Chapter 29: Poverty, Homelessness & Food Insecurity

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Welcome back to the Deep Dive.

I'm so glad you are here because today,

today we are wading into some waters that I think a lot of people find uncomfortable.

Uncomfortable is definitely the right word.

Yeah.

But necessary.

Absolutely.

We are looking at the intersection, the collision really between human health and well, the way our society is structured.

And to kick this off, I want to take you back in time, way back.

How far are we going?

We are going to 1859 Berlin.

There's a German pathologist named Rudolf Virchow.

Now, for the nursing students listening, you might know the name, but Virchow was a titan in social medicine.

Oh, yeah.

And back in 1859, he said something that I think still rattles the cages of medicine today.

I think I know the quote you're talking about.

It's a classic.

He said, all diseases have two causes, one pathological, the other political.

It's just such a heavy statement.

One pathological, the other political.

It stops you in your tracks, doesn't it?

Because traditionally, how do we teach medicine?

You know, how do we teach nursing?

We focus on the pathological.

We look at the bacteria, the virus, the broken fumer.

The clogged artery.

Exactly.

We treat the body.

Right.

The biological machine.

We fix the parts that are broken.

Exactly.

But Virchow, over 150 years ago, was arguing that you just can't separate the body from the body politic.

You can't separate the patient from the laws, the economies, the social structures they live in.

And that is the core tension we're exploring today, isn't it?

If you view nursing or, you know, health care in general, as just treating injuries or dispensing meds, you are missing half the picture.

Maybe more than half.

Maybe.

You are missing the world that is making the patient sick in the first place.

So here is our mission for today's Deep Dive.

We are cracking open Chapter 29 of Community Health Nursing, A Canadian Perspective.

The chapter is titled, Poverty, Homelessness, and Food and Security, written by Catherine Hardell.

And I want to be clear about who this is for.

If you're a nursing student, this is obviously crucial for your exam, sure.

But honestly, if you're just a human being living in Canada, trying to understand why our emergency rooms are full.

Or why we see tent cities in our parks.

Exactly.

This is for you.

We want to bridge that gap between the sort of dry theory you get in a lecture hall, the definitions, the models, all the acronyms, and the gritty, complex, often heartbreaking reality of community health nursing on the ground.

We're going to move from the abstract to the concrete.

Precisely.

Here's the roadmap for today.

We're going to start with the lenses,

the theoretical ways we need to look at the world so that these problems even become visible to us.

Then we're going to look at the hard data.

We're going to talk about poverty and homelessness in Canada.

The numbers that will probably shock you.

And finally, we have to talk about action.

What does a nurse actually do about it?

We're going to discuss the difference between working upstream and working downstream.

It's a journey from understanding the why to addressing the what.

So let's unpack this.

Section one, the theoretical lenses.

We'll do it.

I want to start with a term that gets thrown around a lot in health care, but I feel like people just nod their heads without totally grasping the gravity of it.

The social determinants of health or SDOH.

Right.

SDOH.

It's on every syllabus, every PowerPoint.

What does it actually mean?

The World Health Organization has this definition.

The conditions in which people are born, grow, live, work, and age.

It sounds almost benign, doesn't it?

The conditions.

But if you really think about what that encompasses, I mean, we aren't just talking about whether you have a gym membership.

We're talking about the distribution of money, power and resources at a global, national and local level.

It's huge.

And in the specific context of this text, the Canadian context authors, McConan and Raphael, identify 14 specific determinants.

We're talking income, race, gender, housing, disability, early childhood development.

The list goes on.

Right.

And here is the sort of the key takeaway, the nugget you really have to hold on to.

These determinants exert a stronger impact on the health of Canadians than lifestyle choices.

Wait, say that again.

Stronger than lifestyle choices?

Yes.

That's the part that is really startling.

If you've been raised on the eat your veggies and go for a run model of health.

Which most of us have been.

For sure.

The data shows that your income, your housing status and your race affect your longevity and your health outcomes more than whether you smoke or exercise.

