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Undergraduate Medical Education
Global Health Program
Family Medicine Clerkship
Community Health Experience
Primer on Homelessness, Poverty and Harm Reduction
Carl Ren
Javeed Sukhera, MD, FRCPC
HOMELESSNESS AND HEALTH
When thinking about homelessness, we often define it as a condition where there is
an absence of physical shelter. This is known as “absolute homelessness”. There is
also “relative homelessness” in which there is a physical shelter, but it is lacking in
basic standard for safety and health [1]. Both can make an impact on an individual’s
health, but “absolute homelessness” is often used to define the population in
research. Demographics are varied within the homeless population, affecting single
individuals and families alike [2]. Homelessness can be due to variety of factors such
as poverty, increasing house price, or mental illnesses [3]. Regardless of the cause,
these individuals often face detrimental health effect in addition to their struggle to
survive.
The mortality rate of homeless males is 8 times those of general population in
Toronto (9 times in Montreal) [4], and 31 times higher in females [5]. Although
increased age corresponds with lower odds ratio, the odds never converge to one.
Deaths are often due to unintentional injuries, collision with motor vehicles, and
drug overdose [4]. 60% of the male population also suffers from alcohol disorder (67 times higher than the general population), and substance abuse with marijuana
and cocaine are common [6]. Mental illness, as mentioned previously, can lead to
homelessness, which can exacerbate the mental illness [6-8]. Approximately 2040% of homeless individuals have mood disorder in their lifetime. Schizophrenia is
present in approximately 6% of the individuals [6].
The use of public shelter in major cities has increased in the past few years to reflect
the rise of the homeless population. However, there can be an increased risk of
infection such as tuberculosis due to crowding issues [9-11]. The risk of tuberculosis
(TB) in the homeless population is significantly higher than the risk in average
citizens, particularly for primary infection rather than reactivation [12]. Other risk
factors contributing to TB include alcohol abuse, malnutrition, and AIDS [11].
Prolonged standing, exposure of feet to moisture or cold can also lead to cellulitis,
venous stasis and fungal infection [13, 14]. In general, treatments of conditions are
difficult due to loss to follow up, non-compliance, prolonged infectivity and drug
resistance [15-17]. Directly observed therapy may play a role in increasing
compliance in this population [18]. Risks for HIV are also high due to prostitution,
multiple sex partners, unsafe sex practice and unclean injection needles [11, 19, 20].
Safe injection sites and needle exchange programs are present in cities to lower
such risks (see resources below). Unsafe sex practice and sexual assault has led to
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an increase in pregnancy in homeless youth, accompanied by an increase in sexually
transmitted disease [21].
Other health risks include inability to perform follow up for hypertension or
diabetes as contact with homeless individuals are often transient (lack of permanent
address or phone number) [22, 23]. Cold weathers in Canada can result in frost bites
and hypothermia, death is a possibility as well [24, 25]. Although homeless
population stays longer in hospital than non-homeless individuals, there are
significant barriers for them to access health care. Although there is universal care
in Canada, many homeless individuals do not have a health card [26]. 6.7% have
been refused care because they are unable to produce evidence for coverage [27].
Overall, homeless individuals face health problems much earlier and more severe
than the general population.
What can be done to help?
There are several avenues that are available, split into four categories: biomedical,
educational, environmental, and legislative.
Biomedically, Assertive Community Treatment (ACT) has been shown to be effective
at reducing hospital time in mentally ill homeless patients [28]. ACT involves a
group of health care professionals (i.e. psychiatrist, nurses, and social workers) that
offer intensive care outside the hospital at an individual’s residence. However, ACT
does not change the quality of life, psychiatric symptoms or substance abuse issue
[28, 29]. Contribution can also be made by becoming involved in student-run clinics,
or establish one if one is not available locally. Student-run clinics not only provide
free care, clean needles, and sexual education to those who needs them, they also
offer a chance to interact with the homeless population and see the health issues
they face first hand [30]. In addition, most medical initiatives benefit from the
presence of housing.
Housing allows a homeless individual to experience a change in their immediate
environment. By building a supportive environment for homeless individuals, we
can encourage behaviour change. Although public shelters are available, their
negative effects on health have been mentioned before. The lack of housing
availability and rise of housing price can make it difficult for homeless individuals to
obtain their own living space [31]. However, there are government programs aimed
to subsidize the cost of housing. For example, Community Homelessness Prevention
Initiative (CHPI) offers $251 million in funding for homeless individuals looking for
long term housing. For additional program offered by Ministry of Municipal Affairs
and Housing (MMAH), Ministry of Community and Social Services (MCSS) and
Ministry of Health and Long-Term Care (MOHLTC), please consult the links listed in
the resource section below.
