Friday, October 30, 2009

Class, Nation, and Health: with some thoughts about H1N1, and building movement capacity

What follows is a rough version of a talk i gave at Montreal's Native Friendship Center, at the Anti-Colonial Thanksgiving organized by Frigo Vert last night. Many of the articles and documents referenced here are also referenced on the new Kersplebedeb H1N1 page.

I’m here to say just a few words about health inequalities, with particular attention to this new flu, the H1N1 or swine flu, and some concerns around it.

The flu is something I became interested in earlier this year, when my husband caught it and became very sick. He spent two months in the hospital, most of that time on a ventilator in a medically-induced coma, and he probably would have died if not for the fact that he received excellent medical care.

People say that you have to already have a serious health condition to be at risk from H1N1, but my husband’s only relevant health problems were very mild asthma and the fact that he gets migraines. In fact, they’re saying now that a quarter of the people who have died of H1N1 were in perfect health beforehand.

Now luckily my husband didn’t die, though his seven weeks in the ICU did make me realize some things. For one, it gave me an appreciation of the fact that even though not many people were dying of the flu, an unknown number of people were getting very very sick, and it was only the fact that there were enough ventilators and ICU beds that allowed them to survive. (The clearest figure i could find about this was that for every H1N1 death, there were four people critically ill with the virus who had to be kept alive in an ICU.)

And that got me thinking about health inequalities, and how they might play out with the flu.

By “health inequality”, I don’t mean the fact that some of us are more healthy than others, or that some of us see the doctor more often. I don’t even mean just the fact that some of us have more ready access to medical care, though that's getting closer. What I’m talking about is not an individual thing, but a collective phenomenon. The fact that different groups of people face different obstacles and challenges to being healthy. That the family you were raised in, the neighbourhood you grew up in, the job you end up doing and the place where you end up living as an adult, these factors all affect your chances of getting particular illnesses, they affect how readily you’ll have access to treatment if you do get sick, and as a bottom line, these things all affect how long you’re likely to live.

That’s what I mean by health inequality.

Health inequality is normally the result of some other kind of inequality. It’s not just caused by bad luck or genetics. More often than not, it is a result of financial inequality, unequal power relations, your position in society.

There are many useful ways of looking at this, but two that i find particularly helpful are class and nation.

Class and Life Expectancy: Some Examples from Montreal

If you go out this door, walk down to St-Catherine street and then take a left and walk for an hour, you’ll end up in Hochelaga Maisonneuve, Montreal’s working-class east end. Folks there have a life expectancy in their low to mid-seventies. In fact, bucking the general trend in most countries, the life expectancy for older residents of the neighbourhood actually went down between 1998 and 2008. (By life expectancy we don't mean how old most people are dying now - that's referred to as the "average age of death" and is usually significantly younger. Life expectancy is capitalism's forecast as to how old people born today are likely to live - indeed, the fact that there continue to be such discrepancies in life expectancy is a stark indicator that the 21st century is not intended to be any more egalitarian than the last one was.)

If on the other hand, you were to go out this door, walk down to St Catherine street and take a right, and walk for about an hour, you’d be in Westmount, one of the wealthiest neighbourhoods in all of Canada. The folks there, just to use the same measure, have a life expectancy in their eighties.

Now what makes a life expectancy? Lots of things, for instance: how common violence is in your community, what kind of food people eat (and what kind is sold at your local supermarket), what opportunities you have for physical exercise, how stressful or dangerous your job is likely to be, and of course how likely you are to get sick with various diseases due to poor sanitation or overcrowding or pollution.

