In October, Dr. Theresa Tam, Chief Public Health Officer of Canada, released her 2020 annual report on the State of Public Health in Canada: From Risk to Resilience: An equity approach to COVID-19. Two new products now available which were developed to support the annual report are What We Heard: Indigenous Peoples & COVID-19 and Best Brains Exchange Proceedings Report: Strengthening the Structural Determinants of Health Post-COVID-19

One of the key findings of Dr. Tam’s report indicated that ”existing health inequities meant that some groups most at risk from COVID-19 were the same populations disproportionately impacted by public health measures…..While the pandemic affects all Canadians, we did not all have access to the same resources and choices before or during the pandemic, leading to different health, social and economic impacts.”

Noting that, “Health equity models which explore the underlying conditions contributing to positive and negative health outcomes can help to clarify how disease can affect groups of people differently.” A framework was created to explore the influence of determinants of health on the differential risk of COVID-19 morbidity and mortality, using previous research on influenza as a basis.

Figure 5. Direct and indirect consequences of COVID-19

The report notes the impact of intersectionality and COVID 19:

There are overlapping and compounding risks related to sex, gender, racialization, income, housing, employment, and other socioeconomic factors. For example, racialization intersects with employment: in Canada, approximately 41% of meat processing workers are members of racialized groups, compared to 21% of the workforce in generalFootnote152. Elevated risk can also be shaped by the intersection of gender and racialization. For example, the vast majority of staff in nursing and residential care facilities, as well as home care, are women, including the majority of nurses' aides, orderlies and client service associates. From 1996 to 2016, the share of immigrants in these occupations grew more quickly than in all other occupations, from 22% to 36%. Of all Canadian workers in these positions in 2016, 31% were immigrant women and the proportions were higher in larger metropolitan areas such as Toronto, Vancouver and Calgary where over 70% of these positions were filled by immigrants, the majority of these immigrant womenFootnote153. Further, 12% of all workers in these occupations were Black and 11% were Filipino despite Black and Filipino workers only making up 3% of workers in all other occupationsFootnote153.

The report explores in detail the impacts of differential exposure, differential susceptibility, and differential treatment in relation to COVID-19, looking at:

·      Exposure at work:

o   Who can and cannot work from home? Educational factors were a key element in this area. More women than men hold jobs which can be done from home, particularly those aged between 35 to 64.

o   How risky is work for those who cannot work from home? “Research found that workers in low-income occupations are working in jobs that put them at greater risk; this is particularly true for women, immigrants, and racialized workers.” The report notes that “workers in precarious employments – jobs outside of the standard employment relationship, meaning not full-time, permanent, and accompanied by benefits – are less likely to have important employment and economic protections, particularly among those who are low-income. The absence of these protections is challenging at any time, but, during a pandemic, the consequences can be more severe and may increase risk of virus exposure and transmission. These disadvantages include economic and employment insecurity, a lack of paid sick leave, and the need to work multiple jobs to make ends meet. For example, these factors were identified as consequential for personal support workers in long-term care homes.” Production-line work, with difficulty in maintaining safe distances from co-workers, such as in meat processing plants, was a factor in a number of outbreaks. “The CDC further noted that workers at meat processing plants may be at greater risk because of additional factors beyond the work environment, including shared transportation to and from work, congregate housing, and high community contact with colleagues.”

·      Exposure at home:

o   Group living facilities (long-term care facilities): The report notes, “Older adults in LTC homes, as well as the healthcare workers who support them, have been seriously and devastatingly impacted.”

o   Group living (group homes): Similar issues occurred in these settings, particularly for individuals requiring personal assistance. The report notes:

o   Group living (shelters): Overcrowding and lack of/shared facilities, ability to wash hands frequently or disinfect surfaces, were noted as particular issues. “In addition, people experiencing homelessness have high rates of chronic physical conditions, heightening the risk of suffering complications if they contract COVID-19.”

