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Homelessness Is Not a Choice, So Lose the Apathy

We know the dangers of having too many choices -- but what about not having any? Who in their "right mind" (you might wonder how many of "those" people are mentally sound and might be surprised to know the vast majority are) would sleep on a bench in "last seasons" (off-trend or simply off-prudence) clothes in freezing cold weather?

In 1915 a Scottish physician named Dr. John Scott Haldane became one of the first proponents of "sentinel animals," those that provide us with warnings of impending danger. He was one of the first public health physicians in the U.K., and investigated the effects of toxic gases (the eponym "Haldane Effect" is after his work). He was credited with using canaries and white mice, dropped into a coalmine, to signal the presence of carbon monoxide. Their fast metabolism would lead them to present with symptoms of carbon monoxide poisoning much earlier -- indicating when miners should exit to prevent death by asphyxia. The idiom "canary in the coalmine" comes from Dr. Haldane's observations.

On Tuesday, 100 years after Dr. Haldane coined his famous expression, a man died after another similar toxic cause, serving as our "canary," but we have yet to fully respond. What was the reason behind his death? It's not homelessness - the "H-word." This term merely assumes that the "lack of a home" is to blame, which simplifies things. Moreover, the H-word is stigmatized, and stigma is too-often a barrier to change. It's not the "cold," as it has been argued. Besides, it would be far too easy to blame a human death on temperature fluxes which ultimately do not have a human face -- in a way pardoning those of us that do. No, it's neither of these factors.

His passing, and that of another man the day before is linked to "choicelessness" on their part, and apathy on the part of many of us. His death, not unlike the canaries of the early 20th century, is what we refer to in public health as a "sentinel event" -- signalling that the outcome is more than a result of his underlying health status, but linked to another, more clandestine, cause that we have yet to fully recognize. It is crucial that we move forward now to address it, and it starts with providing choices to fellow Canadians who have been left with none, while also acknowledging that we need to shift from apathy to empathy.

Let's start with the paradox of choice. We know the dangers of having too many choices -- but what about not having any? Who in their "right mind" (you might wonder how many of "those" people are mentally sound and might be surprised to know the vast majority are) would sleep on a bench in "last seasons" (off-trend or simply off-prudence) clothes in freezing cold weather? Easy answer: there was simply no other viable option -- the term 'viable' is not the operative word of course. When given a choice, we usually choose the best option, and the one that most preserves our dignity, available with the knowledge and perspective we have at that moment. And when there is only one option, well that's what we choose.

A few years ago as a medical student in Toronto, I met my first "choiceless" individual, as he presented as a patient with severe frostbite of his legs. He was in his 50's, like the gentleman who passed away on Tuesday. He became a very important teacher for me, particularly closer to his discharge day. He admitted that his pain was exaggerated in the hopes of remaining in hospital for a few extra days. "Where would I go after this?" he asked. Unclear of the right answer to give a patient with "No Fixed Address" (a more sterile and objective medical term for the "H-word"), I offered, "a shelter?" He looked at me as though I had chosen the most obvious, yet grossly incorrect answer to his question. I knew that look - young trainees see it often. "Do you know what happened the last time I went to a shelter? I had to leave my shoes near the door, and the next morning someone had stolen them. So I left the shelter barefoot. No, I won't go back."

It was an important teaching moment for me. I would never again advise anyone, let alone a patient, to do something that I had absolutely no experience with. Indeed, the issue of the "H-word" is unlikely to be solved until we see it in a broader context of choice, of lack thereof. If the choice of attending shelters that are safe, secure, warm, and with capacity, is available, surely more individuals will choose that option. Reaching a little wider, if given a choice to live in housing set aside as a social good and human right (which it has yet to be realized in Canada) compared to facing the elements, most would choose the former. The mission to provide these basic choices to the most marginalized of Canadians -- many of whom in any given year transition between having housing and not -- rests in providing options. Traditionally the reason our society values material goods and wealth isn't of course those principles themselves but in that both provide us with choices. It's the element of choice that gives us dignity, and ultimately supports our health and well-being. The paucity of choice, on the other hand, has the opposite effect, and this is nowhere more evident than with the social determinants of health.

There are 30000 individuals living without a home in Canada, 2800 of these who have no choice but to inhabit our streets. There are many others who have no choice but to seek their basic needs from hospitals. And there are still others, particularly youth, who may have no choice but to become involved in crime as a means of survival. We quote statistics as an attempt to pull us out of the blanket of apathy we have created; strangely while the numbers climb, our compassion still wanes. Surely hundreds, if not thousands, of us walked past this gentleman in a T-shirt on a cold bench on Monday, or on any other day of the year. Perhaps brief flirtations with pity or annoyance might arise, but these emotions are usually quelled with a few footsteps in another direction, rendering the individual out of sight, and out of mind.

Psychological research has described a similar phenomenon with violent crime -- the "bystander effect". But what happened on Tuesday morning was a result of "the apathy effect." Apathy is a central part of the choiceless issue. For it is only when we truly identify with another who is -- through circumstances that could easily befall ourselves -- choiceless, can we instigate systematic change Indeed, it's not a homelessness "problem," poverty "issue," or technical "conundrum" around how our communities define "extreme weather." These are distractors from our own responsibility - our own ability to create options out of gargantuan societal discrepancies between the choiceless and the privileged. At the intersection between irritation, guilt, pity and anger is the sweet spot of empathy, which motivates such novel solutions.

At 5:30am on January 6, 2015, paramedics were called to the busiest intersection in Canada to find a choiceless man dead. None of us know his exact age. Nor his name. Or anything about his life and what he contributed to our world. As of this writing he remains anonymous, yet more recognized and cared for in death than during his life. Perhaps he froze. Perhaps it was "natural causes" that led to his demise. Perhaps it may have even been an intentional "choice" made by a man who had no other. All we know for sure is that he was likely alone when his heart stopped. And with it, the pulse of the city, albeit for a brief moment that we are currently inhabiting. What seems obvious is this man is our sentinel event -- our canary in the coalmine -- signalling that much worse is yet to come if we do not institute change. Together we have the privilege of choice to make this moment the start of a bonafide shift in how we care for our most in-need Canadians, or to make it merely a brief moment of pause before we bury deeper under our blanket of apathy. These are all moments after all -- as mundane as passing a choiceless man on a cold city bench or as profound as this same man's lonely last breath.


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