Capitalism is making us sick: behind the SARS crisis in Toronto.

The outbreaks in Toronto shone a harsh light on the inadequacies and outright failures of neoliberal public health policies and practices.

They also clearly showed the extent to which neoliberal governments prioritise business security above the health and social security of workers. Even more than this, however, the SARS crises revealed some of the ways in which the pressures of capitalist social relations make people ill.

Public health officials in Ontario first received warnings of SARS in early February, and a full-blown crisis was emerging by March.

By late April, Ontario's Tory Premier, Ernie Eves, had not even recalled the legislature--which had been on hiatus since Christmas--in order to devise a plan for dealing with the various aspects of the crisis.

For weeks, the Tory plan appeared to consist of little more than suggestions such as 'wash your hands', or 'eat in Chinatown.' Government only responded, and even then largely in terms of public relations, after the embarrassment of the late-April WHO (World Health Organisation) travel advisory, and the threat of losses for tourist industry owners. Even worse, the provincial government's rush to assure tourists that the crisis was over, following the wto advisory, seems to have played a major part in a renewed outbreak at the end of May.

The nurses' unions reported publicly that, prior to the second outbreak, its warnings to the government that it was too soon to let up on SARS had gone unheeded. Clearly it was public relations, rather than public health, that was at the forefront of Tory concerns.

Making Ontario susceptible: The impact of neoliberal restructuring

Healthcare in Canada operates in a complex space where federal and provincial mandates intersect. Healthcare is considered a provincial responsibility, but the majority of funding is provided by the federal government through the national Medicare programme. The federal Liberal government has instituted, over its three consecutive majority terms beginning in 1993, a massive reduction in funding to the provinces. Beginning in 1995, the federal government removed regulations covering healthcare funding that had previously ensured that it went directly to healthcare. This left Ontario's governments free to apply $987 million of federal healthcare money to areas such as cost overruns in the hydroelectric industry (Diebel, 2003: A8). This situation was compounded when the former finance minister and current prime minister, Paul Martin, cut $6 billion from healthcare funding to Ontario over the four years between 1995 and 1999.

Most of the harm to Ontario's healthcare system has been inflicted by the provincial Progressive Conservative (Tory) government. Like the Walkerton tragedy before it, in which several people died and hundreds became sick after privatisation and cuts to water inspection contributed to E. coli contamination of the town's drinking water, SARS revealed the extent of the damage done to Ontario's healthcare system by the Tories. When the Tories assumed power in 1995 under the leadership of Eves's predecessor Mike Harris, they pursued a stated policy of creating a crisis in public services in order to encourage privatisation and cutbacks. Harris withdrew $1.3 billion from hospitals in order to underwrite a policy of tax-cuts for the wealthy and for corporations (Diebel, 2003: AI). With regard to healthcare, Harris maintained that Ontario employed too many nurses, and worked to reduce staffing levels by laying off thousands of nurses. Between 1995 and 1999, 25,000 hospital positions were cut in Ontario (Diebel, 2003: n8). In addition, nursing in the province was increasingly casualised, with fifty per cent of nurses working part-time and often holding down two or three jobs at separate hospitals. Only 18 months before the SARS outbreak, the government had fired five leading laboratory scientists working with a Toronto reference laboratory unit that monitored coming infections and new disease threats (see 'Hospitals and public health units across Ontario relied on their work', Toronto Star, 2003b: a9).

Under-funded and under-staffed infection surveillance and control systems in hospitals played a part in the spread of SARS. Contaminated medical equipment and improper hygiene, identified as emerging problems in Ontario's hospitals, also contributed to the disease's progress (Nikiforuk, 2003: A23). The source of these problems resides partly in the privatisation of such services in Ontario's hospitals since x995 (see 'The evangelical search to save money in hospitals has also assisted and fortified microbes', Nikiforuk, 2003: A23).

