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Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 2 - Evidence - Meeting of December 6, 2007

OTTAWA, Thursday, December 6, 2007

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:47 a.m. to examine and report on the multiple factors and conditions that contribute to the health of Canada's population, known collectively as the social determinants of health.

Senator Art Eggleton (Chair) in the chair.


The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology. Today, we will be examining poverty, homelessness and housing.


Our committee has two subcommittees, one on population health and the other on the major challenges facing our cities. Given that poverty, housing and homelessness are issues common to both subcommittees, we decided to meet as a full committee. We are also building upon some previous work done in the Senate in the matter of poverty, most notably the 1971 report headed by Senator Croll and the 1997 report by Senator Cohen, which was entitled Sounding the Alarm: Poverty in Canada.

At the same time, our study is complementary to the work being done by the Standing Senate Committee on Agriculture and Forestry, which is chaired by Senator Fairbairn. At the request of Senator Segal, they are dealing with the issue of rural poverty.

That is the context. Today we will focus on homelessness with our four panellists.

Dr. Elizabeth Votta is a project manager and writer with the Canadian Population Health Initiative and the lead for the recent report entitled Improving the Health of Canadians: Mental Health and Homelessness.

I might add that Senator Keon, who has arrived, is the chair of our Subcommittee on Population Health.

Rebekah Peters is a nurse practitioner and clinic director of Saul Sair Health Centre within the Siloam Mission in Winnipeg. This clinic opened earlier this year and is funded by a substantial donation from a Winnipeg pharmacist. It is the first health clinic operating within a shelter for homeless people.

Deborah Kraus is an independent consultant with more than 20 years in housing and research. She is co-author of Homelessness, Housing, and Harm Reduction: Stable Housing for Homeless People with Substance Use Issues.

Tim Crooks is the executive director of Phoenix Youth Programs, a Halifax-based multi-service agency for young people from the ages of 16 to 24. The organization runs a shelter for homeless youth, supervised housing for youth learning independent living skills, a learning and employment centre, and practical supports including showers and laundry facilities.

Welcome, all of you.

Elizabeth Votta, PhD, Program Lead Reports and Analysis, Canadian Population Health Initiative: Thank you for this opportunity. Mental health is more than the absence of a diagnosed mental illness. According to the World Health Organization, WHO, mental health is ``a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.''

Individual, social, economic, cultural and other factors can shape patterns of health in numerous and complex ways. The genes we inherent from our parents and what we learn as children may matter; so may our education, income and employment levels as well as our social relationships, housing and neighbourhood characteristics. By focusing on specific groups in the population, such as Canada's homeless, we can further explore these links. Some of these links were explored in Improving the Health of Canadians: Mental Health and Homelessness, a report released on August 30, 2007, by the Canadian Population Health Initiative, a part of the Canadian Institute for Health Information.

No one knows exactly how many Canadians are homeless. Although definitions and counting methods vary, data assembled for the report suggest that more than 10,000 people are homeless on any given night across Canada. Further, data also show that mental illness and poor mental health are more prevalent among the homeless than among the general population. But which comes first? Some studies suggest that mental health and mental illness can worsen with continued homelessness. Other research has found that people with poor mental health or mental illness are at risk of becoming homeless. Further, as noted, individual-level factors and broader social determinants of health, such as income and education levels, separately or in combination, are linked to both mental health and homelessness.

Increasingly, studies involving the homeless have had a mental health focus. Compared to the general population, various studies show a high level of poor mental health among the homeless, where this is measured by higher levels of stress, lower perceived self-worth, less social support and less effective coping strategies. For example, a Kitchener- Waterloo study found that street youth were more likely to engage in substance use and self harm as a means of coping. Non-homeless youth, on the other hand, were more likely to cope by talking to someone they trusted or through productive problem solving. One Ottawa study found that homeless male youth reported an overall stress level that was more than two times higher than that reported by the group of non-homeless male youth. Another Ottawa study found that 15 per cent of adults living on the street reported receiving no social support.

Of note is the fact that research also shows that factors such as poor coping, high stress, low self-esteem and low social support are associated with suicidal behaviours, addictions and symptoms of mental illness. For example, research involving homeless male youth shows that those who coped by avoiding problems and withdrawing from social networks were more likely to report high levels of depressive symptoms, behaviour problems of both an internalizing and externalizing nature — such as withdrawing, somatic complaints and aggressive behaviours — and both suicidal thoughts and attempts.

Outcomes such as these have themselves often been the focus of research involving the homeless. Compared to the general population, various Canadian studies show higher prevalence levels of alcohol and substance abuse disorders, depressive disorders, psychotic disorders such as schizophrenia, and both suicidal thoughts and attempts among the homeless. Published reviews indicate that homeless individuals with both a mental illness and substance abuse disorder, known as concurrent disorders, are likely to remain homeless longer than other homeless people.

New data from the Canadian Institute for Health Information, CIHI, presented in the report also indicate that homeless persons are more likely to use hospital services, including in-patient and emergency visits, for mental disorders. In contrast, mental disorders are not among the top five reasons for emergency department visits and in- patient hospitalizations among the general population. Data show that 35 per cent of visits by homeless persons to selected emergency departments, mostly in Ontario, were related to mental disorders. Of these, 54 per cent were for substance abuse and 20 per cent for psychotic disorders. In comparison, mental disorders accounted for 3 per cent of visits among the general population. Similarly, 52 per cent of in-patient hospitalizations among the homeless were for mental disorders. In comparison, mental disorders accounted for 5 per cent of hospital stays among the general population.

Given the prevalence of compromised mental health among the homeless and the numerous factors affecting both mental health and homelessness, the Canadian Population Health Initiative, CPHI, report examined the effectiveness of two types of initiatives: housing and community mental health programs. Our scans of the policy and program landscape found relatively few evaluations for long-term health outcomes. That said, we did find evaluations indicating the effectiveness of some programs at both stabilizing mental health problems and helping the homeless achieve stable housing. For instance, research suggests that some housing programs, such as those with a Housing First approach, are effective at helping the homeless achieve stable housing. Housing First approaches provide clients with housing first and then any necessary training or treatment they may require, on a voluntary basis.

A number of community-based mental health programs provide support to homeless persons with mental health problems. Some programs are effective at helping homeless individuals achieve stable housing, obtain greater satisfaction with their overall well-being, and require fewer hospitalizations and emergency department visits.

To conclude, mental illness affects a broad range of Canadians. Not all of those people, however, are or will become homeless. Further, many people who are homeless have not been diagnosed with a mental illness. Nonetheless, there is an over-representation of both compromised mental health and various types of mental illnesses among the homeless compared to the general population.

The relationship between mental health and homelessness is complex. However, while it is not always clear what comes first, it is clear that many factors that affect patterns of health are also linked to determinants of homelessness. People with severe mental illness may experience limited housing, employment and income options. People who are homeless tend to report higher stress, lower self-worth, less social support and less effective coping strategies. These factors are associated with depressive symptoms, substance abuse and suicidal behaviours. Information presented in CPHI's report indicates that programs that provide housing first, twinned with appropriate and flexible mental health services, appear to be effective at helping those who are homeless to stabilize their mental health problems and to achieve stable housing.

Deborah Kraus, Housing Policy and Research Consultant, as an individual: I am very pleased to be here to discuss the study I co-wrote with Luba Serge, a researcher from Montreal, and Michael Goldberg, former research director of the Social Planning and Research Council of British Columbia. We have collaborated on many studies related to homelessness. These include studies about homeless youth, families, young women, people with mental health issues and addictions and the street homeless.

Today, I am here to discuss our report on housing programs for people who are homeless and who have substance use issues — problems related to drugs and/or alcohol. Many of these people also live with a mental illness. Copies of the research highlights are available.

The research was funded by Canada Mortgage and Housing Corporation and the Homelessness Partnering Secretariat. The opinions and recommendations are the responsibility of the authors and do not necessarily reflect the views of CMHC or the Homelessness Partnering Secretariat.

Of all the research and reports we have written, this study is most the important because it really gets to the heart of what we can do to end homelessness in Canada.

To conduct our research, we undertook a literature review and profiled 13 initiatives in Canada, the U.S. and the U.K. We also conducted face-to-face interviews with 33 individuals who were living in housing or receiving services from the case study agencies in Canada and the U.S.

I would like to point out three things from the literature review that provided context for our research. First, in 2001, it was estimated that approximately 30 per cent to 40 per cent of shelter clients had substance use issues in urban centres such as Vancouver, Victoria, Ottawa, Calgary, Edmonton and Montreal. The numbers might be higher now. In Vancouver, according to the 2005 homeless count, about one half of the homeless people had substance use issues.

Second, abstinence-based approaches to treatment work for only a very limited number of people with addictions. During the 1980s and 1990s, increasing numbers of practitioners recognized that new approaches to treatment were desperately needed. There was growing interest in harm reduction. Harm reduction is defined as an approach aimed at reducing the risks and harmful effects associated with addictions without requiring abstinence.

All the initiatives that we documented in our study incorporate harm reduction. This does not mean that they simply tolerate consumption. The agencies actively engage clients in making positive changes in their lives, but through persistence rather than insistence. There are rules about behaviours. Harm reduction does not mean ``anything goes.''

