McGill Journal of Law and Health

Contributed by Raiha Shareef

Introduction 

Though an often silenced injustice, homelessness became an unavoidable topic for Regina, Saskatchewan this past summer. A large camp was erected on city hall grounds by Rally Around Homelessness, a grassroots housing advocacy group. The camp supported over 100 unhoused people. Volunteers took shifts providing food, water, naloxone, and mental health support to camp residents. The camp quickly became an entrusted and central area to receive lifesaving services for drug overdoses. In addition to the health services offered at the camp, this encampment was a community for those often living in alleys or abandoned bins. However, after the camp’s 42nd day, the City of Regina declared to shut it down. Over 30 armed police officers and firefighters tore down tents, removing what once was a home for the homeless. The absence of the camp was felt by many who relied on its resources. Rally Around Homelessness states that forcibly removing encampments exacerbates deaths among the homeless. However, in a country that provides universal healthcare, what are the shortcomings in our health policies and laws that lead to a dependence on encampments for health services? This blog post provides an overview of the living conditions, legal documentation, and stigmas that aggravate mortality and morbidity of the people facing homelessness.  

Living conditions that exacerbate illness 

Unhoused people often face worse health outcomes than the general population. According to an Oxford study, approximately 90% of adults experiencing homelessness have two or more chronic physical or mental health conditions. Living in public spaces outside exacerbates health conditions for the homeless. Even when an individual is diagnosed with a simple cold, it can escalate to more chronic conditions such as pneumonia. This is because unhoused people have less resources for transportation to a clinic, cash to pay for over-the-counter medications, lower immunity because of poor nutrition, and because they lack spaces to keep warm during the winter. Because of legislation like the Ontario Safe Streets Act, which prohibits people from staying in public spaces like parks and sidewalks for extended periods, the homeless must continuously travel from one area of the city to the next. The constant move is burdensome for unhoused people and causes increased stress for the fear of getting ticketed or harassed by the police. Travelling also makes it challenging for unhoused people to maintain consistent use of prescription drugs for viral infections or chronic conditions because they are more likely to have their things lost or stolen as they move between different public spaces. Homeless encampments instead centralize resources, eliminating issues with transportation and allowing the homeless to seek immediate support for acute conditions without these conditions developing to more chronic concerns. 

Medicare cards as a barrier to healthcare 

The Canada Health Act requires patients in every province to provide proof of valid provincial health insurance to access primary care. However, obtaining and keeping identification safe is extremely difficult for unhoused people when living in public spaces. If their health card was lost or was never created, making a new health card requires a birth certificate and social insurance number which most unhoused people may not have in possession either. A new medicare card also requires a permanent address to which unhoused people do not have. Valid identification cards are costly—a five-year term costs $51.45 in Alberta and a fine of $115 for not updating permanent addresses within 14 days. While clinics and pharmacies require a medicare card, the emergency department does not, leading homeless people to frequent emergency departments with acute conditions as opposed to being empowered to seek treatments before it becomes an emergency. 

In a study investigating barriers to health care among people facing homelessness in Toronto, Ontario, 74% of respondents had at least one chronic illness but 34% were not in possession of a health card because it was either stolen or lost, rendering insured health services inaccessible to them. Family physicians play a crucial role in detecting chronic illnesses at earlier stages and providing preventative treatments to avoid developing other illnesses. Without this care, minor illnesses develop into chronic health issues. As these conditions become more serious, unhoused people are more likely to seek emergency services at hospitals. Medicare cards are thus an administrative barrier that perpetuates lower health outcomes for unhoused people.  

Stigma in healthcare 

Stigma and discrimination in healthcare are major barriers for patients facing homelessness. An Ontario study found that patients facing homelessness felt judged by emergency care providers when seeking treatment for substance addiction, mental health, or chronic pain. In these instances, care providers assumed unhoused patients were only seeking out prescriptions for narcotics, invalidating their pain and other stressors. A participant in the study writes: 

“Once I went for kidney stones, [the doctor] started yelling at me that all I wanted was pain killers. I’m like, “excuse me?” I’m on suboxone. Because I’ve been on pain killers for so long, they red flag you for it. A lot of the times they think you’re just there for pills. Sometimes they look at me and judge right away. To look at everybody as if they’re a drug addict as soon as they come in, I get that that’s part of their job but not every person is.” 

Because of the stigma, rude behaviour, and invalidation of health concerns, patients facing homelessness become less motivated to seek health services, perpetuating lower health outcomes and high mortality.  

Ways forward 

A study found that the Rotary Club of Toronto Health Bus, a public mobile health unit for unhoused people, supplemented the traditional healthcare system and was frequented in high number by the unhoused population. Public mobile health units were seen to be successful in the study as they provide needed resources to the homeless in local communities such as socks and vitamins, yet also provide an opportunity for contact between homeless people and the healthcare system in an informal fashion. While the majority of the homeless patients visiting the health bus did not have issues with obtaining health cards and had access to a family physician, many preferred the bus because they felt respected and enjoyed the social interaction with the health providers. This study found that mobile health units complemented traditional modes of health delivery as they reduce barriers for unhoused patients like transportation, documentation, and discrimination. While mobile health units cannot replace the traditional stationary healthcare system, they play a significant supportive role in making healthcare more inclusive and accessible to people facing homelessness.  

Conclusion 

The homeless population in Canada has lower health outcomes because their living conditions exacerbate illness, insured health services are inaccessible to them, and the stigma in healthcare leads to mistrust in the system. With the increase in housing insecurity in the country, centralized and community-based health services are an effective way to support unhoused people. Mobile health units like the Rotary Club Toronto Health Bus re-establish trust in the healthcare system and encourage unhoused people to use health services before their health problems develop into emergencies. Community-based care is one step forward to realizing true universal healthcare in Canada.  

To get involved and support people facing homelessness, there are legal projects across Canada that work to aid individuals get identification for health cards. The Community Legal Assistance Services for Saskatoon Inner City (CLASSIC) “Project ID” helps attain or replace ID for people in Saskatoon.  

About the Author 

Raiha Shareef is the Junior Online Editor of the McGill Journal of Law and Health. She is currently in her first year of the BCL/JD program at McGill University’s Faculty of Law. Raiha’s interests include reproductive justice, housing advocacy, and transformative gender equality. Prior to her studies, Raiha partnered with Plan International Canada as a Youth Ambassador advocating for international gender equality policies. She later became the Youth Spokesperson for P&G Always’ Menstrual Hygiene Day campaign, educating Canadians across the country on menstruation, breaking the period stigma, and the role of poverty in reproductive health risks in Canada.