That is such a hard pill to swallow.

We love the idea of personal agency.

We love the idea that if I just jog every morning, I'll be healthy.

And you might be.

But if you're jogging in a neighborhood with high pollution and you're stressed out of your mind because you can't pay your rent and you're facing systemic racism at your job,

that jog can only do so much.

It's like patching a leak on a sinking ship.

That's a good way to put it.

To really drive this contrast home, the chapter includes a photo.

It's photo 29 .1.

I want you to picture this in your mind.

It's a photo of the author, Catherine Hardell, and a colleague, Kathy Simpson.

It is a very galvanizing image.

That's the word the text uses.

Describe what we're looking at here.

So you see two nurses, they're standing outdoors, they're distributing bottled water and toilet paper.

Now, if you just looked at their hands, the water, the basic sanitation supplies, you might assume they're on a medical mission in a crisis zone.

Right.

Like a refugee camp or after a natural disaster somewhere.

Exactly.

Maybe a developing nation after a hurricane.

But then you look up.

And that's where it hits you.

Exactly.

You look at the background and towering over them, gleaming in the sun is the CN tower.

The ultimate symbol of Toronto, the financial heart of the country.

Precisely.

So they are standing on some of the most expensive real estate in one of the richest cities on the planet.

And yet they're handing out toilet paper to people living in what was known as 10th City.

That contrast is just it's jarring.

You have immense towering wealth literally casting a shadow over immense deprivation.

And that is the entire point of the photo.

That's why it's in the textbook.

Poverty isn't just a number on a spreadsheet.

For a community health nurse, poverty is the lack of clean water in the shadow of a skyscraper.

The author calls these galvanizing experiences.

Galvanizing like it hardens you.

Or does it wick you up?

I think it's more that it shifts your worldview.

It forces a change in perspective.

You stop seeing just a patient with a hygiene problem.

You start seeing an environment that has failed to provide the basics of life in the midst of plenty.

So you stop asking, why didn't this person shower?

And you start asking, why is there no water here?

That is the shift.

That is the lens.

But now we have to ask the big question.

Why?

Why is there a tent city under the CN tower?

And to answer that, the text introduces a concept that I think trips a lot of people up.

It's a bit of a buzzword, but we need to nail it down.

You're talking about neoliberalism.

I am.

It's a big ism.

And I feel like people sometimes use it to mean things I don't like politically.

But it has a specific definition, doesn't it?

It does.

And understanding it is absolutely essential to understanding the modern landscape of health in Canada.

So let's unpack it.

The text defines neoliberalism as a political and economic ideology that really rose to prominence in the 1970s.

Correct.

Think about the 70s.

You have the world debt crisis, stagflation.

Governments were panicking.

And organizations like the International Monetary Fund and the World Bank started pushing a very specific recipe for economic recovery.

OK.

And what was in that recipe?

The core ingredients were free markets,

deregulation.

And this is the big one for our conversation.

Drastic cuts to social spending.

So the government pulls back less of a safety net, less funding for affordable housing, less funding for welfare.

Exactly.

The philosophy is individual responsibility.

The idea is that the market is the most efficient system.

And if we just get the government out of the way, everyone will prosper.

A rising tide lifts all boats, that kind of thing.

Pull yourself up by your bootstraps.

That is the mantra.

But we need to talk about the trickle down effect this had on health care, because when you have austerity measures, when you cut budgets to reduce national debt, where does that money come from?

It comes from the social safety net.

And when you cut the net, people fall through.

They do.

But neoliberalism adds this psychological twist

that is really dangerous for health care providers.

It assumes a level playing field.

What do you mean by that?

A level playing field?

It assumes that everyone starts at the same place.

So if the market is free and fair, then your success is up to you.

But the flip side of that is if you fail, if you're poor, if you're sick.

Then that must be my fault.

I didn't work hard enough.

I made bad choices.

Bingo.

The ideology implies that your poverty is a result of your personal moral failure.

And this leads us to what the text calls the lifestyle trap.

The lifestyle trap.

