"Henry", 48 years old. I met him in January, he was homeless, struggling with alcohol use and serious mental illness. Over the course of 4 months we advocated for Henry and found him housing. Not "shelter", housing. Its now August and Henry is recovering from his alcohol use and on his way to find employment. Henry is happy.
This is one example of the narrative our system strives to tell- the story I want to tell. Unfortunately in my experience so far I've learned that Henry is not the norm and this is not the story our system allows.
I charged into July ambitious as a first year resident to make an 'impact' working with the homeless in Toronto, Canada's largest urban sprawl. After all, what is more "inner city health" than advocating for the homeless at the front lines? It wasn't long before I found myself working over two months at Toronto's largest men's shelter.
It was at the shelter that I met him, Henry- 48 years old, recently involved in a criminal case and newly homeless in the last month. Henry has a long history with alcohol use and recently it had peaked to 2-3 large bottles of vodka per day and the use of rubbing alcohol. I met with him three times per week and for the first two weeks felt like we were taking all the right steps forward. On a scale of 1 to 10 he consistently ranked "8" in his readiness to reduce his use of alcohol. It wasn't long before I learned my first lesson with Henry-its difficult to motivate as a cure for social isolation.
Each week he deteriorated further, his cognition declined and his alcohol use became worse. One day I came to the shelter to find out that he had been admitted into hospital after an alcohol withdrawal seizure. I visited Henry a week into his admission. Henry had improved, he slurred his speech less, he hadn't drank alcohol in a week and no longer shook. To my surprise, the plan was for him to be discharged back to the shelter. One day later he was back to using alcohol heavily. I learned my second lesson- our system has a big transitions of care problem and those in our society who are most voiceless are impacted disproportionately.
Henry used to be a cook, he was employed just 3 months ago. In the shelter Henry's skills atrophied. Despite meeting drinking-mates at the shelter, he told me he felt increasingly more lonely. Henry was on social assistance, he couldn't afford housing. Perhaps the goal then is to get him affordable housing?
I learned my third lesson- Housing is a dream.
In 2015 a record 171,360 households in the province of Ontario were waiting for affordable housing with average wait times of 4 years. Toronto has the longest wait times in the province with the average wait for subsidized housing at approximately 10 years.
It became increasingly clear to me that Henry's story wasn't unique. Even the most veteran resident of the shelter who has up to 15 years of experience on the street started off like Henry. Whats more, with Toronto's shelters almost always operating at >90%capacity, for every person like Henry who was living in shelter there were many who lived outdoors. Its not surprising that chronic homelessness cuts a person's life expectancy by approximately 50%.
I finished my final month at the shelter and concluded my fourth and most important lesson- "health is a political choice and politics is a continuous struggle for power among competing interests". Analyzing chronic homelessness from a political determinants lens reveals that it is a social problem that traps people in a state of helplessness.
The solution? I'm not sure. What I do know is that homelessness is complicated. Homelessness is nuanced and its solution is predicated on more than niceties and 'trying things out'. The solution isn't just more soup kitchens and clothing donations. Homelessness is a national emergency and requires data driven policymaking that distributes resources equitably. As primary care providers we're positioned to host a joint discussion to explore the political determinants of health. Above all, as primary care professionals this requires a willingness to bring together a public health perspective rooted in a lens that deals with the nature of power, systems, uncertainty and most importantly... complexity.