Third, there is a new way of thinking about the role of housing in addressing addictions. Practitioners used to think that clients had to be clean and sober before getting housing. The result was that many clients became homeless. Some agencies came to believe that housing needs to come first — before treatment or regardless of treatment. This is the essence of Housing First.

Housing First is defined as the direct provision of permanent housing to people who are homeless. But it is not just housing. Central to this idea is that clients will receive the services they need and want.

A number of the initiatives that we profiled in our study use the Housing First approach. They offer permanent housing to homeless people on the street, along with support. One agency that does this successfully is right here in Ottawa: the Canadian Mental Health Association, CMHA. They have agreements with private and non-profit landlords to provide housing. They even purchased 27 condominium units for their clients.

CMHA says that for homeless people with addictions, being able to keep their housing is a powerful motivation for change. They also say that most tenants have been stable and have reduced their substance use and that one would never know they had a mental illness. Some have secured full- and part-time jobs, and some parents have been able to regain custody of their children because they are housed.

Our study is significant because it clears up a misconception — a mistaken belief that there is nothing we can do about homeless drug addicts and alcoholics unless they first become clean and sober. This study shows that people who are homeless and have addictions can be housed successfully. They can become productive and contributing members of society. In fact, many of the residents that we interviewed were proud and passionate about being able to give back to the community and to help others.

Most of the residents we spoke to said they were using less, and some had stopped altogether. This is because they were feeling better since being housed and having support services.

Almost all the agencies we interviewed said that housing was the most effective service they provided. Housing provides the safety and security that makes it possible for people to begin to make positive changes in their lives. It is easier to provide services and focus on root causes of homelessness and addictions when people are housed rather than when they are on the street or in a shelter struggling to survive.

Agencies also said that support is a key factor for success. This includes a harm reduction approach, which accepts clients where they are at and focuses on the needs of each individual. A number of projects make it explicit that they will never give up on a person. Pathways to Housing in New York promises clients that ``we will house you forever'' no matter what.

The residents also said that having a home was responsible for the changes in their lives and that the support they received was important too. This includes the way they were treated by staff, who they felt cared about them and treated them with respect and who were available when needed.

In conclusion, we have people in Canada who are living and in some cases dying on the street, needlessly. They are young people, older people, men and women. We know that with housing first, and with a harm reduction approach, they can be housed successfully and can be productive and contributing members of society. We can end homelessness, and I hope that the work of this committee will help to make this happen.

Tim Crooks, Executive Director, Phoenix Youth Programs: It is a great pleasure to be here and to discuss some of the work of Phoenix Youth Programs. You should have a purple binder in which you will find a hard copy of the PowerPoint presentation. In the interests of time, I will provide a few highlights and I hope that our discussion later will allow us to get into more depth.

I will begin at page 3. I want you to have some understanding of Phoenix and the continuum of supports and services that we provide. They include Phoenix Prevention Program, primarily school-based where we have three clinical therapists on staff to respond to children and their families who are in need; Phoenix Centre for Youth, which is a walk-in centre located centrally in Halifax; a 20-bed emergency youth shelter; Phoenix House, our first program of some 20 years ago; a supervised apartment program, which is the next step of independent living; a learning and employment centre that provides pre-employment training and life skills training; and a follow-up or aftercare program.

As an agency, we work primarily with at-risk and homeless youth between the ages of 12 to 24. It is important to note that across our programs we also provide health services, a parenting support program to work with our youth who in turn have children of their own, and a special initiatives program that allows for our youth to explore their strengths in the areas of arts and culture and through therapeutic recreation.

Turning to page 4, there for your access are some statistics, most of which you know, but I wanted to be sure you had an understanding. These trends frame our work, so I want to share a few that are important and that we feel the pressure of, and then I want to share some fundamental truths from the body of our work as an agency.

One highlight from the national trending is that, some 18 years after the 1989 joint all-party resolution in the House to end child poverty by the year 2000, our rates of child poverty stay at exactly the same level as they were in 1989 — 11.7 per cent.

Regarding the absence of a national housing strategy and affordable housing stock, you can see some details compliments of the Canadian Housing and Renewal Association, CHRA, and the Canada Mortgage and Housing Corporation, CMHC. You can see in a vibrant way the staggering statistics: we went from almost 25,000 units of affordable housing being built a year in the early 1980s down to a place from which really there is no recovery, and we feel the impact year after year.

With respect to regional trending, one in every 10 Nova Scotian children is living in poverty. I want you to understand that the Halifax Regional Municipality has a real intensification of the number of youth living in the city. On page 7, you will see some highlights. HRM has the highest concentration per capita of 18- to 25-year-olds of anywhere in Canada, and we are feeling the pressure of that. HRM also contains 40 per cent of the province's population, and the best estimates are that within the next decade that will increase to 50 per cent.

You can see some of the local research that we have done. We have provided two snapshots — and they were limited, just snapshots. One is from 2003, on a night in the middle of June, and a snapshot in the same month two years later saw a 48 per cent increase in the number of youth that were on the street. If we look forward to 2020, based on the best projections of Halifax, we will have 112,000 or more individuals under the age of 20 living in Halifax.

Looking a little closer to home, at Phoenix, I want to refer to a Youth Matters research piece done in partnership between Phoenix Youth Shelter, the IWK Health Centre, which is the local children's hospital, and Dalhousie University. We looked at intake at some of our clients coming into that program. Here we have a quick demographic snapshot of some of the youth we have the privilege of getting to know through the span of our services: 34 per cent have lived in two or more family situations; 30 per cent have experience with foster or group homes; 65 per cent come from one-parent families; 32 per cent have mental health symptoms in a clinical range, needing clinical interventions; 61 per cent have only Grade 10 or less education; and 89 per cent have learning or attention behaviour difficulties. You can understand why, based on some of those statistics.

I want to turn our attention to some of the fundamental truths. Looking at page 10, one thing I want us to understand by way of normalizing the experience of our homeless youth is that we do a disproportionate amount of fundraising as a community-based organization for a group of our size, so it involves a lot of public speaking. On a regular basis, when we are out dealing with people, we ask them to identify the most important things in their lives and give them a few minutes to reflect. With great consistency, they come back with the same kinds of things I am sure that we would answer if we were asked: home, family, health, education and employment.

Now we ask them to envision that something has transpired, something beyond their control, that has created a loss so that they have lost these things, and we ask what would they be left feeling having experienced that loss. Again the list is, almost without exception, consistent: anger, sadness, confusion, being overwhelmed, being scared.

The exercise of homelessness is an exercise in loss. It is a bone-crushing, right-to-the-core experience of loss of all of those things that we value and believe to be so near and dear to us. Understanding that helps us to resist the temptation of talking about ``them'' and ``us'' and to understand that the strategies that are needed are ones that unite us and not those that divide us. There is no separation. We would react the same way, having experienced that loss.

On page 11, you will see a quick and simple pictorial overview of this. If we look at it from a structural perspective, for many of the youth we see, experiences beyond their control propel them to a space of loss, and if you picture that as a funnel, once you are into that space, it is not a stagnant experience. It goes very, very quickly and brings you down deeper and deeper at a rapid rate.

Turning to page 12, I want to talk about our investment opportunities and our stages or opportunities for intervention. I want to start with stage 2. As a nation, we are mostly consumed with putting our priority and our corresponding resources into stage 2, which is that reactive response. If you are talking about it in terms of child welfare, we tend to monitor those things by the number of kids taken into the child welfare system in any given year. If you are talking about the health care sector, we often monitor it by emergency room visits, wait times and those kinds of things. That takes us away from a public discourse of understanding the importance of investing in early intervention and prevention and of understanding stage 3, which is the community-based supports that we would need in order to be relevant and to provide meaningful support to someone. At Phoenix, we have worked hard to provide a continuum of supports and services that reach over that range and include all three of the stages.

Beyond that, we know a couple of things: We know that investment only in stage 2, crisis management, is an exercise in social control, and all of the research, and you have heard some here today, and all the discussion from those of us providing service in the field speak to the same things. There are certain guaranteed results by investing only in the social control piece, and that is more emergency shelters, higher incident of troubling behaviour, higher level of incarceration, increased number of children and families living in poverty, higher level of human suffering and higher financial costs to government and citizens.

If you look at the longitudinal studies, some suggest that on average every dollar invested on the front end is a $7 saving on the back end, and some go as high as to suggest it is a $20 savings, so a 20-to-1 ratio. By contrast, we know that investment in stage 1 and stage 3 — prevention and early intervention and community-based supports — tends to yield something very different.

The social investment opportunities on page 16 would include strategies like front-end loading, and again the examples we would have through Phoenix are the prevention program, special initiatives and the parenting support program, just to name a few.

We need outreach that is flexible and mobile. We need education that allows our youth to access support programs and provides a flexible means for furthering education. Everyone knows the importance of housing — affordable, supported and centrally located.

Community engagement allows us to have a dialogue about how our youth can become creators of cultures, contributing to our culture as opposed to being just consumers, and there is a call to action for the general community if we frame it in this way that allows each Canadian to understand their responsibilities and opportunities to help make a difference.

