For a recent example of the unique vulnerabilities of Indigenous communities, Kandola and others tasked with protecting such populations could also turn to the 2009 H1N1 pandemic. Those living in First Nation communities were 2.8 times more likely to be hospitalized from the flu strain, and had an ICU admission rate that was three times higher than that of non-Indigenous people. Or, put another way: while Indigenous people represent only 4.3 per cent of the population, during the first wave of H1N1 they accounted for 27.8 per cent of hospitalizations and made up 25.6 per cent of critically ill patients in ICUs across Canada. A history of colonialism and the resulting and persistent inequities, together with the very isolation that could potentially protect communities from SARS-CoV-2, hold much of the blame for such poor health outcomes—both directly and indirectly. Colonial policies and legislation in Canada are, as many Indigenous rights advocates have said, a pandemic unto themselves. For centuries, this complex web has perpetuated countless socio-economic, cultural, and political injustices, many of which, in turn, make it hard to fend off an unyielding killer virus.
Chronic disease is a risk factor. Crowded, multi-generational housing is a risk factor. Poverty is a risk factor. Dirty water is a risk factor. Poor nutrition is a risk factor. Lack of access to dependable health care is a risk factor. Discriminatory and racist health care is a risk factor. Low trust is a risk factor. Delayed and badly communicated public health information is a risk factor. A history of low and no resources is a risk factor. The remoteness that made the region seem so attractive to naive southerners is a risk factor. As Kandola herself acknowledged, most communities in the North don’t have easy access to a hospital. A number of them don’t even have a permanent nurse on site every day. Treatment would be slow, if it came at all. “If we get the novel coronavirus in our communities,” Kandola asserted, “it will spread.” Unless, of course, she acted quickly and decisively.
The N.W.T. confirmed its first case of COVID-19 on March 21, hours before closing its borders to non-essential visitors. Kandola told me she’d already made the decision to shut the territory to air, road, and port travel before a resident in Yellowknife tested positive. She had been watching the case counts climb in the provinces to the immediate south and wanted to be proactive. She wanted to make wise use of the time she had before the virus arrived—even if, as it turned out, she didn’t have any time at all. By that point, the territory had already administered hundreds of COVID-19 tests, and it planned to keep administering them aggressively, despite the low case count. The first positive test belonged to a person who’d travelled to Alberta and B.C. before returning home, just as Kandola anticipated might happen. The person and their family were told to self-isolate after receiving the diagnosis and did so, immediately. Then, Kandola and her team tracked down seventy people who had come into contact with that person and prescribed another round of mandatory isolation. Over the next few weeks, another four people tested positive in the territory. The last of them recovered without incident in mid-April, and nobody else tested positive for months.
Throughout it all, Kandola remained vigilant. She worked constantly, through evenings and weekends, describing the period as “intense.” The idea of 5 p.m. signalling the day’s end became laughable; seeing her family, a husband and four children, became near impossible. In a way, it was almost familiar, too: during H1N1, Kandola had missed her youngest son’s first birthday; she’s missed a lot of stuff this time around, as well. During the non-stop early days, an epidemiologist on her team presented Kandola with a superhero cape, calling her “Super Kami.” She hung it on the back of her chair, thinking of all the Avengers movies she’d been watching with her twelve-year-old son. “It’s a flavour of how our team is dealing with the pandemic. The mentality is that it’s not just about you—you are trying to protect society at large and the people you love and care about need you to be focused,” she said. “They need you to put their needs before yours.” She took the philosophy to heart as she led her morning huddles, and, as she began making tough decisions to protect her real-life population, she hoped everyone else would too.