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Health care professionals need to play an important role in educating the homeless
about resources available to them to help them off the street temporarily or in the
long term. These resources go beyond simply funding for housing, but also
organizations that can educate about tenant rights. In addition, when providing a
treatment plan, be sensitive to the situation of the homeless. Because they are
required to balance multiple priorities with limited resources, it can be difficult for
them to adhere to treatment plans especially when they involve prescription drugs
[32], or modification to diet [23].
Since health advocacy is one of the CanMeds competencies, it is also important to
advocate on a legislative level. Only policies can influence the health concerns of the
homeless systematically, on an institutional level. Like the Vancouver agreement,
policies can induce changes in urban development to address the economic, social,
and health concerns. They provide the disadvantaged individuals with new clinics,
new programs, and new opportunities. This is something that is difficult to
accomplish with only one-on-one interaction between the health care worker and
the patient. Therefore, even outside of the medical practice, the role of a physician
continues.
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REFERENCES
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Fiedler, R., N. Schuurman, and J. Hyndman, Hidden homelessness: An indicator-based
approach for examining the geographies of recent immigrants at-risk of homelessness
in Greater Vancouver. Cities, 2006. 23(3): p. 205-216.
Force, T.M.s.H.A.T. and A. Golden, Taking Responsibility for Homelessness: An Action
Plan for Toronto: Report of the Mayor's Homelessness Action Task Force. 1999.
Susser, E., R. Moore, and B. Link, Risk factors for homelessness. Epidemiologic
Reviews, 1993. 15(2): p. 546-556.
Hwang, S.W., Mortality among men using homeless shelters in Toronto, Ontario. Jama,
2000. 283(16): p. 2152-2157.
Roy, E., et al., Mortality among street youth. The Lancet, 1998. 352(9121): p. 32.
Fischer, P.J. and W.R. Breakey, The epidemiology of alcohol, drug, and mental
disorders among homeless persons. American Psychologist, 1991. 46(11): p. 1115.
Caton, C., et al., Risk factors for homelessness among women with schizophrenia.
American Journal of Public Health, 1995. 85(8_Pt_1): p. 1153-1156.
Caton, C., et al., Risk factors for homelessness among schizophrenic men: a case-control
study. American Journal of Public Health, 1994. 84(2): p. 265-270.
Nolan, C.M., et al., An outbreak of tuberculosis in a shelter for homeless men. Am Rev
Respir Dis, 1991. 143: p. 257-261.
Curtis, A., et al., Analysis of Mycobacterium tuberculosis transmission patterns in a
homeless shelter outbreak. The International Journal of Tuberculosis and Lung
Disease, 2000. 4(4): p. 308-313.
Zolopa, A.R., et al., HIV and tuberculosis infection in San Francisco's homeless adults:
prevalence and risk factors in a representative sample. Jama, 1994. 272(6): p. 455461.
Barnes, P.F., et al., Transmission of tuberculosis among the urban homeless. Jama,
1996. 275(4): p. 305-307.
Moy, J.A. and M.R. Sanchez, The cutaneous manifestations of violence and poverty.
Archives of dermatology, 1992. 128(6): p. 829-839.
Raoult, D., C. Foucault, and P. Brouqui, Infections in the homeless. The Lancet
infectious diseases, 2001. 1(2): p. 77-84.
Schluger, N., et al., Comprehensive tuberculosis control for patients at high risk for
noncompliance. American journal of respiratory and critical care medicine, 1995.
151(5): p. 1486-1490.
Pablos-Mendez, A., et al., Drug resistant tuberculosis among the homeless in New York
City. New York state journal of medicine, 1990. 90(7): p. 351-355.
Pablos-Méndez, M., et al., Nonadherence in tuberculosis treatment: predictors and
consequences in New York City. The American journal of medicine, 1997. 102(2): p.
164-170.
Weis, S.E., et al., The effect of directly observed therapy on the rates of drug resistance
and relapse in tuberculosis. New England journal of medicine, 1994. 330(17): p.
1179-1184.
Robertson, M.J., et al., HIV seroprevalence among homeless and marginally housed
adults in San Francisco. American journal of public health, 2004. 94(7): p. 1207.
Allen, D.M., et al., HIV infection among homeless adults and runaway youth, United
States, 1989-1992. Aids, 1994. 8(11): p. 1593-1598.
