With 10,000 COVID deaths across the country and another 6,000 predicted by the end of the year, there are two possible courses: watch and wait, or take action. Trudeau warned that “there are more tragedies to come” and that the best we could hope for was an eventual vaccine and the passage of time: “We will get through this. Vaccines are on the horizon. Spring and summer will come and they will be better than this winter.” But Canada’s Chief Public Health Officer, Dr. Theresa Tam, has made it clear in her new report that are multiple areas for action: “we can continue to build upon the social, health and economic responses employed to support Canadians during this unprecedented time and improve these systems through broader systemic change.”
With her annual report, Tam has provided a comprehensive overview of the first wave of COVID-19 and the concrete steps needed to recover, guided by the central principle that “no one is protected until everyone is protected.” As she explains in From Risk to Resilience: an Equity Approach to COVID-19, “While the COVID-19 pandemic affects us all, the health impacts have been worse for seniors, essential workers, racialized populations, people living with disabilities and women. We need to improve the health, social and economic conditions for these populations to achieve health equity and to protect us all from the threat of COVID-19 and future pandemics.”
In the first section of the report, she summarizes the impact of COVID-19 across the country up until August—including disproportionate infections among essential workers, and disproportionate deaths among long-term care residents. She also discusses some of the major outbreaks—from farms and meat processing plants, to prisons and northern communities. Whereas Trudeau has called the COVID death toll a “national tragedy” as though it is simply a natural disaster, Tam explains how the scale and disproportionate impact of the pandemic were largely driven by inequities which existed prior to the pandemic and which worsened during the pandemic. As she writes with regard to the 80% of Toronto cases from racialized communities, “Toronto Public Health noted that they may be related to pre-existing health disparities, the stress of racism and discrimination, difficulty complying with public health recommendations due to roles as essential workers or overcrowding at home, as well as inequities in healthcare and social service accessibility.”
Differential exposure, susceptibility, treatment, and pandemic response
In the second and longest section of the report, Tam goes into detail to explain how structural determinants of health shape who is exposed to the virus, who is susceptible, how they access and experience the healthcare system, and how they are affected by public health measures. Differential exposure results from precarious working conditions for long-term care and migrant workers, and precarious living conditions for elderly people in long-term care, people with disabilities in groups homes, people experiencing homelessness, and prisoners. As she explains, “This is particularly consequential for essential workers who are precariously employed. …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.”
She specifically addresses the multiple policies that put migrant workers at risk of infection, and acknowledges the impact of the migrant justice movement in bringing these issues to light: “Migrant farm workers may face challenges with physical distancing, due to housing which features close proximity among occupants and shared or inadequate bathroom facilities. Migrant workers may also be reluctant to report symptoms or participate in testing due to fear of reprisals and economic loss. They also face challenges with access to health care, including appointment availability outside of their work hours, transportation to appointments, lack of translation services, limited knowledge of the healthcare system, and lack of accessible public health information. Advocates for migrant workers have pointed to structural issues such as the dependence on employers for housing and sanitation.”
As the report explains, there is not only differential exposure to COVID-19 but differential susceptibility and differential treatment. COVID-19 mortality is higher for those with chronic health conditions like diabetes and heart disease, but these also “are related to the social and structural determinants of health and are not simply the result of individual choices.” Drawing on her report last year on stigma within the healthcare system, Tam also explains how the same groups encounter barriers to safely accessing healthcare, free from discrimination—because of Canada’s ongoing history of colonization and racism.
The report also describes the differential impact of pandemic response, which offers a critical look at public health measures. The dominant messages from public officials was to restrict traveling, stay at home, and consider remote learning and virtual health. But an equity lens shows that these responses not only failed to protect many people but made them more vulnerable. Travel restrictions in the name of public health led to a spike in xenophobia and racism: only 1.4% of travel-related cases came from China (as opposed to 35% from the US), but surveys found that 30% of Chinese Canadians experienced increased discrimination since the start of the pandemic. Working from home was not possible for many low-wage workers, disproportionately women and racialized people, which led to three times the rate of job loss. While the lockdown allowed some to safely stay at home, for others it meant confinement in housing that was unsafe from overcrowding or domestic violence. Distance learning is not equally accessible, and virtual healthcare can exacerbate pre-existing inequities: “Racialized and newcomer populations may have additional concerns about trust in the context of virtual care, related to stigma and discrimination within health systems or — particularly for recent or undocumented immigrants — additional concerns related to confidentiality, privacy, and data security. Healthcare providers may not be aware of these disparities, and may not consider how their patients and communities access or interact with technology.”
How do we win systemic change?
Citing years of public health research and the experience during the first wave, Tam lists evidence-based policies to address the pandemic by developing “new ways of living and working”. As she explained, “Equity matters—not only to those who are unjustly excluded—but to all of us. This report describes the emerging broader consequences of COVID-19 including the wide reaching impacts of these historical inequities. Ensuring that a health equity agenda is an integral component of pandemic planning and response efforts means that the actions we take to improve economic security and employment conditions, housing and healthy built environment, health, social service and education systems, and environmental sustainability can better protect people in Canada from health crises and create resilience and lasting equitable opportunities.”
Reflecting on the preventable disaster in long-term care and on farms, she calls for secure jobs with benefits, workplace protections, paid sick leave, workplace inspections, and specific workplace safety for migrant workers. Referencing housing policies during the lockdown—including a moratorium on evictions, rent deferrals, and the reduction of people held in jails—she calls for safe and stable housing and community supports. Considering the increasing emergence of pandemics from industrialized agriculture, and their threat to essential migrant farm workers, she calls for “the need to reassess food systems, including how we produce and process, in order to make them more accessible, sustainable and resilient…We need to ensure good pay and conditions for every worker along the food production chain, while also addressing the specific needs of temporary foreign workers.”
This report is a vindication, and a reflection, of every movement and campaign that has centered equity in its pandemic response—from decent work to migrant justice, from housing justice to prison abolition, and from childcare to public transit. Every “area of action” called for in the report has been a movement demand for years if not decades prior to COVID-19, and has been raised with a renewed level of urgency during the pandemic. These movements have not only popularized these demands, but identified them as a step towards ultimate goals that go beyond this report: safety for migrant workers through status for all, support for prisoners through prison abolition, and support for Indigenous communities through sovereignty.
If there is a weakness in the report, it is that achieving the systemic change it calls for is seen as being delivered from above by governments acting on behalf of society as a whole. Tam claims that “there has been incredible collaboration across sectors and between individuals, community organizations, businesses, governments and scientists. The aim of this report is to suggest opportunities to build on this collaboration.” But this glosses over that much of pandemic response has not been a collaboration but a struggle: housing justice advocates have fought rent and evictions, but Mayor John Tory has supported legislation against them; decent work advocates have demanded paid sick days and workplace inspections, which Doug Ford cut and has refused to bring back; migrant justice advocates have called for status for all, which Trudeau has resisted. Systemic change clearly won’t come from politicians reading a report and realizing the errors of their ways, but it can come from movements drawing on this information to continue mobilizing for new ways of living and working.
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