In closing, I would share this: Mr. Ronald Labonte, who has worked in the field and written quite extensively, has a great definition of empowerment, an often much overused word. In very simplest form, the empowerment we seek to engender through Phoenix Youth Programs, and I would suggest this is what programs across the country should be looking to do, is an experience where our youth have a moment of success, where their shoulders go back and they think, ``What a wonderful thing I have done today,'' so they feel they belong and have a sense of community, a sense of connection that is absent from many of their lives, and they start to understand their ability to influence not only the course of their future but of the world around them.

On page 19 is a very simple fact, a fundamental truth. When we think about hopeful youth, we know that healthy individuals lead to healthy neighbourhoods, which leads to healthy commerce, an essential piece of this equation, which leads to healthy communities and a higher chance of healthy individuals. That circular relationship is undeniable.

I am thrilled to have had this opportunity today to speak to our experience at Phoenix Youth Programs.

Rebekah Peters, Health Clinic Director, Saul Sair Health Centre: Thank you for inviting me to speak to you today. I am deeply honoured by this opportunity. I am a nurse practitioner and the director of the Saul Sair Health Centre at Siloam Mission, in the heart of Winnipeg.

Until I came to Siloam Mission, I had no idea what homelessness meant. It is a very different thing to read it on paper than it is to encounter homeless individuals on a daily basis. My experience had been primarily in the Aboriginal northern communities and, essentially, I did not see homelessness in the North. Poverty and homelessness are, of course, multi-factorial. Today I will share with you my short, yet valuable, experience in providing health care to the poor and homeless.

Siloam Mission is the largest compassionate ministry to the homeless in Manitoba. The homeless population in Winnipeg is estimated at over 1,700. In our twentieth year, Siloam is growing rapidly. In the last year, we have established a 100-bed shelter, started a visual arts program, doubled our clothing program and continued to grow in our meal program, serving over 500 meals per day, and, most near and dear to my heart, developed the Saul Sair Health Centre. All services and programs are provided without charge and with no preconditions, and are all located at our 58,000-square-foot, four-storey facility.

It is worth noting that in our 2006-07 fiscal year, government funding accounted for only 4.25 per cent of the $2 million of resources that were entrusted to us. The balance came from our 25,000 private, corporate, church and foundation supporters. Siloam Mission also averages over 400 individual volunteers per month.

Siloam successfully assists homeless individuals to transition to employment and more self-sustaining lifestyles. We also serve the chronically homeless, who are homeless mostly due to addictions and mental health issues. This segment of the population will likely always need our help.

The health centre was named after a pharmacist who donated $1 million to establish the program. Just a few months into our program, we have a busy walk-in clinic with primary care, foot care, chiropractic care and dental care. Since opening in August of this year, we have seen almost 900 patients, 80 per cent of them men, most of them homeless and most of them Aboriginal.

With the exception of three staff employed by the mission, all health professionals are volunteers.

The most common chronic problems we see are lung problems, diabetes, HIV, hepatitis C, hypertension, and of course mental health issues. If these patients have primary care providers, we encourage them to see them. What we find over and over is that, like so many other Canadians, these people do not have access to good primary care. We also see many episodic health concerns, like skin infections and wounds, respiratory illness, head injuries from assaults and accidents, and musculoskeletal complaints.

Requests for letters and forms to advocate for housing, income assistance and medical benefits are a daily occurrence. As programs are developing, we are able to offer a one-stop-shop approach, which our patients appreciate and we find is more effective. As we build relationships and develop our programs, my dream is to focus on the prevention of health issues, building our way to a healthier population.

I would like to share with you a few stories that illustrate some of the challenges facing our homeless population.

This is the story of Greg. Greg is one of the homeless working poor. He developed a simple fungal infection in his feet and was unable to keep it clean because of lack of access to bathing facilities and clean clothing. The infection eventually landed him in hospital on intravenous antibiotics. When he did not need IV treatment, he was discharged and given a prescription. As is the case with many homeless people who are working poor, he did not have the resources to buy the medication. It was not covered by any drug plan. Barely able to walk, he could no longer work and was getting more and more discouraged. You can see how a simple problem quickly spirals.

Sarah is a solvent user. While intoxicated, she was hit by a car and suffered a nasty wound on her leg. She came to me when the wound was quite infected. I referred her to a local wound care clinic because I felt some expert help was needed. She showed up that evening but was refused entrance because she smelled of solvents.

Ben had a heart attack a few weeks ago. The ambulance workers knocked his door down and he was subsequently kicked out of his apartment with no chance to gather his belongings. Homeless, he presented to the health centre with symptoms of anxiety and depression. While in hospital, he received advance cardiac surgery and medications worth thousands of dollars. Now he can barely afford his baby aspirin.

Pam is a broken young woman with a long history of abuse and addictions. In the summer she fell and broke her leg. For many reasons, she did not get treated for her fracture, using a wheelchair instead. She then developed a severely infected ulcer on her leg. Fearing that she might need an amputation, I pleaded with her on several occasions to get to emergency, but she said she did not care if she died. Frustrated, the health centre staff and volunteers prayed for her one morning. We prayed that she would have the will to get better. That morning she came in again, her pants soaked with blood and pus from her wounds. Giving up on the hospital idea, we treated her the best we could at the health centre. Today her wound is healing and she will not lose her leg.

These stories illustrate several issues. First, a significant portion of the population does not have access to common drugs. As small problems are left untreated, they grow into large problems, costing the health system unneeded dollars. We need a national pharmacare program that does not leave anyone out.

Second, while massive amounts of health dollars go to expensive diagnostic imaging and groundbreaking surgeries, permanent care often lacks resources.

Third, the only effective health service for the homeless is service that meets them where they are geographically, is very accessible and is provided by people they trust.

Fourth, the role of the non-profit organizations in alleviating poverty and homelessness cannot be denied. They are fiscally responsible, creative in approach and not afraid to make things happen while waiting for government. Most of all, as Siloam's mission statement includes, they are the connecting point between the compassionate and the less fortunate, not only connecting resources but also lives. People are looking for a way to make a difference.

I would like to conclude by talking to you about another one of my passions, the role of the nurse practitioner. Nurse practitioners are being integrated into our health system across Canada, but there are still barriers — barriers within our health system, within the medical community and even within our own nursing organizations. Especially in marginalized groups, nurse practitioners can bring a unique and valuable aspect to care. We can independently and collaboratively provide primary care and are trained to embrace holistic care, as well as focus on health promotion and disease prevention. Health care reform in Canada must embrace this role.

The Chair: Thank you for relating your experiences with your new centre.

Thank you all for your presentations. There was a lot of discussion about mental health, an issue this committee is aware of, having produced, a year ago, the report Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada.

The first two presenters talked about permanent housing. Did any of you mention anything about transitional housing, which was part of the description of what was needed up until recently? The thought was that many people who are experiencing mental health problems or addictions needed something transitional before getting to permanent housing out of emergency shelter. Is transitional housing no longer considered to be part of the requirement?

I also want to focus on the hard-to-house group of people. When people in my city of Toronto and other major cities think of homeless people, they think of people they see on the grates on the street corners, et cetera. We know they are the tip of the iceberg. There are many other invisible homeless people out there, including families and children. Some of them may be couch surfing. They deal with their homeless problem in a number of ways.

For many people, homelessness is those visible people on the street. Some of them are the most difficult people to house, because they are the ones you are talking about with mental health difficulties, addictions, and so on. Many of them do not like going to emergency shelters. In fact, it can be very difficult to encourage them to leave the streets. It is not because they consciously choose to live on the street but because many of them feel that if they go to an emergency shelter they will be robbed or beaten up, or they may have social behaviour problems themselves and not fit in with other people and have difficulties in that respect.

There are a number people who have complex problems. Everyone is an individual, and some individuals have a combination of all the things you are talking about. How practical is it to go to permanent housing even before treatment? The first two of you said you thought that was the way to go.

Ms. Kraus: Those are excellent points and I am glad you brought them up. You are talking about the hard-to-house. The people we are talking about, and the people in my study, are exactly the people you are talking about: the most chronic homeless, the people who cycle in and out of shelters, and the people who are on the street. People have been shrugging their shoulders and saying that these people are not only hard to house but also impossible to house and there is nothing we can do for them. The agencies we profiled said that they would try something different.

In my work in Vancouver, we interviewed close to 200 people who were living on the street. They are concerned about shelters. They do not want to stay in shelters for all the reasons that you mentioned, but they all said that if they were offered a place to live, they would gladly take it. They are looking for their own private place. Many of them, especially if they have mental health issues, do not feel comfortable in a congregate setting. They do not feel safe or cannot manage in that kind of environment. They want their own small place where they can lock the door. They would be willing to move into housing, but they are not comfortable using the shelter system.

Our study showed that yes, they can be housed directly off the street, along with the support. From people I talked to, the people that they approached directly off the street, they cry with happiness when they see the housing that they are able to move into. They welcome the kind of support that they are getting through these programs. Again, it is the staff who work to engage them. It is a very slow process of gaining trust and working with the clients.

There has been tremendous success, I think. I am not so good with the percentages, but between 80 per cent and 90 per cent of the people are able to remain in their housing after being taken directly off the street.

