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"We can't just expect people to be healthy... if they live in a house with 10 other people and have no running water," Manitoba's chief public health officer Dr. Joel Kettner said after the H1N1 flu pandemic swept through Island Lake in spring 2009.
Unsafe water and sanitation are the source of 85 per cent of preventable diseases globally, according to Maude Barlow of the Council of Canadians.
Nurse Florence Nightingale figured out the connection between hygiene and health 150 years ago, but what exactly are the consequences of living without tap water and flush toilets?
In St. Theresa Point alone, hundreds of people got sick during the first phase of the H1N1 flu pandemic and at least a dozen had to be airlifted to Winnipeg hospitals because they couldn't breathe, according to the chief.
Mary Jane Harper barely survived, lost the child she was carrying and still suffered from nerve damage many months later. Her pregnant cousin died, though the baby was rescued through a caesarean section.
With every medevac costing $5,000, Health Canada would have spent $60,000 for the flights from that community alone. The intensive-care treatment that followed would have cost the provincial government much, much more.
If the chief's estimates are correct -- governments refuse to give community-specific numbers -- St. Theresa Point probably had one of the highest infection rates in Canada during H1N1's first wave, considering that only 136 people with H1N1 were admitted to Manitoba hospitals that summer.
Is it a coincidence that the H1N1 flu spread so rapidly in a community where 60 per cent of homes have no running water, making the "frequent handwashing" mantra of pandemic flu prevention a joke?
It's hard to say, especially since an epidemiological report on the St. Theresa Point outbreak has not been released to the public, despite more than six months of requests from the Free Press, including a formal access-to-information application.
However, research in Alaska provides some clues. A 2008 study in the American Journal of Public Health found people age 65 and older were twice as likely to be hospitalized for pneumonia or influenza in areas where a lower proportion of homes have tap water and flush toilets.
Infants in under-serviced villages had a five times higher rate of hospitalization for lower-respiratory-tract infections and respiratory syncytial virus, and were 11 times more likely to be hospitalized for pneumonia compared to the overall U.S. population.
Meanwhile, a whooping cough (pertussis) outbreak this spring hit the Island Lake area especially hard. Public health officials refused to disclose which northern First Nations were affected, but a source said most of the children who had to be hospitalized were probably from the three communities on the shores of Island Lake. Since there's no hospital there, that would have involved further expensive medevacs to Winnipeg.
"Proper hand washing may prevent the spread of pertussis," the Public Health Agency of Canada points out on its website about the bacteria that can kill babies quickly if they haven't yet been vaccinated.
FIRST Nations in the Burntwood Regional Health Authority of northern Manitoba -- which account for about two per cent of Manitoba's population -- are responsible for almost half the new Manitoba cases this year of a superbug known as methicillin-resistant Staphylococcus aureus.
It often causes nasty skin boils that are hard to treat because the bug has become resistant to common antibiotics, and it can be fatal if it moves deeper into the body. Dr. Hanka Hulsbosch, who works in Garden Hill, said MRSA boils are much worse than ordinary boils.
"They're festering and huge and disgusting and painful," she said, noting they can be up to 10 centimetres in diameter.
Medical workers in Island Lake say they treat an alarming number of the telltale boils, which patients are supposed to wash with soap and clean water.
It's not uncommon for whole families to come down with painful boils as the superbug spreads in homes without enough wash water. Robert Little of Garden Hill said he got boils on the back of his ear and on his back. His wife got one, too, and his daughter had one on her knee.
Dr. Bruce Martin, director of the University of Manitoba's Northern Medical Unit, said he's not aware of any MRSA fatalities in Manitoba communities with little running water.
But he warns "it's probably a matter of time, whether it be that organism or, over time, others."
Winnipeg hospitals work hard to keep MRSA from spreading between patients, but the number of positive test results has increased steadily since 2005. A spokeswoman for the Winnipeg Regional Health Authority said there's no way to track whether patients flown in from the north are contributing to the rising numbers in Winnipeg hospitals.
Health Canada doesn't reveal whether Island Lake has a worse MRSA problem than other Burntwood First Nations with better water and sewer services, but the Canadian Pediatric Society acknowledges lack of quality running water as one of the reasons MRSA is spreading on First Nations.
"There's a critical number of litres per day where it seems to be the tipping point," Martin said. While he couldn't specify what that number is, it's likely Island Land residents without running water fall below the threshold, since most get by on far less water than the United Nations considers healthy.
A Manitoba doctor aware that a child in Nunavut has already died from MRSA said "it's unethical not to fix water and sanitation where a kid could die of a bug we thought we'd conquered in the 1950s with penicillin."
Think about running to a -30 C outhouse multiple times in the middle of the night when you're so sick you can barely get out of bed and you'll realize it's not realistic.
Many people without flush toilets end up using an indoor bucket when they have severe diarrhea. In the morning, other family members emptying the bucket can easily contaminate their hands with the diarrhea-causing germs, especially when there's no sink to wash hands under a running tap.
"We always have severe cases of diarrhea, especially amongst the kids," said Red Sucker Lake Coun. Clifford Harper.
