Posts Tagged 'society'

Web refuseniks as second-class citizens: librarians can only do so much for the offline classes

People who don’t want to – or simply can’t – be part of the digital world are being subjected to bullying tactics.The NHS is not alone in disenfranchising, tormenting or otherwise penalising citizens who, living offline, are already defined as excluded. Employers, too, demand that job applications be submitted online; banks and shops, travel, insurance and energy companies save competitive products for online customers; even councils demand applications for social housing be made, exclusively, online.

Britain’s millions of refuseniks seem to be surviving. In public spaces all round the country, librarians help the offline classes to fill long, complicated forms with pieces of sensitive personal information. How long have they been unemployed? Have they ever been in trouble? Any problems with neighbours? Need help? For that you will need an internet address, ask your librarian.

Want to complain to someone about your new, digital designation as a second-class citizen? Tough, losers: you can only do that online.

Catherine Bennett. If you’re not online these days you’re a second-class citizen. “Comment Is Free” The Guardian, Sunday 16 May 2010

cc licensed flickr photo by sp3ccylad

Will Smitherman clean up Toronto’s soggy bottom? The man with the incontinence product runs for mayor

The Globe and Mail reported today on the official entry of George Smitherman into the race for mayor of Toronto.

A former health minister and deputy premier, Smitherman is renowned for much more than merely having been Ontario’s first openly gay MPP. Over the years the aggressive politician dubbed “Furious George” left a trail of arched eyebrows and stares of incredulity as he blundered into modest notoriety.

Two years ago, in what will surely be remembered as the nadir of his public career, Smitherman demonstrated appalling, cringe-making insensitivity as he made a bad mess worse in responding to criticism of the treatment of the elderly in the province’s largely private nursing homes. He told the media that he was prepared to don an adult diaper — and use it — to justify his government’s policies. Not surprisingly, this deranged outburst did not sit well with an outraged public.

The criticisms Smitherman’s health ministry received were justified. The Ontario Association of Non-Profit Homes and Services for Seniors claimed that seniors in nursing homes should be getting at least three hours of personal care; it said the average in the province is about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, called for a standard of 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, 2008, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn’t only critics of the Liberal government who were angry. There were loud calls for the minister’s resignation, even within his own caucus.

Wags and cynics sharpened their quills. In March the National Post published an imaginary Smitherman diary entry, with entries like this:

Major confession, diary. I tried out an incontinence diaper today. It was so … freeing. I had three large coffees … and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won’t make that mistake again! I think this will really help in my discussion with the nurses’ union. Five hours seems to be the limit before things get a little soggy. I think I’ll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Of course, an apology followed immediately. “I wasn’t trivializing the matter,” Smitherman said. “I take it really, really seriously.” The minister could not be reached for comment for a long time after that; but his “diary” entry gives us some insight into why:

After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper “stunt.” I explained that I only thought it would gain a better understanding of the issue, but he wouldn’t listen. “Also, George,” he said, “please tell me you weren’t wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift.” I told him my cellphone was cutting out and I hung up.

Sam Solomon, writing in his blog Canadian Medicine, addsed that this wasn’t the first time that “Furious George” has run off at the mouth:

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as “Taj Ma-hospitals.”Another classic outburst was featured on Stephen Colbert’s American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists “a bunch of terrorists, and I don’t negotiate with terrorists.” “Bravo, sir,” Mr Colbert said. “Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs.”

During the “incontinence product” controversy in 2008 Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE’s Ontario chapter, who said the minister completely missed the point. The problem wasn’t the products, but the cruel reality that residents in long-term care facilities were forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario’s health minister possibly be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should have tried absorbing some of those important statistics and the advice of experts. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.

From here is a a taste of what to expect when Smitherman hits the Toronto campaign trail – a few Diaper George gems:

On announcing his candidacy intent: “A native son is coming home to serve.”

On wearing adult diapers to ensure nursing home residents are getting adequate care: “I’ve got one of these incontinence products … on my desk and I’m really giving this matter very serious contemplation.”

On controversial energy audits for homebuyers: “They taught me in some Grade 10 course — which was almost at the end of my stream of education — the notion of caveat emptor, buyer beware.”

On music: “I’ve been working out to the new Whitney Houston. I’m a gay man, so I love Whitney.”

On working with others: “Nobody should associate me with the status quo.”


1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.

