HEALTH AND HOUSING: A CALL TO ACTIONHEALTH AND HOUSING: A CALL TO ACTION

NATIONAL SYMPOSIUM ON HEALTH AND HOUSINGOCTOBER 2 – 4, 2003CALGARY, ALBERTA

Report prepared for the Canadian Housing and Renewal Association byMerrill Cooper, Guyn Cooper Research AssociatesCalgary, Alberta

ACKNOWLEDGEMENTS

This document summarizes the information shared, the viewpoints expressed and theideas generated at the National Symposium on Health and Housing in Calgary,Alberta. Thanks are due to the 111 delegates to the conference for contributing theirideas for research, programming, and policy, drawing on their work in the fields ofhousing and health.

Particular thanks go to the many speakers who shared their expertise and made thesymposium such a worthwhile experience for all: Alberta Minister of Seniors StanWoloshyn, Calgary Mayor Dave Bronconnier, Calgary Alderman Bob Hawkesworth,Judy Butler; Philip Deacon, Erica Di Ruggiero, Dr. James Dunn, Dr. Gary Evans, Dr. Cheryl Forchuk, Dr. Gloria Gutman, Sandra Hill, Dr. Stephen Hwang, Dr. MarjaKorhonen, Dr. Richard Lessard, Jeff Polakoff, Stephen Samis and Judy Walsh.

Many thanks are due to the National Symposium Steering Committee for generouslycontributing their time, skills, and knowledge in organizing the event:

Joyce Potter, Chair of the National Symposium Steering Committee and 1st

Vice-President, CHRA Board of Directors

Karen Charlton, Manager of Social Development, City of Medicine Hat, andMember, CHRA Board of Directors

Rob Cressman, Director of Housing, Municipality of Halton, and Chair, CHRAResearch and Policy Committee

Dr. James Dunn, Assistant Professor, Community Health Sciences, University ofCalgary

Bob Hawkesworth, Alderman, City of Calgary

Dr. Stephen Hwang, Inner City Health Research Unit, St. Michael’s Hospital,Toronto

Iris Ingram, Member, CHRA Board of Directors

David Seymour, Director, National Aboriginal Housing Association, andSecretary, CHRA Board of Directors

Dr. David Swann, Associate Clinical Professor, Community Medicine,University of Calgary

In addition, thanks go to the staff of CHRA for their ongoing hard work andcommitment in developing and holding this important event.

The National Symposium on Health and Housing was made possible throughfunding from the Canada Mortgage and Housing Corporation and the support of thefollowing sponsors: Canadian Institutes of Health Research–Institute of Populationand Public Health; Canadian Institute for Health Information–Canadian PopulationHealth Initiative; the City of Calgary; and Raising the Roof. Their assistance isgratefully acknowledged.

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TABLE OF CONTENTS

EXECUTIVE Summary ........................................................................................................1

I. Introduction........................................................................................................................4

II. Establishing the housing–health connection ...............................................................6

III. Addressing the housing and health needs of priority populations ...................... 8

IV. Key findings from the presentations and discussions ...........................................16

V. An agenda for action......................................................................................................17

Appendix 1. Symposium presenters................................................................................21

Appendix 2. Symposium participants .............................................................................22

EXECUTIVE SUMMARY

The National Symposium on Health and Housing was an initiative of the CanadianHousing and Renewal Association (CHRA), a national non-profit organization thatpromotes access to adequate, affordable housing and seeks to heighten awareness of affordable housing issues through research, advocacy, networking andcommunications. The purpose of the symposium was to bring together housing andhealth professionals to clarify and reach consensus on the links between housing andhealth, to explore solutions, and to develop action plans to promote policydevelopment and decision-making in the realms of health and housing.

Symposium participants acknowledged that adequate housing is the right of allCanadians and easily reached consensus on housing as both a direct and indirectdeterminant of health. They agreed that improving housing in all its dimensions,and by extension, population health, requires an increase in the supply of affordablehousing and new and enhanced social and supported housing programs. This inturn requires increased prominence for housing on macro-level policy agendas andtargeted policy initiatives to address the needs of sub-populations. New housingprograms and policies need to be informed by more and better research to sort outthe complex relationships between housing and health, and to establish theeffectiveness of existing and proposed interventions. Shared responsibility andcollaboration across sectors will be needed to further the research and effectivelyincorporate the housing–health connection into policy and program decision-making. National research and social policy organizations, such as CHRA, areideally positioned to foster collaborations and move the agenda for action forward.

Presentations and discussions at the symposium revealed the dearth of systematic,experimentally designed Canadian research on the complex relationships betweenhousing and health. Although there exists a rich body of rigorous researchdocumenting the health effects of biological and structural housing risks, we are stillunable to answer vital questions about “dose–response” thresholds, and we have yetto sort out the complicated causal pathways between these physical risks and other“intermediate” variables. These include socio-economic status, tenure andneighbourhood. In recent years, researchers have begun to explore the connectionsbetween some aspects of housing and physical, mental and social well-being, butmost of the studies have been descriptive. It is known that access to affordable,adequate, and appropriate housing has benefits beyond the mere provision ofshelter, but the ways in which specific factors cause specific outcomes have yet to bedelineated. Existing interventions point to a firm link between supported housingprograms and social and health benefits for residents and reduced health care costsoverall. However, we have only begun to collect the concrete evidence to prove it.Symposium participants agreed that both primary and applied research are urgentlyrequired, as are new approaches to research. These include ecological studies and“natural experiments,” which require significant advance planning to ensureconsistency and the capacity to synthesize data across sites and studies, and overtime.

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“To every complex

question there is a

simple answer… and

it’s wrong.”

Rob Cressman, quoting

H.L. Mencken

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At present, Canada does not have sufficient research capacity to conduct thecomprehensive, systematic research required to sort out these complex and multi-directional relationships. As Dr. James Dunn discovered in a national consultationwith stakeholders, this “research capacity deficit” occurs across service provider,government and academic organizations. Service providers often lack the expertiseto complete or make use of experimental research; governments and academics lackthe networks and research infrastructure, along with the links to agencies andconsumers, to efficiently conduct broad-based primary and meaningful appliedresearch. Fortunately, the national research organizations that presented at thesymposium have individually and collectively launched a wide range of initiativesto further the research agenda, and they are willing to consider others. For example,the Canadian Institute for Health Information’s Canadian Population HealthInitiative is shifting its focus from investigator-driven research to knowledgesynthesis and dissemination, and is commissioning evaluations of existing policiesand interventions. CIHR’s Institute of Population and Public Health is placinggreater emphasis on standards of effectiveness for interventions, investing insynthesis research, and encouraging alternative approaches to research tosupplement quantitative studies. CMHC is now working in the area of populationhealth and is researching ways of developing and transferring information on healthand housing topics and the effects of housing programs on health. In addition,CMHC co-chairs and supports the work of the ongoing National Housing ResearchCommittee (NHRC), which is comprised of federal, provincial, industry, socialhousing and consumer representatives. The NHRC’s new Housing and PopulationHealth Working Group intends to synthesize current research into plain languagedocumentation for policy-makers, and to complete a study on the health effects ofthe traditional housing needs criteria using a natural experiment model.

Shortcomings in the research undermine efforts to reinstate or elevate housing ongovernment policy agendas. However, while the case for developing new housingsolutions will be bolstered by improved research, “best should not be the enemy ofbetter.” Participants noted the danger of delaying investments until more research isdone, pointing out that we do have sufficient information to develop policy andlaunch change in some directions. An excellent case in point is the success realizedby Dr. Richard Lessard. As Montreal’s Director of Public Health, Lessard and histeam have made housing a health priority and are collaborating across sectors toimprove social housing and neighbourhood conditions. Likewise, establishedhousing programs for people with mental illness, people with disabilities, and thefrail elderly, along with a promising new initiative for northern Aboriginalcommunities, offer great promise for improved health and well-being and significantcost savings in other sectors. Although the case for expanding and replicating suchprograms would be bolstered by better evaluation, it may be the will to act, ratherthan the mere absence of information on which to act, that is lacking.

Government willingness to enact policy also hinges in part on public opinion. Atpresent, awareness of the social determinants of health, including housing, is verylow. Shrewd strategies will thus be required to lure media attention, increasediscourse, and engage the public in spurring decision-makers to action.

