Early in the COVID-19 pandemic, the phrase, “we’re all in this together” was repeated like a mantra by Canadian politicians, then turned up as posters in the windows of numerous homes and businesses in cities such as Toronto. The goal was to show solidarity with those impacted by COVID-19. However, as one wave after another occurred, and detailed information on infection and mortality rates came to light, the data showed that, much like previous pandemics, COVID-19’s impact has not been equitable and we were never “all in this together.”

The data underscored significant disparities in viral infection, hospitalization and mortality rates. In Ontario, a COVID-19 hotspot, a regularly updated COVID-19 report found that from mid-January to early June 2020, neighbourhoods with the greatest levels of material deprivation (e.g. poverty, limited ability to access and achieve basic material needs), had 69 per cent higher rates of hospitalization and 52 per cent higher death rates than neighbourhoods with the lowest level of deprivation.

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Neighbourhoods with the highest rates often had large, racialized populations, recent newcomers to Canada and those living in apartment buildings, which made social distancing and isolating due to COVID-19 infection difficult. These rates underscored pre-existing inequities and governments’ underinvestment in supporting the health and well-being of those who have historically been at increased risk of dire health outcomes during pandemics. That needs to change before another wave of COVID-19, or the next pandemic, hits.

Unfortunately, this data is not surprising and the fact that airborne and respiratory infections are inequitable is old news to those who have been researching health inequities in Canada for years. For instance, a retrospective review of the 2009 H1N1 pandemic found Indigenous populations accounted for 10 per cent of all positive cases although they comprised only 4.6 per cent of the country’s population. Those hospitalized with H1N1 were more likely to live in neighbourhoods with low rates of employment and income.

Another study that investigated the link between ethnicity and H1N1 infection found that East/Southeast Asian, South Asian, Black and recent immigrants in Toronto were more likely to test positive for the virus. Although researchers did not identify a sole reason for these disparities, many of them, much like the COVID-19 researchers of today, pointed to variations in the social determinants of health (e.g., income, employment, racism) that influenced individuals’ risk of viral exposure and poor health outcomes.

Despite these previous patterns of viral disparities, many health-care institutions and governments were seemingly unprepared for COVID-19 and were alarmed by its impact on various populations. A review of government responses to the pandemic in relation to prior plans may explain the failure to address these disparities at the very start of the pandemic. In 2018, all three levels of government collaborated to update the document Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector after H1N1. This update included actions such as enhancing connections across surveillance activities, epidemiology capacity and primary health care. The plan aimed to curtail serious illness and deaths as well as reduce societal disruption. It helped inform early governmental responses to the virus, which often centred on containing viral spread.

Although this approach likely saved many lives, these short-term, rapid responses often did not include data collection that went beyond information needed for contact tracing to identify, isolate or quarantine those at risk of spreading the virus. The plan also acknowledged the importance of equity as well as the need to consider and try to limit health inequities during a pandemic. However, it did not provide concrete steps that policymakers and researchers could use to examine the impact of, and government responses to, the virus on various populations through an equity lens.

In response to the ongoing pandemic and findings from disaggregated data collection by some researchers and health-care institutions, calls have increased for equity-informed approaches to COVID-19. These calls have become even louder in recent years with numerous agencies noting their commitment to equity and equity-informed approaches to care. Despite these calls, the pandemic responses of several jurisdictions have been equity-blind.

It does not have to be this way.

Some public health units in Ontario, such as Toronto and Peel, have created equity-informed responses such as collaborating with community agencies and stakeholders to identify culturally relevant community supports for individuals with COVID-19. Unfortunately, research is scarce on equity-informed pandemic policies; how Canadian institutions are fulfilling their equity commitments; and how equity is used to improve health-care and health outcomes of vulnerable patients.

There are several, fundamental issues underpinning the lack of equity responses to the pandemic.

First, no universal definition of equity exists, making it difficult to search for and learn from any pre-existing equity-informed pandemic policies. Alongside this lack of a definition, there is no shared approach to discussing and assessing equity in pandemic responses and health care. These gaps are compounded by many institutions that use the terms “equality” and ”equity” interchangeably but incorrectly.

While both terms centre around ensuring that all individuals get access to health-care, one focuses on the same level of care for all (equality) while the other focuses on providing health-care support and resources that match individuals’ level of need (equity). Although some may argue that they are essentially the same, there is danger in viewing these two terms in the same light because, for example, health-care access for all does not always align with reality and can produce health-care barriers for some.

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For example, virtual care can increase health-care access for many and eliminate transportation barriers or the need to book time off work for appointments if after-hours care is provided. However, if virtual care becomes an increasingly common mode of delivery, it can cut out those with low digital literacy, poor internet access or who need translation services.

Equity-based data collection is a key step in developing effective pandemic policies and is vital to helping identify, challenge and address health inequities. However, data collection within and across health-care institutions is inconsistent. As noted by Ontario Health, among others, this data gap undermines policymakers’ ability to determine the extent of health disparities and the impact of interventions.

To tackle COVID-19 and other pandemics to come, future planning must include equity-informed policies that provide a level of flexibility that fosters community involvement, intervention and redevelopment in real time. It must include a robust and well-thought-out knowledge-dissemination strategy to counter misinformation that will likely emerge and spread through social media, as we have seen with the current pandemic. The plan must also be cognizant of the ways that experiences of racism, sexism, homophobia, transphobia, ableism and other forms of discrimination within health-care systems may affect individuals’ willingness to seek care or accept new vaccines from the same systems that have caused them pain rather than care in the past.

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This is particularly true of Indigenous and Black populations, who have a history of being subjected to medical experimentation by these very systems. Additionally, pandemic policies must include swift equity-informed health-care strategies that occur in tandem with disaggregated data collection. These overlapping actions will help determine if health-care responses are working, need revisions and which populations require additional support. Toronto and Peel public health units have shown we can rapidly build capacity for this data collection and use it to inform responses.

Equity-informed pandemic responses can be implemented quickly. For instance, in the U.S., improving on equity was a key requirement in COVID-19 reopening measures for the state of California from August 2020 to June 2021.

Although pandemic plans can be beneficial, embedding an equity lens into them may not only save more lives but also help bring us all a bit more “in this together” when the next pandemic occurs.

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Nakia Lee-Foon
Nakia Lee-Foon is a postdoctoral fellow at the University of Toronto’s Dalla Lana School of Public Health. Her research interests range from health equity to the state of sexual and reproductive health care for Black populations in Canada.
Adalsteinn (Steini) Brown
Adalsteinn (Steini) Brown is the dean of the Dalla Lana School of Public Health at the University of Toronto. He is a fellow of the Canadian Academy of Health Sciences.
Emily Verghis
Emily Verghis is an alumni of University of Toronto with an HBSc double major in human biology, and women and gender studies. Her current work focuses on health equity and integrated care.

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