Jared Knoll: Welcome to Upstream Radio, where we dive deep into all the social and economic determinants of health — the root causes of how we live, and when we die. I'm Jared Knoll. Last episode, we spoke about housing as a human right with Shaun Dyck, ED of a grassroots organization that researches solutions to address homelessness, and Sheri Benson, a member of Parliament with a motion for the federal government to step up its response to our growing crisis of homelessness. Unfortunately, that bill did not pass, but Benson isn't about to stop trying.
Part of the problem is with our attitudes towards housing. We look at it as an expense that our neighbors are just expected to cover, like a new phone or a Netflix subscription. But it's not that. Decent housing is essential for our health. We pay tax dollars out of our noses for emergency rooms, addiction treatment, and other downstream costs of people not having homes. Why can't we just put some of that investment upstream, and provide people with what they need to be healthy in the first place?
We can all agree in Canada, that healthcare is a right. We just need to acknowledge the now mountainous evidence that housing is fundamental to our health, and expand our definition of care. Homelessness is complicated. There's not one easy or simple solution, but we cannot let those remain excuses for doing nothing, or even too little.
RG: Canada is a high-income country, and despite everything we hear and the fears we sometimes have, we can afford to provide people safe and affordable housing. We can afford to provide people the child care they need, the medications they need, high-quality healthcare.
JK: That's Dr. Ritika Goel, family physician at the Inner City Family Health Team, on the board of Canadian Doctors for Medicare, and is involved in the Decent Health and Work Network, as well as the Social Accountability Department of the Ontario College of Family Physicians. You may remember her from episode four as well.
Two years ago, the United Nations Committee on Economic, Social and Cultural Rights completed a decade-long review of Canadian housing. They concluded that our homelessness situation is a human rights crisis. We finally now have a national housing strategy, but part of the reason we haven't really moved the dial on homelessness is that it's largely a hidden crisis for most Canadians. But it's not hidden at all for health professionals like Dr. Goel, working in Toronto's inner city.
"I realized was that providing healthcare and managing people's medical condition, while important, failed to address some of the underlying challenges that were impacting their health."
Ritika Goel: In working with people on the frontlines that are experiencing homelessness and experiencing poor housing, it's difficult to really feel that that much progress has been made since the beginning of the report. So we have a situation where housing is not only extremely unaffordable, but often very poor quality for the people that are not able to access what they need. In Toronto alone, we have a situation where the affordable housing list to the city is extremely long. People have to wait sometimes another seven to 10 years before they're even able to get access to subsidized housing. And unfortunately, during that time, they usually end up in the shelter system. And the shelter system is in itself, under a lot of strain.
So in Toronto, we've recently had some activity to try to get the city to increase the number of shelter beds, which they said they will, which is great to see. But the system has really just been overburdened and stretched with years and years, and we see that in places like a drop-in that I worked at, which is now open 24 hours a day for women, and is really operating as a shelter when it shouldn't be, because the shelter spaces just aren't available, and the affordable housing spaces aren't available. So you're seeing people that are working on the frontline for community services really stretched beyond capacity, and providing housing that's not safe and not ideal, and definitely not affordable.
JK: How well do we understand how bad that is? How well do we know our own homelessness problem nationally and locally, where you work in Toronto?
RG: I think the average person probably doesn't have a great idea of what that really looks like on the ground. The reality is that, I think, homelessness is something that people hear about, and they have a general idea of what it means — but I think really knowing what it means to experience homelessness, and what it means to go through the system that we have, and how dehumanizing that can be, and how undignified that is, I think that's something that's quite difficult for the average person to understand.
And unfortunately, I think because people who are experiencing homelessness are often also those who are marginalized in society, and have less power, and in many ways have other things happening, they also don't necessary have as much of a political voice. And so sometimes, I think we may not see action for the most marginalized in our society because of that. So I think there's a lot of work to be done in that area.