Addiction and poverty of the spirit

In a consumer society there are inevitably two kinds of slaves: the prisoners of addiction and the prisoners of envy. ~ Ivan Illich, Tools for Conviviality (1973)

I am addicted to the twentieth century. ~ Martin Amis, Money (1984)

Two years ago the Conservative Canadian government launched a multi-million dollar National Anti-Drug Strategy, with its predictably punitive crackdown on illicit drugs, mandatory minimum sentences, hectoring propaganda, abstinence-based “treatment,” and police-heavy approach – in short, a classic drug-prohibition stance.

No one questions that drug addiction is a problem, but the Harper government’s dogmatic handling of this complex issue betrays its inability to get at the true roots of substance use and abuse. The resurgent puritanism in Ottawa angers Bruce Alexander, who has recently published a new book, The Globalisation of Addiction: A Study in Poverty of the Spirit (Oxford University Press).

Alexander, a psychologist and Professor Emeritus at Simon Fraser University, believes that addiction is not about sinners in need of salvation, but about the society they live in. “The conventional wisdom depicts addiction most fundamentally as an individual problem,” he writes. “Some individuals become addicted and others do not. An individual who becomes addicted must somehow be restored to normalcy.”

The government’s dogmatic thinking fails to recognize that a problem as terrifying as addiction has its roots in the kind of fragmentation that is inevitably produced by free-market economics. The solemn press conferences and media images of frowning officials in dark suits or uniforms simply repackage and reinforce the old idea that the reason we have people who aren’t behaving properly is drugs – that drugs have a magical quality of taking over human beings who would otherwise be normal smiling happy people shopping at Wal-Mart.

The Globalisation of Addiction presents a radical reappraisal of the nature of addiction, which science and sermons have failed to manage. There are no reliable methods to cure it, prevent it, or take the pain out of it. There is no durable consensus on what addiction is, what causes it, or what should be done about it. Meanwhile, it continues to increase around the world.

Addicts are people struggling to adapt to and deal with difficult psychological and social circumstances. Viewing addictions of all kinds as adaptive responses to dislocation seems odd at first, for we have been taught to view addiction superstitiously as some kind of malevolent entity taking over the soul. But understanding addiction not as “possession” but as an adaptation makes the phenomenon both more comprehensible and more familiar, and is ultimately a deeply sympathetic and humane perspective. It is also a hopeful one, offering a variety of options that can help addicted individuals find social integration and therefore happier lives.

Alexander argues that the failure to control addiction can be traced back to the conventional wisdom of the 19th and 20th centuries which focused too single-mindedly on the afflicted addict. Although addiction obviously manifests itself in individual cases, its prevalence differs dramatically among societies. For example, it can be quite rare in a society for centuries, and then become common when a traditional culture is destroyed or a highly developed civilization collapses. When addiction becomes commonplace in a society, people become enslaved not only to alcohol and drugs, but to a thousand other destructive pursuits: money, power, dysfunctional relationships, gambling, or computer games.

A social perspective on addiction does not deny individual differences in vulnerability to addiction, but it removes them from the foreground of attention, because social determinants are the more influential factor. This book shows that the social circumstances that spread addiction in a conquered people or a declining civilization are also built into today’s globalizing free-market society. Capitalism is magnificently productive, but it subjects people to irresistible pressures towards individualism and competition, tearing rich and poor alike from the close social and spiritual ties that normally constitute human life. Alexander calls this a “worldwide rendering of the social fabric.” People adapt to their alienation or dislocation by finding the best substitutes for a sustaining social and spiritual life that they can, and addiction serves this function all too well.

The most effective response to a growing addiction problem is a social and political one, rather than an individual one. Because addiction is an individual and social response to “dislocation” – especially severe social, economic, and cultural dislocation – the solution is “psychosocial integration.”

“People can endure dislocation for a time. However, severe, prolonged dislocation eventually leads to unbearable despair, shame, emotional anguish, boredom and bewilderment. It regularly precipitates suicide and less direct forms of self-destruction. This is why forced dislocation, in the form of ostracism, excommunication, exile, and solitary confinement, has been a dreaded punishment from ancient times until the present.”
“Material poverty frequently accompanies dislocation, but they are definitely not the same thing. Although material poverty can crush the spirit of isolated individuals and families, it can be borne with dignity by people who face it together as an integrated society. On the other hand, people who have lost their psychosocial integration are demoralized and degraded even if they are not materially poor. Neither food, nor shelter, nor the attainment of wealth can restore them to well-being. Only psychosocial integration itself can do that. In contrast to material poverty, dislocation could be called ‘poverty of the spirit’.”

Overcoming poverty of the spirit through such integration would not put physicians, psychologists, social workers, policemen, and priests out of work, but it would incorporate their practices in a larger social project to reshape society with enough force and imagination to enable people to find social connectedness and meaning in everyday life. Then great numbers of them would not need to fill their inner void with addictions.

