and added stress to make the system work for homeless persons, and deliver what they consider adequate care, the battered system is able to continue - "secure in its 'institutional bad faith', riddled with tensions and antagonisms that work against collective action, and propped up by the secret ministry of its own

85 These providers are not alone in their efforts to improve the capacity of the existing system to address the needs of underserved populations, though they are primarily aimed at changing attitudes and practices rather than systems. For example, a roundtable discussion called "The Frontline Health Dialogues," co- sponsored by a federal government affiliate and a pharmaceutical company, was hosted in Ottawa, Ontario in June 2007 for 20 administrators and academics to discuss strategies and solutions from the frontlines of health to "inform and improve mainstream health care delivery" (Pierre and Seibel 2007), Other efforts are targeted at medical training, with development of curricula variably label poverty medicine, frontline medicine, and homelessness and health, and urgings for physicians and nurses to expand their role as health advocates for their patients (Bandiera 2003). 199 reluctant agents" (Hopper 2006:223). These providers are ultimately subsidizing the system, and buffering the impact of reform, by making the system appear to be functioning correctly and well (Lamphere 2005). In this sense, this homeless health care infrastructure supports the neoliberal foundation upon which it was created.

It is wiser to heed these tensions than to attempt to eliminate them; indeed, they should be considered the foundation upon which to create improved alternatives

(Armstrong and Armstrong 2003; Hopper 2003). This study offers initial understanding as to why those tensions exist for persons trying to care for individuals who are homeless within the current system, and what improved alternatives might look like.

Vf. Summary

This chapter traced the development of the Sherbourne Community Health Centre

Homeless Infirmary ("Sherbourne Infirmary") from its origin as a recommendation in a

1998 mayor's report on homelessness to its opening in March 2007. Using the Infirmary as a case study affords a clearer understanding of how homeless-targeted services evolve within this political-economic context, and uncovers factors affecting its capacity to respond to individual and community needs in both the short and long-term.

Though the need for the Infirmary was initially defined as a resting place, reforms during the decade in which it was developed transformed this need into one more urgent and more complex. Another local infirmary in a homeless men's shelter which was developed during roughly the same time period provides a reference point to compare

200 and contrast how the two infirmary models have been designed expressly to both address

acute-care needs (a "band-aid" role) and to make the mainstream system more responsive

(a preventive role). Providers interviewed in both hospital and community settings are

relieved that the new Infirmary is available to fulfill this important gap in care. They also

expressed concern, though, that it could become inundated with referrals due to the

volume of need and result in tightened admission criteria, and that it could become a

"dumping ground" for hospitals as pressures to discharge in those settings increase.

Findings from this study provide support for both of these responses about the

Infirmary's short-term impacts. The Infirmary is addressing needs not otherwise met,

especially for homeless women who have not had any aftercare options. Clients served

by the program had multiple, complex health and psycho-social needs, yet showed

improvement not only in their health but also housing and income supports. All of the

providers who made referrals to the Infirmary during the study period reported that its

absence would have resulted in deterioration of their client's health and made their jobs

far more difficult. And, because the Infirmary is located within a Community Health

Centre and can care for individuals without OHIP cards, it has the capacity to serve

hidden homeless populations, including women and new immigrants who might not

otherwise be served. Concerns, too, are somewhat supported by these findings. For

example, the Infirmary's ability to address the needs of hospitals and communities

equally may already be jeopardized by the reality that referrals from hospitals are more predictable and less complicated. And, its capacity to place the ultimate burden of

201 aftercare on existing resources, and to address a greater volume of need in the community, is limited by the availability of those resources.

While providers are relieved that the Infirmary is available to address a critical need, they are also disgusted that homeless-targeted health services are increasing in their city, within the context of a universal health care system. At the same time, they acknowledge the importance of offering services customized to the unique needs of homeless persons, and the superior ability of their community programs to do this. The universal health care system is not currently responsive or accessible to the needs of homeless persons, which makes the development of this infrastructure, including the

Infirmary, look inevitable. As this study has shown, though, the failure of this system has significantly sharpened with reforms which narrow the focus of hospital care and shift health care burden to the community without providing sufficient resources. These politically-driven reforms have crippled flexibility in the system for providers to care for their patients' needs; cut beds in physical, mental-health, and addictions treatment facilities; and demonized the harm reduction philosophy unanimously considered a critical component of health care for homeless persons. These changes are the result of specific, political-economic, cultural decisions; the development of these targeted services and the Infirmary has not been inevitable. Now that an infrastructure of sorts exists, it provides a low-cost alternative to catching people that are falling through the safety net. These targeted programs are fulfilling this function without a voice powerful enough that the system needs to heed it, and without the mechanisms to meaningfully

202 collaborate with each other. Thus it affirms its neoliberal foundations. The government co-sponsoring "frontline dialogues" with big-pharma, and mutually espousing the benefits of frontline services, supports this.

203 CHAPTER VI

CONCLUDING REMARKS

This thesis exposes factors which have contributed to unprecedented growth of

Toronto's homeless population, exacerbated the complexity of their health problems and how they find and receive health care, and inspired the development of targeted homeless health care services in the city, all within the past decade. A political economy framework situates these issues within their specific socio-historical context, specifically drawing links to the globalization of capitalist modes of production and neoliberal values.

This globalization process has demonstrably widened health disparities throughout the world by killing impoverished people, dismantling public health infrastructures, eroding social safety nets, and emphasizing cost-effectiveness and privatization in the health care marketplace.

Emphasis on the market as the arbiter of societal values and resource allocations underlies the struggles Toronto currently faces with its homeless population, and the solutions being implemented to address their needs. The origin of homelessness as a

"crisis" in Toronto is generally considered to have begun in earnest when the neoliberal platform of Ontario Premier Mike Harris in 1996 guided changes including massive cuts to affordable and social housing supplies, and the slashing of social assistance benefits.

Medicare, too, has been effected by insidious privatization. Expiration dates and

204 identification requirements implemented to Ontario Health Insurance Cards, the key to

access to medicare, greatly increased access barriers for homeless persons. Many

preventive services have been delisted, hospitals closed, inpatient stays shrunk and

services more generally focused on acute-care needs; hospitals are discharging patients

"quicker and sicker." Health care services not covered by the Canada Health Act have been more profoundly affected by imposition of a business model and profit-driven motives to bound their services. The overall shift in responsibility of care from hospitals to families and communities is especially problematic for individuals heavily reliant upon hospitals for their preventive and primary health care needs. Locally, as well as globally, these effects are most devastating especially to women and visible minorities.

Toronto's homeless population has expanded considerably throughout this decade of systemic changes, including persons literally living on the streets and in emergency shelters, but also those living in unsafe or overcrowded housing or at-risk of losing their homes due an inability to pay the rent. Though homelessness is broadly understood to include the latter, and the experience of homelessness is episodic and transitory for most, policies and programs consistent with a business model narrowly target the small minority who are chronically homeless and most costly to serve. This approach not only fails to reinvest in the social determinants of health which led to homelessness in the first place, but serves to entrench myths and stereotypes that dog homelessness and effectively divorce the issue of homelessness and poverty altogether. Given that women and visible minorities are most discriminated against in employment and housing markets, it is not

205 surprising that these are populations most apt to be missed. Yet by culturally constructing the homeless population in public discourse as a homogenous group of

(primarily) white and Aboriginal males living on the street, issues of systemic sexism and racism in the structural causes of homelessness are effectively masked.

