Kathy Hardill's Closing Plenary Address January 2008
Closing Plenary Address
RNAO Board of Directors Assembly
January 25, 2008
Let me begin by saying just how pleased and honoured I am to be here among such a large gathering of nurses from across the province. I am especially pleased to be speaking this afternoon about a subject very dear to my heart – and that is the link between illness, the social determinants of health and nursing practice.
In the past twenty years I have had the good fortune to work in acute care, intensive care, home visiting nursing, and community based primary care. I have spent much of my nursing life doing so-called “street nursing” which refers to providing health care to homeless people, perverse though that is in such a rich country as this.
Recently, I have begun another chapter in my nursing life – providing primary care with the Bancroft Family Health Team, which is located in a small medically underserviced community of 3500 people, about 250 km northeast of Toronto.
No matter where I go – inner city Toronto, working class Hamilton, or the mineral capital of Canada which is Bancroft, Ontario – and no matter what type of nursing I do, I am struck, over and over again, by the fact that the single most important determinant of whether people are healthy or not is poverty.
It is not smoking, it is not obesity, it is not physical inactivity – yes, of course those things are relevant. But it is income level that makes more difference than anything else. The relationship is directly proportional: the higher your income, the healthier you and your family will be. Income creates huge disparities in key health indicators including life expectancy, infant mortality, chronic disability and chronic illness.
If you are like me, you will have learned about health promotion in nursing school – and you will have learned how to counsel people about smoking, alcohol, nutrition, exercise, bike helmets, safe cribs, car seats, hand washing, immunizations – the list goes on and on – and of course all of these things do promote health, and of course they are important. But chances are, if you are like me, you will not have learned that the single most important risk factor for illness is poverty. And if you did learn it, or figure it out yourself, I would also bet that no one told you what you, as a nurse, can do about it.
York University professor Dennis Raphael is an expert on the social determinants of health. He has a tongue in cheek list of rules for health promotion which include “if you want to be healthy, don’t be poor,” “don’t have poor parents,” and “if you are poor, try to quit being poor as soon as you can.”
I spent many years nursing at what I call the epicentre of the homelessness disaster, here in downtown east Toronto, because there are more homeless people in an area encompassing several city blocks than anywhere else in Canada. We borrow the term epicentre from meteorological language, but there is a certain appropriateness because cataclysmic natural disasters like hurricanes or earthquakes often cause injury, illness, and internal displacement, as does the preventable human made disaster which is known as homelessness.
In Toronto, the situation is desperate. 5000 shelter beds are not nearly enough. Homeless people are living in abandoned buildings, ravines, parks, and under bridges. People are living in their cars. 100 children enter the shelter system every week in Toronto, and have done for the past five years. Shelters are dangerously overcrowded. It is not uncommon to find two or three people squeezed into a sleeping space which the United Nations says is the minimum amount of safe space for one person in a refugee camp.
In Ottawa, one shelter has opened a palliative care unit because of the number of shelter residents with terminal illnesses. I know of homeless health outreach programs in London, Hamilton, Kitchener, Barrie, York County, Kingston, and Sudbury.
Although we often characterize homelessness as an urban phenomenon, the homeless people I know come from everywhere. They are primarily economic refugees – poor people – and they come from places like Elliot Lake, Timmins, Sarnia, Napanee, Geraldton, Smith Falls, Cobourg . . . every village and small town and hamlet you can name, all the places you have come from. People are forced to migrate to large cities because their small towns lack the infrastructure to adequately support large numbers of poor people.
No one living in shelters sleeps well, because shelters are noisy, crowded, and sometimes dirty. For the past several years, many Toronto shelters have become infested with bed bugs, which are nocturnal insects that detect human body heat and come out at night to enjoy a blood meal. I have treated many, many people who are covered in insect bites, some of whom scratch so much that they develop secondary bacterial infections.
I know people who have refused to enter a bedbug infested shelter even in subzero temperatures. I know many people who stay awake in shelters all night, hypervigilant, watching for bugs, and who then try to “cat nap” somewhere quiet during the day. But of course, there is nowhere safe or quiet in which to do this, so they just become more and more sleep deprived, more stressed, more immune suppressed.
In some shelters, there are one or two toilets for 60 or 80 or 100 people. Recalling what it may be like in your house in the mornings, when two or more people are vying for bathroom time, imagine what it would be like to deal with that in the context of 80 strangers. It is very difficult to get access to showers and laundry services. It is very difficult to get access to menstrual supplies. Imagine what that feels like.
Some people make what to me seems to be a rational decision to avoid shelters. They may sleep in tents or makeshift shelters scattered throughout cities. They often face harassment by public works officials or police, and live in constant fear of having their shelters destroyed or removed. There are very few public toilets accessible to homeless people.
