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Alya Niang

Tents and homeless encampments have become a day-to-day reality in most communities across Canada, the result of poverty, illness, addiction and rising housing costs.

Marie-Ève Goyer

In the vast majority of cases, the reason we’re seeing more homelessness is a lack of access to affordable housing. There’s a shortage of rental units, rental and housing prices have gone up, and there are fewer rooming houses and options we might refer to as “low-threshold.”

Alya Niang

According to Statistics Canada, over a quarter-million Canadians experience homelessness in a given year. They get sick, often go untreated and are the most frequent users of emergency services. In today’s episode, we’ll look at homelessness and the costs in terms of health and our health care system. According to the latest data from the Canadian Institute for ������ϱ� Information, homelessness takes a heavy toll. People experiencing homelessness with medical needs spend twice as long in the hospital as the national average and cost twice as much as the average patient. Dr. Goyer is here to tell us about the extent to which people experiencing homelessness suffer.

Marie-Ève Goyer

I have patients who tell me they sleep outside in minus 30-degree weather. I asked one patient how she managed to bathe or take a shower while living in a tent in the winter. She told me she hadn’t showered in two years.

Alya Niang

Hello, and welcome to the Canadian ������ϱ� Information Podcast. We call it the CHIP for short. I’m your host, Alya Niang. Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of CIHI, but this is a free and open discussion. Today, we’ll be talking about the thousands of Canadians who are living in ravines, on the side of the road and in parks, and who often end up in the hospital. This is a growing problem. Hello, Dr. Goyer. Welcome to the podcast.

Marie-Ève Goyer

Thank you.

Alya Niang

Dr. Goyer, we’ll be discussing a fairly sensitive and difficult topic today. Before we delve in, could you tell us a bit about yourself and what you do?

Marie-Ève Goyer

Sure. First of all, thank you for having me on the podcast. I’m the medical chief of homelessness and addiction services at the CIUSSS Centre-Sud-de-l’île-de-Montréal. It’s in the downtown core, so we have a significant number of people experiencing homelessness. I’m also the scientific director of the clinical and organizational support team in addiction and homelessness. Our role is to develop tools and clinical guides to better support the health care network’s practices for treating people in vulnerable situations. We also work with managers and the Quebec health ministry to try to organize services to ensure that people in vulnerable situations are properly cared for.

Alya Niang

Thank you. One of the ways to understand how people experiencing homelessness use medical resources is to track their hospital visits. ������ϱ�recently published a report that examined the usefulness of a specific code to identify people experiencing homelessness, as well as their characteristics and their use of hospital services. What are your thoughts on this? Are there challenges in using this code?

Marie-Ève Goyer

On a broader scale, the biggest challenge really is access to the health care system for people experiencing homelessness. So, generally speaking, I think it’s a good idea to look at emergency departments to see how this population is using services. But it’s also a problem because it’s often the only entry point to the health care system.

Why is that the case? In most Canadian provinces, the way we set up health care requires a health insurance card as proof of coverage. That means having a physical card, and usually a stable address and a way to be reached. As a general rule, none of my patients experiencing homelessness have that. As you can see, what we’re discussing today is a result of a system that isn’t at all adapted to people in vulnerable situations.

Unfortunately, in Canada, our system is a little backwards in that the most organized, healthiest and most educated people have access to the health care system while the sickest, least organized people, who are in situations where they need more care and flexibility, struggle to get into the system.

If you’re experiencing homelessness, your only entry point is the emergency department, and we both know about the condition of Canada’s emergency departments right now. It isn’t a place that will address homelessness. They’ll manage an isolated situation. If someone has a laceration or an infection, they’ll treat it, but it’s extremely rare that they’ll go beyond that. They have to move quickly to treat the problem instead of looking at why a person experiencing homelessness would be lacerated or wounded.

Homelessness is almost never addressed in hospitals because we have a fast-moving system where the goal is to discharge patients from the hospital as quickly as possible. Once you’re discharged, the services and your access to care end. So, our health care system is a long way from being equipped to properly address homelessness.

Alya Niang

Let’s look at some of the data. According to this study, people experiencing homelessness with medical needs spend twice as long in the hospital as the national average and cost twice as much as the average patient. Why is that?

Marie-Ève Goyer

There are several reasons. Obviously, there aren’t any easy answers, but we can look at day surgeries, or fairly simple surgeries. Most procedures that are done are day surgeries. They’re basic procedures where the patient is sent home. But, since they involve light anesthesia, patients are asked to have someone pick them up since they won’t be able to drive. They’ll be feeling the effects of the medication and they’ll be asked to spend a few days in a safe place to recover and have their surgical wound changed by their local health care centre.

