November 10, 2020
Written by: Jenna McHugh
Homelessness has been and continues to be a major concern in urban areas. Complicating the challenge is the uncertainty of whether the COVID-19 pandemic has increased the numbers of individuals sleeping rough, or simply made homelessness more visible. Social distancing guidelines mean there is less space available in shelters, but cities’ willingness to expand their services allowed homeless individuals to reside in hotels and community centres that were not being used, making increased visibility of homeless perplexing. Perhaps some homeless individuals moved into more central locations to access services and felt comfortable to sleep rough more publicly as local businesses had closed their doors and foot traffic lessened. Or, the homeless situation may be worsening alongside economic fallout and increased precarity of employment. There are multiple fronts to consider, and adding to the murkiness of the problem, some cities have postponed the point-in-time count (a method used to gain information on the numbers of homeless) until 2021 because of the pandemic. The lack of current data on the extent of homelessness in cities, coupled with a desire to remain sympathetic, is complicating an already confusing set of challenges that requires evidenced decision making and careful consideration. Homelessness is a dreadful situation for all parties; cities struggle to manage the issues, communities grapple with disdain mixed with sympathy and some of the individuals themselves are participating in trauma induced drug use. Homeless populations are at a higher risk of contracting hepatitis, typhus, and tuberculosis and many other illnesses due to the lack of access to hygiene facilities, crowded conditions in shelters, and greater susceptibility to illness. Both structural and individual ownership of the multifaceted problem is necessary to make headway on this issue, but the current measures of harm reduction public health champions to support individuals who are homeless are falling short, helping only some of those who are homeless and leaving others to skip parks every few weeks.
Situations are dire and it’s not for lack of trying with cities increasing annual spending to try to help the problem, but numbers of homelessness continue to grow. One of the most notable homeless crisis exists in Los Angeles, California with 66, 433 people homeless, an increase of 13% from 2019 according to the most recent count in January 2020. In LA, the city allocated $1.6 billion for subsidized apartments and emergency shelters over the last few years to no avail. Alternatively, the situation in Canada is not as grim, with 35,000 people homeless on a given night. California and Canada have a relative population size (39.51 and 37.59 million, respectively) and LA’s homeless population is almost double the total number of homeless people in Canada. However, according to a 2019 study, Canada spends a combined total of more than $30 billion per year on fragmented social services and non-profit programming to support homelessness.
Alongside the haziness of the current scale of the homelessness problem is the increasingly serious problem of illicit substance abuse, again, complicated by the pandemic. There have been increased numbers of injection drug overdoses throughout Canada. By March of 2020, the crude rate of total apparent opioid-related deaths in Canada was already higher than 2019. Academics refer to homelessness and substance abuse as a twin problem, recognizing that ending homelessness also includes addressing concerns related to substance abuse. Imagining substance abuse and homelessness on something like a Venn diagram would almost look like a completed circle. There would only be slivers of the circles where substance abuse and homelessness didn’t overlap. It’s perhaps more closely aligned with a cause-and-effect scenario, where one problem perpetuates the other even when they do exist separately. The mainstream public health strategy to remedy this complex problem is a harm reduction approach called Housing First. It is considered an evidence-based solution that encourages cities to provide adequate numbers of social housing for those who voluntarily accept, in combination with support systems. While I do not dispute that these strategies can be useful for a large majority of the population, I contend that the development of affordable housing units, coupled with Housing First, is not the silver bullet to the problems we are currently facing.
