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Welcome to She They Us, a podcast about making room in housing for women and gender-diverse people brought to you by the Pan-Canadian Voice for Women’s Housing.
Join host Andrea Reimer to hear about why Canada’s housing crisis is hitting households led by women and gender-diverse people harder and what you can do about it.
Please be advised that the topics discussed in this series can be challenging to listen to and explore topics of homelessness, abuse, torture, racism, transphobia, and drug use. Please take care while listening and if you need support, unfortunately there isn't a national crisis line in Canada, but you can find provincial crisis lines and other resources on the podcast website.
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The healthcare system is becoming a place that people are using as a warming centre. And we don't want to kick people out in the winter and we also can't have this happening. Like the emergency department was getting, you know, quite full and we're trying to help people find beds. Like talking to the frontline workers, they were on the phone trying to help people find beds. There was just nowhere to go. All the beds were full.
Welcome back to She. They. Us., a podcast brought to you by the Pan-Canadian Voice for Women's Housing. I'm your host, Andrea Reimer. I'm a former City Councillor for the City of Vancouver, an Adjunct Professor of Practice at UBC's School of Public Policy and Global Affairs, and a housing advocate who has experienced homelessness firsthand. In our last episode, we met Jill Atkey, CEO of BC Nonprofit Housing Association,
former Vancouver Mayor and current Member of Parliament and Minister of Housing and Infrastructure, Gregor Robertson, and Lisa Guerin, a current Program Manager and former tenant in supportive housing. In our discussions, we took a deep dive into some of the ways a motivated local government can help and also how an unmotivated one can hurt those most vulnerable in a housing crisis by looking at how that's played out in Vancouver.
We heard about some good progress and the impacts that had, and we also heard about how those gains are now at risk. So with that in mind, today we are discussing what is happening to those who are seeking shelter but can't find it in places that aren't building housing that is accessible for those most vulnerable in the housing crisis.
When the government fails to build housing, where do you go? When I was making season one of this podcast, a study was released about exactly that. It said that in Ontario, non-urgent emergency room visits among unhoused individuals during winter rose by 24% across the province since 2018. In Toronto specifically, it rose by 68%.
In the same period, there was no increase of those who were housed coming to the ER for non-urgent visits. I wanted to learn more, so I tracked down Jesse Jenkinson, who is a senior research associate and adjunct scientist at MAP Centre for Urban Health Solutions in Toronto. It's a research centre that's attached to a hospital led by Stephen Hwang, who Jesse works under. The work she does is mostly around hospital-based interventions for people experiencing homelessness,
and really trying to understand and improve the situation of folks when they're in the hospital and when they leave the hospital. I asked Jesse how she got into this work. It's a little bit of happenstance and a little bit of passion that I feel very lucky formed into a career, which I think is a gift when that can happen. I was doing a different project that was looking at women's empowerment programs in Africa and East Africa,
and really trying to understand whether the term empowerment was really focused on local understandings of what that meant, or if it was more of a Western approach to empowerment put on people that were there. And long story short, I was getting involved with this side project around hospital discharge, and then I just became the thing that I thought, okay, I live in Toronto and I'm here, and this is an area that people...
are aware of, but not really doing much research on that, just for whatever reason. So I just decided to make that my focus. And then I worked with Dr. Stephen Hwang, who I still work with, and he's incredible. And this is his whole area of work as well, really focusing on trying to address these issues. And so he was incredibly supportive and we just kept going with it. And he was developing interventions that I got involved with. So it kind of just snowballed from there that,
okay, this is the team, this is the work, this is what I want to do and I want to hear people's stories because when we're talking about healthcare and the health system, we talk about numbers a lot, but you really need to hear people's stories to understand what people are going through, so how we can improve things based on that. So that kind of got me in. I got really invested in this area of work and it's been really challenging and depressing,
and invigorating as well because I think there's lots of pathways forward. We are going to talk about what this area of work is and why it's depressing as well as the original reason I contacted her. But first, a few key concepts. I asked her to explain what a hospitalization is. I thought I understood that term, but it turns out I didn't. And this is going to become important in a minute. Yeah, so if somebody comes into the emergency department,
and then they're seen in the ED by a doctor. So they get triaged and they're seen in the emergency department. A hospitalization is only if the emergency department decides that they actually need to be admitted for longer care. So that would be somebody who's actually admitted to the hospital. They're moved onto a different unit like surgery or general medicine or cardiology, whatever their specific healthcare might be. But a hospitalization and a hospital admission does not include emergency department.
Okay, with that, we are ready to explain what Jesse's work is, and it is both going to blow your mind and help you understand the challenging and depressing parts of Jesse's job. So for example, in Ontario right now, all hospitals are mandated to code for people, for patients who are experiencing homelessness. So there's a homeless code that gets reported and it gets reported back to ICES, which is a big data pool all over the country, administrative data.
