DAWN Ontario: DisAbled Women's Network Ontario

Homeless Women Crisis
Homeless women 10 times more likely to die

Risk of death among homeless women:
a cohort study and review of the literature

Angela M. Cheung and Stephen W. Hwang


Background: Homeless people are at high risk for illness and have higher death rates than the general population. Patterns of mortality among homeless men have been investigated, but less attention has been given to mortality rates among homeless women. We report mortality rates and causes of death in a cohort of women who used homeless shelters in Toronto. We also compare our results with those of other published studies of homeless women and with data for women in the general population.

Methods: A cohort of 1981 women not accompanied by dependent children who used homeless shelters in Toronto in 1995 was observed for death over a mean of 2.6 years. In addition, we analyzed data from published studies of mortality rates among homeless women in 6 other cities (Montreal, Copenhagen, Boston, New York, Philadelphia and Brighton, UK).

Results: In Toronto, mortality rates were 515 per 100 000 person-years among homeless women 18–44 years of age and 438 per 100 000 person-years among those 45–64 years of age. Homeless women 18–44 years of age were 10 times more likely to die than women in the general population of Toronto. In studies from a total of 7 cities, the risk of death among homeless women was greater than that among women in the general population by a factor of 4.6 to 31.2 in the younger age group and 1.0 to 2.0 in the older age group. In 6 of the 7 cities, the mortality rates among younger homeless women and younger homeless men were not significantly different. In contrast, in 4 of the 6 cities, the mortality rates were significantly lower among older homeless women than among older homeless men.

Interpretation: Excess mortality is far greater among homeless women under age 45 years than among older homeless women. Mortality rates among younger homeless women often approach or equal those of younger homeless men. Efforts to reduce deaths of homeless women should focus on those under age 45.

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Media Responses

Homeless women 'crisis' -- In Toronto, they're dying at 10 times the normal rate
AIDS, drugs, suicide common causes, researchers find

by Elaine Carey, Medical Reporter, Toronto Star
April 13, 2004

Homeless women in Toronto are dying at 10 times the rate of other women between 18 and 44, according to a new study released today in the Canadian Medical Association Journal.

A commentary accompanying the study calls the "stunning" death rate among homeless women "a clarion call to our society and our health care community. This smouldering public health crisis can no longer be ignored."

HIV-AIDS and drug overdoses are the most common causes of death among younger homeless women. Depression leading to suicide was also a high risk, according to the study, co-authored by Dr. Stephen Hwang of St. Michael's Hospital and Dr. Angela Cheung of the University Health Network.

Yet homeless women get little attention and few treatment programs, said Hwang, who is part of St. Michael's inner city health research unit.

"It's one of the reasons I wanted to do the study because they are just as disadvantaged as homeless men," he said in an interview. "Their death rate reflects the really disadvantaged circumstances that homeless women are living in."

Women don't fit the stereotype of homelessness, he said. "Most people imagine an older man sitting on a street corner. The women tend to make themselves less visible. They avoid putting themselves in the public eye."

The study followed 1,981 women who used Toronto shelters during 1995, tracking their health over the following three years and comparing their death rates with the broader Canadian population, and with similar studies of homeless women in Montreal, Copenhagen, Boston, New York, Philadelphia and Brighton, U.K.

Homeless men in Canada have a death rate much lower than those in the United States. But there is no similar advantage for women, Hwang said.

"Just putting a health card in someone's pocket doesn't mean everyone is going to get exactly equal access to exactly equal health care," he said.

The death rate for homeless women aged 18 to 44 in Toronto is almost one-third higher than in Boston, even though Canada has universal health care.

That's "a curious and troubling observation," according to Dr. James O'Connell, president of the Boston Health Care for the Homeless program, who wrote the opinion piece accompanying the Journal article.

"Impoverished women and men without homes bear an undue and unacceptable burden of illness and are dying prematurely in our streets, in the very shadows of our towering health care institutions," he wrote.


`You see people die off and you go to a lot of funerals.'

Cathey Milley, client of 416 Drop-In Centre


O'Connell added: "This public health crisis will not be ameliorated until housing and health care become a fundamental right for every human being."

Tracking the homeless using records is difficult, Hwang said, acknowledging the study authors found evidence some women used different names to enter various shelters. As well, if any of the women died outside Ontario, the researchers wouldn't have learned of their deaths.