Over time, providers who care for homeless persons in community settings have responded to the increased numbers of homeless persons and their health problems by building frontline services and trying to enhance the capacity of existing community agencies to address these health care needs. That the universal health care system is not currently responsive or accessible to the needs of many homeless persons makes the development of this infrastructure look inevitable, but as this study has shown it is a consequence of specific, political-economic, cultural decisions. The infrastructure is piecemeal, having grown organically in response to needs, otherwise not being met, as they arose. These efforts are characterized by innovation and sensitivity to unique needs of the homeless population. Yet these programs and services are under-resourced, usually with short-term and insecure funding not conducive to long-term planning, reliant upon volunteer staff or staff working for compensation below private sector levels, and especially vulnerable to governing structures built on a business model which runs directly counter to the needs of homeless persons. And their capacity to serve women,

Aboriginals, and visible minority populations such as new immigrants and refugees is also limited, thereby reproducing stratification seen in the broader health care system as a whole. Now that an infrastructure of sorts exists, it provides a low-cost alternative to

206 catching people that are falling through the safety net. In this sense, it is unwittingly entrenching a separate tier of health care for the growing number of persons unable to access medicare, and reinforces the intents of reforms aiming to commodify health care.

This thesis focuses on the tensions the growing homeless population's unique set of needs cause providers in hospitals, at the point of negotiating discharge, and those in the community agencies increasingly burdened with the responsibility to care for them.

This tension exists precisely as a result of these reforms and systems changes which are outgrowths of globalization and increasingly entrenched neoliberalism. Providers in hospital settings struggle to serve homeless persons, who are heavily reliant upon hospitals and emergency rooms for their health care, within a medical model of care not conducive the complexity of needs they bring. Reforms have compromised their ability to be flexible and provide equitable treatment to homeless persons, already challenged when patients are not able and/or willing to comply to treatment directives due to their housing status. Under pressure to discharge patients more quickly, these providers face a dilemma when their patients have no home to go to for recuperation. Many of these homeless patients end up at homeless shelters or drop-ins, which do not have the trained staff, facilities, or resources to respond adequately to their needs. Demands on providers in both settings severely limit their capacity to communicate or coordinate care for these patients, and this point of discharge from hospitals is precisely where homeless persons are caught in the crossfire.

207 The Sherboume Health Centre's Homeless Infirmary, which originated at the onset of this homeless crisis in 1998 and opened about a decade later in 2007, serves as a case example to focus this thesis. It exists as an explicit consequence of- and in direct response to - coinciding changes in Toronto's public safety net and health services. The

Infirmary, developed to alleviate this tension and to catch persons caught in this discharge gap between the hospital and the street or shelter, stands at the unique intersection and frequent point of conflict, between hospital and community providers.

The design of the program expressly aims to both address acute-care medical needs (a

"band-aid" role) and to make the mainstream system more responsive (a preventive role).

It is also at the crux of two perspectives which drive so much health policy and funding, the battle over whether more energy and resources should be put into social determinants of health, or into medical care. The Homeless Infirmary is also just one of several infirmaries newly cropping up in developed nations around the world within a variety of health care systems, and thus also serves to uniquely spotlight the effects of globalization on health disparities, homelessness, and the providers who take care of society's most vulnerable.

Interviews with individuals caring for homeless persons in both community and hospital settings, many over the past decade, provide insight into how they have negotiated this newfound tension in addressing homeless persons' needs, and into the development of the homeless-targeted health care infrastructure in general. The recurring theme is one of negotiating a delicate balance. While they are relieved that the Infirmary

208 is available to address a critical need not otherwise being met, they are also disgusted that homeless-targeted health services are increasing in their city, within the context of a universal health care system. They acknowledge the importance of offering services like the Infirmary which are customized to the unique needs of some homeless persons, and the superior ability of their community programs to do this; at the same time, they believe the mainstream system needs to enhance its capacity to treat homeless persons equitably.

This study demonstrates that the impact of reforms is not as predictable or unidirectional as is often assumed, and that while global trends have driven these reforms, the specific local context has a major impact on their effects.

209 REFERENCES

Abella, Rosalie S. 1984. Report of the Commission on Equality in Employment. Ottawa: Minister of Supply and Services Canada.

Albrecht, Dennise. "Community Health Centres in Canada." International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services ll(l):v-x.

Anderson, J.A. 2001. "The Politics of Home Care: Where is 'Home'?" Canadian Journal of Nursing Research 33(2):5-10.

Anonymous. 1995. "Take a Second Look at Photo Health Card." The Record, March 30, A6. Kitchener, Ontario.

Antrosio, Jason. 2005. "Disappearing Act: Race and the Neo-liberal State." Social Analysis 49(2): 199-204.

Armstrong, Pat. 2001a. "The Context for Health Care Reform in Canada." Pp. 14-56 in Exposing Privatization: Women and Health Care Reform in Canada, edited by P. Armstrong, C. Amaratunga, and J. Bernier. Aurora, Ontario: Garamond Press.

—. 2001b. "Evidence-Based Health-Care Reform: Women's Issues." Pp. 121-145 in Unhealthy Times: Political Economy Perspectives on Health and Care in Canada, edited by P. Armstrong, H. Armstrong, and D. Coburn. Toronto: Oxford University Press.

Armstrong, Pat, Carol Amaratunga, and Jocelyne Bernier. 2001a. Exposing Privatization: Women and Health Care Reform in Canada. Aurora, Ontario: Garamond Press.

Armstrong, Pat and Hugh Armstrong. 2003. Wasting Away: The Undermining of Canadian Health Care. Toronto: Oxford University Press.

Armstrong, Pat, Hugh Armstrong, and David Coburn. 2001b. Unhealthy Times: Political Economy Perspectives on Health and Care in Canada. Toronto: Oxford University Press.

Backer, Thomas E., Elizabeth A. Howard, and Garrett E. Moran. 2007. "The Role of Effective Discharge Planning in Preventing Homelessness." Journal of Primary Prevention 28:229-243.

210 Bandiera, Glen. 2003. "Emergency Medicine Health Advocacy: Foundations for Training and Practice." Canadian Journal of Emergency Medicine 5(5):336-342.

Bassuk, Ellen, J. Buckner, J. Perloff, and S. Bassuk. 1998. "Prevalence of Mental Health and Substance Use Disorders Among Homeless and Low-Income Mothers." American Journal of Psychiatry 155:1561 -1564.

Bauman, Zygmunt. 2004. Wasted Lives: Modernity and its Outcasts. Oxford: Blackwell Publishing, Ltd.

Berg, Bruce Lawrence. 1998. Qualitative Research Methods for the Social Sciences. Boston: Allyn & Bacon.