In addition, more detailed and specific information, in “user-friendly” formats, isrequired to advance a compelling case for housing to a broader range of policy- anddecision-makers, at all levels of government. Information must be relevant to thepolicy-makers’ constituencies and clear about the kinds of interventions required:the services, the manner of delivery, the means of delivery, the level of intensity andthe duration. Moreover, in the current climate of fiscal restraint and increasedaccountability to taxpayers, the cost savings to the health and other sectors as a resultof housing interventions must be tracked, proven, and quantified. And of course, themessages must be delivered to the “right people, at the right time.”

Each component of the strategy—housing and programs, research, and policy—willrequire financial investment from a range of government, private, and philanthropicplayers, and collaboration across sectors, horizontally and vertically. Theinvolvement of national research and social policy organizations, such as CHRA,will be crucial. These organizations have the expertise to develop concrete policyrecommendations from scientific research findings, and the connections to carrythem forward and to influence the right people, at the right time. Moreover, they areideally positioned to play a coordinating role across the complex webs of the public,private and philanthropic sectors to promote housing and health connections, fosterresearch and service alliances, and encourage collaborative funding arrangements.

Summaries of Symposium presentations are available on the CHRA Web site atwww.chra-achru.ca.

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INTRODUCTION

Background and Objectives

The National Symposium on Housing and Health was an initiative of the CanadianHousing and Renewal Association (CHRA), a national non-profit organization thatpromotes access to adequate, affordable housing and seeks to heighten awareness ofaffordable housing issues through research, advocacy, networking andcommunications.

The purpose of the symposium was to bring together housing and healthprofessionals to clarify and reach consensus on the links between housing and health,and to propose solutions and develop action plans to promote policy developmentand decision-making in the realms of health and housing. In recent years, the healthof Canadians and the state of the health care system have been prominent onprovincial and national policy agendas. The report of the Commission on the Futureof Health Care in Canada, headed by Roy Romanow, confirmed the value thatCanadians place on effective, efficient investments to maintain a high quality publichealth care system. We know that health is closely connected to housing quality andaffordability. The cost and conditions of housing, along with the neighbourhoods inwhich housing is located, are key components of our environments, and are directlyand indirectly related to individual and population health and well-being. We alsoknow that, for some groups, supported housing can be part of a successful and cost-effective health treatment—or illness prevention—program. And yet, despite a moveby Health Canada and others in the health sector to adopt a population healthapproach, the importance of housing as a determinant of health is not well known bythe general public, and remains low on policy- and decision-makers’ agendas. How,then, can we clarify the housing–health connection? How can we ensure thatdecision-makers receive the information they need to begin improving housing for allCanadians? How do we make the case for housing as a determinant of health?

Overview of the Symposium

The symposium was attended by an enthusiastic group of over 100 participants fromuniversities, national organizations, community agencies, municipalities, andprovincial and federal governments.

Participants were welcomed to the symposium by CHRA’s President, Dr. JohnMetson, and by Calgary’s mayor, His Worship David Bronconnier. The gathering wasformally opened by Joyce Potter, CHRA’s 1st Vice-President and Chair of the NationalSymposium Steering Committee, followed by addresses from Calgary Alderman BobHawkesworth and Alberta’s Minister of Seniors, the Honourable Stan Woloshyn.

Dr. Richard Lessard, Director of Public Health for Montreal-Centre, delivered theopening keynote address, advancing a persuasive case for housing as a healthpriority. Dr. Lessard discussed his research linking housing conditions with the healthof Montreal’s inner-city, low-income population. He described his success in workingcollaboratively across sectors to address housing problems, providing insight andinspiration to participants.

Participants heard from many other distinguished speakers over the course of thesymposium. Drs. Stephen Hwang, Gloria Gutman, Marja Korhonen, Cheryl Forchukand Gary Evans summarized the recent research on the multifaceted relationshipsbetween housing and individual and population health. The academic presentershelped to clarify what we know with certainty and what we have yet to sort out.

Front-line service providers and program developers Judy Walsh, Judy Butler andSandra Hill shared success stories about the broader, positive health effects that canbe realized by well-designed and managed supported housing programs. JeffPolokoff presented a promising new strategy to improve housing conditions forAboriginal peoples in northern Manitoba.

Erica Di Ruggiero, Stephen Samis and Phil Deacon updated symposium participantson new directions and initiatives undertaken by three national research and fundingorganizations to improve the state of health and housing research in Canada.

Participants and presenters quickly came to consensus on housing as a keydeterminant of health, and began fruitful discussions on priorities for both researchand action. Participants formed into smaller working groups to discuss strategies forinfluencing policy that would meet the inter-related housing and health needs ofseniors, the homeless, people with mental illness, children and families, andAboriginal peoples.

The highlights of the symposium were ably summarized by health and housingexpert Dr. James Dunn in the final keynote address. Dr. John Metson formally closedthe symposium.

Biographical sketches of symposium presenters are provided in Appendix 1.Summaries of the presentations are available on the CHRA Web site at www.chra-achru.ca.

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ESTABLISHING THE HOUSING–HEALTHCONNECTION

Overview of the research

There exists a substantial body of research into the many linkages between housingand health status. The majority of this research has focused on the connectionsbetween substandard and crowded housing conditions and incidence of injury,disease, and myriad physical ailments. Epidemiological studies have established thatcertain contaminants in the indoor residential environment, such as mould,dampness, and cockroach antigens, cause or exacerbate a range of respiratoryproblems, particularly among children. In addition, negative health consequenceshave been conclusively linked to the physical structure of the home, includingovercrowding and structural deficiencies. The research has also documented a longlist of health problems associated with exposure to environmental hazards, includingcarbon monoxide, heat waves, excessive noise, pesticides, tobacco smoke and so on,both within homes and in the larger residential environment. A recent analysiscompleted by Dr. Richard Lessard and his colleagues in Montreal, for example,revealed that the prevalence of environmental risks in inner-city, low-incomeneighbourhoods coincides with a dramatically higher incidence of serious healthissues, such as asthma, and shorter overall life expectancy.

Over time, the investigation has broadened to include other ways in which housingmay influence physical, social and mental well-being. There is substantial evidencelinking housing type, quality and structure with psychological health and, forchildren, with a range of developmental outcomes. Studies in Canada, the UnitedStates, the United Kingdom and elsewhere have also begun to look beyond thestructural characteristics of dwellings to explore the connections between health andneighbourhood design and features, housing tenure and stability, and housingaffordability. In addition to the direct links between the physical conditions ofdwellings and health, neighbourhoods that are unsafe, with limited access to essentialgoods and services and few opportunities for social integration, also pose health risks,particularly for the poor, the elderly, and other vulnerable groups.

Just as housing is a prerequisite for good health, homelessness has emerged as acritical health issue for Canadians. Hundreds of studies provide incontrovertibleevidence of the associations between homelessness and higher rates of mortality,injury, addictions, a broad range of mental and physical health problems, anddiminished quality of life overall.

Despite the challenges inherent in proving that specific factors bring forth specificoutcomes, the research has clearly substantiated some relationships and providesstrong evidence of others. We know that access to appropriate, affordable housingoffers benefits beyond the mere provision of shelter, which include but are not limitedto improved health and well-being. For many groups, including children, seniors,people with mental illness, and Aboriginal peoples, housing may serve as a gatewayto and a lever for other forms of support and intervention with broader, positiveindividual and social outcomes.

“Global housing

conditions that are

favourable to health

are created by

ensuring that housing

is exempt from

contaminants and

other risks to health,

supporting the

development of social

housing for the poor

and housing for

groups with special

needs, and improving

the overall quality

of residential

neighbourhoods,

particularly in poor

and underdeveloped

areas.”

Dr. Richard Lessard

Shortcomings in the research

Further investigation is needed into the multiple and two-directional relationshipsbetween the health and housing variables in order to clarify and confirm causalconnections. There is a dearth of experimental research establishing cause and effect.In addition, many of the existing studies are marred by weak research designs that failto control for confounding variables such as socio-economic status, length ofexposure, and self-selection bias, and by designs that feature subjective definitionsand self reports of both housing problems and mental health status. Likewise, studiesexploring the connections between housing and mental health often overlook factorsthat might explain how and why housing influences mental health, such as housinginstability and, with respect to children, parenting practices.

