Category Archives: Health

Tracking Homeless Deaths

As of January.1st, 2017, the City of Toronto has begun tracking homeless deaths. The process is still in its infancy and has taken the city a while to speak to the public about how the new system is working and what their findings have been.

A press conference was held on January.10th with public health officials, some city councillors discussing how this is a problem that needs addressing in order to fully understand the scope of how many people are dying while homeless. We need this information for raising awareness and improving health.

cathy crowe press conference

Street Nurse Cathy Crowe

Up until now, tracking deaths has involved some volunteers from the Toronto Homeless Memorial Network who have called around to a few agencies once a month to find out who has died. The only other information provided by the city are lists of deaths that have occurred in city-funded shelters and even so, this page is not always up to date.Therefore, this does not include any deaths in hospitals or any other locations in the city.

Needless to say, there are many deaths that are not being recorded and we need to do better. Hopefully this new system will show us the extent of the homeless crisis in our city, but we have yet to hear more.

The Death of a Service User

When a homeless person dies, not only do friends and family members of that person become affected, but so can front line workers. Richard Lakeman, Mim Fox, and R. Dean Wright and colleagues conducted separate research on how service workers are affected by deaths of people who are homeless. Lakeman tells us that service workers can encounter deaths frequently (2011:928). Wright et al., suggest that service workers may feel self-doubt and might ask questions such as “Did I do enough?” or “Was there something that I could have done differently?” (1999:245). Fox explains how social workers see the deaths and continually feel powerless (2005:196).

I volunteered with two different agencies a while back, doing street outreach for homeless youth. Luckily, I never did experience the death of someone I knew directly, probably because I had only volunteered for a few months. However, I did counsel some youths who had friends pass away on the streets. At this point, I was out of school from Child and Youth Work, so that support system was no longer available. There were people that I volunteered with and the service providers who understood, but many of them were dealing with their own problems. This was a tough time for me personally, as I was finding myself burning out and nowhere to turn for help.

stress

 

Maslach et al., define burnout as “…emotional exhaustion, depersonalisation, and reduced personal accomplishment” (1997:192). I know this feeling all too well. You simply feel as though you no longer have the mental capacity to handle day to day situations, let alone help anyone else.  There is a sense that things will never change and you can even start doubting yourself and your abilities.

Research shows that depersonalisation can happen when a service provider loses someone. Even the terminology we use at times is depersonalising. “Service user” and “Client” are ways to distance our professional selves from those we serve. Wright et al., found that “[a] common, although dysfunctional, response among staff to the multiple losses they experience is professional distancing. They may deny any feelings for the deceased and detach from other guests so as not to be ‘affected’ or place themselves in jeopardy of suffering more loss” (1999:244). Lakeman says workers may expect more deaths in the future and that a feeling of uselessness may occur (2011:933).

When front line workers don’t get the services they need after dealing with many deaths in the community they may suffer from intrusive memories or experience anxiety, wondering who will be next (Lakeman 2011:942).

burnout

 

What can be done?

Few organizations have the capacity or resources to fully attend to the needs of service workers (Wright et al., 1999:247). Lakeman suggests that a positive response to the death of a service user includes the ability to preserve the memory of that person, like a picture on a wall (2011:942).

Some organizations have their own ways of dealing with the loss of people they work with. Lakeman learned that some service providers would do things like “…convening a special group, planting a tree, or having a sing-along…lighting a candle or spending a few moments in quiet reflection at some point during the working day” (2011:937). Wright et al., made a similar finding that staff may hold a moment of silence, or have an annual service to recognize those homeless people who have died throughout the year (1999:241).

candles

 

An organization here in Toronto has a Reflections Memorial Project that helps everyone grieve and remember those who have passed away. The project was inspired by the need for people to process loss and encourage healing through art, expression and memorial.

Firstly, they have an ongoing scrapbook, where photos, artwork and writings are added when someone dies. The book can be looked at by service providers whenever they want to remember. Secondly, they have a wall mounted display which is magnetic.  Small circular buttons are placed on the wall that contain initials, artwork, photos or writings that each represent someone who has passed away. The display is hanging on the wall in a visible space in the organization. Lastly, they hold a Reflections Memorial Event in the fall every year, symbolic of change, transition and reflection. Poems are read, candles are lit and the memory book is available for others to read.