I think when people think of homelessness, there is a caricature that comes to mind, and that's the person that you see sleeping on the street. And we do have street homeless in Canada, and people experiencing street homelessness tend to be more visibly... Tend to be male, whereas the hidden homeless often consist of more women. So there's that difference in terms of gender. Also, families are much less likely to be visibly homeless on the street. So we have a huge deficit in terms of homeless... Of housing available, both for women and for families.
And then beyond that, I think one particular group that's religiously pushed and impacted is Indigenous people. And we have some services that are specifically geared for the Indigenous population, but not a lot of them. And I think really thinking about how we have services available that are catered to certain populations and their needs.
Another really important one is LGBT youth. We know that in youth homelessness, there's a very disproportionate amount that are LGBT, as that often are reasons for family breakdown and for homelessness resulting. But not having specifically-targeted safe spaces, or ensuring that the existing spaces are safe with that population, can be a real challenge.
"Coming out of my, I guess, career as a homeless addict, I was just trying to survive. I was desperate enough, and I was just trying to survive. When I got to rehab, I was trying to figure myself, and I was asking myself questions of, "Why were there so many other Indigenous people like me in the exact same situation? In the same jails, in the same places that I ended up like in welfare offices, why are they all Indigenous?""
JK: Canada has always had as a principal value of being Canadian: universal healthcare, and the idea that we take care of people. We know from the Mental Health Commission survey that came out a couple years ago, over five years, 10,000 or 15,000 subjects, and then confirmed by other studies in the States, that the cost of maintaining homelessness, the cost of having homelessness with increased services, health services, police, prisons, shelters, etcetera outweighs the cost of providing housing.
What has been your experience personally as a physician? What are some of the most striking times for you, or perhaps the most striking time, when you thought, this is the health impact of not having a place to stay?
RG: As you eloquently said, the difference in the cost of providing affordable housing for a night, compared to the cost of having someone in jail, having someone in the emergency room, or a juvenile education facility, or even in a shelter, all of those costs outstrip just providing someone affordable housing. And this is very, very commonly seen in clinical care.
The rate at which we end up sending patients, 'cause I work in primary care, that are experiencing homelessness to the emergency room is much higher than the rate of the general public. And that's because they're much more likely to be in some type of a mental health crisis. They're much more likely to have a physical health issue that's been left to the point of requiring inpatient intervention. They're more likely to just be in a state where they're unable to cope with what may otherwise be a medical issue, or a mental health issue that could otherwise have been easily addressed.
So very frequently, I'm sending my patients to the emergency room for issues that definitely could have been otherwise addressed. And so that's just one example. And then I do see also my patients interfacing with the justice system. And it's very clear I think when you're providing healthcare, how all those things are laid. That if I have someone who has stable housing, they have a place to store their medication, they generally just don't have that chronic anxiety that you have when you don't know where you're sleeping at night.
They are able to take care of their health by having to store healthy food, they're able to control what they're eating. They're not reliant on the shelter food, which sometimes is not the best for people with dietary needs. There's just so many, hundreds and hundreds of ways where having your own place to stay, that is safe and that is of good quality, is more important.
Because that's the other piece. I also see people who are already living in subsidized housing, but their housing is making them sick. They're living in a place where there might be mold, or the size of the housing makes it so that, for example, their PTSD is being triggered because of being in their cramped conditions, or not have enough decent sunlight, or whatever it is. So I think it becomes very clear that when people have access to safe, affordable, high-quality housing, their health improves, and we're able to prevent unnecessary hospitalization, and we're able to keep people outside the justice system because they're just doing better.
JK: That must be so frustrating, to be a doctor and see people coming in again and again with conditions, with circumstances, with illnesses that you know can be socially and economically treated for, if not pennies on the dollar, then certainly the same cost. Does that wear down on you? Does that frustration build up over time?
RG: Well, I think the people it frustrates the most probably is the people experiencing it. I think nobody knows it better than the people experiencing homelessness, that they would be much better off, and in fact the best prescription for their health is just safe and affordable housing. It's just so obvious for them.
