Staff of the Parliamentary Research Branch (PRB) of the Library of Parliament work exclusively for Parliament conducting research and providing analysis and policy advice to Members of the Senate and House of Commons and to parliamentary committees on a non-partisan and confidential basis.  The documents on this site were originally prepared for general distribution to Canadian Parliamentarians to provide background and analysis of issues that may arise in the course of their Parliamentary duties. They are made available here as a service to the public. These studies are not official Parliamentary or Canadian government documents. No legal or other professional advice is offered by the authors or the Parliamentary Research Branch in presenting its publications or in maintaining links to other Internet sites.

PRB 99-1E

HOMELESSNESS

MODULE CONTENTS

OVERVIEW
   The Growing Numbers of the Homeless
   1987: A Turning Point in Research on the Homeless
   Objectives of This Modular Document

DEFINITION OF HOMELESSNESS
   The Search for a Definition of Homelessnes
   Three Types of Homelessness
   Methodological Issues
   Summary

COUNTING THE HOMELESS
   At the Heart of the Debate: How Many Homeless People are There?
   The Canadian Situation in the Enumeration of the Homeless
      A. First Attempt at Enumerating the Homeless
      B. Second Attempt at Enumerating the Homeless
   Lack of Official Data on the Homeless
      A. The Committee’s Comments
      B. Responses of Governments
   A Political Issue
   A Methodological Research Process Designed to Enhance
   Our Knowledge about Homelessness in Canada
   Summary

COMPOSITION OF THE HOMELESS POPULATION
   Some Groups Previously Underrepresented among the Homeless
      A. Women
      B. Youth
      C. Aboriginal Peoples
      D. Families
   Summary

HEALTH AND HOMELESSNESS
   Introduction
   The Health of the Homeless
   General Barriers to Good Health and Possible Solutions
   The Health of Specific Homeless Groups
      A. Youth
      B. Women
     C. The Mentally Ill
     D. Aboriginal People
   Federal Role in the Health of the Homeless

HOUSING AND PARLIAMENTARY ACTION
   Overview
   Chronology

INTERNATIONAL PERSPECTIVES ON FACTORS
CONTRIBUTING TO HOMELESSNESS
   Overview
   The American Experience
      A. A Brief Chronology
      B. U.S. Studies: Possible Explanations for the Rise of Homelessness
         1. Decline of Inexpensive Housing Stock
         2. The Decline of the Casual Labour Market
         3. Deinstitutionalization
         4. Substance Abuse and the Advent of Crack Cocaine
         5. Changes in Income Distribution

Parliamentary Research Branch

PRB 99-1E

OVERVIEW

Prepared by:
Lyne Casavant
Political and Social Affairs Division
January 1999

Homelessness is not confined to the world’s poorest countries; in every country, including those considered to be the wealthiest on the planet, there are clearly many people who find themselves without shelter over a relatively long period.(1) Nor is this necessarily brought about by disasters of natural or human origin. Many studies have found that a wide variety of events can force people into the ranks of the homeless. Today, homelessness is a reality for many men, women and children of very different backgrounds. This is not new; at various periods throughout history some people have been unable to find appropriate housing, and for many reasons. Since the 1980s, however, the phenomenon has grown, and the composition of the homeless population has become increasingly varied.(2)

The Growing Numbers of the Homeless

The most recent estimates of the number of homeless, published by international organizations, are alarming. On a world scale, it is estimated that more than one billion individuals are poorly housed and that 100 million of them are literally living on the street. According to a UNICEF report, every night there are 850,000 homeless people in Germany and 750,000 in the United States In Canada’s largest city, Toronto, emergency shelters for the homeless took in an average of 6,500 persons each night in 1997.(3)

The experts agree that, in addition to its constant growth, the homeless population has over the last 20 years or so undergone some substantial changes. In North America, for example, the homeless population includes a large and growing number of women,(4) youth,(5) families,(6) mentally disturbed people,(7) new immigrants,(8) and members of various ethnic communities; in Canada,(9) it includes many Aboriginal people.

1987: A Turning Point in Research on the Homeless

In 1987, the United Nations declared the International Year of Shelter for the Homeless and homelessness became the focus of attention of a large number of researchers and field workers. In the years since then, this public recognition of the homeless population has been reflected in research, policy development and action, as witnessed in the proliferation of literature on the subject. Researchers at the University of Quebec in Montreal found that in an inventory of scientific articles on homelessness published between 1980 and 1993 in three computerized indexes (Sociofile, Psyclit and Medline), 91% of the 1,214 articles had been published since 1987.(10)

Generally speaking, these studies have helped to alter our conception of homelessness and our simplistic explanations of the problem, which was long associated almost exclusively with alcohol abuse.(11) It must now be acknowledged that the traditional image of the homeless as a relatively homogeneous group of alcoholic and vaguely crazy older men is outdated and that alcohol abuse is not the sole source of homelessness.

While existing knowledge of the subject is based on a substantial body of research and publications, experts have advanced as many explanations of homelesness as solutions for curbing its growth. There is no consensus as to the scope of the phenomenon, its causes and remedies, or even on the composition of the homeless population. Although the explanations multiply and become more complex as our knowledge of the subject deepens, there is much debate as to the relative weight that must be given to the various contributing factors, such as poverty, shortage of low-cost housing, drug abuse, and mental illness. This is no doubt why, notwithstanding the range of studies on homelessness, many continue to be ignorant about the overall phenomenon and what can be done to overcome it.(12)

Objectives of This Modular Document

This modular document does not claim to say everything about homelessness. Our primary objective is to present the major characteristics of the homeless population in Canada and to offer an overview of the major explanations for the situation.

