The Ontario Coalition Against Poverty works with the Downtown East Toronto community where we have been based for over 25 years. This community has one of the highest rates of poverty and homelessness in Canada. We also work in coalition with other poor communities across Toronto and Ontario, especially with people who are on social assistance. We are a membership-based grassroots organization and focus on action-based campaign work to fight for better housing, income, and services for people who are living in poverty. We also provide case work support for individuals in the community who are facing problems with social assistance, housing, or access to services.
About the author: Ontario Coalition Against Poverty
For more information about the Ontario Coalition Against Poverty visit www.ocap.ca
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People who are homeless or living in poverty are often denied access to many services, including health care. It is well established that poverty is the biggest determinant of health in that, without adequate income and a decent place to live, the life expectancy of poor and homeless people is dramatically reduced. People who are unable to meet these basic needs suffer from an incredible amount of stress and stigma, including when coming into contact with the heath care system.
Why be concerned about poverty and health?
Fundamental issues when it comes to homelessness and health
Limited access to nutritious food and water
Physical / Cognitive impairment
Higher risk of abuse
Developmental discrepancies (as often poor children grow up to be poor adults)
Higher risk for communicable diseases
Behavioural health problems
Serious and complex health conditions
Discontinuous or inaccessibility of health care
Lack of resources
Lack of transportation
Lack of social supports
Barriers to social/disability assistance
Cultural / Linguistic barriers
Criminalization of poverty/homelessness
The harmful effects of poverty on the health of people and communities cannot be overstated. Poor health and poverty are inextricably linked. Lack of housing or shelter, lack of support services, and lack of adequate income are all structural factors affecting the health of poor and homeless people. In this context, continuous and reliable access to health care services is clearly crucial but the reality is, poor or homeless people face significant barriers when it comes to accessing health care.
In the last decades, what services meant as stop-gap measures meant to alleviate the overwhelming negative consequences of poverty and homelessness on people’s health have been dwindling, as they face cuts in their funding or complete defunding. This looks like people sitting on wait-lists for a community health centre, for mental health supports, or to see a caseworker. Or it can look like features that made important programs accessible to more people be taken away/discontinued. For example, outreach work and flexible opening hours do make an enormous difference in terms of meeting people’s accessibility needs. The closure or the cutback of services that were once offered after hours or directly in drop-in centers mean that many people who used to access care in those locations and/or at those times often end up disconnected from health care services entirely.
This can look like: the funding being cut for a community health bus which used to roam the Downtown East to offer pap tests for women on the streets at irregular hours. Why is this a big deal? While getting pap tests is a crucial part of preventing cervical cancer, some people experience barriers when it comes to getting screened regularly. Living in poverty or being homeless can mean dealing with one emergency after another and can make regular preventative care difficult to access if nothing is done to flatten the barriers they may face because of their circumstances.
Barriers to comprehensive health care
The availability and accessibility of (affirmative, compassionate, respectful..) health care services play a role in our community’s health and wellbeing so what gets in the way of ensuring that?
For people struggling to meet their basic survival needs accessibility means having after-hours availability, an acknowledgement that travel costs are an accessibility factor, and that physically accessible spaces without stairs or with a functional elevator are important. Requiring a valid ID can be a barrier to people accessing care as is treatment plans that cost money or even something seemingly as simple as a place to rest.
Similarly, sexual and reproductive health care can be difficult for people to access due to hours and location of services, a lack of understanding of how trauma may impact peoples’ willingness to trust service providers, and the continued and pervasive stigma around poverty, survival sex work and coping mechanisms that are perceived to be self-destructive, for example, drug use. People with mental health struggles also have their choices around birth control limited by providers who may make judgements around people’s willingness and ability to comply with treatment plans or the interaction between mood and thought disorders and hormonal birth control.
What’s your relationship status?
For some people who are able to access community health centres or a primary health provider such as a nurse who is community focussed, their relationship with health care providers can be good. But for others who are left to clinics, hospitals or unfriendly health providers their relationship can be fraught with stigma on the part of the health provider and their frontline staff.
It is crucial to dedicate time for people to be able to form a relationship of trust with healthcare providers, especially considering that many poor or homeless people have experienced neglect, mistreatment, being infantilized, being criminalized or not being believed in health care settings.
Many assumptions about poor and/or homeless people get in the way of these important relationships. People living in poverty face enormous stigma from the general population, including from healthcare providers.
That everyone has the same opportunities and therefore, that people are poor because of laziness, lack of intelligence, or willingness to make bad decisions.
That homelessness is caused by individual character “flaws” such as alcoholism, mental illness or a desire to avoid employment.
That poor people engage in “risky behaviors” and bring illnesses or injuries upon themselves.
That poor people don’t care about their health, are noncompliant, don’t take care of themselves, are neglectful.
That all poor people are substances users and that people who use substances “deserve what they get”. Similarly, that sex workers “deserve what they get”
That poor people are unreliable, can’t be trusted, are schemers, are irresponsible.
That poor people are ineffective parents.
That poor and/or homeless people are dangerous, strange, “crazy”, abusive, scary.
Discontinuous or inaccessibility of health care
That poor and/or homeless people are criminals.
Instead, keep in mind that:
Accessing and maintaining basic needs such as shelter, housing, legal assistance, income supports, and food cannot be divorced from health care, which makes supporting patients in these endeavours an important intervention.
The person with whom you are dealing may not have had enough to eat or a place to sleep in the previous 24 hours.
Having public transportation tickets or tokens available makes a big difference in people being able to show up for appointments, to follow-up with specialists, etc.
The availability of water and snacks could be beneficial for many of your patients.