We don't have that same mandate for race or gender. So right now hospitals are not mandated to record and report on race or gender. And the challenge with that is that we then don't have administrative numbers, numbers from across Canada to say, okay, we have this number of patients. Like I think in 2022, 2023, there were 30,000 hospitalizations across Canada for people who were homeless, coded as homeless. 30,000. That's huge. Just, you know, as homeless.
I am astounded by this number, but also know that it's likely an undercount. I asked Jesse about this. My colleague, Lucie Richard, did a validation study, which means that she was looking at this coding to try and understand, are we capturing people experiencing homelessness in our coded data and our administrative data? And in the validation study, for the most part, it's pretty good. It's not perfect. There's a lot of problems with our coding and capture.
But what we are finding is that we're not doing a very good job of capturing women who are experiencing homelessness, and we're not doing a very good job at capturing based on race. So we don't really know any of those numbers. And we did a validation study using our own data, so to try and really understand. The validation study found that it could be an overcount, but it could also be an undercount.
One of the more frustrating things about homelessness generally and women and gender diverse people's homelessness specifically is how little data is collected, which we will dive into more in a minute. In the meantime, that's actually not the most astounding thing about these numbers. Hospitals are acute centers, so they're emergency places where if you go in for an acute issue, it's not something that your family doctor can take care of if you're lucky to have a family doctor these days.
It's surgery, it's different things, and hospitals are meant to address those acute issues, get you the term they use as "medically optimized" or like in a state where you could recover and recuperate outside of the hospital, and then discharge you with follow-up supports, with follow-up appointments, maybe you have home care coming to the house to check on you or do wound dressing and changing your wounds, medication management, things like that. So a lot of it is around, let's get you
fixed up and then let's discharge you to recover at home. Because the idea is also that the longer you stay in hospital, the more susceptible you could be to other infections and things like that. So it's not great to stay in hospital. So it really is geared around this idea that you have a place to go to, whether it be long-term care or rehab, physical rehabilitation programs or your home that you'll have a space to go to, that you have support networks who can help take care of you, help transport you to appointments,
that you have medical advocates, people in the hospital who can help get you home when you're leaving, all these kinds of things. That's what the system's built on. The reality is that we don't have good systems and processes for when that assumption is gone, when that assumption isn't true anymore. We have a lot of individuals trying to do the best they can, but we don't have any systems in place to support this. So, say I go in for surgery, I go home and all of this stuff gets supported.
Right now, if you go in and you don't have a home to go to, what is likely going to happen is that you're discharged to a shelter. Shelters aren't set up to support people with complex physical and medical needs. They're not mandated to do that, and they're not medically resourced to do that. Some have some medical supports, but, you know, there's nobody that can help you self-transfer, meaning, like, if you need help in the shower or anything like that, that's not what they're set up to do. There are supports that can be organized to
go visit a patient at a shelter, but it's very complicated. It doesn't always happen. Sometimes some of those individuals are not comfortable going into the shelter. There's lots of things that kind of fall apart. So shelters aren't great for that. And the street is obviously a terrible discharge destination for somebody who has an open wound that needs wound change or mobility challenges. So then what we end up seeing is a lot of those folks are coming back into the emergency department.
Just to give a little bit of a statistic perhaps, we did a study at the hospital, we just pulled some administrative data and we found that we had a 27% readmission rate within 90 days of hospital discharge and that's very high. So within 90 days, 27% of the people who were admitted to general medicine, just the general medical unit, were readmitted within 90 days. So that is alarming. That means people aren't getting the care they need in the community. And then like you said, they're just...
They're coming back to the hospital. They're coming back to the ED. So we have... Our costs in the hospital are going up. People's health is suffering. They're not getting healthier. They're not recovering. They're not able to rest. And we're getting a lot of repeat readmissions, which is kind of a sign that something's broken and it's not working right now. I asked for clarification on the 27% that Jesse referenced. That was just for unhoused. And that's higher than for people who are housed, quite a bit higher.
These are shocking numbers and behind them are piles of resources in health care that could be saved if governments simply housed people. It's not even the reason I originally got in touch with Jesse for, which was this research. That was led by my colleague Lucie Richard and included Stephen and Carolyn Snider and a bunch of other people who work at St. Mike's in Unity Health Toronto. Carolyn Snider was the chief of the ED at the time.
And she got in touch with us saying like, we are seeing so many people who are coming in who don't seem to need healthcare specifically. They're not coming in for a specific healthcare reason or if they are, it's something that's not very serious. And is there a way that we could figure out how to like... There's just no shelter space, there's no warming spaces. They're coming in to get out of the cold. So how are we gonna enumerate this? How do we show this in numbers?
