I've been a
street nurse in Toronto for 17 years. In the spring of 2004 I received the
Atkinson Economic Justice Award which permits me to pursue, for up to three
years, my passions for nursing and working on homelessness and housing
issues. In this newsletter I hope to report on my activities, create a
link to a broader group of individuals who care about these social issues
and encourage critical debate.
Further information about subscribing to the newsletter is found below.
I want to hear from you - about the newsletter, about things that are
happening in the homelessness sector (what a sad term!), and about goodthings which will provide inspiration for all of us.
I’ve been wanting to write about the Pandemic Flu for some time.There are lots of dramatic storylines to write about –
profit-hungry drug companies, the role of agribusiness, global poverty and
world indifference, post 9/11 governments and the war on terror.The scientific and political history of H5N1/Avian Flu reads like a
science fiction novel in process – except it’s true.
Recommended reading: The Monster at Our Door. The
Global Threat of Avian Flu by MacArthur fellow Mike Davis (2005, The New
Press). It’s necessary reading
and is also a serious reminder that dismantled public health systems,
poverty and homelessness and lessons not learned (i.e. post SARS) pose
problems that we better face – here in
. I also urge you to check out www.fluwikie.com
So, consider this newsletter a Pandemic primer – just
an initial foray into some of the issues regarding the impact of the
pandemic, especially on vulnerable populations here in
- people living in poverty and those who are homeless.
Pandemic and Poverty
A pandemic is an infectious disease that can spread
across many countries or around the world in a short period of time. An
influenza pandemic occurs when the influenza virus has mutated into
something dangerously unfamiliar to our immune systems, causes illness and
has the ability to jump from person to person- usually through a sneeze,
cough or touch. It might be mild
or catastrophic in its assault.
Will it be H5N1
……also known as bird or avian flu?
H5N1 is a zoonotic disease, which means it is capable
of moving from animals to infect humans.It is the latest in a growing number of diseases able to make the
jump to humans. In fact, 38
illnesses have made that jump in the last 25 years. HIV/AIDS, Ebola, SARS,
and BSE (mad cow disease) were all zoonotic diseases.
H5N1 has been widespread in wild water-bird populations
in parts of
for some time and more recently it has spread to mammals and humans.To date, birds remain the primary vehicle for spread of the virus as
it has traveled from
, and it’s still moving.
H5N1has killed over 90 people so far, most in
when the virus re-emerged from a quiet period in 2003. It
appears to kill about half the people it infects. “It’s
the worst virus I’ve ever seen” said Dr. Robert Webster of St. Jude
, a leading authority on bird flu.
H5N1, as of writing this newsletter, is not yet known
to transmit from person-to-person, but it would appear to be just a matter
of time.The track record of
H5N1 virus, which is the anticipated culprit to produce the next pandemic,
does not suggest a wimpy pandemic according to Frederick Hayden, a
virologist who advises the World Health Organization.
It’s been 38 years since the last influenza pandemic
hit and we’re due. Experts
around the world all say, it’s not IF
the pandemic hits, it’s WHEN. The
New York Times recently reported that each bird-to-human transmission gives
the virus another opportunity to mutate into a form that could cause a
A Toronto Public Health backgrounder says:
“Everyone is potentially
at risk during an influenza pandemic. Certain
groups may be at greater risk that (sic) others but that will not be known
until the pandemic virus emerges.”
Well, I do think we know which groups are already at
greater risk and we are ignoring that information. Global
pandemic experts all agree that poorer countries will be hardest hit.Likewise we can predict that poor communities, whether they are in
‘megaslums’ or western homeless shelters will be hard hit. Poverty,
malnutrition, chronic and acute illnesses were all powerful determinants in
the deadly 1918 pandemic.
We also know that certain populations are more at risk
for influenza complications and deaths – it’s why we immunize high-risk
groups.Research has also shown
that infant mortality from influenza is higher in poorer countries. Even
in ‘developed’ countries like the
, seasonal influenza kills tens of thousands of mostly elderly and
especially poor Americans each year.