Originally, harm reduction was considered a philosophy and a strategy to reduce the harms associated with injection drug use, without encouraging the stopping of the substance use altogether unless done voluntarily. It’s a client-centred, evidence based approach that seeks to meet the client where they are at. Essentially, the person is provided a choice to determine how they would like to minimize harms. The treatment is non-coercive and non-judgemental. This works alongside homelessness under the premise that those who are homeless should be able to gain support and housing, while being able to use injection drugs with minimal risks, such as clean needles, supervision and support available. Most notably, Overdose Prevention Sites fall under a harm reduction approach, sometimes referred to as Safe Injection Sites. It’s relevant to mention these locations as there are often connections to the homeless populations and OPS. The facilities provide an environment for people to use substances under the supervision of medical professionals, provided sterile supplies, education on safe consumption, referrals to drug treatment, housing and income support. The sites work under the guise that harm reduction supports those with addiction or substance issues with dignity and respect, and allows individuals to make informed decisions most effectively to themselves, while also reducing the potential harms. Harm reduction has become a key element of homeless services within the Housing First model.
The Housing First model states that someone who is struggling with the twin problem must first be housed in order to overcome the obstacles associated with substance abuse. A place to live is provided without the initial motivations required to participate in drug treatment programs on a voluntary basis for the previously homeless individual. The evidence to support the efficacy of this treatment to end the cycle of homelessness is impressive, as well as the decreased costs in hospitalizations and services. Housing First programs are able to sustain approximately an 80% housing retention rate for those who are chronically homeless and mentally ill. Logically, it makes sense; if someone is struggling with addiction and wishes they have a place to live, but can’t get it together enough to maintain a rental or even apply for one, a place to stay is appropriate so they can tackle the addiction in a supportive, and safe environment. The Housing First model allows the consumer to connect freely with the harm reduction service provider; ideally, the person would have multiple service provider touch-points to stay safe and informed regarding their substance use. The program also creates a model that allows people to be honest about their substance use. Previously, a homeless person would need to go through a detox program before getting housed, which was a deterrent for many. However, if the substance use becomes a problem, meaning that the individual is endangering the health and safety of themselves and other building residents, the Housing First program will encourage rehab and treatment, with an option to return to their unit when discharged from treatment, or their condition improves. Housing First will re-house the individual if the landlord chooses to evict the person.
The problem is that this approach doesn’t work for everyone and for those who this approach doesn’t work for, it leaves them to continue seeking out community on the streets. This is displayed in the literature findings from Henwood et al., (2014):
‘There were rare occasions (and consumers) for whom harm reduction didn’t work. Speaking of one of these exceptions, a Housing First provider opines, “he cannot-he doesn’t have the power, the harm reduction is not working. For dependent clients, harm reduction is not working. I can say that. Even though there’s so many times I’ve said that to other people and they’ve said “Oh you are judging people” or “that’s not right”, but this is the reality.”’
The goal of Housing First is to work towards abstinence, while recognizing that people will falter and slip-up. However, some of those who are homeless are not interested in entering housing. There are certain social norms that are required in an apartment building, or subsidized living space, even when there is an understanding that abstinence is not required. Things like rent payments, generally capped at 30% of one’s income in social housing, and the personal responsibilities attached to maintaining a unit or home are required in order to remain housed. To many on the streets, living amongst a community with a similar lifestyle, who are addicted to and/or supplying drugs is a more desirable option, with the added benefit of rent-free living and no one to answer to. Some even considered it a safer option for themselves. These communities at the person to person level are considered positive because people begin to look out for one another, providing companionship and support. Furthermore, the option of housing is unreachable for many who are homeless and have experienced heavy trauma. Often those who are homeless are simply unable to plan for the future as they are coping with negative experiences in their past and are using substances to forget or numb the pain. Even though providing housing may motivate consumers to address their addictions, the dangling carrot of housing is not always enough for some to be able to participate in the norms associated with remaining housed.
A voluntary solution doesn’t work for everyone and to ignore the repercussions of the individuals who choose to remain on the streets is disheartening. For those for whom the harm reduction approach is not effective, as cited above, what does a municipality do? These scenarios played out in Hamilton, Ontario over the last 6 months. In April, it was reported that the City of Hamilton was spending $2.5 million more a month on the homeless population because of the pandemic. The City allocated resources to open up rooms in hotels and community centres, and turned the First Ontario Centre into a temporary shelter. This was all done to provide shelter to those who need it, while protecting those from COVID-19 outbreaks and to abide by social distancing recommendations.
