Emma Finlayson-Trick is a second-year medical student at the University of British Columbia (UBC) and holds a MSc in microbiology and immunology from Dalhousie University. Her interests include infectious diseases, medical microbiology, and science communication. Recently, Emma completed a summer interning with the B.C. Patient Safety and Quality Council where she investigated the cognitive barriers to hand hygiene amongst healthcare staff in a local emergency department. Emma is the senior co-editor-in-chief for the UBC Medical Journal and leads the microbiome analysis for a project examining the effects of iron supplementation on gut health in Cambodia. She is also currently organizing Vancouver’s first Soapbox Science event to promote the visibility of women in science, technology, engineering, and mathematics. Emma is eagerly pursuing a career as an infectious disease specialist with an interest in medical policy and governance.

“This past year I was placed in a family practice clinic where many of the patients had experiences with homelessness. In speaking with these individuals, I became acutely aware of how much time and energy they devoted to accessing resources, such as shelter, food, and healthcare. Following these interactions, I found myself wanting to help improve homeless health and wellbeing, but I was daunted by such a broad and complex area of care. Fast forward a few months and the COVID-19 pandemic hit. While I was quickly pulled from clinical experiences to protect my own health, I was reminded of the homeless patients from clinic and I worried about how they would manage to advocate for their needs during a pandemic. As I learned more about the lack of pandemic planning in regards to homelessness I became inspired to write this policy proposal.”

The last two decades have been punctuated with pandemics (SARS, H1N1, Zika, and COVID-19) that have jeopardized the health and safety of people around the world. To mitigate the impact of future pandemics, countries rely on pandemic planning. A key component of planning is recognizing vulnerable populations—children, pregnant women, the elderly, and people with chronic conditions are most commonly noted—and implementing strategies to reduce their risk of infection. While homeless people have historically been left out of pandemic planning, they too represent a vulnerable population. Homeless people are diverse, and they experience multiple health challenges including poorer health outcomes, inadequate nutrition, and barriers to accessing healthcare and stable housing [1]. Furthermore, they are at a greater risk of contracting infectious diseases as they are required to survive in overcrowded environments and do not have the luxury of social distancing or “staying home” during a pandemic [2]. It is for these reasons, and many more, that homelessness poses unique challenges to pandemic planning. Nevertheless, pandemic preparedness is a collective responsibility that involves not only government and community agencies, but also empowered citizens [3]. Homeless people, like anyone else, need to be equipped to help themselves and others during a pandemic.

Several pathogens have the potential to cause pandemics, however, due to the unpredictable yet recurring nature of influenza, the World Health Organization specifically advocates for national pandemic influenza planning [4]. Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP) is the only federal guidance document in Canada to support provincial and territorial pandemic planning [5]. Last updated in 2018, CPIP emphasizes that pandemic plans need to be equitable and fair, so decision makers are encouraged to “take health inequities into account and try to minimize them, rather than make them worse” [5]. Furthermore, CPIP recognizes that vulnerable populations “might become more marginalized if pandemic health services are streamlined into standard approaches to reach the general population” [5]. As such, provincial and territorial pandemic influenza plans are meant to address the requirements of local populations by guiding pandemic planning for organizations and health authorities. While the majority of plans focus strictly on influenza, CPIP and plans from British Columbia (B.C.) and New Brunswick (N.B.) state that they can be applied to other public health emergencies.

Following SARS and H1N1, researchers spoke with homeless populations and frontline workers across Canada to identify areas of pandemic planning in need of improvement [3],[6]. Notably, many of the same concerns were identified following both SARS and H1N1. These concerns fall into three main areas: communication, infection prevention and control, and system capacity. Seeing as very few steps have been taken to address these concerns in current provincial and territorial pandemic plans, there is clearly still a need for improvement [3]. If provinces and territories want pandemic plans that are equitable and fair, the needs of all vulnerable populations have to be considered. This proposal seeks to begin a conversation about how pandemic planning policy can better support those experiencing homelessness. The recommendations below attempt to address some of the inequalities that exacerbate the marginalization experienced by homeless populations during a pandemic.

The proposed actions for provincial pandemic plans (PPPs) are inspired by observations made from SARS, H1N1, and COVID-19.

1. Update PPPs to reflect past experiences and ongoing research.
   Despite intentions, PPPs are not regularly updated to reflect current knowledge and best practises. The B.C. plan, for instance, states that it will be revised every two years, but has not been updated since 2012. Moreover, there are still several plans — Quebec, Manitoba, N.B.— that have not been updated to reflect the lessons learned from the 2009 H1N1 pandemic [7]-[9]. As no plan has been updated since 2016, when a major study on homelessness and H1N1 was published, it is not surprising that Canada’s homeless population remains largely invisible in PPPs [3]. Ontario is the only province to currently provide homeless-specific guidelines [10].I propose the following three recommendations to keep information up-to-date in PPPs and to improve the transparency of the planning process. Firstly, within each provincial Ministry of Health there should be a Provincial Pandemic Planning Committee (PPPC) dedicated to updating pandemic plans on a regular basis. The PPPCs would also be responsible for meeting with stakeholders, such as homeless citizens, to hear their concerns. Secondly, every CPIP update should be sent to the PPPCs so that they can make appropriate changes to the PPPs. Thirdly, PPPs should be accessible to the public through the “Pandemic Plan” page on the Government of Canada website so that stakeholders can see how their input is incorporated. Currently, only five plans are accessible through the website: Alberta, Manitoba, Ontario, Quebec, and N.B. [11].
2. Include housing for homeless in PPPs.
   The Canadian response to homelessness, especially during a pandemic, does not adequately address the social (and broader structural) determinants of health. Pandemics have highlighted how congregate settings – for example prisons (which have important ties to the homeless population) – can escalate community spread of an infection [12]. Regardless of whether there is a pandemic, affordable housing is a global strategy used to prevent homelessness by limiting the time people spend on the street and in crowded shelters [3]. During a pandemic affordable housing has the added benefit of enabling homeless people to take control of their own pandemic response as the majority of public health guidelines are geared towards those with a home. I propose that PPPCs work with provincial housing to establish guidelines for the homeless to enable rapid and effective control of transmission. During COVID-19, the B.C. Government partnered with non-profits and municipalities to allocate hotel and community center spaces in Vancouver and Victoria to homeless people [13]. This action should set a precedent for including homeless housing in PPPs.
3. Include guidelines for safe consumption and overdose prevention sites in PPPs.
   Guidelines for safe consumption and overdose prevention sites, which offer evidence-based harm reduction services, are missing from every PPP. I propose that PPPCs meet with front-line workers and site users to assess how to include these life-saving services into PPPs. COVID-19 has highlighted how important it is to include these sites in planning. Since March, major cities such as Vancouver have noted increases in overdose-related deaths [14]. These sites have been stretched to increase infection prevention and control measures while still serving a large number of people. Moreover, there are reports that many substances have become more toxic during COVID-19 putting further demands on these sites [15]. In response, the B.C. Government has moved towards a ‘safe supply’ of prescription opioids [15]. In order to live up to the mandate of CPIP, provinces need plans that seek to improve, rather than exacerbate, the health disparities in Canada.