I work in primary care and addiction medicine in inner-city Toronto. Having worked in the ER during SARS, I feel for my colleagues in emergency and critical care medicine. And while my highly respected colleagues see my patients downstream, struggling to breathe, I see the disasters unfolding leading to their inevitable infection with SARS-CoV-2. The writing is on the wall for my patients – it always has been, why would the narrative be any different with the current pandemic?
My days have become different. Long gone are the days spent counselling on the use of naloxone, prescribing curative hepatitis C treatments, and stressing the importance of smoking cessation. That is not what my patients are now willing to hear. It is now all about daily survival – how to evade COVID-19 infection and not die from fentanyl or one of its more deadly analogues. It’s a double-whammy afflicted on the most vulnerable and marginalized in society.
Fentanyl has not lost its grip during this pandemic, and in fact has never had a more devastating hold. I spend hours desperately netsurfing trying to find a coveted COVID-19 vaccine appointment for those most willing. As COVID-19 continues to inequitably devastate those most vulnerable and disenfranchised, the testing and vaccination system in place in Ontario is set up to further disempower those most in need of its services. Why is a certain level of privilege required to navigate a system during a pandemic that has been shown to affect those with the least amount of privilege?
Having no access to internet services themselves, my patients cannot make use of web-based booking. They don’t carry their OHIP cards with them; many haven’t even seen them in years. And most are not likely to wait on hold for hours to either schedule a COVID-19 test or book a vaccination appointment. So, my days are spent assessing for possible COVID-19 symptoms – trying to tease out what is pre-existing COPD and what could be something more.
For those patients in need of COVID-19 testing, it’s inevitably never the same day and never nearby. Few ever make it to their appointments. And can we blame them? How effective is our working memory when faced with daily struggles like food security and precarious housing?
The trajectory is predictable – most never get tested, many unknowingly infect others, and all await their fate in the hope of avoiding hospitalization. Hopefully. Most can eloquently speak of stigmatizing experiences in the very institutions offering testing and vaccinations. But many refuse institutionalized care, fearing the litany of judgements and whisperings that takes place when others think nobody’s listening. They are. They fear substance withdrawal if admitted to hospital and fear the strong hand of the law when wanting to quell that withdrawal. Instead, they wait, wait for symptoms to improve, cling to the hope offered by puffers, and default to the detachment offered by more drugs.
We can serve them better – we are charged with that privilege. COVID-19 testing and vaccine rollout is failing my patients and for the first time I’m feeling helpless and powerless. Paralyzed by a system intent on knowing what is best for my patients. My letters go unanswered, solutions unread. Where are the rapid point-of-care COVID-19 devices that our governments promised? Surely, they would be ideal in this setting? Why are primary care providers, those who have spent their careers establishing therapeutic relationships with their patients, left out of testing and vaccinating their patients in the very offices they attend?
Without on-site testing and vaccinations, I fear what outcomes await my patients. I shudder to think of how my patients will fare under triage guidelines given the severity and extent of their comorbidities and silenced voices.