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#39 - November 2007 Newsletter

I've been a street nurse in Toronto for 18 years. I have received the Atkinson Economic Justice Award which permits me to pursue my passions for nursing and working on homelessness and housing issues. In this newsletter I hope to report on my activities, create a link to a broader group of individuals who care about these social issues and encourage critical debate.

Further information about subscribing to the newsletter is found below. I want to hear from you - about the newsletter, about things that are happening in the homelessness sector (what a sad term!), and about good things which will provide inspiration for all of us.



1.  Sherbourne Health Centre Opens Infirmary
     by Pat Larson, Nurse Practitioner,
      Sherbourne Health Centre

2.  The United Nations is a Witness
      to “Our Katrina”

3.  Housing Not War

The slogan ‘Think globally, act locally’ has never been more important. This newsletter begins by introducing my friend and nursing colleague Pat Larson, who describes the innovative work being done at the local level, at the Sherbourne Health Centre’s Infirmary for homeless people in Toronto.  Secondly, the United Nations recently paid Canada a visit, with the Special Rapporteur on Adequate Housing Miloon Kothari witnessing firsthand the crisis of homelessness in communities across the country.  I met with Miloon Kothari and I share with you my presentation to him.  Finally, I first became an activist during a much earlier peace movement and now I’m finding it critical to confront Canada’s growing financial investment in militarism and the war in Afghanistan.

1.  Sherbourne Health Centre Opens Infirmary
by Pat Larson, Nurse Practitioner, Sherbourne Health Centre

When Cathy came to ask me if I would provide a guest article for the Cathy Crowe newsletter, I had just returned from a short sick leave.  As it turns out, so had Cathy.  We shared our stories (remarkably similar) of our experiences with a particularly virulent form of infection and our contact with health care providers.  We each noted having felt exhausted which easily led to a discussion of the Sherbourne Health Centre Infirmary program and its role in the lives of people who are homeless, a topic that has been on my mind in the past few years.

Before I get on to that topic, I want to “place” myself.  Like Cathy, I have a nursing background; for about 15 years I have been a nurse practitioner in Toronto, working with people who are marginalized, often who are homeless.  As a nurse, Cathy singularly stands out among us as a tireless advocate and activist.  While I occasionally delve into the world of activism, my nursing work has tended to focus on the front-line aspects of health care.  Over the years I have provided nursing care in drop-ins, rooming houses, boarding homes, shelters, under bridges, in ravines, near to train tracks and in parks and abandoned buildings and cars.  These experiences have brought me face to face with the daily issues of people who are homeless, especially with people's illnesses, problems and the quest for caring solutions.  It seemed a natural trajectory to join Alice Broughton (the Infirmary’s manager) in the development of Canada's first non shelter-based infirmary at Sherbourne Health Centre.

Infirmary or Respite Care

Perhaps I should say a word about infirmary or “respite” care, as it is known in the United States.  Many large American cities have a long history of respite programs for people who are homeless and ill.  Most are “virtual”, meaning that a certain number (or percentage) of beds in a shelter are allocated to individuals who are sick, with health care agencies or providers offering needed care.  In 2005, a large study of American respite programs identified different models of respite care; shelter based, supportive housing-based and community stand-alone.  Some infirmaries/respite programs are long-term, providing health care and support for many years, while others offer short-term health care support.

American literature on respite programs describe the circumstances leading to their necessity including an increasingly impoverished and marginalized “underclass”, a shortage of affordable housing in medium and large U.S cities and a lack of health care eligibility for millions of Americans.  In many states, whatever social safety net existed has been eroded.  Sound familiar?  Many of the same circumstances have been created here in Canada.  Ontario along with other Canadian provinces are recording increasing levels of homelessness, housing inaffordability, welfare or social system cuts, and health care system changes resulting in people being moved out of hospitals sooner and increasing acuity (illness) in the community. 
In Ontario, the idea of infirmary care was formally introduced in 1999, when the ‘Anne Golden Report’ was released recommending a short-term inpatient program in the urban core of Toronto, with a focus on providing a site for “home health care” to homeless individuals.

Sherbourne Health Centre was identified as well-situated to develop such a program.  In the meantime, both Seaton House in Toronto, and the Ottawa Inner City Health program developed infirmary programs.  Seaton House's Infirmary is located within its shelter facility and provides much needed health support for men while Ottawa's Infirmary program is multi-site and includes both shelters and a palliative care site.  Both programs have the option of long-term health care and support as they are linked to or located within the shelter or residential care system.

