"Helping Hands" sculpture by Ralph Hicks at a drop-in and social housing building in Regent Park, Toronto, Ontario.
"Helping Hands" sculpture by Ralph Hicks at a drop-in and social housing building in Regent Park, Toronto, Ontario. Credit: Cathy Crowe Credit: Cathy Crowe

If a tree falls in the forest, and no one is around to hear it, does it make a sound? 

This is of course a philosophical question.

If 43 nurses who provide health care to homeless people in a pandemic are terminated, does anyone care?

This is a political question.

Journalist Joanna Lavoie reported that 43 nurses who care for unhoused people across Toronto were terminated as of March 31. This was due to the planned ending of Ontario pandemic funding. (Note: It’s 44 if you count the nurse manager, and I do.)

The nurses were employed by Inner City Health Associates (ICHA) in Toronto, a predominantly physician organization. The nurses expanded the provision of health care to homeless people during the pandemic. This included clinical care at the Toronto COVID-19 isolation/recovery hotel, seven of Toronto’s shelter hotels, and doing outreach to encampments.

SEIU Healthcare, the union who represents the 43 nurses, issued a media statement calling on ICHA and the provincial government to reverse the cuts.

ICHA for its part issued a statement that in many ways reads like an obituary. 

“Transitions after such long, challenging and complex initiatives are always immensely difficult, and we want to express our deepest appreciation to everyone involved in this work…The entire nursing team has had a profound impact on their clients, first and foremost, but also on each other, their interdisciplinary teams and community and hospital partners, and should feel proud of all they have accomplished.”

“This is an affront to nurses”

By all accounts these nurses provided exemplary care. I often said the isolation/recovery hotel was the one COVID-19 response for homeless people that Toronto got right, that is until they cut it.

I had a very emotional reaction to these nursing terminations and took to Twitter: “This is an affront to nurses. There should be a moratorium on ANY healthcare worker job loss in a pandemic OR afterwards. Absolutely revolting, disgusting, disrespectful and degrading to both nursing and people who are homeless.”

I also questioned why ICHA provided no heads up to the broader community so we could advocate for the government to continue the funding. I pointed out (with angry emojis) that the nursing cuts were happening in a 6th wave. They were happening in a city-wide shelter collapse that includes an escalation in COVID shelter outbreaks and shelter deaths.

Who decides that “planned” funding for nurses can or should take place in a pandemic? In this case it was Ontario’s Conservative government with acquiescence by ICHA.

Back to the question: If 43 nurses who provide health care to unhoused people in a pandemic are terminated, does anyone care?

While I waited and watched for the answer to this question, I thought a lot about what the pandemic has taught us about how nursing is valued.

Pandemic work conditions for nurses

There has been well-deserved attention to the workplace issues that nurses in hospitals and long-term care settings face. This includes personal support workers who provide care. Issues include inadequate PPE early in the pandemic, chronic nursing shortages, wage suppression legislation in Ontario and poor working conditions.

The work of nurses in the community has been less visible, except for the heroic work of public health nurses. The majority of these nurses were moved from their home visiting or sexual health clinics to mass vaccination efforts. Nurses I know also reported dangerous pandemic working conditions in the community such as shelters with poor infection control practices and inadequate isolation of people with symptoms.

To this day, governments have failed all nurses and the people who need them. 

I was heartened when I learned that ICHA had hired 43 nurses who were eager and committed to provide health care to homeless people. That wasn’t always the case. 

Street Health as a grassroots solution

In 1986, Toronto-based Street Health began in response to homeless people’s request to provide health care. They identified experiencing barriers, stigma, and discrimination in health care, and that included at the hands of nurses. 

Street Health was built on grassroots community development work that saw the volunteer nurses listen, consult, and respond to what homeless people told them. 

Based on the principles of primary health care the nurses began offering nursing clinics at shelters and drop-ins. This was innovative and a first in Canada – a free-standing nursing organization that was independent of physician or hospital control. However, that meant in a medically dominated and illness-based health care system, it would not be funded. After several years, the nurse manager threatened a press conference if the province did not step up and fund them. She won. (Full disclosure: in 1989, I was the second nurse hired.) 

Street Health challenged the notion that the medical perspective was the appropriate response to homeless people’s health needs. It worked to define health as social and political in nature and held systems accountable through enormous advocacy. 

Yet, the very existence of Street Health, the provision of health care to unhoused people, demonstrated a colossal failure of Canada’s so-called universal health care program. I consider “street nurse” as a political term to point out our country’s failure to rehouse people in what Ursula Franklin pointed out was a “man-made” homelessness disaster.

For decades, nurses, with a variety of job titles, pioneered homeless health care across the country. They were situated in community health centres, shelters, mobile teams, or as part of disease specific teams such as tuberculosis in public health units. Over the years, their work was further enhanced with HIV/AIDS outreach, mental health, and harm reduction workers. 

Their work continued because the federal government’s response to the 1998 TDRC Disaster Declaration was to only offer some homelessness funding — not housing.

As a result, homelessness worsened. Shelters were full and discrimination continued. Disease outbreaks like tuberculosis took hold. Encampments grew, and many people died. 

Blame the individual rather than the system

I remember the day in 1999 when I took Claudette Bradshaw, the newly appointed federal Minister responsible for Homelessness on a disaster tour at an emergency shelter at the Fort York Armoury. My purpose was to convince her government to re-enter the social housing field. Looking across the armoury floor, which was covered in cots and with people milling around, she expansively stretched out her arm at the scene. She said to me, “Look, these are the chronics.”

This was the first of many times that I began to hear the term “chronics.”  It was not a reference to people stuck in homelessness due to the “chronic” housing shortage. Instead, it became a term that labelled people for personal failings of usually addiction or mental illness. Homelessness became increasingly pathologized by politicians and researchers. 

The term “chronics” in Canada became conveniently linked to “Million dollar Murray.” The term was made famous by Malcolm Gladwell’s 2006 New Yorker column which chronicled the huge health care costs of Murray, a homeless, alcoholic man who frequented emergency departments. This blaming, paired with the American Housing First ideology (which Bradshaw promoted) and its 10-year plans (to end homelessness), took Canada on a neoliberal right-turn away from a social program that would ensure housing for all.

In the early 2000s something changed in homeless health care delivery. It became more medicalized, more institutional and advocacy within organizations was crushed.

I haven’t chronicled the expansive growth of the medical domination of homeless health care by physicians, I just know it happened. ICHA boasts on their website: “In less than 15 years, Inner City Health Associates has become the largest homeless health organization in Canada…”

Why we should all care

And 43 nurses just lost their job there and we should all care.

The last word goes to them. On behalf of the 43 ex-ICHA nurses, Daniela Graziano stated:

“We are the 43 nurses that have suffered a major loss. The loss was not just ours it was also the relationships we made with our patients. It was these relationships that made them feel safer to seek care and get the care they deserve.

It took a tremendous amount of work to build these relationships as we are often repairing harmful experiences caused by other sources of healthcare and oppressive institutions. This is particularly important when you are in a pandemic and the only guidance they trust is yours.

The opportunity to finally attempt to fulfill one of the greatest gaps in healthcare was, for us, a proud moment to be part of, and having these cuts is now one of our greatest disappointments, along with the 2 weeks’ notice to try to make up once again for the damage done by a system that was not created for our patients.”