In addition, very little research has been done on the effectiveness of interventions.The vast majority of the studies completed have been descriptive and, in some ways,of little practical use to those who make policy, design programs, and deliver services.Rigorous evaluation of existing and new interventions is vital to bolstering the casefor housing as a component of population health. As yet, however, we do not have thedata to answer questions about thresholds: How severe do the risks have to be, aloneand in combination, to cause harm? How extreme must the interventions be, and forwhat duration, to prevent or redress the harm? There is an urgent need to explorethese pathways further and to establish the effectiveness of housing interventionsthrough experimentally designed research.

Recent steps to improve the state of the research

National research and funding organizations have begun to incorporate housing as adeterminant of health into their strategies and frameworks, and to restructure theirapproaches to address needs, gaps and opportunities in housing and health research.CMHC is now working in the area of population health and is researching ways todevelop and transfer information on health and housing topics and the effects ofhousing programs on health. In addition, CMHC is supporting the work of theNational Housing Research Committee (NHRC). The NHRC’s new Housing andPopulation Health Working Group intends to synthesize current research into plainlanguage documentation for policy-makers, and to complete a study on the healtheffects of the traditional housing needs criteria using a natural experiment model. TheCanadian Population Health Initiative (CPHI) of the Canadian Institute for HealthInformation (CIHI) is shifting its focus from investigator-driven research toknowledge synthesis and dissemination, and is commissioning evaluations ofexisting policies and interventions. Finally, the Institute of Population and PublicHealth (IPPH) of the Canadian Institutes of Health Research (CIHR) is placing greateremphasis on standards of effectiveness for interventions, investing in synthesisresearch, and encouraging alternative approaches to research to supplementquantitative studies.

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“The health and

housing research is

not being done well

enough in Canada,

and the Canadian

context matters.”

Erica Di Ruggiero

“We need to alter the

discourse to include

housing as a vessel for

other influences, and

as both a facilitator of

and a buffer against

other factors in

people’s lives.”

Dr. James Dunn

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ADDRESSING THE HOUSING AND HEALTHNEEDS OF PRIORITY POPULATIONS

CHILDREN AND FAMILIES

The issues for children and families

Children’s health and well-being are closely connected with housing quality,suitability and affordability. Studies indicate that stable, safe and secure housing isvital to children’s healthy development. Housing is a key component of both thephysical and social environments in which children live, and it plays both a direct andindirect role in the achievement of positive developmental outcomes. Factorsaffecting these outcomes include the cost, quality, tenure and stability of the housing,along with the neighbourhood in which the housing is located.

These factors are mediated by socio-economic status. Low-income families spend agreater proportion of their incomes on basic shelter needs and, therefore, less moneyis available for other necessities, including food. In addition, low-income families aregenerally restricted to housing at the bottom of the market, which is often cheaperbecause of its poor physical quality or because its surroundings have social orenvironmental problems detrimental to physical health. The research showsassociations between child developmental problems and low levels of neighbourhoodsafety and cohesion, neighbourhood affluence, employment, and other risk factors.Poor dwelling and neighbourhood conditions have been conclusively linked to illnessand injury. Finally, low-income families tend to move households more frequentlythan middle and upper income families. Numerous studies show negativeassociations between residential mobility and behavioural and cognitive problems,even controlling for socio-demographic characteristics.

Recent research completed by Dr. Gary Evans of Cornell University has helped toclarify how poverty may be connected with adverse socio-emotional developmentamong children. Briefly, Dr. Evans’ research confirmed that low-income children areexposed to a substantially greater number of housing-related stressors, such as noisy,crowded, low-quality housing, than their middle-income counterparts. Moreover,low-income children exhibit higher levels of stress, as reflected by heightened levelsof secretion of cortisone, epinephrine, and norepinephrine, than middle-incomechildren with exposure to each individual stressor. The research also shows that thedifferences between low-income and middle-income children increase over time withexposure to cumulative risks. These findings suggest that cumulative stressorexposure resulting from poor housing may partially account for the well-documentedmental health risks that accompany poverty.

Priorities for addressing the health and housing needs of childrenand families

For children and families, the National Children’s Agenda and the new federal urbanagenda provide opportunities to promote low-income children and families as amajor need group and to showcase the net societal benefits and the cost savingsrealized in other areas by increasing investment in both affordable and social housingfor children.

To these ends, key players from other sectors must be engaged to promote the causeby tying housing to larger, related policy issues in children’s services, education,social assistance and health care. Key players should include school boards, hospitalsand front-line community service providers.

“We want to be able

to say to policy-

makers: We are not

controlling for poverty,

we are explaining how

poverty relates to the

housing problems

experienced by

children that have

health effects; i.e.,

when you are poor,

you live in dwellings

where there is more

crowding, more noise,

poor quality. The

research shows that

the effects are

cumulative, and have a

significantly greater

impact on poor

children.”

Dr. Gary Evans

SENIORS

The issues for seniors

By 2021, Canadians aged 65 years or more will comprise 20 per cent of the population,a dramatic increase from the 13 per cent of 2001. There is growing concern thatincreasing numbers of older people will have catastrophic consequences for society,specifically, that they will “break the bank” with demands on the health care andpension systems. These outcomes may be averted if we take steps to ensure seniors’health and well-being so that they can continue to be productive, offset projectedlabour shortages, and foster Canada’s ongoing economic growth and stability. Tothese ends, it is vital that we address seniors’ housing needs appropriately, now andin the future. Many studies have established that living in appropriate, affordable andsafe housing of good quality contributes to seniors’ quality of life. Housing is tied tomany of the 12 determinants of seniors’ health as identified by Health Canada,including physical environment, social environment, social support networks,income and social status, lifestyle and health care. Likewise, the World HealthOrganization has described physical and mental activity, participation, and security(which includes health, income, and housing) as the three “pillars” of “active aging.”

Promising housing programs for the frail elderly: EdwardsPlace

Edwards Place is a 149-unit apartment building for low-income seniors in inner-city Calgary. In 2000, Edwards Place launched a supportive services program tomeet the health and social needs of frail elderly residents and thereby prolongtheir ability to live independently. A community resource coordinator providesneeds assessment and advocacy services, linkages to required health and socialservices, and assistance in relocating individuals in need of more supportiveliving environments.

An evaluation of the program in 2002 reported a decrease in the number ofresidents having to move to nursing homes and other forms of acute care, alongwith decreases in the number of visits to hospital emergency rooms and hospitaladmissions. Evaluators attribute these changes to better and more timely accessto medical and social services facilitated by the community resource coordinator.

Evaluators credit the program’s success to the on-site community resourcecoordinator; the positive personal relationships developed between each residentand the coordinator, which informs the design and quality of individual caseplans; the positive relationships with the various service providers; and thecareful delineation and coordination of responsibilities among service providers.

Priorities for addressing the health and housing needs of seniors

The priority for seniors is to ensure the development and implementation of a rangeof housing models and choices to accommodate the diverse needs of thisheterogeneous population comprising wide ranges in age, ability, culturalbackground and income. It is unlikely that the high proportion of single-parentmothers and unattached women under the age of 65 currently living below thepoverty line will shrink as the population ages, so housing affordability will becomeeven more important in the future. In addition, there is a pressing need to preserveand expand the housekeeping and other supports available to seniors to enable them

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“I’ve got news for you

fellas. You can’t pay

women to have babies.

We need to keep older

people working if we

want to maintain the

size of our workforce

and, along with it,

economic growth and

our standard of living.

And this means keeping

seniors healthy and

active, not idling away

in nursing homes.”

Dr. Gloria Gutman

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to remain in their own homes. In conjunction, there is a need to develop the “rightmix” of housing models, including supportive housing, assisted living, and carefacilities, with attention to overseeing and being accountable for services to the frailelderly who cannot advocate for themselves.

To accomplish these goals, we need to raise awareness about the housing and healthconnection for seniors and put seniors’ housing on the policy agenda. To develop the“right mix” of housing for seniors will require the reallocation of federal andprovincial dollars and new intergovernmental and intra-sectoral funding protocols.Decisions about investments in seniors’ housing should reflect projections informedby research on the types of housing, and the proportions, that seniors of the future aregoing to require, demand and expect.