A number of aspects of homelessness are briefly discussed in the following sections. First, homelessness is defined and the methodological and policy issues associated with adopting a particular definition are identified. Discussion then turns to the problems in enumerating the homeless population, the living conditions of the homeless, and, more particularly, the impact of these conditions on their health. Finally, the links between homelessness and prison and mental illness are examined, as well as proposals for legislative measures to try to stem the growth of the problem.

Because this document focuses on the situation in Canada, it presents Canadian statistics on the scope of the problem and its components.

The following pages show that since the 1980s homelessness has been increasingly linked to numerous concerns in the areas of criminality, public health and the economy. We will see that these concerns, because they tend to result in measures aimed strictly at the homeless, are leading to greater social control over this population. This increased control, which is often seen in the regulation of public space, promotes the criminalization of the homeless and consequently helps to reinforce the popular image of them as deviants. Some writers argue that, by criminalizing the living conditions of those who live in extreme poverty, we are to a large degree fostering their marginal status in society.

(12) Anne Golden, "The Faces of the Homeless," Globe & Mail (Toronto), 28 May 1998.

PRB 99-1E

DEFINITION OF HOMELESSNESS

Prepared by:
Lyne Casavant
Political and Social Affairs Division
January 1999

The definition of homelessness is at the centre of some major policy considerations. Clearly, any definition has a direct influence on quantitative evaluations of the number of people affected by the phenomenon and consequently on the scope of the resources that ought to be devoted to it. For example, the use of relatively broad definitions tends to increase the number of those deemed to be homeless and implies the need for a reassessment of the criteria for access to decent housing, low-cost housing construction policies, and the funding of the services directed to this population.

The various definitions used in the literature on homelessness are briefly discussed below, as are some of the methodological problems resulting from the lack of consensus on a definition of the condition.

The Search for a Definition of Homelessness

The difference between those with shelter and those without seems obvious, at first glance: to be "homeless" is to be without a place in which to live. The issue surrounding this situation is complex, however, and is expressed through a set of definitions. For example, there is clearly more than one answer to the question of who is to be classified as homeless; some writers even maintain that there are almost as many definitions as there are studies on the subject. To reflect the significance of the variations in the definitions, some researchers refer to a "continuum of homelessness."

At one extreme on this continuum, a "homeless" person is defined solely with reference to the absence of shelter in the technical sense; this is obviously the most restrictive definition. But, although a large sector of the community has adopted this definition, and use the term "homeless" exclusively to describe people living on the street or in emergency shelters, and although all of the researchers and field workers agree that such people certainly ought to be characterized as homeless, many think that this is too restrictive a definition.

At the other extreme, researchers propose a broad and inclusive definition such as that adopted by the United Nations when it declared the International Year of Shelter for the Homeless. According to this definition, a "homeless" person is not only someone without a domicile who lives on the street or in a shelter, but can equally be someone without access to shelter meeting the basic criteria considered essential for health and human and social development. These criteria would include secure occupancy, protection against bad weather, and personal security, as well as access to sanitary facilities and potable water, education, work, and health services. The right to a home must be seen as a basic humanitarian principle, recognized in the Universal Declaration of Human Rights:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.(1)

The United Nations definition acknowledges that the absence or extreme precariousness of housing gives rise to a number of problems that are major factors in the deterioration of the quality of life, such as difficulty in maintaining emotional ties, obtaining services, protecting personal property and securing physical safety. The lack of access to a decent private space that would allow the homeless to prepare for work or school and to provide and receive care and attention keeps them in extreme poverty.(2) The UN definition would therefore include persons who, because they inhabit inadequate dwellings, are in serious danger of being thrown into the street.(3)

Between these two opposite ends of the continuum, a number of researchers propose other definitions of homelessness. Each is valid to some degree and to attempt to compare the various definitions is virtually impossible. To cite only one example, in 1987, the Homeless Committee of the City of Montreal adopted the following definition of the homeless, which was subsequently applied by the Quebec Department of Health and Social Services in La Politique de la santé et du bien-être:(4)

[Translation] A person with no fixed address, stable, safe and healthy housing for the next 60 days, an extremely low income, adversely discriminated against in access to services, with problems of mental health, alcohol and drug abuse or social disorganization, and not a member of any stable group.(5)

Those who favour this definition say that it has the advantage of taking into account the complexity of the functional problems in the dynamics of homelessness. However, this definition, like those presented earlier, remains subject to interpretation. How, indeed, should housing be defined? Can a car, an unused building or even a trailer be considered to be housing? And what about individuals who sleep at friends’ homes, a woman fleeing spousal violence who seeks assistance in a shelter, a former prison inmate temporarily residing in a halfway house, or a drug addict undergoing substance abuse treatment in a specialized centre? Should all of these people be considered homeless?

Overall, it is clear that all the definitions of homelessness can be interpreted in different ways and reflect a particular point of view. And it is just as clear that all the definitions are governed by some time considerations. The changing status of those who experience homelessness creates difficulty for anyone attempting to define the population touched by this tragedy. Homelessness is not a characteristic of an individual but is rather a life situation that may be temporary, periodic or more or less permanent. Some longitudinal studies seem to indicate that a lack of housing over a long period is uncommon, at least in North America.(6) Some U.S. and Canadian researchers have even said that "typically, homelessness consists of residential instability, rather than an enduring absence of accommodation over a long period of time."(7) Accordingly, many researchers add a time element to their definition of homelessness, so that, for example, to qualify as homeless a person must have been without housing for a certain number of days or weeks.

