Street Nurse Job Description:
Care, Prevention and War on Poverty
Cathy Crowe, RN
Atkinson Economic Justice Fellow
Presentation to the Nursing Volunteers for
The Caring Profession exhibit
at the Canadian Museum of Civilization
This is a great honour to be able to speak to you today, knowing that you will be interpreting a very important aspect of nursing, to the visitors here in the Caring Profession exhibit at the Canadian Museum of Civilization. You will be doing what we as nurses do a lot of - translating, educating and answering questions. You will also be demonstrating a very different kind of nursing – the role of the Street Nurse.
Let me briefly tell you how this came to be, how I became what is known as a Street Nurse and how my black bag came to this exhibit.
I knew from the age of 5 that I wanted to be a nurse. Why? Well, I saw my mother going off to work to the Emergency Department at the Cobourg General Hospital wearing her crisp white nursing uniform and cape. I sensed that to be a nurse was a good thing. But I knew too, that nursing was one of the only acceptable job options for a girl back then. I could have been a teacher, except I was petrified of speaking in public.
I’ve been different types of nurses in my career: a cardiac nurse, a public health nurse, a camp nurse and a nurse practitioner. One of my hobbies is a collection of Harlequin style nurse books with job titles I’ve never had like “Cruise Ship Nurse”, “Peace Corps Nurse”, “Factory Nurse” and “Settlement Nurse”.
I ended up working in the area of homeless health care when I had the opportunity to join a very tiny organization called Street Health in Toronto. It was nurse driven and that’s why I went there, so that once and for all, I could determine what I did as a nurse, and not have doctors or hospital managers tell me what I could or should do – or, more importantly, what I could not.
The term ‘Street Nurse’ was coined by a ‘street person’. One day, a homeless guy who knew us hollered across the street “hey, Street Nurse!” and laughed. And we laughed and the term stuck.
I use the term ‘Street Nurse’ to this day because it tells a story. It tells a story of how things today are different than they used to be. It explains that this country now has a nursing specialty which is homelessness – and that, I suggest to you is obscene.
As a nurse, I have been part of two worlds. My earlier world was interesting but somewhat predictable – nursing in a hospital and then in the community. Then I became a nurse in another world and what I saw and continue to see are conditions that are not only unjust they are cause for national shame: tuberculosis outbreaks, malnutrition, mats on floors in shelters, not enough bathrooms or showers, I could go on and on. I’ve been reading a lot of Florence Nightingale lately, and it is quite shocking to see what we have returned to, given what is known in medical science about the links of poverty and crowding to disease.
Although I ended up doing street nursing quite accidentally, there’s nothing accidental about what has caused mass homelessness and poverty across this country.
I’m still a bit shocked that there is a nursing specialty in this country called street nursing. Several weeks ago, Street Nurses from across this country had our first national get together. Many have been working in the field for over 10 years. That alone should speak to the need for a national housing program. Coincidentally, many of us began this work around the time the federal government cancelled its national housing programme.
I have worked in this area for about 17 years. I worked at community health centres, first South Riverdale CHC, then Regent Park CHC, also Toronto Public Health, and then Street Health and Queen West Community Health Centre, all in the core of the City of Toronto. I would do outreach to shelters and hold nursing clinics at drop-in centres, in shelters and in social housing buildings. I would primarily see homeless or formerly homeless men and women although I also saw youth, families and children.
I also work on larger issues related to shelter conditions and I respond to new emergencies whether it is a squat, an eviction, deaths, outbreaks like SARS, shelter closures, etc. I’m not alone. There are over 50 street nurses in the City of Toronto, working for various employers, who provide health care to men, women and children who are homeless. In 2004 I received what is known as the Atkinson Economic Justice award, which has allowed me to pursue my work for up to three years. I’m currently “housed” at the Sherbourne Health Centre in Toronto and I’m working towards bringing back a national housing strategy.
I used to think of human rights as relevant to starving children, or questions of discrimination like racism, or families fleeing military dictatorship or war or torture or a natural disaster. The question of human rights has come a lot closer to home during the course of my work as a street nurse.