Bierman, Arlene S., and James R. Dunn. 2006. "Swimming Upstream: Access, Health Outcomes, and the Social Determinants of Health (Editorial)." Journal of General Internal Medicine 21(1):99-100.

Bragg, Rebecca. 1996. "Life on the Streets Beats Shelters, Hearing Told." Toronto Star, June 25, A6. Toronto, Ontario.

Brickner, Philip W., Linda K. Scharer, Barbara Conanan, Alexander Elvy, and Marianne Savarese. 1985. Health Care of Homeless People. New York: Springer Publishing Company, Inc.

Bridgman, Rae. 2003. Safe Haven: The Story of a Shelter for Homeless Women. Toronto: University of Toronto Press.

Bryant, Toba. 2004. "Housing and Health." Pp. 217-232 in Social Determinants of Health: Canadian Perspectives, edited by D. Raphael. Toronto: Canadian Scholars' Press.

Buchanan, David, Bruce Doblin, and Pablo Garcia. 2003. "Respite Care for Homeless People Reduces Future Hospitalizations." Journal of General Internal Medicine 18(S1):203.

Buchanan, David, Bruce Doblin, Theophilus Saj, and Pablo Garcia. 2006. "The Effects of Respite Care for Homeless Patients: A Cohort Study." American Journal of Public Health 96(7):1278-1281.

Butt, Leslie. 2002. "The Suffering Stranger: Medical Anthropology and International Morality." Medical Anthropology 21:1-24.

211 Canadian Harm Reduction Network. 2007. "Ideology Trumps Science in the Harper Government's 'New' Drug Policy." Periodic Newsletter, October 8.

Canadian Institute for Health Information. 2007. "Improving the Health of Canadians: Mental Health and Homelessness." Ottawa, Ontario.

Canadian Institute for Health Information. 2005. "Hospital Trends in Canada: Results of a Project to Create a Historical Series of Statistical and Financial Data for Canadian Hospitals Over 27 Years." Ottawa, Ontario.

Canadian Public Health Association. 1997. "CPHA 1997 Position Paper on Homelessness and Health." Ottawa, Ontario.

Carmichael, Kevin. 2008. "Soaring Food Prices Now Top Threat, IMF Says." The Globe and Mail, April 13, A1.

Carrier, Carolyn. 2003. "From Home to Hospital and Back Again: Economic Restructuring, End of Life, and the Gendered Problems of Place-Switching Health Services." Social Science and Medicine 56:2289-2301.

Casavant, Lyne. 1999. "Counting the Homeless." Ottawa: Political and Social Affairs Division, Parliamentary Research Branch, Government of Canada.

Charlebois, Edwin D, David R. Bangsberg, Nicholas J. Moss, Matthew R. Moore, Andrew R. Ross, Henry F. Chambers, and Francoise Perdreau-REmington. 2002. "Population-Based Community Prevalence of Methicillin-Resistant Staphylococcus Aureus in the Urban Poor of San Francisco." Clinical Infectious Diseases 34:425-466.

Church, John and Paul Barker. 1998. "Regionalization of Health Services in Canada: A Critical Perspective." InternationalJournal of Health Services 28(3):467-486.

City of Ottawa. 2005. "Evaluation of and Recommendations for Services for the Aboriginal Homeless in Ottawa." The City of Ottawa Community Capacity Building Team for Homelessness. Ottawa, Ontario.

City of Toronto. 2003. "The Toronto Report Card on Housing and Homelessness." Toronto, Ontario.

Coburn, David. 2001. "Health, Health Care, and Neoliberalism." Pp. 45-65 in Unhealthy Times: Political Economy Perspectives on Health and Care in Canada, edited by P. Armstrong, H. Armstrong, and D. Coburn. Toronto: Oxford University Press.

212 —. 2004. "Phases of Capitalism, Welfare States, Medical Dominance, and Health Care in Ontario." Pp. 225-243 in Political and Economic Determinants of Population Health and Well-Being, Controversies and Developments, edited by V. Navarro and C. Muntaner. Amity ville, New York: Bay wood Publishing Company, Inc.

—. 2006. "Health and Health Care: A Political Economy Perspective." Pp. 59-84 in Staying Alive: Critical Perspectives on Health, Illness, and Health Care, edited by D. Raphael, T. Bryant, and M. Rioux. Toronto: Canadian Scholars' Press Inc.

Conrad, Peter. 2005. "The Shifting Engines of Medicalization." Journal of Health and Social Behavior 46:3-13.

Coroner, Province of Ontario. 1986. "Inquest into the Death of Drina Joubert, 1986." Verdict of Coroner's Jury. Accessed from the Canadian Urban Policy Archive, University of Toronto in May 2008.

Crowe, Cathy. 2007a. Dying for a Home: Homeless Activists Speak Out. Toronto: Between the Lines.

— 2007b. "Toronto Disaster Relief Committee Newsletter, February 2007." Toronto, Ontario.

Daiski, Isolde. 2007. "Perspectives of Homeless People on Their Health and Health Needs Priorities." Journal of Advanced Nursing 58(3):273-281.

Daly, Gerald. 1989. "Homelessness and Health: A Comparison of British, Canadian and U.S. Cities." Cities 6(l):22-38.

De Jong, Iain. 2007. "Healthier, Happier, and More Positive: What 'Housing First' Means to People Housed Under Toronto's Streets to Homes Program." Results of 2007 Post-Occupancy Research. Presented at the National Alliance to End Homelessness Conference, Washington D.C., July 10.

Doyal, Lesley and Imogene Pennell. 1979. The Political Economy of Health. London: Pluto Press.

Eakin, Lynn. 2007. "We Can't Afford to Do Business This Way: A Study of the Administrative Burden Resulting From Funder Accountability and Compliance Practices." Toronto: Wellesley Institute.

213 Eberle Planning and Research. 2002. "Research Project on Homelessness in Greater Vancouver." Vancouver, B.C.

Editorial (No Author Listed). 2001. "Hospitalizing the Homeless." Canadian Medical Association Journal 164(6):741. Retrieved May 17, 2008. (www.cmaj .ca/cgi/content/full/164/6/741)

Edmonton Joint Planning Commission on Housing. 2003. "Interim Edmonton Community Plan on Homelessness, 2003-2006." Edmonton, Alberta.

Evans, Robert G. 1997. "Going for the Gold: The Redistribution Agenda behind Market- Based Health Care Reform." Journal of Health Politics, Policy and Law 23(2):428-465.

Evans, Robert G., Morris L. Barer, and Theodore R. Marmor. 1994. Why are Some People Healthy and Others Not? The Determinants of Population Health. New York: Aldine De Gruyter.

Evans, Tony. 2002. "A Human Right to Health?" Third World Quarterly 23(2):197-215.

Farmer, Paul. 2005. Pathologies of Power: Health, Human Rights and the New War on the Poor. Berkeley: University of California Press.

Feldberg, Georgina and Robert Vipond. 2006. "Cracks in the Foundation: The Origins and Development of the Canadian and American Health Care Systems." Pp. 221- 239 in Staying Alive: Critical Perspectives on Health, Illness, and Health Care, edited by D. Raphael, T. Bryant, and M. Rioux. Toronto: Canadian Scholars' Press Inc.

