Associating healthcare, homelessness, policy and political determination by Nagina Khan

Winter 2022 is approaching again in Canada and sub-zero temperatures kill the homeless – I know this from my volunteer work at a homeless and outreach centre in Ontario. A 52-year-old male told me that he lives in a tent under a tarp in a backyard of a home. The owner doesn’t know he’s there so he can’t make any noise and must leave during the day. A 53-year-old female living in a storage locker will have to move to a park and she feels vulnerable and afraid. The only time she’s ever felt safe was at a refuge in a local church’s ‘out of the cold program.’ To witness our mothers, daughters and sisters living in such unpredictable conditions and circumstance would be unimaginable.

Everyday, advocates in healthcare and not-for-profit organizations repeat their warnings – Freezing weather kills the homeless, only protected by temporary interventions that fall through, creating a vicious cycle of recurring homelessness.1 Approximately 235,000 Canadians experience homelessness and the number continues to rise. Every given night 25,000 to 35,000 people experience homelessness. To measure against prior years, e.g., in 2005, the federal estimation figure of homeless in Canada was 200,000, about 1% of the population.2

Last year’s snowstorms in Canada devastated Shelter occupancy already full and close to collapse due to cold weather.3 Temperatures falling to deadly depths meant covid-19 infections spread because isolation sites, simply had no room and shelters had no choice but to keep infected residents on site.

The Government of Canada invested $119 million annually to address homelessness through the Homelessness Partnering Strategy and there has been no noticeable reduction in homelessness.4 Advocates of homelessness and the homeless have remained disgruntled and disillusioned for decades expressing frustrations on social media sites at frequent and needless loss of life.

In 2021, The Government of Canada launched a call for concepts for innovative projects to prevent and eliminate homelessness under the Community Capacity and Innovation stream of Reaching Home.5 Canada’s Homelessness Strategy (NHS) by the Minister of Housing and Diversity & Inclusion, was providing approximately $6 million over three years, starting in 2021–22, for scalable projects that would test and develop new and innovative approaches.

Budget 2022 has been directed at investments to build more homes and make housing more affordable in Canada.

  • With $1.5 billion to extend the Rapid Housing Initiative, and
  • $500 million allocated through the Cities Stream and
  • $1 billion through the Projects Stream. However, the city-by-city allocations and exact timelines for applications were not announced.
  • $200 million to create the new Affordable Housing Innovation Fund’s rent-to-own stream.6

But one can not help and think ‘are these programs and task forces set up as Quasi-Autonomous Non- Governmental Organisation (Quangos) causing bureaucratic and excess waste or are they actually reducing the numbers of homelessness?’

And during such times of crisis the Minister of Housing and Diversity & Inclusion was talking about possible future invention?

For those that are dying everyday because the ‘rights’ are not an ‘enforceable standard,’ means that they are not ‘citizens’ of our society and we need to ‘open our eyes wide,’ this is real life and the reality for a host of the population in Canada who cannot merely wait or rely on invention alone to ‘survive.’

How do we break from this endless cycle of advocacy and political posturing? The best evidence has come from Countries who have decided to tackle the problem through a Constitutional change and are ‘legislating from the bench.’

In Great Britain, homeless people have had a legal right to long-term rehousing since the 1970’s and in Scotland there is a statutory scheme which has proved successful.7 Housing is one of the powers devolved to the Scottish government, and in 2012 Scotland changed the statutory duty so that it applied to virtually all categories of homeless people.8 Abolishing a ‘needs test,’ meant that anyone who is assessed as being unintentionally homeless has the right to settled accommodation and securing the right to secure and affordable tenancy in social housing. In 2021, Scotland introduced a new ‘prevention duty’, which meant that public bodies, such as health services, were required to ask about a person’s housing situation and act or support individuals and families to resolve any housing needs.9 These safeguards now guarantee that no one leaves an institution, such as prison or hospital, without somewhere to sleep that night.

Jon Sparkes, Chief Executive of CRISIS a homelessness Charity, welcomed the First Minister Nicola Sturgeon’s commitment on changing the law to prevent homelessness.10

He said: “These proposals hold the potential to make Scotland a world-leader when it comes to ending homelessness.’’

So, Scotland successfully offers a more affordable and more secure tenure but at the sacrifice of reduced choice. Not much of a sacrifice compared to Canada on the other hand, who has played the optional card since 1976. It signed the International Convention on Economic Social and Cultural Rights (ICESCR), only to neglect the socioeconomic sense of duty and in 2017 these failings further appeared in the United Nations General Assembly.7

In Finland the pattern of housing tenure might resemble Canada’s. Yet, there is a ‘vast difference’ that is not ‘spoken clearly,’ for example Finnish Constitution explicitly references the “right to housing.” Section 19 of the Finnish Constitution specifically relates to other key welfare rights which are ‘legally’ enforceable via the courts.7 Like Canada, the Finish winter climate can be brutal but unlike Canada the Finish Constitution guarantees ‘right to life,’ and, it includes the ‘right to emergency shelter.’7

Intrinsically, the right to housing status is considered a fundamental human right. Yet, the Canadian Charter of Rights and Freedoms sadly falls short too as the ‘right to housing’ is not one of them.

Effectively, as good, as good intentions go, our Canadian governments at any levels do not have anything concrete that links to any ‘lawful legal obligation or commitment’ to make brave decisions to save homeless lives.

If Canada was to shift to a statutory legal over programmatic right approach to housing, it would involve the judicial enforcement to transfer policy making power from the political to the legal sphere.7

 We need to question if our current ‘programmatic rights’ approach is effective or useful anymore?