PEOPLE WITH DISABILITIES AND PEOPLE WITH MENTALILLNESS

The issues for people with disabilities

Difficulties in accessing and maintaining housing can be extreme for people withdisabilities. In addition to affordable housing shortages, these groups face specificbarriers in securing and retaining safe and suitable accommodation. By the 1970s,advances in medicine were prolonging the lives of paraplegics and other physicallydisabled adults, but accommodations for these individuals were primarily limited tonursing homes and parental homes. This problem continues today. In most urban andrural centres, there are too few housing units that are accessible to people withdisabilities, many of whom also require personal attendants and other supports. As aresult, many of these people remain in long-term care facilities rather than livingindependently.

Promising housing programs for disabled young adults: TenTen Sinclair Housing Inc. TenTen Sinclair is a 75-unit, wheelchair-accessible apartment building inWinnipeg. The facility opened its doors in 1975 with a view to providing peoplewith disabilities with affordable, transitional accommodation along with the lifeskills required to function independently in an integrated community setting.The building is staffed by a social worker, occupational therapist, homeeconomist and several coordinators. To provide an integrated learning and livingenvironment, 25 units are reserved for non-disabled individuals.

Although the program has not been formally evaluated, individual successstories, along with residents’ and service providers’ observations, suggest thatcombining accessible and affordable housing with learning programs has apositive impact on the health and well-being of residents. Keys to TenTenSinclair’s success include its independent living philosophy and tenants’motivation to exploit the opportunities available to them.

People with mental illness

The issues for people with mental illness

The widespread shortage of social and affordable housing combined with policies todeinstitutionalize the mentally ill have contributed to a lack of appropriate supportedhousing options for people with mental illness and discharged psychiatric patients,with social and health consequences. Many of these people have neither the financialnor the personal resources to gain access to the few housing options available. Inaddition, landlords are often reluctant to rent to people with mental illness. As aresult, many people with mental illness become homeless or live in squalid housingconditions, which often perpetuates and exacerbates their psychiatric conditions. It isestimated, for example, that about one-third of homeless people in Toronto sufferfrom mental illness, often in conjunction with addictions, and many of them receiveno treatment. Homelessness itself can precipitate mental illness and substance abuse.

Recent research completed by Dr. Cheryl Forchuk and colleagues challenges the myththat homeless people choose to live on the streets or in shelters. In fact, virtually all ofthe homeless respondents in her study indicated that they would prefer to be housedand living alone or at least in a situation that affords them some privacy. About one-third of the respondents had experienced homelessness during adolescence, and 20per cent had experienced three or more “undesirable moves” (moves they neitherinitiated nor wanted) in the past two years. Many of the respondents with housingdetailed their abysmal living conditions, explaining that they stayed because therewere no alternatives. Financial benefits provided through income security programsare insufficient to cover rental costs, damage deposits, telephones and transportationcosts, making it very difficult to secure adequate accommodation or to achieve areasonable quality of life. In addition, the study revealed many problems in accessingbenefits, some attributable to arbitrary program policies and simple lack ofcoordination among various benefit programs and policies.

Promising housing programs for people with mental illness: 350 Prideaux Street 350 Prideaux Street is a permanent supportive housing project in Nanaimo forsingle adults with physical or mental disabilities or with a history of mentalillness. The overall objective of the project is to assist residents, most of whomhave psychiatric issues, to maintain long-term tenancy by helping them developbetter independent living skills, linking them with appropriate services, andencouraging their participation in the broader community.

A qualitative evaluation of the project in 2001 revealed that the project had metand exceeded its objectives. Findings support other research showing that mentalhealth needs are best addressed after basic survival needs have been met, andfurther, that linking supports to housing significantly improves psychiatricoutcomes. Tenants at 350 Prideaux Street reported increased independence inbasic living skills; establishment of interpersonal relationships and increasedsense of belonging; increased use of preventive health care and consistency ofhealth service providers; increased positive use of time through engagement inmeaningful or productive activities; and increased perceived quality of life, asreflected by problem-solving and decision-making abilities, sense of self-worth,sense of security and outlook for the future. Tenants’ need for assistance frommental health support workers decreased, which was ascribed to an increase inthe number of hours of homemaker support provided. Moreover, tenantsexperienced dramatic reductions in both hospital admissions and length ofhospital stays, for both medical and psychiatric reasons.

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“This research clearly

dispels the myth that

homeless people are

on the streets or in

shelters because that

is where they want

to be. Virtually all

homeless people

want safe and

permanent housing

that affords them

some degree of

privacy.”

Dr. Cheryl Forchuk

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Evaluators attribute the project’s success to five factors: affordability, with rentmatched to benefit levels; permanency; availability of home support, includinghousekeeping and personal care; a strong focus on “wellness,” whereby residentsare considered to be “well” with periods of illness; and security of tenure duringperiods of hospitalization.

Priorities for addressing the health and housing needs of peoplewith mental illness

The priority for “hard to house” people with mental illness is to reduce homelessnessand promote better physical and mental health through housing interventions. Thiswill require the development of more integrated (rather than segregated) housingunits that are affordable, safe, and supported so that people with mental illness can“choose, get, and keep” the type of housing they want. Housing should afford somemeasure of privacy to tenants, and should guarantee tenure during absences fortreatment or other reasons and after mental health improves.

Obtaining better housing for people with mental illness will require increasedincentives to build more affordable housing; development and integration of coherentpolicies and services across the housing, health and mental health sectors; commonterminology to define and explain available housing options and models; and publiceducation to reduce barriers to obtaining housing, particularly the stigma associatedwith mental illness.

Further research is needed to demonstrate the effectiveness and cost benefits ofsupported housing interventions to decision-makers. A first step would be to bringtogether academics, consumers and service providers to build a national database ofoutcomes from existing programs. Participants would collectively identify desiredoutcomes (such as quality of life, length of tenure, housing history), defined andmeasured the same way to allow for synthesis of data. This would allow for thecreation of baselines and measurement of outcomes to inform policy developmentand to educate and generate greater understanding among the public.

THE HOMELESS POPULATION

The issues for homeless people

Because of the challenges associated with collecting data on the homeless, we do nothave an accurate estimate of the number of people who are absolutely homeless(those who live entirely on the streets or in shelters) or the far greater number ofpeople who are relatively homeless (those who live in tenuous or seriouslysubstandard housing and are at serious risk of becoming absolutely homeless). We doknow, however, that the number of Canadians who are absolutely homeless hassharply escalated over the past decade, sparking a surge of studies on the causes andconsequences of homelessness, along with a range of new interventions to address thehealth and housing needs of the diverse homeless population.

The links between homelessness and health are incontrovertible. Homelessness isassociated with higher rates of accident, injury, physical and sexual assault, and arange of physical health conditions including tuberculosis, skin infections andconditions, poor blood circulation and foot problems. Rates of mental illness amongthe adult homeless population are estimated at between 10 and 50 per cent. In

addition, in his recent study of homeless men in Toronto, Dr. Stephen Hwang foundthat they had higher mortality rates compared to other Toronto residents. Mortalityrates were eight times higher among men aged 18 to 24 years, four times higheramong men aged 25 to 44 years, and twice as high among men aged 45 to 64 years.

Priorities for addressing the health and housing needs of thehomeless population

The priorities for preventing and providing pathways out of homelessness are: toincrease the sustainability of program interventions by securing operating funding inaddition to capital funds; to improve the continuum of care through enhancedcoordination of interdisciplinary services and improved access to and quality ofprimary health care; and to increase the stock of affordable, adequate and supportedhousing.

Further evaluation and outcome measurement is required to build a compelling caseto decision-makers about the links between housing, health, and other sectors, suchas justice. Research connections should be fostered between agencies, universityresearchers and policy researchers, locally and nationally, and across sectors toachieve consensus on definitions and approaches to evaluation. Connections are alsoneeded to foster better and more appropriate ways of conducting individual andmulti-site program evaluations. One objective would be to develop a best practicescompendium. CHRA could utilize its national and local connections and championthe cause for interdisciplinary primary and applied research. In addition, CHRA isideally positioned to stimulate advocacy at the grassroots level for a national housingstrategy, to carry the message forward to decision-makers in multiple sectors, and toplay an influential role in policy development.