Sherbourne Health Centre Infirmary

In April 2007, Sherbourne Health Centre’s Infirmary opened to provide 24-hour per day health care for homeless people of all genders to recuperate from an illness or injury.  The facility is autonomous and community based, situated near Allan Gardens in the newly renovated Sherbourne Health Centre (formerly the Central Hospital site of Wellesley-Central Hospital).  Typically admissions range from a few days to 3 weeks, with an average of 7 to 10 days.  The program provides short-term health care support, similar to what is provided in people’s homes when they are ill or injured.  Referrals are accepted from hospitals and community agencies and from individuals who wish to self-refer.  Eligibility criteria include being homeless, having a physical health problem such as an illness or injury so that a short-term stay (days or a few weeks) in a non-acute care setting is required.  While many people who come to the infirmary have mental health or addiction issues neither of these can be the main reason for requesting admission.

When the Infirmary program is fully funded, the capacity will be 20 clients or beds.  Twenty-four hour care is provided by a Community Health Worker (CHW) and a Registered Nurse (RN), with a Case Manager (CM), Nurse Practitioner, consulting MD, Program Manager and Program Assistant providing administrative support, health care consultation and continuity of care so that realistic care plans are developed with clients.   

The Infirmary site itself as well as the practices and programming are intended to be respectful, restful, recuperative and realistic.  Harm reduction is a central feature of care.  Partnerships exist with a number of dedicated individuals and agencies – and are critical for providing health care, emotional and spiritual support, housing access, welfare  system access to name but a few. 

Our Initial Experience

Thus far, the range of issues that people have had are varied and include wound infections or cellulitis, pneumonia, broken bones, cardiac problems, liver problems, recuperation following childbirth, major surgery or during cancer treatment, and for HIV/AIDs care.  There have been admissions pre-surgically to help individuals prepare for surgery or testing and following procedures such as colonoscopy or cataract surgery.

While there have been individuals who have had fairly straightforward health issues such as broken bones, the majority have had complicated health and medical problems.  Many individuals have barriers to access; some have not had active health insurance (OHIP) while others have been without needed identification (ID) or drug coverage, despite being in a financial situation where the need for drug access would seem logical.  

We believe we are making a positive contribution for people who are homeless in Toronto, which seems to be borne out in comments from clients and referees. Feedback has been largely positive, as people have recovered to the point where they have been able to return to independence.  There have also been bittersweet moments as individuals reflect on the difficulty of leaving what they describe as a nurturing and healthy environment and the dedicated, caring staff. Some have described the opportunity of healing and rest following experiences of chronic sleeplessness in the shelter system as nothing short of miraculous.  There have been moments of anger and frustration as individuals have left knowing they are returning to the street, a shelter or substandard housing.  Similar feelings have been expressed by infirmary staff when clients have had to return to homelessness, despite diligent effort to assist them to access housing or set in motion needed identification, welfare benefits and health care.  

Emerging Issues and Challenges

Recently, the 2007 Street Health Report ( was released, chronicling the worsening conditions for people who are homeless, the significant health disparities and barriers to health care system access.  Our experience in the first six months of the Sherbourne Health Centre Infirmary is consistent with the findings of this study, pointing to the barriers to health care system access as well as the complex health care needs of many homeless people.

We anticipated having a steady but small number of referrals for people who are homeless and living with HIV and AIDs.  However, nothing prepared us for the overwhelming number of referrals and their complexity, coupled with the lack of community and housing resources, especially those with a harm reduction focus. While we realized that there would be referrals for mental health as the main constituent, again we find ourselves grappling daily with the lack of options for people in acute mental health distress, especially when their lives are compounded by homelessness, poverty and at times, addictions.  Addiction care resources are also difficult for people who are homeless to access, as inpatient detoxification or withdrawal management programs have gradually been replaced by “home” based programs.  Quite a problem, when you are homeless. 

The lack of inpatient resources and the need for hospitals to discharge patients quickly has also been evident.  Discharge planners, in very difficult “squeezes” work hard to find solutions and possibilities when people have few resources and options.  We hear comments as to the moral or ethical dilemmas that hospital staff face when discharging clients to situations that are likely to result in a re-admission in the near-future.  On a daily basis we are asked by staff in hospitals and community health care agencies to help find ways for their vulnerable housed individuals to access support and care when they are ill.  As a nurse of a “certain age”, the notion of the hospital “social admission” is etched in my brain; admissions equally are as much about recognizing that many people lack support in their lives as about preventing complications or a future re-admission.    

