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By April 13, Nova Scotia’s State of Emergency had been in effect for 23 days, schools were closed, most businesses shuttered, and people were feeling the effects of the “lock down.” At the daily COVID-19 briefing, Premier Stephen McNeil and Dr. Robert Strang, the province’s chief medical officer of health, updated reporters on the number of deaths — by that point there were three. At publication time, 44 people have died, 38 of them were residents at Northwood, the province’s largest long-term care facility, located in Halifax, and so far the epicenter of the disease.
In a telling exchange that took place at the press briefing — one that El Jones of the Halifax Examiner reported here — McNeil was asked a salient question.
Michael Tutton from the Canadian Press asked:
Premier, the unions that represent workers in nursing homes say that the COVID crisis is revealing a deep underlying problem of staff shortages that should have been remedied years ago. It will continue to reveal that… Does this cause you to reflect and think the time has come to change those staffing levels in Nova Scotia?
It was an opportunity for the premier to finally come clean and acknowledge his government’s role in the chronic underfunding of not only continuing care facilities, but of the health care system in general — one that was challenged to provide for patients under normal circumstances, let alone during a global pandemic.
In 2014 and again in 2017, Auditor General Michael Pickup admonished the province for its long wait times — I didn’t know this but Nova Scotia has some of the highest in the country — and for not adopting his 2014 recommendations to deal with operating room usage and surgical wait-time reporting.
But despite the AG’s recommendations, by 2019, things hadn’t gotten much better. Emergency room closures were announced almost daily as a result of doctor shortages, like this one in Springhill. The gaps in service were not only undermining the principle of universal access but had become so routine in Nova Scotia that some were calling it the “new normal.”
The knock-on effect of ER closures in one area meant open ones were overcrowded, with reports of patients suffering interminable wait times, often in hallways before beds were available, with staff scrambling and unable to meet the demand. We heard of the expectant mothers, who were being told they had to drive more than two hours to properly staffed hospitals to give birth, and of a 33-year-old cancer patient, who, without a family doctor, had lost precious time. Inez Rudderham posted a heart wrenching Facebook video that went viral in which she challenged Premier McNeil to “tell me there is no health care crisis.”
Health care professionals were also noticing the long-standing neglect. A union survey of 1,000 nurses revealed that 93% of them felt patients were being put at risk due to staff shortages, and only 12% said they felt safe at work.
At the April COVID-19 press briefing, McNeil didn’t acknowledge any of this. Instead, this was his reply:
This is not, quite frankly, the time for anyone to begin to negotiate — negotiation [sic] contracts of staffing models. This is about a time of Nova Scotians coming together to ensure that we provide the frontline workers with the stuff that, the support they need, and wrapping our arms around each other in this community. There’ll be lots of times for debate, and unions and others will have their opportunity to criticize or question what we have done or what has been done in the past.
McNeil’s defensive reflex was revealing.
We all know — because we’ve been told over and over again — that the purpose of the lockdown was to “flatten the curve,” so our health care system wouldn’t buckle under the surge of serious cases and lead to a horrific spectacle of triage deaths. We had to pull together and “stay the blazes home” to avoid overwhelming the health care system. But by all accounts, it had already been overwhelmed for years, a result of the incremental shift towards fiscal restraint on the part of governments — a subject we’ll return to.
It’s no coincidence that the “heroes on Northwood’s pandemic-relief team” don’t earn a living wage, or that because health care funding has barely budged for years, the public must shoulder the responsibility of keeping us safe, or that a growing swath of Canadian society is vulnerable to succumbing to the disease.
What the need for extreme measures has exposed is that decades of austerity have left us not only ill-equipped, but much more vulnerable.
Politics shapes our health
By the late 1980s in Canada, there was already an emerging recognition that there was a lot more to good health than meets the eye. In 1986, “The Ottawa Charter for Health Promotion,” endorsed at the time by the World Health Organization, the Canadian Public Health Association, and Health Canada, identified the key determinants or prerequisites of health to be peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.
In other words, a person’s health status was not only influenced by their lifestyle behaviors, the environment, and their genetic makeup, but also by their economic and social status.
Around the same time, new research in the field of medicine corroborated the connection between income, education, wealth, influence, and power with the risk for disease.
Carole Shively was a pioneer in the emerging field. The primatologist and professor of pathology at the Wake Forest School of Medicine in North Carolina was devoted to understanding how environmental factors — social stressors in particular — influence women’s health. Her work involved the effects of stress on macaque monkeys.
Putting aside for the moment the ethical considerations involved in studying highly sentient creatures, Shively found that macaques with less power and control — holding subordinate positions in the group — were found to be in a state of chronic stress. The subordinate animals had almost no control over what happened to them.