Someone who’s experiencing homelessness can’t do any of that. That means that their stay will be extended out of concern for their safety. The staff won’t want them back on the street if they have wounds, need rehabilitation or have medical needs that can’t be treated there. Not to mention the weather challenges in Canada. It’s even more worrisome to let someone leave in the winter when it’s minus 30 or minus 40 degrees out. A patient may have gotten over their pneumonia and no longer need hospital care or oxygen, but they’ll still be a little out of breath and coughing quite a bit. They will also need antibiotics and to be in a comfortable place, which they can’t do. That leads to longer hospital stays and more complex costs for those patients.

A number of homeless shelters and resources have worked really hard to meet these post-hospital needs, but that can put a very heavy burden on community organizations. They often lack the 24-hour medical or nursing staff to provide post-hospital care, which you have if someone is sent home with a CLSC to go to or to a seniors’ facility, for example.

As you can see, there are issues in the way we organize services and, ultimately, issues due to people not having a safe place to recover from an illness that required hospitalization.

Alya Niang

Right. One of the main causes of hospitalizations is substance use disorders, which represent more than a quarter of hospitalizations, or 18% of them. Does that percentage surprise you? And what’s behind this level of addiction?

Marie-Ève Goyer

Unfortunately, it doesn’t surprise me at all. We know that some issues are over-represented among people experiencing homelessness or housing insecurity. Substance use disorders are one. Mental health issues are another. And I haven’t even touched on all of the issues related to neurocognitive disorders, such as people in the early stages of dementia who haven’t been diagnosed, people who don’t have a lot of family, who are slipping, who forget to pay their rent, who leave the stove on, who end up homeless but actually have a cognitive disorder. We’re seeing that more and more with the aging population.

So, to answer your question, substance use and addiction are among the known causes for the loss of or the inability to maintain housing. That’s the first thing. Substance use disorders lead to homelessness. But the other thing we’re seeing is that the rental stock and even community organizations are failing to meet peoples’ needs so that they can maintain housing. Let me explain: Given that shelters are underfunded, very few of them will tolerate intoxication, or even substance use, on their premises.

That leads to a greater number of people experiencing homelessness who have a substance use disorder in public spaces. That can have all kinds of consequences, such as people having nowhere to sober up and then being rounded up by the police and taken to the hospital. So, we’re seeing emergency rooms often being used as places for people to sober up because they have nowhere to go. It’s concerning and they need a certain amount of monitoring.

But these people also need care for substance use disorders, treatments, detoxification, etc. And we know that substance use disorders and homelessness often go hand-in-hand, unfortunately.

Alya Niang

Dr. Goyer, the same study shows that 93% of these patients were admitted to the hospital via the emergency department, suggesting inadequate access to primary care for addressing health care needs. In terms of family doctors, how is the system adapting to improve access to care for these vulnerable patients?

Marie-Ève Goyer

This is a man-made problem. We’ve set these rules for everyone. But, when we realize that we’ve left our most vulnerable people behind, we have some thinking to do as a society. That’s happening, but we need to adjust and adapt the system to ensure that we can care for our most vulnerable patients. For example, we need to be able to treat people who don’t have a physical card. We need to be able to bypass the system when it requires entering a postal code, etc.

But the system needs to be adapted at every level because, in the past, the clinics and primary care providers who adapted and the doctors who agreed to see these patients often did so on a pro bono basis. They did it in good faith because they didn’t want to leave these patients behind. And, of course, it isn’t sustainable to base our services on goodwill and good faith. So, I think that our decision-makers and our health ministries need to ask themselves how we can institutionalize flexibility and the ability to adapt. This would ensure that, first and foremost, we serve our most vulnerable patients who don’t have the ability, education, time or electronic devices to take on the herculean task required by citizens to get access to care.

It takes a lot. You need to be a patient online, have a phone, call at the right times, fill out paperwork, mail it, wait to receive paperwork sent to an address, etc. Already, that’s close to 10 obstacles that my patients face every day.

Alya Niang

And many people think of homelessness as sleeping on the street or in a shelter. But there’s also hidden homelessness. Can you tell us a bit about that?

Marie-Ève Goyer

You’re right. There are two types of homelessness that we regularly encounter. Visible homelessness, which is what people most often picture: people in the streets and people in homeless shelters. But there’s also hidden homelessness, where people are facing housing instability. These are people who don’t have a home of their own and couch surf in different people’s homes, women in crisis or experiencing violence who go stay with family, then friends and then in a shelter. It’s a much less visible segment of the population that’s more difficult to quantify but that’s experiencing major housing instability and insecurity.