Some of you will recall the large shantytown which grew up at Lakeshore and Parliament Streets. It became known as Tent City, and by the time it was dismantled in September 2002 almost one hundred people lived there. Tent City was a very difficult, dangerous place to live. It was isolated. There was no hydro or running water. There were many accidents and fires and constant injuries. The nearest phone was ten minutes away. The site was an illegal dumping ground, and hazardous materials were constantly being dropped off.
It was also toxic from its earlier industrial life. When my nurse practitioner colleague Cathie Simpson and I went there, we distributed bottled water, candles, insect repellant, toilet paper. This is what you do during a disaster, in a developing country. It’s mind boggling to consider that this is what health promotion looks like in Canada’s richest city in the twenty first century.
Now that I am living and working in rural Ontario, I am witnessing the effects of harsh, isolated rural poverty. Within the first month of starting my new job, I had met a homeless couple who were living under a tarp, catching fish for food, and frantically trying to build a rough cabin before winter. They had an old vehicle, but no money for gas. Even if they could get gas money, they could not afford insurance for the car, so they would have to risk driving uninsured or try to get a ride into town from someone. They had no way to get to the food bank which in my community is open 3 hours a week. They had no way to get to town for shopping or medical appointments. No way to wash clothes. No way to get dry after a day of rain. No way to get to the welfare office which, in my town, is out on the highway and accessible only by car.
I have met a young mom with 4 children, who was 8 ½ months pregnant, living in a ramshackle farmhouse with no neighbours. Her husband had taken their only car for work, and when I visited her she was hauling wood into the house to feed the woodstove. The kids were crying, she was profoundly depressed and she said to me as she put a log into the stove: “There is an oil furnace but we can’t afford to run it. I just hope my water doesn’t break before my husband gets home ‘cause I have no way to get to the hospital” – which is more than one hour away by car.
I have met a teenage mother whose young partner works all night long loading logging trucks. He comes home in the morning, falls asleep, and she basically functions like a single mother, alone all night and basically alone all day. She missed one prenatal appointment because she had no transportation, and the obstetrician called children’s aid to report her “concern” that this young woman was likely unfit to parent. She is not unfit to parent, she is devoted to her baby girl but she is poor and she is struggling, and all too often we in the health professions do exactly what this physician did – we interpreted her poverty as a personal failing which provides evidence of being a generally flawed human being.
I recently met a woman with shoulder pain, whose ultrasound revealed a full thickness supraspinatous muscle tear. When I asked her if she knew what might have caused it, she disclosed to me that she had endured sixteen years of violence from her partner. There are no shelters. There is nowhere for poor women to go, even if they had the means to leave. In a small community, people talk and people take sides and women are afraid of losing their jobs if they “out” an abusive man.
I have met an eighty year old man living at the end of seasonal road with no running water and a wood stove for heat. I have been thinking about him, when we get yet another 20 cm of snow, and wondering how he is managing with no way into town for months at a time.
My colleague Cathie Simpson now does outreach nursing in Barrie. She has noted the high prevalence of so-called “couch surfing” because there are so few shelter beds in her community. She also sees many people who are put on a bus from the huge superjail in Penetang with a one way ticket to Barrie – many of whom are taking psychiatric medications who arrive with no meds, no drug cards, no access to health care – and she tells me that too often they end up in hospital or back in jail.
There are many dire health consequences of poverty. Infectious disease is among the most serious. During the Great Plague of London, wealthy people fled the city and many survived. They left behind the impoverished masses to their ugly deaths in crowded filthy hovels. Today, we have tuberculosis; hepatitis A, B, and C; and HIV/AIDS. We know that globally, AIDS is a disease of poor people in poor countries. This is also the case in North America – where HIV rates are very high in areas of concentrated poverty.
Globally, about 1 in every 3 people is infected with tuberculosis, or TB, mainly in poor countries. In Toronto, approximately 40% of homeless people are infected with latent TB – higher than the global rate. TB is fueled by poor health and overcrowding – exactly the conditions found in homeless populations all across Canada. When I was in nursing school, TB did not even warrant a mention in course curriculum. Now it has come back with a vengeance. In fact, Toronto has had two TB outbreaks in the shelter system. In all, four homeless men died – of TB, of consumption, in the 21st century in Canada’s richest city.
Mental health issues also figure prominently in the health costs of poverty. Homeless people report very high rates of depression, anxiety and chronic stress. The Street Health Report, published 10 years ago, revealed that 1 in 2 homeless people had thought about committing suicide, and 1 in 4 had attempted suicide. These are astronomical rates. I am seeing very high rates of depression and anxiety in my rural practise. I had one older woman break down in my office describing the unrelenting stress of always worrying about money, and never having enough for all the bills.
