Reports / Articles

Friday December 14, 2001

Worst Christmas Ever

Part A: Toronto's Shelter System: Overcrowded, Dangerous and Not Enough Beds
Part B: The City of Toronto Tuberculosis Outbreak: Homeless People at Risk
Part C:
Tent City Solutions Stalled

Part A:
Toronto's Shelter System: Overcrowded, Dangerous and Not Enough Beds

In October 2000, TDRC researched and wrote a report describing the appalling situation for homeless people in the City of Toronto.  State of the Disaster:  Winter 2000 revealed a homelessness situation spiraling out of control, and a shelter system in chaos.  

We found that shelters are dangerously overcrowded and filled with seriously ill people.  Many shelters do not meet minimum United Nations standards for refugee camps.  We identified a need for approximately 1000 additional shelter beds to accommodate all those who need safe shelter (including harm reduction options) and to reduce crowding and disease. 

One year later, the city’s response to our report and its recommendations can be summarized in two words:  denial and inaction.

Shelter Facts

  • In June 1999, City Council moved that if shelter occupancy exceeds 90%, new shelter beds must open on an emergency basis.  Since that time, overall shelter occupancy has consistently exceeded 90%.
  • Historically, shelter use decreased in summer months.  Since 1997, there has been little or no seasonal reduction in shelter use according to city staff.
  • In November 2000, city staff reported that there were 2892 beds in the single adult and youth shelter system.  In November 2001, staff reported that there were 2904 beds in the system – an increase of 12 beds.
  • In March 2001, the 1000 additional beds recommended by TDRC and approved by City Council were axed during the budget process.  Overall shelter occupancy was 92%.
  • In September 2001, occupancy was reported at 94-95%.  The Homeless Advisory Committee called for the immediate opening of a large, temporary shelter for use until a sufficient number of beds are in place for the winter.  This was not done.
  • In October 2001, city staff admitted that shelters are full when occupancy reaches 90%.  At the end of October 2001, occupancy levels were reported to be 97%.
  • In November 2001, city staff announced 500 additional “beds” to reach a projected target of 3400 beds needed for winter.  One third of these are mats in church basements provided through the Out of the Cold Program.  One quarter of these were to have been at the former Princess Margaret Hospital site which the city now says is not an option.  32 are provided by adding beds to already crowded existing shelters.
  • In November 2001, Toronto Public Health revealed that the city’s first tuberculosis outbreak in decades occurred earlier this year at the city’s largest shelter, Seaton House.  One man died.
  • In some Toronto shelters, it is not uncommon for two to three people to share a space which the United Nations says is the minimum safe amount of room for one person in a refugee camp.
  • The Boston Manual of Common Communicable Diseases in Shelters recommends at least three feet of space between shelter beds to reduce the risk of airborne disease transmission.  This standard is often not met in city shelters.
  • We have a death rate among homeless people of between 2 to 4 per week.
  • According to research conducted by Dr. Stephen Hwang on homeless men living in Toronto’s shelter system, the average age of death is 46 years.  Men between the ages of 25 and 44 are almost four times more likely to die than their housed counterparts.
  • In October 1998, Toronto City Council declared homelessness a national disaster.

Recommendations

We recommend that Toronto City Council direct the Commissioner of the Community and Neighbourhood Services Department to do the following:

1)      Order a moratorium on shelter closures for the duration of the homelessness disaster.

2)      Open 1000 shelter beds:

a.      Immediately open four emergency shelters or warming centers, to be run by an aid organization such as the Red Cross, and able to accommodate up to 150 men, women and couples each.  They should be available for the duration of the homelessness disaster.

b.      Open a number of appropriate smaller shelter facilities (for example, which are smaller, more private, with increased supports on site) to meet the needs of women, people with disabilities, aboriginal people, youth, people with serious addictions or health/mental health problems, and people living with AIDS, to make up the remaining 400 beds required.  Included in these beds should be at least one “wet hostel” for women and other harm reduction facilities to meet the needs of people in the above groups with addictions.

3)      Ensure that the above facilities and existing facilities meet the United Nations standards for refugee camps.  For example, an adequate number of toilets must be accessible; beds or cots and not mats on the floor must be provided; adequate space allocation must be provided; food must meet nutritional needs; health services should be provided on site.

4)      Ensure that the above facilities and existing facilities operate from a harm reduction philosophy.  There must be adequate staffing levels and adequate staff training with respect to mental health issues, harm reduction and crisis de-escalation to ensure both safety and the meeting of standards.

5)      Direct the Medical Officer of Health to carry out a special investigation of health standards in the shelter system to ensure that they meet international public health standards.

Part B: 
The City of Toronto Tuberculosis Outbreak: Homeless People at  Risk

The Facts:

Definition: An outbreak is the occurrence of more cases of a communicable disease than expected in a given time period, within a given population.

An outbreak of TB was predicted by activists in the mid 1990s.

Between the Spring of 2001 and August 2001 there were 9 linked cases of TB found in Seaton House, the largest men’s hostel in Canada. All were Canadian born. 1 person was co-infected with HIV. 1 person has since died. Cases were linked by DNA testing.  Street nurses know of 3 other cases preceding this outbreak within the same block.

60% of the men tested at Seaton House tested positive, indicating exposure to TB. This is up 57% from the 38% figure in a 1996 TB testing pilot.

What has been done? Treatment of individuals. Fans have been installed to promote air-exchange. Windows opened to maximize ventilation.

What was not done?  No notice or communique or alert to community health workers, street nurses or former members of the Tuberculosis Action Group. No warning to Hostel Services Department to not increase the crowding in existing shelters. No alert to the Out of the Cold programme even though shelter crowding, poor ventilation and forced migration are the major causes of TB infection and transmission.