Three Types of Homelessness

The issue of duration is significant for everyone interested in homelessness. Often, how long homelessness has lasted becomes the decisive factor in distinguishing the varied levels of difficulty experienced by the individuals. One of the most common ways of categorizing the homeless is to divide the total population into three subgroups: the chronically homeless; the cyclically homeless; and the temporarily homeless.(8)

The chronically homeless group includes people who live on the periphery of society and who often face problems of drug or alcohol abuse or mental illness.

The cyclically homeless group includes individuals who have lost their dwelling as a result of some change in their situation, such as loss of a job, a move, a prison term or a hospital stay. Those who must from time to time use safehouses or soup kitchens include women who are victims of family violence, runaway youths, and persons who are unemployed or recently released from a detention centre or psychiatric institution.

Finally, the temporarily homeless group includes those who are without accommodation for a relatively short period. Likely to be included in this category are persons who lose their home as a result of a disaster (fire, flood, war) and those whose economic and personal situation is altered by, for example, separation or loss of job. Some researchers do not consider this group as being truly homeless and exclude them from their studies.

Methodological Issues

The range of definitions used in the literature on homelessness constitutes a very real obstacle to research. Since researchers, in presenting their findings, often do not specify the definition they adopted for analytical purposes or their method of identifying the homeless, it is quite difficult to conduct comparative studies. Significant variations in the number of homeless people reported in one country, or even one city, may be explained by the different definitions or methods adopted by researchers.

All definitions present some difficulties in terms of their application, posing substantial challenges to research in, for example, the choice of the environment for data collection, evaluation of the representative sample, the extent to which the results can be generalized, and comparison of results. Though most researchers in Canada adopt the definition used by the United Nations, it is hard to use from the methodological standpoint. How, in fact, can one locate the people living in dwellings that do not meet the basic UN criteria? Given these difficulties, most of the empirical research in Canada relies on the first part of the UN definition ¾ that is, homelessness as meaning literally without shelter. The research methods are therefore focused on the services directed to the homeless. So the definition is cited in terms of theory, but in practice is used only in part. In Canada, however, it is acknowledged that these methods make it impossible to have the full picture of the situation, whose gravity is therefore underestimated.

In addition to all the difficulties of identifying the concept of homelessness, as expressed in the lack of consensus over its definition, it should be stressed that no one definition has been systematically applied in the studies of homelessness. There is therefore a lack of consensus on the term and the appropriate methods for assessing the phenomenon ? that is, how to determine who is included in the definition and who is excluded.

Summary

In summary, two issues must be kept in mind when reviewing studies of homelessness. The definition of that term favoured by the researchers and the method they employ to identify the homeless must both be clear. It is important to remember that the term "homelessness" can refer to various situations — people living with friends, women staying for a short period in shelters for abused women, and prisoners are all sometimes put into this category. It is necessary, therefore, to be aware that, unless they are seen in context, the research findings are meaningless.

(8) Some researchers propose two subgroups, one consisting of the chronically and permanently homeless and one consisting of the occasionally and temporarily homeless.

PRB 99-1E

Prepared by:
Lyne Casavant
Political and Social Affairs Division
January 1999

At the Heart of the Debate: How Many Homeless People are There?

What is a homeless person? How many are there? These are the two main questions driving the discussion on homelessness. The two questions, albeit distinct, are in fact closely linked; the answer to the first will determine the second. Thus, the estimated size of the group directly depends on the criteria used to define homelessness; the definition of homelessness will itself determine their number. The more inclusive the criteria, the larger the estimate, and vice versa.

We should not be surprised, therefore, to find some significant variations in the estimates. Two U.S. researchers have given estimates for the United States as a whole varying between 250,000 and 3,000,000 homeless.(1) This debate, which is primarily between activists and public servants, is particularly lively in the United States. Estimates world-wide, according to the United Nations, vary between one hundred million and more than one billion homeless. The differences in numbers are explained by the fact that the definition proposed by the UN includes those living in various degrees of unsatisfactory housing: those without a roof over their heads, those who sleep in temporary shelters or institutions, and those living in unsanitary or low-quality accommodation. Depending on which of these definitional components is used, the estimates of the homeless can vary from several million to more than one billion people.(2)

There is much at stake politically in counting the homeless. Very often, human and financial efforts to manage the problem are justified according to the head count. Generally speaking, the greater the estimate, the greater the number of services that will be directed to the homeless.

The Canadian Situation in the Enumeration of the Homeless

In comparison to the ongoing debate in the United States, the discussion on the numbers of the homeless is relatively recent in Canada. In fact, it was not until 1987, the International Year of Shelter for the Homeless, that Canadian researchers became interested in counting this population.

   A. First Attempt at Enumerating the Homeless

The first Canadian attempt to estimate the numbers of homeless people was carried out in 1987 by the Canadian Council on Social Development (CCSD). Its survey was aimed at shedding light on the causes of homelessness, profiling the homeless, determining the scope of the problem and developing some strategies to eliminate it.

All the agencies in Canada that provided temporary or emergency shelter, as well as those providing particular services to the homeless, were sent questionnaires to be filled out on 22 January 1987. Out of a total of 472 questionnaires distributed, only 283 were returned completed.