The thing about these various factors, is they all follow the same contours of wealth and political power. When I was doing a bit of research for this talk, I came across a page hidden like a needle in a haystack on the Quebec government website, in which Montreal was divided up into different neighbourhoods and each neighbourhood was listed along with the prevalence of various diseases, various "quality of life" indicators, and also average annual income. These statistics are not completely honest, engaging in a bit of demographic gerrymandering, by including a few blocks where people are poor into the wealthier neighbourhoods, and including a few middle class blocks in with the working-class neighbourhoods, to dilute the impact of the numbers - but even so, a predictable pattern emerges. The same neighbourhoods – places like Hochelaga Maisonneuve, St-Henri, Montreal North –
suffer from higher rates of various health problems, and the same places enjoy better than average health, and those are the wealthier and safer areas. (Although lacking the health information, similar socio-economic statistics can be found on this City of Montreal web page.)

It makes sense, after all, this is one of the big reasons people want to be middle class, or upper class, the fact that they can then afford a healthier and longer and safer and more pleasant life, not only for themselves but for their children, too.

This all is one way of thinking about heath inequality.

National Disparities Within Canada

If class is one useful way to look at injustice, another important concept is nation. The two aren’t the same, but they’re closely related.

Different nations, different peoples, live inside what is called Canada, experiencing very different living conditions, and obviously this leads to differences in health. We may live just down the block from each other, but for all that many of us effectively live in different countries.

Again, to use life expectancy as a bottom line, folks in Westmount might be expected to live into their eighties, folks in Hochelaga Maisonneuve into their mid- seventies, well Indigenous people in Canada, on average, have a life expectancy in their low seventies (high sixties for men, mid-seventies for women). That's all the Indigenous folks counted as such by Statistics Canada, including those who have "made it", including those in communities with more resources: a national average just slightly below that of the poorest of Montreal's neighbourhoods.

Canadian colonialism and genocide create this discrepancy - the Indigenous life expectancy results from different health issues and trends than what is found in the settler community. We're not just talking a little more of this disease or slightly less of that vitamin, but tragically high death rates amongst young people, often due to violence and various forms of substance abuse (See pages S54-S55 of the Revue Canadienne de Santé Publique Vol. 96, Supplément 2). That’s a direct result of genocide, Canada's long term assault on the ability of subject nations to reproduce and maintain themselves in a healthy way.

Looking at Communities

Now these statistics are just that, statistics. They’re all about averages and generalities, they deal with large numbers of people, millions in fact. For that reason, while they're useful as an initial tool, they can also trick you into missing some important details. Just as it's misleading to talk in broad generalities about “Canada” without specifying the different classes and nations here, it’s also misleading to talk in generalities about neighbourhoods or broad national categories like “Quebecois” or “settler” or “Indigenous” without keeping in mind that not everyone in these categories is dealing with the same situation. Definitely not all settler communities are the same, definitely not all immigrant communities are the same, definitely not all Indigenous communities are the same. Ignoring this has real political consequences that can screw us up.

Now a community may be geographic, like Hochelaga Maisonneuve or St. Henri or Kanesetake, but it may be more amorphous than that. Not all communities are found on maps, not all communities have a longitude and a latitude. We may not normally think of them as communities, but in terms of health, your job may provide a community, for instance a factory may be a community. A school may be a community. If you're a sex worker, then that may be a community. And if you’re living on the street that’s a particular community, if you’re living at the Y, or staying at a shelter, then that’s a particular community. If you’re in prison, then you'd better believe it: in terms of your health, that's a distinct community.

Locked Up or On the Street

This does not diminish the importance of nations and classes. On the contrary: if you check out these situations, or if you’re forced to live in them, you see that in fact they’re not separate. In fact, it is in specific communities that nations and classes exist in their sharpest, most intense, form. Like on the street: in Hamilton, Ontario, for instance, where Indigenous people represent 2% of the city’s population, but 20% of the homeless population. Or Edmonton, where Indigenous people make up 43% of the homeless population, though only 6% of those who have homes. (Aboriginal Housing Background Paper, Canadian Mortgage and Housing Corporation November 2004)

