Vulnerable Populations in a Pandemic

Homelessness, a significant health inequity requires accountability and action from local, municipal and provincial leadership along with federal support. The urgency of homelessness became an even greater public health concern during the COVID-19 Pandemic. The burden of this social determinant, homelessness, has gone underserved for many years in the province of Ontario. According to Early “The health challenges people face are greatly influenced by the wider health determinants which are social, cultural, environmental, economic and political” (Early, 2016). As a result those who are under-

housed, precariously housed or temporarily housed will continue to require ongoing support, equitable health care and health system support throughout the pandemic and beyond. Those who faced health inequity prior to the COVID-19 pandemic, such as the homeless, for example, continued to face inequity throughout the pandemic. The pandemic created a global awareness of the inequities faced, not only by the homeless, but many vulnerable populations.

Since viruses know no international boundaries, it affects citizens in all countries throughout the world, however it will impact those from vulnerable populations at a disproportionate rate. This new awareness from the impact of the pandemic brought about new actions within municipalities and at the provincial level to create shelters for those experiencing homelessness. In addition, other measures were required for those needing to be on self isolation in order to stop further transmission and to address the overcrowded shelters. In urban centres municipalities created alternative locations for shelters such as hotels. During the COVID-19 pandemic it became evident that public health measures such as hand hygiene, cleaning and disinfecting, masking, physical distancing, screening for COVID symptoms as well as other measures which became mandatory interventions to stop the spread of COVID would be a challenge for vulnerable populations. Moreover homeless populations were not able to comply with the mandatory orders under the Emergency Orders and subjected to fines as was evidenced over the past few years.

Unfortunately vulnerable populations and other so-called marginalized social groups such as the homeless, mental illness, LGBTQ+ communities, for that matter, are virtually ignored. Furthermore access to health care is challenged by some employees working in the health care system because of these ostracised groups’ lack of political capital. “Health care systems, public health systems, and the higher education systems that prepare individuals to work in these sectors must continue to evolve in order to support more effective preventative and population based engaging approaches. It is only then that we can truly create and support a “culture of health” (Early, 2016). This type of health care discrimination against the homeless, mentally unwell, addictions is not only illegal, but it also shows up in an equivalent manner against the LGBTQ+ communities, as well.

According to the Healthy People 2020 initiative the social determinants that affect the health of LGBTQ+ relate to the impact from oppression and discrimination (Healthy People 2020). Historically, in places like Toronto, for many years, some hospitals such as St. Michaels, for example, would not even treat individuals from the LGBTQ+ community. Health care professionals, including doctors, would cite their catholic religious belief for not wanting to or merely being able to disregard and not treat individuals who theses healthcare professionals deemed the lifestyles of the LGBTQ+ community patients was contrary to their religious beliefs. “Discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide” (Healthy People, 2020).

Mental Health, Addictions and Stigma

Along with homelessness, stigma associated with mental illness and addictions, social determinants such as poverty unemployment compound the persons’ health outcomes. This is evident in the data regarding the unemployment rate for those with the severe mental illness where the “rates of unemployment are as high as 70% to 90%” (CAMH, 2020).

The disease burden of mental illness and addiction in Ontario is 1.5 times higher than all cancers put together and more than 7 times that of all infectious diseases as reported by Public Health Ontario (PHO). Furthermore, it is estimated that a persons’ life expectancy will decrease by 10 to 20 years due to a mental illness diagnosis (PHO).

Mental illness is not uncommon and in 2006, there were 77,430 people receiving income support through the provincially funded disability program in Ontario (ODSP) who were diagnosed with a serious mental illness (Stats Canada, 2016). According to the Centre for Addiction and Mental Health “1 in 3 persons collecting ODSP are diagnosed with mental illness. (CAMH, 2020). Alternatively, ODSP rates are significantly lower than what is needed to cover the cost of necessities, such as food, clothing, and housing and psychotherapy a key component for health care for those with mental illness.