But definitely, I think working in the system, it's also quite clear to me that the way to address people's health and to improve people's health is to work on that upstream level. To talk about policy issues, to have those public conversations on why housing is important. And not just housing, but income, and education, and actual job opportunities, and addressing broader issues like racism, and sexism, and transphobia, homophobia, etcetera. All these things really impact people's lives.
And sometimes it's hard to see that connection when we're having a big medical conversation, but I think when you see someone who's going through that day in and day out, and it's really impacted them in a tangible way to the point that they're living in poverty and experiencing homelessness, and have experienced trauma as a result, because that's the other really big threat that we see in the homeless population, then it becomes so obvious that we need to, not just do the band-aid work of frontline care, which is important, but also facilitate these bigger conversations, and really push people in power to meet people's needs through upstream policy change.
JK: We've recently started tracking homeless deaths, and in big cities like Toronto, we found thousands and thousands of annual homeless deaths, that before just weren't counted. We historically haven't really... Maybe we've noticed somewhat, but we haven't actually recorded them.
RG: Absolutely. In Toronto, people have been calling for counting homeless deaths for decades. You may be familiar with the Homeless Memorial that is run once a month. There's a community gathering where people add names to this memorial, and it's absolutely heartbreaking to look at the list because a lot of them are just unidentified, or we know that there was a death but we don't know the circumstances. And the community has felt like that's something that they need to take up themselves, because it felt like there's such a low accountability from people in positions of power.
So I think, yeah, until you count it in a way, you don't know the problem is there. And that may have been by design, so I'm really, really happy that we're now going to be collecting the data and asking the right questions because that will hopefully make it harder to ignore the problems that many people working in the community, or that are part of the community, already know exist.
RG: And I think the other piece there is that it will hopefully help us hone in on what some of the specific impacts are. So of course, right now, we're seeing a huge proportion of the deaths being related to opioid overdose. And so having that data is really important to show what's really happening with the population, and where things are going wrong. So not only do we need housing, but for example, we need to address harm reduction, we need to have harm reduction services, we need to include education and healthcare providers as part of that.
There's so many different factors that go into addressing one specific related cause in homeless deaths, so yeah, absolutely. And then the other piece is that although it's being counted now, it's also important to acknowledge that that is happening as a result of that community pressure, that this is finally being taken up.
JK: And we need all the pressure we can get. Pressure makes policy action happen. But why does it take thousands of homeless people to die for us to pay attention?
SH: Deaths are something that people very much understand. It's something that gets people at a level where they can't say, "Well, that's not a problem." But when they see that people are dying at an early age, or dying in preventable ways, that certainly tends to move people.
JK: That's Dr. Stephen Hwang, Director at the Centre for Urban Health Solutions at St. Michael's, a Toronto hospital with an outstanding focus on the social determinants of health. Dr. Hwang went into medicine to improve the wellness of his fellow humans, but he had an important light-bulb moment.
Stephen Hwang: What I realized was that providing healthcare and managing people's medical condition, while important, failed to address some of the underlying challenges that were impacting their health.
JK: So when we know that housing, that providing housing, or housing first policy take on it can be cost-neutral, because you save on police, you save on prisons, you save on emergency rooms, do you think that there's a problem in getting public pressure for policy action, in that people don't think it could happen to them? Do you think there needs to be more communication of the benefits to everyone?
SH: Oh, yeah, definitely. So I think that it's extremely important to try to communicate to people that this is not about helping a certain group of disadvantaged or poor people, at the expense of the average person. I think it's really important to communicate the fact that we all benefit when we reduce these disparities, that ultimately are corrosive to our entire society. The idea is that "Because I'm not the person who's the big loser, in the sense of I'm not the person who's homeless, so therefore, I'm not benefiting from efforts to help people who are homeless," is one that I think is what we really need to communicate around.
JK: So how do we achieve that, and change the conversation?
