Homelessness and public health

On any given night in Canada, 35,000 people find themselves homeless.¹ These folks are a combination of youth, adults, elderly, and families with children, and are part of the more than 235,000 Canadians who live on the street at some point during a year.² This number continues to rise in spite of the nearly $7 billion spent in 2014 on health care, justice, and social services to address homelessness.¹ Although national data are lacking, cities are seeing increases in shelter use: rates in Greater Moncton increased by 8% between 2013 and 2014, while those in Winnipeg increased by 14% between 2008 and 2011.^3,4 Vancouver reported the largest homeless population in city history in 2014.⁵

Complicating this situation is the fact that at least one third of homeless people in Canada live with mental illness; this circumstance is often combined with substance abuse.⁶ The particular challenge to this population is that in many cases they must attain a period of sobriety before they are deemed “ready” to be housed.⁷ Since drugs and alcohol are often used to cope with mental or physical pain, it is especially challenging for them to stay sober without first resolving underlying issues,⁶ but these issues are unlikely to be resolved when survival remains the priority.⁷

There is another approach to addressing this situation. The Housing First model, pioneered in New York City more than two decades ago, has become an established practice for improving the lives of the homeless.⁸ By housing the homeless, Housing First satisfies individuals’ basic needs for survival and allows them to work on improving their health and well-being.⁷

The data from the US support an optimistic view of this model. Studies have reported high housing retention rates, decreased alcohol consumption, and increased medical compliance.⁹ There are many other benefits to being housed, such as reconnecting with family members, reducing exposure to violence, and promoting engagement in preventive medical services.⁹ These outcomes have led the US Department of Housing and Urban Affairs to support the Housing First model, and the US Interagency Council on Homelessness to declare Housing First a “best practice”.¹⁰ The question is, what will it take to produce positive results in Canada?

A 2012-2014 trial of this model followed 2,000 people in Moncton, Vancouver, Winnipeg, Toronto and Montreal. Results from this test showed positive outcomes related to quality of life, community functioning, recovery, and employment.⁷ The majority of newly-housed individuals succeeded in retaining their homes, described improvements related to substance use and mental illness, and reported a more positive life trajectory.⁷ Researchers behind the trial are optimistic that over time, housing stability will sustain improvements in mental health and substance use among previously homeless populations; however, it is not yet clear to what extent Housing First improves long-term mental health and substance use outcomes.⁷

It is estimated that the investment required to limit homelessness in Canada over a period of 10 years would total $4  billion, while the estimated return on investment could exceed $8 billion per year nationally through reduced spending on emergency accommodations, health care, social services, and corrections.^1,2 For example, a day spent in supportive social housing is estimated to cost at least $38 less than a day’s use of a shelter bed, $112 less than a day spent in jail, and $624 less than a day in a psychiatric hospital.¹¹ While attaining stable housing does not always result in rapid improvements in the lives of homeless Canadians, it is a first step to improving their health and ultimately enabling them to contribute to society.