Fenlon, Brodie. 2008. "Canada's Visible Minorities Top 5 Million." The Globe and Mail, April 2, Al.

Fitzgerald, Scott T., Mack C. Shelley II, and Paula W. Dail. 2001. "Research on Homelessness: Sources and Implications of Uncertainty." American Behavioral Scientist 45(1): 121-148.

Fooks, Cathy and Steven Lewis. 2002. "Romanow and Beyond: A Primer on Health Reform Issues in Canada." Canadian Policy Research Networks.

Forster, Alan J., Heather Clark, Alex Menard, Natalie Dupuis, Robert Chernish, Natasha Chandok, Asmat Khan, and Carl van Walraven. 2004. "Adverse Events among

214 Medical Patients after Discharge from Hospital." Canadian Medical Association Journal 170(3):345-349.

Forum Summary. 2003. Conference: Living on the Ragged Edges: Immigrants, Refugees and Homelessness in Toronto. Held: March 28 at Metro Hall in Toronto, Ontario.

Frankish, C. James, Stephen W. Hwang, and Darryl Quantz. 2005. "Homelessness and Health in Canada." Canadian Journal of Public Health 96(Supplement 2):S23- S28.

Galabuzi, Grace-Edward. 2001. "Canada's Creeping Economic Apartheid: The Economic Segregation and Social Marginalisation of Racialised Groups." CSJ Foundation for Research and Education.

Gantt, Ami B., Neal L. Cohen, and Anthony Sainz. 1999. "Impediments to the Discharge Planning Effort for Psychiatric Inpatients." Social Work in Health Care 29(1): 1- 14.

Garrett, Laurie. 2000. Betrayal of Trust: the Collapse of Global Public Health. New York: Hyperion.

Gill, Paramjit and Gilles de Wildt. 2003. Housing and Health: The Role of Primary Care. Oxon: Radcliffe Medical Press.

Gladwell, Malcolm. 2006. Dept. of Social Services. "Million-Dollar Murray." The New Yorker, February 13, 96ff.

Goering, Paula, Jennifer Pyke, Heather Bullock, Jeffrey Hoch, Stephen Hwang, Sheryl Lindsay, George Tolomiczenko, and Donald Wasylenki. 2004. "Health, Mental Health and Addiction Treatment Needs of People Using Emergency Shelters in Toronto." Toronto: Shelter, Housing and Support Division - Community and Neighbourhood Services.

Golden, Ann, William Currie, Elizabeth Greaves, and E. John Latimer. 1999. "Taking Responsibility for Homelessness: An Action Plan for Toronto." Report of the Mayor's Homelessness Action Task Force, City of Toronto, Ontario.

Gordon, Todd. 2006. "Neoliberalism, Racism, and the War on Drugs in Canada." Social Justice 33(l):59-78.

Gruskin, Sofia and Daniel Tarantola. 2001. "Health and Human Rights." Boston: Francois-Xavier Bagnoud Center of Health and Human Rights.

215 Haddad, M. and T. Wilson. 2005. "Tuberculosis and Homelessness in the United States, 1994-2003." Journal of the American Medical Association 293(22):2790-2793.

Hay, David, Judi Varga-Toth, and Emily Hines. 2006. "Frontline Health Care in Canada: Innovations in Delivering Services to Vulnerable Populations." Ottawa, Ontario: Canadian Policy Research Networks Inc. Research Report F|63.

Health Resources and Services Administration. 2007. 2006-2007 Health Care for the Homeless Grantee Profiles. Washington D.C.

Hilfiker, David. 2005. "Stupid Deaths." Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 9(3):403-416.

Hopper, Kim. 2003. Reckoning with Homelessness. Ithaca: Cornell University Press.

—. 2006. "Redistribution and its Discontents: On the Prospects of Committed Work in Public Mental Health and Like Settings." Human Organization 65(2):218-226.

Hwang, Stephen W. 2006. "After Insurance Issues are Settled." Annals of Internal Medicine 145:150-151.

Hwang, Stephen, Tomislav J. Svoboda, Iain J. De Jong, Karl J. Kabasele, and Evie Gogosis. 2005. "Bed Bug Infestations in an Urban Environment." Emerging Infectious Diseases 11(4):533-537.

Hwang, Stephen W. 2001. "Homelessness and Health." Canadian Medical Association Journal 164(2):229-233.

Hwang, Stephen W. and Ann L. Bugeja. 2000. "Barriers to Appropriate Diabetes Management among Homeless People in Toronto." Canadian Medical Association Journal 163(2):161-165.

Hwang, Stephen, Patricia.M. Windrim, Tomislav J. Svoboda, and William F. Sullivan. 2000. "Physician Payment for the Care of Homeless People." Canadian Medical Association Journal 163(2): 170-171.

Illich, Ivan. 1976. Medical Nemesis: The Expropriation of Health. Great Britain: Penguin Books.

Infirmary Working Group. 2001. "Key Findings and Recommendations from the Final Report: Treated Well." Toronto, Ontario.

216 Institute of Medicine. 1988. "Homelessness, Health, and Human Needs." Committee on Health Care for Homeless People. Washington, D.C.

Irwin, Alec, J. Millen, J. Kim, J. Gershman, B. Schoepf, and Paul Farmer. 2002. "Suffering, Moral Claims, and Scholarly Responsibility: A Response to Leslie Butt." Medical Anthropology 21:25-30.

Kappel Ramji Consulting Group. 2002. "Common Occurrence: The Impact of Homelessness on Women's Health." Toronto, Ontario.

Kelly, Fred. 2008. (11 January) "Where Do They Go After Hospital? Healing Sought for Homeless." in The Charlotte Observer. Charlotte, North Carolina.

Kertesz, Stefan G. 2008. "Homelessness, Addiction and Housing Interventions: What We Don't Know So Far." Presented at 2nd Annual Camillus House Institute of Homeless Studies Symposium: Applying Research to End Homelessness, Miami FL, February 5.

Kertesz, Stefan G., Stacy Swain, M. Posner, James J. O'Connell, M. Schwartz, and A. Ash. 2004. "Hospital Discharge to a Homeless Medical Respite Program Prevents Early Readmission." Journal of General Internal Medicine 19(S1):159.

Kim, Jim Yong, Joyce Millen, Alec Irwin, and John Gershman, eds. 2000. Dying for Growth: Global Inequality and the Health of the Poor. Monroe ME: Common Courage Press.

Kingfisher, Catherine. "Discursive Constructions of Homelessness in a Small City in the Canadian Prairies: Notes on Destructuration, Individualization, an the Production of (Raced and Gendered) Unmarked Categories." American Ethnologist, 34(1):91-107.

Kolko, Gabriel. 1999. "Ravaging the Poor: the International Monetary Fund Indicted by its Own Data." Inter nationalJour nal of Health Services 29(l):51-57.

Labonte, Ronald, Michael Polany, Nazeem Muhajarine, Tom Mcintosh, and Allison Williams. 2005a. "Beyond the Divides: Towards Critical Population Health Research." Critical Public Health 15(1):5-17.