Or take a look at Canadian prisons and penitentiaries: Indigenous people are locked up over six times as often as anyone else in Canada. A few years back they did a "snapshot" study of all the prisons, penitentiaries and jails in Canada, to see exactly who was locked up: in Saskatchewan Indigenous people were imprisoned at almost ten times the overall provincial rate; they were 76 per cent of that province’s prisoner population. In Manitoba, 61 per cent of prisoners were Indigenous; in Alberta, it was over 35 per cent. (Racial Profiling in Canada, p. 81, quoted in Sketchy Thoughts)

So when we’re talking about communities, even when we don’t mean actual geographic communities that you can find on a map, even when we’re talking about something like being on the street or in prison, it should be clear that we’re still talking about something that has very clear class and national characteristics. Not everyone has an equal chance of ending up in these situations, not everyone has an equal chance of getting out of them.

In terms of health, in terms of well-being, if you’re in a particularly oppressed community, your reality will be a lot more intense than what you see in the broad reassuring national statistics. To give an example: 1 in 125 people in Canada is thought to have Hepatitis C, a potentially fatal illness. According to a study carried out in 2004, the rate is almost one in four (23.6%) for prisoners in the federal system. To give another example: Canada-wide, just over one in a thousand (0.13%) people were HIV positive in 2004, but almost one in twenty women in prison (4.7%) had the virus. (Moulton, Donalee. "Canadian inmates unhealthy and high risk." CMAJ: Canadian Medical Association Journal. 2004) Similar kinds of discrepancies exist if you’re talking about tuberculosis or many other serious health problems.

Prisoners are one such group, people without good housing are another. A study that just came out this week in the British Medical Journal tells us that in Canada, if you're a woman living in a rooming house at age 25, your life expectancy is less than fifty years of age. If you’re a man living on the street at age 25, your overall life expectancy is less than forty. Less than half the national average. (Hwang, Stephen W., Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study, BMJ 2009;339:b4036)

Understand it: nations and classes find their lived reality in communities. Communities with their own vulnerabilities and peculiarities, their own cultures, their own realities. This is important when thinking about health crises, because when disaster strikes, it will normally strike first in a specific community. Partly because germs and pollutants are distributed that way, and partly because social power and wealth are distributed that way. When there's an outbreak of some disease, most communities will probably be mildly affected, if at all. Oftentimes, there will even be big differences within various oppressed and colonized peoples, as only certain subgroups are made to bear the brunt of whatever capitalism is dishing up this season. (At least at first.)

So we have this obscene situation, that as a society, we’re often moaning about possible disasters that aren’t very likely at all, while people around us are actually living the disaster, or living the crisis, right now before our eyes. But most people choose not to see it.

It’s important to keep this in mind, because if you yourself are in a community struck by disaster, then these big reassuring statistics can make you feel like what's happening to you is exceptional and aberrant, perhaps even your fault or your community's fault. But in reality while it may be exceptional, it is also intrinsic to the system, and more often than not your personal hell has been noted and deemed acceptable by those who claim to be in charge.

On the other hand, if you are lucky enough to not be in the line of fire, then those statistics, by lumping people and communities together in these big categories, can give you a false sense that nothing anywhere is really all that bad. Those cases where people are in a serious crisis, where diseases like tuberculosis and Hepatitis C are not only common but are the norm, those situations end up being hidden, camouflaged by the large numbers of cases where people are managing to hold it all together.

H1N1: Parsing Opinions

This new flu, the "swine flu" or H1N1, it's an easy topic to spin bullshit about, and a lot of people are spinning bullshit about it. It’s easy to spin bullshit because this is a new strain of the flu, and it hasn’t been around during a flu season yet, and so no one can really know how serious it will be. According to some people the flu will wipe everyone out, according to some people it’s harmless but the vaccine will kill you – and all these folks seem to contradict themselves and rely on junk science, but they get a hearing because most of us know we can’t trust the government, and we’re often scientifically illiterate ourselves. If you’re bored, you can make up any old end-of-the-world fantasy story, and someone out there is likely to believe you. (If you don't believe me, just try it.)

