PoPulationand Public HealtH etHics

practice
Nations’ constitutional rights to water under the Canadian Charter of Rights
and Freedoms and the Constitution Act. 8
Poor living conditions in First Nations communities — together with limited
access to medical care — are associated with a range of adverse health outcomes,
from higher rates of gastrointestinal illness and infection, to disease
and death. 9 For First Nations people in Canada, who already experience a
disproportionate burden of ill-health compared to the non-Aboriginal population,
well-documented inequities in water, sanitation, and housing 4–7 played a
critical role in the H1N1 influenza pandemic of 2009. 10, 11 This case examines
the ethical considerations of poor living conditions within the context of the
2009 H1N1 outbreak and the efficacy of targeted public health interventions.
Case
Canada experienced two distinct waves of H1N1 influenza during the pandemic:
the first in the spring of 2009, the second in the fall of that same year.
The illness caused generally mild symptoms for most people; some groups,
however, appeared to be at higher risk of more complicated or severe illness,
with the First Nations population included in this number. This was
particularly true for those in remote areas with large distances to travel to
hospitals for acute care and with limited access to health services in general.
Although a remote and isolated communities task group was established to
ensure effective and coordinated federal and provincial/territorial pandemic
response, targeted interventions on-reserve were insufficient in many areas
because of poor living conditions.
Only 80% of communities had pandemic plans in place at the onset of the
outbreak, many of which had not been tested and/or did not clearly articulate
aspects of when and under what circumstances they would be implemented. 12
As well, recommended infection prevention and control measures were not
well suited to conditions on many reserves. For example, standard practices
such as frequent hand washing and keeping common areas clean and disinfected
were not realistic for communities without running water and indoor
plumbing. Attempts to mitigate water and sanitation challenges, most notably
through the provision of alcohol-based hand sanitizers, were delayed
during the spring outbreak over concerns that the alcohol content might be
abused. 13 Other measures, such as staying at home when sick, did not work
PoPulation anD Public HealtH etHics
154