Labonte, Ronald, Michael Polany, Nazeem Muhajarine, Tom Mcintosh, and Allison Williams. 2005b. "Interrogating Globalization, Health and Development:

217 Towards a Comprehensive Framework for Research, Policy and Political Action." Critical Public Health 15(2):157-179.

Laird, Gordon. 2007. "Shelter. Homelessness in a Growth Economy: Canada's 21st Century Paradox." Calgary: Sheldon Chumir Foundation for Ethics in Leadership.

Lalonde, Linda. 1997. "Tory Welfare Policies: A View from the Inside." Pp. 92-102 in Open for Business, Closed to People: Mike Harris's Ontario, edited by D.S. Ralph, A. Regimbald, and N. St-Amand. Halifax: Fernwood Publishing.

Lamphere, Louise. 2005. "Providers and Staff Respond to Medicaid Managed Care: The Unintended Consequences of Reform in New Mexico." Medical Anthropology Quarterly 19(l):3-25.

Leduc Browne, Paul. 2000. "Public Pain, Private Gain: The Privatization of Health Care in Ontario." Canadian Centre of Policy Alternatives.

Lewington, J. 2007. "Proportion of Poor Families Skyrocketing in Toronto, Report Says." The Globe and Mail, November 26, A12.

Lyon-Callo, Vincent. 2000. "Medicalizing Homelessness: The Production of Self-Blame and Self-Governing within Homeless Shelters." Medical Anthropology Quarterly 14(3):328-345.

Mackey, Eva. 1999. The House of Difference: Cultural Politics and National Identity in Canada. Toronto: University of Toronto Press.

Mahoney, Elinor. 2001. "The Tenant Protection Act: A Trust Betrayed." Toronto: Parkdale Community Legal Services.

Marmor, T.R., M.L. Barer, and R.G. Evans. 1994. "The Determinants of a Population's Health: What Can Be Done to Improve a Democratic Nation's Health Status?" Pp. 217-230 in Why are Some People Healthy and Others Not? The Determinants of Health of Populations, edited by R.G. Evans, M.L. Barer, and T.R. Marmor. New York: Aldine de Gruyter.

McBride, Nan. 2004. "Reaching In to Help Out: Relationships between HCH Projects and Jails." Nashville, TN: National Health Care for the Homeless Council.

McDonald, Lynn, Julie Dergal, and Laura Cleghorn. 2007. "Living on the Margins: Older Homeless Adults in Toronto." Journal of Gerontological Social Work 49(1/2):\9- 46.

218 McGuire, James and Alvin Mares. 2000. "Hoptel Equalizes Length of Stay for Homeless and Domiciled Inpatients." Medical Care 38:1003-1010.

McKeen, Scott. 2007. "'Wet' Shelter Needs Political Will." The Edmonton Journal, March 7.

McMurray-Avila, Marsha. 2001. Organizing Health Services for Homeless People: A Practical Guide. Nashville TN: National Health Care for the Homeless Council.

Meyer, Ilan H. and Sharon Schwartz. 2000. "Social Issues as Public Health: Promise and Peril (Editorial)." American Journal of Public Health 90(8): 1189-1191.

Miles, Barbara. 2003. "Report on Infirmary Focus Groups Held on Behalf of Sherbourne Health Centre." Sherbourne Community Health Centre. Toronto, Ontario.

Ministry of Health and Long-term Care. 2007. "Resource Manual for Physicians." Ottawa, Ontario.

Ministry of Health and Long-term Care. 2006. "2006 Annual Report of the Office of the Auditor General of Ontario." Ottawa, Ontario.

Montauk, Susan Louisa. 2006. "The Homeless in America: Adapting Your Practice." American Family Physician 74(7): 1132-1138.

Moscovitch, Allan. 1997. "Social Assistance in the New Ontario." Pp. 80-91 in Open for Business, Closed to People: Mike Harris's Ontario, edited by D.S. Ralph, A. Regimbald, and N. St-Amand. Halifax: Fernwood Publishing.

Murdie, Robert A. 2005. "Housing Affordability: Immigrant and Refugee Experiences." CERISPolicy Matters{\l):\-6.

Native Women's Association of Canada. 2007. "Aboriginal Women and Homelessness." Prepared for the National Aboriginal Women's Summit, June 20-22 in Corner Brook, NL.

Navarro, Vicente and Carles Muntaner. 2004. "Political and Economic Determinants of Population Health and Well-Being, Controversies and Developments." Amityville, NY: Baywood Publishing Company, Inc.

Nelson, Nancy L. 2005. "Ideologies of Aid, Practices of Power: Lessons for Medicaid Managed Care." Medical Anthropology Quarterly 19(1):103-122.

219 Nguyen, Vinh-Kim and Karine Peschard. 2003. "Anthropology, Inequality and Disease: A Review." Annual Review of Anthropology 32:447-474.

O'Carroll, Austin, Fiona O'Reilly, Mary Corbett, and Liam Quinn. 2006. "Homelessness, Health and the Case for an Intermediate Care Centre." Dublin, Ireland: Mountjoy Street Family Practice.

O'Connell, James J. 1999. "Utilization and Costs of Medical Services by Homeless Persons: A Review of the Literature and Implications for the Future." Bureau of Primary Health Care.

Omi, Michael and Howard Winant. 1994. Racial Formation in the United States From the 1960s to the 1990s. New York: Routledge.

Ontario Coalition Against Poverty. 2006. "Ontario Coalition Against Poverty Newsletter, March 2006." Toronto, Ontario.

Ornstein, Michael. 2006. "Ethno-Racial Groups in Toronto. 1971-2001: A Demographic and Socio-Economic Profile." Toronto, Ontario: Institute for Social Research.

Pan, E., B. Diep, and Edwin Charlebois. 2005. "Population Dynamics of Nasal Strains of Methicillin-Resistant Staphylococcus Aureus - and their Relation to Community- Associated Disease Activity." Journal of Infectious Diseases 192(5):811-818.

Pearson, Carol, L., Gretchen Locke, Ann Elizabeth Montgomery, and Larry Buron. 2007. "The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness: Final Report." U.S. Department of Housing and Urban Development.

Pederson, Ann and Dennis Raphael. 2006. "Gender, Race, and Health Inequalities." Pp. 159-191 in Staying Alive: Critical Perspectives on Health, Illness, and Health Care, edited by D. Raphael, T. Bryant, and M. Rioux. Toronto: Canadian Scholars' Press Inc.

Petchesky, Rosalind P. 2003. Global Prescriptions: Gendering Health and Human Rights. New York: Zed Books.

Picard, Andre. 2006. "Complex Issues Behind CMA Showdown." The Globe and Mail, August 22, A5.

220 Pierre Nathalie and Helen Seibel. 2007. "The Frontline Health Dialogues: Finding Common Purpose, Common Passion, and Common Experience." Report from the Ottawa Roundtable. Frontline Health: Beyond Barriers. June 21. Ottawa, Ontario.

Podymow, Tina and Jeffrey Turnbull. 2006. "Shelter-Based Convalescence for Homeless Adults." Canadian Journal of Public Health 97(5):379-383.