ABORIGINAL PEOPLES

The issues for Aboriginal peoples

Housing problems for both urban and rural Aboriginal peoples are pervasive andacute. By comparison with the general Canadian population, a disproportionatenumber of on-reserve and off-reserve Aboriginal peoples, including Inuit, Métis, andFirst Nations, live in very poor housing conditions. Crowding (defined as more thanone person per room) has resulted from housing shortages in conjunction with largefamily sizes and families “doubling up” to reduce overhead costs or because there isnowhere else to live. Although crowding has decreased somewhat over the pastdecade, this problem continues to be widespread and acute: In non-reserve areas, 17per cent of Aboriginal peoples live in crowded conditions; in the far north, 53 per centof Inuit people, escalating to almost 70 per cent in some areas, live in crowdedconditions.

Moreover, the homes of Aboriginal peoples are far more likely to need major repairs(due to defective plumbing or electrical wiring, or to serious structural problems)than the homes of other Canadians. Eighteen per cent of Aboriginal peoples living off-reserve reside in housing in need of major repairs; 40 per cent of First Nations on-reserve homes are inadequate. Finally, between 27 and 34 per cent of all Aboriginalpeoples are in “core housing need,” which, as defined by CMHC, refers to“households that are unable to afford shelter that meets adequacy, suitability andaffordability norms.” The poor condition of the housing that is available isattributable to crowding and excessive wear and tear, lack of maintenance, poorconstruction and/or materials, and the effects of climatic extremes.

13

14

The health and social ramifications of such poor living conditions are enormous. It iswell established that the health of Canada’s Aboriginal peoples is poorer than that ofCanadians generally: life expectancy is lower, and rates of infectious diseases, infantmortality, suicide, injury, substance abuse, and family and inter-personal violence aredramatically higher. Each of these factors is associated with inadequate housing,although it is far more difficult to establish firm causal connections for some of thevariables than for others. We do know, for example, that faulty structure andinadequate heating can cause accidental injuries; fire is one of the leading causes ofaccidental death among First Nations children. Likewise, crowded living conditionscan lead to transmission of infectious diseases, such as tuberculosis and hepatitis A,and higher incidences of respiratory illness, particularly when there are smokers inthe home. These and other health problems are exacerbated by inadequate hygienefacilities, poor ventilation, mould and contaminated drinking water. Studies have alsoestablished or strongly suggest that overcrowding and poor housing is associatedwith emotional and mental health problems. For example, excessive noise, sleepdeprivation, and lack of private space have various negative psychological effects,including irritability, aggression, depression and inability to concentrate, and maycontribute to family tensions and violence. And of course, if there is no alternatehousing available, it may be impossible to escape an abusive home situation.

Clearly, more and better housing is urgently required, particularly in northern andremote areas, but there have been many barriers to success. These include but are notlimited to difficulties in obtaining mortgages and housing loans, higher constructioncosts in remote locations, extreme environmental conditions, social and economicissues, and jurisdictional issues.

Promising housing strategies for Aboriginal peoples:Manitoba’s Northern Housing Strategy Manitoba’s Northern Housing Strategy was developed by the Manitoba Housingand Renewal Corporation (MHRC), in partnership with five northern Aboriginalorganizations, to address housing needs in the northern part of the province.Housing in northern Manitoba, as in other northern areas of Canada, representsa critical area of need. The Northern Housing Strategy offers great promise forimproving housing and thus the health, social, and economic conditions innorthern Manitoba.

To overcome the many problems associated with conventional building methodsin the north and to provide “the best house for the best price,” panelized housingtechnology, which features pre-manufactured, well-insulated panels, wasselected for the construction of a northern model house. Using this technology isexpected to improve individual health, enhance training and employmentopportunities, and increase economic development. The actual design features ofthe home were created with input from those who will eventually live in thedwellings. Examples of these features include large bedrooms separated intodifferent zones, a structure that anticipates “building on,” northern entry, andmany features relating to accessibility. Ensuring that the homes are specificallydesigned to accommodate the individual, family, and community circumstancesand conditions of northern and Aboriginal peoples is expected to have a positiveimpact on other determinants of health for residents.

The success of the Northern Housing Strategy so far is credited to several factors:the recognition that personal and community consequences of housingdeficiencies have impacts on individual and community health and concomitant

“There has been a lot of

talk about building

Aboriginal capacity to

take responsibility and

to take care of

ourselves but we need

tools, training, and

infrastructure to take

this on. It is not always

clear that health

disparities in the

Aboriginal population

are really a priority.”

Dr. Marja Korhonen.

costs; the ability of the partners to temporarily set aside jurisdictional issues tofirst identify solutions; the ability of different departments and levels ofgovernment to collaborate; funding provided by the province and the federalgovernment through the Affordable Housing Initiative; and meaningfulconsultation and collaboration with Aboriginal organizations and future housingconsumers.

Priorities for addressing the health and housing needs ofAboriginal peoples

The utmost priority for Aboriginal peoples is to increase the supply of appropriate,sustainable housing and, in particular, the number of homes owned by Aboriginalpeoples.

Housing should be designed by Aboriginal peoples so that it meets their uniquephysical and social needs and serves as a lever for other social change, in addition toproviding adequate and affordable shelter. This will require the provision of varioussupports, including education about home ownership and maintenance, which inturn requires collaboration among policy-makers and Aboriginal service providers.Existing barriers include issues of property ownership on reserve and the federalgovernment’s devolution of responsibility for housing to the provinces.

Aboriginal housing development should incorporate best practices based onevaluation of existing and future interventions. Further research is not required toestablish a need; the primary problems of poor quality, crowded housing on reserveand lack of housing off reserve are well documented. What remains to be determinedare such things as the effects of various housing support services on the health ofAboriginal peoples, whether home ownership increases commitment to maintaininghousing, and whether Indian and Northern Affairs Canada funding formulae andhousing policies achieve their desired outcomes.

15

“Health and well-being

are part of Aboriginal

culture and values.

Housing needs to

reflect those values—

this is part of the

definition of

‘adequate’ housing

for Aboriginal

peoples.”

David Seymour

16

KEY FINDINGS FROM THE PRESENTATIONSAND DISCUSSIONS

From the research

• There is sufficient evidence to conclude that adequate, affordable and appropriatehousing is a prerequisite for good health.

• Further experimental research is required to delineate the complicated causalpathways between housing and health, to answer questions about dose–responsethresholds, and to identify “best practices” for programs and other interventions.

• Both the provision of shelter and the provision of supported housing can serve ashealth interventions for low-income and marginalized groups. However, shelteralone is insufficient to address the problems experienced by people with mentalillness, seniors, and homeless and marginally housed individuals and families. Awide range of supported housing options is required to address the varied needsof diverse demographic groups. There is no “one-size-fits-all” solution.

• The supply of adequate, affordable and appropriate housing and supportedhousing is insufficient to meet current and future demand.

• Incoherent housing policies and practices, in conjunction with lack of cross-sectorcoordination, contribute to the difficulties faced by hard-to-house individuals andfamilies in securing both short- and long-term housing.

• The dearth of quality research on housing and health, in conjunction with lack ofpublic awareness about the housing–health connection, limits the case that can bemade to policy-makers and governments to improve housing conditions.

From the promising housing programs

• Evaluations by service providers strongly suggest that the cost of providingsupported housing programs to people with mental illness, people withdisabilities, and seniors with health concerns is more than offset by savings to thehealth care system. In fact, it appears that these programs may result in significantreductions in heath care costs. However, more thorough evaluation is required toquantify and conclusively demonstrate the cost-effectiveness of supportedhousing interventions to policy-makers.

• Common barriers to housing for people with mental illness, people withdisabilities, and seniors with health concerns include lack of appropriate housing,inadequate shelter allowances, social stigma, discrepancy between policy andneed, and inconsistencies and lack of coherent connections between the health,social service and housing sectors.

• Financial support for constructing new supported housing initiatives is relativelyeasy to obtain; the challenge lies in securing funding to sustain operations.