At her order, restaurants, gyms, schools, and some offices remained closed until the territory ticked into June. At the end of August, a checkpoint in Hay River, close to the Alberta border, was still refusing entry to at least a dozen vehicles a day. As fall hit, the territory enacted mandatory mask measures at airports, and so too did many stores. By October 9, the N.W.T. had completed over 5,570 virus tests, and the number of COVID-positive results never budged. Nor did Kandola, even as criticism of too-strict measures surfaced in the territory, as it did elsewhere in Canada. Much of that grumbling arrived as she and her team prepared for what Kandola saw as the inevitable second wave—there hadn’t yet been a pandemic in history without one. And indeed, after a months-long virus drought, the N.W.T. recorded three new cases in mid-October. Kandola knew they were coming. For her, the previous six months had only been a drill; the real test was still on its way. Standing at the base of another possible mountain, she vowed to put even stricter precautions in place if she had to. After all, she said, examples of worst-case scenarios abounded. In particular, she looked with worry to northern Saskatchewan, a public health failure close to home—and a place similar in both population size and demographics to the N.W.T. “You can never know how much prevention stopped,” she said, “but we know by looking at unmitigated public health measures what could have happened.”
On April 15, Saskatchewan’s far north reported its first COVID-19 case in La Loche, a Dene village that’s home to about 2,800 people. Health officials later confirmed that the virus’s arrival in the community was linked to travel from an oil sands camp in Alberta. The virus quickly spread. By the time the province restricted non-critical travel to the province’s north eleven days later, the area accounted for twenty-five of the fifty-seven active cases. The communities dotted there faced the same challenges as those in the N.W.T., and, arguably, in every Indigenous community and reserve across Canada. When housing is overcrowded and inadequate, self-isolation doesn’t work no matter how hard people try, or how responsible they are. The virus pillaged the region for three months. By the time the last active case was deemed recovered in July, the area accounted for nearly one-third of COVID-19 infections in Saskatchewan. More than two hundred people in La Loche got sick, and another sixty-two became ill in nearby Clearwater River Dene Nation. Some died. And it wasn’t, of course, simply Indigenous people in remote areas who faced higher risks.
“I mean, the system is racist everywhere,” said Lisa Richardson, an Indigenous internist at Toronto General Hospital. “There is so much systemic racism. There is individual racism. There is structural racism, and there is epistemic racism.” Richardson is also the vice-chair of culture and inclusion at University of Toronto’s School of Medicine and the lead strategic advisor in Indigenous health for both U of T’s Faculty of Medicine and Women’s College Hospital. Richardson has thought a lot about what it means to offer trauma-informed, anti-racist, culturally safe care in the time of COVID-19. She knows that many Indigenous people mistrust the healthcare system and the privilege-steeped idea that it is there to help them feel better, to keep their bodies and their minds healthy—and for good reason. Even when they do enter the system, Richardson added, they face major barriers to treatment, including a dearth of humane and culturally safe care. That might mean, for example, a doctor who doesn’t understand they are treating a patient who’s been to residential school and been forced to undergo medical procedures. Or it might mean hospital staff who are blatantly racist and cruel, callously endangering their patients’ lives.
Consider the tragic, deplorable death of Joyce Echaquan. The thirty-seven-year-old Atikamekw woman and mother of seven drove three hours from her home in Manawan to a hospital in Joliette, Quebec, one Saturday morning in late September 2020. Echaquan sought help for her severe stomach pain and also suffered from a chronic heart condition. By Mond
ay morning, she was in even worse pain. She feared she was being given morphine, which she was allergic to, and worried she was over-medicated. Nurses only derided her. So, Echaquan began live-streaming her experience on Facebook. It lasted seven minutes, and in it a nurse can be heard saying, in French, “Are you done acting stupid? Are you done?” Echaquan groans in pain, and another nurse joins in. “You made some bad choices, my dear. What are your children going to think, seeing you like this?” The first nurse responds, “She’s good at having sex, more than anything else.” Her cousin saw the video and, shocked and worried, sped down to the hospital to pick up Echaquan, to get her out of that place. When she arrived, nobody would let her see her cousin or give her any information. Finally, upon discovering why she was there, a nurse told her, “Oh, you don’t know yet? She’s died.”