These are just some great suggestions for how other organizations may approach remembering people who have died while homeless.  These rituals are a way for service providers to mark death, which “…serves a therapeutic function in that it helps people to experience emotions and is part of properly framing death. Marking death is undertaken in highly personal and private ways as well as collectively through formal mechanisms such as memorial services and funerals” (Lakeman 2011:936).

Working with socially excluded people is a tough job. It requires resiliency, stamina, support, compassion and coping strategies in order to keep going. Much respect goes out to those who continue to serve others despite the hardships, your efforts are greatly appreciated.

 

References

Fox, M. (2005). To die destitute today: What are the implications for social work?. Australian Social Work, 58(2), 188-198.

Lakeman, R. (2011). How homeless sector workers deal with the death of service users: a grounded theory study. Death studies, 35(10), 925-948.

Maslach, C., Jackson, S. E., & Leiter, M. P. (1997). Maslach burnout inventory. Evaluating stress: A book of resources, 3, 191-218.

Wright, R. D., Wright, S. E., & Jones, A. (1999). Dying homeless but not alone: Social support roles of staff members in homeless shelters. Illness, Crisis & Loss, 7(3), 233-251.

What Do Homeless People Think About Death and Dying?

John Song and colleagues conducted research that asked people who are homeless about their thoughts and experiences surrounding death and dying. The following post is a summary of that research.

What is this research is about?

Many people who are homeless are not treated in the same way as the rest of the population. This study explored what homeless people think about death and dying and what their experiences are with death and dying.

What you need to know

People who are homeless have specific needs when it comes to coping with their own mortality and those they have lost. Typically, being exposed to death early on in life and also in their present lives leads to further problems. Issues such as mistrust of health care workers, risky behaviours, isolation, serious illness or injury and overall fears of death can inform how their end of life care is addressed, or not addressed.

alone

What the researchers did

The researchers went to six different agencies that serve people who are homeless and recruited 53 people over 18 years old. They used both focus groups and in-depth interviews with people who are homeless over a 5-month period to understand their thoughts, feelings, desires and experiences about death.

What the researchers found

After transcribing the information from the interviews and focus groups, the researchers found two different themes that arose, which were personal/internal experiences and relational/external experiences.  Personal themes that were common included the experience of loss early on in life, death of loved ones both past and present, life-threatening experiences, many fears and uncertainties about death, unhealthy coping strategies, and behaving in risky ways or more cautiously in life.  Relationally, the researchers found that people who are homeless are influenced by their experiences with health care practitioners, most claimed to have had negative experiences.

Using this research

Knowing the attitudes and experiences of people who are homeless can help us to better understand ways to prepare them for death and to cope and advocate for themselves. Researchers suggest using this information to improve end of life care by addressing issues of trust of health care providers and legal documentation.

About the researchers

John Song Center for Bioethics, and Department of Medicine University of Minnesota
Edward Ratner Department of Medicine, University of Minnesota
Dianne Bartels Center for Bioethics, and Department of Medicine University of Minnesota
Lucy Alderton Division of Chronic Diseases, Philidelphia Department of Public Health
Brenda Hudson Office of Clinical Research, University of Minnesota
Jasjit Ahluwalia Department of Medicine and Office of Clinical Research, University of Minnesota

Reference

Song, J., Ratner, E. R., Bartels, D. M., Alderton, L., Hudson, B., & Ahluwalia, J. S. (2007). Experiences with and attitudes toward death and dying among homeless persons. Journal of general internal medicine, 22(4), 427-434.

 

Homeless Deaths Motion at City Hall

There is a motion recommended by Paul Ainslie and Joe Cressy regarding homeless deaths in the Toronto community.

The following is a list of their recommendations from the City of Toronto website.  City council will be considering this motion on March.31st, 2016.

UPDATE: Motion passed 36-1!!

Recommendations
Councillor Paul Ainslie, seconded by Councillor Joe Cressy, recommends that:

1. City Council direct the City Manager to instruct the appropriate City staff to collect all relevant data related to the deaths of homeless individuals for occurrences within and outside homeless shelters.

2.  City Council direct that the data collected be shared with the public, agencies, City divisions and Provincial Government ministries for the purposes of influencing decision making through policy and legislation.

3. City Council direct the City Manager to correspond with the appropriate staff within the Government of Ontario in support of introducing a provincial mandate to track all deaths of homeless individuals for the purposes of data collection to introduce policy and legislation.