Let me quote you from a Canadian Press article from the year 2000:
Tonight, more homeless people per capita will sleep on the streets and in shelters of Toronto than in several major US cities. In fact, statistics show that homelessness in Canada’s largest urban centre is comparable to levels in New York City, long considered the homeless capital of North America.
Homelessness is now considered a national disaster in Canada. Canada is now widely seen to have violated numerous United Nations covenants and declarations. How did we, how could we, as a country come to this?
Let me give you the Coles’ notes version of how we came to recognize homelessness for what it is – a man made disaster:
· In 1993 the federal government cancelled its national housing programme.
· In 1995 the Ontario provincial government did the same, including cancelling 17,000 units already under development. In addition about 3,000 rent geared-to-income social housing units and 3,300 rent supplement units in privately owned buildings were cancelled. The Ontario government also cut welfare rates 21.6 % and made significant changes to the landlord tenant act.
· Within months of the 1995 housing and welfare cuts, we saw homelessness essentially double on the streets and in drop-ins. We saw clusters of homeless deaths. We saw the return of tuberculosis, more deaths, malnutrition, and more visible homelessness on the streets in most major Canadian cities and then also in towns!
· In the 1996 federal budget, the then-finance minister Paul Martin announced plans for the federal government to download national housing programs to the provinces and territories. Academics and housing advocates were aghast - Canada became one of the few countries in the entire world without a national housing strategy.
· Then, in 1998, finance minister Martin ordered that Canada Mortgage and Housing Corporation - the federal government's housing - be "commercialized". CMHC was converted from an agency with a mandate to ensure all Canadians were decently housed to a profit centre for the federal government. In recent years, CMHC has turned an impressive profit. This year alone, CMHC's annual surplus is estimated at almost three-quarters of a billion dollars - $728 million to be exact. That growing surplus for our national housing agency doesn't get ploughed back into affordable housing - as you might think. Under the government-wide commercialization initiative launched in the 1990s, surpluses are returned to the central treasury. So, Canada by the end of the last century had both a nation-wide housing crisis and homelessness disaster and also a record-breaking surplus in the accounts of its national housing agency.
· In May of 1998 a few of us formed the Toronto Disaster Relief Committee. Then in October 1998, we issued a declaration declaring homelessness a National Disaster and the rest is history. www.tdrc.net
· We made our case all across the country and to the United Nations, and we started to witness widespread “buy-in”.
· National groups, city councils like Ottawa, Vancouver, Victoria and Toronto, and community groups, came to agree that the homeless crisis people faced was a disaster. The United Nations similarly agreed and responded with statements that reflected a polite condemnation of the Canadian government policies that allowed the situation to occur.
Why call homelessness a disaster?
I don’t want to dwell on what we saw a few years ago because I think it is evident now that homelessness qualifies as a man made disaster. But consider this: over 250,000 Canadians will be homeless this year in Canada. There is enormous loss of life. In Toronto an estimated 400 seniors will use the shelter system tonight, and there are approximately 300 women who are pregnant and homeless this year. Each month we add between 6-8 names of homeless individuals to the homeless memorial at the Church of the Holy Trinity beside the Eaton Centre.
The World Health Organization describes disaster as
“any occurrence that causes damage, ecological disruption, loss of human life, deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community.”
What is our situation today?
I want to tell you about what I call the “hotspots”.
Hotspot #1: The shelters are full and unhealthy
Shelters are full and overflowing – both night shelters and day shelters which are called drop-ins. On cold nights mats and cots are squeezed in. This type of congregate living is proven to support infectious disease spread and poor mental health.
In big cities there is an increased municipal reliance on, both the use and abuse of, the volunteer sector and faith based Out of the Cold programs for additional emergency “beds” in the winter months. Homeless people sleeping here move night by night. No longer can we say these people are “guests” of the church or that they choose to avoid shelters or housing. They are economic refugees, displaced people, in need of both proper shelter and support and ultimately housing. We need to provide these basic necessities, just as we would in a natural disaster that left people homeless. In fact the UN defines internally displaced persons as:
“persons or groups of persons who have been forced to flee or to leave their homes or places of residence, in particular because of, or in order to avoid, the effects of armed conflict, situations of generalized violence, violations of human rights or natural or man-made disasters….”