OK, this seems really, really relevant for nursing students, right?

Because a huge part of nursing is health promotion.

It is a huge part.

And this is where it gets incredibly tricky.

Imagine you're a nurse.

You have a patient with type 2 diabetes.

OK, standard situation happens every day.

What do you tell them?

The standard advice.

I tell them you need to watch your blood sugar.

You need to eat fresh vegetables, lean protein,

cut out the processed carbs, and you need to exercise 30 minutes a day.

Sound evidence based medical advice.

But let's look at this patient through the lens of neoliberalism and the social determinants of health.

What if that patient is a single mother working two minimum wage jobs just to pay rent?

She has no time.

She has zero time to cook.

She has no time to go for a jog.

And what about the food itself?

Have you seen the price of fresh produce lately?

It's skyrocketing.

And if she's low income, she's probably buying whatever is cheapest and most calorie dense, which is usually processed high sugar foods.

Exactly.

Her rent takes up 70 percent of her income.

She literally cannot afford the good choices.

So when I, the nurse, stand there and tell her to choose better, you were setting her up to fail.

And the text argues that this approach isn't just ineffective.

It is unethical.

Unethical.

That's a strong word.

It is.

But think about it.

You are blaming the victim for barriers they cannot control.

You are individualizing a systemic problem.

You are treating a political issue, the lack of a living wage, the lack of affordable healthy food as a personal failure of the patient.

Wow.

That really flips the script because you're taught in school that educating the patient is always a good thing.

But if you're educating them to do the impossible.

You're actually part of the problem.

You are reinforcing that shame.

You are reinforcing the neoliberal idea that if you are sick, it is because you didn't try hard enough.

Right.

And that is exactly what Virchow meant.

The disease, the diabetes has a pathological cause.

Yes.

But it also have a political cause.

OK.

I think we have firmly established the lens.

We can't just look at the person.

We have to look at the structure they are trapped in.

So let's look at that structure.

Let's get into the weeds.

Section two, poverty in Canada.

Let's look at the numbers.

I think most Canadians have this self -image that we are a very egalitarian society.

You know, we're not like the U .S.

We have a safety net.

We have universal health care.

It is a nice story.

We tell ourselves it feels good.

But the numbers tell a very different story.

What are we looking at here?

The data is it's sobering.

The text states that one in seven Canadians live in poverty.

That's four point eight million people.

Four point eight million.

That's more than the entire population of Alberta.

It's a massive number.

And the text makes a point to say this isn't just a statistic.

It's a daily grinding reality.

It's the heat or eat dilemma.

Do I pay the hydro bill so my kids don't freeze or do I buy groceries?

Do I pay for the bus to get to a job interview or do I pay for my child's field trip?

It is a constant, exhausting calculation,

a constant stress.

And measuring this is surprisingly complex.

You'd think poverty is a simple line.

You're either above it or below it.

But it's not that simple, no.

Statistics Canada actually uses three different yardstick to measure poverty.

And for the students listening, you actually need to know the difference because they tell you different things about who is struggling and why.

OK, let's break them down.

I have seen these acronyms and I always get them mixed up.

First one, LICO, the low income cutoff.

OK, LICO.

Think of this as a relative measure.

It's all about how much of your pie, your income, goes to the absolute basics.

Food, shelter, closing.

OK, so it's about proportion.

Exactly.

Statistics Canada looks at the average family.

Then they look for families who are forced to spend 20 percent more of their income on those basics than the average.

So if the average family spends,

say, 40 percent of their money on survival and I'm spending 60 percent or more, then I'm below the LICO.

That's it.

Exactly.

It identifies people who are in straitened circumstances.

They have very little wiggle room compared to the norm.

Got it.

OK, next one.

LIM,

the low income measure.

This is also relative, but it's simpler.

It's purely about income numbers.

It takes the median national income.

That's the exact middle point of what all Canadians earn.

OK, the 50th percentile.

Right.

And it just draws a line of 50 percent of that number.

If you earn less than half of the median income, you're considered low income under LIM.