But just because we don’t know something, that doesn’t mean that we can’t talk intelligently. Just because any crazy idea will get a hearing, doesn’t mean that it’s pointless to try and be logical and reasonable in seeing what might come.

Within the sane range of opinion, there’s two ways of looking at H1N1, and at what is likely to occur. One way is to point out that most people do not get very sick from it. Only 90 people in Canada have died so far from H1N1, while the regular flu kills thousands every year. This is an important point. According to this view, it's not so much a pandemic as a scamdemic, a fabricated excuse for some big pharmaceutical companies to boost their profits.

But it’s worth keeping in mind that the regular flu normally kills hardly anyone in the summertime or spring, and that’s when H1N1’s deaths have occurred so far. To compare the regular flu's winter toll with that of H1N1 over the summer is to make certain assumptions that contradict what years of epidemiology tell us about when flu infections - and serious illnesses, and deaths - will spike.

The bottom line is we just don’t know how serious or how mild the flu will be this winter, and winter is when the vast majority of flu deaths normally occur.

In the meantime though, we do have the experience of the H1N1 this spring. Then the virus played itself out much like other illnesses: people in less wealthy and more oppressed communities were more prone to catching it, and thus formed a larger proportion of those who got very sick. There was a good article in the Globe and Mail a little while back, in the science section, which made exactly this point; its title was “Influenza has a cure: affluence”.

To give one example of how this worked, in June, 14% of people with H1N1 showing up at emergency rooms all across Quebec were showing up at just one hospital, the Montreal Jewish General. This may in part be because it’s just a better hospital and more proficient at diagnosing people, but it may also have something to do with the fact that it’s located in the middle of Cote-des-Neiges, one of the more heavily immigrant neighbourhoods in Montreal. While Cote-des-Neiges is a mixed class neighbourhood, it does contain pockets of real poverty, bad living conditions, and overcrowding. (This statistic, of 14%, was discussed at an information seminar about H1N1 at the Jewish General in June. i am unaware of it having been published to date.)

But there’s something important to grasp beyond the general fact that the flu will be more prevalent in less wealthy neighbourhoods. Like I was saying, no matter what the picture painted by broad statistics, when you look at the specifics you’re going to always find certain communities dealing with much worse situations.

That is precisely what we saw this spring, in a number of communities, where H1N1 became something much much worse. When it became so widespread that a tipping point was reached. To speak in dialectics, one could say the quantitative – the numbers of people sick - became qualitative, meaning it changed the nature of the entire situation. Local resources were overwhelmed, and the crisis entered a different phase. In Garden Hill, St. Theresa’s Point, Sandy Lake – all Indigenous communities – the flu pandemic got completely out of control, local nursing stations were unable to support people’s needs, and over a hundred people had to be medi-vacced to intensive care units in Winnipeg hospitals. Several people died.

Tipping points are like dominos, when one occurs it always risks setting off the next. In terms of what happened this summer, this almost did happen, as ICUs in Winnipeg filled up with critically ill H1N1 patients and there was a real fear that there would not be enough ventilators. Had that occurred (thankfully it didn't) many more people would have died.

While Garden Hill, St. Theresa's Point and Sandy Lake were the only places we know of where things escalated to that level, Indigenous people across Canada were suffering disproportionately from the flu. According to the way the government measures these things, Indigenous people make up less than 4% of the Canadian population – but this summer by the same measure Indigenous people made up 25% of those who got critically ill from H1N1. In Manitoba, where Indigenous people make up roughly 10% of the population, this summer at one point they were over 60% of those who found themselves on ventilators, struggling for life in ICUs.

Nor is it only Indigenous people. Compared to most places, Canada is a fairly “white” country, but according to a recent article in the Journal of the American Medical Association, less than 50% of those who became critically ill with H1N1 in Canada this summer were white; the majority were people of color. It’s perhaps also worth noting that that same report found that almost 70% of those who got critically ill were women, which shows this disease has a gender profile that hasn’t been given enough attention.