She found that these animals also had high levels of cortisol coursing through their blood streams. Cortisol is a stress hormone released by the adrenal gland and when high levels of the hormone are sustained over time, it has a negative effect on cellular function, tissues, and ultimately health. Shively found, for instance, that the chronically stressed-out monkeys were developing arterial plaque at increased rates relative to the dominant or non-stressed monkeys, and were at greater risk of heart attack. 1
Similarly, in the late 1990s, Sheldon Cohen, a pioneering psychologist at Carnegie Mellon University in Pittsburg, conducted some groundbreaking work in humans that shed light on the effects of psychological stress, social support, and social status on immunity and susceptibility to infectious disease.
By studying otherwise healthy volunteers, Cohen wanted to find out more about the connection between stress and the immune system, so he devised a study whereby a drop containing the cold virus was inserted into their nostrils. He also measured their cortisol levels by testing their saliva. Cohen found that the people who were more likely to catch a cold were also the people with higher cortisol levels. But he also discovered that these same people tended to have less income and less education.
Cohen’s discovery was very significant, according to Dennis Raphael, a professor at the School of Health Policy and Management at York University in Toronto. Raphael is Canada’s leading expert in the field of social determinants of health, particularly on how poverty and inequality influence health outcomes, and has authored or co-authored at least 10 books on the subject.
I reached Raphael at his home, where he was working as a result of the COVID-19 lockdown measures.
Raphael says there is now evidence, coming from studies in the US and the UK, that people of colour, immigrants, and people working in lower paying jobs are more likely to contract COVID-19 and then die from it.
“It’s not clear whether this greater susceptibility to the illness is due to physiological factors related to a suppressed immune system or whether these lower income people are forced to work in environments where protection measures are inadequate,” he says.
The other factor that’s extremely relevant here is that the data so far indicate that those most at risk of dying from the virus have comorbidities, that is, other chronic ailments. A 2015 study published in the journal Health Promotion and Chronic Disease Prevention in Canada, looked at the prevalence and patterns of chronic disease “multimorbidity” and whether it was associated with other economic or social determinants. The researchers found that the proportion of the Canadian population living with multiple chronic diseases is increasing, and that Canadians living in the lowest socioeconomic groups — with the lowest household incomes and lower education levels — are not only more likely to develop multiple chronic conditions, but tend to develop them earlier in life.
Raphael also points out that many of the economically insecure in Canada — those who have precarious work, and have been considered “unskilled” and therefore low paid, are still employed and ironically, their work in many cases deemed “essential.” These are the grocery store clerks, cashiers, cooks, cleaners, custodians, those caring for people in long-term care facilities, among others, he says.
“These workers are now at greater risk of contracting COVID-19 than the well-off whose high status work allows them to work at home,” he says, acknowledging that he falls into that “well-off” category.
Raphael points to personal support workers (PSWs) who have been identified as a potential source of COVID-19 spread among nursing homes.
“PSWs are forced to work at more than one nursing home in order to earn a living wage, serving to spread the virus, but these jobs are precarious, poorly paid and without benefits,” he says. The working arrangements don’t benefit the employees or those in their care, but they do benefit the employers, who typically don’t have to pay benefits. In many cases, nursing homes have not had sufficient quantities of Personal Protection Equipment (PPE), and in many cases have been instructing their staff to reuse masks and other protective devices, he says.
He says that the workers we now see as being “on the front lines” deserve job security and a living wage.
“This pandemic has accentuated the systemic inequalities…and intensified the need for immediate government intervention in the form of the massive provision of benefits” for those who are now unable to work, says Raphael. The feds have announced “numerous measures to support workers who have no paid sick leave, are sick, or in quarantine, or need to stay home to care for their children.”
Ottawa and the provinces and territories have just announced a shared program to boost the salaries of essential workers including those working in long-term care facilities, front-line workers in hospitals, and those working in the food industry.
It does make one wonder why this newfound concern didn’t apply to those who were living in poverty prior to the pandemic, especially given that we know, and have known for decades, of the significant costs to society associated with inequality, including all the health-related ones.
According to OECD data, in 2018 — well before the pandemic — Canada’s poverty rate was already one of the highest when compared to wealthy developed nations. It stood at 12%, still better than the US at 18%, but double that of Denmark, which ranked lowest at 5.8%, followed by Finland at 6.3%. 2
Neoliberal ‘tenets’ shaping public policy
When it comes to health care spending, those who argue that it’s “unsustainable” often assert that public health spending is continually going up, and that it’s taking up an increasing share of total government spending. 3 But neither of these bear out in the actual data.