They did find death certificates for 26 of the women, 21 of whom were under age 45. Older women tracked in the study — those aged 45 to 64 — were also more likely to die prematurely than women who weren't homeless. But their death rates were much closer to the norm for their age.

Most homeless women have mental health problems as well as addictions and that "puts them at the bottom of the totem pole — they're not a priority as far as anyone's concerned," said Joy Reid, director of the privately run 416 Drop-In Centre on Dundas St. E., where homeless women come for food, companionship, clothing and health care.

Cathey Milley, 49, used to know all the women at the centre, but she said they're all gone now.

"Now it's a lot of new people — only because the ones who used to come here have died, and that's really sad," said Milley, sitting at a table in the living room of the house that serves as home to 250 women like her every day.

"You see people die off and you go to a lot of funerals."

Belinda Greville, 45, has been spending her days at the 416 Drop-In for nine years, since she found herself homeless after a life of abuse, drugs and trouble with the law.

"They've helped me stay stable in some ways so I can keep moving," she said. "In a place like this, I feel secure and the people I know don't judge me. They accept me for who I am."

Asked where she sleeps at night, she pointed to the Council Fire shelter across the road. "But they fill up quick," she said.

Toronto's 15 shelters for single women have a total of 565 beds but they housed a record high of 5,683 different women during 2002. "We're certainly seeing more women who have complex problems, serious mental health issues and addiction issues," said Fiona Murray, manager of planning and development for Toronto's hostel services.

If a homeless woman does decide to go to a hostel, "there's a good chance there won't be a bed to go to," said Lynn Hemlow, a registered nurse who struggles to provide health care and preventative programs at the 416 Drop-In. "For men, it's different. There's a huge, huge organization."

With files from Canadian Press

Source: Toronto Star

Her life on the street is dodging death
Globe and Mail
Tuesday, April 13, 2004 - Page A11

For the past four years, Samantha Lazaroff has spent her life cheating death on a well-worn track in the downtown east end.

When she's not running from dealer to dealer and john to john, you'll find her here at Street Haven at the Crossroads, a shelter for homeless women, trying to outrun the drugs and the demons that have chased her all her life.

"It's a small block," she says, puffing on a bummed cigarette, "but it's many miles when you keep running in circles."

At 39, Ms. Lazaroff says she has pondered death "many times" since she left the relative stability of work and a relationship in Shelburne, Ont., in 2000, and returned to the tired streets of her chaotic childhood.

In addition to the bipolar disorder and epilepsy she already had, she soon added a long list of ailments -- liver disease, hepatitis C, a heart murmur, a viral infection and chronic bronchial asthma -- products of her addiction to crack and the prostitution that pays for it.

It was no surprise to Ms. Lazaroff, then, to hear that homeless women in Toronto aged 18 to 44 are 10 times as likely to die as women in the city's general population.

That finding, published in yesterday's Canadian Medical Association Journal, came from a study led by Stephen Hwang, a researcher at St. Michael's Hospital.

Working with Angela Cheung of Toronto's University Health Network, Dr. Hwang tracked 1,981 women who used homeless shelters in 1995 and found that those under 45 died at a rate far higher than older homeless women, and close to that of young homeless men, despite women's inherent tendency to outlive men.

"These observations suggest that efforts to reduce deaths among homeless women should focus on those under the age of 45 years," the doctors wrote, citing drug abuse, mental illness and disease as factors behind the high death rate.

Those factors are all too familiar to Ms. Lazaroff, who differs only in that she is not yet dead, though she'll tell you "there are some days when that's actually your hope."

Raised in south Regent Park, she was exposed early and often to drugs and dysfunction by her alcoholic mother and heroin-addicted father, who rarely got along. Abuse at the hands of a stepfather started when Ms. Lazaroff was 8 and went on for four years.

"I had the luxury of being in [Children's Aid Society] custody until I was 15," she says, and lasted only a month when she went back home to her mother. She quit school, took a factory job and spent her evenings on the streets.

Later, she moved to a better job, as a chef's supervisor at a nursing home in Shelburne, which lasted 10 years until her relationship with her spouse disintegrated. Her past began to claw away at her, and she ran back to it.

"Then, my addiction set in," she says, "and this is where I'm at now, struggling."