The survey disclosed that 10,762 people were staying in the shelters inventoried in the survey. These people were for the most part in Ontario (42%), Quebec (17.5%) and Alberta (14%). According to the agencies, during the year preceding the survey there were between 130,000 and 250,000 homeless people in Canada; that is, many thousands of men, women and children had no housing or were poorly housed.(3)

The validity of this estimate has been widely disputed, however. Major criticisms included the failure to include those who on 22 January 1987 were not staying in the documented shelters, the low participation rate of the agencies (283 out of 472), and the exclusive reliance on service providers as informants. With respect to the first criticism, it should be noted that the survey had omitted persons who, at the time of the survey, were doubled up with friends or family members, were sleeping in hotels or homes not included in the survey, were in prisons, hospitals, detoxification centres, or who were sleeping in entrances to apartment houses or abandoned buildings. Consequently, the results underestimated the scope of the problem in Canada. The strategy used by the CCSD has been characterized as an ineffective way of coming up with an overall picture of the homeless.

   B. Second Attempt at Enumerating the Homeless

The second Canadian attempt to count the homeless, carried out by Statistics Canada during the 1991 Census, used a strategy analogous to that used by the CCSD and subsequently perceived as controversial and methodologically suspect.

The Statistics Canada survey, which took place in the course of one day in June 1991, covered about 90 soup kitchens located in 16 Canadian cities. Census-takers based in the agencies asked clients where they had spent the previous night. In contrast to the CCSD survey, however, no results were published by Statistics Canada; in 1995 the agency officially announced that results would not be published because of the mediocre quality of the data.

Not surprisingly, given the method used, the Statistics Canada survey, like the CCSD survey, proved controversial. Some criticisms were that the homeless had been polled at the beginning of the month, when poor people have less recourse to soup kitchens because they have just received their welfare cheques; and that the poll had relied on a single type of agency (soup kitchens) for information when even the officials of such agencies state that these are seldom frequented by some subgroups of the homeless, including young people.

Lack of Official Data on the Homeless

To this day, Canada has no official data on homelessness, a situation that has come in for comment from the United Nations Committee on Economic, Social and Cultural Rights.

   A. The Committee’s Comments

In 1993, after considering Canada’s second report on economic, social and cultural rights, the U.N. Committee explicitly regretted the lack of Canadian data on homelessness:

The Committee notes the omission from the Government’s written report and oral presentation of any mention of the problems of homelessness. The Committee regretted that there were no figures available from the Government on the extent of homelessness, on the numbers of persons evicted annually throughout the country, on the lengths of waiting lists or the percentage of houses accessible to people with disabilities.(4)

Since Canada was unable to provide the Committee with such data, the Committee repeated its criticism in June 1998, when Canada filed its third report. This time, the Committee asked the government, by way of supplementary questions, to

Please provide any available data on the extent of homelessness in various cities in Canada. At what point would the government consider homelessness in Canada to constitute a national emergency?(5)

   B. Responses of Governments

After the two attempts, in 1987 and 1991, to collect national data on homelessness, the Government of Canada told the UN Committee that the data obtained in these enumeration attempts were neither reliable nor representative. It added that, although some Canadian cities had tried to estimate the scope of the problem, the strategies used and the definitions of homelessness varied so much that it was impossible

to compare the results. At the same time, the government spoke of the difficulties associated with gathering data on homelessness.

Enumerating the homeless is indeed an enormous task. Researchers face a number of obstacles, such as the lack of consensus on an operational definition of homelessness; double-counting of the population; the geographical and durational variations in homelessness; and the high costs of enumeration.(6)

The governments of the provinces and territories were also asked to reply to the supplementary questions of the UN Committee on Economic, Social and Cultural Rights arising out of its consideration of the Canadian report. All of them replied that there were no government data on the scope of the homelessness problem in various cities in Canada. Moreover, although there are some data originating from private sources, only the Quebec and Alberta governments presented the Committee with any of these statistics.

The Alberta government told the Committee, that on the basis of a survey conducted by private sources, it was estimated there were between 100 and 1,000 homeless in Calgary, out of a total population of 800,000 inhabitants.(7) The Quebec government reported that some studies had estimated the number of homeless in the province as a whole at 15,000 persons, with 10,000 in the City of Montreal alone. It was noted, however, that these data did not reflect the number of people without shelter every night, but rather the number who had had some experience of homelessness for some period during a year.(8) Moreover, the Quebec government also stated that estimates vary widely depending on the definition of homelessness used, and commented on the difficulty of counting homeless people.(9)

The federal government provided the Committee with the sole fact that just under 26,000 people had used the shelter network in Toronto in 1996.(10) This information was selected on the grounds that "the new City of Toronto has the largest and probably the most robust data series in the country with regard to homeless persons."(11)

A Political Issue

The governments could, however, have reported other data to the Committee that would have given different impressions of the scope of homelessness in Canada. In Canada, as elsewhere, opinions differ widely as to the seriousness of the situation, and the political implications of the estimates of the numbers of the homeless are formidable: the size of the estimate directly affects the funding of relevant services, as well as the evaluation of the criteria for access to decent accommodation and for building low-cost housing. (For further information, see the section entitled "Definition of Homelessness.")

A Methodological Research Process Designed to Enhance Our Knowledge
about Homelessness in Canada

To correct the lack of reliable and representative data on homelessness in Canada, and to add to information about the problem as a whole, the federal government told the UN Committee that since 1994 the federal agency charged with implementing the National Housing Act, the Canada Mortgage and Housing Corporation (CMHC),(12) has made homelessness a research priority. For example, in the spring of 1996 the CMHC organized a three-day workshop on the problems of enumerating the homeless.