• “Appropriate” housing means housing that is designed and supported as per thespecifications of those who will live in it. “Affordable” should mean that rent isgeared to benefit levels, and that tenants have some flexibility with respect toissues such as damage deposits.

• Wherever possible, housing should be permanent rather than transitional, andshould include security of tenure during periods of absence for reasons includingbut not limited to hospitalization.

• When contemplating new housing initiatives, it is vital that all relevantstakeholders—service providers, consumers, funders and government decision-makers—are involved in the planning process from the outset.

• Home supports, such as housekeeping and personal care, are not luxuries; rather,they are vital supports that directly contribute to the health and well-being ofresidents.

From the Northern Housing Strategy

• The construction of appropriate housing for the northern Aboriginal populationmay be a vehicle to improve the health, social and economic conditions forresidents and communities.

• To address the housing needs of the northern Aboriginal population, solutionsmust include new building technologies, alternative designs, financing, andmanagement techniques.

• When devising housing solutions for Aboriginal peoples, Aboriginal peoplesmust be the key decision-makers, with government experts bringing the plans tofruition.

• In devising housing solutions for northern Aboriginal communities, it is mosteffective to bring stakeholders together to work on the solutions, and to sort outjurisdictional issues later.

AN AGENDA FOR ACTION

Conference participants acknowledged that, first and foremost, adequate housing isthe right of all Canadians, and easily came to consensus about the role of housing asboth a direct and indirect determinant of health. They agreed that improving housingin all its dimensions, and by extension, population health, requires an increase in thesupply of affordable housing and new and enhanced social and supported housingprograms.

At present, however, the importance of housing as a determinant of health is not well-known by the general public and remains low on the policy agendas of many policy-makers in health, housing, and other sectors. Participants agreed that a coherentstrategy is required to put forward a compelling case to policy-makers. The strategyshould include four components: (1) increasing the stock of adequate, affordable andappropriate housing; (2) raising public awareness about the health–housingconnection; (3) improving the research; and (4) developing and bringing forwardconcrete policy recommendations.

Increasing the stock of adequate, affordable and appropriatehousing

Although the case for developing new housing solutions will be bolstered byimproved research, “best should not be the enemy of better.” We need not wait fordefinitive proof of causation on every link between housing and health to moveforward and, in any case, the right to housing should take precedence over the role ofhousing as a determinant of health.

With a view to addressing housing shortages in the immediate future, new incentivesare required to encourage the private sector to participate in developing affordablehousing. However, affordable housing for all will not be accomplished withoutsignificant capital, subsidy and regulatory commitments from all levels ofgovernment. These sorts of initiatives should be linked to the new federal urban

17

“Best should not be

the enemy of better.

Even if we cannot

definitively prove

every causal

relationship right

now, we can still

communicate

what we do know

reasonably well.

We are well positioned

to make some

recommendations

now.”

Dr. Gary Evans

18

agenda. Also, alternate solutions should be explored, such as working with privatelandlords to provide tenants with mental health and social service supports inexchange for long-term leases or guaranteed rent subsidies. Finally, new monies arerequired to sustain, expand and replicate promising supported housing programs. Atpresent, financial support is more easily secured for land, bricks and mortar than forthe ongoing subsidies and programming required by tenants.

When assessing needs and solutions, the unique circumstances in rural and northerncommunities must be understood. One factor is the virtual absence of a voluntarysector in the north. In addition, it is vital that the consumers or target populationgroups be properly consulted about program design and structure. In particular,Aboriginal people should lead the decision-making process when designing housingfor Aboriginal populations, with support and input from other stakeholders. It willalso be helpful to adopt common terminology to define and explain available housingoptions, including the types of support services included with the housing (e.g.,supported housing, independent living), along with commonly identified anddefined desired outcomes (e.g., quality of life, health care utilization, independence).

Raising public consciousness

Engaging the public is crucial to facilitating policy action on housing and health.Decision-makers are unlikely to give priority to housing as a determinant of health inthe absence of public pressure. Unfortunately however, public knowledge about thesocial determinants of health in Canada is extremely low. In a recent CPHI-commissioned public opinion poll, fewer than two per cent of Canadian respondentslisted housing among the determinants of health. Strategies are required to raisepublic awareness of the ways in which health is tied to housing. These may include apublic education campaign about the social determinants of health. Past efforts toeducate the public about individual determinants of health, such as smoking,nutrition and lifestyle, have been effective in raising awareness. Similar efforts shouldbe considered with respect to housing and health, for example, by profiling affectedindividuals to put a human face on the issues, or by attracting well-knownindividuals or celebrities to champion the cause.

Improving the state of the research to influence policy-makers

The evidence in support of housing as a socio-economic determinant of health isstrong, but the case would be substantially improved by more thorough research anddocumentation. There is an urgent need for rigorous, experimentally designedresearch and evaluation of new and existing interventions that are relevant to thosewho make policy, design programs and deliver services. New research and evaluationmust seek to establish the effectiveness of specific housing interventions in improvingindividual and population health and well-being, and strive to delineate thecomplicated causal pathways among health, housing and socio-economic status forall demographic groups. Rigorous cost–benefit studies will be needed to quantify thefinancial savings realized in the health and, possibly, other sectors as a result ofsupported housing programs.

Initiatives such as the promising housing programs presented at the symposiumprovide opportunities to do quasi-experimental research on the efficacy of housing asan intervention for health, particularly for children in low-income families, seniors,people with mental illness and disabilities, or Aboriginal peoples. Researchcollaborations with university researchers, social service and health care providers,and service recipients or consumers may be the best approach to ensuring research onnew and existing programs is both rigorous and practical. Joint evaluations of

“The public must be

engaged in order to

spur governments to

action. Canadians

continue to be

somewhat smug about

health care, and there

is a media vacuum and

an absence of pubic

discourse about

health.”

Dr. Michael Hayes

"We need to talk about

housing from a health

perspective. We need

to re-package our

approach. We need

to capture public

interest."

Phil Deacon

multiple programs would be particularly useful for increasing the impact of the data.In addition, research is required to better project demand for various types ofhousing, particularly for seniors, a population that will continue to grow over the nexttwo decades.

The quality and relevance to policy-makers of the housing–health research can beimproved by using the best methodology possible, avoiding or controlling forconfounding variables, and relying on trained observers rather than on self-reports.Researchers should also: use measures that are standardized, widely appreciated andapplicable to the normative population; ensure the sample represents the policy-makers’ constituencies; and pay more attention to risk thresholds.

Methodological challenges to measuring the health effects of housing are notinsurmountable. It would be possible to collect longitudinal data by including morehousing-related variables in existing national, longitudinal surveys. It would also bepossible to take advantage of “natural experiments” that arise every day, whennatural conditions approximate experimental conditions. For example, servicerecipients, who serve as the study group, can be compared with people on waitinglists for service, who serve as the control group; health status can be measured beforeand after each individual obtains social housing. In some cases it is possible to usehealth care utilization data as a proxy for health status. One advantage of naturalexperiments is that large groups can be followed longitudinally to observeenvironmental mechanisms at work, and to sort out some of the discrete linksbetween housing factors and health outcomes. The challenges include correctlyanticipating these links and ensuring that the required data will indeed be collected.As well, researchers should consider greater use of ecological, or systems, research,wherein the unit of observation is the population or community, and the focus is onassociations between problems and exposure to known or suspected causes.Ecological studies can be advantageous in that they often rely on existing data. In thecase of housing and mental health, the “ecology of poverty” and the ways in whichchildren exposed to poor housing may also be exposed to many other risk factorsshould be considered.

In addition, unlike most other western countries, Canada has never completed anational housing survey. This is an opportune time to launch such an initiative and tocollect data on a wide range of variables, including housing conditions and tenure,“softer” measures such as sense of community and civic engagement, and simple,robust measures of health status. A national housing survey would allow for furtherexploration of the relationships between housing and determinants of health, such associo-economic status.