As the Street Health Report notes, it seems that the Sherbourne Health Centre Infirmary program is an idea whose time has come.  I have no doubt that we will be able to provide much needed relief, recuperation and a chance to heal for many people who are homeless.  We will also add a further credible source of information as to health care system deficiencies and stress points, which may prove invaluable as LHINs (Local Health Integration Networks in Ontario) actively pursue ways to weave our system into a more full, radiant and connected network for all Ontarians, including those who are vulnerable and marginalized.

The question has been asked by many before me….Do we as a society have the collective will to develop real and lasting solutions, such as adequate, supportive, affordable housing and health and social support systems which truly support each of us?

For more information go to

Photo credit: Lisa Huang

2.  The United Nations is a Witness to “Our Katrina”

In October Miloon Kothari, UN Special Rapporteur on the Right to Adequate Housing crossed Canada to hear testimony and examine Canada’s realization of the right to adequate housing. The following is my presentation to him when he came to Toronto. Cathy

Homelessness was first declared a national disaster in 1998 by the Toronto Disaster Relief Committee (TDRC). The declaration was supported by hundreds of organizations and by city and regional levels of government across the country. More importantly, the appeal for emergency disaster relief monies to alleviate homelessness and for government funds for affordable housing was welcomed by homeless people.

We believed the widespread acceptance of the disaster declaration, the abundant research and evidence, the sheer numbers of people in shelters and living on the street in big cities, and more prominent homelessness in rural communities, that aid would come from the government. 9 years later homelessness has increased dramatically and the severity of the state of homelessness has worsened for the men, women and children who are left homeless for increasingly longer periods of time. In addition, the problems associated with homelessness have been compounded by senior levels of government with policies and practices that emphasize privatization, a diminished role for government and deeper cuts to social spending.

When so many people are unhoused we have a community-wide crisis.  When the numbers are allowed to grow and when all reasonable analyses point to even more homeless people each and every day, we have a disaster – a situation that requires emergency relief and prevention measures – in the same way as when a flood or a storm leaves people homeless.  9 years later, this is our Katrina. Not unlike the hurricane victims, people homeless in Canada are left languishing in insufferable conditions on the street and in shelters by all levels of government, in particular the succession of federal governments which have resisted the reintroduction of a national affordable housing program.

The following is a brief summary of what I refer to as ‘hotspots’ - new and emerging threats that I am witnessing in Toronto and across the country.  These hotspots are evident in both large and medium size Canadian cities including Vancouver, Calgary, Edmonton, Regina, Winnipeg, Kenora, Thunder Bay, Sault Ste. Marie, Sudbury, Sarnia, Hamilton, Ottawa, Kingston and Halifax.

Emerging Hotspots

1.  Shelters versus Housing.  The deserving and undeserving.  Evidence suggests that homelessness is growing across the country while affordable housing is rarely being built.  In most of the communities I have visited, with diminished resources from the provincial and federal governments and the pressures of NIMBYism (Not In My Back Yard), municipalities are forced into debates about shelter instead of housing.  Many Canadian cities are inviting experts like Philip Mangano from the United States Interagency Council on Homelessness to advise Canadians on how to create a ‘business’ plan to end homelessness.  His prescription, and it’s very questionable as to whether it has worked in the United States, diverts energies away from advocating for more senior level government responsibility for housing to an almost ‘tough love’ municipal approach to homelessness, by targeting the most visible what he calls the chronically homeless.  This usually results in programs such as ‘Streets into Homes’ in Toronto, or anti-panhandling campaigns or punitive by-laws which criminalize homelessness.  This is the dominate discussion in cities like Calgary and Toronto, instead of focusing on real and long-term solutions.  One of my colleagues recently showed me tickets totaling $2,160 given by Toronto police to one homeless woman over several months.

In addition, writers like Malcolm Gladwell, famous for the ‘Million Dollar Murray’ story published in the New York Times, have also influenced Canadian public policy resulting in the targeting of resources towards the more obvious ‘street homeless’, and the development of plans  that determine who is deserving and not deserving of city funding or of being housed.  A notable example is in Toronto where street outreach agencies have been de-funded for their work in the provision of ‘survival’ supplies (blankets, sleeping bags and hot food) to those living in absolute homelessness.  In Calgary, families languish in a temporary emergency (and volunteer driven) shelter system and are forced to move nightly from church basement to church basement while resources are diverted to deal with the single adult ‘problem’.

2.  Charity instead of publicly funded programs.  Since 1998, Canada has witnessed an unprecedented outpouring of care by the faith and volunteer sectors in response to homelessness.  However, numerous municipalities now rely on the dozens of volunteer and faith based programs to provide congregate style emergency shelter and other services in the winter months.  The reduction of federal and provincial contributions toward social programs means that the volunteer sector replaces adequately funded organizations and properly trained staff.  With increasingly complex medical and social needs, this is an inadequate and dangerous response for our growing homeless population.  We would not want our health care program Medicare to be operated in this fashion.