To answer your question about transitional housing, when we finished our report, that was the big question for us: Why transitional housing? It causes tremendous stress for people when they reach the end of their time period, whether it is two years or whatever. They finally have been getting a lot of support, they have become integrated in the community, and then they have to leave. Where will they go? The major issue is the lack of housing for them to move into.

I think you are right that the traditional thinking was that you engage the people, get them into a drop-in centre, then to a shelter and then move them along to transitional housing. In particular for people with mental health issues, that process is very destabilizing when they have to move out of their transitional housing. The other problem with the whole continuum is that most people never get to that end. They never get to that permanent housing.

However, if you give them the housing first and then the support, that provides the safe and secure base where they can address the problems, and that has been found to work.

Ms. Votta: I would echo what Ms. Kraus said. Our review of the literature found the same thing with respect to the transitional housing. While it was a very short-term solution, it was not addressing that permanent housing need which then spoke to some of the broader social determinants issues around twinning the supports around activities of daily living, providing the income assistance, the educational assistance, the employment skills training and then twinning that with the mental health services support, whether for a diagnosed mental illness or addiction. The evidence for us was overwhelming that the Housing First approach as opposed to treatment first approaches or transitional housing approaches appeared to be more effective.

I would echo what Ms. Kraus said about the hard-to-house. One reason we wanted to print as much information as we could about the various community mental health programs is that they are all designed to address the complex needs you will see among the homeless. The assertive community treatment program will address one set of needs; it is multi-disciplinary in nature. There is an intensive case management approach for a different need; it is a one-on-one, individualized approach. There are outreach services, which are more short term in nature and provide that linkage to some of the longer-term services, but all with that end of getting to that permanent housing twinned with the supports.

Mr. Crooks: I am in large agreement with what I am hearing. I would underscore that it not only makes sense in terms of the quality of life consideration, which is the driving consideration for those of us in the field, but it also makes good economic sense. We had a study done regionally in the Halifax area by Frank Palermo from Dalhousie University and with the cities and planning unit of that university. He examined our cost related to the supportive housing that has been provided in Halifax and looked at the cost to the system in the absence of that. He did quite a comprehensive study and looked at 42 research pieces that related to this.

At the end of that study, the estimate was that there is a 40 per cent, on average, cost saving from a Housing First strategy that provides supportive housing as opposed to the absence to of that and trying to deal with it through our traditional mechanisms. In my presentation, that is what I referred to as the stage two interventions, where crisis has happened and we rush to try to keep up by emergency room visits and a variety of other means. That is not at all cost- effective.

As we take a long-term view on some of these issues, our hope on the community side, as service providers, is that we can reach that place of epiphany. Once you get there, then there is no turning back. We would like to see the investment go accordingly.

On the hard-to-house piece — and I also touched on this in our presentation — one of the essential considerations is the absence of substantial and meaningful relationship for many of these individuals. We need outreach that allows us to have the initial engagement to establish relationships. At the end of the day, if you ask the common sense question, ``If you had a place to live, would you rather that than here,'' I do not know of any examples where someone has answered, ``No; I am content, thank you.'' I want to reframe some of the ways in which we think about these things. I appreciate the question.

The Chair: My colleagues now have questions. Senator Munson is from Ontario, but his heart is in the Maritimes.

Senator Munson: Ms. Kraus, you say Housing First programs provide permanent housing for homeless people. What do you mean by ``permanent''? Does it mean forever? How are homes paid for and maintained? Do residents build equity? Also, on your second page you talked about homeless people with addictions. You say that most tenants have been able to reduce their substance use. What programs are in place to reduce that? How are they monitored? Is there a privacy issue there in terms of monitoring them when they are trying to reduce their substance abuse?

Mr. Crooks, can you please give us examples of what early intervention would be in stage one? Are there examples of effective school-based prevention programs?

A thought just came to mind. I lived in Halifax for five years or so and I have witnessed amalgamation across this country. We had people who lived in their cocoons or their silos in communities with a higher tax base and effective programs. Has amalgamation affected the way cities deliver programs for the homeless? All of a sudden, it is Halifax, Dartmouth, Bedford and other places. As a former reporter, I have seen less and less money going toward these programs. Amalgamation was supposed to be the panacea of all that is good, but people are left behind. Those are a few questions for thought.

Ms. Kraus: By permanent housing, we are generally talking about rental housing with non-profit housing providers and also with private landlords. The people have a lease like any other tenant. If people are on income assistance, the rent is usually paid from the shelter component of their income assistance allowance. The rent is generally geared to income if it is in non-profit housing, or people have a rent supplement, if there is a rent supplement program available.

When the Canadian Mental Health Association first started their program, there were so few units available that they ended up buying some condominium units to rent to their clients. Clients stay as long as they want and as long as the rent is paid.

Following up on what Mr. Crooks said about the outreach workers, they are the ones who go on the street and establish the relationships with people on the street; they help them get into housing and then get settled in their housing. Those relationships are very important and successful.

Senator Munson: Do the outreach workers work to help reduce drug abuse?

Ms. Kraus: In terms of the substance use, once people are in the housing, it takes time. There are many different techniques, but the harm reduction approach is the starting point of working with the clients. Sometimes it is an ongoing process of talking with the clients and asking, ``How are you feeling today?'' When the response is, ``Oh, I am really hung over today; I do not think I can go to work,'' there are various techniques like focusing on the strengths of each client and especially motivational interviewing, which is asking, ``How is your substance use affecting where you really want to be with your life?''

In this research project we interviewed 33 individuals. Twenty-two of them said that they were using less, and out of those maybe four had stopped all together. These people were using crystal meth, heroin, crack — drugs that are difficult to stop using. People said that once they were housed and had a relationship of support and trust with somebody, they felt better. One person said, ``I do not need drugs and alcohol as much as I did before,'' because they are feeling better. They are getting other elements of their life in place. That was echoed by the agencies, who reported overall reduced substance use. Sometimes the outreach work involves sending their clients to treatment, if that is what the clients decide they want. Treatment is an option; but they still have their housing.

Mr. Crooks: You had two questions, one about intervention and the other about amalgamation. First I will speak to early intervention. I encourage us to think about that in two ways. I will give two corresponding examples. One is our ability to intervene early in someone's life, and the other is our ability to intervene early on an identified issue. Those could be two different interpretations of early intervention.

Let me talk about providing support early in someone's life. Our example at Phoenix Youth Programs would be the parenting support program. We work intensely with those youth who have kids of their own — and most of them are single parents — to build skills and capacity and to understand the challenges that any single parent has, including the need for respite and providing good nutrition for their kids. We have a program designed around providing those supports, some of which are educational and some of which focus on the need to socialize with others in a similar situation, to be heard and to build a sense of connection and community.

Early intervention in the form of our prevention program means the ability to respond quickly to an identified need. We have three clinical therapists on staff who are based in the community rather than in an institutional setting.

We have what we refer to as community educators. They do some creative work within the schools in Halifax Regional Municipality. Some of it involves building skills and competency through specifically designed workshops, but some is just activity-based communal projects, such as being involved in school musicals and a variety of other things.

Out of that process and also from internal referrals for the youth we see across our continuum of programs, kids are referred to our clinical therapists who work with them and their families. We are able to respond by starting a therapeutic process in a matter of days or weeks, as opposed to some of the institutions that have a wait list of six months or even a year. That is the ability to intervene early.

As you may know, Nova Scotia just launched a child and youth strategy on Monday of this week. The lead department is the Department of Community Services, but the strategy involves four other departments as well: justice, education, health, and health promotion. They focused on working collaboratively, which I am pleased about. One element of the strategy is the Schools Plus program. The point is to understand schools as a place where we have a captive audience; schools are hubs of activity and gates to a variety of issues, and there is an opportunity to provide supports around and through schools.

Early school leaving is one of the biggest risk factors for anybody, so the more we can have marginalized kids stay attached to their schools, the better.

With respect to amalgamation, I feel as if you have been eavesdropping on some of the conversations I have had over the last two weeks, because you are right on point on this. We have a huge issue in Halifax. We went through amalgamation, which goes back to 1993. The issue in that period of time was that, as the responsibility for social service delivery moved to the province, so did the money. The residual impact of that is that at a municipal level, we have a municipality that traditionally — although this is changing under the leadership of the mayor — has been very hesitant to be involved in a substantive and meaningful way on imminent quality of life issues, acute quality of life issues, not only for those who are marginalized but for all of the citizens of Halifax Regional Municipality. As the highest tax base dollars go to outlying areas to service lots, build roads and sewers, those monies have left our city in a bad position to invest in social supports and social programming. There has traditionally been a tug-of-war jurisdictionally. The issues play out on the streets and in the communities of Halifax.

The mayor had a round table recently. I was on his advisory committee for that process. I think there is renewed energy and dialogue that I hope will lead to some changes. Those amalgamations have largely been devastating on social issues, certainly in Halifax Regional Municipality.