Interestingly, Hamiltonians saw headlines about increased ticketing for homeless populations if they weren’t following social distance guidelines that included comments from social justice campaigners comparing street corners to living rooms, and for police to use discretion in ticketing. Early on it was established that those living on the streets were not subject to the same laws other Hamiltionians were during the pandemic. Whether these complaints led to leniency from police or out of convenience for those in need, large encampments began to erupt in areas that provide public services for the homeless. The course of action for the homeless encampment communities, with some as big as 60 tents, sparked controversy between activists and city councillors. In July, a group of doctors, lawyers and harm reduction advocates won a 10-day injunction that barred the city from forcing people living in encampments to vacate their tents, which was then extended by a Superior Court judge until September. During this time, the City and outreach workers connected with those in encampments to make attempts to move them into shelters, hotels and affordable housing units. Legal and medical advocates cited the need for the City to recognize that the encampments are where these folks felt safe, especially with the pandemic. However, even though the city was proactive in trying to get people housed, not everyone is interested. The hotel rooms were not suitable, as some individuals were evicted after 2 days and shelters have restrictive rules like curfews and pet restrictions. Much of these challenges are compounded by mental illness, affecting 24-50% of the homeless population on average.
Housing First works for most individuals, who have fallen on hard times and are dependent on illicit substances, but not everyone. The allure of one’s chosen substance is too strong. In consultation with a friend who previously worked directly with people struggling with addiction, it’s clear, “Their number one priority is getting their fix, always.” Even when someone does volunteer to be housed, it’s still an uphill battle to try to help them get healthy and remain housed. In October, the Hamilton activists and the city appeared together before the Superior Court to withdraw the application for the injunction in agreement that the city will continue to engage with provincial health authorities to support those who are homeless. In keeping with the by-laws, those in encampments were offered a place to stay, and those who chose not to accept were asked to move on. The large encampments were cleared by outreach workers, with police support. It’s unfortunate that not everyone chose to accept a place to stay, and some who didn’t have only moved a couple blocks and re-pitched their tents. In my opinion, the re-pitching of one’s tent in a different park is not an adequate solution.
With the Housing First harm reduction strategy there is the need to develop the affordable housing units to place those who agree to be housed. The communication from public health that developing affordable housing, in order to apply Housing First practices, is the solution, but governments are taking too long to build units. I find this argument futile for multiple reasons. Firstly, there is a long-list of those who wish to live in subsidized units, and many of them are not homeless struggling with addiction and substance abuse problems. I would be pleasantly surprised if I learned that those who are homeless are on the social housing waitlist, but I expect many are not. Folks on the waitlist simply cannot afford to live in market-rent properties and need to decrease their costs of housing in order to improve their lifestyle. Often, these people are on a fixed income. These types are likely much better tenants than those struggling with addiction. Secondly, an increasing number of subsidized housing does not offer a long-term, financially stable solution for societies. It creates a scenario where more and more housing is provided, where increasing government funding is necessary to subsidize the costs of the housing units. For instance, if a subsidized housing unit costs $1000 to maintain and the tenant is only paying $500, as per the 30% of one’s income that is required, government subsidies are covering the other $500 of that unit. Increasing the number of these units creates a scenario where the government is responsible for a larger and larger percentage of housing. With that, the units need to be updated and reasonably maintained, costing more. Finally, the development of affordable housing, even in haste, does nothing for the small minority who do not want to be housed, and who would rather remain in a tent community on the streets.
To me, the affordable housing explanation is a low-hanging fruit; emphasis on structural problems that only governments can solve makes the argument hollow. A city like Hamilton, has a waitlist for social housing of approximately 7,000 people, a 3-5 year wait, with the solution cited as the development of more affordable units by social housing providers. In 2010, Hamilton had 14, 600 subsidized housing units and last month, Hamilton was provided $10.8 million from the federal government, which will only be enough to fund about 30 units as each unit costs around $330,000 to $340, 000 to purchase and construct. It is next to impossible to catch up to the number of those on the social housing waitlist, while maintaining the current units.