Commemoration Events And Causes of Death

The Stone and Glass Art Installation launch was beautifully done.  Artist Rebecca Houston had a vision along with the Myseum Intersections project. How can we tell stories that reflect the culture of Toronto while including historical dimensions?

Rebecca chose to highlight the numerous homeless deaths that have occurred over the past few decades. Names, initials, Jane and John Doe’s were projected onto the Church of the Holy Trinity’s front façade. This is where the Toronto Homeless Memorial happens every second Tuesday of the month at noon, to remember those who have passed away.

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To open the night, a few remarks were made by Rebecca, Britt Welter-Nolan, street nurse Cathy Crowe, and Reverend Sherman. Andrew Wesley began smudging and recited a prayer and then the Smoke Trail Singers began drumming to initiate the projection of the names.

Visitors were then encouraged to stand vigil as the names scrolled across the church wall. Otherwise, people could go inside and experience other interactive pieces. There was an audio installation where you could hear stories about people’s lives and the intersections of homelessness, as well as a reading of the names.

Cups were placed on a table next to the list of people who have died and you could write one of the names on the cup in memoriam to that person, which was placed on the carpet to act as a “headstone.”  Art pieces and a reflections board were displayed where people could write down any thoughts about the night or about homeless deaths in general.

 

What are the causes?

I have written previously on how death is widespread within the homeless community. However, I want to bring to light the causes of death.  Before I get into some of the research, I will say right up front:

People who die when they are homeless, die because they were homeless.

You may be thinking, “what do you mean? They die from stabbings, and alcohol and other things!” Well, those “other things” are actually just symptomatic. Other researchers have also suggested that homelessness itself is the main risk factor for death that needs to be addressed (Hibbs et al., 1994:308, Barrow et al., 1999:533, Condon & McDermid, 2014:3). Let’s explore further.

We know that both individual AND structural factors are involved with why people become homeless in the first place (Fazel et al 2015:1). We also know several times over that people who are homeless die younger than the general population (Hibbs et al., 1994:307; Cheung & Hwang 2004:1243; Barrow et al., 1999:529; O’Connell 2005:13). In British Columbia, “[t]he median age of death for a homeless person…is between 40 and 49. The average life expectancy for the general population in British Columbia is 82.65 years” (Condon & McDermid, 2014:4). In Copenhagen “[h]omeless people staying in hostels, particularly young women, are more likely to die early than the general population” (Nordentoft & Wandall-Holm 2003:81).

When homeless people are at almost half the life expectancy as the general population, then we have a major crisis that needs addressing.

For people who are homeless, many die from violence and trauma from being on the streets (Wright et al., 1999:244). “In the USA…younger people die disproportionately from external causes of death (suicide, accidental overdoses, and homicide) and infectious diseases, and there is also a spike in older homeless people” (Fazel et al. 2015:5). Some researchers suggest that “[d]rug overdose has replaced HIV as the emerging epidemic” (Baggett et al., 2013:2). The St.Michael’s Hospital Centre for Research on Inner City Health recently released this quick read guide that highlights health problems and mortality rates. Mental illness is a major factor in homelessness, but I will be writing about that in more detail in a future post.

Numbers, numbers and more numbers

The 2015 Annual Review of Statistics on Deaths of Shelter Residents was recently released. This report provides rough estimates of deaths since 2007 specifically of shelter residents, which does not include many others who choose not to go to shelters. People have suggested that we need a count of the number of people who are homeless at a particular point in time. Researchers say that, “…without sufficient provincial data it is difficult to determine the necessary steps to minimize homeless deaths across the country” (Condon & McDermid, 2014:18). I understand how policy makers like to use evidence based decisions to tackle social issues. As a graduate student, I also understand the need for research and providing evidence in order to strengthen arguments.

numbers

However, in this case, do we really need a count? We know people are dying. The government needs a number? How high must the number be in order for these deaths to be seen as a significant issue? For me, one death would be enough. Apparently there needs to be many, but we don’t know what that number is since the government is not making this a priority, nor are its citizens. A child gets shot, we fight for gun laws. A child is hit by a car, we fight for road laws. A child dies on the streets and apparently we don’t give a shit.