We may not be able to predict the future, but given what we do know, we can make some reasonable guesses about the flu this winter. It is clear that the incidence of disease will not be random, and that not all communities will fare the same. No matter what the broad, general, abstract “Canadian” experience this winter, it is guaranteed that in some specific communities the situation will be much much worst. Those hardest hit will almost certainly be Indigenous communities, immigrant communities, working class communities.

A Suggestion to My Comrades

At the height of the outbreak in Garden Hill this spring, Grand Chief David Harper asked Health Canada to set up a field hospital in the community, an idea that the government rejected.

Since then, the Assembly of First Nations asked the federal government to send flu kits to Indigenous households across the country – Health Canada didn't see the point, so instead the AFN had to raise money on its own from the provinces and the private sector.

Just a couple of weeks ago Grand Chief Harper was quoted in the newspaper again, saying “By now, we would have liked to have field hospitals set up so our people don’t have to wait to be airlifted to Winnipeg for treatment.”

This is a reasonable request: for months now everyone from local healthcare providers to the World Health Organization has been saying that if a major crisis occurs in Canada, if a tipping point is reached, if the quantitative becomes qualitative, it will most likely happen in one of the many remote and impoverished Indigenous communities. But the government isn't worried.

So it begs a question for me – which of our movements have things like this on the radar? Which of our movements is poised to respond to a request for a field hospital, or any kind of useful emergency intervention? It reminds me of the ice storm back in 1998, when the whole city of Montreal was paralyzed, many without electricity for weeks, and the army was sent in. Many people were relieved to see the soldiers, we felt we needed rescuing. Why couldn’t any of our movements have played that role?

And why does this question seem silly to some of us? As if the ability to respond to a crisis, the ability to serve the people when the people really need serving, as if all of that was beyond the scope of our responsibilities.

Some of us have the skills, and i know many of us would love to see these capacities developed, but the question is a collective one, not an individual one. We need to explicitly decide as a movement that that’s where we’re going. We need autonomous structures, separate from (and ideally hidden from) the state, in which those with medical skills can frame their work, even if they may be operating within a hospital or a community health organization. We need to become scientifically literate, so that we don’t fall for the latest ridiculous conspiracy theory. Even if not everyone has the interest or the proclivity to get a grasp on "hard sciences", as a movement we need to value that kind of thinking, to appropriate it, to make it our own.

Most importantly, we need to think in terms of filling the role that the state plays, dealing not only with healthcare, but also with everything from garbage disposal to sewage treatment to conflict resolution. If we claim to be against the state, then that becomes our job. If we fail at it, if we fail to do a better job than what's being done now, then even if we do someday drive out the state, even if we do establish no-go areas, sooner or later it will be the people themselves who will demand the enemy's return.

H1N1 may or may not play itself out as a disaster this winter. I certainly don’t believe it will be some Canada-wide cataclysm, but I think it’s likely that in certain specific areas it will be a serious problem, and some people will suffer. If tipping points are reached, if the surge capacity of particular communities is overwhelmed, it won't be pretty. I can tell you from personal experience that the disease can be horrendous.

We know the Harper government is ideologically predisposed to letting poor people die. We know capitalism and colonialism will only make the situation worst. Knowing this, I would argue that our movements have a responsibility to think beyond zines and blogs and lobbying, that we have a responsibility to start doing what we can to build our capacity to offer real help to people whenever and wherever a crisis does occur.


  1. Hello, I'm not a regulare reader of this blog, just happened to make some research on H1N1 and I found your article. I really liked your post, I think it gives a lot insight on H1N1. I'd like to know what do you do for a living? How did you hear that 14 % of people with H1N1 showed up at the Jewish Hospital? I don't remember hearing that stat in the media, but it is really interesting.

    Thank you!


  2. The 14% figure was provided by Dr. Matthew Oughton at an information seminar at the Montreal Jewish General in June of this year.