While, “everyone is potentially at risk”, it is not
a huge leap of logic to predict that certain vulnerable populations in
Canada will be more at risk during a pandemic because of their diminished
health status, limited choices and income level.This includes people on social assistance or other forms of fixed
income, people who are homeless and using night or day shelters/drop-ins,
people whose poverty means they often use the food and support services in a
day time drop-in centre or soup kitchen, people in nursing or retirement
homes and people in correction facilities.Also at risk are the thousands of people working in those sectors.
Certain groups were harder hit in the aftermath of
Hurricane Katrina, so I don’t know why public health officials can’t
acknowledge that a similar pattern could repeat itself in a pandemic
catastrophe and begin planning for it.
In fact, health providers are already facing challenges
ensuring vulnerable populations have access to basic medical care and
supplies. Street Nurses in
had to lobby for years to convince the local health department to establish
a comprehensive flu shot program and TB screening program for the thousands
who were homeless.As recently
as November 2005, the United States National Association of Community Health
Centres reported a shortage of the seasonal flu vaccine at Community,
Migrant and Homeless Health Centres around the country. “It
is indeed ironic that delays with vaccine supplies to providers come as our
nation’s leaders craft a federal response strategy for responding to a flu
pandemic or an avian flu strike,” said Tom Van Coverden, President and CEO
What to expect?
Here are some examples of predictions made by public
392,000 - 914,000 ill
1,600 - 14,000 require hospitalization
630 - 4,300 deaths
74,000 - 135,000 ill
850 - 2800 require
328 - 862 deaths.
1.2 million ill
*note – most US city websites had more information on
anthrax than pandemic flu.
In addition experts predict that:
pandemic could hit Canadian cities within several days, but no later
than 3 months after the pandemic is first declared by the World Health
pandemic could occur in waves, each wave lasting 6-8 weeks
will not be available for 4-6 months after the pandemic begins
will not be enough antiviral drugs
much as 60% of the work force will be too sick or scared to leave their
homes and they will not show up for work, disrupting business, industry
disruption in things we take for granted such as delivery of food and
supplies to markets will cause shortages and potentially violence
What has history taught us?
Speed and prevention are the two weapons at hand to
contain an outbreak.
There have been no Olympic records set in
on either of these fronts.Toronto
politicians and public health officials were more than sluggish in their
response to repeated warnings in the 1980s by health care workers when they
forewarned that the crowded, impoverished and unhygienic conditions the City
was keeping homeless people in was a public health disaster waiting to
happen. Well, it turned into
one.Almost one-half of
’s homeless population are now infected with latent TB; a TB outbreak in
the shelters eventually killed 3 homeless men and cost Toronto Public Health
more than $500,000; shelter workers have been infected with active TB; and
more recently a bedbug infestation throughout the shelter system has caused
serious skin infections and has furthered mental anguish.
Were lessons learned?
When SARS hit
it was evident within weeks that shelters and drop-ins and all the people in
them would have to fend for themselves.The City’s best plan in the event that homeless people were exposed
to SARS, included a proposed ‘lockdown’ of Seaton House - the largest
men’s shelter in
, and ‘home’ quarantine in the same shelter. No
plans for proper quarantine facilities. No
plans for drop-in centres.No
plans to stop the night by night movement of people who are homeless and
forced to use the volunteer based Out of the Cold emergency shelter sector. This
lack of planning would have made it impossible to contain the outbreak
should SARS have entered this population.
It has been said that
contained SARS imperfectly, slowly and with major problems utilizing
primarily traditional public health containment measures: home quarantine,
hand washing and self-isolation.I
wonder if the business community fully appreciates the fact that had SARS
shown itself at, say the inner city St. Michael’s Hospital or the weekly
Osgoode Hall meal for the homeless or at St. Andrew’s Church Out of the
Cold, the devastating impact on the economy could have extended beyond
tourism and the hotel industry, it could have hit Bay Street.
Today, 3 years post SARS, Toronto has plans to improve
public health information technology and communication, yet I still see no
improvements in basic public health measures such as guaranteed access to a
clean and safe space, an adequate amount of toilets and soap for drop-ins
and shelters, and (we should dare to dream) what Virginia Woolfe would call
‘a room of one’s own.’