Not everyone has a safe place to store a health card. For those who have lost theirs, it can be very challenging to obtain new ID.
It may be hard or even impossible to follow treatment plans if medication and transportation cost money, if someone doesn’t have anything to eat or a place to stay, if they have nowhere to store medication that requires refrigeration, if they are in and out of jail, if they don’t have valid ID, if they work three jobs and have to walk to each of them, if all their mental energy is spent on finding ways to meet basic needs, etc.
You can’t assume people’s use of drugs, sexual choices, and mental health diagnoses just because of the way they look.
It may take building a long term relationship of trust for people to fully open up to you.
Poverty is criminalized in many ways, including by municipalities using bylaws to criminalize the most vulnerable members of our communities and police services enforcing laws in a discriminatory way, disproportionately targeting poor people. This traps people in cycles of incarceration, of criminalization and in antagonistic interactions with law enforcement agencies.
Calling 911 can mean that the police is also being called, which is risky for many people because of their immigration status, the threat of being criminalized for drugs or sex work, having them check on release conditions, because of a past history of negative interactions with police services, stigma, etc. In some poor neighbourhoods or at certain addresses (drop-ins, needle exchange programs, shelters, etc.), it is often ‘policy’ that an ambulance will wait for the police to get there before engaging with people, making it chancy to access that service too.
For people with mental health issues, there is a history of police escalating what are already stressful situations and harming people.
Many poor or homeless people may have had traumatic experiences with health care in the past, especially when disclosing mental health symptoms can get a person forcibly incarcerated and drugged against their will.
Hospitals or after-hour clinics may be far away and so, without money to get in a cab or get a drive, they are hard to get to or leave from.
Community Health Centres are often full, some services are only available (for example) once a week, there is a lack of transportation money to access these services, and that policies exist around not lying down at clinics, limiting the access of people who feel really ill.
Many people also feel like a primary diagnosis is used against them, for example, everything becomes about mental health, especially if it plays into assumptions people have of people who are poor or homeless, when the real problem could be, for example, a flu or a toothache.
There are numerous barriers to accessing preventative or non-urgent care, like long wait times, the need for a referral, transportation needs or the inability to ‘walk in’. All can deter someone who is busy trying to survive on a day to day basis from seeking care when it’s not ‘urgent’.
There are financial barriers to many therapies or services that can play an important role in maintaining good health.
For those who seek to apply for ODSP (Ontario Disability Support Program), or similar financial assistance programs, in order to access services often have trouble finding a doctor to fill out the application.
In order to make informed decisions about sexual and reproductive health, people need a consistent relationship with a health care provider.
The availability of accessibly/peer-written information available for people to take away with them to aid in making the best choices for them is important.
There is a need for more services on the streets: healthcare providers must campaign against cuts to services and programs, and fight for increased services overall. Support campaigns for housing, shelters and income supports. Respect and listen to peer workers: they often know better than ‘trained professionals’. They should be paid adequately and treated with respect.
People are more than the sum of their behaviours.
It is important for ALL your patients to be allowed choice and control over how their health care concerns are managed.
Understand that “choice” can be complicated in the context of poverty – some of your patients may not get to make choices about what to eat in a day, where to sleep, who they have to interact with.
It is important to acknowledge the limitations in your education when it comes to dealing with people’s lived realities, and that lived experience of poverty gives people valuable expertise to share when they are made partners in their care.
How to foster better outcomes for people who are poor and/or homeless
Make your practice person-centered, trauma-informed, recovery-oriented, non judgmental, based on trust and facilitate frequent encounters.
Train emergency workers, paramedics, hospital and clinic workers, including all of those who support the work of health care providers, on the ways that stigma show up in health care settings and how it is a barrier to health care for people on the streets.
Train hospital and clinic workers on de-escalation techniques that can help avoid involving police services.
Mandate harm reduction training for all people working the services (including front-desk).
Ask your patients about their transportation plans once discharged and be prepared to assist them to get where they need to go safely.
Fund, staff and/or support increased access to after hours care that serves people who are homeless, use drugs or alcohol, are sex working, and/or have mental health issues.
Familiarize yourself with the costs of medications and what provincial formularies cover or don’t cover.
Consider offering incentives that may promote engagement with your services: food, drink, vouchers, hygiene products, bus fare, etc.
Be mindful of your language and speak up when you hear colleagues make disparaging comments about patients. It is not ok to call someone a ‘druggy’, ‘crack head’ or a ‘hooker’ or to make jokes at patients’ expenses.
Don’t assume what substances people may or may not be using – let them tell you if they want.
Inform yourself about the realities of poverty and its impact on health – be mindful of the disparity in privilege and how class based discrimination can play out in the health care context.
Support your patients in making informed choices about their own health care.
Respect your patients’ pace when it comes to disclosing information about themselves or their history. Treat everyone with dignity and respect.
Make treatment plans with your patients that does acknowledge that basic needs will be prioritized. Establish list of priorities and strategize around what would help adherence and/or follow-ups.
When it comes to medication, opt for simple regimens when possible, explore barriers to taking the medication, and what would facilitate sticking with treatment.
When possible, coordinate medical, dental and psychosocial services.
If possible, look into increasing the flexibility of your services. For example, permit walk-ins.
Assist patients in ensuring that they have access to the resources they need like access to convalescent care or supported housing, sign forms for financial assistance programs, for Special Diet allocations, etc.
Consider supporting outreach programs, offering care in soup kitchens, walk-ins, shelters, etc
Become a leader in your community to address the structural causes of homelessness and be an advocate for change and for the end of health disparities.
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