We really are grateful for all your support. One of the things it allows us to do is closing the gap. It's our annual conference in Ottawa, now in its third year, where we bring together top-level policymakers like Ministers Jane Philpott and Carolyn Bennett, our most prolific gurus of the social determinants of health, like Sir Michael Marmot and Richard G. Wilkinson, and people with frontline experience like Cindy Blackstock and this year's Tanya Talaga, to fuel and evolve our public conversation and policymaking for the health and well-being of all of us, by taking the mainstream upstream.
One of our speakers this year is Jesse Thistle, a PhD candidate at York University, with a wealth of scholarship in Indigenous history, and the National Representative for Indigenous Homelessness for the Canadian Observatory on Homelessness.
Jesse Thistle: Coming out of my, I guess, career as a homeless addict, I was just trying to survive. I was desperate enough, and I was just trying to survive. When I got to rehab, I was trying to figure myself, and I was asking myself questions of, "Why were there so many other Indigenous people like me in the exact same situation? In the same jails, in the same places that I ended up like in welfare offices, why are they all Indigenous?" 90% of the places I went to was like that. The first time I heard my language was in the Don Jail. Why is that?"
JK: Homelessness, addiction, and mental health issues don't occur in a vacuum, and we probably can't address and overcome these social crises without understanding their root causes. For thousands of Canadians, the biggest and deepest one is colonization. Indigenous peoples living in Canada are four times more likely than non-Indigenous Canadians to live in a crowded dwelling, are three times more likely to live in a home requiring major repairs, and are vastly more likely to live in conditions where they lack access to safe drinking water. The health impacts of colonization on First Nations, Inuit, and Métis health are staggering, and we're gonna dive deeper into them next week. But for right now, I ask Jesse where his story began.
JT: I lived this suburban veneer of paradise I grew up in. But I bought into that dream like everybody else from that era, but what was different about me was that my family fell apart in the late '70s. My mom's people are from Saskatchewan, and my dad actually grew up in Weston. And they both have what's called intergenerational trauma in their lines. And so when they met in the early '70s and started having kids, they had all this historical factors that come down from both of them.
My dad's family, his grandfather, David McKenzie, went to Spanish residential school. On my mom's side, they were rebel Cree-Métis people that fought against the government of Canada in 1885. And then on my dad's father's side, they were displaced Highland Scots, what are called the Highland Clearances that were put in Nova Scotia and basically forgot about. So all of these competing historical lines of trauma affected my family, even all the way up until the '70s. And then by the time my parents had us boys, it was just too much, and our family fell apart, and we were lost to the system.
JT: After my dad robbed some stores, and then my grandparents in Toronto, who raised my father knew, heard what happened, and came and got us. And so they came and they raised us in Brampton. And on the surface, it looked like everything was okay, but we had all this underlying trauma from our lines, as well as we were with lots of portions of our Indigenous identity, and we didn't really know who we were. Our mom was in our life, kind of... She would call. She visited, I think, twice over the course of 13 years, until I grew up.
"Homelessness is something that people hear about, and they have a general idea of what it means — but I think really knowing what it means to experience homelessness, and what it means to go through the system that we have, and how dehumanizing that can be, and how undignified that is, I think that's something that's quite difficult for the average person to understand."
And all these things impacted me. Not knowing who I am, not knowing where I fit into community and society, not knowing really my family history led to me making a bunch of poor choices in my early adulthood. And that led to hard-core addiction, me getting in trouble with the law, and the eventual homelessness. Yeah. So that's kind of the long journey of my life history, and what it was like to grow up in Brampton.
JK: I want to dive into all of that, get into more on having these driving forces of intergenerational trauma, that at the time you didn't really understand. But let's first talk a little bit about your experience of growing up and having not much security in housing — how did that connect to your health?
JT: Okay. My houselessness and homelessness kind of began when I was 19, when I moved up to Vancouver, and my brother kicked me out because I was using drugs at his place. I had an addiction by then already. And I lived in a car in Vancouver. And I went from a healthy young adult, about 190 pounds, down to 130 pounds. And from then on, we're talking 1997, I would just sleep wherever I could.