The reality is that City officials continue to:
people into shelters beyond the safe 90% capacity level
‘beds’ (really mats) to the overcrowded shelter system during
‘cold weather’ alerts
on the continuation of the volunteer based Out of the Cold program
(it’s been over 16 years!)
money to projects that have no measurable impact on a homeless
person’s state of homelessness, for example the Spring 2006 ‘street
count’ where homeless people will be counted and asked what services
Flu moves with speed. A
short incubation period means that if someone is exposed they may have
symptoms within 2 days and will ‘shed’ (spread) the virus even before
greatly contrasts to SARS which had a 10 day ‘window’ allowing public
health officials to track and find people and impose ‘home’ quarantine.
So, let’s imagine a realistic Pandemic Flu scenario.
David who is homeless is exposed to the virus in the
waiting room at St. Michael’s
Hospital Emergency Department. He’s
discharged and immediately goes to the All
Saints Drop-In to pick up his belongings and tell the Street Health nurse about his visit to emerg and arranges to see her
the next day for follow-up. He
then goes to the other side of the church to the Friendship Centre for the
meal, then goes on to St. Simon’s
Out of the Cold for the night. The next day a similar pattern repeats
itself however he now has to travel to the west end of the City to sleep at Trinity St. Paul’s Out of the Cold which
is the only one with space available. Now,
he’s beginning to feel sick. He
visits Scott Mission for lunch,
then back to see the nurse at All
Saints. She helps him get a
real shelter bed at the Salvation
Army Gateway because he feels so ill. He
goes back to St. Michael’s Emerg.Hundreds, literally hundreds of people have now been exposed to the
virus through no fault of David.He’s
been on the social housing waiting list 8 years.
Public Health officials in the western world are
ignoring important preventive measures they could take now to reduce
crowding and congregate living. Yet,
the key concept of “social distancing” which includes measures such as
closing schools or banning public gatherings is widely recognized as a
life-saving public health measure, but only AFTER the onset of the pandemic.
In a bizarre twist of prevention, officials in
recently took the unusual and perhaps eccentric measure of isolating indoors
the 7 ravens, who call the
home. Not because there is any
concern they are sick, but to protect them from illness should infected
birds arrive in
.As the legend goes, if the
ravens ever leave or die, the tower and the kingdom will fall.
who are sleeping ‘in the rough’ should be so lucky.
Dr. Brian Ward, Chief of McGill’s Division of
Infectious Disease has said very succinctly that a key measure to protect
people in the event of a pandemic is to discourage public gatherings.
“This happened to some extent in the 1918 pandemic: movie theatres were
closed and people stayed home. Similar
strategies were employed during some of the large polio epidemics as well.
Preventing people from getting together can certainly slow the spread of
What we could and
should be doing.
Federal and provincial governments should allocate
sufficient funds to ensure municipalities can implement the following:
supply cheques for people on social assistance and fixed income like
seniors, to assist them with the costs of stockpiling emergency supplies
such as food and water.
of emergency supplies for distribution by a NGO such as the Red Cross or
civil servants (fire departments or Canada Post).
purchasing of cleaning supplies, soap, paper towels, toilet paper,
Kleenex, gloves and masks for distribution to community agencies.
Municipal shelter or community services divisions
Out of the Cold type programs to cease operation immediately, i.e. in
advance of a pandemic
replace the beds per night provided by Out of the Cold type programs
with a municipal shelter facility that has individual rooms
standards or emergency protocols are developed to minimize the daily
forced relocation of homeless/underhoused people. (For example measures
that should include the provision of 3 meals a day on site in shelters,
ending maximum length of stay requirements, and issuing a moratorium on
Isolation sites for people without homes
harm reduction sites for quarantine or isolation of people with serious
potential locations where trailers or pre-fabs could be placed
Provincial governments should:
at least 20,000 emergency rent supplements to municipalities for the
specific purpose of moving homeless people into housing and thus
reducing crowding in homeless shelters. In particular a protocol and
timeline should be developed to ensure specific populations are
prioritized for re-housing: seniors, families with children, people with
chronic illness or conditions that affect their immune systems such as
HIV, Hepatitis C or cancer
an appropriate shelter facility (such as the Family Residence in
Toronto) to pilot the rent supplement program, recognizing that the
building, when empty, would be an ideal location for an alternate care
site for people needing to be quarantined or isolated
physicians and pharmacists to, when possible, renew patients medications
for a three month supply
as did the Dutch national health agency, the benefits of providing
pneumonia vaccine to the usual risk groups in the population in order to
reduce hospitalizations by as much as 30%
I’d be very interested to hear what’s happening in
your community? Does your
municipality have a pandemic flu plan that addresses vulnerable populations?