And why is this one useful?

It's great for international comparison.

Most developed countries use a similar metric.

So if we want to ask, does Canada have more poverty than Sweden or the US?

We use the LIM.

It's an apples to apples comparison.

OK.

And the third one.

The MBM, the market basket measure.

This one feels the most tangible to me.

It is the most tangible.

And it's actually Canada's official poverty line as of recently.

There's an absolute measure.

How does that work?

Imagine a literal shopping basket.

Statisticians go into a specific community,

say Halifax or Vancouver or Brandon, Manitoba, and they price out exactly what a modest basic standard of living costs for a family there.

Like they're physically going to the store and checking prices.

Basically, yeah.

What does a healthy diet cost in this city?

What's the average rent for a two -bedroom apartment?

Clothing, bus passes, Internet, they add it all up.

If your income cannot buy that specific basket of goods and services, you are in poverty.

I like this one because it accounts for geography.

I mean, living in Toronto costs way more than living in rural Quebec.

Exactly.

A dollar is not worth the same everywhere.

The MBM captures that reality.

So we have 4 .8 million people struggling no matter how you measure it.

But poverty isn't distributed equally, is it?

It's not a random lottery.

Far from it.

The text has a table.

Who is most likely to experience poverty in Canada?

And if you want to see where the system is broken, you just have to look at this table.

It's a roadmap of inequity.

So let's walk through the groups who are most vulnerable.

Who is at the top of the list?

First, people with disabilities.

They're twice as likely to live below the poverty line.

In fact, some estimates suggest that 45 percent of homeless individuals may have a disability or mental illness.

That is a huge overlap.

It suggests that if you can't work in the traditional sense, the safety net just isn't there to catch you.

Or the support to help you work isn't there.

Then you look at families,

specifically single parent families.

And I'm guessing there's a gender divide here.

A massive one.

The text states that 21 percent of single mothers raise their children in poverty.

Compare that to only 7 percent of single fathers.

Wow.

Three times higher for moms.

It speaks to the wage gap, the burden of child care and what's often called the feminization of poverty.

And then there's the racialization of poverty.

I want to pause on that term racialized.

The text is very careful to explain this.

We aren't saying race causes poverty in a biological sense.

No, absolutely not.

Race is a social construct.

It's a category society invented,

but racialization is a process.

It is how society categorizes people, treats them differently and shuts them out of opportunities based on that category.

And the numbers bear that out starkly.

The text notes that one in five racialized families live in poverty compared to one in 20 non -racialized families.

One in five versus one in 20.

That is a staggering difference.

It is.

And for racialized women, it's a double whammy.

The text mentions they earn 32 percent less at work compared to non -racialized men.

That's the wage gap right there in black and white.

And this connects directly to nursing practice because you can look at these stabs and feel totally hopeless.

Or you can do what Carolyn Acker did.

Oh, I love this story.

This is the pathways to education example, right?

Yes.

This is a perfect example of a so what now what approach.

Carolyn Acker was an RN, a nurse working in Regent Park in Toronto.

It's a very well known low income housing community.

OK.

And she noticed a pattern.

She saw massive high school dropout rates among the youth in the community.

Now, if you use that neoliberal lens we talked about earlier, you might say, well, these kids just don't value education.

They're making bad choices.

Exactly.

You would blame the students.

But Acker looked upstream.

She realized it wasn't a failure of the students.

It was a failure of support.

These were often children of newcomers.

Their parents were working precarious jobs, maybe night shifts.

They couldn't help with homework because of language barriers.

And the kids had financial pressure, too, I imagine.

Huge pressure.

Some were dropping out just to work minimum wage jobs to help their families pay rent.

Or they literally couldn't afford the bus fare to get to school every day.

So what does she do?

This is the nursing part that's so cool.

She didn't just stand there and tell them to study harder.

She created a structure,

the pathways to education program.

It provided academic tutoring, mentoring.

And this is key financial support like bus tickets, bus tickets.

Lunch vouchers.

Removing those small but insurmountable financial barriers that made school impossible.