I'd end up at my brother Jerry's house in Toronto. I hitchhiked all across the country. I'd get a room maybe for a month or two or three, and lose it, and end up back in a shelter, get welfare. Repeat the cycle over and over and over again. It felt like it was never gonna end. And the whole time, I'm trying to work too at temporary job agencies. So my employment was always precarious. That was just what it was like in the late '90s and early 2000s for someone without a high school education.
So I just was trying to make it through. I'd be eating out of food banks, and just bouncing around. And then my addictions took over, and my health seriously started to degrade by 2004. And then in 2005, I fell off a building and shattered my leg. I was staying at my brother's house at the time, and one of my friends stole the neighbor's bike. And my brother had no choice but to kick me out with my girlfriend, who I was living with who was there with me. And we ended up moving around a bunch of times.
And then out of desperation and fear, I robbed a store, and that was the beginning of me getting off the streets. I was finally a real problem, so the justice system, they started to take note of me. And I still got in trouble, I'm not gonna lie. And I still was relapsing and using, but I had made the decision to try and get well. And I was trying to access things like rehab and stuff years before, while I was bouncing around, and it wasn't until I went through the justice system that I had an immediate "in" to rehab. I was court-ordered.
I was actually bailed out of Ottawa court in 2008, and that's how I got into rehab. It was a direct... They were my surety. It was a big... I almost lost my leg, both my wrists were shattered when I fell off that building. I still have a hard time walking today, my right side. So very real health consequences for me. That's just the physical stuff. And now the psychological things that have really impacted me all the way up until this day, it's traumatizing to live that kind of a life. And despite all the awards and things that I've done with my research, I'm still traumatized from that, and I'm still working through my own trauma personally, and then the trauma of my history of my people.
JK: There's probably some who would look at your life and your history, and say, "Oh well, he finally took it upon himself... " And I think it's clear, it's obvious that you did, but they would focus on the fact that, "Oh, he finally got his stuff together. He finally pulled himself up by his bootstraps. We just need more people who don't have a place to live, and who don't have work, and who struggle with addiction to just pull themselves up by their bootstraps like Jesse did." Coming from a place of scholarship of Indigeneity and of history, and of getting back in touch with a culture where people actually used to take care of each other, what do you think we should do about the housing crisis? Especially in that context of a lot of people thinking, "We just need to pull ourselves up more by our bootstraps."
JT: Yeah, that's happened actually a couple times with my story, where I share, like I am with you now, and then whoever writes it goes away and thinks it as a bootstrap narrative, right? But it wasn't like that at all. It was the community that wrapped around me. Through each step, the promise to my grandmother, I reconnected with my kin after years and years of not talking with them. I went to a rehab that loved and cared for me, and gave me hope.
That's where I found the courage to have hope and dream again, was in that rehab. And through there, I got educated, I started to take education. And then while I was at rehab, I met my wife Lucie, who interceded at a specific time in my life where, if she wouldn't have, I would have gone back out into the shelter system in Ottawa. And she gave me a home, and she trusted me and loved me. And that trust and love that she gave me did more to keep me off the streets and sober and out of jail than years of incarceration ever could, because she brought me back into the circle and she loved me.
And so that gave me confidence and value as a person. I could see that I had worth, and that I could contribute again. And the promise to my grandmother gave me the will to go on and try to figure myself at university. And when I got to university, there again was another community of Indigenous people at the Center for Aboriginal Student Services that wrapped around me, that made me believe in who I was as an Indigenous person, that loved me as a community member, and allowed me to contribute. And from that, I got confidence.
I started to see myself as a real society member that had responsibilities and roles within that community; and from that, blossomed my scholarly career. And then through that, I met my mom and my people out west. I reconnected with them, and that brought me full circle. That made me whole. I could see my history, and I knew myself as an Indigenous person. So really, I had to do some work, yes. It wasn't... But the real success of it all was from being brought into community, and people loving me back into myself. I don't know if that makes sense to you, but that's what it was.
