Our hospitals and prisons are failing because we're using them to house people instead of to help them.

The terms "rounders" and "frequent fliers" are used as shorthand for those who frequently come into contact with Ontario's criminal justice system and our emergency rooms. But they wrongly put the onus on these groups of people when hospitals and jails are over capacity or costly. Concealed is the fact that as a province, we rely on hospitals and prisons to manage the basic needs of marginalized people who could instead be benefiting from help outside their walls; a solution that would help relieve hallway medicine but one that has received little attention.

For these populations, there is a revolving door between hospitals and prisons but their underlying needs are rarely met in either institution. Two things are certain: 1) our shortsightedness about these issues is expensive for the province, and 2) the most marginalized individuals are not receiving the adequate supports they deserve.

Embarking on a $15 billion deficit, this government has sought to find efficiencies in public spending and specifically to address hallway medicine, the term used to describe Ontario's oversaturated stock of available hospital beds. However, in their recent budget, these efficiencies were found in places that will actually end up hurting our most marginalized populations. Legal Aid Ontario, an organization which provides legal assistance for low-income people in Ontario, had $133 million cut from their budget. And public health units, which prevent hospital admissions through upstream, community-based interventions, saw $200 million in cuts (retroactive cuts to the latter have since been reversed but future cuts will continue).

Currently, we criminalize homelessness and poverty using police as first responders. As a result, marginalized populations, especially those who are racialized, Indigenous, low income, homeless, and those with mental illness and addictions end up in frequent short term emergency department stays or much worse, in jail.

According to 2013 data from Dr. Stephen Hwang's team at St. Michael's Hospital, homeless people were "8.5 times more likely to visit the emergency department, 4 times more likely to be hospitalized for medical issues or surgery and 9 times more likely to experience a psychiatric hospitalization".

The number of those in custody is not significantly decreasing either. Despite some successful bail reforms under the previous government, bail remains a major issue. According to 2016/2017 statistics from the Canadian Centre for Justice Statistics, 70% of those in custody were in remand; meaning awaiting trial or sentencing. Those in remand often have yet to be convicted and are awaiting trial, many for allegations of non-violent offences. While in remand, individuals are exposed to violence, underlying health conditions are exacerbated, they receive inadequate health care and they are denied access to meaningful rehabilitative programs.

Often when bail is unlikely to be granted, many plead guilty, whether or not they are guilty. They serve their sentence and then return to the same if not worse circumstances (such as homelessness) that resulted in them being in conflict with the law initially.

We treat people poorly. This is inhumane - full stop. It is also counterproductive given the high cost of institutionalizing people.

The Ontario Ministry of Corrections annual budget is approximately $3 billion. Of that, we spend nearly $1 billion incarcerating people. Data published in a study called At Home/Chez Soi in 2017 showed that the average annual cost of one individual remaining homeless in Toronto was $59,000. Of this, 40% of costs were related to health service utilization and 25% of costs were associated with police and incarceration costs.

There are evidence-based solutions to these issues. In the Netherlands, prisons are closing because of relaxed drug laws, increased funding for rehabilitation over punishment and allocating funding towards social services.

Research published in 2018 in the Canadian Medical Association Journal found that even if total government spending didn't change and we simply shifted health dollars towards social programs, we could improve the health of populations and support their needs in the community, thus keeping them out of hospitals and jails. We need to fund upstream, social programs like legal aid and public health that address the root causes behind hospital readmissions and the revolving door of the criminal justice system.

We can start with the approaches undertaken by the Dutch but we need to invest in supportive and affordable housing, fund mental health and addictions programs including safe injection sites, re-instate the basic income program, and support meaningful discharge planning and community case management. We need to change custody conditions so that we can disrupt the cycle of charges, prevent people from languishing in custody at the remand stage, and prevent them from pleading guilty to be released. Otherwise we're failing them over and over again.

We don't support marginalized people to become productive members of society in our hospitals and prisons. Instead we house them unnecessarily at very high costs. Ontario's government is looking in the wrong places for inefficiencies, they need to start spending on social services that will get people out of hospital hallways and prison cells.

Question

1. What are some conclusions or lessons learned from this case study with respect to health promotion and community development?