o   Migrant workers/temporary foreign workers: Close proximity in living quarters and shared or inadequate bathroom facilities, added to reluctance to report symptoms due to fear of reprisals or economic loss were issues for this group, along with challenges (transport/accessibility/language/familiarity with systems) in accessing medical support.

o   Prisons: Particular issues noted were overcrowding, balancing security and health concerns, withholding of early symptoms to avoid additional restrictions, along with staff working in more than one facility, leading to increased transmission risk. COVID-19 restrictions have led to increased isolation for inmates.

o   Overcrowded housing: This has been an issue in high-concentration population areas, particularly in urban centres. A Massachussetts study examining the social patterns of excess morbidity during the beginning of the pandemic “found that the surge in excess death rates was greater in areas of higher poverty, higher household crowding, higher percentage of populations of color, and higher racialized economic segregation.”

o   Public transportation: While there is no clear research on this as yet, the report notes that “physical distancing in a confined space, the inability to easily screen passengers for illness, and the presence of high-touch surfaces” are potential risk factors.

o   Differential susceptibility: “As of the end of August, 2020, available research data indicated that 86% of hospitalized cases (for which clinical information was recorded) reporting having one or more pre-existing conditions.”

o   Differential treatment: “While universal in principle, access to health care has been identified as a challenge for a number of groups in Canada that may face greater exposure and susceptibility to COVID-19, including populations experiencing homelessness, racialized and Indigenous populations, immigrant populations, migrant workers, temporary foreign workers, people with disabilities, and populations living with low-income. Accessing relevant, meaningful and culturally safe health care is a challenge for many groups who experience stigma and discrimination due to implicit and conscious biases; a lack of respect for and understanding of historic and social determinants that influence health; and stigmatizing organizational cultures.” 

The report discusses how public health measures implemented to stop the spread of COVID-19 have had disproportionate effects on some populations, which may have longer-term implications. Impact areas discussed include:

·      Stigma, discrimination and violence, with increased identification of poorer mental health and discrimination amongst Canadians of East Asian background during the pandemic.

·      Loss of employment/decreased employment, particularly amongst workers in lower-wage jobs. “Emerging evidence suggests that these types of job losses will disproportionately affect women with small children and families since women are largely represented in the service and retail sectors and in the absence of childcare, they will be unable to return to the workforce. One Canadian study reported that women’s participation in the labour force dropped to its lowest in 3 decades and 1.5 women lost their jobs in the first 2 months of the pandemic. As public health restrictions were eased in some provinces in May, there was a recovery of low-wage jobs; however, men were more likely than women to benefit (20.5% versus 5.2%). Gains in jobs were particularly low for women whose youngest child was less than 6 years of age, compared to women whose youngest child was between 6-17 or men with children 0-6 or 6-17 years of age. Research has demonstrated that these is a gender gap in employment between parents of school-aged children as a result of the pandemic, which is greater for low-income women since they already have fewer economic resources and vulnerable labour market positions….In August, 51/1% of teleworking mothers with a child under 6 years old reported concerns that returning to their normal work location would create childcare or caregiving challenges.”

·      Workers who are racialized, immigrant and /or Indigenous: “In August, 2020, the employment rate for those born in Canada was closer to pre-pandemic levels compared to immigrants who have lived in Canada for more than 5 years. Employment among Indigenous populations living off-reserve (91.4% of the pre-pandemic employment level, in February) has not rebounded as quickly as for non-Indigenous Canadians (96.7% of February employment).

·      Youth and post-secondary students: “Youth (aged 15 to 24) have experienced significant and lasting impacts of the shutdown….Unemployment was much higher among youth who identified as a member of a group designated as a visible minority (32.3%, not seasonally adjusted), compared to youth who did not identify as indigenous or with a group designated as a visible minority (18.0%).

·      Employment and health: “Income inequality is associated with higher mortality rates, poorer health, and mental health outcomes.”