3.  Growing intolerance, discrimination and hate in Canada towards the homeless.  I remember the year we saw our first homeless murder in Toronto.  It was the first in a succession of murders and it occurred during a period of time when the police chief, the mayor and certain right wing media were using derogatory and discriminatory language to describe squeegee youth and homeless people sleeping outside.  I did not expect to see brutal attacks on homeless people in our Canadian cities.  I assumed that was an American phenomenon.  But it has now happened in all of our cities including Calgary, Edmonton and Toronto.  Most notably, Paul Croutch, an elderly man sleeping outside in a Toronto park who was beaten to death in his sleeping bag. Three army reservists have been charged with his murder. 

It still surprises me to this day, given the education of our journalists, that homeless people can be described in mainstream media as vagrants, bums, drifters, gangrene, hard core, and street people.  Media continue to perpetuate this ignorance. It is still shocking that the title of an article on homelessness in the Canadian news magazine MacLean’s was ‘Canada’s gangrene’.

4.  Two-tiered health care.  Despite a national health program in Canada, many health care providers treating homeless people point out that as long as we have the need for mobile outreach programs and nurses with knapsacks filled with duct tape, socks, underwear and other health supplies, visiting people in ravines, store doorways, parks and in shelters, we in fact have a two-tier health care system.  The need for palliative care services for the underhoused has now reached a ‘code red’ state of emergency.

5.  Deaths.  There is a well documented rising death rate amongst our homeless and poor populations.  The Homeless Memorial outside the Church of the Holy Trinity in downtown Toronto has now well over 500 names.  Health and social justice advocates have been unable to convince any level of government or any Office of the Chief Coroner to take responsibility for tracking and monitoring the growing number of homeless deaths.

6.  Inhumane and unhealthy shelter conditions.  Poor health and homelessness go hand in hand.  However, in recent years homeless people have had to face new and emerging health threats, worsened by the situation of congregate shelter living, forced nightly migration in ‘Out of the Cold’ volunteer style programs and day and night shelters that have been unable to meet some of the basic pre-requisites outlined by the United Nations Standards for Refugee Camps. For example, overcrowding often equates to people sleeping on mats, in hallways or in a chair all night.  Washroom, hand washing and shower facilities are totally inadequate.  These conditions have been ripe for bedbug infestations which have now hit most major cities.  Several tuberculosis outbreaks have led to homeless deaths.  We are now seeing new and emerging threats of viruses such as Norwalk and ‘bugs’ like MRSA.  Despite Toronto’s experience with SARS, our City continues to rely on the volunteer ‘Out of the Cold’ program, which forces homeless people to move nightly from church basement to church basement in the winter months – surely a risky endeavour should SARS, Norwalk or TB present itself and we require contact tracing, medical follow-up or prophylaxis.

Federal spending diverted away from social programs like housing

While funds have not been made available for an affordable housing program, the federal government has recently announced a $13.8 billion surplus. The Rideau Institute, an Ottawa-based organization reported that the Department of National Defense estimates that Canada’s military spending will reach $18.2 billion in 2007-8, the highest amount since the Second World War.  The military budget now represents 8.5% of all federal spending. This flies in the face of housing advocates and their long time demand for an additional 1% of the federal budget per year ($2 billion) to be allocated towards a new national affordable housing program and an end to homelessness.

3.  Housing Not War

At the October 27th  pan-Canadian Day of Action against war in Afghanistan the Toronto Disaster Relief Committee launched a Housing Not War campaign.  Based on similar organizing methods used when TDRC declared homelessness a national disaster in 1998, TDRC spokesperson Beric German read the following declaration and asked people to sign on.

The Declaration

I support the demand that the federal government implement a
Housing Not War strategy.  Canada is at war in Afghanistan.
Homelessness remains a national disaster in Canada.
Canadian troops should come home, and funding directed
towards war and militarism should go towards housing and
other peaceful purposes.

As homelessness worsens in Canada, the federal government
can no longer justify spending untold billions of dollars on war.
We call for the 1% solution, which would double current federal
spending on social housing to $4 billion per year.

Housing Not War campaign materials will be on the TCRC website soon.

The declaration will be used across the country to collect names that will be taken to municipal councils asking them to pass resolutions supporting the declaration.  It is critical to build momentum. Housing Not War. Childcare Not War.  Education Not War. 

See pictures from the rally and march held in Toronto courtesy of John Bonnar


Thanks to Dave Meslin for layout and Bob Crocker for editing.


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