When I began looking into these problems, almost 3 years ago, I was on the side of the activists promoting the harm reduction approach without giving it a second thought, but deeper consideration of the problem has led me down a different path, where I find myself asking, ‘What is the compassionate thing to do?’ From my perspective, the individuals who are living in the tent encampment communities are suffering; from drug addiction, mental illness, trauma, and all the other physical and mental effects that come from not being able to have a permanent address. There is no doubt about it, having a stable living environment, even when there are external stressors, is better for the psyche than a tent on public property amongst 60 others. To have compassion means to empathize with someone who is suffering, but the caveat of compassion is to feel compelled to reduce the suffering. Allowing people to suffer at this scale, while promoting a harm reduction strategy that is continually falling short is by no means compassionate.
When addiction and mental illness is the driving force in your decision making there needs to be something beyond the voluntary option of housing and assistance. How many times is too many for a homeless person to deny housing support? How many times should the police ask the same person to pick up their tent and move on to a new space? A ‘Harm Reduction Approach’ seems to now be disguised as a ‘Look the Other Way Approach’. An unwillingness for left-wing liberals to place harsh judgement on any type of lifestyle, even when it’s misaligned with civilized Canadian values and norms of helping others. It has become an opportunity for ‘do-gooders’ to turn a blind eye to suffering because it’s inappropriate to pass judgment. The harder thing to do is to be honest about the cruelness of addiction, how it takes over, and for some, the harsh realities of what it takes to give help to those who won’t accept it when an addiction is making decisions for them. I propose a more drastic solution for consideration, where those who are unable to look after themselves because of an addiction or mental illness, on such a level that they are homeless, should be obliged to check-in to a facility where they will be provided the opportunity to have treatment, a bed, and a comfortable space, with the caveat of a locked door from the outside. This is not a life-sentence for those who can recover; it’s an opportunity to get a life back. Harm reduction and Housing First shouldn’t be voluntary for those who are struggling the most on the streets. I acknowledge it has the potential to be nightmarish for folks who are comfortable on the streets, but I don’t see the long term solution for allowing people to move on to a new place, continue illicit substance use and hope that they don’t die from an overdose the following week. People suffering from substance abuse don’t wake up with a choice, they have their mission for the day, and will die for it.
Much of the argument against forcing an individual to receive treatment, or reside in a facility until they are able to self-regulate within society is doing so is taking away from the individual rights and freedoms of the person struggling with addiction. To this, I would agree. It’s seemingly unfair to force someone with agency who is experiencing hardship to live in a facility with a locked door, however, when someone is struggling so fiercely with addiction that they would do anything to find the next fix, I pose the following questions: Does that person have the agency required to make the decision about what’s good for themselves? If their families are unable to deal with the turmoil of having their kin in and out of their home with a substance abuse problem, who is responsible for that person when they can no longer take care of themselves? What’s better for a person when they are not making rational decisions and prioritizing behaviours, a clean bed and a locked door, or an opportunity to inject a substance that may kill them? These are questions that ought to be considered when the overdose rates are climbing, the number of people homeless are increasing, and when the size of encampments are growing.
Recognizing that each homeless person is an individual, with their own unique needs for support, this is not a perfect solution. However, it is clear that the current solutions being pushed by public health are inadequate. There needs to be room for options of this nature at the table. It’s not ideal for those struggling with homelessness and its challenges to be forced behind a locked door, but aren’t they suffering in other ways on the streets? The combined problems of drug addiction and homelessness can not continue to go on. Encampments aren’t good for anyone; children are pricking themselves with used needles and finding them close to their schools, cities are overwhelmed with an increasing reliance on social services, and communities should have safe access to their parks and sidewalks. Compassion must compel us to continue to look at these issues plaguing our communities and recognize when changes in support need to be made.
Jenna McHugh is the Founding Editor of Vigor. Follow her at @jennoratorr