Based on Canadian and U.S. research experience, the workshop helped to identify the most appropriate means of carrying out this task.(13) The federal government also told the UN Committee that the CMHC is developing a computerized research tool that will standardize the collection and management of admission data for services directed to the homeless. This should help to provide a uniform head count of those using such services in Canada and should soon be established in shelters for the homeless.

Summary

Research certainly continues to be the best way of advancing our knowledge of homelessness. It is still hard to produce data on the scope of the problem in Canada, whether nationally or provincially, but it is hoped that, thanks to the research undertaken by the Canada Mortgage and Housing Corporation, it will soon be possible to quantify the problem on a national scale. It must be stressed, however, that the major obstacle to counting the homeless continues to be the lack of a consensus on how to define them. (For further information, consult the section entitled "Definition of Homelessness.")

(13) The participants recommended, inter alia, that estimates of the number of homeless be based solely on services, in view of the high costs associated with a census of street people who use neither services nor shelters for the homeless and the fact that their exclusion would result in the total size of the homeless population being underestimated. For further information, see T. Peressini, L. McDonald and D. Hulchanski (1996).

PRB 99-1E

Prepared by:
Lyne Casavant
Political and Social Affairs Division
January 1999

Even today, many people think of the homeless as a relatively homogeneous group largely composed of older, alcoholic and vaguely crazy men. This traditional image, which has long informed our collective imagination, as it has the literature on the subject,(1) does not correspond, however, to the present composition of the homeless population.

With recent changes in this population, it is no longer possible to speak of one profile of homelessness rather, there is a diversity of profiles. The homeless now include women, children, teen-aged youths, the mentally ill, newly arrived immigrants, refugees, women victims of spousal violence, persons recently released from prison, and casual workers. Each of these homeless subgroups may be further broken down by age, sex, ethnic origin and occupational status.

A number of studies have revealed that the shelters for the homeless are being frequented each year by welfare recipients, the unemployed, the mentally ill, former psychiatric patients and the physically disabled. According to the 1987 survey of the Canadian Council on Social Development (CCSD), 20% of the persons who were in shelters in Canada on 22 January 1987 were suffering from mental illnesses or had previously received psychiatric treatment, 3% were afflicted with a physical disability, close to 50% were unemployment insurance claimants and about 50% were on social assistance. A 1997 study in Calgary found that 45% of the homeless who were interviewed were working, albeit in unstable and low-paying jobs.(2)

Researchers and field workers increasingly suggest that the causes and risk factors for homelessness are not the same for everyone. In fact, they say, each of the homeless subgroups appears to have significant differences that ought to influence how we deal with homelessness. Moreover, the solutions with the greatest promise for eliminating the problem, researchers suggest, could be very different, depending on whether they are directed to women, young people, native people, or refugees.

The following paragraphs examine the features of the various subgroups among the homeless and the risk factors for each one. Canadian literature on the subject is sparse and fragmented so that data on the scope of the problem for each subgroup, or even the factors involved in the descent into homelessness, are not available. Some homeless subgroups (women, youth and Native peoples) have attracted particular attention from Canadian researchers with opinions varying widely as to the sources of the problem. It should be noted that only the data from the CCSD 1987 survey apply to Canada as a whole; while incomplete, they are nevertheless the best data on the changes in the composition of the national homeless population since the 1980s. As well, the results of various Canadian studies often give widely differing pictures of the homeless. These differences are explained by the significant discrepancies in the definitions and methodologies adopted by the researchers. Thus, it is difficult, to say the least, to attempt to compare the research results.

   A. Women (3)

According to the CCSD survey and a number of Canadian studies, women account for about 30% of the homeless population(4) and are therefore less noticeable than the men. All researchers agree, however, that this lower visibility of homeless women results from a number of factors. First, since the enumeration of the homeless is generally based on the users of services, homeless women are less evident simply because fewer services cater to them. Some studies have also suggested that homeless women are less visible on the street because they pay more attention than homeless men to their personal hygiene and clothing.(5) Furthermore, women are normally homeless for shorter periods than men, since they often manage to find shelter in exchange for sexual or domestic services. One writer even states:

They are simply not safe. As well, because they are so at risk "on the street," women are frequently forced into the condition of cohabiting with men, often residing in physically, sexually, and emotionally abusive relationships.(6)

The relationship between violence against women and homelessness is complex, however. Some studies have indeed shown that a large percentage of homeless women have been subjected to sexual and physical violence, are more likely than men to experience violence while they are homeless, and are often living on the street because they are fleeing family violence."

Numerous risk factors are associated with women’s homelessness, such as poverty, family violence, alcoholism, drug abuse, mental and physical health problems, and lack of affordable housing. However, if we compare the situation of women with that of men,(7) it appears that women are relatively more affected by a weakening of family ties. A number of studies have in fact shown that many women become homeless as a result of a breakdown in a relationship. The financial consequences of a divorce or a breakdown in marital relations are generally unfortunate for women. After a divorce, for example, a woman’s income tends to decrease, while that of a man tends to increase: "While men’s income increases slightly, women’s household income after divorce drop [sic] over 40%, and the poverty rate for women increases almost threefold…."(8) The language used by homeless women also confirms the importance of relationship breakdowns in causing their homelessness; generally speaking, homeless women tend to explain their situation by reference to the family. But, although there are many reasons why women become homeless, it is clear that their greater poverty, together with sexism, aggravate their vulnerability when it comes to finding housing.