Prevention

Researchers have not only mentioned that homelessness itself is a risk factor for death but also that homeless deaths are largely preventable (Hibbs et al., 1994:304,Condon & McDermid, 2014:3). Hwang et al. maintain that “[a] large part of the premature mortality in people living in shelters, rooming houses, and hotels was potentially avoidable” (2009:6).

For individual circumstances, we need to “… include behavioural health integration into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness” (Baggett et al., 2013:2).  For young people it is suggested that they receive “…psychiatric treatment, detoxification treatment, medical treatment, social advice, and accommodation. The prevention of social exclusion should start early in life” (Nordentoft & Wandall-Holm 2003:81). For older homeless people “the management of chronic diseases, geriatric conditions, frailty, and end-of-life issues is more prominent” (Fazel et al. 2015:5).

prevention

In order to prevent people from dying way earlier then they should, we need a national housing program and social supports that include counseling, better access to health care, decriminalization, employment help and training programs. These must be used together. If you only have housing first programs or only have employment training, then they will fail.

Tackling stigma is another factor in preventing homeless deaths from happening in the first place. Some common stigmas include racism, sexism, AIDS, autism, homophobia, and ageism, among others. Attitudes and beliefs can make the difference between someone being housed or homeless.

The fight will be a tough one and we need more people that can speak out against the crisis of homeless deaths. People are needlessly dying. We need to notice and we need to care. Ending homelessness in our towns is not some esoteric unattainable concept, others have done it. So why don’t we?

 

Featured Image artwork by Jim Houston

 

References

Baggett, T. P., Hwang, S. W., O’Connell, J. J., Porneala, B. C., Stringfellow, E. J., Orav, E. J., Singer, D.E., & Rigotti, N. A. (2013). Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA internal medicine, 173(3), 189-195.

Barrow, S. M., Herman, D. B., Cordova, P., & Struening, E. L. (1999). Mortality among homeless shelter residents in New York City. American Journal of Public Health, 89(4), 529-534.

Cheung, A. M., & Hwang, S. W. (2004). Risk of death among homeless women: a cohort study and review of the literature. Canadian Medical Association Journal, 170(8), 1243-1247.

Condon, S., & McDermid, J., (2014). Dying on the Streets: Homeless Deaths in British Columbia. Street Corner Media Foundation. https://d3n8a8pro7vhmx.cloudfront.net/megaphone/pages/7/attachments/original/1415231881/Dying_on_the_Streets_Homeless_Deaths_in_British_Columbia.pdf?1415231881, accessed Mar.10, 2016.

Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384(9953), 1529-1540.

Hibbs, J. R., Benner, L., Klugman, L., Spencer, R., Macchia, I., Mellinger, A. K., & Fife, D. (1994). Mortality in a cohort of homeless adults in Philadelphia. New England Journal of Medicine, 331(5), 304-309.

Nordentoft, M., & Wandall-Holm, N. (2003). 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. Bmj, 327(7406), 81.

O’Connell, J. J. (2005). Premature mortality in homeless populations: A review of the literature. Nashville, TN: National Health Care for the Homeless Council, 1-16.

Wright, R. D., Wright, S. E., & Jones, A. (1999). Dying homeless but not alone: Social support roles of staff members in homeless shelters. Illness, Crisis & Loss, 7(3), 233-251.

Signatures Needed – Please Sign

Cathy Crowe, street nurse and local homelessness advocate, has started a petition to bring attention to Mayor John Tory to address the homeless deaths in our city.

She is hoping that there will be more funding for shelters and warming centres in the 2016 budget. Let’s all pitch in and do what we can, and hope that council will approve the funding

Sign here!

Death Is Everywhere

Death was always there, as if it were another parent raising me as a child. By the age of 12, I had experienced three deaths in my family, including my father. Death was quite salient for me throughout the rest of my life as well, heading into adulthood there were more deaths of friends and loved ones.

Death is not the only way to be introduced to the idea of mortality, as other experiences can cause people to reflect on their mortality, such as illness, injury or disability. Over 30 years of psychological research has been conducted on how becoming aware of our inevitable deaths can affect our behaviours. Those of us who have had to deal with mortality reflecting hardships understand that time is limited and precious. People in different vocations have to live with the salience of death in their lives, such as doctors. However, when it comes to the homeless population, the story becomes even more complex.