In Toronto, people who are in shelters face a 5-10 year stay while they wait on lists for social housing. While there, they face conditions that believe it or not, often, do not meet the UN Standard for Refugee Camps. For example, there may be an inadequate number of showers and toilets, there may be overcrowding, and there may be no provision for storage of belongings, for privacy or emotional security. You may be familiar with secret video footage that we used to expose this. Some of these problems have now been fixed.
Hotspot #2: People do not choose to sleep outside.
Tonight in Toronto there are approximately 1,000 people sleeping literally outside, in North York alone there are an estimated 200 people sleeping outside – or as the Brits say, “sleeping in the rough” It’s rough all right. Some are on street corners, others on grates, in alleyways, in parks, ravines, along train tracks. Some are robbed or raped, or have their stuff stolen. Any visitor to Toronto will walk by cardboard structures used for shelter, and piles of flattened cardboard and blankets used to shield sleeping bodies from the damp and cold pavement. We had 5 murders of homeless people sleeping outside in 2001. That’s like an American statistic.
We now see encampments and groups staying together for protection. Prior to the by-law banning homeless people sleeping at Toronto City Hall there were up to 80 people.
We now spend an enormous amount of time trying to find sleeping bags. The Winter Relief Project estimates we will need up to 20,000 bags this winter – and note that the bags we are able to afford are Chinook bags, they are not meant for -10 or 15 degrees, i.e. winter camping.
Hotspot #3: Plagues. TB has returned and it is evident that people’s weakened immune system is a major factor in the higher incidence of TB infection and death.
Since 2001 there were 16 active cases of TB in a cluster among homeless men and women in Toronto, 15 of them DNA linked, and three died. Ironically the last case in this cluster was a political refugee from a TB endemic country who contracted TB in a homeless shelter. In addition, two shelter workers have contracted active TB.
SARS is a warning to us. Public health officials, politicians and the media have all ignored our alert to them that if SARS had entered the homeless population it would have been a social catastrophe. Despite warnings there is still inadequate prevention, quarantine plans or intentions to protect people. The recent made-for-TV movie “Plague City”, although dramatized, clearly demonstrated the problems that need fixing.
Hotspot #4: The grief. People are dying – all the time.
In Toronto the people who are homeless are dying at the rate of 6-8 per month and they are dying young, from TB, from AIDS, from trauma, from fire. The impact on their friends who are homeless, on their families, and on the workers is truly devastating. The monthly memorial at the Church of the Holy Trinity is a monthly moment of remembrance and healing for us all. There are now more than 300 names added to the memorial.
I have been using Toronto examples for all of these hotspots, but I can tell you from visiting communities and talking to colleagues, the same hotspot conditions are evident across this country.
Since declaring Homelessness a National Disaster there have been victories.
· The Prime Minister appointed a Minister Responsible for Homelessness. Even better news is that we now no longer have that Minister but we do have an actual Minister of Housing – Minister Joe Fontana.
· In 1999 the National Housing and Homelessness Network was formed, as was the National Coalition on Housing and Homelessness. They are both very strong national lobby groups for social housing.
· In 1999 the federal government announced its homelessness strategy and $753 million over 3 years.
· In December 2000 a MacLean’s survey reported that 85% of Canadians agreed with increased spending to eliminate homelessness.
· Just last month a Leger Poll reported that in the GTA: 81% of GTA residents say homelessness should be a priority of local government; 46% want more homeless shelters in their City; 68% would allow homeless shelters in their neighbourhood; but – and this is unfortunate, only 15% perceived that no affordable housing was a top cause of homelessness.
· We now celebrate and fight for housing on a nationally proclaimed day – November 22 is National Housing Day, marking the day the Big City Mayors Caucus declared homelessness a national disaster.