It is important to remember as well that poverty and homelessness affect children. Homeless children suffer significant disruption – they lose their homes, their friends, their teachers, their classmates, their familiar routines. Parents are stressed. Kids are stressed. Family shelters have constant outbreaks of colds, coughs, stomach flu and diarrhea. Children living in poverty face increased rates of illness, injury, hospitalisations, mental health problems, poor school performance and early school leaving.
Poverty also leads to higher rates of chronic illess such as type II diabetes and heart disease. In fact, poor children have a higher risk of developing cardiac disease even if they stop being poor as adults.
The bottom line? Poor people get sick more often, and die earlier than people who are not poor. The relationship between illness and income is inverse – the lower the income, the higher the burden of illness.
In essence, we are allowing an entire group of people – an entire social class of human beings – to get sick and die prematurely simply because they are poor. I think that is unacceptable. I know it is unnecessary. So why is it allowed to happen?
I believe it is allowed to happen because it is a consequence of specific and intentional policies which are favoured by governments and those who tell governments what to do. Some people are simply considered expendable. In 1995 in Ontario, we saw the province cut welfare rates by 21%. As a direct result, homelessness increased exponentially. New provincial landlord and tenant laws were created which favour landlords and make it easier to evict tenants. In Toronto, there are 100 applications made to evict people every single business day – that is 2,000 every month.
The federal government has reduced access to income support programs such as EI, WSIB and CPP. Globally, we are feeling the effects of a corporate agenda which favours low wages, and the gutting of labour laws, worker protection and environmental protection.
You may wonder what all of this has to do with health – well, I have learned that health is political. One cannot address the basic determinants of health – the roots of illness – without becoming political. Nineteenth century German doctor and pathology professor Rudolf Virchow said, “All diseases have two causes – one pathological, the other political.” I couldn’t agree more.
The causes of poverty are not to be found at the individual level. Homeless people are not homeless because their characters are flawed, or because they cannot budget, or because they are lazy or shiftless. They are homeless because governments and their big business masters have a financial interest in maintaining an economic and social underclass. That group is largely made up of those with few skills, few resources, or with serious health issues. But it is a political decision whether we as a society reach out to those with few resources and many challenges, and ensure they have what they need to live well and participate fully in life, or whether we consign them to sickness and early death in twenty first century hovels.
So what are we, as nurses, to do?
It helps very much to develop one’s own understanding of the relationships between health, illness, and public policy. I would suggest that it is incomplete, it is misleading, and it is unethical for nurses not to become fully knowledgeable about the root cause epidemiology of illness. One could argue, in fact, that such ignorance constitutes a lack of professional knowledge and competence, because it leads to incorrectly blaming people for their poverty, and generating interventions which do not work.
Once you have extended your epidemiological knowledge base beyond simple pathophysiology, you can begin to meaningfully incorporate your knowledge of the social determinants of health into day to day nursing care. Do not assume people have material or personal resources. Be intentional about ensuring people can carry out the plan of care you’ve organized. Do not equate “social issues” with “things to be dealt with by social workers” – practise as if “holistic” means “holistic.”
- Can your patient fill his prescriptions? If not, intervene and advocate for a creative solution – a less expensive drug in the same class, assist with obtaining a drug benefit card, provide the person with samples, request a Section 8 or compassionate release from the drug company.
- Where is this person going after discharge? Gently inquire about the living situation to which they are returning – is there anyone there to assist them? Do they have access to running water? Do they feel safe returning there? Will they be able to get groceries, prepare food? Does this pensioner with a fractured hip have to climb three flights of stairs to his tiny rooming house room? Does he normally get his one meal a day at the soup kitchen, and if so what will he do now that he is home-bound?
- Is this woman with the fractured jaw returning to an abusive situation? Has anyone thought to ask? Has anyone offered to find a shelter, or give information for her to use to potentially save her life in the future?
- Does your prenatal client on social assistance have all the financial entitlements she can get? Medical transportation funds? Special diet funds? Winter clothing allowance for her children?
- Screen low income clients for conditions you know they are at risk for: iron deficiency anemia, calcium deficiency leading to osteoporosis, folate deficiency, diabetes, heart disease, depression
There is no end of creative ideas for improving the health of our low income clients. Once you start thinking about the social determinants of health in your practice, I guarantee you will not be able to “unthink” it.
Moving a little further away from direct practice, we must do as American nursing professor Patricia Stevens suggests – “…to document through research…the human costs of dismantling the social safety net…(and) through…scholarly work and political action, nurses can offer new vision for the goals of public policy” (p. 9, A Nursing Critique of US Welfare System Reform, ANS 2000).