Greene, J.M. and C.L. Ringwalt, Pregnancy among three national samples of runaway
and homeless youth. Journal of Adolescent Health, 1998. 23(6): p. 370-377.
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22.
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32.
Lee, T.C., et al., Risk factors for cardiovascular disease in homeless adults. Circulation,
2005. 111(20): p. 2629-2635.
Hwang, S.W. and A.L. Bugeja, Barriers to appropriate diabetes management among
homeless people in Toronto. Canadian Medical Association Journal, 2000. 163(2): p.
161-165.
Tanaka, M. and S. Tokudome, Accidental hypothermia and death from cold in urban
areas. International journal of biometeorology, 1991. 34(4): p. 242-246.
Sebastian, J.G., Homelessness: a state of vulnerability. Family & community health,
1985. 8(3): p. 11-24.
Khandor, E., et al., Access to primary health care among homeless adults in Toronto,
Canada: results from the Street Health survey. Open Medicine, 2011. 5(2): p. e94.
Crowe, C. and K. Hardill, Nursing research and political change: the street health
report. The Canadian Nurse, 1993. 89(1): p. 21.
Dixon, L., et al., Assertive community treatment and medication compliance in the
homeless mentally ill. American Journal of Psychiatry, 1997. 154(9): p. 1302-1304.
Allen, G., Effects of Three Treatment Programs for Homeless Mentally Ill People.
Hospital and Community Psychiatry, 1992. 43(10): p. 1005.
Simpson, S.A. and J.A. Long, Medical student-run health clinics: important
contributors to patient care and medical education. Journal of general internal
medicine, 2007. 22(3): p. 352-356.
Moore, E. and A. Skaburskis, Canada's increasing housing affordability burdens.
Housing Studies, 2004. 19(3): p. 395-413.
Hwang, S.W. and J.L. Gottlieb, Drug access among homeless men in Toronto. CMAJ:
Canadian Medical Association Journal, 1999. 160(7): p. 1021.
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RESOURCES
Prevention of Homelessness and Legal Support
Landlord and Tenant Board for tenant’s legal rights
http://www.ltb.gov.on.ca/en/STEL02_111281.html
Community Legal Services at Western University for eviction protection
https://www.law.uwo.ca/clinics_and_centres/community_legal_services/index.htm
l
Community Legal Clinic
London:
http://www.legalaid.on.ca/en/contact/about.asp?place=607050&addr=lond
on
Windsor:
http://legalassistanceofwindsor.wordpress.com/
Housing
Documentation of Best Practices Addressing Homelessness
https://www.cmhc-schl.gc.ca/publications/en/rh-pr/socio/socio041.pdf
Statistics on Shelter Availability
http://www4.hrsdc.gc.ca/[email protected]?iid=44
Housing and Homelessness Program in Ontario
http://www.mah.gov.on.ca/AssetFactory.aspx?did=6790
Community Homelessness Prevention Initiative
http://www.mah.gov.on.ca/Page9183.aspx
List of Shelters and Lodgings Available
London:
http://lifespin-org.doodlekit.com/home/housing_shelter
Windsor:
http://www.citywindsor.ca/residents/housing/Lodging-andHomelessness/Pages/Lodging-and-Homelessness.aspx
Homeless Coalitions
London:
http://londonhomeless.ca/
Windsor:
http://www.homelesscoalitionwindsor-essex.com/
Medical Related
Strategies for Keeping Contact with Homeless Population
http://www.cmhc-schl.gc.ca/odpub/pdf/63685.pdf?fr=1408077231210
Needle Exchange
London:
http://www.hivaidsconnection.ca/needle-syringe-program
https://www.healthunit.com/needle-exchange
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Windsor:
http://www.aidswindsor.org/Drug-Use-and-Harm-ReductionServices/needle-exchange-program.html
Assertive Community Treatment (ACT) Team
London:
http://www.mentalhealthhelpline.ca/Directory/Program/14782
Windsor:
http://www.mentalhealthhelpline.ca/Directory/Program/18005
Student-Run Clinics
http://www.jripe.org/index.php/journal/article/viewFile/80/61
Future Plans for Homeless Community
London:
https://www.london.ca/residents/Housing/HousingManagement/Documents/HomelessPreventionandHousingPlan.pdf
Windsor:
http://www.citywindsor.ca/residents/housing/Lodging-andHomelessness/Windsor-Essex-Housing-and-HomelessnessPlan/Documents/Final%20HHP%20April%2029,%202014%20Wind
sor%20Essex.pdf
Vancouver Agreement
http://www.vancouveragreement.ca/
NEEDLE EXCHANGE PROGRAM
The use of unsterile needles is a risk factor for the transmission of HIV, hepatitis B
and hepatitis C. To reduce this risk, there are two principles applied in policies and
programs: harm reduction, and use reduction [1]. Needle exchange programs (NEP)
focus on the principle of harm reduction. They involve reducing drug related harm
for individuals who continue to use injection drugs. This is advantageous over use
reduction because it preserves an individual’s dignity and is non-judgmental. There
are approximately 41000 injection drug users (IDU) in Ontario [2], so it is important
to have program established to reduce their risk of infection.