Several researchers have stressed the feminization of poverty as a causal factor in women’s homelessness…. Women-headed households in advanced industrial countries are more likely to have serious housing problems…, and, internationally, women face problems of attaining shelter that are directly related to their gender….(9)

   B. Youth  (10)

Thousands of children run away from home each year in Canada. In 1995, for example, 75% of the 56,749 missing children who were reported to the police were runaways. Police departments say that, although 90% of these runaway children return home within 60 days of leaving, the others never go back. Alarming as these figures are, runaways account for only a portion of the homeless youth population, which also includes young people living in shelters with their mother or both parents. The 1987 CCSD survey found that 11.5% of the people in the shelters documented were under the age of 16. Street or homeless youth tend to range in age between 12 and 24, the girls being generally younger and the boys older.(11)

The situation of homeless youth, as portrayed in the data from the relevant services, is clearly not encouraging. Several researchers and field workers have noted in this regard that the street children and runaway youth use various strategies to survive when living on the street or running away: staying with friends, engaging in prostitution and committing offences. And the longer they are homeless, the more likely they are to commit offences in order to survive.

Mistreatment is often cited as a factor in youth homelessness. A number of studies have confirmed that many homeless young people have been victims of sexual, physical or psychological abuse. A 1992 study by social service agencies in the Ottawa-Carleton region indicated that 75% of the street children interviewed had left home because of sexual assaults or physical and/or psycho-emotional abuse. Living on the street is no protection, however: although street life is a violent environment for anyone, it is even more violent for homeless young people and women, and is often accompanied by multiple risks.

Again, more than one factor is associated with youth homelessness, however. The literature on the subject commonly links changes in the job market, particularly the growing use of casual labour, to the increased vulnerability of young people. Casual, unskilled employment in the service sector often does not provide the security and wages needed to acquire secure housing. Many young people are not managing to earn enough income from employment to provide themselves with stable accommodation. Given the threshold skills that have been required for most jobs since the 1980s, access to the job market is especially difficult for those without specialized training or much academic achievement.

The growing presence of young people among the homeless is a phenomenon noted by virtually everyone in the field. However, there is much work to be done before we have an adequate understanding of why this is the case in Canada.

   C.   Aboriginal Peoples (12)

There is no denying the obvious presence of homeless Aboriginal people in some regions of the country. A number of studies have attempted to quantify the problem in certain Canadian cities.

• According to a report on the health of the homeless in Toronto, Native people, Blacks and Asiatics made up one third of the sample studied.(13) In Toronto, Native people account for 25% of the homeless population, although they make up only 2% of the city’s total population.(14)

• It has been estimated that 72% of the homeless men in some Winnipeg neighbourhoods are Aboriginals.(15)

• In Vancouver, a study of 60 homeless women in the downtown area disclosed that 50% of them were Aboriginals.(16)

• A survey in Calgary found that of the 615 homeless people surveyed on 26 May 1996, 20% were Aboriginals, 3% Asiatics and 3% Blacks.(17)

• A Saskatoon study found that the majority of young people living on the street were Aboriginals.(18)

Generally speaking, the Aboriginal population differs significantly from the non-Aboriginal. Research has shown that the Aboriginal population is characterized, inter alia, by lower educational and income levels, higher unemployment and poverty levels, a larger proportion of single-parent families and generally poorer housing, which is more likely to be rented. These factors are major contributors to Aboriginal homelessness, although others (such as drug and alcohol abuse and mental illness) are often cited. As one author has stated:

Aboriginal homelessness has many features in common with homelessness in the general population, but it also has several distinctive features (e.g., rural-urban migration, racism and discrimination, "Third World" on-reserve housing). Similarly many of the same strategies are recommended to address both Aboriginal and non-Aboriginal homelessness. However, the literature indicates that the Aboriginal homeless have special needs (e.g., cultural appropriateness, self determination, traditional healing techniques).(19)

The literature on housing discrimination emphasizes racism and sexism. Clearly, racism aggravates the vulnerability of Aboriginal people; however, it also affects members of the ethnic communities and increases their vulnerability to homelessness. It should be noted in this connection that Canadian studies on homelessness have generally ignored ethnicity, although U.S. studies consider it to be a significant risk factor. Racism and language barriers clearly constitute additional obstacles to finding housing for some members of the ethnic communities.

   D. Families

In the United States, unlike the case in Canada, it is increasingly common to find entire families among the homeless. The literature frequently attributes this difference to Canada’s relatively higher levels of social assistance. The U.S. studies have shown that most homeless families are headed by women,(20) something that the Canadian data suggest may be equally true in this country. In fact, in the Ottawa-Carleton area, women headed most of the 1,263 families (with 2,036 children) that sought refuge in shelters between January 1986 and August 1988. An article in The Globe and Mail in February 1996 reported a 45% increase over the previous year in the number of families seeking emergency shelter in Metropolitan Toronto. Most of these families had been evicted from their homes for failure to pay the rent. Some attribute this problem to a reduction of about 22% in social assistance.

Families, especially single-parent families headed by women, are very vulnerable to homelessness, which often seems to result when potential back-up resources, such as the extended family and friends, are exhausted. Social isolation is a major factor in family homelessness.