So far, governments have chosen to ignore Alexander’s analysis, which was first introduced in his much-read 2001 paper The roots of addiction in free market society. Not surprising in a nation that is rapidly moving to the right and busy squandering its treasury on unwise stimulus spending and war-making.


Alexander BK. The globalisation of addiction: a study in poverty of the spirit. Oxford University Press; 2008. ISBN 978-0-19-923012-9.

Alexander BK. The roots of addiction in free market society. Ottawa: Canadian Centre for Policy Alternatives; 2001. Available from:

Levine HG. Review of “The globalisation of addiction: a study in the poverty of the spirit” by Bruce K. Alexander. Harm Reduct J. 2009; 6: 12. Published online 2009 June 23. doi: 10.1186/1477-7517-6-12. Available from:

Hard-to-reach, hard to research

From a public health perspective, who are the hard-to-reach and how can we find research articles about them?

I was asked this question by a manager in the Winnipeg Regional Health Authority. He was looking for research specifically on immunization programs for the hard-to-reach as part of the WRHA’s ongoing preparation for the expected H1N1 epidemic. In order to assist my client, how was I to construct a search strategy in PubMed and other databases that would gather disparate materials together without a comprehensive catch-all subject heading?

Finding appropriate literature is just one of many challenges associated with conducting research on hard-to-reach populations. In the first place, how do we identify and sample certain groups of individuals for health research? Undoubtedly some populations are particularly vulnerable and difficult to contact. Other populations may be defined by characteristics such as ethnicity or sexual preference that are not recorded in routinely available data sources. Yet while the need for research on the hard-to-reach is pressing, a comprehensive definition of this population is lacking, and hence it is difficult to get one’s bearings.

Before creating my search strategy, I had to do some research of my own in order to get a handle on exactly the groups that I would be investigating.

Defining the hard-to-reach

What exactly is meant by ‘hard-to-reach’ is a matter of some debate. The term is inconsistently applied. It will sometimes be used to refer to minority groups, such as immigrants, LGBT people, or the homeless; it can be used to refer to ‘hidden populations’, groups of people who do not wish to be found or contacted, such as illegal drug users or gang members; at other times it may refer to broader segments of the population, such as the elderly, or young people, or people with disabilities. In the service context, hard-to-reach often refers to the underserved, certain minority groups, those slipping through the social safety net, and those who are deemed to be ‘service resistant’.

Yet another term used in this context is ‘hidden populations’, meaning those who are hidden from the point of view of research sampling. Hidden populations may also actively seek to conceal their group identity, as for example in the case of sniffers, injection drug users, LGBT people who are in the closet, sexually active teens, etc.

The hard-to-reach are also called the ‘seldom heard’. The use of this term indicates that these are people who do not have a collective voice and are often under-represented in consultation and involvement activities about developing services. ‘Hard-to-reach’ suggests that there is something that prevents their engagement with services. ‘Seldom heard’ emphasizes the responsibility of agencies to reach out to excluded people, ensuring that they have access to social care services and that their voices can be heard.

One of the chief difficulties in defining the hard-to-reach is the unintentional imputation of a homogeneity among distinct groups that does not necessarily exist. Or it may imply that the problem is one within the group itself and not within the approach. Attempts at categorization can have a stigmatizing effect. Hard-to-reach audiences have, with varying degrees of prejudice, been called obstinate, recalcitrant, chronically uninformed, disadvantaged, have-not, illiterate, dysfunctional, and information poor.

Associative and Nonassociative

In addition to these various ways to categorize the hard-to-reach, we can distinguish between ‘associative’ hard-to-reach populations, such as people at risk of AIDS, and ‘nonassociative’ hard-to-reach populations: those whose members do not normally have contact with other members.

Nonassociative populations share two primary characteristics. The first is demographic. There is no effective centralized information about them, and a large proportion of their members do not know each other. The second is that their members share characteristics or attributes that make it important for health and human services to have information about them to inform service planning, policy, and delivery. In addition to these features, they are often low-frequency populations, and they might be subject to stigma of various kinds.

There has been a large amount of research on associative hard-to-reach populations, those whose members are socially networked with each other and form a community (with literally thousands of studies being done on populations at risk of HIV and AIDS, such as injection drug users) – but there have been very few rigorous studies of nonassociative populations, particularly those that are less in the public eye, such as shut-ins.

The central focus of my search strategy was to gather together information precisely on these nonassociative populations. I was looking for groups defined by individual attributes (such as health or social status) where there is often no overriding reason for within-population socializing and where a substantial proportion of population members do not have strong social links with other members and, indeed, might even resist such contact. These hard-to-reach groups must be taken into account in immunization planning. No effective H1N1 prevention strategy can exclude them.

