Responses to COVID-19 for persons experiencing homelessness in Toronto: An update

Public health officials – both provincial and City of Toronto – distinguished between two different COVID-19 disease processes, during their second modeling press conference on April 20th – the spread through community and the spread of the virus through congregate settings. They claimed, cautiously, that COVID-19 spread in the community has peaked but that spread is growing in congregate settings. The evidence of the virus’ devastating effect on long-term care and retirement homes has been laid out in these reports. With yesterday’s news that 752 lives have been lost so far in long term care facilities, they account for 78% of all COVID-related deaths in Ontario. While the health and care of residents in long term care has been the focus, the situation in shelters for the homeless population remains uncertain. RNAO has ringed the alarm for several weeks fearing a similar tale than that of LTC. Our calls, including for open and transparent reporting of data, remain unanswered.

Here is what we know.

In previous reports, we have cited evidence of the particular vulnerability to COVID-19 of those experiencing homelessness. The evidence from the US suggests that people experiencing homelessness will be twice as likely to be hospitalized, two to four times as likely to require critical care and two to three times likely to die from this virus. And, evidence emerged just this week that points to, on average, a twenty-five percent COVID-positive rate amongst residents in a sample of shelters in a number of US cities.  Notably and of great concern, the 66% COVID-positive rate amongst residents at a San Francisco shelter suggests that the high infection rate at Willowdale Welcome Centre (see below) may not be an outlier.

Dr. Aaron Orkin, Population Medicine Lead with Inner City Health Associates, has noted in my April 7 report that shelters are “analogous” to long term care homes “but in some ways more calamitous for population health.” In spite of this, coordinated universal testing in the shelter system has yet to be triggered by public health authorities. (In fact, the Chief Medical Officer of Health of Toronto, home to about two-thirds of the province’s homeless population, makes a point – regularly - of citing provincial jurisdiction over testing.) Although Toronto has more than 60 city-funded and city-operated shelters, the city is reporting the results of COVID testing in only 14 shelters suggesting that testing across the system remains very limited and disorganized. Only as late as April 16, the province changed its guidelines to allow mass testing of homeless shelters. Provincial protocols previously did not allow for those in shelters to be tested en masse.

Unsurprisingly, a COVID-19 outbreak has surged among Toronto’s homeless in the last 10 days with at least 135 cases, the majority of which come from one shelter that houses refugees and other persons experiencing homelessness. Now there are 88 residents, out of 200, at the Willowdale Welcome Centre alone who have tested positive for the disease. Luckily, officials say the majority of the cases at the shelter are asymptomatic or have mild symptoms of the disease. The local councillor asked why the province didn’t allow for mass testing on the site at the time after the first positive case of COVID-19 came in two weeks ago, which would have avoided the spread.

The Willowdale experience suggests that now is not the time to overturn plans to provide health care capacity for people experiencing homelessness if tragedy is to be averted. These were plans for a 400-bed COVID-positive recovery site for people experiencing homelessness supported by Médecins Sans Frontières bringing their global expertise in dealing with pandemics. Yesterday’s news that the City of Toronto has overturned the plans are hugely worrisome. At its daily press conference, the General Manager of Toronto ‘s Shelter, Support & Housing Administration (SSHA) acknowledged that 130 beds at the city’s existing 175-bed COVID-positive recovery centre were full (the City says it has a 200 bed capacity). Clearly, another outbreak like Willowdale – even a mild outbreak in another sizeable shelter – will overwhelm the existing and committed resources to care for people experiencing homelessness. Instead of the cancelled plan for an “open-air congregate setting”, the City informs it is actively working with the provincial government and healthcare partners to open a second recovery site in a hotel. We are not aware of an explanation from the City why this is a preferred model over the cancelled one, nor when will it open.

A coalition of public-interest organizations filed legal proceedings on Friday against the City of Toronto over what they're calling "deplorable" conditions in the city's shelter system and respite sites amid the COVID-19 pandemic. The groups threatened to file proceedings earlier this week if the city didn't act swiftly to enhance its physical distancing measures and procure additional shelter space. "Beds or cots are still only two feet apart, people are in bunk beds, bathrooms aren't being cleaned more," said Greg Cook, an outreach worker with Sanctuary Ministries. Cook says he'd like the city to enact an order ensuring two metres of distancing within shelters. "People's lives are at risk, people's health is at risk and we're kind of using any tool we have to make sure the city moves faster," Cook said.

In an announcement, the City of Toronto informed of other actions details of actions it has taken with partners to rapidly tailor solutions for the city's most vulnerable. As of Friday, the City says it has opened 11 new facilities and secured more than 1,200 hotel rooms. Some 770 people have been moved to hotel rooms and another 492 people to community space. Earlier, the City had opened a 200-bed recovery facility for people experiencing homelessness who have tested positive for COVID-19. This first-of-its-kind facility in Canada was done in partnership with Inner City Health Associates and other community health providers. It is also utilizing its fleet to safely transport individuals awaiting COVID-19 test results and those who test positive to isolation and recovery facilities. The City is also working with the Provincial government to ensure scaled up proactive COVID-19 testing is being conducted in the shelter system.