Cathy Crowe




Newsletter No. 21  March  2006


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 good things 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 North America .  I also urge you to check out


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 Canada - people living in poverty and those who are homeless.



The 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, West Nile and BSE (mad cow disease) were all zoonotic diseases.


H5N1 has been widespread in wild water-bird populations in parts of Asia 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 Southeast Asia to India , Iran , Nigeria , France , Hungary , Germany , and it’s still moving.


H5N1has killed over 90 people so far, most in Asia 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 Children’s Research Hospital in Memphis , 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 University of Virginia 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 pandemic.




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 United States , 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 Toronto 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 of NACHC.  


What to expect?


Here are some examples of predictions made by public health officials:


Toronto   (Ontario, Canada )

            392,000 - 914,000 ill

            1,600 - 14,000 require hospitalization

            630 - 4,300 deaths


Quinte-Kingston-Rideau (Ontario, Canada)

74,000 - 135,000 ill

850 - 2800 require hospitalization

328 - 862 deaths.


Province of Manitoba (Canada)

            176,000-410,000 ill

            700-1,600 deaths


In King County, Seattle, USA *

1.2 million ill

57,000 require hospitalization

11,500 deaths


*note – most US city websites had more information on anthrax than pandemic flu.


In addition experts predict that:


  • the pandemic could hit Canadian cities within several days, but no later than 3 months after the pandemic is first declared by the World Health Organization
  • the pandemic could occur in waves, each wave lasting 6-8 weeks
  • vaccines will not be available for 4-6 months after the pandemic begins
  • there will not be enough antiviral drugs
  • as 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 and services
  • serious 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 Toronto 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 Toronto ’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 Toronto 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 Canada , 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 Toronto 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:


  • pack people into shelters beyond the safe 90% capacity level
  • add ‘beds’ (really mats) to the overcrowded shelter system during ‘cold weather’ alerts
  • rely on the continuation of the volunteer based Out of the Cold program (it’s been over 16 years!)
  • allocate 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 they require


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 becoming symptomatic.  This 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 noon 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 England recently took the unusual and perhaps eccentric measure of isolating indoors the 7 ravens, who call the Tower of London home.  Not because there is any concern they are sick, but to protect them from illness should infected birds arrive in England .  As the legend goes, if the ravens ever leave or die, the tower and the kingdom will fall.   Britains 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 some viruses.”


What we could and should be doing.


Federal and provincial governments should allocate sufficient funds to ensure municipalities can implement the following:


  • Emergency 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.


  • Warehousing of emergency supplies for distribution by a NGO such as the Red Cross or civil servants (fire departments or Canada Post).


  • Bulk purchasing of cleaning supplies, soap, paper towels, toilet paper, Kleenex, gloves and masks for distribution to community agencies.


Municipal shelter or community services divisions should:


  • direct Out of the Cold type programs to cease operation immediately, i.e. in advance of a pandemic
  • immediately replace the beds per night provided by Out of the Cold type programs with a municipal shelter facility that has individual rooms
  • ensure 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 shelter barrings/bannings.)
  • develop Isolation sites for people without homes
  • develop harm reduction sites for quarantine or isolation of people with serious addictions
  • identify potential locations where trailers or pre-fabs could be placed


Provincial governments should:


  • allocate 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
  • identify 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
  • direct physicians and pharmacists to, when possible, renew patients medications for a three month supply
  • examine, 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 Centre.”  If necessary?



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 Kingston 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 Centre.”


Your six week emergency check-list available at:


Approximate cost: $300. (quantities for one person)


  • 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

  • Paper towel

  • Paper plates

  • Plastic knives, forks, spoons

  • Paper cups

  • Toilet paper

  • 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 France that did not undergo heat processing.  The Quebec poultry farms that were quarantined had recently imported live ducks and hatching eggs from France – 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 days.

Quebec recently took the precaution of passing legislation prohibiting domestic poultry producers from keeping their stocks outdoors, and while there is no law in Ontario , according to Margie Taylor of the Chicken Farmers of Ontario, the province's 1,100 commercial chicken producers all keep their poultry inside.

3. Canadian customs 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 disease to Canada comes from travellers and not migratory birds.

Travellers from a list of 20 countries exposed to the virus face questions by Canadian authorities, including whether:

  • They have visited a farm in Europe ;
  • 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 Canada ," 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.


Cathy Crowe




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