Podymow, Tina, Jeffrey Turnbull, and Doug Coyle. 2006. "Shelter-Based Palliative Care for the Homeless Terminally 111." Palliative Medicine 20(2):81-86.

Poland, Blake, David Coburn, Ann Robertson, Joan Eakin. 1998. "Wealth, Equity and Health Care: A Critique of a Population Health Perspective on the Determinants of Health." Social Science and Medicine 46(7):785-789.

Porter, Catherine. 2005. "Church Shelters Scrutinized; Out of the Cold Now a 17-Year Old 'Band-Aid'." Toronto Star, January 4, 3.

Post, Patricia A. 2001. "Casualties of Complexity: Why Eligible Homeless People are not Enrolled in Medicaid." Nashville, TN: National Health Care for the Homeless Council.

Price, David, Allyson M. Pollock, and Jean Shaoul. 1999. "How the World Trade Organisation is Shaping Domestic Policies in Health Care." The Lancet 354:1889- 1892.

Ralph, Diana S. 1997. "Introduction." Pp. 13-19 in Open for Business, Closed to People: Mike Harris's Ontario, edited by D.S. Ralph, A. Regimbald, andN. St-Amand. Halifax: Fernwood Publishing.

Randall, Glen E. and A. Paul Williams. 2006. "Exploring Limits to Market-Based Reform: Managed Competition and Rehabilitation Home Care Services in Ontario." Social Science and Medicine 62:1594-1604.

Raphael, Dennis. 2001. "From Increasing Poverty to Societal Disintegration: the Effects of Economic Inequality on the Health of Individuals and Communities." Pp. 223- 246 in Unhealthy Times: Political Economy Perspectives on Health and Care in Canada, edited by P. Armstrong, H. Armstrong, and D. Coburn. Toronto: Oxford University Press.

—. 2006a. "Social Determinants of Health: An Overview of Concepts and Issues." Pp. 115-138 in Staying Alive: Critical Perspectives on Health, Illness, and Health

221 Care, edited by D. Raphael, T. Bryant, and M. Rioux. Toronto: Canadian Scholars' Press Inc.

—. 2006b. "Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions." Inter nationalJour nal of Health Services 36(4):651-677.

Raphael, Dennis, Toba Bryant, and Marcia Rioux. 2006. Staying Alive: Critical Perspectives on Health, Illness, and Health Care. Toronto: Canadian Scholars' Press Inc.

Right to Healthcare Coalition. 2007. "Backgrounder for Community Members and Policy Makers Advocating an End to the OHIP 3-Month Wait Period for Recent Landed Immigrants in Ontario." Toronto: Access Alliance Multicultural Community Health Centre.

Rioux, Marcia. 2006. "The Right to Health: Human Rights Approaches to Health." Pp. 85-110 in Staying Alive: Critical Perspectives on Health, Illness, and Health Care, edited by D. Raphael, T. Bryant, and M. Rioux. Toronto: Canadian Scholars' Press Inc.

Robertson, Ann. 1998. "Shifting Discourses on Health in Canada: from Health Promotion to Population Health." Health Promotion International 13(2):155-166.

Romanow, Roy. 2002. "Building on Values: The Future of Health Care in Canada - Final Report." Ottawa: Commission on the Future of Health Care in Canada.

Salit, Sharon A., Evelyn M. Kuhn, Arthur J. Hartz, Jade M. Vu, and Andrew L. Mosso. 1998. "Hospitalization Costs Associated with Homelessness in New York City." New England Journal of Medicine 3 3 8(24): 1734-1740.

Serge, Luba and Nancy Ganedinger. 2003. "Housing Options for Elderly and Chronically 111 Shelter Users." Canada Mortgage and Housing Corporation. Socio-economic Series 03-019

Sherbourne Community Health Centre. 2006. "Sherbourne Family Health Team Business Plan." Toronto, Ontario.

Shields, John and B. Mitchell Evans. 1998. Shrinking the State: Globalization and Public Administration "Reform". Halifax: Fernwood Publishing.

Shinn, Marybeth. 2007. "International Homelessness: Policy, Socio-Cultural, and Individual Perspectives." Journal of Social Issues 63(3):657-677.

222 Shu, Albert. 1996. "Successive Ontario Governments Forced to Grapple with Problem of Health Care Fraud." Canadian Medical Association Journal 154(9):1412-1414.

Simmons, W. June. 2007. "Discharging the Homeless (letter to the editor)." Hospitals and Health Networks 81 (7): 10.

Sinclair, Duncan. 2000. "Looking Back, Looking Forward, The Ontario Health Services Restructuring Commission (1996-2000). A Legacy Report." Health Services Restructuring Commission (HSRC).

Skinner, Mark W. and Mark W. Rosenberg. 2006. "Managing Competition in the Countryside: Non-Profit and For-Profit Perceptions of Long-Term Care in Rural Ontario." Social Science and Medicine 63:2864-2876.

Smith, Susan J., Ann McGuckin, and Robin Knill-Jones. 1991. Housing for Health. Essex: Longman Group.

Statistics Canada. 2001. "Aboriginal Peoples Survey 2001 - Initial Findings: Wellbeing of the Non-Reserve Aboriginal Population." Cat.# 89-589-X1E. Ottawa, Ontario.

Stergiopoulos, Vicky and Nathan Herrmann. 2003. "Old and Homeless: A Review and Survey of Older Adults who use Shelters in an Urban Setting." The Canadian Journal of Psychiatry 48:374-380.

Street Health. 2007a. "The Street Health Report." Toronto, Ontario.

Street Health. 2007b. "Failing the Homeless: Barriers in the Ontario Disability Support Program for Homeless People with Disabilities." Toronto, Ontario.

Svoboda, Tomislav. 2005. "Measuring the 'Reduction' in a Harm Reduction Program for Homeless Men Experiencing Harms Related to Alcohol Abuse and Problem Behaviours." PhD dissertation, University of Toronto, Toronto, Ontario.

Toro, Paul. 2007. "Toward an International Understanding of Homelessness." Journal of Social Issues 63(3):461-481.

Toronto Shelter, Support and Housing Administration. 2007. "What Housing First Means for People: Results of Streets to Homes 2007 Post-Occupancy Research." Toronto, Ontario.

223 Toronto Shelter, Support and Housing Administration. 2006. "2006 Street Needs Assessment: Results and Key Findings." Toronto, Ontario.

Trickey, Jean. 1997. "The Racist Face of "Common Sense"." Pp. 113-121 in Open for Business, Closed to People: Mike Harris's Ontario, edited by D.S. Ralph, A. Regimbald, and N. St-Amand. Halifax: Fernwood Publishing.

Truemner, Mary. 2007. "An Overview of the Residential Tenancies Act: A Tenant Advocate's Perspective." Advocacy Centre for Tenants Ontario. van Laere, I., M. Buster, and P. Janssen. 2002. "Homeless Admitted in a Salvation Army Shelter Infirmary in Amsterdam." Tijdschr Gezondheidswet 18(4):9-10.

Wade, Robert Hunter. 2006. "Should We Worry About Income Inequality?" International Journal of Health Services 36(2):271-294.