Ms. Votta: I have a point on the early intervention issue. Other research we did at the Canadian Population Health Initiative looked at positive development among youth. The study focused on early intervention and looked at a number of health outcomes: self-rated health; their tendency to use alcohol, tobacco, marijuana; their sense of self worth; and their level of reported anxiety. We also looked at their social ties, or what we called assets — for example, feeling nurtured by your parents, feeling a sense of monitoring by your parents, feeling connected and engaged with your school, connected to your peers and connected to your community. We found that the more assets kids had, the better their self-reported development. Even kids who had only one asset were better off in terms of their development than kids who did not have any, so it speaks to a number of early intervention opportunities.

Senator Keon: I thoroughly enjoyed these presentations. You are preaching great gospels about public-private engagement and so forth. I agree with you that if good things will happen, you have to get out in front of government. It is too bureaucratic.

I am familiar with your operation in Winnipeg, and I also looked at Friendship House in Vancouver about a year ago. Your philosophy was confirmed by Ms. Kraus.

Mr. Crooks, you made the statement that although we are trying to do many good things, we are fundamentally standing still when we look at the statistics.

That brings me to the question I will ask Ms. Votta to address. I have been familiar with your initiative since it started and I congratulate you and CIHI for everything that is happening. It is exciting. Glenda Yeates will be coming before the Subcommittee on Population Health later. However, I want to raise with you again what I have already raised with some people at CIHI. There is a tremendous need for tool kits that can drill down at the community level, even though in most places we do not have the organization at the community level that we would like to have.

There is a tremendous need for tool kits that can measure the intake to an operation like Ms. Peters', as well as measure the outputs and the effect on overall population health for that pocket of population. I was stimulated to do the study on population health because the pockets of poor population health are easily identifiable. You folks, the Public Health Agency, CHIR and the local or the provincial public health agencies can put their finger on them immediately. What they cannot do is mobilize the 12 or 15 people around the table that Mr. Crooks talks about and put them to work on the solution to this problem in the community.

Of course, it is interesting to note that in conversation the leaders of public health or population health do not dare go there bureaucratically. It is suicide. However, we can go there, because we are a Senate committee.

I want you to talk a little about how you think you might be able to modify the organization you have in place — which is extremely good, but it is at 30,000 feet — to create tool kits to get to the ground to demonstrate just how good Ms. Peters is.

Ms. Votta: That is a loaded question. We do work very closely with our stakeholders to hear from them what we can do to help them promote their strategies and efforts. We talk about the need to base decisions on evidence, but then frequently the evidence is not there, so we fall short of being able to speak to what works.

We are doing a number of things right now. For example, we are working with researchers and funding some intervention research, because we are hearing that it is one thing to say we need this evidence, but another to have the means with which to get it; there is a lack of funding or a lack of knowledge about how to conduct evaluations and how to assess where these synergies are in terms of what is working at the population level. Therefore, we are now funding some research. Three studies are taking place across Canada that will focus on a real population approach but will look at what is working from a community level to get at some of the grassroots initiatives.

We are also looking at things like our portal mechanism, where again we can be working at the regional health authority level to get that information to the people who need it in order to foster their needed action.

We do a number of workshops within the Canadian Population Health Initiative; we go right to the communities where they need us, and we talk to them about the data they have or the data they do not have or the data we need. Again, it is a question of what we can do to mobilize you, in terms of understanding the information you have, and then putting that into action.

Our goal at CPHI is twofold: first, to understand the factors that affect the health of Canadians, and then, more important, to take that action and understanding and foster some dialogue that ultimately will result in actions that will improve the health of Canadians.

We also work a lot with researchers and decision makers. We do a number of knowledge exchange activities where we bring researchers and decision makers together and say, ``We are telling you the research.'' It is stopping just short from saying, ``This is what we need from you as a decision maker.'' At CPHI, we see ourselves as that middle person or that conduit to fostering discussion and action.

Senator Keon: Have you had any contact with NICE, the British National Institute for Health and Clinical Excellence? We will be teleconferencing with the British population health initiative in the near future. The reason they interest me is that they talk about tool kits to get down to the community level.

Ms. Votta: I have not had contact with that organization, but perhaps someone else in my organization has, the director or vice-president of research and analysis. I could inquire and get back to the committee, if you like.

Senator Keon: Have any of the rest of you any ideas? With the population health study, we do not want to just repeat the facts that if you do not have housing, food, education, et cetera, you have bad health. We all know that. We also know where the pockets of bad population health are. At the end of the day, we want to help all the people involved — public health agencies, CIHI, the institutes and CIHR — that cannot go to government to say, ``Look, enough is enough. This stuff has to be tied together; we have to correct these areas of abhorrent population health.''

It has to be done at the community level. That is open and shut; it has been demonstrated all over. There are big things like vaccination programs, and that is fine for the provinces. Do you have any ideas about what organizations can get you there?

Mr. Crooks: I am thrilled with the questions that are being asked. Let me state the value of research for those of us who are practitioners in the field. We always get excited about the research because it affirms what we already know. That is important. I know that sometimes research is critiqued for reasserting what we already know; however, you are only as good as your current research in the public realm. As we are doing public education in our surrounding community, relevant and current research that we can quote is helpful for having the general public follow along in some of these discussions.

Regarding what I said in my presentation, in the Maritimes we still have a notion of Maritime hospitality. However, we also still have a desire to make the separation of ``those folks,'' meaning the homeless, in really negative ways. This is especially true when they interfere with our ability to do effective commerce. We like to point out that they are there because of some kind of bad individual decision, as opposed to acknowledging a structural understanding of what has transpired to create marginalized and vulnerable folks. The research is very helpful in that public discourse. I wanted to comment on the value of that.

Regarding the tool kits, it really is about the funding. We are approached at least once a week and sometimes as often as three times a week. We want to engage and support that work, but you get caught in a process that takes time and energy and detracts from your core work. Also, from a general infrastructure perspective, it can be problematic for us to engage, and often it comes down to technical shortcomings like having the right software or hardware to participate in a process.

It is very labour intensive for NGOs to do that work. We recognize the value and try to accommodate it, but it is labour intensive. I am also frustrated when a research piece goes forward that is not inclusive, or cannot be inclusive, of understanding the costs for an NGO and compensating them accordingly. If we want some uptake on the tool kit, which I support, we must understand that it is an essential part of the deliverables and then compensate NGOs accordingly. There is a huge funding disconnect presently.

The Deputy Chair: Canadians have to develop a social conscience. Some guy who has taken hundreds of millions of dollars out of the system and spends most of his life flying in his private jet and sitting on his yacht in the sun has an obligation to come back and help the people who have nothing. You cannot get at them through the tax system. The closest we ever came is with the GST.

Mr. Crooks, what you are doing is terrific and you are exhausting your energies trying to deal with your mayor and so on. You should also get a list of the rich guys and you should send someone to them to say it is time.

Mr. Crooks: You are welcome at our organization any time.

Senator Trenholme Counsell: I want to thank you for who you are and what you are doing. It is inspiring, informative and visionary.

As I listened to you, I thought you are really talking about coping skills. One of my mentors talks about the development of coping skills in our children and youth, and I think that is one thing missing when we are discussing this issue.

We are hearing what we heard in the mental health study, with a slightly different bent. However, it is good to hear it again, and of course it fits into these two reports and two studies.

First I must go to my pet theme — children and their development. Mr. Crooks, I looked at page 9 of your report, and thought that is what it is all about. You see almost the same statistics from our jails and prisons — 89 per cent with learning disorders, attention disorders and behavioural difficulties. That is the sad truth, but the other figures are all about family, children, mental health and homes. That is a very important chart.

I want to turn to page 12 in your report. I must make my pitch and then I will ask you whether you would like to redo this chart.

You have stage 1 as school-based prevention programs. We load more onto the schools all the time. I think that stage 1 would be the early childhood intervention and parenting programs and that stage 2 would be school-based.

I hope you agree that for all the factors on page 9 that lead to homelessness, we have to try to diagnose, find, identify and intervene in these problems. Nearly all of them can be identified and will benefit from intervention much earlier than school. The schools have a very important ongoing role, but I do not like to see them targeted for a big role in this.

The greater Halifax area has had a 48 per cent increase in these problems between 2003 and 2005. That must indicate that troubled youth from all over Atlantic Canada are migrating to Halifax. It must also represent an increased rate of troubled youth in your own region.

On a positive note, every province is coming to its senses and is aware that a number of departments have to be involved in child and youth strategies. It should be in the Schools Plus program, but in my opinion, that is not early enough. It should be in the entire intervention scheme, but it seems they are focusing on schools.

Ms. Peters, I want to ask about the model in your mission, which is excellent. Are you able to exert your influence and get this model into the communities? Do any Manitoba community health centres incorporate elements of the model, especially with regard to nurse practitioners?

Mr. Crooks: I agree 100 per cent with your observation about the chart that I provided on page 12. Something always suffers when you try to present complex work in a short time. In this case, a little more explanation would have been helpful.

The school-based prevention program cited under stage one is only one example. I was trying to give examples of where our Phoenix programs arrange themselves along that continuum, but I am not suggesting that that is the starting point under stage one or that there are not a thousand things that should start much earlier than that. That school- based program just happens to be one of our examples of interventions in an earlier stage. That having been said, I agree with your observations completely.