According to Flood & Thomas’ summary of the Canadian Health Care Act (CHA),” universal coverage is limited to “medically necessary” hospital and physician services… excluding vital care and services such as outpatient pharmaceuticals, dental care, long-term care, and many mental health service” (Flood, 2016). With the evidence of the need for financial support for those with mental illness and a lack of meeting those mental health needs with a fair living wage and absence of care in the Canadian Health Care Act there is little help for a future of wellness and hope. Dhalla and Tepper’s note in, Improving the quality of health care in Canada, they identify that “quality of health care in Canada is good, but not great,” (2018). Further analysis shows that significant improvement in health outcomes are noted for those with mental illness when psychotherapy along with medication is provided, therefor providing pharmaceutical coverage would better be served for on improved patient outcome. In contrast providing health care coverage for costly procedures such as arthroscopy has little to no improved health outcomes.

Furthermore, the environment in a shelter can bring about even more stress due to the unpredictable environment, exposure to drugs, violence, abuse, injury or attack. This further stress on the person can contribute to poor health due to lack of sleep, security, privacy, safety, nutrition, lack or missing their medication and as a result negatively impact the person’s ability to be well for a duration. This person may require assistance with the factors that contributed to being homeless at this time. Often persons in the shelters are also facing mental health and addictions which has certainly contributed to their lack of housing. “The disadvantages tend to concentrate among the same people and their effects on health accumulate during life. The longer people live in stressful economic and social circumstances, the greater the wear and tear they suffer and the less likely they are to enjoy a healthy old age” (Wilkinson & Marmot 2003).

Quality of Life (QoL) is considered an important outcome variable in health-care practice and research. Consideration of QoL provides health-care providers, researchers, and policy makers insight into how variables of interest (e.g., chronic disease, medication use, and living environment) impact a person’s subjective well-being, which is instrumental to improving health-care practice systems. QoL measures may be of potential value in comparing outcomes in clinical trials, evaluating interventions, commissioning programs of care, assessing the outcomes of new treatments, and in audit work. Measuring health-related QoL (HRQoL) can facilitate discussion between patients and professionals in health care and stimulate the dialogue between medical outcomes and patients’ subjective views (de Wit et al., 2013).

Moreover, according to Turan, people in diverse settings experience intersecting forms of stigma that influence their mental and physical health and corresponding health behaviors (2019). Collection of this data is imperative to assist with affecting change. Unfortunately this data has not consistently been included in surveys at the national or provincial level (Healthy People, 2020). What is needed is further qualitative, quantitative, and mixed methods approaches to reduce the significant knowledge gaps that remain in our understanding of intersectional stigma, shared identity, and their effects on health. Williamson and Reuter (1999) conclude, “evidence about the relationship between income, inequality and the health of populations, along with findings about the manner in which a variety of psychosocial factors influence health, leaves little doubt that relative conceptualizations and measurements of poverty ought to guide the development of policy” (pg. 360). Utilizing the social ecological model created by Bronenbaker requires a more creative approach to working with each person in their individual situation while also looking at the contributing factors and the societal factors affecting the community they live in. Further I will hope for a change in the future and in the words of Nelson Mandela, “It always seems impossible until it’s done,” “When people are determined they can overcome anything.”

References:

A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals. Retrieved November 18, 2021. https://www.healthypeople.gov/2020/tools-resources/evidence-based-resource/providers-introduction-substance-abuse-treatment

Canadian Mental Health Association, Poverty and Mental Illness. (2007). https://ontario.cmha.ca/documents/poverty-and-mental-illness/

Deanna L. Williamson, Linda Reutter, Defining and measuring poverty: implications for the health of Canadians, Health Promotion International, Volume 14, Issue 4, December 1999, Pages 355–364, https://doi.org/10.1093/heapro/14.4.355

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Irfan A. Dhalla and Joshua Tepper, Improving the quality of health care in Canada, CMAJ October 01, 2018 190 (39) E1162-E1167; DOI: https://doi.org/10.1503/cmaj.171045. https://www.cmaj.ca/content/190/39/E1162

Open Minds, Healthy Minds Ontario’s Comprehensive Mental Health and Addictions Strategy. https://www.health.gov.on.ca/en/common/ministry/publications/reports/mental_health2011/mentalhealth_rep2011.pdf

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