Walton, Dawn. 2007. "CMA Head Admits He Used Connections to Jump Queue." Pp. A15 in Globe and Mail. Toronto, Ontario.

Wente, Maggie. 2000. "Urban Aboriginal Homelessness in Canada." Toronto: Faculty of Social Work, University of Toronto.

Wermuth, Laurie. 2003. Global Inequality and Human Needs: Health and Illness in an Increasingly Unequal World. Boston: Allyn and Bacon.

Whitzman, Carolyn. 2006. "At the Intersection of Invisibilities: Canadian Women, Homelessness and Health Outside the 'Big City'." Gender, Place and Culture 13(4):383-399.

Williams, A. Paul, Raisa Deber, Pat Baranek, and Alina Gildiner. 2001. "From Medicare to Home-Care: Globalization, State Retrenchment, and the Profitization of Canada's Health Care." Pp. 7-31 in Unhealthy Times: Political Economy Perspectives on Health and Care in Canada, edited by P. Armstrong, H. Armstrong, and D. Coburn. Toronto: Oxford University Press.

Williams, Jean C. 2003. "A Roof Over My Head:" Homeless Women and the Shelter Industry. Boulder: University Press of Colorado.

Wolfe, J.M. 1998. "Canadian Housing Policy in the 1990s." Housing Studies 13(1):121- 133.

224 Wood, David. 1992. Delivering Health Care to Homeless Persons: The Diagnosis and Management of Medical and Mental Health Conditions. New York: Springer Publishing.

Wright, James D., Beth A. Rubin, and Joel A. Devine. 1998. Beside the Golden Door: Policy, Politics, and the Homeless. New York: Aldine de Gruyter.

Yelaja, Prithi. 2001. "Home-Care Patients Face Service Cuts, Long Waits; Budgets Frozen for Ontario's 43 Access Centres." The Toronto Star, June 2, A01.

Yin, Robert K. 1989. Case Study Research: Design and Methods. London: Sage Publications.

Zerger, Suzanne. 2002a. "Chronic Medical Illness and Homeless Individuals: A Preliminary Review of Literature." Chicago: Interfaith House Phase One Planning Grant.

—. 2002b. "Substance Abuse Treatment: What Works for Homeless People? A Review of the Literature." Nashville, TN: National Health Care for the Homeless Council.

—. 2004. "Health Care for Homeless Native Americans." Nashville, TN: National Health Care for the Homeless Council.

Zerger, Suzanne, Bruce Doblin, and Lisa Thompson. 2008. "Medical Respite Care for Homeless Persons: A Growing National Phenomenon." Journal of Healthcare for the Poor and Underserved (forthcoming).

225 APPENDIX A

Study Protocol

226 HOMELESS INFIRMARY STUDY PROTOCOL STAGES OF DATA COLLECTION

Study Period: April 16-Julv 16, 2007

QUESTIONS? CONTACT:

SUZANNE ZERGER PHONE: 647-435-4616 E-mail: szerger(g),nhchc.org

227 STUDY MATERIALS CHECKLIST

CLIENT CONSENT KIT

• Consent Checklist (yellow) • Sets of 2 Consent Forms (one white, one blue) • Sets of 2 identical Study ID labels • Study Intake Log (green) • Pen and Marker

REFERRAL FORMS

• Study ID labels • Community Infirmary Program Referral Forms • Hospital Infirmary Program Referral Forms • Pen or Marker

STUDY NOTEBOOK (One each with Alice, Pat, and Tracy)

• Study Protocol • Master copies of all forms (other than Study Intake Log, which should not be photocopied) • Contact Information sheet • Extra (blank) Study ID labels

228 CLIENT RECRUITMENT AND CONSENT TASK PERSON STEPS MATERIALS Compile materials. HI Case Manager • Ensure all materials listed in the right-hand column • Sets of CONSENT FORMS {white and blue) pre- or Intake Staff are available prior to client intake. signed by the Principal Investigator • Confirm that all consent forms are pre-signed by the • Pre-printed Study ID labels Principal Investigator • CONSENT CHECKLIST {yellow) • STUDY INTAKE LOG {green) • Ink Pen • Marker Recruit clients into the HI Case Manager • Inform every client admitted to the Infirmary about study. or Intake Staff the study. • Invite client to read/review the CONSENT FORM. • Review the CONSENT CHECKLIST with client. Obtain signed consent HI Case Manager If client agrees to participate: from those who agree to or Intake Staff • Apply matching Study ID labels to each of two participate CONSENT FORMS (one white, one blue). • Record the Study ID, client name and the day's date on the STUDY INTAKE LOG. • Have client sign each of two CONSENT FORMS. (Note: Initials or aliases are acceptable.) • Sign each of these two CONSENT FORMS. • Give one signed CONSENT FORM to respondent. • Store the second signed CONSENT FORM in a secure location. If client decides to • Thank the client for considering participating in the withdraw from the study. study after giving • With a marker, cross out the clients' name and Study consent. ID on the STUDY INTAKE LOG. Note: The STUDY INTAKE LOG is the only document which links the client name with the Study ID. To avoid confusion, it should be kept in one location and not be photocopied.

229 RIvll.RRAI.'lRAtK .NO Prepare materials. Community Health • Obtain the STUDY INTAKE LOG from Tracy • Community Infirmary Program REFERRAL Worker Warne FORM • Obtain REFERRAL FORMS from Pat Larson • Hospital Infirmary Program REFERRAL • Ensure other materials listed in the right-hand FORM column are available. • STUDY INTAKE LOG (green) • Study ID labels (blank) • Pen • Black Marker Prepare referrals Community Health • Photocopy all Community and Hospital Infirmary forms for Worker Program REFERRAL FORMS researcher. For clients who were admitted to the Infirmary:

• Locate client name on the STUDY INTAKE LOG • Record that client's corresponding Study ID number on one of the blank Study ID labels with a pen or marker • Place the Study ID label over the client name on the photocopied referral form • Retain original referral form for records. For clients not admitted to the Infirmary:

• Using a black marker, cross out the client's name on the photocopied referral form to ensure it is no longer readable. • Retain original referral form for records.

230 APPENDIX B

Study Consent Forms

231 APPLY CLIENT ID LABEL HERE

SHERBOURNE HEALTH CENTRE HOMELESS INFIRMARY CONSENT FORM FOR CLIENTS

THE PURPOSE: Sherbourne Health Centre wants to learn about the Homeless Infirmary services it provides, specifically how and whether it is improving health and social outcomes for clients like yourself. We are grateful for your willingness to help us understand these issues and create better services. WHAT WE ASK OF YOU: We are asking you to allow a researcher to review the information the Homeless Infirmary staff collect from you during your stay. The information they collect will include basic descriptions of you and your health needs, the services they provide you during your stay, and your plans when you leave. If you agree to participate in this study, no identifying information about you personally will be shared with the researcher. PRIVACY AND CONFIDENTIALITY: Everything you say will be kept confidential. Your name will not be placed on any materials nor will anything you say be reported in a way that would let you be identified. Confidentiality of your information will be ensured within the limits of the law. Although we keep all information confidential, it is important for you to know that laws require us to report information about current child abuse or neglect, threats of self-harm or harm to others.