According to the OECD, in 2018 in Canada, roughly 70% of the total health care spending came from public money. This means the remaining 30% was private, including out of pocket expenses or insurance. According to the Canadian Institute for Health Information (CIHI) this public-private split has been fairly consistent since about 2000. But when Canada’s public share of health spending is compared across OECD countries, it ranks towards the bottom.
Raphael points out that while Canada’s public spending on health care in 2018 was about 7.5% of GDP, it has not increased in relation to the country’s wealth, and has remained fairly constant since 2010. He says that considering the country’s aging population, it’s something he would have expected to increase.
“The making of public policy has been subjected to government’s acceptance of the ideology of neoliberalism and the imposition of austerity measures,” writes Raphael in his forthcoming book The Politics of Health in the Canadian Welfare State. The neoliberal “tenets” that emerged in the 1970s include that the “markets are the best and most efficient producers and allocators of resources,” and that societies are “chiefly” motivated by “material or economic considerations,” he writes.
In other words, the new dogma involved a hands-off approach to economics: the unrestrained accumulation of capital, the concentration of private power and wealth and a hollowing of the protective and interventionist role of government.
“In Canada, acceptance of neoliberal ideology led to governments at all levels [and I would add, of all stripes] scaling back on the economic and social supports they provide to Canadians. This is being done despite Canada being wealthier than it has ever been,” he writes.
This erosion of the government’s role is “usually presented as a means to reduce governmental deficits and debt, but in reality it serves to meet the needs of the wealthy and powerful at the expense of others.”
Raphael points to the financial crisis of 2008-2009, which he says led many governments to scale back the “welfare state.” For nearly a decade starting in 2006, Canada had Conservative Stephen Harper at the helm. If any government took full advantage of a crisis to ram through ideologically driven policies, change laws, and cut funding, it was his. But it’s also worth noting that once draconian cuts are made, they are usually never reversed by subsequent governments, and tend to become the “new normal.”
Back in Nova Scotia, data from the Canadian Institute for Health Information (CIHI) indicate that since 2000, public health care spending has stagnated in real terms. In other words, after adjusting for inflation, the dollars spent in 2019 are not that much different in terms of purchasing power than the dollars spent in 2010, even though the population has increased, and it’s an aging one. When you look at per capita spending in real terms, in 2010 the province spent $2,900 per person and by 2019, nearly a decade later, it had only increased by $100 — to just over $3,000. 4
A very recent analysis out of the Canadian Centre of Policy Alternatives says there are already lessons that can be learned from the pandemic, particularly when it comes to long-term residential care, which has been where most of the fatalities have occurred across the country thus far. The changes include developing a universal public long-term care plan that is accessible and adequately funded; stopping privatization and promoting non-profit ownership; ensuring protective equipment is stockpiled for the future; building surge capacity into labour force planning and the physical structure of facilities; and establishing and enforcing minimum staffing levels and regulations.
It may not be the time to talk about all this for Premier Stephen McNeil, but the pandemic has become incredibly revealing and instructive. I hope he’s paying attention.
Linda Pannozzo is an award-winning freelance journalist and the author of two books. She lives in Nova Scotia.
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- Research into how social status alters immune regulation and response to infection in macaques monkeys continues today. ↩
- OECD poverty rate data from Dennis Raphael’s forthcoming book: Bryant, T. and Raphael, D. (2020). The politics of health in the Canadian welfare state. Toronto: Canadian Scholars’ Press, p. 19. Raphael has another book coming out in 2020: Poverty in Canada: Implications for health and quality of life 3rdedition. Toronto: Canadian Scholars’ Press. ↩
- Both the Fraser Institute and the CD Howe Institute, so-called think tanks that are deeply marinated in right-wing free market ideology, assert that government spending on health is not “sustainable.” The CD Howe Institute warns that health care spending must be reined in and that “spending discipline” must be applied. Similarly, the Fraser Institute presents the same message, that health care spending has skyrocketed and the trend projected into the future will leave the country bankrupt. ↩
- All dollar figures here are in 1997 constant dollars. Which leads me to this important observation: upon closer inspection, the Fraser Institute’s government spending comparisons linked to above are made in “nominal” terms. They are not adjusted for inflation, which is incredibly misleading. Comparisons of dollar amounts over time, particularly over long time periods, should always be made in “constant” rather than “current” dollars, as the former accounts for inflation. One can only guess as to why the report authors would choose not to analyze funding amounts in real terms. My guess is that their motivation was purely ideological, since the “real” funding numbers would have shown that public health funding has pretty much stayed the same for more than a decade. ↩