Shelter From the Storm
November 17, 2014
After a day of heavy rainfall, the Downtown Eastside is strangely deserted. Apart from the soup kitchen lineup at the Carnegie Centre and the flea market hustlers along Hastings, the quiet is uncanny, as if the street people-who for decades have made this area one of North America's largest open-air dormitories-decided to…just head indoors, complying with Mayor Gregor Robertson's long-standing pledge to end street homelessness by 2015. "I guess everyone's staying in," muses Dave Cunningham, a writer and activist who guides scientists studying the area's mix of the dispossessed and the desperate. "Homelessness is getting to be a lost art around here."
Is this it? Has the mayor hit his mark early? Over the course of an hour searching a large area around Oppenheimer Park (before this summer's tent city), Cunningham finds just a few people willing to admit they're actually homeless. Gordon, 51 and pushing a shopping cart past the First United Church Mission, stops to talk. Describing himself as a "psychiatric survivor," he lists his favourite writers on the rights of the mentally ill, starting with Thomas Szasz's The Myth of Mental Illness. Gordon refuses to be housed, and with his gold-rim glasses, dead-level gaze, and sobriety, he does seem convincing. He aims his rationale squarely at Robertson's anti-homelessness strategy, which he labels "aggressively coercive."
"I don't want a damn thing from the mayor," he fumes. "I'd rather sit on a pitchfork."
Immediately following his election six years ago, and desperate to tone up the city for the 2010 Olympics, Robertson began pushing Vancouver to eradicate its most visible human blight. In 2008, according to that year's official homeless count, the city had 2,660 homeless people, up 60 percent from 2005. (It's now at 2,777.) Backed by the province's Assistance to Shelter Act, a hastily passed law disparagingly dubbed the Olympic Kidnapping Act, he began sweeping people into emergency shelters. Then, pushed by an agreement brokered by the Vancouver Games Olympic Committee, Victoria, and the city (backed with $380 million from Ottawa), Robertson acquired and renovated 1,800 units of existing rental housing to begin permanently housing the homeless.
It was a bold effort, one that as the Olympics wound down was only just hitting its stride, integrating police, psychiatrists, social workers, and life coaches to deliver permanent supportive housing-including "medical, psychosocial, and rehabilitation services"-to thousands of street people in scores of low-rent buildings and private apartments. Four years after the Olympic torch left town, the International Olympic Committee points to Vanoc's attack on homelessness as a marquee legacy of the Games. All of which would sound promising to almost anyone in the face of the Downtown Eastside's palpable suffering-anyone except many of those it's most meant to help: for Gordon, at twilight with nowhere to call home, it amounts to a sinister and repressive formula aimed at gentrifying the DTES while warehousing and pacifying its most problematic denizens. "If I take their housing, they'll force me to see a shrink," he summarizes with mounting shrillness. "Anything forced is wrong."
Amidst this remarkable transition in civic thinking, and the gigantic experiment in social engineering it has triggered, the question remains-how do you accommodate the hundreds of people who hate being corralled?
Robertson, propelled by police reports demanding action on homelessness, substance abuse, and mental illness, has responded by reversing the provincial government's decades-long push to deinstitutionalize thousands of patients from Riverview, the giant century-old psychiatric hospital in Coquitlam that finally closed in 2012. The pendulum has now swung back toward institutionalization because, according to a recent provincial review, "In addition to the significant social and health risks facing this population, there is also a growing public safety risk to bystanders." The reaction against deinstitutionalization was underway even before Riverview closed, though. Flushed onto the streets in the 1990s, the homeless, the addicted, and the mentally ill are now being ushered through shelters, courts, and hospitals and into specialized long-term care facilities: part prison, part hospital, part retirement home.