In his closing address, Dr. James Dunn reported that a recent national consultationwith stakeholders revealed that Canada lacks the capacity to conduct both the basicand the applied research required to move forward. The “research capacity deficit”occurs across all sectors. Service providers generally do not have the resources orexpertise to carry out or make use of experimental or quasi-experimental research;governments and academics lack the network and research infrastructure toefficiently conduct broad-based primary and applied research. And at present, policy-makers have a limited capacity to receive and make use of research findings.Therefore, to present a compelling case for housing as a determinant of health, thereis a pressing need to invest in both research and “policy receptor” capacity.

19

“We need to plan for

research in advance,

not look back

desperately through

existing, heterogeneous

data in hope of finding

something.”

Dr. Stephen Hwang

“At present, housing is

developing in a

vacuum; policy-makers

and developers alike

are thinking about

housing development

and construction

without paying

attention to the

determinants of

health.”

Dr. Gloria Gutman

20

Dr. Dunn called on symposium participants to endorse three actions that could beinitiated immediately and simultaneously: First, each of the major funding bodies(including CMHC, CIHR and CIHI) could be approached for financial contributionstoward establishing a national research network to collect standardized data andconduct meta-analysis of the health effects of housing programs. Second, CMHCcould be approached to complete or fund a national housing survey that measures thevarious dimensions of housing and includes robust measures of health status. Third,grants could be solicited from foundations to support a number of targetedhousing–health training and career development awards at the master’s, doctoral,post-doctoral and New Investigator levels.

Developing policy recommendations and bringing them forward

Each component of the strategy—housing and programs, public awareness, research,and policy—will require financial investments from a range of government, privateand philanthropic players, and collaboration across sectors, horizontally andvertically. The involvement of national research and social policy organizations, suchas CHRA, will be crucial in moving forward. These organizations have the capacityto initiate national research efforts involving a wide range of stakeholders. They alsohave the expertise to develop concrete policy recommendations from scientificresearch findings, and the connections to carry them forward and to influence theright people, at the right time. Moreover, they are ideally positioned to play acoordinating role across the complex webs of the public, private and philanthropicsectors to promote housing and health connections, foster research and servicealliances, and encourage collaborative funding arrangements.

“Policy results from the

interconnected factors:

information, ideology,

and the will to bring

about change.”

Dr. James Frankish

“We need to package

and present policy

options to decision-

makers in order to

convey the message

that better housing

is a common-sense

approach to improving

health and reducing

health care costs.”

Stephen Samis

APPENDIX 1. NATIONAL SYMPOSIUM ONHEALTH AND HOUSING: PRESENTERSJudy M.E. Butler earned her bachelor of social work at the University of Calgary, has an extensivework history in the field, and currently serves as the Community Resource Coordinator at theTrinity Place Foundation of Alberta, in Calgary.

Philip Deacon’s career with the Canada Mortgage and Housing Corporation spans more than 20 years. In that time he has undertaken challenging activities ranging from researching energy-efficient building practices to developing policy on housing seniors. Since 1996 he has worked ona program of population health research, with a focus on Aboriginal housing.

Erica Di Ruggiero holds a master’s of health science in community nutrition, and brings over 12 years of experience to her current position as Assistant Director, CIHR-Institute of Populationand Public Health.

Dr. James Dunn holds several faculty and research posts, including faculty associate at theUniversity of Calgary’s Centre for Health and Policy Studies, and associate member of thePopulation Health Program of the Canadian Institute of Advanced Research. The relationshipbetween socio-economic dimensions of housing and health inequalities is one of his key researchinterests.

Dr. Gary Evans is a professor in the Department of Design and Environmental Analysis andHuman Development at Cornell University. His teaching and research activities focus on the roleof the physical environment in the health and well-being of children and their families. Hiscurrent research is on housing, noise and children, and the environment of poverty.

Dr. Cheryl Forchuk is a professor at the School of Nursing, University of Western Ontario, witha cross appointment in the Department of Psychiatry, Faculty of Medicine and Dentistry, and ascientist at Lawson Health Research Institute in London, Ontario. Dr. Forchuk is also theacademic director of a community-research alliance on housing and mental health.

Dr. Gloria Gutman is an esteemed author and educator and has been a consultant on topicspertaining to gerontology since establishing the Gerontology Research Centre at Simon FraserUniversity in 1982. Still serving as Director of the Research Centre and the Simon FraserGerontology Program, which she also established, Dr. Gutman recently published a nationalreport on housing options for older Canadians.

Sandra Hill holds a degree in home economics from the University of Winnipeg, and has workedwith people with disabilities for over 15 years. Ms. Hill is currently employed by TenTen SinclairHousing Inc., where she is responsible for delivering the Learning Through Living program.

Dr. Stephen Hwang’s research as a clinician-scientist at the Inner City Health Research Unit at St.Michael’s Hospital in Toronto focuses on, among other things, homelessness and health. Dr. Hwang earned a medical degree at Johns Hopkins School of Medicine and a master’s ofpublic health degree at Harvard University.

Dr. Marja Korhonen is a policy analyst for the Inuit Centre of the National Aboriginal HealthOrganization in Ottawa. Her background is in education, social work and counselling, and for thepast 15 years she has lived and taught in Nunavut. Dr. Korhonen has a deep interest in housingissues and the mental and physical consequences of inadequate and crowded housing.

Dr. Richard Lessard is a physician specializing in community health. In addition to his academicposts at l’Université de Montréal and McGill University, he serves as Director of Public Health,Montréal-Centre Regional Health and Social Services Board.

Jeff Polakoff is the Executive Director of Programs for the Manitoba Housing and RenewalCorporation (MHRC). As Director of Agreements Management and Coordination and AssistantDeputy Minister of Northern Affairs with the Government of Manitoba, Mr. Polakoff wasresponsible for the negotiation of federal–provincial agreements, including MHRC, theAffordable Housing Initiative.

Stephen Samis has a master’s degree in sociology from Simon Fraser University and currentlyserves as Manager of Research, Analysis and Infrastructure at the Canadian Institute for HealthInformation’s Canadian Population Health Initiative (CPHI). Mr. Samis is responsible for CPHI’sresearch and knowledge synthesis activities.

Judy Walsh holds a master’s of science degree and brings over 25 years of experience with youthand families to her current position as a tenant support worker for the Nanaimo AffordableHousing Society.

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22

Bev AdamsCalgary Health Region, Mental HealthCoordinator Contracted Servicesbev.adams@calgaryhealthregion.ca

Janet Arnold Bridging the Gapjanet.arnold@shaw.ca

Jane Bankes Calgary Health Region

Ray BiggsGerontology Program, Simon Fraser Universityray.biggs@pchr.ca

Carol Burke Health Policy Analyst, Ontario Federation ofIndian F.C.cburke@ofifc

Kathy Cairns Faculty of Education, Division of Psychology,University of Calgarykcairns@ucalgary.ca

Louise Crane Aboriginal Health Facilitator, Alexandra Community Health Centre

Pierre Denault Environmental Health Officer, First Nations andInuit Health Branch, Health CanadaPierre_Denault@hc-sc.gc.ca

Erica Di RuggieroInstitute of Population and Public Healthe.diruggiero@utoronto.ca

Sheila Dodge Canadian Mental Health – Central Regioncommunityoutreach.cmha@shaw.ca

James Dunn University of Calgary, Assistant Professor,Community Health Servicesjimdunn@ucalgary.ca

Gretta Lynn Ell Director, Program Development and PerformanceSupportRegina Qu’Appelle Health Regiongrettalynn.ell@rqhealth.ca

Ross FindlaterChief Medical Health Officer, SaskatchewanHealthrfindlater@health.gov.sk.ca

Fee Forbes Calgary Health Region

Cheryl ForchukFaculty of Health Sciences,University of Western Ontariocforchuk@uwo.ca

James Frankish Institute of Health Promotion Research, Universityof British Columbia

APPENDIX 2. NATIONAL SYMPOSIUM ONHEALTH AND HOUSING: PARTICIPANTS

HEALTH DELEGATES

Garth Goertz AIDS Calgaryggoertz@aidscalgary.org

Tanya Grierson Leader, Healthy Public PolicyCalgary Health Regiontanya.grierson@calgaryhealthregion.ca

Gloria Gutman Director, Gerontology Research Centre, SimonFraser Universitygutman@sfu.ca

Michael Hayes Institute for Health Research and Education,Simon Fraser Universitymhayes@sfu.ca