And the results.

The dropout rate fell by 70 percent.

High school completion skyrocketed from 20 percent to 80 percent.

That is incredible.

And that counts as nursing.

That is community health nursing in its purest form.

She diagnosed a community problem, poverty and lack of support.

And she treated the root cause.

She didn't prescribe a pill.

She prescribed a bus pass and a tutor.

I love that.

Now, we have to talk about another group that is disproportionately represented in poverty statistics.

You have to talk about indigenous poverty.

This is a critical section.

The text outlines what McDonald and Wilson call the three tiers of child poverty in Canada.

Three tiers.

OK, walk us through them.

Tier one is non racialized, non indigenous children.

Their poverty rate is about 12 percent.

OK, that's the baseline.

Tier two includes racialized children, immigrant children and MEDIS or Inuit children.

That rate jumps to between 22 percent and 33 percent.

So that's already double or even triple the baseline.

And then there's tier three, status First Nation children.

Fifty percent live below the poverty line.

Fifty percent.

And in some provinces like Saskatchewan, it goes up to 64 percent.

So in some parts of Canada, it is statistically more likely than not that a First Nations child is living in poverty.

Correct.

And we must be crystal clear on the root causes here.

The text references Britain and black stock.

We cannot talk about this without talking about colonialism.

Connect the dots for us.

This isn't an accident.

This isn't some historical coincidence.

This is a direct legacy of the dispossession of land.

The Indian Act, which restricted economic development, the residential school system, which decimated family structures and culture.

This poverty was in many ways legislated.

And there's a note here about data gaps, too.

The text mentions a study by Firestone at all in Hamilton.

This is so important.

The official census data is the government count.

But it often undercounts indigenous poverty.

Why?

Because of historical and ongoing mistrust.

Many indigenous people might not fill out the census or they're transient and missed by the count.

So the Firestone study did something different.

They use community led research.

They built trust.

And when they looked at urban indigenous people in Hamilton, they found that 70 percent were in the lowest income bracket.

70 percent.

So the official numbers, as bad as they are, might actually be underestimating the crisis.

It's very likely.

Yes.

OK, before we move on, we have to touch on rural poverty because poverty in the city looks like tent city.

But in the country, it's different.

It's often hidden.

It's less visible in rural areas.

There are fewer social supports.

You don't have the same shelter systems or large food banks.

And the economies are often fragile, single industry towns,

forestry, mining, fishing.

If the mill closes, the town dies.

Exactly.

And the cost of living can be much higher, especially the further north you go.

The text mentions the northern equivalent scale.

What's that?

It's a calculation that shows life in the north costs significantly more.

A family there needs one point four, six times the income of a southern family just to survive.

So a dollar in Nunavut buys you way less than a dollar in Ottawa.

Way, way less.

And we'll see that again when we talk about food insecurity.

Finally, before we hit homelessness, we need to link all of this poverty back to actual disease.

The text talks about a gradient.

It's a linear relationship.

This is the rule of thumb.

As poverty increases, morbidity, that sickness and mortality, that's death increase.

It's that simple and that brutal.

Give us some examples.

What conditions are we talking about?

Diabetes, hypertension,

COPD.

Depression is a huge one.

It's 58 percent higher in low income populations.

The stress just grinds people down.

And there's a critique here about how we treat obesity in this context.

Yes, Medvedeuk et al.

argue that the medical focus on obesity is a distraction.

If you focus on the patient's weight, you are stigmatizing them.

You're ignoring the fact that poverty causes the diet that leads to the weight.

So instead of a war on obesity, we should have a war on poverty.

That's the upstream way of thinking.

Treat the cause, not the symptom.

OK, that is poverty, the soil in which disease grows.

Now, let's look at what happens when the safety net fails completely.

Section three, homelessness.

And the text calls this a manufactured crisis.

That's such a strong term, manufactured.

It implies it was made on purpose, or at least made by humans.

It was.

The text points to the 1980s as a turning point.