I want to go back to your comment on the statistics found on page 9. I again refer you to your purple binder. You will find included in that two articles on narrative work, about which we are incredibly excited. Narrative therapy is an innovative therapeutic approach authored primarily by Michael White, who has done some very creative work. Out of that process, we start to understand the way in which the lives of the youth we have the privilege of knowing through Phoenix start to get storied. Stories start and then turn into detailed narratives. This lends again to the separation of us and them. When we can talk about kids who are lazy or stupid or just problematic, it makes it easier to write them off. However, when we understand that theirs are stories that need to be changed, that we need to start the rewriting of those stories and to invite them into a process where they explore strengths, which then become the dominant narrative, things start to change.

We all perform in the ways in which we are expected to perform. As senators, you are expected to be well travelled, very wise, savvy and professional, and you perform to that expectation wonderfully. As a nation we are suffering with the same issue with our youth. We expect the very worst of them, and when we do that, we run the risk that they will perform to that expectation.

One of the lead authors on that narrative approach is Alison Little, a clinical therapist in our prevention program. Senator Trenholme Counsell, I understand that you knew her in your practice days in Sackville, New Brunswick, so it is indeed a small world.

The really innovative piece of that narrative work is its application from a clinical setting to front line service delivery. How do we start to change the stories of how our youth view themselves? We see some very dramatic things starting to happen. We have done a learning series within Phoenix where we have modified what normally takes place in a closed-door clinical session and talked about its application when you are standing shoulder to shoulder washing dishes with a kid at Phoenix House, which is a residential setting, or in some other environment. How do you start to engage them about understanding their potential in a very different way and then developing that as the dominant narrative?

This is very exciting work. I think of one young woman in particular who used to come to our walk-in centre. Within the first two minutes of meeting someone new, she would say, ``Hi, I'm so and so, and I have mental health issues.'' She would start talking about all the things that defined her in troubling and problematic ways.

We involved her with Special Initiatives, the program that allows our youth to explore their strengths. We have a partnership program with the Art Gallery of Nova Scotia. This young woman was involved, learned how to paint and turned out to be an incredibly talented painter. Along with a group of friends, she learned how to curate, and they launched a long-standing show. It was on display for two months at the Art Gallery of Nova Scotia. In one corridor were a set of Monet paintings, and around the corner were a set of painting by our youth.

Several months later I heard her introduce herself again. She said, ``Hi, I'm so and so, and I'm an artist.'' She then started to talk about her ability, her talent and her work in a way that made the hair stand up on the back of my neck as I understood that the transition had happened, that she is starting to define herself in new ways with new opportunities and new prospects for the future.

We all play into this. We are all part of the audience in that narrative process. We must start to understand our roles as a nation, to understand that we need to start rewriting the stories of our youth and to view them as an investment. They are not dangerous commodities to be managed; they are our potential for the future, and we need an investment strategy that reflects that.

That is some of the narrative work that is groundbreaking and innovative for us. We are incredibly excited about it and its impact. I leave you to refer to those articles.

Senator Trenholme Counsell: I had asked Ms. Peters how she will promote the concept of collaborative care with nurse practitioners. I would like to hear a bit more from her on that very important matter.

Ms. Peters: I do believe it is very important. The Manitoba government has been a little slow in allowing for initiatives to come up from the regions to employ nurse practitioners. There is still much work to be done in Manitoba. I think other provinces are a little ahead of us in that regard.

So much of primary care is private, with fee-for-service physicians. We need more initiatives to allow those private services to put in proposals to employ nurse practitioners. That is where I believe nurse practitioners will come into play. Their role should not be restricted to community health centres funded by regional health authorities, as is the case in Manitoba; rather, the private sector must be allowed to bring nurse practitioners and other disciplines into those practices. It is growing slowly, but it is coming, and I think it is very important.

Senator Trenholme Counsell: I encourage you to be a leader and a catalyst and to spread your good news and your success.

Senator Cordy: Thank you all very much for your excellent presentations this morning. At 10:30 this morning I got a call from someone in Nova Scotia who was watching our committee on television dealing with the issue of homelessness. She said, ``I cannot believe this is happening in Canada. We have so many resources. What is going on?''

You are showing us that there are indeed some good programs in place, but the problem is huge, and we have to start dealing with it as an entire nation.

Because I am from Nova Scotia, I have to give an infomercial for Phoenix House. I used to be on the board of Phoenix House. Mr. Crooks, you are providing outstanding leadership in Nova Scotia on the entire file of homeless youth. By your comments, I think everyone in the room can tell you think of each person who enters the door of the Phoenix program as an individual, and that is true of all the staff and all the volunteers. The staff are not making six- figure incomes, yet they go above and beyond. When I was a board member, the centre had just started and the apartment program was just beginning. The people there worked all day at Phoenix House and then had speaking engagements in the evenings. The program has evolved tremendously within only 20 years. You have not rested on your success but gone on to build more and more facilities for the kids in Nova Scotia. You are giving them a chance, and I thank you very much for that.

You spoke about the disproportionate amount of fundraising that you have to do and the amount of time that is spent on fundraising. You made an excellent point about people who are doing research figuring in an amount for NGOs, because, if I recall correctly, not only do you get requests for fundraising speaking and for people who are doing studies, but in addition to those you get requests from other cities, both nationally and internationally, that want to set up programs similar to Phoenix House, and that all draws on very limited resources.

While it does provide opportunities for community engagement, and it is very important that the community is aware of what is happening, do we need a national impetus for the issue of poverty and homelessness? From what all of you have said this morning, you cannot look at homelessness in isolation. Dr. Keon made reference to a number of issues. Ms. Votta spoke about some issues and Ms. Kraus said that mental health issues are often part of problem of homelessness.

In 1989, when parliamentarians voted unanimously in favour of having a strategy on child poverty, I think they all knew it was the right thing to do. I imagine they all thought, ``Oh good, here is a beginning; something will happen.''

We see the statistics, and nothing is happening. It is flatlining. Where do we begin and what do we do? The delivery of the programs has to be at the community level, where the issues are. That is where the people are homeless — in our backyards — but do we not need a national focus? Within that national focus, how do we ensure that things are going to happen?

Ms. Kraus: That is a very good question. Where can we go as a nation to address the tremendous poverty and homelessness? You have a call from someone saying, ``We should not have homelessness in Canada,'' and that person is absolutely correct. We know that we do not have to have homelessness in Canada. We know what is needed to address it.

The balance between national and community roles is very interesting, and we do have a program now through the Homelessness Partnering Strategy, which replaces the National Homelessness Initiative. One of the excellent things about that program was that it put in place a community process. Communities across the country were forced to get together and decide how to tackle homelessness in their community. There are about 60 of these groups, and each community has a community advisory board. I am familiar with ones in Kelowna and Vancouver. These committees include a broad range of stakeholders who want to address poverty issues and homelessness. They worked to develop plans, thinking about the full range of services that are needed, including emergency services, mental health services, services for youth, employment services, health care and housing. These communities have done a lot of work thinking about what kind of strategy can be put in place in the community to address poverty and homelessness.

I have to say that the communities are coming around to saying they need housing. I know some communities have decided to put all of their funding into one housing project; other communities have said they need outreach to work with the people on the street and a full range of services in addition to housing.

This is where the national strategy comes in. The problem is that there needs to be sufficient funding. Mr. Crooks already mentioned that community groups are doing so much, trying to scrounge around a few dollars, and we really need a national impetus, a national housing policy, a national housing program, because we know that is what it will take to tackle the problems. Housing is the centre. Once people are housed, they can get the health services they need; they can start to look for employment opportunities. That is what it will take. It is a partnership. The communities have done a fabulous job of getting all of the stakeholders together and saying, ``Okay, what do we really need in our community? Let us work together.'' They are including the private sector; they are including the full range. They have done a great job and they know what they need. Now they need the full partnership of all the levels of government and they need a lot of money. They need the housing.

Mr. Crooks: In Atlantic Canada, Phoenix feels the weight — and Senator Trenholme Counsell touched on this — of the number of youth that make their way in from rural areas. Statistically we see it through the census information. Not only are they making their way on a temporary basis but in many cases they are moving into larger urban areas like Halifax. If we are not able to service and support them there, then we lose them to larger urban centres where street culture is better developed, so we see them going to Toronto or Montreal and sometimes even further west.

It is rare to see one of our Maritime kids go to one of those areas and return. It is rarer still to see them return with a good-news story. That is troubling to us, and we feel the pressure.

We need to connect in terms of a national process and structure. The Voluntary Sector Initiative, which was healthy and running for a period of years, allowed our sector to develop capacity and some strength and to have a national dialogue, which was great. Now that has been dramatically scaled down from its original format, and we feel the loss of that.

I would echo what Ms. Kraus said around a national strategy. We need a national housing strategy; that goes without question. It needs leadership from federal government. It needs to be informed by all the front-line experience, savviness and information we have as service providers, but we need the leadership to happen at the federal government level, and we need an accompanying national poverty reduction strategy as well. Those two cannot exist independently. They need to be hand in hand.