Alya Niang

I imagine that hidden homelessness can also be a challenge when using the code because these people don’t necessarily self-report as experiencing homelessness.

Marie-Ève Goyer

The devil is in the details when using indicators like that, to see how homelessness is defined for the indicator, how people are identified and how we do our reporting. If you ask someone whether they have a home, a place to sleep, and they say yes, we often don’t ask further questions, like how long they’ve slept there or if they plan to sleep there for several nights.

Alya Niang

Homelessness really isn’t black and white.

Marie-Ève Goyer

Yes, the word “homelessness” covers a wide range of scenarios. That’s the first thing. The second thing is that not everyone experiencing homelessness wants to reveal their status because it carries a lot of stigma and shame. So, if you question someone, they won’t necessarily feel comfortable revealing their housing instability.

Alya Niang

Absolutely. Dr. Goyer, what types of sustainable programs and strategies have been implemented to help find solutions to this problem and potentially eradicate it?

Marie-Ève Goyer

That’s a complicated question. How can we combat homelessness? It isn’t a disease. It’s the lack of a home or housing. How do we combat it? By providing housing. But the answer isn’t that simple.

Alya Niang

I can imagine.

Marie-Ève Goyer

But I do want to talk about the elephant in the room. In the vast majority of cases, the reason we’re seeing more homelessness is a lack of access to affordable housing. There’s a shortage of rental units, rental and housing prices have gone up, and there are fewer rooming houses and options we might refer to as “low-threshold,” i.e. highly flexible housing that allows for a number of scenarios and has few rules. These are gradually disappearing.

And the other indirect factor is poverty. If people had more money in their pockets, access to housing would likely be less of a problem, even if the housing market is a bit saturated. That adds a layer of complexity. We need to find accessible housing that’s flexible and adaptable, with the capacity to accommodate people. And to get back to the health care system, we could also find housing and support people so they stay there. Because if we provide housing to someone with serious substance use and mental health issues, they may need support, care and guidance for it to go well.

So to answer your question, access to affordable housing that’s adapted to the issues that population presents. One challenge in combating poverty is low incomes. The cost of food and the cost of living have gone up significantly, but the amount provided for social assistance and similar benefits is insufficient, at least based on what I know about Quebec. People receive about $800 per month, but the cost of renting a room in Montreal is higher than that. So, with the basic amount, you can’t buy food or linens. So, it’s tough to make the rent with that.

Of course, as a doctor, the third avenue for me is to care for these people so they don’t end up homeless, or treat the factors that led them to homelessness, such as substance use, mental health issues or a neurocognitive disability. There are medical and clinical services available to support them. And that goes back to what we were talking about earlier. Should these be accessible outside the emergency department? That would take dedicated teams with the capacity to do outreach, to provide care on site, with minimal demands. We use the term “low-threshold approach” to refer to finding ways to remove any obstacles to access to care and retention.

If the obstacle is getting to us, we go to them. If the obstacle is not having an up-to-date health insurance card, we treat them without a card. If the obstacle is not being able to see a doctor within normal hours, we adapt to their needs rather than making them adapt to the system.

Alya Niang

We know that everyone experiencing homelessness has their own unique story, and sometimes a family who is suffering. What would you say to our listeners who have a loved one in this situation? What can they do to help, to mitigate the impact of homelessness?

Marie-Ève Goyer

I think it’s important for citizens in general not to fall into the trap of questioning someone’s motivation. If someone wants to get help, there are a lot of measures in place, everything is available, and health care is free in Canada. So, if they really want help, they can get it. In terms of motivation or a lack of motivation, not many people would choose to be homeless or sleep in a tent when it’s minus 30 degrees out, with no way to bathe and no access to a washroom or drinking water. It’s really not a choice. It’s difficult to think about issues such as homelessness because they’re extremely complex.

But to get to that point... I have patients who tell me they sleep outside in minus 30-degree weather. Can you imagine? I asked one patient how she managed to bathe or take a shower while living in a tent in the winter. She told me she hadn’t showered in two years.

There are a lot of interconnected factors at play. What I mean is, people who have suffered from repeated trauma end up in situations where they, unfortunately, experience further trauma because their encampment is taken down in the middle of the night or their things are stolen because they weren’t locked up. Their vulnerabilities accumulate.