In 1998, the provincial government shifted public health costs and responsibilities onto already cash-strapped municipalities, which lacked the resources to cope properly. Currently, less than 83 per cent of necessary public health services, according to provincial standards, are actually being delivered in Ontario (Diebel, 2003: A8). In Toronto, the public health department requires $5 million to reach a full complement of staff (Toronto Star, 2003a: F6). Due to budget constraints resulting from chronic under-funding by the provincial government, the department is currently 65 workers short. During the SARS outbreaks, people were pulled off other programmes to assist with the crisis, and health workers had to be brought to Toronto from other areas of the province.

Tory privatisation of front-line health services played a major part in the province's inability to keep up with the sags outbreaks. Likewise, healthcare cuts put systems under greater strain and left fewer resources to pick up the extra work, which also resulted in delays for people requiring other services. Not only does Ontario's healthcare system have little or no room for 'surge capacity' in the event of unexpected outbreaks or emergencies, but it also lacks the adequate capacity to meet ongoing needs. SARS was a relatively narrowly confined illness, affecting mostly healthcare workers and family members of SARS patients, which should have been quickly and easily contained. Unfortunately, few Ontario hospitals have the necessary numbers of infection control nurses, as outlined in provincial recommendations. The diminished state of Ontario's healthcare system, with its inadequate facilities and staff levels for proper infection control, means that 'the spread of infections such as SARS is inevitable', according to the former chief of infectious diseases at Toronto's Hospital for Sick Children (quoted in Diebel, 2003: A8). This already untenable situation was exacerbated by the response to the outbreak, which saw hospitals closed to all but the most serious cases, and the cancellation of hundreds of operations. Several otherwise avoidable deaths, during the crisis, have been attributed to delayed or cancelled operations (Diebel, 2003). Clearly, public healthcare in Ontario requires a substantial increase in resources.

SARS and work

The problems caused by a lack of public health resources were compounded by the failure, at any level of government, to compensate workers who had to go into quarantine and those not quarantined, but who thought they had SARS symptoms and should stay home from work. The fact that this failure played a part in the spread of SARS in Toronto, and in the spread of panic over the outbreak, was highlighted when an infected nurse from Mount Sinai hospital took the GO train and the TTC subway and bus to work on April 14 and 15, because she could not afford to miss work.

By mid-June, the province had still failed to increase hospital resources and staff. At St. Michael's Hospital in Toronto, thirty extra healthcare workers were required for SARS duty during the second outbreak. But even double-time wages were not enough to entice many workers to put themselves at risk, given the inadequacies of the resources that remained. A Ministry of Labour investigation during the outbreak found St. Michael's, as well as North York General Hospital, to be in violation of the workplace Health and Safety Act for having provided inadequate equipment and training to nurses, including SARS masks that did not fit. The hospitals responded by threatening compulsory work for nurses, in order to deal with the SARS cases. Finally, during the second outbreak and after weeks of working stressful overtime shifts, and suffering some of the city's highest infection rates, nurses put forward a demand for 'danger pay' through their union. But no amount of danger pay could make up for the tragic fact that SARS left two nurses dead, while making dozens more ill.

Incredibly, other hospitals responded by laying off nurses. Lakeridge Health Corporation laid off fifteen registered practical nurses, including eleven who were in quarantine at the time. Premier Eves responded to criticisms about the firings by claiming that they were part of the province's attempt to build a 'flexible system' that 'would be able to move resources as we need them within the healthcare system' (quoted in Boyle & Mallan, 2003: A6). Indeed, further layoffs were proposed as hospitals scrambled to make up a deficit of approximately $400 million. Of course, the flexibilisation of healthcare--a key aspect of Tory policy--had already placed the system in an extremely vulnerable position.

Federal and provincial governments also failed to offer assistance to workers suffering layoffs and reduced hours in the industries negatively affected by SARS, particularly in hospitality and tourism. As late as May 27, Local 75--the Toronto affiliate of the Hotel Employees & Restaurant Employees International Union (HERE)--was still unsuccessfully requesting meetings with federal Industry Minister Allan Rock and Human Resources Minister Jane Stewart.

