Image of a person in jeans and white shoes with a cardboard sign that says "Everyone should have a home." Credit: scribbletaylor

We’re still in that once in a lifetime (we hope) global health catastrophe — a pandemic.

The majority of people who were homeless at the beginning of the pandemic are still homeless. No one really knows the extent to which homelessness has grown due to economic evictions.

People working on and living the issues of poverty and homelessness are witness to the downstream impact of the structural denial of social housing, a liveable wage, or decent social assistance and pension rates. They knew the writing was on the wall decades ago. (Nod to the late Bishop Desmond Tutu who popularized the “upstream, downstream” concept.)

A look at some recent disease history in Toronto’s shelters shows the decades of neglect that has led to the current collapse of the shelter system under COVID-19.

1. Tuberculosis

Twenty years ago, the Toronto Disaster Relief Committee released a report titled: Worst Christmas Ever. Here is an excerpt from the section, The City of Toronto Tuberculosis Outbreak: Homeless People at Risk:

An outbreak of TB was predicted by activists in the mid 1990s.

Between the Spring of 2001 and August 2001 there were nine linked cases of TB found in Seaton House, the largest men’s hostel in Canada. All were Canadian born. One person was co-infected with HIV. One person has since died. Cases were linked by DNA testing. Street nurses know of three other cases preceding this outbreak within the same block.

60% of the men tested at Seaton House tested positive, indicating exposure to TB. This is up 57% from the 38% figure in a 1996 TB testing pilot.

What has been done? Treatment of individuals. Fans have been installed to promote air-exchange. Windows opened to maximize ventilation.

What was not done? No notice or communique or alert to community health workers, street nurses or former members of the Tuberculosis Action Group. No warning to Hostel Services Department to not increase the crowding in existing shelters. No alert to the Out of the Cold programme even though shelter crowding, poor ventilation and forced migration are the major causes of TB infection and transmission.

The silence of the city during this outbreak is telling. It reeks of paternalism. The most senior nursing manager in Toronto Public Health at the time told me the secrecy was specifically because they didn’t want homeless people to be afraid to enter the Seaton House shelter.

Heath advocates were astounded at the complicity between the city’s shelter division and public health.

TB or not TB? There is no question is a report of a public inquiry in 2003. Inquiries were a common political action tool at the time, used to heighten awareness and push public policy forward. An expert panel would hear testimony from frontline workers and homeless people, prepare a final report with recommendations that would then be presented to city hall committees, the media and the public.

TB or not TB? tells the story of this tuberculosis outbreak that ultimately led to an inquest. In total 15 men acquired tuberculosis and three died. I always ask students – why is this an issue? The answer: because tuberculosis is both preventable and treatable. No one should die of tuberculosis today. It is and has always been a disease of poor social conditions.

Dr. Melissa Melnitzer, a witness at the inquiry who at the time worked in Parkdale Community Health Centre, gave this recommendation in her testimony:

“…Affordable housing and adequate social assistance could whittle away the very existence of homelessness…the tragedy I see every day…is preventable, but better conditions in homeless systems could keep people healthier in the meantime.”

2. SARS – Severe Acute Respiratory Syndrome. Also known as SARS-CoV.

Toronto was hit hard by SARS in 2003. While SARS didn’t hit the shelter system, we still saw how poor people were treated in the face of a deadly disease. Drop-in centres and shelters often did not have enough basic hygiene supplies including soap, tissues and toilet paper, or PPE. A prominent (albeit silent) physician leaked the news to me that Toronto’s plan, should SARS enter the shelter system, was to initiate a lockdown of the shelter, essentially imprisoning healthy people with unhealthy people. He urged me and others to expose that information and fight for isolation hotel rooms in Toronto and region should they be necessary. We did.

The words of street nurse Barb Craig, who gave this testimony as a witness at the TB or not TB? inquiry, haunt me today:

“What if the first person with SARS had walked into St. Michael’s Hospital, a downtown hospital used by many homeless people? Had SARS entered the shelters, it would have been impossible to contain. The consequences are unthinkable.”

I provided evidence at the SARs Inquiry and can’t think of one recommendation I made that was adopted.

3. Streptococcus A

The entire TB story repeated itself in the form of a dangerous and invasive form of Streptococcus A in an outbreak at Seaton House in 2017. Same story: secrecy, death, and continuation of congregate shelter conditions.

Intentional neglect and a further retrenchment by governments leaves us where we are today.

COVID-19 (SARS-CoV2)

In the first year of this pandemic the World Health Organization, Canada’s Chief Public Health Officer Dr. Theresa Tam, provincial medical officers of health and Toronto’s medical officer of health were rarely heard to say the words homeless, underhoused, shelter, or encampments. Not much has changed. Public health measures ranging from priority for masks, testing, physical distancing, and vaccination for this population lagged and continue to be inadequate.

Media, especially health and social policy journalists seem oblivious to the high-risk situation homeless people are left in during a pandemic. Only a few media outlets have routinely tackled the issue and usually only in response to something sensational — a homeless man dies of COVID, middle-class people protest outside a new shelter, a fire in an encampment or police brutality at encampment evictions. Then there is the tired media coverage of extreme cold weather and where do “the homeless” go that touches on COVID. I can predict media calls by the temperature.

Infectious disease doctors, public health doctors, epidemiologists? I’m pretty much their number one fan but remain puzzled at their inattention. It’s not rocket science that the COVID hotspot sites include congregate settings: long-term care, prisons, group-homes, schools, and shelters. Conditions in many Canadian shelters are comparable to refugee camps and the poor health status of the homeless population has been researched to death. One would think these medical experts would see the “canary in the mine shaft” or as Andrew Nikiforuk so vividly elucidates – the Fourth Horseman.

Well, the front-line workers and unhoused people do see the danger. This week, the Shelter and Housing Justice Network took the extraordinary step of issuing a media release stating that Toronto’s shelter system had collapsed and the city’s approach to isolate people in situ, and deny N95 masks is tantamount to neglect.

At the time of writing, 48 Toronto shelters were in outbreak, 317 people were infected in those outbreaks and the 60-bed Recovery Hotel program normally used to isolate people was essentially full (57 of 60 beds full).

Long-term care homes, schools, prisons, and shelters are not receiving adequate attention or protection. Homeless people, who are not unhoused and in shelters by choice, are trapped with a dangerous virus lurking.

Dr. Andrew Boozary, the head of social medicine and population health at the University Health Network sums it up in a tweet:

“…the thing that bothers me most about ‘let the virus rip now’ is it basically means everyone that is under housed, people in poorer neighbourhoods with more essential work and kids in less safe schools, elders and health workers will have to continue living this nightmare.”

Editor’s note, January 12, 2022. Previously, this article stated: “At the time of this writing, 34 Toronto shelters were in outbreak, 214 people were infected…” However, by the time this piece was published, those numbers were actually 48 outbreaks in Toronto Shelters and 317 infected people. The story has been updated.

Cathy Crowe

Cathy Crowe

Cathy Crowe is a street nurse, author and filmmaker who works nationally and locally on health and social justice issues. Her work has included taking the pulse of health issues affecting homeless people...