The final thing that has been incredibly problematic as a service provider is the ongoing directional change both at the provincial and at the federal level. I was involved in some of the policy writing around sustainability under SCPI, the Supporting Communities Partnership Initiative, which had a dramatic impact through some resources it provided to communities for the issue of homelessness. That was under the National Housing Initiative Ms. Kraus referred to. Initially there were very rigid guidelines around sustainability, and it basically read that the one-offs, the bricks and mortar stuff, were to be encouraged, and it was risk adverse around other possibilities. Eventually we were able to write a different expectation around sustainability.

NGOs will exist as long as we need to. Our mission and vision statement read that we would like to be out of business. We see no sign of that any time soon. Our connection and our commitment to our youth, in the case of Phoenix, is to be there for them long term. Therefore, initiatives that run a two-year to four-year cycle are highly problematic for us. It is extremely difficult to gear up for that and fear the withdrawal of support and the implications then of taking away commitments that we made to our youth about stability and long-term presence and meaningful supports until they are no longer needed.

We take that as a sacred trust. That is the relationship piece we enter into with great integrity with our youth, so when governments say we would like to do such and such, my first question is always, ``How long are we talking?'' I absolutely agree that we need a framework going forward, one that has a long-standing commitment to provide the dialogue, infrastructure and appropriate resources to deal with the issues.

Senator Cordy: How would you see federal funding filtering down to the NGOs within the communities? In Canada we have this federal-provincial jurisdiction which sometimes gets so bogged down that resources do not get where they are supposed to be going. Would federal funding go to the provinces as flagged funding so that it has to go to specific programs?

Mr. Crooks: I will tell you the way quickly how we did it relating to SCPI in Halifax, which was, I understand, fairly unique. We had a community group of people who came together who were elected to represent different parts of the homeless population. They were elected by the sister and brother organizations in Halifax that were the community NGOs. We had ex officio representation from the city and from the province, and of course our counterparts on this were from Human Resources and Social Develop Canada because they had the dollars. At the end of the day, they had the final word on whether we contracted with an agency to provide service. We understood that entitlement. They were, of course, accountable to their process.

Through a request for proposal with identified areas through a community plan, agencies were able to apply, and the community members, with great equity and respect and often at a sacrifice to seeing dollars themselves, made decisions about the best investment of those dollars. It was streamlined, it happened fast and we ended up asking for money that was not being spent in other regions because of other bureaucratic processes. We were ready to spend it, and it was our great catch-up period. Through that mechanism, we invested in a wide diversity of services and programs, from buildings to actual service delivery.

I do not think the process has to be that complicated. It needs to be transparent and accountable, but I think it can happen in a streamlined way.

Ms. Kraus: I would like to follow up on that, because that is the process I was talking about as well through the Homelessness Partnering Secretariat, where the communities have identified the priorities and needs and have developed a plan. Then they apply through that program to get the funding. It has worked very well in the communities I have been involved with as well.

The only problem is that there has not been enough money. For example, Kelowna was not able to meet its priority of supportive housing. However, the process has been good in terms of the community identifying the full range of things that are needed. If they can get the funding to meet their priorities, then that works.

Senator Cook: Thank you for a very enlightening morning. I come from the province of Newfoundland. Have any of you heard of the Stella Burry Community Services? This organization came about 65 or 70 years ago as the vision of a wonderful woman, and we are storytellers so maybe we need a bit of levity. She went into a nursing home in her late 80s. She was physically handicapped by this time but her mind was as sharp as a tack. About a month ago I saw her at a meeting, and I said to her, ``Ms. Burry, I thought you were at Agnes Pratt,'' and she said, ``No, my dear, I came out because it was for old people.'' Out of that vision has come an incredible community.

Ms. Kraus, I am very glad that you stressed and reaffirmed what that director has been saying to me for the past five years: housing first.

The project started from one building for the homeless, but she funded it from bed-sitters for people like me who lived in an outport and who came to town and could only find modest accommodations. From the beginning there was an integration of people in her facility. There was a clothing store where you paid five or 10 cents for her to buy new shoes, because everyone should walk in new shoes, and these were her principles.

We have now evolved into a corporation. We had to. It grew like Topsy. We have four housing complexes now. We have one for homeless young girls off the street where we just provide a warm bed and food, and if they want to move through the continuum, there is an option for them. We have the second stage where we offer life skills and they can move within. The transitional thing happens within. This summer, we opened Stella's House and a grocery store. We have taken over the downtown in my city because housing is vacant, and you go to the mall now to buy groceries. A couple of months ago she bought an old drug store on the adjacent corner. I think we are up to a couple of hundred units. The interesting thing about Stella's circle is its peer supervision. There are apartments within. I kept saying, ``Where are we going to find the people to manage all of this?'' She said that they will do it themselves, and she is a firm believer in that. I would like to hear your opinions on that. However, it is working for us.

Also, there is a little café, and it is really popular, especially in the summertime. It is not for profit and it is done by the clients who live in the house. The flower gardens are done. The pattern for living is contained with all its elements there. It is a wonderful idea.

I think NGOs are the soul of the community when it comes to providing housing. We take whoever. The referrals come from hospitals and the police, and the provincial government has bought in because we are providing a service for the community that they do not have the capacity to do, and also we take the risk because we hold the mortgages. They are quite content to pay for the clients because there is no risk to the government. We, the corporation, take the risk for the mortgages.

There are pockets of programs and strategies across this country that are working, but they are fragmented. Mr. Chair, as I understand our role, we are trying to meld those pockets into a national program that will be so good and will contain so many wonderful elements that no one will be tempted not to try it. I do not know whether that makes sense, but I think that is what we are about. All the elements are there.

I loved your idea about the nurse practitioner. I will go home and tell her about it.

The other piece we have is a drop-in centre, mostly for men and people with mental problems. First it was a place to go and have a smoke, after we put the $800 fan in to take the smoke out, and there are TV and cards and so on. There are also wonderful visionaries who run those programs, and now we have the local recreation youth in the providing walks, hikes and picnics in the summertime. The city provides students and programs. More importantly, however, we have nursing students who come as part of their rotation and as part of that little fledgling group program. Therefore within the community and at the community level is where our strengths are to bring about change.

When I look at this I see some barriers. I would like to hear your opinions and your experience with Canada Mortgage and Housing Corporation. I remember an incident at the board where Chevron was giving $750,000 but the contract was not signed at Canada Mortgage and Housing Corporation and we would lose the private contribution because of the inaction of the bureaucracy.

How can we move the responsibility of the federal side, or what do you see as barriers to move that along the continuum? In my province, the provincial government has bought into it because we have eliminated the risk primarily. However, it is working and we are providing a wonderful service to people but they are doing it themselves. It would be nice if you could see this facility, where peers are running their own affairs.

Last week, my daughter told me that she had joined the board of Stella Burry. She is a psychologist. They are choosing people around their board with expertise that can help them in a limited way. These are just ideas that I am throwing at you. Then she asked me if I wanted to buy a bed for this new complex in the medical building. It cost $6,000.

I know the stresses on you for adequate funding, but I think somewhere in this there has to be a mechanism where the needs are assessed at the level where the need has been established. You have to be able to say to the government, ``Cough it up.'' I welcome your comments.

Ms. Kraus: I think you have said it all.

Senator Cook: I would like to hear about Canada Mortgage and Housing Corporation.

Ms. Kraus: In terms of which barrier?

Senator Cook: Access to funding and the free flowing of that money, along with the bureaucratic red tape and the time it takes to fill in applications to access funding from the myriad places where you can get it if you are innovative — including your mother. Do you have any problems of that nature?

Ms. Kraus: I think the biggest problem is that we do not have a housing program anymore through Canada Mortgage and Housing Corporation. We do not have a national non-profit housing program, so there is no funding for groups to apply for in order to build the housing that we used to build — and that we have a desperate need for. The only thing available now for the homeless population is through the Homelessness Partnering Secretariat. That is the only place where there is funding, and they are not funding permanent housing.

They may fund some transitional housing. To their credit, they have recognized Housing First as a concept. They are saying, yes, we need to be working to get people off the street and into housing. But where is the money for the permanent housing? It is not there.

Community groups are doing a fabulous job. They are being very creative and they have really been thinking about what is needed. The work you mention is a prime example. Communities have been doing a fabulous job thinking about this and coming up with very creative solutions, but this is where the role of the federal government comes in. There needs to be sufficient funding because we do not have a housing program to be able to provide the housing that the communities are saying is needed.

There is a disconnect there. Communities are identifying what is needed and coming up with creative solutions. There is the vehicle, now, through the Homelessness Partnering Secretariat — it is not even through CHMC because they do not have a housing program anymore — but it is not a housing program. There is no recognition that we need permanent non-profit housing. The biggest barrier for CMHC is that they do not have a housing program to deliver.

Senator Cook: That is incredible. Would you venture an opinion as to why they terminated that program?

Ms. Kraus: The national non-profit housing program was terminated in 1993. Groups at the time said we will have people who are homeless on our streets if we do not have these programs, and that is exactly what happened.

Mr. Crooks: Whenever we have a situation, either provincial or federally, where dollars get tight, we are having a growing understanding of the relationship between the horse and the cart and what drives what. Increasingly, in our past, we made cuts in areas where we thought we could afford to make cuts. Only now, several decades later, do we discover that these are the things haunting us the most and we need to get back to business on some of them.