Local 75's president, Paul Clifford, noted: 'There has been no additional funds from senior levels of government directed towards hospitality workers. No EI [employment insurance] funds, no waiving of the two-week waiting period for EI, no relaxing of EI regulations and many workers and their families are going under' (quoted in McGran, 2003b: A6). During the second outbreak, more than 7,000 people were quarantined. Incredibly, compensation packages were still not made available. More than two months into the outbreak, the federal Liberal government finally waived the two-week waiting period for claims. Unfortunately, they did nothing to relax eligibility regulations--a particularly relevant factor given that many hospitality and restaurant workers are part-time, and therefore not eligible to receive EI payments under the normally tight EI restrictions.

It should also be pointed out that EI payments do not cover full wages, even for already low-paid workers in the hotel and restaurant industries. Similarly, nothing was forthcoming to assist either tenants facing evictions, or people unable to meet their utility bill payments due to SARS layoffs or work cutbacks.

SARS and circuses: Tourism and Toronto's economic ailments

The fact that each level of government was more concerned with helping tourist industry bosses than helping workers was made clear by who received compensation or subsidy packages, and who did not. Provincial money arrived in the form of subsidies to capital, especially those involved in the entertainment industry.

Mirvish Entertainment--the producers of spectacles such as The Lion King and Mamma Mia--benefited, as did Rogers, owner of the Blue Jays baseball team and notorious for not paying its cable installers. Exclusive restaurants and hotels also received subsidies.

For the most part, the federal Liberal government, which precipitated the crises in healthcare by slashing health funding to Ontario by $6 billion, offered symbolic support such as holding a Cabinet meeting at an exclusive Toronto hotel, to and from which they were chauffeured with great haste. Other responses were little more than gimmicks, including a proposal to pay the Rolling Stones $10 million in public money to put on a 'free' concert. Ironically, this was the same amount as the total federal relief package to compensate laid-off and quarantined workers, and small businesses affected by SARS.

Tourism in Toronto had been ill for some time before the SARS outbreak. A spokesperson for the Toronto Transit Commission (TTC), which runs the city's subway and buses, noted that the TTC had experienced a general city-wide reduction in the number of journeys made prior to any word of SARS.

Like the entertainment industry giants, however, the TTC was not about to miss an opportunity. Promoting downtown events among Torontonians, the Transit Commission urged residents to 'find out what it's like to be a tourist in your own town'. The TTC public address system broadcast messages from prominent Torontonians, encouraging its 800,000 passengers to 'wine, dine, entertain and shop in Toronto'. The suggestions for becoming a hometown tourist included, in a familiar vein, going to the theatre, trying a new restaurant and, incredibly, staying in a hotel. These twenty-second messages were broadcast every fifteen minutes in sixty-nine subway stations. Yet again, capital's cure for what ails us was the suggestion that we go shopping. This was, of course, reminiscent of George W. Bush's plea for Americans to go shopping after 9-11.

SARS simply provided a fortuitous cover for government at all levels to obscure the relationship between government policies, the whims of investors and speculators and Ontario's economic troubles. In fact, manufacturing and retail are vastly more significant aspects of Toronto's economy that have suffered from changes in global economies and government bungling.

Two key factors behind recent economic concerns have received almost no mention: the value of the Canadian dollar, and rising electricity costs. The dollar's increase in value has played a far greater part in the fall in tourism than SARS has, and has also affected demand in the United States, which takes 85 per cent of Canadian exports. The dollar surged from a record low of 62.1 cents (US) in January to a six-year high of 74 cents (US) in May. The Tory deregulation of utilities has resulted in a doubling of electricity costs for many companies, raising costs to twice the levels in Quebec.

