Wednesday, June 24, 2009

Paternalism and prevention

This appalling story comes via the Globe and Mail: medical supplies were withheld from Manitoba reserves while health officials debated the risks of sending alcohol-based hand sanitizer into the fly-in communities.

It's easy to make fun of the public work-up about H1N1, but in some places it really has reached the level of a pandemic; Northern provincial and Southern territorial reserves host the largest outbreaks in the country and some of the fastest transmission rates. The flu is travelling in Nunavut, and here as elsewhere it has been happening predominantly in the fly-in communities (although that description catches Iqaluit too - and there have been a few cases here).

No matter how you spin it, this delay should never have happened.

Alcoholism and other addictions tend to be major problems on reserves, but this is true of lots of other identifiable, easy-to-target communities in Canada. I don't think Health Canada would have hesitated to send these supplies into non-reserve Northern Ontario towns, or Vancouver's East side.

There are major problems with alcohol and drug abuse in urban centers too, but none of the provisions that I have found in the Canadian Pandemic Influenza Plan make any reference to limiting access to sanitizer to people with past or current problems with alcohol. If this is a legitimate concern - theoretically - then shouldn't Health Canada be as worried about non-reserve alcoholics as they are about alcoholics living on reserve? As a potential future white, urban alcoholic, I resent that!

Furthermore, this would not be the first time people living on these reserves were ever exposed to hand sanitizer. It's available in drug stores, and lots of people there probably use it. Anyone who was ever going to abuse it has already had ample opportunity, although I continue to think that most people - even First Nations people! - have the good sense to understand that drinking hand sanitizer is dangerous.

There is an Annex to the Canadian Pandemic Influenza Plan that deals specifically with First Nations reserves. It's here. I've skimmed it, and while it recommends in a couple of provisions that hand sanitizer be used, it does not contemplate complications arising from potential abuse. If concerns over abuse were based on good evidence from Health Canada, this issue would have been worked into the Plan. It's not.

Which signals, to me, that this is no more than paternalistic hand-wringing of the kind that so often plagues public health debates. These debates almost always have a racial/class-based dimension, which is only more explicit here. The same issues, manifested differently, arise in arguments about everything from condom distribution to public funding of methodone clinics.

But let's be cold-hearted about this. Let's permit the assumption that white and urban people understand the subtleties of hand sanitizer in a way that Canadian Aboriginal people don't. Let's take the human factor out and look at the numbers. Sure.

In the time these supplies weren't being sent out to communities, "dozens" (says the article) of Aboriginals got sick enough that they needed to be flown into more urban centres for hospitalization. At one point, the article notes, "two thirds of all flu victims on respirators in the province were aboriginal." So for all those people, the province of Manitoba flew them in for hospital treatment and has supported elaborate medical care for them, when prevention measures would have cost no more than a few dollars per person. Even if, theoretically, a small number of people got sick as a result of ingesting the sanitizer, I doubt this would approximate the financial or human cost of all these flu victims in either frequency or severity.

And this is why the paternalistic approach to public health fails and the harm reduction approach wins. Help people get what they need to protect themselves, and they will.

So. What's the stupid to evil ratio on this? I'll go with 50-50 - half ignorance, half indifference.

At least the G&M had the good sense to disable comments.

1 comment:

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