·      Inclusion: While working from home can reduce viral exposure, the report notes that creating an appropriately adapted work environment poses significant challenges, along with increased social isolation. “Isolation associated with physical distancing may be particularly challenging for children, older adults, and individuals with disabilities.”

Significantly, the report notes, “…quarantine and physical distancing measures may mean that physical support of others is limited, or unavailable, for bereaved individuals during the grieving process. While the long-term impacts of these adjustments are not yet know, research from previous pandemics suggest that those who suffer multiple losses related to death and interruptions to social norms, rituals and mourning practices, may be at increased risk for complicated grief.”

The report speaks to increased levels of stress, fear and worry and exacerbation of pre-existing mental health issues, food insecurity, substance use, opioid deaths, family violence, caregiver stress, child safety issues, demand for services and shelters, throughout the pandemic. It looks at the possibility of long-term impacts on economic stability, effects of interrupted educational opportunities and differential access to distance learning, effects of reduced access for broad-spectrum health supports as pandemic issues have had to be prioritized by the health system, and reduced levels of physical activity (particularly for children living in urban areas with limited access to safe accessible outdoor spaces).

The report focuses its recommendations, post-pandemic on a health equity approach. “This pandemic has demonstrated that inequities in our society place some populations – and ultimately, all Canadians at risk. No one is protected from the risk of COVID-19 until everyone is protected.”

The Health Equity Approach to COVID-19 framework proposes work in 4 high impact areas based on the consequences of COVID-19 described in Section 2 of this report: (1) economic security and employment conditions; (2) stable housing and healthy built environment (3) health, education and social service systems; and (4) environmental sustainability (Figure 6). This work will need to be supported by a foundation of tangible actions to eliminate stigma and discrimination, strengthen cross-Canada commitments to robust data and research, clear public health communication, and collaboration across levels of government, sectors and civil society.

The report’s recommendations are summarized in:

What We Heard: Indigenous Peoples & COVID-19 is an independent report, written by an Indigenous scholar and her team, that summarizes discussions from two community engagement sessions with Indigenous partners in August and September 2020. First Nations, Inuit and Métis individuals participated in the community engagement sessions and shared their knowledge and experiences living through the COVID-19 pandemic.

Structural inequalities brought forward by participants included:

• broadband internet access and infrastructure

• affordable and safe homes

• access and available clean usable water

• food security and sovereignty

• land and environmental stewardship

• employment, labour and workforce participation

• health and healthcare and mental health services

• materials, supplies, and other needs

• transportation

• funding and finances

• stereotypes, discrimination, myths, and racism

• relationships (or lack thereof) with different governments

• policy discounts and discredits Indigenous Worldviews: values, beliefs, ceremonies, knowledges, and kinships

Best Brains Exchange Proceedings Report: Strengthening the Structural Determinants of Health Post-COVID-19 summarizes the proceedings of the virtual Best Brains Exchange (BBE) held in July 2020 to help inform the CPHO 2020 Annual Report on COVID-19. The BBE aimed to better understand the intersectional COVID-19 impacts on the health and well-being of priority groups in Canada, to inform the design of protective strategies moving forward.

Key themes arising from the session, as identified by Bonnie Hostrawser in closing remarks, included:

1. Stigma is fundamentally woven into everything discussed today. We need to address ageism, ableism, and racism, among other socially constructed stigmas. COVID-19 has further exposed the systematic devaluation of a number of groups and there is an opportunity for a paradigm shift.

2. Data and frameworks are needed to understand inequities in an intersectional manner. A framework of SGBA+ can be useful for this work, as well as equity-based data. This was also identified in the 2019 CPHO Annual Report focused on stigma.

3. Governance is critical, and needs to include community members and diverse leadership. We need to ensure people are not left out.

4. We need to re-think and reform our current structures. Fundamental reforms of many systems are needed, including immigration, caring for seniors, primary care, employment, and correctional facilities.

5. We need to ensure integration across these systems, including addressing other issues or crises as they arise.