Ralph Hubele Supported Living, Calgary Health Regionralph.hubele@crha-health.ab.ca

Stephen Hwang St. Michael's Hospital, Inner City Health ResearchUnithwangs@smh.toronto.on.ca

Marja KorhonenNative Aboriginal Health Organizationmkorhone@naho.ca

Kaj KorvelaThe Organization for Bipolar Affective Disordersobad@obad.ca

Murray Lee Family Physician (Alberta/Nunavut)murphlee@telusplanet.net

Richard Lessard Director of Public Health, Montréal-CentreRegional Health and Social Services Board

Charlotte McKay Alberta Council on HIVcharlotte.mckay@catholicsocialservices.ab.ca

Cathy Morton-Bielz Director, Community CareYukon Territorial Governmentcathy.morton-bielz@gov.yk.ca

Joanne Mueller Regional Manager, Capital Health Authority,Edmontonjmueller@cha.ab.ca

Lance Nelson Manager, Fraser Health Authoritylance.nelson@fraserhealth.ca

Colin Penman Aspen Family and Community Network

Darryl Quantz Institute of Health Promotion Research, Universityof British Columbiaquantz@interchange.ubc.ca

Stephen Samis Canadian Population Health Initiative, CanadianInstitute for Health Informationssamis@cihi.ca

Rudy Small Health Services ManagerBC Housing Management Commissionrsmall@bchousing.org

Kerry Snatic Calgary Health Region, Mental Health HousingCoordinatorkerry.snatic@calgaryhealthregion.ca

Dennis Suwala Vancouver Island Health AuthorityManager, Special Needs Housingdsuwala@shaw.ca

23

Chris D'ArcyNunavut Housing Corporation, Director, Policy &Planningcd'arcy@gov.nu.ca

Barb De Ruyter CHRA, Research and Policy Coordinator

Phil Deacon Senior Researcher, CMHCpdeacon@cmhc-schl.gc.ca

Henri DorvilProfesseur titulaire, Université de Montréal, dorvil.henri@uqam.ca

Janne Dunnion Senior Policy Advisor, Homelessness, NunavutHousing Corporationjdunnion@gov.nu.ca

Dave Eddy Executive Director, Vancouver Native HousingSocietydeddy@vnhs.ca

Gary EvansProfessor, Departments of Design andEnvironmental Analysis & Human Development,Cornell Universitygwe1@cornell.edu

Carol Finnie Victoria Cool Aid, Executive Directorcfinnie@coolaid.org

Judy Forrest Housing Consultantjudy.forrest@rogers.com

Helen Gardiner Director, Vista Evaluation & Research Services

Alfred J.Gay Policy Analyst, National Association of FriendshipCentresalfredg@nafc-aboriginal.com

Marie-Chantal Girard Team Leader, Research HRDCmariechantal.girard@hrdc-drhc.gc.ca

Cameron Gray Director, Housing Centre, Community ServicesCity of Vancouvercameron_gray@city.vancouver.bc.ca

Debbie Taillefer Housing Development Specialist - Mental Health,Winnipeg Health RegionWinnipeg Regional Health Authoritydtaillefer@wrha.mb.ca

Rick Volpel Bigstone Health Commissionrickvolpel@hotmail.com

Laurie Weiman Saskatchewan Healthlweiman@health.gov.sk.ca

Carol Zemrau Sherwood Park Housing

Irv Zemrau Sherwood Park Housingirvzemaru@aol.com

HOUSING DELEGATESMarion AkanHomemaker, Pasqua First Nation Reserve

Kevin AlbersActing Executive Director, M'akola Group ofSocietieskalbers@makola.bc.ca

Kathy Barnhardt Manager, City Wide Services Branchkathy.barnhart@gov.edmonton.ab.ca

Peggy Birnberg Houselink

Laurie Boucher Affordable Housing Coordinator, City of Calgarylaurie.boucher@gov.calgary.ab.ca

John Burrett Manager, Economic and Social Policy, FCMjburrett@fcm.ca

Judy Butler Community Resource Coordinator, Trinity PlaceFoundation of Albertajbutler@telus.net

Karen Charlton City of Medicine Hat, CHRA Board Memberkarcha@city.medicine-hat.ab.ca

Sharon Chisholm Executive Director, CHRAschisholm@chra-achru.ca

Kathy ChristiansenCalgary Alpha House Societykathy.christiansen@shaw.ca

Bob Cohen Past President, CHRAchaltfim@netrover.com

Merrill CooperPrincipal, Guyn Cooper Research Associatesmerrillcooper@shaw.ca

Rob CressmanDirector, Regional Municipality of Haltoncressmar@region.halton.on.ca

Eleanor Cyr Student, Pasqua First Nation Reserveonline@aolfq.com

24

Jackie Harbron Independent

Bob Hawkesworth Alderman, City of Calgarybhawkesw@gov.calgary.ab.ca

Sandra Hill TenTen Sinclair Housing Inc., Tenant DevelopmentCoordinatorshill@tenten.mb.ca

Carole Hubbard Executive Assistant, CHRA

Gilles Huizinga Wood Buffalo Housing and DevelopmentCorporation

Iris Ingram CHRA Board Memberiris@ingramconsulting.ca

Martina Jiveckova Calgary Homeless Foundation, CommunityAction Coordinatorcac@calgaryhomeless.co

John Johnston Montreal Municipal Housing Authorityjohn.johnston@omhm.qc.ca

Darrell Jones Deputy Minister of Housing, SaskatchewanHousing Corporationdjones@mah.gov.sk.ca

Henry Kamphoff Executive Director, Capital Region HousingCorporation

Gerry Kennedy Newfoundland and Labrador Housing Corp.gfkennedy@a1.nlhc.nf.ca

Daryl Kreuzer Senior Planner-Housing, City of Edmonton,Community Servicesdaryl.kreuzer@edmonton.ca

Tanya Kyle Graduate Student, University Calgary

Pierre Lacroix Consultantpierrelacroix@rogers.com

Joe MacLean Administrator, Seton Foundationsetonfoundation@ns.sympatico.ca

John MartinDirector, Housing Services South, Alberta Seniorsjohnmartin@gov.ab.ca

Katerina Maximova Human Resources Development Canadakaterina.maximova@hrdc-drhc.gc.ca

John Metson CHRA Presidentjohnm@crcselfhelp.ca

Paul Morin Université Quebec à Montréal, ProfesseurAssociet, École de servicecollectif@videotron.ca

Jennifer Parnell Executive Director, Raising the Roof,jennifer@raisingtheroof.org

David Peters CHRA Research and Policy Committee, ONPHAdavid.peters@onpha.org

Jeff Polakoff Manitoba Housing and Renewal Corporation,Acting Director, Housing Servicesjpolakoff@gov.mb.ca

Joyce Potter CHRA 1st Vice-Presidentjp@inthehack.com

Shirley Reddy Kerby Centre Housing Registry

Reid Rossi Interim ED CHRArrossi@chra-achru.ca

Claude Roy Société d'Habitation du Québec, Urnaiste. Soutiena l'initiative communautaireclaude.roy@shq.gouv.qc.ca

Michelle Rypstra Durham Region Non Profit Housing Corp.,General Managermicheler@idirect.ca

Debbie Saidman Executive Director, Edmonton Housing TrustFunddsaidman@ehtf.ca

David Seymour Director, National Aboriginal Housing Associationseymourd@inac.gc.ca

Sharon StroickResearch Social Planner, City of CalgarySharon.Stroick@gov.calgary.ab.ca

David Swann Associate Clinical Professor, CommunityMedicine, University of Calgaryswann@ucalgary.ca

Ryan Walker Queen's University

Judy Walsh Nanaimo Affordable Housing Association, TenantSupport Workerjwnahs@island.net

Jim Wasilenko c/o Saskatoon Housing Authorityjwasilenko@sasktel.net

Joan White Supportive Housing Coalition of Metro Toronto,Manager of Tenant and Member Serviceswhitej@supportivehousing.ca

Brigitte Witkowski Executive Director, Supportive Housing Coalitionof Metro Torontowitkowskib@supportivehousing.ca

The Hon. Stan Woloshyn Minister of Seniors, Government of Albertasharon.schneider@gov.ab.ca