When she's "on a run," Ms. Lazaroff will spend weeks at a time without decent food or sleep, keeping herself alive on a dead-end diet of crack, dangerous sex and petty crime. When her will to fight returns, she makes her way back to the shelter for a warm bed and non-judgmental help with her addiction.

"You feel like a human being here," she says, "you feel like you belong."

The hospital, where Ms. Lazaroff has landed often in recent years, is another story. Which brings us to Dr. Hwang's study, and more specifically, what it did not examine: how homeless drug addicts are treated compared with "the general population."

"We go to hospitals and see doctors for a reason," she says. "We put our trust in them, and the last thing I see when I walk into a hospital is trust."

Ms. Lazaroff speaks of longer-than-necessary waits, superficial assessments and personal questions, asked in the waiting room "with everybody looking at me."

Heather Martin, program manager at the shelter, backs her up, saying many of her clients are reluctant to seek medical treatment.

While he didn't address the issue in his study, Dr. Hwang has enough on-the-ground experience to know these women have a point.

"I think it's fair to say that people with addiction, and people who are perceived to have problems that are, quote, end-quote, their own fault, tend to get treated differently from people whose illnesses are perceived as being not due to personal behaviours," Dr. Hwang says.

A future study will look at these kinds of issues, he says.

Whether Ms. Lazaroff will be around for its release is another question, but one she hopes to answer, some day, with a yes.


Homelessness raises death rate for women (London Free Press)

Canadian Press
Monday, April 12, 2004

TORONTO (CP) - They don't call them the mean streets for nothing. But living on the street seems to be a particularly harsh existence for young and middle-aged homeless women, a new study suggests.

Homeless women under age 45 are basically at the same vastly elevated risk of dying as homeless men in the same age category, making them perhaps the only group of women who don't routinely outlive the men in their age and income brackets.

"Just to put it in context, in that age range, a woman in the general population would be expected to have a death rate that was only one-third or one-half that of a man," said Dr. Stephen Hwang, senior author of the study, published Tuesday in the Canadian Medical Association Journal.

"I think what this really tells us is that the women are facing very severe circumstances."

The study, which tracked 1,981 homeless women in Toronto for just over 2½ years, found those in the 18-to-44 age group were 10 times more likely to die than women of the same ages who had homes.

Studies looking at the conditions facing homeless women in seven other cities - including New York, Copenhagen and Montreal - also found women in this age group were much more likely to die young than housed women.

An advocate for health care for the homeless called the Toronto study's findings "stunning" and "a clarion call" for social change.

"This public health crisis will not be ameliorated until housing and health care become a fundamental right for every human being," Dr. James O'Connell, who teaches at Harvard Medical School, wrote in a commentary also published in the journal.

O'Connell, president of a Boston program called Health Care for the Homeless, said the findings were particularly troubling given that Canada has universal health care. "It does not appear to be sufficient to prevent premature death among homeless people," he said.

Hwang and co-author Dr. Angela Cheung focused on single homeless women, noting that earlier studies have shown that homeless women with children have far fewer health problems.

Hwang is with the inner-city research unit of St. Michael's Hospital in Toronto, while Cheung is with the women's health program at Toronto's University Health Network.

Using records, they compiled a database of single women aged 18 to 64 who had stayed in at least one homeless shelter in the city during 1995. They then searched Ontario's death records for the years 1995 through 1997 for the women.

Tracking the homeless using records is difficult, Hwang acknowledged in an interview, admitting that they found evidence some women used different names to enter different shelters. As well, if any of the women died outside Ontario, the researchers wouldn't have learned of their deaths.

They did find death certificates for 26 of the women, 21 of whom were under age 45. HIV/AIDS and drug overdoses were the leading causes of death in the younger age group.

The older women in the group - those aged 45 to 64 - were also more likely to die prematurely than women who weren't homeless. But their death rates were much closer to the norm for their age.

Hwang admitted he was surprised by that. "I was expecting the reverse. I was expecting older homeless women to be more disadvantaged."

He can't say, based on the data, why the older women aren't at as great a risk as younger homeless women, though he has some theories.

"My suspicion is it's primarily related to the whole substance use and the whole social milieu that younger homeless women are living in," he said.

"To the extent that these women are exploited, that might put them at risk for getting HIV infection or for becoming addicted or having access to drugs that might lead them to overdosing."

The work was supported by a grant from the dean's fund of the faculty of medicine at the University of Toronto.

© Copyright 2004 The Canadian Press

Source: London Free Press

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