Tara Kiran is a family physician at the St. Michael’s Hospital Academic Family Health Team and the Fidani Chair of Improvement and Innovation at the University of Toronto.
In Toronto, as in many other cities in Canada and the United States, the coronavirus crisis is twinned with a different crisis: homelessness.
Sometimes all it takes is one person to illustrate how the system is failing.
Miriam* has struggled with housing for years. A couple of years ago, when her landlord ended her lease, she was unable to find another apartment that she could afford. Despite days and days on the phone with central intake, she could not get into a city shelter in Toronto. She was eventually advised by a housing worker to go to London, Ontario (a city of about 400,000 two hours drive away) – where she still could not get a shelter bed. She spent several nights in a McDonald’s until she was taken in by a local church.
Fast forward to this year. Miriam returned to Toronto in the hopes of settling back in the city where she had friends and a support system. She still couldn’t get a shelter bed but was offered space in a respite centre. The conditions were abysmal – “not fit for animals” was how she put it. She began to lose all hope and became suicidal.
When she came to see me the week before the coronavirus crisis began, I felt the only safe option was for her to go to our emergency department. She was admitted to the psychiatry unit for a few days and transferred to a mental health crisis bed in the community where she could stay up to 30 days. There she regained a modicum of hope and her will to live.
But as the coronavirus crisis spiralled, she lost her crisis bed. She was asked to leave without any plan for where to go. She called central intake and was directed to a shelter that turned out to be full. Our social work team was at a loss on how to help. All excess capacity from other organizations providing crisis beds for people with mental health, addictions, or physical conditions were closed. The respite centre she had been staying at was also closed.
At the last minute she was directed to a bed at a converted community centre. She was grateful for the shelter but struggled with the conditions. Beds were within 2 metres of each other and there was no privacy. But she was doing what she could to remain positive – anchoring, she told me, on the kindness and support shown to her by our team.
Late Friday afternoon, I received an email from Miriam that she felt unwell. When we spoke on the phone, she described a new headache and cough. Even though her symptoms were mild, guidelines indicated she needed to be tested for coronavirus right away. One positive person in a respite centre or shelter could spark an outbreak. And Miriam, in her 50’s, has a chronic condition that makes her immunocompromised and at higher risk of death if she acquires coronavirus.
I asked her to go to our local covid assessment centre and provided her and the shelter staff with the instructions pulled together by our team. Take a taxi, wear a mask and gloves, ride in the backseat with the windows down. Bring your medications and some belongings because you will need to stay somewhere temporary while you wait for your test results.
She didn’t test positive. The test came back in less than 24 hours. But in the space of that time, it was unclear where she was to go if she tested positive, and whether she had a bed to go back to. She is now back at the respite centre but doesn’t have the luxury of following new guidance to self-isolate if you have an underlying medical condition.
The coronavirus crisis has magnified our crisis of homelessness.
There is not enough affordable housing. There aren’t enough shelter beds. That’s been the case for years. Now residents in shelters are made vulnerable to the rapid spread of coronavirus inherent to the close quarters. For that reason, coronavirus testing needs to be done at the first hint of even mild symptoms. But the logistics are not straightforward.
Where do patients without a home wait for results? Will they have a bed to return to if they test negative? How can they self-isolate if positive? And what happens if they do not agree to testing – or to isolation?
It was great to hear this weekend that the City of Toronto has acquired vacant hotels and rental buildings to convert to temporary shelters. There is tremendous leadership from organizations on the front-lines. It’s good to see people are working together and moving quickly – but it still seems not fast enough.
*Miriam is not the real name of the person described here. She has given permission for her story to be told.