Indigenous people know all too well that, despite politicians’ protestations otherwise, such incidents are far from rare. So, then, how do you convince communities and individuals that public health measures are trying to keep them safe? How do you convince them that getting tested for COVID-19 is a smart idea? Throughout the pandemic, Richardson worked with Anishnawbe Health Toronto’s mobile testing unit to try and do exactly that. The mobile unit was designed to bypass the assessment centre and meet Indigenous people where they were at, literally. It travelled to the city’s shelters and homeless encampments, but also outside the downtown core, where pockets of Indigenous people live but don’t have access to care. Once people agreed to be tested, Richardson practised clear and kind communication, explaining what she was doing and why. If a patient was still, understandably, apprehensive, she learned to offer to let them do the invasive-feeling test themselves. She’d clasp their hand and, thus joined, help guide the swab inside the nose. If that didn’t work, she’d offer a throat swab, always taking her cue from the patient. She cites the mobile unit as one example of Indigenous-led health solutions during the pandemic. But there also were many others.
Plenty of communities did shut their borders, and fast. One Inuit association made their own educational materials to disseminate, written in Inuktitut and using common examples from the daily lives of community members. Richardson helped Women’s College Hospital adopt a medicine wheel framework that incorporated elder knowledge and focused on building physical, emotional, mental, and spiritual resilience. Through these measures, many Indigenous communities reversed their expected fate: poor outcomes similar to H1N1, only magnified by the scale and force of COVID-19. First Nations, Inuit, and Métis communities actually had lower rates of COVID-19 in the first six months of the pandemic. Those on reserve had a virus case rate four times lower than the general population, with three times fewer fatalities and a 30 per cent higher recovery rate. And in La Loche, the outbreak finally ended because all levels of government collaborated—prompted in part by a letter from twenty-four Indigenous communities to the province’s CMO that read, “We ask you to learn from us, and with us”—and followed a community-crafted response plan. As Richardson put it to me: it’s amazing to see the difference power and control can make.
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The pandemic thrust many women into vise-like leadership positions. The trial under near impossible pressure wasn’t limited to people in visible, political roles. Everywhere, people had to make decisions with devastating costs, often to prevent even worse fallout. Leadership skills were tested and discovered, and sometimes it really did feel like walking through fire. Nadine Abdullah was in the fourth year of her five-year term as the internal medicine program site director at Toronto Western Hospital when the pandemic struck. As the site director, she’s responsible for every internal medicine resident at the hospital. That responsibility includes their training, but Abdullah also acts as their role model, their advocate, their support system, their cheerleader—and all of it together helps shape each resident’s career. She realized the enormity of that role during a pandemic while seated in Toronto’s Royal Alexandra Theatre watching the musical Come From Away in early March. She briefly thought, We probably shouldn’t be here. Then, she thought, We have to trust in our public health authorities. And then, in the middle of the show, the frantic phone calls started: from residents; from colleagues; from faculty at U of T, through which the residency program is run. Everyone wanted to know what they should do. The next day, everything changed. Abdullah had never thought she was a strong leader; she was terrified.
She wasn’t scared of everything she’d have to do as a mother: grocery shopping, home-schooling, getting medications renewed. She knew how to plan for all of that. What scared her was working on the hospital’s Armageddon plan: scenarios for one hundred patients, two hundred patients, three hundred patients. “That’s a war,” she said. Abdullah suffers from multiple chronic diseases, including one that requires she take Trump’s purported cure-all, hydroxychloroquine, and she worried about potential shortages of said medication. As someone who is at higher risk, she knew she likely wouldn’t survive the virus. Would she have to engage in care that would put her own life at risk? How would she learn about the disease if she didn’t? And how would she teach her residents about it? And, more than anything, how would she keep them safe? Questions tumbled through her mind, and she had trouble sleeping, night after night. What about PPE? Would there be a shortage? Had the hospital made a mistake in requiring only surgical masks be worn, not N95 masks? Would they run out of ventilators? At first, after ample consideration, she told her site lead that she didn’t feel comfortable working with COVID-19 patients; her own health put her at too high of a risk. Then, she applied the same person-by-person approach to each resident. She answered every call and text to her cellphone. She had socially distanced meetings. As she privately dealt with her own fears, she heard theirs. “No one was treated equally,” she told me. “It was all about what did everybody need for them?”