JK: What do you think could happen if we brought that value of wrapping around people, of lifting people up into our politics, into how we operate as a society?
JT: I think that's what's needed. It's a restoration of relationships, and that means loving each other, and treating each other as relations. And that's the teaching that we have as Indigenous people, that we're imbedded within a network of what's called "all my relations," where we're related to everything.
"I literally looked like death. And so that's the physical. That's just looking and seeing yourself... And then the psychological: I have emotional health, I have spiritual health, I have all these things that are hard to quantify and to explain to people."
JK: So while housing is fundamental to health, it's really just the first step. Doctor Hwang's research at the Centre for Urban Health Solutions lines up with Jesse's personal experience.
Stephen Hwang: Housing First is promising because it changes the paradigm from requiring people to get healthy in order to qualify for housing, or to comply with treatment in order to get housing, and instead makes it kind of the first step and the fundamental first step toward recovery and becoming healthy. The caveat to that is that housing is not sufficient to improve people's health. So I think that just like adequate... A healthy diet and good nutrition is necessary to people's health, it's not the only thing that... It's not sufficient in and of itself.
And so we have to think about, "What's next after housing?" So I think that it's really important because it makes it clear that it's a fundamental first step. I think that the question that it raises after that is, "What next, after housing? And what else do people need? What kinds of supports, and what kind of community do they need? What kind of social supports and friendships and human connections do they need? What kind of services are needed to allow people to be healthy and to flourish?
JK: If we want a healthier society, we have to ensure that all our neighbors have the foundations for a healthy life, including a home and including community.
Jesse Thistle: The way I talk about it when I lecture, I said, "As housing scholars, what we've been doing is we are taking a seed and we're sticking it in the ground and we're covering it, and we're saying that that seed is now a plant. It's not until we water it with relationships, the sun, the way we treat it and tend to it and take care of it, those are the relationships that come after, that it then grows into a healthy plant." Well the same needs to be done with humans. We need to get them in houses, yes, but then we need wraparound services afterwards that reconnect them back into community and to society as a whole.
And I use my own experience with my wife, who gave me a house and loved me, that brought me back from basically years of being homeless and an addict. That was what got me better. And so I use my own experience, as well as what I know in the field of housing to make that point.
JK: How have you seen your own health blossom? Or how have you seen your own health improve since having permanent, steady, stable housing?
JT: Well, my foot healed up after I moved in with my wife. I had a hole in my foot when I got out of rehab, and it grew over. I have scar tissue there. So I got to keep my leg. And then I run a bunch of half marathons, and I'm now 250 pounds. I'm a middle-aged Native guy, and I'm kinda round, but we're supposed to be kinda round. I'm healthy. I can look in the mirror and see flesh on my face, And for me... I could show you old jail photos of me, where I'm 138 pounds and I look like Skeletor. I literally looked like death. And so that's the physical. That's just looking and seeing yourself... And then the psychological: I have emotional health, I have spiritual health, I have all these things that are hard to quantify and to explain to people.
But there was an incident with my wife, when I first moved in with her. We were just moving a TV around, and we got into an argument, and I freaked out, and I lost my temper, and I ran out of the house, and I... And she told me recently, she's like, "I understood what was going on then. You just had no emotional maturity or health. And you were broken, and you're just frustrated." Now when we get into a little argument or we have problems, I don't run away and cause a big stink. I deal with it, and we get along better because I have that emotional health that I didn't have before.
JK: It's hard to have the tools to be a person when you don't have the basic needs that people need, right?
JT: Exactly. That's eloquent.
JK: There's a lot more to this conversation. In Jesse's journey to discover his cultural roots and develop his identity, he has a great deal to teach us about decolonization, reconciliation, and Indigenous healing. It's coming in just a week in episode 14. The Next 150, reconciliation and health, along with a discussion with Tanya Talaga, author of Seven Fallen Feathers, and more. For now, thanks for listening. I've been Jared Knoll. Until next time, keep thinking upstream.