Background on TB:

In 1991 the Centre for Disease Control and Prevention (Atlanta) recommended that low income populations (i.e. homeless) should be screened using a TB skin test.

In 1992 the Morbidity and Mortality Weekly Report (MMWR) recommended that TB case finding should be part of the regular health care provided to homeless persons.

To this day the Department of Public Health has no program for routine screenings in the homeless population in the City of Toronto. Without doubt, the Seaton House outbreak is the tip of the iceberg.

What do we know about the Toronto TB numbers?

q       In 1994  there were 170-180 TB cases/year in the City of Toronto

q       In 1994 Dep’t of Public Health Dep’t followed 7 active cases that were homeless. From 1990 to1994 there were 6-16 cases of TB/year that were homeless.

q       In 1996 a TB Pilot Subcommittee (combination of community and City staff) completed a survey and issued a Report on the Tuberculosis Pilot Project in the Homeless and Underhoused.  This report stated that the prevalence of active TB among homeless persons is estimated to be, in some areas, as high as 150-300 times greater than the general population (i.e. housed population).

q       The 1996 report showed that 38% of the homeless people tested positive meaning they had come in contact with someone with active TB. St. Michael’s Hospital issued a statement in March, 1996 “the statistical findings of the pilot project….should be considered a wake up call.”

q       The 1996 report made several important recommendations relevant to today’s TB outbreak:

Recommendation  4.1: That the department should intensify efforts in TB case finding which would include Public Health Nurse liaisons with agencies working with the homeless; symptom screening and targeted Mantoux skin testing on a regular basis at agencies serving the homeless and underhoused.

Recommendation 5.1: “The Toronto Department of Public Health develop a resource center and a means of keeping the broader health and social service community up to date on information and trends.”

Recommendation 5.2: “The Toronto Department of Public Health continue to research the literature on environmental factors related to TB transmission including ventilation, bed-spacing and ultra/violet lighting and to advocate for infection control measures in spaces where people are congregating.”

Up to and including 1996 many activists from the Tuberculosis Action Group appealed to the Department of Public Health for a more active and aggressive TB prevention program.  In 1996 Cathy Crowe, a street nurse warned “the conditions are ripe for an epidemic."

q       In 1998 there were 450-500 cases of TB/year in Toronto (Dr. Jeff Edelson, St. Michael’s Hospital)

q       In 2000 there were 376 cases of TB

q       Millions of people continue to die from TB around the world

q       1 in 10 people infected will go on to develop active disease. This number is higher if conditions of immune suppression exist. The conditions of stress, malnutrition, poor access to health care or proper shelter contribute to weakened immune systems, as do infections and disease such as HIV, Hepatitis, cancers and chronic illness such as diabetes or arthritis.

Today

Activists, homeless people, health care workers come together to share their concern and to appeal to the Department of Public Health and the Homeless Advisory Committee of the City of Toronto to act. 

Their concerns and recommendations are based on fact, experience and the knowledge that in New York City measures which included TB screening were essential to prevent TB outbreaks. The Canadian Tuberculosis Standards, issued by Health Canada in 2000 recommends  that groups that should be considered for systematic screening include the poor, especially the urban homeless. (p.189)

Recommendations:

  1. The City notify the provincial government regarding the current danger homeless people face with respect to TB and ask for financial assistance for improving shelter conditions, housing and enhanced TB program funding.
  2. The Board of Health immediately reappoint and call into action the pre-existing TB Subcommittee of the Board of Health.
  3. The Board of Health hold an immediate inquiry into TB among the homeless.
  4. The Medical Officer of Health issue a communiqué to all health care providers working with homeless people to alert them to the new TB crisis.
  5. The Department of Public Health begin TB screening programs in the immediate vicinity of Seaton House including drop-in centers, Out of the Cold programmes and other shelters and that this radius of testing be expanded to other parts of the city.
  6. The Department of Public Health examine the New York city process that houses homeless people with HIV infection within 24 hours.


Part C: 
Tent City Solutions Stalled

Background 

Three different organizations applied to the City for Supporting Community Partnerships Initiatives (SCPI) funds to set up transitional housing at 525 Commissioner Street for homeless people. The development of these proposals cost many thousands of dollars and the energies of skilled and talented homeless people and professionals.  In the end, Homes First was given the go-ahead to work on the project.  

Homes First, the homeless people, and the Tent City Relocation Group (of which TDRC is a member) have been meeting to achieve this much needed interim strategy while waiting for permanent housing.

The sad part of this story is that the plans for the innovative proposal which largely came out of looking for a solution to the Tent City situation has been left in limbo.  At the last City Council meeting this December 4-6, nothing more than a city staff report was submitted.  Now the land which the City had identified and selected for this project is in question. City staff name several planning concerns relating to the site including the existence of a restrictive covenant on the site from the 1994 Agreement of Purchase and Sale between the Toronto Port Authority (a Federal body) and TEDCO.

Now, any resolution cannot be decided upon until the next City Council meeting in February, thereby pushing the development of housing further and further back.  In fact, begging the question, will this project ever get off the ground and transitional housing built?  Will the continuing negotiations and plans of Tent City dwellers, Homes First and the Tent City Relocation Group all come to naught? 

This process that has been going on for over a year has so far led to only the exchange of words, expense of money, endless paperwork, and the dashing of hopes of homeless people who very much need a transitional inexpensive housing strategy.

We wait as Christmas nears and homelessness grows.

Recommendations:

  1. The City expeditiously proceed with negotiations with the Port Authority to make the site available for development of transitional housing before the next City Council meeting in February.
  2. In the alternative, the City find another suitable site and finish negotiations by the February City Council meeting.

For more information, contact TDRC at tdrc@tdrc.net

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