And of course we must work “upstream” to reduce the root causes of scourges such as poverty, homelessness, environmental degradation and violence against women.
We must add the credible voices of nurses to advocacy campaigns such as the fight at the provincial and federal levels for a national housing strategy. The Toronto Disaster Relief Committee was co-founded by a nurse, Cathy Crowe, and a community worker – Beric German. To learn more, go to www.tdrc.net, and if what you see makes sense to you, participate in actions, as individuals and as RNAO.
In 2005, a group of nurses, physicians, dietitians and other health providers formed Health Providers Against Poverty, or HPAP. We came together around calling for an increase to social assistance rates in Ontario, citing the vast epidemiological literature supporting the relationship between preventable illness and low income. HPAP has developed clinical practise tools for health providers on how to incorporate the social determinants of health into every day practice, we have lobbied politicians and bureaucrats around poverty reduction strategies, and we have participated in conferences, workshops and clinical rounds to try to educate other health providers about the links between health and poverty.
A few years ago, I took a canoe trip that started near Wilberforce, Ontario. There is a wonderful Red Cross Museum there, which is full of archival nursing material, including pictures of the nurse making calls on horseback and on snowshoes. Astonishing to me, and deeply disturbing, were her nursing notes from the early part of the century describing the number of rural children coming into the care of child welfare agencies because of their parents’ poverty and poor housing.
In Toronto, today, one of the primary reasons children come into the care of child welfare agencies is their parents’ homelessness. A hundred years later, despite unprecedented technological advances in medicine, it is still the twin plagues of social conditions and poverty which most threaten the health of our people.
And so I call on nurses. We know what makes people sick. We say we specialize in promoting health. Let’s do that. Let’s speak out loudly and clearly and bravely on behalf of the thousands of Ontarians we look after who have nowhere to live, who are malnourished, who are contracting infectious diseases because of their living circumstances, who are disabled by years of neglected emotional trauma, whose families are being destroyed by poverty and violence. Over the past twenty years or so, nursing in Ontario has come quite a distance in terms of political advocacy. RNAO has strong leadership and has taken some courageous steps in speaking out on issues such as homelessness, violence against women and homophobia.
There is no end to creative means of advocating to reduce poverty on Ontario. RNAO and member groups like NPAO could make political health advocacy the theme of an upcoming conference. We could organize “Politics of Health 101” workshops across the province to give nurses the knowledge and tools they need to advocate strongly for vulnerable Ontarians. Nurses across the province could hold “determinants of health” media conferences during Nurse’s Week, highlighting the preventable health issues created by poverty and deprivation.
Nurse practitioners could draft position statements on areas within our scope of practice, like the way Ontario Disability Support Program application packages are designed to deny vulnerable people disability benefits. We can create and disseminate clinical tools to help us learn how to circumvent cruel bureaucratic red tape which exists to keep poor people languishing in squalor.
Governments actually count on us to be consumed with tending to the sea of unending human disasters – because it means that we won’t have time or energy to turn our attention towards them – but this is what we must do. Working politically is vitally important. It is the sort of work that helps people have access to the basic determinants of health – food, shelter, income, safety.
There is a wonderful poem written many years ago by the German poet and playwright Bertolt Brecht, who incidentally studied medicine but preferred literature. Part of it goes like this:
Are you able to heal?
When we come to you
our rags are torn off us
and you listen all over our naked body.
As to the cause of our illness
one glance at our rags would
tell you more. It is the same cause that wears out
our bodies and our clothes.
The pain in our shoulders comes
you say, from the damp, and this is also the reason
for the stain on the wall of our flat.
So tell us:
Where does the damp come from?
We need to work upstream on getting rid of the damp – so that whole groups of people – in our cities, in our towns and villages, on reserves, in remote fly in communities in the north, out in the bush on seasonal roads – are not simply written off to get sick and die early and never have a chance at life at all.
Although understandably nursing organizations desire influence with provincial governments so that the profession is protected within the health care system, we must see clearly that it is often those very governments whose policies jeopardize our vulnerable clients. Quoting Professor Patricia Stevens again: “Nurses need to demonstrate the political will to break through this aura of inevitability and blame, because it is possible to reduce poverty with humane policies, and poverty must be reduced in order to achieve healthy outcomes as a nation….Nurses do not need an elaborate theory of justice to back their actions because the ethics of the situation are clear” (pp9-10, ibid).
Like that Red Cross nurse on snowshoes, who understood that it was poverty, not bad parenting, which was hurting the children in her care, let us recognize that poverty is a health risk, let us put that meaningfully into compassionate nursing practice, and let us speak the truth without fear.
Kathy Hardill, RNEC