NEPs are not only responsible in increasing the use of sterile needle and reducing
number of used needle in circulation, but they also provide condom distribution,
education, referrals and counseling [3]. In general, increase in NEPs are correlated
with decrease in needle sharing and decrease in HIV transmission [4]. Early NEP
implementation is also associated with low HIV prevalence (<5%) in cities like
Toronto [5]. Effects of NEP on HBV and HCV transmission, however, have been
conflicting [2, 6-8]. Currently, NEP contribute only a small proportions of sterile
needle used (5% of required in Montreal) [9].
Although NEP reduces the number of needle sharing, a small number of needle
sharing can still lead to a high risk of transmission, especially for individuals with a
high viral load. Opponents to NEP also argued that the presence of NEP can
encourage injection drug usage. Harm reduction does not fix the underlying
problem of drug abuse, and can lead to a reliance on needle exchange program by
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drug users [10]. NEPs will not lead to a complete elimination of health issues
brought about by drug abuse, so there must be other programs or policies in place.
Despite their limitations, NEPs play an important role in saving health care
resources. Preventing even a few cases of HIV infections (24 cases) in 5 years would
result in millions of dollars saved [11]. This benefit can only be gained if NEPs are
implemented as soon as possible, easily accessible, and sustainable. NEPs are
recommended to provide as many sterile needles as needed without asking for
needles in return, although individuals are encouraged to return used needles.
In comparison to Canada, NEP programs in the USA faces considerable pressure due
to the prescription laws on sterile needles [12]. In most states, it is not possible to
purchase sterile needles without a prescription, and some NEP can only operate
illegally because of this. Therefore, it is fortunate that all NEPs in Canada are
legalized and have the potential to continue to expand.
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REFERENCES
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Marlatt, G.A., Harm reduction: Come as you are. Addictive behaviors, 1996.
21(6): p. 779-788.
Millson, P., et al., Injection drug use, HIV and HCV infection in Ontario: The
evidence 1992 to 2004. 2004: HIV Social, Behavioral and Epidemiological
Studies Unit.
Ontario Public Health Standards, O.M.o.H.a.L.T. Care, Editor. 2008, Ontario
Ministry of Health and Long Term Care: Toronto.
Des Jarlais, D.C., et al., HIV incidence among injection drug users in New York
City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV
prevention services. American Journal of Public Health, 2005. 95(8): p. 14391444.
Des Jarlais, D.C., et al., Maintaining low HIV seroprevalence in populations of
injecting drug users. Jama, 1995. 274(15): p. 1226-1231.
Hagan, H., et al., Syringe exchange and risk of infection with hepatitis B and C
viruses. American journal of epidemiology, 1999. 149(3): p. 203-213.
Hagan, H., et al., Reduced risk of hepatitis B and hepatitis C among injection
drug users in the Tacoma syringe exchange program. American Journal of
Public Health, 1995. 85(11): p. 1531-1537.
Thorpe, L.E., et al., Risk of hepatitis C virus infection among young adult
injection drug users who share injection equipment. American journal of
epidemiology, 2002. 155(7): p. 645-653.
Remis, R.S., J. Bruneau, and C.A. Hankins, Enough sterile syringes to prevent
HIV transmission among injection drug users in Montreal? JAIDS Journal of
Acquired Immune Deficiency Syndromes, 1998. 18: p. S57-S59.
Roe, G., Harm reduction as paradigm: Is better than bad good enough? The
origins of harm reduction. Critical Public Health, 2005. 15(3): p. 243-250.
Gold, M., et al., Needle exchange programs: an economic evaluation of a local
experience. Canadian Medical Association Journal, 1997. 157(3): p. 255-262.
Lurie, P., et al., The public health impact of needle exchange programs in the
United States and abroad. Summary, conclusions and recommendations.
Atlanta: Centers for Disease Control and Prevention, 1993.