She never told her residents about her own health problems, or let on that she might be more scared than they were. As April advanced, she decided that she no longer wanted to hide from COVID. If her residents were in a position where they might have to look after virus patients, she had to face it, too—no matter the risk. She wanted to show them she could be their leader; she could be on the COVID-19 team. And that first shift? “It was nothing.” She felt safe in her PPE. At home, she quarantined in her basement, taking her dinner to the top of the stairs to eat together with, but apart from, her husband and two children. They’d prop up her phone and watch Kim’s Convenience together. She began to feel like she was getting a grip on leading through the pandemic.
That new confidence cracked shortly after, in the beginning of May. Around that time, four COVID-19 outbreaks shook Toronto Western, spreading to nineteen patients and forty-six staff members. Hospitals were set to rotate residents, and suddenly none of them wanted to accept anybody who had been working at Toronto Western. Panic set in and a well-intentioned U of T intervened to create its own policies. Unfortunately, the resulting memo failed to properly communicate with hospitals or residents, adding havoc to the mix. On Monday, many residents didn’t show up to work, as directed in the memo. Abdullah called a town hall to clarify what had happened, to apologize, and to explain how the hospital and university would move forward together. It didn’t go well. Or, as Abdullah said, “It was a disaster.”
Emotions ran high. While most residents seemed to understand, several wouldn’t accept the explanation and they became aggressive, even vitriolic, she told me. They accused the hospital and program of using residents as human shields. “I can’t tell you how I felt I failed,” said Abdullah. “I just couldn’t control the tears.” She did take it personally, and, in her next meeting, offered to resign. Logically, she knew that she hadn’t done anything wrong. She knew that she, and everyone else, had made the best decisions they could, given the constraints; other decisions, and mistakes, had been out of her control. At the same time, she also felt like the town hall was a vote
of non-confidence; she felt like maybe she wasn’t doing a good job after all. But her resignation wasn’t accepted. Her colleagues and her own superiors wanted to keep her in leadership. Her own children and her husband told her: we hear you on your daily calls; those residents need you.
When I spoke with her months later, she was still upset and seemed ambivalent about staying in her position. “What people don’t understand,” she said, “is that we’re going through the pandemic, too. We’re terrified, too. And we’re barely keeping it together.” Still, she had kept working with COVID-19 patients, kept helping the residents, and kept wondering if she was doing the right thing, leading the right way, making the best decisions. When it came down to it, like all the new leaders of the pandemic, she had simply kept going, doing it all, even when she wanted to stop.
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Hinshaw woke up at 5 a.m. for months. She began her day by working at home before heading to her office. There, she’d read the latest SARS-CoV-2 science and use it to lead decisions on everything from testing strategies to lockdown measures to industry closures. She announced those decisions daily at 3:30 p.m. Back at home, she’d work until 10 or 11 p.m. Then, repeat. Like the virus, Hinshaw’s routine was constant and relentless, obliterating breaks, balance, and weekends. Characteristically humble and gracious, she credits her team and her husband, her “greatest cheerleader,” for helping her keep it together. Her mother also helped big time, looking after Hinshaw’s two elementary school–aged children for half the week at her own house and half the week at her daughter’s. Hinshaw’s faith tradition grounded her, infusing her with the belief that she is always part of something bigger than herself, one chain-link of connection with the whole. Still, there were days when she didn’t feel so Zen. It didn’t happen often, but there were times where she had pushed and pushed and pushed for something—or, conversely, had been pushed—until she’d finally had enough. She’s thankful those rare times happened when she was with supportive people. She could let it out, cry in her office, wipe her eyes, pick herself up, and get back to it. “Honestly,” she said, “I think it’s important to cry”—to release the grief, to admit despair. “So much suffering has happened—not just as a direct result of the infection, but also the impact on people.”
Women of the Pandemic Page 16