So, I think we have a responsibility as citizens to avoid rushing to judgment and stigmatizing people, which adds an additional layer for people who already feel overlooked by society. I think the first step is to realize that our society is made up of individuals who have lived through extremely complicated situations, have had to face so much trauma and complexity in their lives that they’ve ended up at this point, living on the fringes of society and left behind. And I don’t think we should perpetuate that.

Those of us who’ve been lucky enough to have a more comfortable, simpler life should lend a helping hand and let them know that they still belong to society and that we want to find solutions together to better help them.

Alya Niang

Dr. Goyer, you’re very involved in assistance programs for people experiencing homelessness. I imagine it takes a lot of compassion and a strong human touch to work with this vulnerable population. And you were recognized for this through the AFMC-Gold Humanism Award by the Association of Faculties of Medicine of Canada and the Gold Foundation for Humanistic ������ϱ� care. Can you tell us a bit about your work from a personal perspective?

Marie-Ève Goyer

I feel very privileged to work with these patients. They’re often very wary of me at first, as they’ve had to live through a lot of extremely difficult things. Often, the health care system looks down on them, and they can have very traumatizing experiences. So I approach them gently to earn their trust. They’re often seen as dangerous, as bad people who made bad choices. But in my 20 years working in this field, that hasn’t been my experience.

I’ve met fellow human beings who are just like you and me, who often have a richer inner life than many well-off people because of their extensive experiences and reflections. In the street, I’ve also met an over-representation of highly intelligent and sensitive people with extremely traumatizing and dysfunctional families and pasts. As children, they saw, understood and felt everything, and often, they didn’t have much of a choice but to use substances to survive the degree of trauma they were confronted with, to escape.

I really enjoy my job. I get to meet extraordinary people who’ve lived through very difficult pasts. To give you an idea, several times, I’ve felt like I might pass out while listening to someone’s story as it was so difficult to hear. These weren’t even my own stories, but hearing them was too much for my system to handle. So, can you imagine what it was like to live through them? It’s unfathomable for you or me. I’ve never experienced anything close to that level of trauma.

And, to touch on the opioid overdose crisis gripping Canada right now, it’s affecting my patients disproportionately. I’ll give you an example. One of the patients I care about very much, who’s been incarcerated repeatedly, woke up one morning to find his beloved partner dead from an overdose next to him. He tried to revive her and called the police. When the police got there, they took him to the police station and locked him up, so he couldn’t go with her to the hospital or attend her funeral. Can you imagine waking up to find your partner dead next to you and then not being allowed to be with them? That’s inflicting trauma on top of trauma at the highest level.

But, to answer your question, what I find difficult isn’t the patients, it’s the injustices in the system. It’s seeing people being treated the system in a way that’s very difficult and retraumatizing for them, when they should be treated with gentleness and kindness. It’s seeing how, in 2024, we’re asking why we haven’t been able to organize our care so we can properly treat these patients. That’s the most difficult part, and it takes a greater toll on my energy and mental health. It’s seeing the social injustices be repeatedly inflicted over the years.

It’s one thing to acknowledge that there were injustices and traumas in the past. But to deliberately perpetuate them when we know what should be done, when we have the scientific data to show us how things could work, that’s harder for me.

Alya Niang

I know that, based on what you experience and see, this field can make you much kinder and more empathetic to this vulnerable segment of the population.

Marie-Ève Goyer

It’s like anything else, as human beings, we’re afraid of what’s unfamiliar, and we have a tendency to maintain stereotypes. When you get to know these patients, when you break down the walls, you realize that they’re people just like you and me, who were likely less fortunate, but who are incredibly resilient, and who face the same human challenges we all do: the need to feel loved, be safe, be respected, connect with others, develop, be happy, ensure that their loved ones are happy. They face the same human challenges as everyone else.

Alya Niang

Thank you very much, Dr. Goyer, for shedding light on these issues related to homelessness. It’s such a sensitive and important topic. You’ve made an invaluable contribution to this podcast. Thanks again.

Marie-Ève Goyer

Thank you.

Alya Niang

Canada has implemented a national strategy to combat homelessness, which aims to prevent and reduce chronic homelessness by 50% on a national scale by 2027. For the data on hospitalizations of people experiencing homelessness, visit the ������ϱ�website at cihi.ca.

Thank you for taking the time to listen to our podcast. And please remember that behind every person experiencing homelessness is someone with a unique story. Our executive producer is Jonathan Kuehlein, and special thanks to Heather Balmain, our production assistant, and Avis Favaro, the host of the ������ϱ�podcast in English. Be sure to subscribe to the ������ϱ� Information Podcast and listen to it on the platform of your choice.

I’m Alya Niang. Talk to you next time.