Diarrhea can have serious or even fatal consequences, especially for babies and the elderly, who are more vulnerable to dehydration. Repeated bouts can lead to anemia.
In the developing world, diarrhea is a major killer -- it accounts for four per cent of all deaths globally.
A University of Manitoba master's student in community health sciences went door-to-door in Garden Hill in 2006 and 2007 collecting stool samples from 142 people with acute diarrhea. The study found people who did not have running water, drank lake water or did not have access to an outhouse were more likely to have diarrhea-causing germs.
The research was conducted shortly before the first phase of an infrastructure project got running water to many Garden Hill homes. At the time, nursing station staff estimated the average resident had five to 10 episodes of acute diarrhea a year, while the average Canadian suffers only one.
Another study published in 1997 found that shigellosis -- which kills a million children a year in developing countries -- was three to six times more common on Manitoba First Nations reserves without running water compared to those with piped water. During the 1992 to 1994 Manitoba epidemic, 300 registered Indian children under the age of 10 had shigellosis, including 59 who had to be hospitalized.
Last year, salmonella hit a family in a crowded St. Theresa Point home with little water and kids in diapers. The bacteria that causes stinky, bloody diarrhea and vomiting often comes from improperly cooked chicken, but it spreads between family members when they can't maintain hand hygiene.
However, public health officials have few official reports from Island Lake of water-related gut infections.
"We do still see sporadic cases of... diarrheal illnesses, but in the absence of an outbreak, it's very unlikely that it's associated with water," said Dr. Linda Poffenroth, medical health officer with the federal government's First Nations and Inuit Health. She noted that food is the more likely culprit.
"Linda likes to paint things with a nice rosy brush," said a frustrated doctor who advises First Nations. "Linda will tell you that everything's perfect -- that there's no diarrhea... there's no water issues."
Manitoba researcher Dr. Pamela Orr explained "there is a disconnect between what the doctors and the nurses and the community-health representatives see every day in the communities and what the people who rely on reportable statistics see."
Residents of Island Lake are so used to getting diarrhea and treating the symptoms themselves that they don't always bother going to the nursing station, said Dr. Ethan Rubinstein, who was involved in the University of Manitoba study.
Dr. Robert Slinger of the Children's Hospital of Eastern Ontario believes the cause of the vast majority of diarrheal infections in Canada's northern aboriginal communities goes undiagnosed.
Hulsbosch said she hasn't seen shigellosis in Garden Hill for a few years -- perhaps evidence that getting running water to two-thirds of that community's homes in recent years is starting to pay off.
Josephine Harper works at the St. Theresa Point health station, but she can't prevent her grandchildren from getting rashes because at home, there's no running water.
People living in areas with less water service end up in hospital with skin infections more often than those with an adequate water supply, according to the Alaska study.
Health professionals say impetigo is a common problem in Island Lake children. The contagious bacterial infection causes fluid-filled skin blisters that rupture. Clusters of small sores must be treated with antibiotics because the bacteria sometimes infect tissue under the skin and even the blood, at which point it can become life-threatening. Impetigo can also lead to kidney problems down the road.
"Soap and water has a huge impact on it, but if you don't clear it up, it can cause you major problems," a northern nurse said. "You treat small sores seriously because down the road, you don't know if these kids are going to have kidney disease."
Hulsbosch said Island Lake families who spend time in Winnipeg sometimes find that something as simple as swimming in a chlorinated hotel pool helps clear up skin problems hard to manage at home without running water.
Red Sucker Lake resident Annie Dan thinks the stomach cancer that killed her husband came from drinking lake water.
It's not out of the question.
A study published in 1999 about Wasagamack, another Island Lake region community, reported 95 per cent of adults had been exposed to the H. pylori bacteria that cause ulcers and increase the risk of stomach cancer. The authors speculated that lake water might have been a reservoir for the bacteria, which would get into the water through untreated sewage.
Further research in Wasagamack revealed that children who lived in homes with toilet pails were more likely to test positive for H. pylori than those with outhouses.
A working group looking into high rates of H. pylori in the Canadian Arctic will investigate, among other things, whether the source of drinking water is a factor.
Dan still drinks lake water, even though she blames it for bouts of vomiting and diarrhea, because the community tap that dispenses treated drinking water is too far away.
"We need running water here," she said. "I hope some day I'll see it."
Blood samples collected in Wasagamack in 1999 showed 95 per cent of residents had been exposed to the hepatitis A virus, which causes liver infection and is spread by contaminated water or food.
Most people in developing countries pick up the virus as children and the same held true in Wasagamack, the researchers found.
A study in the early 1990s of hepatitis A outbreaks in northern Manitoba found people living in homes without running water were more than three times as likely to contract the virus. The majority of the more than 600 cases of hepatitis A during a two-year period involved First Nations children.
"Consultation is underway to ensure the provision of a clean, abundant water supply in these communities," Manitoba's 1995 State of the Environment report said optimistically.
Many northern Manitoba First Nations have made progress on water and sewer services in the last 15 years, but Island Lake's four First Nations are still waiting for their "abundant water supply."