The families most at risk are those in which domestic violence prevails. The situation of mothers who are the victims of family violence is particularly acute:

Child custody issues inevitably complicate the situation for a battered woman who has left her home. If she takes the child with her, she can be challenged in court for placing them in an "unstable environment," that is, a shelter. If, for safety reasons, she decides to leave the children with her parents or a friend, she could be attacked in court for abandoning them. If she leaves them with the abuser, she could jeopardize their safety — and be charged with abandonment as well.(21)

It is still very difficult to present a portrait of homeless families in Canada today. Very little research deals with the topic, and none provides nation-wide data, other than the controversial 1987 survey by the Canadian Council on Social Development. Further research into this issue is needed, as it is also needed for all issues affecting women, violence against women and the role of the family in our societies, so that we can improve our understanding of family homelessness.

Summary

At present, we have insufficient knowledge of the composition of the homeless population and the particular characteristics of each of its subgroups. The results of studies of the homeless are hard to compare, given their significant differences. However, notwithstanding the individual characteristics of the various homeless subgroups, all homeless persons, and those in serious risk of becoming so, have poverty in common. That is why, in view of the changes in the job and housing markets, it seems clear that an increasing number of the working poor (single mothers, casual workers, school drop-outs, etc.) are in danger of joining the ranks of the homeless.

(21) Zappardino and DeBare (1992), in Novac, Brown and Bourbonnais (1996), p. 28.

Whether as a cause or a consequence of ill health, homelessness has emerged as a fundamental health issue for Canadians.(1)

The link between health and homelessness is two-fold: ill health can predispose individuals and families to homelessness, while homelessness gives rise to particular health problems. The following sections discuss the health concerns of the homeless, barriers to their good health, and some possible solutions. While much of the focus is on the efforts of municipal and provincial governments, one section deals with the role of the federal government.

As it has moved away from seeing health merely as the absence of disease or infirmity, Canada has over the last three decades achieved international acclaim for its conceptual work in the health area. Beginning with the 1974 report entitled A New Perspective on the Health of Canadians, the federal government has supported the view that health cannot be understood solely in biological or medical terms, but must be seen in a broader social, economic, political and cultural context.(2)  "Population health," one of the key conceptual frameworks for current application, focuses on broad determinants of health; in other words, on those factors that make and keep people healthy. These factors are identified as: income and social status, social support networks, education, employment and working conditions, physical environment, biology and genetic endowment, personal health practices and coping skills, healthy child development, and health services. It is not hard to see that many of these health determinants are likely to be absent for the majority of homeless people. Poverty, unemployment, mental illness and geographic dislocation are among the leading causes and results of their condition.

Studies of the homeless suggest that, while their illnesses are not different from those of the general population, they live in conditions that adversely affect their overall short and long-term health status. They exhibit an increased mortality rate; a Toronto study of deaths among homeless people between 1979 and 1990 showed that 71% of the deaths were of people under 70 years of age, compared with 38% of deaths among the housed population.(3) While deaths among the homeless are occasionally due to freezing, they are mainly the result of injury, substance abuse overdoses, and alcoholic liver disease. Climatic conditions, psychological strain and exposure to communicable disease create an overall environment that sustains a range of health problems, including injury from cold, tuberculosis, skin diseases, cardio-respiratory disease, nutritional deficiencies and sleep deprivation. Lengthy periods of homelessness result in chronic health problems including those that are musculoskeletal and dental.

It is obvious that the main barrier to good health among the homeless is their lack of the adequate, safe, accessible and affordable housing that is linked to employability, community support, personal health care and access to health services.

Homelessness renders access to general health care services difficult or impossible. The homeless are unable to obtain medical treatment without a health card (and applying for a health card requires an address); to pay for items not covered by provincial medical or drug insurance plans; to receive adequate treatment in cases where their personal appearance alarms health providers; to make a health appointment, since they lack an address and a telephone; and to receive co-ordinated care when comprehensive medical records are not kept in one location with one provider. Problems continue following treatment or hospitalisation, because the homeless have no place to recuperate and no consistent caregiver.

As a result, health care delivery to homeless individuals is concentrated in emergency departments in the core of large urban centres and in the institutions set up to address their shelter and social lacks. The need to respond to the acute health problems of this population and to redirect attention to preventive health services has led to some innovative studies and potential solutions.

Suggestions for overcoming the absence of a health insurance card (the case for an estimated 30 to 50% cent of people living in Ontario shelters)(4) are currently being discussed in several provinces. They include proposals for more relaxed rules for homeless people who apply for cards, such as allowing photocopies rather than originals of identification documents. For professionals such as nurse practitioners and physicians, who must have a valid health card number for billing the provincial government, a system might be set up to fund their visits to hostels and drop-in centres. Other possibilities would be to move beyond the fee-for-service system that requires patients to present health cards to providers and allow services to be delivered through salaried staff operating in designated community health centres.

A 1998 Toronto study found that men in emergency shelters were more likely to fill drug prescriptions if they had automatic drug benefit coverage through the shelter.(5) The study involved random samples of 80 men in a government agency shelter where drugs were automatically covered by the provincial drug plan and 76 men in a private non-profit organisation shelter where there was no automatic coverage. Of the 100 men receiving prescriptions, only 6% of those who were automatically covered did not fill them, compared to 20% of those without coverage. The primary reasons given for non-compliance were the high cost of the medication or the lack of a provincial drug card.

Recognising that health care professionals must learn to provide a more welcoming and supportive environment, Toronto’s Wellesley Hospital found a way to provide more compassionate care and decrease repeat visits to its emergency department. In a randomised controlled trial, it found fewer return visits when persons with no fixed address were approached by a volunteer and offered a chance to discuss their health than when similar homeless people received regular care from emergency department staff.(6)

Increasingly assertive interventions for improving the health of the homeless include street patrols, mobile health vans, and outreach programs that involve an integrated, one-stop health and social service contact.