Before the 80s, Canada didn't really have mass homelessness the way we see it now.

So what happened in the 80s?

It was a perfect storm.

Yeah.

The text calls them homeless making processes.

You had the federal government disinvesting in affordable housing.

They just stopped building it.

You had economic shifts where good factory jobs disappeared.

And you had the cutting of those social safety nets we talked about with neoliberalism.

So homelessness isn't a natural weather event.

It is a policy outcome.

Precisely.

And we need to define what it actually looks like.

The Canadian Observatory on Homelessness gives us a spectrum.

Right.

Because it isn't just the person sleeping on a park bench.

That's what we call unsheltered.

And that's just the tip of the iceberg.

Then you have emergency shelter,

people in overnight shelters or, say, shelters for women fleeing violence.

Then provisionally accommodated.

This is the huge category of hidden homelessness.

This is couch surfing.

I imagine a 19 year old student who sleeps on a different friend's floor every week.

They have a roof.

But do they have a home?

No, they have no security of tenure.

And finally, at risk.

These are people whose housing is so precarious.

Maybe they spend 80 percent of their income on rent.

That one lost paycheck, one car repair puts them on the street.

The demographics are shifting, too.

I think the stereotype is the older single man with a substance use issue.

That is the historic stereotype.

Yes.

But the face of homelessness is changing dramatically.

Families are staying in shelters twice as long as individuals now.

And 89 percent of homeless families are headed by women.

Single moms again?

And seniors.

They are the fastest growing group in shelters.

People aged 50 to 64 and over 65.

Can you imagine working your whole life and ending up in a shelter in your 70s?

It's heartbreaking.

And veterans, too.

The text says approximately 2950 veterans are homeless.

People who serve the country.

Now, this next part is fascinating.

And I want to spend a moment here.

Indigenous homelessness.

The text presents a unique definition for this based on the work of Jesse Thistle.

Yes, the 12 dimensions.

This feels much deeper than the standard definition.

It's profound.

It frames indigenous homelessness, not just as a lack of a roof, but as a state of disconnection.

Disconnection from what?

Disconnection from land, from water, from family, from culture, from spirit.

It's a direct result of colonization.

Can we highlight a few of the dimensions to make that clear?

Sure.

There's historic displacement,

the literal loss of traditional lands.

But then there's spiritual disconnection.

If your entire worldview is tied to the land and your relations and you are severed from that, you are homeless in a spiritual sense, no matter where you live.

The text mentions going home homelessness.

That one stuck out to me.

That's when someone is alienated from their home community.

Maybe they were taken in the 60s scoop or they grew up in the city.

They try to go home to their reserve, but they don't know the language.

They don't know the cultural protocols.

They feel like strangers in their own home.

So you could theoretically have a house, but still experience a form of indigenous homelessness in a spiritual and cultural sense.

Absolutely.

Yes.

It broadens our understanding of what home really means.

It means being connected to all my relations.

And finally, for this section, youth homelessness.

What drives a young person to the street?

It's almost always trauma,

escaping abuse or aging out of the child welfare system.

You turn 18 and boom, the support stops.

You're on your own.

The text quotes a use from Edmonton.

I have it here.

Why didn't you do it when we had a few dollars?

Why wait until the bank account is zero?

That quote just highlights the absolute failure of prevention.

We wait for the catastrophe.

We wait until they are destitute with nothing to offer help.

It makes no sense.

And there's a policy barrier mentioned from Vancouver.

Oh, this is a prime example of a broken system.

Yeah.

In Vancouver, at one point, youth had to be homeless for six months before they could qualify for certain housing subsidies.

That is insane.

You're telling a kid, stay on the street, get traumatized, risk your life for half a year, and then we will help you.

It is a perverse incentive.

It illustrates how our systems can actually trap people in homelessness instead of helping them escape it.

OK, let's move to section four, health impacts and nursing care.

We know homelessness is bad for health, but how bad?

The street health report from Toronto provides the data

and a warning.

This is heavy stuff.

Go ahead.

One in ten homeless adults attempted suicide in the past year.