Who are the advocates in your
community on this issue? Does
your agency have a pandemic plan?
An extensive review of pandemic plans in US cities,
Canadian cities and provinces showed a remarkable absence of attention to
vulnerable populations. Many pandemic plans focus on explaining the
hierarchy of decision making.In
some cases, plans seem a few years out of date, such as the Alberta Pandemic
Plan which makes the statement:“If
necessary, the municipality will establish an Emergency Operations
Have you stocked up?
Dr. Gerry Predy, Medical Officer of Health in Edmonton says: "Our
message to the public is 'be prepared before it comes'. Then
when it comes, it will be a 'don't panic' message."
I’m guilty of procrastinating but I’ve
finally stocked up. I
stocked up because I think the Pandemic Flu threat is real and I
think when it hits all hell will break loose. Dr.
Ian Gemmill, Medical Officer of Health in
has said “When I think about the worse case scenario, I think
about Loblaws trucks going down the street throwing out bags of
groceries to people so they don’t congregate at the Kingston
Approximate cost: $300. (quantities for one
12 litres of water
6 cans of meat/protein (combination of
tuna, ham, baked beans)
6 cans of juice
6 cans of fruit
2 jars of peanut butter
6 cans chunky soup
6 cans vegetables
3 boxes of crackers
3 boxes granola bars
3 boxes cereal
Dried fruit, trail mix
1 box powdered milk
Plastic knives, forks, spoons
Candles, matches, lighter
Soap – laundry and dish
Batteries, flashlight, emergency radio, various
materials for first aid kit and medicine cupboard.
Update – March 3/ 2006.Recent events since writing this newsletter:
1.Scientists confirm that a cat in Germany was infected with H5N1.The cat likely picked up the virus by
eating an infected bird.A news report published by the journal Nature suggested there is
evidence of infection in dogs as well.Scientists
had tested 629 village dogs and 111 cats in central Thailand and found 160 dogs and 8 cats carried antibodies
to the virus, suggesting previous infection.The virus's ability to infect cats has been known for some time.In early 2004 there were reports of H5N1 infection in house cats in Thailand.In
October of that year, tigers and leopards in a Thai zoo were fed infected
chicken carcasses and died from the virus.The cats with the disease shed virus through
their nasal passages and in their droppings and are able to pass the virus
to other cats that had not eaten infected chicks.
2.Eight Quebec poultry farms quarantined
as Canada bans all live birds from France.The Canadian Food Inspection Agency also prohibited poultry products from
that did not undergo heat
poultry farms that were
quarantined had recently imported live ducks and hatching eggs from
– the latest country hit by
the deadly H5N1 strain of avian flu.Samples
have been taken to test for the virus and results are expected in a few
recently took the precaution
of passing legislation prohibiting domestic poultry producers from keeping
their stocks outdoors, and while there is no law in
, according to Margie Taylor of
the Chicken Farmers of Ontario, the province's 1,100 commercial chicken
producers all keep their poultry inside.
officials ramp up inspections for travellers from Europe over fear of the lethal
strain of bird flu.Canadian public health
officials have started working with their border security counterparts to
ensure passengers don't import avian flu as it continues to spread across
the European continent.Animal
health experts are saying that the greatest potential for spreading the
comes from travellers and not
Travellers from a list of 20
countries exposed to the virus face questions by Canadian authorities,
They have visited a farm in
They have hunted or
participated in birding; or
Whether they are importing
feathers or other bird products.
"Our agents have been
instructed to ensure these individuals for example have not been on farms
and will not visit farms in
," said Robert Gervais of
Canada Border Services.
The World Health Organization says that so far, there
have been 174 human cases of avian flu in seven countries, with 94 people
dying from the virus.
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