I love the stories that you have just told because they highlight the extensive innovation and creativity of community groups. I do not have a single family member who does not have one of those phones that tells you who is calling, because they all avoid phone calls from me now. To know me, or worse yet to be related to me, is to have made at least 100 significant donations to Phoenix in one way or another. We call in every favour we have to make ends meet and to try to keep pace with demand.

By contrast, as the remaining federal dollars that exist on housing have been devolved to the province, it is very frustrating to us to develop affordable housing stock. In Nova Scotia, we have some of the oldest and most in need of repair housing stock of anywhere in the country. I met and talked with the lead person on our end for the province who managed that file to invest those dollars in affordable housing. We talked about their existing formulas and what our needs were in terms of housing relating to our youth. He was a very wonderful guy, interpersonally and professionally, to deal with; but after a fair amount of thought he looked up and said, ``Yeah, you cannot do any of that under our existing formulas.'' He eventually took on other responsibilities. I met with his replacement and had another go at it. I had the rerun conversation; here is what we want to do and why this makes sense. He thought and then looked up and said, ``Yeah, you cannot do any of that under our existing formulas.''

I would echo what Ms. Kraus has said. Developing relevant housing stock is hugely problematic. We work through the continuum that I have described. In the end, we want to get a place where our youth are what they should be, which is completely independent of us. We want them to have benefitted from our presence in their lives but be ready now to be like everyone else — to live well and to make their contributions to the world accordingly. We cannot find suitable housing stock anywhere for them. It is a significant issue.

Senator Cook: In the absence of the dollars — which I waited for 20 years ago — there has been an evolution that can do nothing but benefit the population. We are bringing in the communities, and the health of those people is improving through innovation — through the nursing student program, through recreation, through learning how to run a little café, whatever. I guess there is a bit of goodness in adversity.

Senator Fairbairn: I have been sitting here listening with great enthusiasm and emotion to what you are doing. It is absolutely terrific. It has taken me back in time to remember something that I was engaged with back in the late-1980s, when I became a senator. You are talking about relationships between the national government and community groups, and things to do with provincial issues. What you are all looking for is to get a special effort to help our young people in every way to be able to join into society and indeed run it as they grow older.

I was involved with the issue of literacy. There was a tremendous partnership between a small group of very dedicated people who were in the National Literacy Secretariat for many years. They worked with the provinces, the towns, wherever they could get people to coalesce with them. The issue they were concerned with was basically very much what you have laid out in your material here. It is a foundational issue for Canadians and for anyone in the world. That issue is the ability to learn, to read and to communicate.

The people in this committee have not given up on this issue. However, a year ago, it was hanging by a string. We caused such a vigorous and eloquent fuss in the Senate — and friends over in the House of Commons did likewise — that the government had to listen, and to a degree it has been restored, although in a different way. It is there on the ground again but not in the way it used to be. Nonetheless, we fight on.

Do you connect yourself with the volunteers within communities in all the things you are aiming to do? In Nova Scotia and in all of Atlantic Canada, I know the groups that are dealing with literacy, and literacy is a foundation issue that connects to the kinds of goals that you are looking for. Any of you may answer. I will be upset if none of you has been involved one way or another.

Ms. Peters: Our organization is truly an emergency situation: putting roofs over people's heads, serving meals and providing clothing. We have tried in small ways to introduce literacy and computer programs, but the population we serve is in such crisis that we have not had a wonderful response. The people we serve are truly in crisis: they are homeless, without food, without clothing and needing a hand up to try to get to that point where they are paying attention to some other things in their lives.

Mr. Crooks: I can relate strongly to what Ms. Peters is describing. There is a time and place to engage on those things, and we are very fortunate at Phoenix Youth Programs because we have a continuum. As people start to settle and have basic needs met, we are able through relationships to start to dream with them a bit about the future. We do a lot of that work. We have 140 volunteers association-wide, most of whom are very interested in tutoring. Probably a high percentage of our volunteers come for that reason. We are also very fortunate that we can do that in a very structured way through our learning and employment centre. We have computers there of course for their use, but we also have what we refer to as a transition program. It allows for academic upgrading and life skill training, as well as pre-employment training.

Specific to your question, we have those front-end pieces around literacy. Our volunteers are active in that. We connect in a very creative way through that learning and employment centre with a specific focus on literacy and training. Years ago, back in 2000 when we were setting up that program, which was a real first for our region, we were looking for curriculum materials. We were excited to discover that there are a lot of curriculum materials for at-risk youth. We ordered them as our budget allowed and they started to arrive. I got a call from the coordinator, who had been through the materials, saying that they are three to four levels above what our youth are capable of. We are still searching for established materials that we could apply to our youth without having to do a labour-intensive overall. It is a real commentary on how homelessness is the equivalent of someone pressing the pause button on your development in the areas of education and literacy. The effect is huge.

Senator Fairbairn: There is one person you should talk to, John O'Leary. We will find a phone number for you, though you may have met him along the line. He was the head of Frontier College in Toronto. He has retired but will always be involved with this issue.

When I got involved many years ago, Frontier College was one of the first places I went to find out what I was getting myself into and to get advice and help. One of the most innovative programs that they ever had was not an expensive thing at all. They started in downtown Toronto and it ended up in Manitoba, I think, and in British Columbia. It was called Beat the Street. It was a street walk-in area and it was filled with trays of books. There were chairs and two or three really nice people. You just walked in. The young people knew what it was, and it was a place they felt comfortable in because it was not like walking into a school. In the end, a tremendous number of lives were changed by such a simple thing. You need the people to help, but it was a question of, ``What do you want to do? How can we give you a hand?'' It was quite astounding. They ended up doing a lot of work also with people who had come out of the prison system who were thinking that they would be right back in there if they did not learn something.

It would be fun for you to sit down with John O'Leary, who is a great guy but has a real mind. Also, remember that even though we are not the same as we were here in Ottawa, the connection is still there in terms of this being a very big issue. You have all mentioned this ability to learn and then to have a fair chance to participate in the life of your community. Anything we can do to help, we will.

Mr. Crooks: Thank you.

Senator Fairbairn: I will get you his number.

Mr. Crooks: Thank you.

Senator Brown: I would like to say that I admire the work that you are all doing. I think these are very worthwhile causes for the future.

I would like to reiterate what I said at the Standing Senate Committee on Aboriginal Peoples hearings a couple of days ago on the same issue of what you call housing. I have been looking at your PowerPoint presentation on pages 9 and 10. I think you have the order of importance absolutely perfect in terms of the words home, health, employment, family and education. The number one thing, if you lose your home, then you are in danger of losing virtually all the rest of them.

I would like to try to get you to think of changing these two terms in your presentation. When you talk about the homeless, then the answer to homeless is to provide homes. Therefore, I would like to encourage you not to use the word ``housing'' anymore because you are trying to provide so much more. You are not just trying to provide a house, even in terms of the emergency care that Ms. Peters provides, but you are trying to provide emergency homes, not really emergency shelters. We have those in all the hotels across this country, and none of them feel like a home, believe me. I have travelled this country from coast to coast to coast three times, and I now travel 2,000 miles each way on Mondays and Thursdays, so I know they are not homes. There is only one home, and that is where you are comfortable. That is really what you are losing when you lose your home — your comfort. In losing that comfort, all of these other words at the bottom of your page come into play. I do not know if anger is number one but it probably plays into it. I think number one should be confusion, followed then by fear and sadness. In some cases, you are overwhelmed and that is what leads you to some form of addiction, whether to drugs or alcohol or something else.

The second term that I worry about is ``mental health,'' because the term is a stigma. When you first lose your home, you do not necessarily have mental health issues, but you do have a tremendous loss of comfort. You should be taking advantage of your meetings with government officials to ask them how they would feel if they lost their homes. It is easier to pry funds out of government when they are thinking more about homes than when they are thinking about shelters or the rest of it because those things all seem to carry a kind of stigma.

The feelings you can generate in the people that you help are better if you tell them that you want to help them have a home again. I know that sounds very simplistic, but the labels are important. It is much more important to use labels that reach to whatever level of sympathy people have for what you are doing. Better than housing or mental health, give someone the comfort of having a home, and calling it a home, whatever form it takes. I travel every week and have many shelters wherever I go, but I sure do not call them home. Even when my wife travels with me, which she almost always does, it is still not home until I get home tonight, some time around midnight.

The Deputy Chair: We are about to lose our technical support because we are a little overtime, but Senator Munson has a quick question.

Senator Munson: I have a quick observation Mr. Crooks, I was struck by your story about the young woman who started introducing herself as an artist rather than as a person with mental health issues. In any strategy, whether profit reduction or national housing programs or any federal-led program, communication is a key component. As you said, you spend most of your time fundraising and developing software, et cetera. Communications is the key to telling your success stories and it is factored into any national housing program where there is a budget for communications. The kind of story you told us can be presented across the country to emphasize the success of your programs. We always seem to carry this attitudinal problem of sadness and we share those. I just thought I would throw that out as a communications observation.

The Deputy Chair: That is a great place to end. Thank you to all. It was a wonderful morning.

The committee adjourned.

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