Many homeless people that die are without the resources of loved ones, proper health care and a home (Song et al 2007a:435). Death is hard for us all, but just try to imagine what it would be like to lose people without having support systems in place. No one to call when you are grieving, no shoulder to cry on and add to that mental exhaustion and the inability to cope. For homeless people, “[n]umerous experiences with death and dying causes homeless people to believe that death is ubiquitous, and should be expected at any moment” (Song et al. 2007b:431). Homeless youth in particular “…are experiencing serious distress as indicated by the high prevalence of suicide attempts, thoughts of death and suicide, and psychiatric disorders” (Yoder et al., 2008:97).

time

Life Expectancy: The Evidence is Clear

According to the report on homeless deaths in Los Angeles county, the average death for homeless people was 48.1 years old, while the average American life expectancy was 77.2 (Stoops, 2007:4). Homeless people die younger than the general population (Hibbs et al., 1994:307; Cheung & Hwang 2004:1243; Barrow et al., 1999:529; O’Connell 2005:13).

James O’Connell reviewed the literature for premature mortality in homeless populations and suggests that mortality rates may be higher than we predict since most studies focus on those homeless people who have utilized shelters and does not include the so called “rough sleepers” who are vulnerable to extreme weather and violence” (2005:12). These studies also do not include those who have moved away and who may have died without the researcher’s knowledge.

Why is death so common on the streets?

If we examine why homeless people face death regularly, then we notice that there are some common themes that arise. We know from research that “[h]omeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect” (Song et al. 2007b:427). We tend to take for granted the little things in life that allow us certain privileges. When you are homeless, it’s not that simple just to walk into your doctor’s office and get treated, especially without any identification or a permanent address. Jonathan R. Hibbs and colleagues explain that “[h]omeless people are likely to die from a variety of preventable causes” (Hibbs et al., 1994:304). Preventable? And yet, they still lose years off of their lives. As a society, we tend to ignore the health aspect to homelessness and dismiss any problems that they encounter by victim blaming. Our individualist culture suggests that when homeless people become sick and die, it’s their fault.

hands

Researchers suggest otherwise. “Homelessness itself, rather than identifiable medical conditions, appears to be the risk factor that most needs to be eliminated in order to reduce preventable mortality” (Hibbs et al., 1994:308). Barrow et al maintain that interventions must be broadly based outside of specific health risks by focusing on “the general phenomenon of homelessness itself and the societal problems of poverty and discrimination that have given rise to it” (1999:533). Much work needs to be done. But in the meantime, maybe by recognizing that homelessness and death are heavily related we can be a little more compassionate when it comes to understand the lives of the homeless.

 

References

Barrow, S. M., Herman, D. B., Cordova, P., & Struening, E. L. (1999). Mortality among homeless shelter residents in New York City. American Journal of Public Health, 89(4), 529-534.

Cheung, A. M., & Hwang, S. W. (2004). Risk of death among homeless women: a cohort study and review of the literature. Canadian Medical Association Journal, 170(8), 1243-1247.

Hibbs, J. R., Benner, L., Klugman, L., Spencer, R., Macchia, I., Mellinger, A. K., & Fife, D. (1994). Mortality in a cohort of homeless adults in Philadelphia. New England Journal of Medicine, 331(5), 304-309.

O’Connell, J. J. (2005). Premature mortality in homeless populations: A review of the literature. Nashville, TN: National Health Care for the Homeless Council, 1-16.

Pyszczynski, T., Solomon, S., & Greenberg, J. (2015). Thirty Years of Terror Management Theory: From Genesis to Revelation. Advances in Experimental Social Psychology.

Shapcott, M. (2005). Dying for a place to call home: Women and homelessness in Toronto and Canada. National Housing and Homelessness Network: Toronto Disaster Relief Committee, 1-10.

Song, J., Bartels, D. M., Ratner, E. R., Alderton, L., Hudson, B., & Ahluwalia, J. S. (2007a). Dying on the streets: Homeless persons’ concerns and desires about end of life care. Journal of general internal medicine, 22(4), 435-441.

Song, J., Ratner, E. R., Bartels, D. M., Alderton, L., Hudson, B., & Ahluwalia, J. S. (2007b). Experiences with and attitudes toward death and dying among homeless persons. Journal of general internal medicine, 22(4), 427-434.

Stoops, M. (2007). Dying without dignity: homeless deaths in Los Angeles County, 2000-2007. Los Angeles Coalition to End Hunger & Homelessness.