The Health of Specific Homeless Groups

The health of the homeless, like that of the general population, is influenced by multiple variables, including age, gender, and ethnicity, as well as socio-economic status, and geographic location.

Abused youth have been identified as being at high risk for homelessness. A 1994 study of homeless youth in Calgary found that more than half had gone through the child welfare system, having experienced abuse at home and problems in school.(7)  A 1992 survey of Ottawa street youth noted that 92% had attempted suicide.(8) Once on the street or without a home, youth can experience a range of physical, psychological and emotional health problems.(9) These are related to unsanitary and precarious living conditions, inadequate nutrition, violence, alcohol and drug use, risky sexual behaviours, low self-esteem and ongoing societal rejection, and economic marginalization.

Ongoing work is needed to identify the different life patterns and resulting needs of young people. For example, a 1996 survey in Ottawa revealed extremely limited use of soup kitchens, shelters and addiction treatment facilities by street youth.(10) Accordingly, interventions need to focus on the whole situation of the individual youth, avoiding a "one size fits all" solution or one aimed only at an immediate health problem.(11) In addition, there must be inter-agency co-ordination and co-operation across health and social spheres with flexible design and delivery for food, shelter, and counselling services as well as life skills training, education, and treatment.

Officials at Adsum House, an emergency shelter for homeless women and children in Halifax, point out that the profile of homeless women is diverse, including pregnant teens and elderly women, women in conflict with the law, women victimised by eviction, fire or flood, and women who are mentally ill or addicted.(12)  Single mothers and battered wives are among the women viewed as most at risk for homelessness. Often suffering from depression because of increased vulnerability, economic strain and social isolation, such women also face the same physical hazards as other homeless women, stemming from poor nutrition, inadequate protection against conception or sexually transmitted diseases, proximity to infectious diseases, and physical violence.(13) As the Canadian Public Health Association reported, the health of the children of these women is also affected by the cycle of low income and tenuous hold on stable shelter: "Welfare motels and hostels are available…however, studies of children housed in such facilities report increasing frequencies of acute illness, chronic illness and developmental slowing or delay."(14)

Perhaps because women are still a minority of the homeless, there is little material assessing the effectiveness of interventions aimed at the various subgroups of the homeless female population. The primary need for all appears to be affordable, accessible, secure housing in combination with social support programs and appropriate health services. These could include access to counselling on nutrition, sexual activity, and substance use as well as pregnancy and parenting programs.

Since the late 1960s, services for persons with mental disorders have shifted away from being predominately institutional or hospital-based to being community-based. In Canada, resources have shifted from psychiatric hospitals to psychiatric units in general hospitals. Data show that between 1960 and 1976 the number of beds in Canadian mental hospitals decreased from 47,633 to 15,011, while bed capacity in general hospital psychiatric units rose from 844 to 5,836.(15) Factors contributing to this shift included: increasing use of psychotropic drugs, growing criticisms of psychiatric institutions, awareness of the community psychiatry movement in the United States, and the exclusion of provincial psychiatric hospitals from the federal-provincial hospital insurance program introduced in 1958.(16) Critics have argued that delivery of mental health services has been seriously fragmented, with negative consequences for those with serious and chronic mental illnesses who reside in the community. In 1994, it was estimated that between 20 to 30% of the homeless in Canada were mentally ill and in need of treatment.(17)

Individuals who are homeless or who have rejected traditional social and mental health services require prevention as well as crisis intervention services. Because mental health professionals typically work in community mental health centres, hospitals, or in private practice, mobilizing and co-ordinating their services for the mentally ill and homeless can be difficult. Active outreach programs that assist such individuals whenever and wherever the need arises can alleviate their periods of dysfunction and prevent some of the costly hospitalizations, or even incarcerations.

Federal and provincial jurisdictional boundaries are seen as a major impediment to the delivery of health and other services for the various Aboriginal groups.(18) Aboriginal people who are homeless can be Indian (status or non-status), Inuit, or Metis and can live in remote rural areas or large urban centres. Although approximately half of all Aboriginal people are status or registered Indians, and therefore eligible for federal benefits such as health care and housing, a large portion of the responsibility for Aboriginal people who live off reserve falls to provincial governments. While federally funded non-insured health benefits are theoretically available for status Indians, regardless of residency, access to them is difficult for status Indians who are homeless.

Aboriginal people living on reserves may reside in crowded and dilapidated buildings; in Canada’s cities, they may face similar inadequate housing or be without shelter. As the Royal Commission on Aboriginal Peoples noted, inadequate housing contributes to the significantly higher rates among Aboriginal people of tuberculosis, pneumonia and other upper and lower respiratory tract infections, gastrointestinal diseases, skin infections, cancer due to second-hand smoking and deaths due to fire.(19) In addition to facing racism, homeless Aboriginal people may be unable to discuss their health problems with medical staff because of language barriers; they may lack access to trained Aboriginal health care professionals or medical interpreters; and they may find the available health programs to be culturally inappropriate.(20) Mental health issues, including suicide, substance abuse and family violence, are repeatedly identified as key concerns among this population. It is essential that they have access to safe, communal housing that is alcohol and drug-free and to readily available and culturally sensitive programs and services.

In the late fall of 1998, both the premier of Ontario and the mayo