The Salvation Army Grace Mansion is an 85-unit provincially funded "transition housing" facility on East Hastings where formerly homeless residents must adhere to "personal development plans" featuring zero tolerance for substance abuse. On a freezing night last winter, Cunningham-veteran of many anti-poverty protests spotlighting the plight of the homeless in the lead-up to the Olympics-eyeballs the facility's high-tech security barrier charily. As part of a team of UBC researchers, he recently interviewed scores of formerly homeless residents in high-security facilities like this. Many of them describe the mayor's "supportive" housing strategies as a mix of intensive pharmaceutical treatment, police-backed domestic containment, and blunt reinstitutionalization of the same people previously discharged from mental wards. And for the very toughest cases? Last year the province promised to finance 300 "long-term and secure mental-health beds" in rapidly expanding sites like the Burnaby Centre for Mental Health and Addictions, which opened in 2008. "The Olympics led investors and the government to finally see that housing the homeless costs barely more than leaving them to die on the street," Cunningham reflects. "But these are difficult, rebellious, and often reckless people with extremely complex needs. They may not want to be shoehorned into the official plan. Let the real games begin."
It's 11 a.m. and there's a discernible-possibly deniable-whiff of alcohol on Mary's breath. But if she's had a drink, who could blame her? She's got ample cause for both celebration and consolation: she's just landed a one-bedroom at Maurice McElrea Place, an 81-unit "abstinence-based housing" facility operated with government financial support by the Union Gospel Mission on East Hastings. The apartment is the first clean, safe, comfortable place she's had for decades, in a life that started in Newfoundland in 1957 and has been a litany of pain: severe sexual and physical abuse as a child, three children put up for adoption, a clinical diagnosis in 1997 of "severe disassociative disorder," housed afterward in a high-surveillance BC Housing facility that proved "too oppressive." Next, housed for more than a decade with a deepening dependency on prescription opioids and alcohol in a hotel on East Cordova with as many as 10 addicts per room. Then, during a spell of homelessness, she was brought by an alcohol treatment worker to the mission. "The alcohol and drugs stop me from reliving the past. It's a way of recovering," Mary explains. "Of searching for love and companionship." But even so, her place at the mission is conditional on abstinence, and she's not in alcohol treatment there. Sobriety is an extremely, perhaps impossibly, tall order. "I don't miss it," Mary gamely insists about the alcohol and drugs. "I want to get back into school, get my Grade 12, and become a nurse."
Housing the homeless is an exercise requiring delicacy, patience, skill, and considerable capacity to accept failure, says Jeff West from his perspective behind the plate glass walls of the reception room at the Bosman Hotel, a rundown hotel on Howe Street. It's not about abstinence; it's about reducing harm. Fusing elements of a hotel check-in, psych ward, soup kitchen, and security checkpoint, West's workspace serves as command post for a now-completed multiyear experiment studying 100 of what he calls "the absolutely homeless." Starting in 2011, when the Bosman was leased by the Mental Health Commission of Canada as a major research location within a $110-million nationwide study of homelessness, West presided over a complex ecosystem in which the Bosman's formerly homeless residents-the vast majority of them suffering from mental-health disorders such as schizophrenia and depression alongside addictions to varying combinations of crystal meth, crack, heroin, illicit pharmaceuticals, pot, and alcohol-were attended by nurses, social workers, physicians, psychiatrists, and employment coordinators.
Along the way, the residents were surveyed and studied by teams of SFU scientists probing their responses to housing and help. Meanwhile, in tandem with the Bosman study, the scientists tracked a matching number of formerly homeless people housed in private apartments. And, in order to be able to compare the lives of the experimentally housed homeless with the lives of the still homeless, the SFU scientists tracked a third group who were recruited into the study and then left on the street without help. "I guess it really comes as no great surprise that the ones left homeless don't fare nearly so well as the ones who get apartments or hotel rooms," says West as he ladles soup into paper cups and passes them to residents through an opening in the barrier. "The scientists referred to the ones in the study who didn't get housing as the ‘treatment as usual' group. I guess you could say they lost the lottery."
Putting aside the question of whether the federal government's study was really needed-"$110 million to prove that homelessness sucks, and not a single permanent home created," mutters Chris Van Veen, clinical team leader at the Bosman who helps West cope with residents' demands for medication, needles, food, and assistance-and the ethics of the decision to recruit a large group of people into the study and then leave them stranded (which the commission itself acknowledges was troubling to many researchers, who consequently opted out of the study), the Bosman residents say they undoubtedly benefited. "It's kept me alive and I feel secure here," says Maddog, 54, in blood-stained white jeans. "Healthwise, it's been a big improvement. I get the medications I need for my HIV and my heart disease. And I could probably get off heroin here."