One in ten.

That's a staggering mental health crisis right there.

One in eight were assaulted by police.

They are 29 times more likely to have hepatitis C, 20 times more likely to have epilepsy.

And the death rate.

What does that look like?

The median age of death for a homeless person in Toronto is forty eight.

Forty eight.

Forty eight.

The average Canadian lives to be, what, eighty two?

Around there.

So we are talking about losing thirty four years of life.

Just gone, erased because you don't have housing.

The text also zooms in on women and families.

There's a study mentioned, the Obstetrical Unit Study by Richter et al.

This one really gets into the nitty gritty of nursing ethics.

This is such a powerful case for students.

It describes nurses caring for homeless pregnant women.

And it found a misalignment.

A misalignment between what?

Between what the patients desperately needed and what the hospital system allowed the nurses to provide.

Give me an example.

Well, imagine a homeless woman comes in to give birth.

Her partner is with her.

He's also homeless.

He's starving.

But the hospital policy says food is for patients only.

So the nurses are stuck.

They know he needs food.

And they face what the study calls moral distress.

They were sneaking food to the partners.

They felt terrible discharging women with their newborns to no fixed address.

They knew they were sending that baby into unsafe conditions, but they had to clear the bed for the next patient.

And the bias.

That's the ugly part.

The study found derogatory jokes and judgmental comments in the break room.

Why is she having another kid?

She's just working the system.

It's a reminder that we have to check our own biases.

The break room culture matters.

Absolutely.

If we judge our patients, they feel it and they won't come back for care until it's an absolute emergency.

Speaking of emergencies,

the text touches on end of life care.

The fear for many homeless people is dying alone, anonymous,

disregarded.

The solution isn't just a traditional hospice, which might have strict rules about curfews or substance use.

Right.

If you're an addict, you can't just stop using to get into hospice.

It's not realistic.

Exactly.

So the text advocates for a shelter based palliative care, models that accommodate substance use, that use a harm reduction approach and provide dignity where the person is.

Let them die with respect to the place they know, surrounded by people who care.

OK.

We have covered poverty and homelessness.

Now, the third pillar, food insecurity, section five.

And the definition here is important.

It is inadequate or insecure access to food due to financial constraints.

It's not just I'm hungry right now.

It's I don't know if I'll be able to eat next week.

The anxiety of it.

The stats say 12 percent of households, one in six children.

But here is the paradox that just blew my mind.

Sixty two percent of food insecure households get their main income from wages.

That statistic busts the myth that food insecurity is just about unemployment.

These are the working poor.

It is about low wages.

People are working, often multiple jobs, and still can't afford to eat properly.

And the health links are huge.

80 percent more likely to have diabetes.

Which brings us right back to that lifestyle trap, doesn't it?

If you can't afford healthy food, you're more likely to get diabetes.

If you get diabetes, you need healthy food to manage it, which you can't afford.

It is a vicious, vicious cycle.

The situation in the north is described as a public health emergency.

The numbers are shocking.

Nunavut has a 46 .8 percent food insecurity rate.

Nearly half the population doesn't have reliable access to food.

That's staggering.

I can't even imagine that.

And the cost.

Residents there spend twice as much on food as the rest of Canada.

I've seen photos online of a jug of milk costing $20, a bag of grapes for $28.

How does anyone afford that?

They don't.

That is why it is an emergency.

And the text critiques the Nutrition North Canada program, which is a retail subsidy program.

The criticism is that it doesn't actually make food affordable.

Right.

The subsidy goes to the retailer and it often doesn't trickle down to the price on the shelves.

And it doesn't reflect northern diets.

It doesn't support access to country food or traditional loading.

It promotes a southern diet that is impossible to afford.

So are food banks the answer?

I feel like that's the default response.

Every grocery store has a donation bin.

The text is very, very clear on this.

No, food banks are a downstream response to an upstream problem.

They are a sign of policy failure.

A bandaid on a gaping wound.

A tiny bandaid.

The PET study shows that charitable meal programs struggle to meet demand.