Some doctors argue that children living on northern Manitoba reserves should be vaccinated against hepatitis A, which is not part of standard childhood vaccinations in the province. In Saskatchewan, children living in northern health regions or on reserves can get the vaccination for free.
Poffenroth said it would be hard to justify widespread vaccination when there hasn't been a hepatitis A outbreak in more than 10 years.
However, Martin is not convinced the outbreaks are over. "I have no inner confidence this is a bygone era."
In places where kids pick up the virus at an early age when it's unlikely to make them sick, they become immune and don't need to be vaccinated.
But now that half of Island Lake homes have running water, the communities could have a potentially dangerous combination: half the residents immune and half not.
"You've got half of the community in the developing world and half in the developed world, so some people reach adulthood without immunity to hepatitis A and then they get infected in their community as adults. People get sicker as adults and they can even die," Orr said.
ORAL HEALTH AND OBESITY
Health professionals in Pikangikum First Nation, Ont., where about 95 per cent of homes have no piped water or sewage disposal, noted in 2006 that lack of water for brushing teeth was leading to tooth decay and gum infections.
That's also a problem when it's easier to store cases of pop for months than haul buckets of fresh water.
While Rose and Geordie Rae of St. Theresa Point explained how hard it is to get drinking water when their vehicle isn't working, their kids wandered around the yard sucking back cans of pop.
"When it's more expensive to put a glass of water on your table than a glass of Coke, and easier than boiling water, you can be sure that's why teeth decay and increasing obesity is what it is, because these kids more often drink sodas than they do a glass of clean water," said a doctor who works with First Nations.
Obesity exacerbates diabetes, so the water issue could be one factor explaining why the Island Lake area has the highest diabetes rate in Manitoba.
Island Lake residents carry and store their water in a motley collection of containers never meant for drinking water -- including used hydraulic oil buckets.
In Wasagamack, it's common to line water pails with plastic garbage bags that can be tied off to prevent the water spilling while driving over rutted dirt roads. Resident Jesse Harper worries that the plastic might break down into chemicals that will poison her kids.
People are also at risk from bacteria and mould that grow inside the containers if they're not cleaned regularly with bleach -- and then rinsed out again with precious scarce water.
Dr. Martin believes the most harmful health effects of living without running water stem from disparity.
"I can't imagine what impact it would have on my children... knowing that they were significantly disadvantaged in what even my seven-year-old would say is a necessity of life."
The associate dean of medicine at U of M said hauling water steals time that could be spent on more meaningful activity.
"If I were to take a half an hour out of my day to gather water, that's likely a half an hour away from... the important things in terms of interaction with each other, and particularly children."
Canadian public health researchers are world leaders in recognizing that people who grow up socially disadvantaged are more likely to become sick and die prematurely.
The Ottawa Charter for Health Promotion -- drafted in 1986 and quoted ever since by health workers around the globe -- states that the fundamental conditions for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Clean water, like clean air, was perhaps too basic to human life for the authors to think they had to mention it.
These stories were partially funded by a journalism award from the Canadian Institutes of Health Research.
April 16, 2010:
The Free Press asks Health Canada for results of its investigation following the 2009 H1N1 flu outbreak in Island Lake.
Health Canada says "all information regarding epidemiological reports needs to be directed to the Public Health Agency of Canada."
The Public Health Agency of Canada suggests the Island Lake flu report belongs to Manitoba Health.
Manitoba Health says the study was conducted by Health Canada. The Free Press again requests a copy from Health Canada.
Health Canada admits "an epidemiological report was developed for Health Canada, however it is a working document that contains confidential medical information and therefore cannot be shared with the public." The Free Press requests a copy of the report with identifying information removed.
Health Canada says the Free Press "may wish to request a copy of the document through Health Canada's access to information and privacy office, which has the role of ensuring that information released by the department respects the Privacy Act and other applicable statutes."
The Free Press mails a formal access request for a copy of the report, specifying that it should first be edited to remove anything that might identify individual patients.
The Free Press receives a letter stating that the request is denied on the basis that the report contains personal information and is due to be published within 90 days of the Free Press's access request.
The Free Press asks Health Canada for names of the report's authors, so they can be asked about a publication date and interviewed about the impact insufficient water in Island Lake homes had on the H1N1 flu outbreak.
Health Canada refuses to disclose the authors' names, saying "any requests for detailed information about this report should be directed through the access to information request process."
The 90-day deadline for release of the report passes, without it having been published.
Health Canada says the report has been submitted to the Canadian Journal of Public Health. "The report cannot be released at this moment because if the report is in the public, the journal will refuse its publication," wrote Health Canada's access adviser. The journal informs the Free Press that it has only recently received the article and, if accepted for publication, it would not appear in print for another year. The Free Press complains to the federal information commissioner that Health Canada appears to be violating the Access to Information Act.
"No further information regarding this file will be released prior to publication," confirms Dr. Linda Poffenroth, director of health protection for First Nations and Inuit Health, refusing to even reveal the name of the principal author.