So we examined monthly ED visits among people experiencing homelessness. Really, we examined it over a number of different winters. By the way, when Jesse uses the term ED, she means "emergency department." And we were trying to understand if there was an increase in the winter of 2022-2023 compared to previous years. And what we found is, and this is across all of Ontario.
And so we did find that there was a 27% increase for non-urgent ED visits that winter in particular compared to cold weather seasons in previous years. But in Toronto, there was a 70% increase of people coming in for non-urgent ED visits. And that was astounding.
For reference, in raw numbers, a 70% increase translates into 5,582 visits per 100,000 people. Back to Jesse. And the reason we also did that was we wanted to present that to the city to say, we know you are doing what you can at the moment to try and find more spaces, but the hospital system is becoming... the healthcare system is becoming a place that people are using as a warming centre.
And we don't want to kick people out in the winter and we also can't have this happening. Like the emergency department was getting quite full and we're trying to help people find beds. Like talking to the frontline workers, they were on the phone trying to help people find beds. There was just nowhere to go. All the beds were full. So these are people who are actively seeking space. They don't want to be outside. They're not choosing to be in an encampment or anything like that. They do want to find a space inside and they had absolutely nowhere to go. So that was a really powerful
way to figure out, okay, how can we show the city that there's an issue here that we actually don't have enough space and there is a demand for it. And it's like leaking over into the hospital system. We're now becoming a warming centre for folks and this doesn't really work for anybody. I'm reminded of Jill Atkey's comments in episode three this season. "Granola bars and referrals to nowhere."
But while the absurdity of using health care resources as a bandaid for housing is hard enough to understand, Jesse tells me something which makes it even more absurd. And then following on that, again, a paper led by Lucie Richard, I would say her name a million times. She's brilliant. That looked at cold weather related injuries. So that was the other thing we were trying to see. Okay, if people are outside and they don't have enough space, are people being harmed?
Is there more harm to people who are unhoused in the winter than there is to people who are housed? To really show that being outside is really bad for your health in the winter time seems obvious, but again, putting numbers and evidence towards policymakers to show it. So we looked at things like different things around cold weather, exposure, hypothermia, foot injury, things like that.
And what we did find was that, yes, it was higher, it was disproportionately higher for people who are experiencing homelessness compared to their housed counterparts. But when you compare housed women to unhoused women, it was significantly higher. It was 20-something percent higher than compared to housed men and unhoused men. And so there's something happening, as we know, about women's homelessness that
puts them in a uniquely vulnerable position where there's greater inequity. So for us, that felt like, okay, we don't have a ton of data on women experiencing homelessness or gender diverse people experiencing homelessness. This is one way we can use these administrative data pieces to really highlight like, there's a deep inequity here. So we really need to figure out how we support that population because they're suffering. This is staggering to hear.
I asked her if there were other places in the research she's seen where the same level of discrepancy of outcomes for women or gender diverse people exists. ⁓ I have so many things to say about that. I mean, we know that women's experience of homelessness and gender diverse folks' experience of homelessness is different. It's a lot more hidden. Oftentimes people might be couchsurfing or staying with friends and family or in abusive relationships or even relationships that
they don't want to be in, but they can't leave because they can't afford to. You have a lot of women who are the head of single households and it's really hard to take care of kids and all this stuff. So you have people coming in, maybe they don't want to disclose their housing status to the hospital system. Maybe they're scared of their children being taken away. Maybe they've had bad prior experiences. Frontline staff in the hospital don't necessarily know someone's unhoused.
So then they can't organize supports. So again, it's about really figuring out how do you make people feel comfortable? How do you find out that information in a safe, trauma-informed way that creates a safe space for people to share some of their more vulnerable pieces that would be important for supporting them when they leave the hospital? There was a report that came out from Toronto Public Health. They reported that from January to June in 2024, so the first half of 2024, there were 135
deaths of unhoused people in the city of Toronto. The median age for the men in that group was 50, which is incredibly low considering in the general population it's 78. The median age of the women who died was 36. 36 years old. That is significantly younger than me and it's wild. And the number is 85 for women in the general population. So the disparity here is huge and...
It's just, there's not enough attention on this. As advertised at the beginning, this is all a little challenging and depressing. I asked Jesse how she copes with it. I don't work frontline and sometimes I think everything that I don't because I don't know that... I would burn out. So I think it's amazing that people continue to do it. But it's really, really hard when you're
telling people over and over again, I'm so sorry, there's nothing else I can do. We have nowhere to send you. I can't find any place in the city that's open. And then maybe it's been two days or three days and you still can't find a place for folks. So it's hard. I mean, there's programs... like in Toronto, Dr. Hwang started the Navigator Program, which is now also implemented in Vancouver at St. Paul's.
