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Dawn Hill, photographed outside her home in Toronto, participated in a ground-breaking study at St. Michael’s Hospital, spearheaded by Dr. Stephen Hwang, Director of the hospital’s MAP Centre for Urban Health Solutions. It’s one of several initiatives aimed at improving the health of people who are homeless or vulnerably housed.Thomas Bollmann

After years of living in shelters and other precarious housing, Dawn Hill found permanent refuge and the mental-health support she needed after being chosen to participate in a ground-breaking study based at St. Michael’s Hospital.

Her tiny basement apartment in Toronto’s east end is a haven, a place to finally call home.

Dawn (not her real name) spent her early teenage years in group homes – which, she says, “had no patience” with her behaviour, caused in large part by undiagnosed depression and obsessive-compulsive disorder. By 16, she was on her own, working however she could to earn a living.

Her greatest sorrow was losing custody of her son and daughter 15 years ago, due to her mental-health challenges. “That was the worst thing that ever happened to me,” she says. “I lost my kids, and I lost my way.”

Recruited while she was staying at a shelter, Dawn, now 45, was chosen in 2011 to participate in At Home/Chez Soi, a large-scale randomized controlled national study to evaluate Housing First, a solution designed to end chronic homelessness among people with mental illness.

Launched and led in Toronto by St. Michael’s Hospital’s Dr. Stephen Hwang, it is one of several initiatives he has spearheaded aimed at improving the health of people who are homeless or vulnerably housed. Director of the hospital’s MAP Centre for Urban Health Solutions, Dr. Hwang is one of the world’s leading researchers in the field of homelessness, housing and health.

He joined St. Michael’s 24 years ago, as its first research scientist focused on the social determinants of health. Over the years, he says, the hospital has developed into “an international powerhouse” in the field. “It’s been a remarkable transition,” he says.

Dr. Hwang, who is also St. Michael’s Chair in Homelessness, Housing and Health, explores the intersecting health crises that affect people who lack adequate housing, particularly relevant today as COVID-19 turns a spotlight on the problems of homelessness.

There are an estimated 8,000 to 10,000 people experiencing homelessness in Toronto at any given time; shelters run at 98 per cent occupancy and waiting lists for subsidized housing can stretch to more than a decade. More than two-thirds of those experiencing homelessness are affected by mental-health and/or substance-abuse issues.

In the past six months, health and government agencies at every level have taken rapid action to alleviate homelessness, in a bid to slow the spread of COVID-19 in shelters and encampments. Empty hotels have been repurposed into temporary housing, and cities have created self-isolation facilities at unprecedented speed.

“COVID-19 has highlighted the fact that not everyone has the same opportunities to be healthy,” says Dr. Hwang. “Housing is a great example of that. The risk for homeless people [for getting the virus] is 20 times higher than for the average person. Those who are homeless can’t stay at home when they’re sick. Any outbreaks in this population can have wider implications for controlling the pandemic.”

Homelessness typically goes hand in hand with many other disadvantages, Dr. Hwang points out. “The factors that determine whether people are healthy are social and economic,” he says. “Things like education, income, meaningful work, access to nutritious food, healthy communities, and safe and affordable housing. We don’t pay sufficient attention to that.”

One of Dr. Hwang’s current research projects, COVENANT, is a longitudinal study to map out and, ultimately, predict the trajectory of COVID-19 among 700 people experiencing homelessness in Toronto.

Tracking the evidence of infection, as well as participants’ interactions with the health-care and shelter systems over the course of a year, the real-time data will help in understanding how to prevent, detect and manage the virus in this high-risk group; and will inform and improve COVID-19 responses in cities across Canada.

Most recently, Dr. Hwang launched Beyond Housing, a program which not only aims to improve the process of matching people who are chronically homeless with permanent housing, but to provide them with the appropriate community and health-care supports to help them stay housed. So far, Dr. Hwang is working with the City of Toronto, the Toronto Alliance to End Homelessness and community agencies on the pilot initiative.

“If we really want to make a difference in the social determinants of health, we need to think outside of just health care,” Dr. Hwang explains. “We need to develop partnerships and collaborations with a broad range of community and government agencies and advocacy organizations. We need to work together to address problems upstream, before [people] get to the Emergency Department.”

For Dawn, St. Michael’s Hospital’s outreach was life-changing. Today she and her children are reunited. Her son rejoined her six years ago, and this year, her teenage daughter made the same choice. Dawn is now a published author of short fiction.

“I thought I’d be shelter-hopping for the rest of my life,” she says. “I felt lucky [to be in the study]. I thought, [it’s] giving me a chance.”

Of course, life still has its stresses, she says, but adds: “I have my kids. I’m good.”

A map to healthy cities

MAP Centre for Urban Health Solutions at St. Michael’s Hospital is a world-leading research centre with a mission to create a healthier future for all.

Director of MAP for the past five years, Dr. Stephen Hwang’s ambitious goal is to “create cities where everyone can thrive; where the economic and social environment allows people to be as healthy as possible.”

Working with a wide range of community organizations and policy makers, MAP develops and tests interventions designed to reduce inequities, and make the results scalable in cities across Canada. In 2019, the Centre received federal grants totalling more than $18-million to further its valuable work.

“A crucial part of our mission is to see that our research is translated into reality; into better and fairer programs, policies and systems”, says Dr. Hwang. “Ultimately, this research is improving people’s lives.”


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