· In November 2001 the Federal government created the Affordable Housing Framework agreement and in 2003 added more money to a total of $1 billion over 5 years, the first federal funds for housing since 1993. But I would like to note that only 9% of this money has been spent yet.
· In June, 2003, Toronto Dominion Bank issued an economics report on affordable housing “one of Canada’s most pressing public policy issues”. The TD Bank report noted: “After ten years of economic expansion, one in five Canadian households is still unable to afford acceptable shelter.”
· 2005 – there will be $1.6 billion for housing in the Layton-Martin budget if it is passed.
So despite these victories, why is homelessness still increasing?
Professor Ursula Franklin suggests that natural disasters such as the 1985 Mexico City earthquakes that killed 10, 000 people, evoke solidarity and tolerance. We have witnessed other landmark Canadian versions of the earthquake, for example the Eastern Ontario and Quebec ice storm, the Manitoba floods, the Mississauga train derailment. These catastrophes all led to both a shelter and rehousing response.
Political and social divisions are put aside and people focus on providing solutions to the injured and homeless while at the same time addressing prevention, including in the Mexico case - improved use of geological knowledge and the role of the subway layout in the amplification of shock waves.
The Ontario and federal government responded to SARS with “disaster relief” - $20 million dollars – for hospital relief and for a tourism campaign.
But, our governments still to not acknowledge homelessness, as a legitimate political earthquake. If they did we would see an organized tri-level government response to homelessness and it’s not unrealistic to expect that.
A friend and colleague, Beric German told me a story recently. A few decades ago a woman couldn’t afford a hospital birth. She lay on the table and her husband helped her deliver and cut the umbilical cord with a knife. When Beric told me this story it was hard for me to grasp its relevancy. He went on to explain that we now understand and know the need for a public Medicare system. He went on to remind me that a baby was born to a Tent City couple but that birth, even in a publicly funded Medicare system, did not occur in a society that also valued their need for housing. We expect and we demand a fully funded Medicare program. We must also expect and we must also demand a fully funded housing program.
I often get asked by people how they can help.
What can you do as nurses? These are just a few suggestions.
· You could implement a social audit of your hospital or agency practices. For example, is there food in your department or clothing or bus tickets? Is there a proper discharge policy? How do existing policies meet poor people’s needs?
· Consider a client support worker in your hospital. For example, St. Michael’s Hospital hired a formerly homeless man to work with homeless and underhoused patients.
· Does your organization have an ethics committee or patient advocate that ensures practices are in place that do not allow discrimination based on housing status?
· Read a newspaper every day, and know who your city councillor, MPP or MP is and communicate your concerns to them – about hunger, about poverty, about homelessness.
· Donate money and volunteer your time to the three established strategies for dealing with this crisis: 1) direct frontline services 2) the development of housing projects, and 3) anti-poverty or housing advocacy groups.
· Wear a 1% button!
Now, let’s get back to my black bag. My friend and colleague Michael Shapcott asked me to bring my black bag to Ottawa for a press conference that Libby Davies, the NDP housing critic was hosting in the press gallery at the House of Commons. Michael felt that it would visually bring the point home. I explained to the press “look, this is what a street nurse has to carry in her black bag because her patients don’t have a home.” As I was pulling things out of the bag to show the media, I was flooded with images of the people I had known and I began to cry. I was pretty puzzled by that because I did not expect to get emotional. I later wrote an article for the Globe and Mail called “My Black Bag Made Me Cry”. This led to many people learning about my bag. Film maker Shelley Saywell contacted me and made the documentary Street Nurse. Christina Bates from this museum contacted me and asked to see my bag. She then asked me to donate it to the Canadian Museum of Civilization. So, here it is.
I’m glad my bag is now here. It’s in good hands. Thank you for your nursing hands and for volunteering to be part of this amazing exhibit that honours nursing.
Check with delivery
Note: A description of Cathy Crowe's Black Bag in English / French is available in the Resource Section.
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