But it's a program of case managers that meet people who are unhoused when they're admitted to the hospital, supports their discharge plan and everything, and then follows them into the community. And we're just writing up some results from the research on that. But anecdotally, talking to people and talking to the workers, the program is huge. It's seen as such a benefit by hospital workers because they know that there's someone who
has special knowledge in this area and has connections in the community to help support people who are leaving the hospital, so it alleviates some of their moral distress because they know patients are being better taken care of. The clients, the patients who are part of the program have reported really good things. They have a person who's their advocate, who's their support, who helps coordinate a lot of their care, who will come pick them up and bring them to follow-up appointments and things like that.
Who tries to get them into housing and working on all those pieces, kind of like their rock, in a way. And the community service providers love it. They're like, there's this program at the hospital, there's somebody I can call and I can talk to them and I know where my client is. And I work with that person, with the counselor to support our client together. We do a coordinated effort. So it's been a great program so far and it's, we're hoping... it's continuing as of now. It's not rocket science,
which is the challenging part of a lot of these things. It's like, ⁓ you have a stable person in your life who has a lot of access to these different resources and can connect you. And they're there to support you, to get you on your way and get you stabilized. Like, get your taxes done, get your ID replaced, get all those things that you need to get into housing, to better support yourself in the shelter system and things like that. And it's just about finding
hospitals and governments that see it as a priority and then are willing to fund it. Because I think that's... you said that earlier, it's the funding, it's not just the ideas, but securing the funding is key. So is there a healthcare solution to housing? I think there's often an argument of why doesn't the hospital hold people longer? And I think it's a fair argument because it's really hard to understand how discharge to the street is even an option.
And I think what we're seeing is anyone who's been to an emergency department in the past little while... I know I was there a couple months ago. I waited for 15 hours total to just get discharged from the ED. Like our system is struggling quite a bit across the country. So there's an immense amount of pressure to move people from beds, to discharge people when they're physically able to leave the hospital, when they're stable, when they're technically able to go. And a lot of the hospital workers will push back and do what they can to try and
get an extra night, an extra two nights for people when there's no discharge destination. But it's really hard. They experience a lot of pressure because you also have a lot of people waiting in the emergency department to come up who need a bed as well. So it's a really fine balance about prioritization and, you know, trying to protect people who have nowhere else to go while also caring for the people who are waiting. asked Jesse what her dream is. What would safety look like for the women and gender diverse people that she's trying to give a voice to
beyond the numbers? We need deeply affordable housing. We need safe spaces for folks to go. We also need better support. So, you know, when we're talking about, like, for example, women and gender diverse people, we need better systems in place to support these groups. I would love to see better resources in the community. They've been slashed so much over the decades.
And we can't say, well, people are supposed to recover in the community and then drain the community of any ways to support folks. Shelters, not just shelters, drop-ins closing. We actually have some more shelters opening up. But the conversation quickly turned back to numbers. It's wild that we don't have better numbers of women and gender diverse folks who are unhoused that we can actually report on a lot more of this data.
All that keeps coming to my mind is we need to do a better job of protecting these groups. We need to do a better job of creating spaces in the community that people can go and be safe. I was talking to somebody for a research study and she was talking about a whole bunch of things, but one of them was about her experience with substance use and that when she became homeless because she had to leave this relationship, she was living on the street and she started using substances to stay awake at night so that she wouldn't be assaulted.
So it was a safety strategy. And then over time, it became an addiction because she couldn't stop using. It was really hard to stop. But when people are, when their situations get worse because they're trying to protect themselves, then you know, we've really failed as a society to protect them. Because that shouldn't be happening. And so, you know, the hospital system is a place where
people come in, it's a place where we can intervene maybe and have the trajectory when people leave the hospital, at least be a bit better, find better resources, connect them to better care. There is opportunity there that might not exist in other spaces. As we close out today's episode, I can't get the numbers Jesse has shared out of my mind. They are shocking, but even more shocking is how few people know about them. You can make a difference by sharing this episode.
There's one group of people for whom even hospitals aren't a last resort for safe shelter, and that's trans women and gender diverse people. In the next episode of She. They. Us., we will talk to housing advocates Jodi Gray and Martha Singh Jennings about some promising efforts to create safe housing for trans and gender diverse people in two of Canada's largest cities, Toronto and Vancouver. Every time I leave home, I think about where I'm going,
if it's safe or not, what I might face when I get there, what I would do if something happened, make sure that I could get out of the situation, know if there's any allies that'll be around me. So I have to think about that everywhere I go. Thank you to Jesse and to you for joining us. I'm Andrea Reimer on behalf of the Pan-Canadian Voice for Women's Housing.
Another Everything Podcasts production. Visit everythingpodcasts.com, a division of Pattison Media.