text: For many people, the first weeks of the pandemic must have felt like being catapulted into the air, then crashing down, with no safety net in sight. For some, this feeling stretched into months, an endless sense of being Alice in Wonderland, tumbling through infinite strangeness, never once landing. Even worse, they may have looked up as they plunged and seen others cradled in safety: a woven lattice of family, government support, a job, their own savings. It's tempting to blame COVID-19 for this free-falling, but the pandemic only exacerbated inequalities that already existed—snipping the last strings of an already-fraying net. The truth is, a lot of people who felt the worst effects of the pandemic never had much of a net in the first place. Public health messaging around "flattening the curve" urged people to retreat inside. And it worked—but only for the whitest, richest neighbourhoods. For others, it made only slight or no impact. Within the first few months of Canada's national lockdown, what little data there was revealed that in Ontario the rates of infection and death were significantly higher in the province's most ethnically and culturally diverse neighbourhoods. Compared to the least diverse areas, the rate of hospitalization there was four times higher and the rate of death was twice as high. In addition, Toronto discovered that newcomers and those living below the poverty line had higher case and hospitalization rates. Such dismal patterns were echoed in other cities. Contrary to the popular refrain, we were not, it appeared, "all in this together."
  
  The disproportionate statistics make an awful kind of sense. People who live in marginalized and lower-income neighbourhoods often did not have the luxury of working from home. They left their houses every day, risking exposure, because they couldn't afford not to. In particular, racialized women and immigrants made up a lopsided share of those on the front lines, underscoring a long-known wage inequity—they were those who had to keep showing up for work, in large part because they never earned enough money in the first place. When you're making sixty-two cents for every dollar a white man is paid, it's hard, if not impossible, to build an income cushion. Add to that a history of inadequate access to health care, fuelled by a woefully racist medical system, and the reasons behind the disparities become even starker. To afford housing, many lower-income families also live together in smaller dwellings, while others are crammed into crowded apartments and public housing, all places where the virus is at its greediest. And yet, such families still may have fared better than those who were precariously underhoused or homeless during the pandemic. After all, it's also exceedingly difficult to follow the "Stay Home, Save Lives" mantra when you have no home to go to.
  
  Not only was it harder for such people to access hygiene prevention tools, but social distancing meant many shelters were not able to operate anywhere near their usual capacity, even as need increased—in May, one shelter went from handing out three or four hundred meals a week to well over six hundred. It certainly didn't help that people who are homeless tend to have a higher prevalence of chronic health conditions, including heart disease, liver disease, and respiratory issues. Plenty of them are also over sixty-five, the age at which COVID-19 health outcomes become more perilous, more grim. All across the country, many of the services vulnerable populations relied on, including safe consumption sites, day programs, and food banks, were temporarily or permanently shuttered. Fentanyl overdose deaths rose, and many shelters, including those who serve youth, reported being unable to access health care for those who were symptomatic. As the crisis wore on, some cities rented shuttered hotels to help house street-involved populations. In Toronto, a cluster of those hotels were located in the city's higher-income neighbourhoods; protestors rallied to denounce the "criminal element."
  
  Lucy Doan is a nurse practitioner in Toronto. In March, she was midway through a one-year fellowship sponsored by the Medical Psychiatry Alliance. The program is designed to provide better care to people in Ontario who suffer from co-morbid physical and mental health illnesses—two streams of care that are typically, and often disastrously, separated. For the year, Doan rotated through different placements, gleaning all she could about how to give better care. During COVID-19, much of her patient population was racialized, low-income, and living in public housing or relying on the shelter system (or, as the pandemic grew, the expanding tent cities). They may have a diagnosed mental illness such as schizophrenia or may be using antipsychotic medication while also suffering from concurrent chronic illnesses, such as heart disease or asthma. They may also be engaged in substance abuse. In normal times, it's already a vulnerable group that does not usually get the care it needs, she explained. But as spring and silence settled over the city, the situation got even worse. "For the general population, it was like 'Oh my God, it's so awesome that GPs are switching to telemedicine, so care is still accessible and doctors don't have to see you in person," said Doan. "But many of our patients don't have homes. They barely have an income—let alone a cellphone or the capacity to access that kind of care. It seemed like the entire population was an afterthought."
  
  She was supposed to stay at her then-current workplace for three months. That tipped into five, putting her on the healthcare front lines of the pandemic everyone seemed to forget. At the start of it all, she matter-of-factly accepted that she would likely contract the virus. She was less worried for herself, though, than she was about becoming an asymptomatic carrier and transporting the virus from place to place like a bad housewarming gift. She knew her clients already had a low baseline of health, and she knew that they'd have a much tougher time accessing care—and worse outcomes—if they did contract COVID-19. The pandemic had destabilized already-shaky ground: some patients battled paranoid delusions, and if they did start exhibiting symptoms, they and many others might also fear going to the hospital. Many such patients also feel stigmatized by the traditional healthcare system. Distrust ran high. Plus, unlike in a hospital, where every patient is treated in a quarantined, vigorously sanitized room and PPE is donned and doffed in crucially sterile settings, the home calls Doan was making required that she dip in and out of poorly maintained and rundown buildings and shelters. She left her own gear on her porch each evening, tied in a garbage bag, and dashed into her house yelling to her husband, "Don't touch me!" She didn't go to the grocery store for months. Risk crackled the air around her.
  
  One day in April (she thinks; everything blended together) Doan changed into her PPE in a creepy downtown alleyway beside a dumpster. A nice, older woman ambled over to chat with Doan and her fellow nurse; they had to frantically ask her to keep two metres' distance. It felt to Doan like she was watching her life from far away, on TV. She made a lot of less-than-ideal wardrobe changes like that, adjusting her armour outside in public spaces before entering high-density buildings. She knew it wasn't proper protocol, but she doused her hands in portable sanitizer and accepted that it was the best she could do. On that particular day, she was making a house call to a woman with a rash. Many of her patients have chronic illnesses that are never addressed and they can be poor historians of their own health, so Doan tries to make as many in-person visits as she can—a seemingly benign symptom can easily be something else. And in this case, it was. Looking at the woman's chart, she realized she had untreated heart failure. After some detective work (a common part of her job), Doan discovered the woman had a GP whom she refused to see. She called the GP and, to her surprise, he also agreed to do a home visit to the woman; he'd been worried about her, too. A few days later, he called Doan to tell her that, when he arrived, the woman's oxygen saturation had dipped to the low eighties. A healthy person is at 92 per cent and above. She was admitted into the ICU and intubated for several weeks. Without intervention, her body would have begun to slowly shut down.
  
  Cases like this haunted Doan throughout the early months of 2020. "What would the outcome have been if I never saw her in person for some rash, never contacted the GP, and he never saw her?" she wondered, even though she already knew the answer. "She would have been dead." She had heard of at least one separate case in which a COVID-positive person who lived in a shelter wasn't intubated at all—if he were someone else, would he have been? She herself had spent one sweltering day, sweating a river through her PPE in an unairconditioned room, trying for nearly two hours to convince a patient to go to the ER. But for every person she caught, how many others slipped through? The helplessness of it all could eat at her. In the public outpouring of gratitude for workers, Doan saw far fewer people delivering free meals and coffee for the nurses and social workers caring for the homeless, thanking them; patients and workers alike were swept under. Doan has never been much of a drinker, and the pandemic didn't turn her into one, but she had also never before finished every shift with a drink, either. She never had more than one drink a day, yet it still felt like a drastic change. She also rented a spin bike and began to exercise constantly. Both distractions numbed her in their own ways.