After much effort I decided to include the following in my search strategy:

  1. The homeless, the marginally housed, street people, and sex trade workers
  2. Shelter residents (including women and youth)
  3. Inmates in the correctional system (the incarcerated, parolees, the recently released, and those in half-way homes)
  4. Persons with serious and persistent mental health issues, including dementia or addiction
  5. Housebound persons (cystic fibrosis, arthritis), shut-ins, and the disabled
  6. The linguistically isolated (people with communication impairments, recent immigrants who are not fluent in English or French)
  7. Selected recipients of Family Services and Housing (employment income assistance, government housing, children in care)
  8. Miscellaneous nonassociative groups (transients, the uninsured, the socially isolated)

PubMed Search Strategy

Here, finally, is the strategy I employed for my PubMed search:

(“Immunization”[MAJR] OR vaccinat*[TI] OR immuniz*[TI] OR immunis*[TI] OR “Immunization Programs”[MAJR] OR “Immunization Schedule”[MAJR] OR “Influenza, Human/prevention and control”[MAJR] OR “unvaccinated population”)


(hard-to-reach OR “seldom heard” OR “hidden population” OR “hidden populations” OR homeless OR homelessness OR  “Homeless Persons”[MAJR] OR “Transients and Migrants”[MAJR] OR “Housing”[MAJR] OR “Prostitution”[MAJR] OR “sex trade workers” OR migrant OR vagrants OR “street worker” OR “street workers” OR “street people” OR “street youth” OR “street kids” OR “street children” OR “street involved” OR “unstable housing” OR shelters OR “shelter residents” OR (marginally[TIAB] AND housed[TIAB]) OR under-housed OR “marginalized population” OR “marginalized populations”

OR “Emigrants and Immigrants”[MAJR] OR “Refugees”[MAJR] OR “recent immigrants” OR “recent immigrant” OR “undocumented immigrant” OR “undocumented immigrants” OR “illegal immigrant” OR “illegal immigrants” OR emigres

OR “Vulnerable Populations”[MAJR] OR “Poverty”[MAJR] OR “Poverty Areas”[MH] OR “Social Class”[MH] OR “Socioeconomic Factors”[MH] OR “Urban Population”[MH] OR welfare OR underserved OR “underserved areas” OR “high-risk inner-city” OR socially-at-risk OR “at-risk population” OR “at-risk populations” OR slum OR slums OR ghetto OR ghettos OR favela OR favelas OR “low-socio-economic” OR disadvantaged OR low-income OR impoverished OR uninsured OR underinsured

OR “Prisoners”[MAJR] OR “Prisons”[MAJR] OR incarcerated OR incarceration OR “corrections facility” OR “correctional facilities” OR  “correctional population” OR prisoners OR probation OR probationers OR probationary OR parole OR parolees OR inmates OR “half-way house” OR “half-way houses”

OR “Drug Users”[MAJR] OR “Substance Abuse, Intravenous/psychology”[MAJR] OR “drug users” OR addicts OR addicted OR “drug addicts” OR “substance abuser” OR “substance abusers”

OR deaf[TIAB] OR “Hearing Impaired Persons”[MAJR] OR “Social Isolation”[MAJR] OR “low literacy” OR “language isolated” OR (linguistically[TIAB] AND isolated[TIAB]) OR homebound OR shut-in OR shut-ins OR “disabled persons”[MH]

OR “Mentally Ill Persons”[MAJR] OR “mentally ill”)


1. Brackertz N. Who is hard to reach and why? ISR working paper 2007. SISRQ/EL 06.07Institute for Social Research (Australia) [online]. Available from:

2. Southern DA, Lewis S, Maxwell CJ, Dunn JR, Noseworthy TW, Corbett G, Thomas K, Ghali WA. Sampling ‘hard-to-reach’ populations in health research: yield from a study targeting Americans living in Canada. BMC Med Res Methodol. 2008 Aug 18;8:57. PubMed PMID: 18710574

3. Stewart M, Makwarimba E, Barnfather A, Letourneau N, Neufeld A. Researching reducing health disparities: mixed-methods approaches. Soc Sci Med. 2008 Mar;66(6):1406-17. Epub 2008 Jan 14. PubMed PMID: 18248867.

4. Thompson S, Phillips D. Reaching and engaging hard-to-reach populations with a high proportion of nonassociative members. Qual Health Res. 2007 Nov;17(9):1292-303. PubMed PMID: 17968045.


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