Before being recruited for the experiment at the Bosman, Maddog, who's been addicted to heroin since he was 19, had been living in a tent in Surrey for almost two years. Before that he'd been at the Biltmore Hotel on and off since 1986. At the Bosman, he feeds his heroin habit through welfare, collecting recyclables, and reselling Oxycontin pills. As to what lies ahead-the fate of the study's housed participants remains unclear once funding runs out next month-Maddog isn't sure: "Maybe back to my tent. If I wasn't here at the Bosman, I would have been in jail a few times. I never seem to last anyplace more than six months. Because I won't put up with shit. But the thought of being homeless again scares me."
Quantifying the costs of and savings from housing the homeless is an imprecise art, but according to Anita Palepu, an internal-medicine specialist who treats a steady flow of homeless patients at St. Paul's Hospital, "there's a sizable group of them who are very high users of emergency health care. And we know that when they are housed, the number of hospital visits is substantially reduced." As Vancouver's homeless population ages, she notes, they increasingly suffer from chronic diseases such as diabetes, and heart and respiratory conditions, alongside TB, HIV, and hepatitis. "The burden of disease is very high, and these patients are very challenging. These are patients who come in late, once their illnesses are well developed on the street or in shelters and much harder to treat. And then when it's time for them to leave, we find ourselves discharging them back into shelters." With emergency-room beds estimated to cost up to $1,000 a day, Palepu explains, home-based health care is extremely cost-effective.
As lead author on a study using data from the Bosman that found that stable housing produces equally positive outcomes for addicted and non-addicted homeless people alike, Palepu has concluded that the mayor's brand of "assertive" care-especially when it enforces abstinence and zero tolerance-may be problematic. Her extensive medical experience with the homeless has taught her that "these are patients for whom regimented spaces are very hard to be in." Aggressive enforcement of treatment produces backlashes, she warns: "Many patients will leave against medical advice."
That's a theme for Jeff West, the Bosman project manager, as well. Blending police with psychiatric and social services is "a very new idea that seems sexy to everyone, especially politicians and property developers," he explains before noting that the Vancouver police department strongly promotes this despite having little expertise in mental-health care. "Many of these people have complex problems like schizophrenia. Having a cop arrive at their apartment door with the spiral-wire earpiece and a gun is the last thing they need-no matter how many nurses and psychologists they have in tow and no matter how many antipsychotic pills they push. ‘Assertive' might sound like a good word to the police and politicians, but for paranoid folk it spells fear. And that's a big reason so many of them remain homeless."
Vancouver's annual homeless count this year supports West's perspective on this approach. Worryingly, although the total number of homeless has been roughly stable since 2005, the number of people shunning the shelters has more than tripled since 2011, according to the Greater Vancouver Regional Steering Committee on Homelessness.
Thomas Kerr, director of the Urban Health Research Initiative, which has tracked drug use and health patterns in the DTES since 1996 and has recently been probing linkages between housing and drug use, echoes West's concerns. Long-term UHRI data confirms, Kerr notes, that homelessness and unstable housing are associated with increased risk of HIV infection, difficulty accessing health care, and poor adherence to HIV treatment. But in a recently completed study, he and a research team including Dave Cunningham found disturbingly coercive conditions in a series of "supportive housing" buildings for formerly homeless women. "Limited guest privileges in one's own home were seen by the women as a violation of their rights as rent-paying tenants," Kerr and his team concluded. "Women also voiced concern that police have in the past been able to access the guest logs, where all their visitors are registered, without having to go through the appropriate legal procedures. Women reported that their privacy and tenancy rights were compromised by daily room checks and the ability of staff to ban residents from the building for hours or days for noncompliance with the rules of the buildings."
The study's findings, Kerr adds, "caution against a tendency towards the surveillance and medicalization of women living in poverty in the context of publicly funded housing programs. These threats to privacy and confidentiality are particularly damaging for the most marginalized women who face stigma and criminalization due to sex work, drug use, and HIV."
From his stool in the Bosman reception area, Jeff West offers a blunt warning. "They've integrated a suite of very coercive methods into their approach, and the potential for backlash is significant." Maddog, sitting on a nearby countertop, summarizes his thoughts more sardonically. "If the police show up at my door," he quips with mock-rueful sincerity as he scratches the lesions covering much of his heroin-ravaged torso, "I'll just tell them I've done nothing wrong."