All results from this study, including a copy of this consent form, will be kept in a locked file drawer for two years in the Infirmary office. During this time, only Program Director Alice Broughton will have access to these forms. After two years, all forms related to this study will be destroyed. INCENTIVE: Because we are ensuring your information will remain anonymous, we will not offer you any financial incentive to participate. YOUR CHOICE: Your participation in this study is voluntary. You have the right not to answer specific questions or to stop participating at any time. Your decision not to participate will not affect any services that you are receiving from the Infirmary, nor will it affect your relationship with any Infirmary staff or the researcher. Your decision not to participate will also not help you receive additional services or benefits. RISK AND BENEFITS: We do not know of any risk to you for participating in this study. And, some people like to participate in studies like this because it may help others to receive better services. MORE INFORMATION: If you want to know more about this study, or have any questions, you may contact Suzanne Zerger, the Principal Investigator and Graduate Student at the Sociology Department of York University (647-435-4616), Audrey Tokiwa at York University's Graduate Programme in Sociology (416-736-5013), or the Manager of Research Ethics for the University at the Office of Research Ethics, 309 York Lanes (416-736-5055). Program staff will provide you access to a telephone if you wish to contact any of these individuals.

232 SIGNATURES: By signing this consent form, you are not waiving any legal rights. If you refuse to participate in this study or choose to withdraw at any time, there will be no negative consequences. ETHICS APPROVAL: This research has been reviewed and approved for compliance to research ethics protocols by the Human Participants Review Subcommittee (HPRC) of York University.

SIGNATURE OF PARTICIPANT

By signing this form, I willingly agree to let the program use my information for this study.

Name of Participant

Signature of Participant Date

SIGNATURE OF HOMELESS INFIRMARY STAFF

/ have explained this study to the participant, and answered all of his/her questions. I believe that he/she understands the information described on this page and freely consents to participate.

Name of Staff

Signature of Staff Date

SIGNATURE OF PRINCIPAL INVESTIGATOR

Suzanne Zerger

Name of Principal Investigator 10 April 2007

Signature of Principal Investigator Date

233 SHERBOURNE HEALTH CENTRE HOMELESS INFIRMARY CONSENT FORM: SERVICE PROVIDER

THE PURPOSE: Sherbourne Health Centre wants to learn about the Homeless Infirmary services it provides, specifically how and whether it is improving health and social outcomes for homeless persons, and what impact it is having on those providers who are referring homeless clients to the program. We are grateful for your willingness to help us understand these issues.

WHAT WE ASK OF YOU: We are asking you to complete a brief survey, which should take approximately 15-20 minutes to complete. The survey will include questions about your professional experience and workplace, about the Homeless Infirmary, about dilemmas you have faced serving homeless persons with health problems, and your opinions about homeless services.

PRIVACY AND CONFIDENTIALITY: Everything you say will be kept confidential. Your name will not be placed on any materials nor will anything you say be reported in a way that would let you be identified. Findings from your survey or interview, along with a copy of this consent form, will be kept in a locked file drawer accessible only to Suzanne Zerger for two years, after which they will be destroyed.

INCENTIVE: We are unable to offer you any financial incentive to participate.

YOUR CHOICE: Your participation in this study is voluntary. You have the right not to answer specific questions or to stop participating at any time. Your decision not to participate will not affect your relationship with or access to services at Sherbourne Health Centre, nor will it affect your relationship with the researcher or York University.

RISK AND BENEFITS: We do not know of any risk to you for participating in this study. And, some people like to participate in studies like this because it may help others to receive better services.

MORE INFORMATION: If you want to know more about this study, or have any questions, you may contact Suzanne Zerger, the Principal Investigator and Graduate Student at the Sociology Department of York University (647-435-4616), Audrey Tokiwa at York University's Graduate Programme in Sociology (416-736-5013), or the Manager of Research Ethics for the University at the Office of Research Ethics, 309 York Lanes (416-736-5055).

SIGNATURES: By signing this consent form, you are not waiving any legal rights. If you refuse to participate in this study, there will be no negative consequences.

ETHICS APPROVAL: This research has been reviewed and approved for compliance to research ethics protocols by the Human Participants Review Subcommittee (HPRC) of York University.

234 SIGNATURE OF PARTICIPANT

By signing this form, I willingly agree to participate in this study.

Name of Participant

Signature of Participant Date

SIGNATURE OF PRINCIPAL INVESTIGATOR

Name of Principal Investigator

Signature of Principal Investigator Date

235 SHERBOURNE HEALTH CENTRE HOMELESS INFIRMARY CONSENT FORM: KEY INFORMANTS

THE PURPOSE: Sherbourne Health Centre wants to learn about the Homeless Infirmary services it provides, specifically how and whether it is improving health and social outcomes for homeless persons, and what impact it is having on those providers who are referring homeless clients to the program. We are grateful for your willingness to help us understand these issues.

WHAT WE ASK OF YOU: We are asking you to complete an interview, in-person or by telephone, with the study's Principal Investigator. You will be asked about your experiences in addressing the health needs of homeless persons, and your perspectives on the actual, anticipated, and unexpected impacts of the Infirmary on this service community. The interview should take approximately 45-60 minutes to complete.

PRIVACY AND CONFIDENTIALITY: Everything you say will be kept confidential. Your name will not be placed on any materials nor will anything you say be reported in a way that would let you be identified. Findings from your survey or interview, along with a copy of this consent form, will be kept in a locked file drawer accessible only to Suzanne Zerger for two years, after which they will be destroyed.

INCENTIVE: We are unable to offer you any financial incentive to participate.

YOUR CHOICE: Your participation in this study is voluntary. You have the right not to answer specific questions or to stop participating at any time. Your decision not to participate will not affect your relationship with or access to services at Sherbourne Health Centre, nor will it affect your relationship with the researcher or York University.

RISK AND BENEFITS: We do not know of any risk to you for participating in this study. You may value the opportunity to participate in this study because you will articulate challenges related to serving homeless persons, and contribute to potential solutions to those challenges .

MORE INFORMATION: If you want to know more about this study, or have any questions, you may contact Suzanne Zerger, the Principal Investigator and Graduate Student at the Sociology Department of York University (647435-4616), Audrey Tokiwa at York University's Graduate Programme in Sociology (416-736- 5013), or the Manager of Research Ethics for the University at the Office of Research Ethics, 309 York Lanes (416-736-5055).

SIGNATURES: By signing this consent form, you are not waiving any legal rights. If you refuse to participate in this study, there will be no negative consequences.

ETHICS APPROVAL: This research has been reviewed and approved for compliance to research ethics protocols by the Human Participants Review Subcommittee (HPRC) of York University.

SIGNATURE OF PARTICIPANT ffy signing this form, I willingly agree to participate in this study.

Name of Participant

Signature of Participant Date

236 SIGNATURE OF PRINCIPAL INVESTIGATOR

Name of Principal Investigator

Signature of Principal Investigator Date

237