Researchers have cited additional problems with the Canadian experience including Litigating the Right to Housing. In 2019, the Canadian federal government passed the National Housing Strategy Act, to ‘obligate’ the government to realize the right to adequate housing as recognized in the ICESCR.7  What was achieved was the creation of several advisory bodies based around the notion of the NHS – again just ‘programmatic rights do not rely on courts.’11

To clarify and make it clear, in Canada, we classify homelessness as a ‘programmatic right’ which means we do not protect homeless persons via the courts or their “right to life.”7

During the summer, we all witnessed horrific scenes in a Toronto Park, homeless people were shunned out of the park and public spaces by order of our elected government representatives. Report from Kwame Addo, Toronto’s ombudsman was launched based on public complaints and concerns to  investigate the impact on some of the city’s most vulnerable residents when encampments at Lamport Stadium, Trinity Bellwoods and Alexandra Parks were made to disappear.12 Encampments are illegal under city bylaws and are not a solution to homelessness. The reality is that the city’s shelter system is inadequate and homeless individuals would rather select public spaces as their makeshift homes.

Our basic human emotions are telling us all and not just healthcare advocates, that something is fundamentally wrong with the Policies that are ‘immoral’ and are still enacted out on certain ‘sections’ of ‘our society.’

Addo’s report accurately documents, encampments connect to a net of intricate reasons that consist of housing, poverty, mental and physical health, reconciliation and harm reduction.12 Furthermore, locally we see daily suffering and survival against the Canadian elements and intentional exclusion from our society. We hear stories of fellow Canadians dying alone on a road, a bus stop, park bench and they pass our thoughts fleetingly. Yet, in our own lives dying without so much as a gentle touch, provision of care or being left alone is unimaginable.

Should not the same values apply to all Canadians?

In Canada, homelessness is a modern constitutional crisis, and in 2023 as we work towards rectifying mistakes made in our Country’s past, let’s deal with homelessness now and not let future generations judge us.

‘All world leaders’ globally need to make a ‘legal connection and commitment to the right to life and the right to safe housing’ so that the right to adequate housing does not just mean that the structure of the house itself must be adequate. “There must also be sustainable and non-discriminatory access to facilities essential for health, security, comfort and nutrition. For example, there must be access to safe drinking water, energy for cooking, heating, lighting, sanitation and washing facilities, and means of storing food, refuse disposal, site drainage and emergency services (p.8).” So that healthcare advocates alike can work together to prevent the loss of life & make the reduction in the homeless numbers a reality, rapid and targeted at genuinely ending homelessness.


  1. Tan J, Ramos H., USRI Final Research Output: Scoping Review on Homelessness in Canada. 2022
  2. Kalajdzieva M., Homelessness in Canada: What’s Going On? 2022 [cited 2022 Oct 25]
  3. Cohen B., Toronto’s shelter system close to collapse due to cold weather, COVID-19, staff shortage 2022 [cited 2022 Oct 25]
  4. Homeless Hub. Cost Effectiveness of Ending Homelessness [cited 2022 Oct 25]
  5. Government of Canada. Government of Canada launches call for innovative concepts to prevent and eliminate homelessness 2021 [cited 2022 Oct 25]
  6. Gouvernement du Canada. Creating nearly 17,000 homes for Canadians across the country 2020 [cited 2022 Oct 25]
  7. O’Donnell J. Does social housing reduce homelessness? A multistate analysis of housing and homelessness pathways. Hous Stud. 2021;36(10):1702–28.
  8. Scottish Government. Homelessness 2022 [cited 2022 Oct 25]
  9. Blissett C. Literature Review: Tackling Homelessness in Scotland. Salvation Army. 2020;1–43.
  10. Matchett C. Scotland could become “world-leader” in tackling homelessness with SNP plans, says charity 2021 [cited 2022 Oct 25]
  11. The National Right to Housing Network. NRHN – Right to Housing Legislation in Canada [cited 2022 Dec 6]
  12. Addo Kwame, Ombudsman T. Ombudsman Toronto Interim Report: Investigation into the City’s Processes for Clearing Encampments in REPORT FOR ACTION Ombudsman Toronto Interim Report: Investigation into the City’s Processes for Clearing Encampments in 2021. 2021;
  13. United Nations. The Human Right to Adequate Housing [2021] [cited 2022 Dec 6]

Nagina Khan

Dr Nagina Khan is a Scientist working in the Schizophrenia Division at Centre for Addiction and Mental Health (CAMH) Canada. Nagina was a Medical Research Council (MRC) Research Training fellow at the University of Manchester, School of Medicine, UK. She has worked as a Postdoctoral Fellow, (Specialty: Mental Health) at the University of Manchester, School of Medicine, NIHR School for Primary Care Research Health Sciences Research Group, Manchester, UK. Nagina also works as an independent researcher, collaborating with the Centre for Health Services Studies (CHSS) University of Kent, Royal College of Psychiatrists, UK and with Touro University Nevada, Dept. of Osteopathic Medicine, US.  Nagina’s research portfolio is focused on i. Mental health, South Asian population and women’s health; complex interventions for people with depression ii. Health systems; healthcare incentivisation and reimbursement schemes, and iii. Medical education and social justice. Nagina is an Editorial Board Member of BMC Medical Education Journal, a Member of the Expert Reference Group – 4 Mental Health, Honorary Member of the Creative Communities Group,
University of Central Lancashire, UK. Nagina also advocates for individuals experiencing homelessness at the Compass Foodbank & Outreach Centre, Ontario, Canada.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None



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