Some surgery required

Anger at the Tories' role in mishandling the outbreak, as part of their larger mismanagement of services, played its part in the provincial elections at the end of 2003. The Tories suffered a devastating loss as the provincial Liberals captured one of the largest majorities in Ontario's history. Tellingly, Premier Eves (now former premier) had cancelled two prior election announcements, including one that had been planned for the week in which the second outbreak occurred, lest the election become a referendum on Tory healthcare policies. Anger over the Tory bungling of the SARS crisis was still running high, extending into their support base among suburban consumers in the regions surrounding Toronto, at the time of October's election, and probably contributed to the loss of several key Tory ridings (constituencies) in the city's suburbs. Notably, Health Minister Clement, a major figure in the party, was among the casualties.

It is too early to tell if the incoming provincial Liberal government will maintain its election commitment to restore funding and resources to Ontario's healthcare system.

Early indications are not promising, which is hardly surprising given the actions of the federal Liberals in undermining medical care in Canada over the last decade. Indeed, the provincial Liberals, upon taking office, broke their promise to end a private-public hospital venture.

Beyond SARS: The hidden illnesses of class

The frantic, if inadequate, attention given to SARS by both media and government highlights other class-related issues in Canadian healthcare.

Other recent outbreaks in Toronto, such as tuberculosis, Norwalk virus and Hepatitis A, have received less government attention due to a sense that these diseases are confined to the poor and homeless populations, and that they are unlikely to spread to the population at large.

SARS had such impact because it affected suburbanites, consumers and, potentially, tourists.

Street nurses Cathy Crowe and Kathy Hardill (2003) note that the TB outbreak in Toronto shelters in 2001 was predicted by front-line health workers as early as 1994. Despite this, the city and province did nothing to address the overcrowding and poor shelter conditions; the lack of affordable housing and community-based programs such as drop-in centres; or the unsatisfactory nutrition, all of which facilitate the spread of such illnesses.

Incredibly, three homeless people died of consumption in Canada's richest city in 2001 (Crowe & Hardill, 2003), and almost 40 per cent of shelter residents have been exposed to TB (Crowe & Hardill, 2003).

The conditions that underlie the spread of TB are really the same as those that underlie the spread of SARS: the insecurity of capitalist economics, which forces people to spend much of their lives working for wages, lest they have to face the consequences of homelessness and hunger.

Many workers know that they are a month's wages away from being homeless, and too many of us are often faced with deciding between paying the rent or feeding the kids.

Lack of access to and control over the necessities of life, which are owned and controlled by various profit-seeking bosses, and the forced compulsion to work in order to survive, undermine the capacity of individuals and communities to make their health a priority.

As Crowe and Hardill (2003) affirm, 'food, income, safety and housing protect people's health. Simply stated, housing is protection from disease'. The same might be said of a guaranteed income.

Clearly, a broad-based programme for community health would include not only increased funding for public health departments, but also more affordable housing; improved conditions in homeless shelters; nutrition programmes; a minimum wage increase to a living wage level; and increased welfare rates or, better, a guaranteed income.

References

Boyle, T. & C. Mallan (2003) 'Quarantined nurses laid off by hospitals', Toronto Star, June 12, pp. A1 & A6.

Crowe, Cathy and Kathy Hardill (2003) 'What would Nightingale say?' Toronto Star, April 24.

Diebel, Linda (2003) '10 questions for a SARS inquiry', Toronto Star, June 8, pp. A1 & A8.

McGran, Kevin (2003) 'Toronto's economic worries flood back', Toronto Star, May 27, p. A6.

Nikiforuk, Andrew (2003) 'Why hospitals can be bad for your health', Toronto Star, May 6, p. A23.

Toronto Star (2003a) 'Lessons from SARS (3): Time to reinvest in public health', June 28, p. v6.

Toronto Star (2003b) 'Ill-planned cuts hurt SARS fight', Toronto Star May 9, p. A9.