You can't charity your way out of structural poverty.

The real solutions are upstream.

Increased minimum wage, higher social assistance rates, affordable housing.

This brings us perfectly to our final section, section six, the role of the community health nurse.

We've been talking about upstream and downstream this whole time.

Let's make this practical for the students listening.

What does a nurse do?

OK, let's start downstream.

This is the clinical practice, the one on one with a patient.

The text mentions a screening tool.

Poverty, a clinical tool for primary care providers.

And it suggests a very simple but powerful question.

Do you ever have difficulty making ends meet at the end of the month?

Why is that specific question so important?

Because patients often won't volunteer that information.

There's shame.

There is stigma.

If a nurse asks directly, it opens the door.

It gives them permission to talk about it.

It allows the nurse to say, OK, this explains why you aren't taking your meds.

You can't afford them.

And then there's the concept of inclusion health.

This is all about building trust, meeting people on their turf, outreach, nursing, being flexible.

If a patient is late because they rely on Apache bus system, you don't turn them away.

You adapt to them, not the other way around.

The text uses a case study here that I think brings it all together.

The heat wave scenario.

Let's maybe role play this a bit.

OK, imagine an inner city clinic.

It is July in Toronto.

It is 40 degrees Celsius with the humed acts.

It's sweltering dangerously hot.

And you have vulnerable client seniors, people with chronic illnesses living in old rooming houses.

These places have no AC.

Maybe the windows are painted shut.

It's an oven inside.

OK, so walk us through the levels of prevention as the community health nurse.

What do you do?

Level one downstream immediate action.

You have people coming into the clinic with heat exhaustion.

You distribute bottled water.

You advocate to open the local community center as a cooling station.

You're treating the immediate threat to life.

OK, midstream.

What's the next level?

That's education.

You are handing out pamphlets on how to stay cool, how to recognize the signs of heatstroke.

You are trying to prevent the emergency for the next person who walks in.

And upstream.

This is the big one.

This is where the nurse becomes a political advocate.

You ask the question, why are these people baking in these houses in the first place?

You advocate for better housing standards.

You lobby the city for a bylaw requiring maximum temperatures and rental units, just like we have minimum temperatures in winter.

That leads to the final point.

Upstream political advocacy.

Some nurses might think, I'm not a politician.

I just want to care for patients.

But as we said right at the start with Vircho, politics is the cause of the disease.

The text highlights the organization Street Health in Toronto again.

They didn't just treat the patients with frostbite and infections.

They published that report we quoted from earlier.

Exactly.

They surveyed their patients.

They gathered the data and they published a report with 13 specific policy recommendations,

things like higher welfare rates.

But also, and this is so specific and so powerful, police training.

Because they saw the data on assaults by police.

Yes.

They proved that research equals political advocacy by documenting the reality of their patients lives.

They created a tool to change the system.

So if you are a nursing student listening to this, you have permission.

Actually, you have a mandate to get political.

You do.

Because if you don't address the poverty, the homelessness and the food insecurity, you are just sending your patients back to the very conditions that made them sick.

You're mopping up the floor while the tap is still running at full blast.

And that brings us to the end of our deep dive into Chapter 29.

It is a lot to take in.

It is.

But it is also empowering, I think.

So let's summarize the main thread.

Poverty, homelessness and food insecurity aren't accidents.

They are not inevitable.

They are created by policy choices.

Neoliberal policies, specifically, as the text argues.

And because they are created by choices, they can be fixed by different choices.

That is the hope right there.

I want to leave you with a final provocation.

This is for the learner in all of us.

Next time you are in a clinical setting and you are treating a patient's foot ulcer or their diabetes or their child's asthma.

I want you to ask yourself a question.

Don't just ask, what is the treatment?

Ask, what upstream factors put this person in this chair in front of me today?

Look for the invisible lines of poverty and policy that lead right to that hospital bed.

And then ask, what can I do about it?

On behalf of the last minute lecture team, thank you for listening.

Keep learning and keep looking upstream.