COVID-19 was always going to be inequitable as many Canadian health-care systems failed to learn from previous pandemics. As a result, they didn’t implement equitable practices, which helped ensure inequities would occur in this pandemic.
Take, for example, an Ontario study that found hospitalized individuals during the 2009 H1N1 pandemic were more likely to have lower levels of education and live in neighbourhoods with low employment rates and limited access to basic resources. Researchers concluded that examining the social determinants of health was a vital component of pandemic planning and reducing severe disease outcomes.
Another H1N1 study found racialized populations were at greater risk of H1N1 versus their white counterparts in Ontario. Racialized populations were more likely to be newcomers and live in neighbourhoods with low income.
Despite this history, federal, provincial and municipal governments have been slow to begin addressing some of the socio-structural factors that have yielded many of these inequities. Instead, in the pandemic’s early days, many governments chose to implement various stop-gap measures to reduce viral spread without considering their long-term ramifications on vulnerable populations as well as their impact on these populations’ trust of governments.
Although these measures placed restrictions on all Canadians, those with privilege were able to adapt and reduce their infection risk. Many others, already experiencing disparities pre-pandemic were caught in the middle, facing even fewer opportunities to protect their health while trying to meet their basic needs.
From the start, the implementation of a state of emergency in March 2020 by the Ontario government had an unequal effect. This order required the immediate closure of public libraries, schools and non-essential businesses. Although this order sought to prevent and limit viral spread, for some businesses deemed non-essential, it also reduced their income, prompted employee layoffs and, ultimately, permanent closures. While the implementation of the Canada Emergency Response Benefit (CERB) proved to be beneficial in providing vital income support to those suddenly out of work, it did not necessarily match the cost of living in some provinces. However, the benefit’s highly accessible, easy application process helped keep many afloat and slow the spread of COVID-19.
Some researchers from the U.S. found that closing low-risk retail business like stores that sold books and clothing along with schools may have been counterproductive. There was no consistent evidence that these closures reduced COVID death rates. Instead, the closures may have pushed some weary citizens to engage in higher-risk activities, like indoor gatherings with friends.
While small businesses were required to close in provinces like Ontario, big-box stores like Walmart and Costco remained open as they sold essentials like groceries. However, they were not allowed to sell items considered “non-essential” like school supplies. Although school supplies could still be ordered online or through curbside pickup, many argued that this move would be detrimental to households with limited internet access and those experiencing low-income. This restriction may have prevented care-givers on limited budgets from accessing the supplies and clothing children needed to thrive academically during school closures.
For frontline workers like clinicians, child-care providers, grocery staff and gig workers who could not work from home, COVID-19 brought along new challenges and restrictions. It also underscored significant disparities in health protection for employees. In the early days of the pandemic, anyone exposed to or testing positive for the virus was required to quarantine for 14 days. This requirement often did not consider the fact that some workers, particularly low-waged, precariously employed individuals were less likely to get paid sick leave. This meant that some may have resisted getting tested for fear of lost wages.
Additionally, the concept of quarantine makes several assumptions. It presumes individuals understand the need to self-isolate, know how the disease is transmitted and have access to space to safely self-isolate. For some racialized populations living in multi-generational households the ability to truly self-isolate was extremely difficult. Toronto recognized the inequity in self-isolating and worked to develop resources like a voluntary isolation centre supported by public health staff.
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As cases continued to soar, the Ontario government gave police power to stop and ticket residents believed to be participating in public events in April 2021. This underscored the government’s attempt at restricting public movement but also triggered concerns that these powers could increase racial profiling.
Again, this opens the door to worsen the pandemic for those already disproportionately impacted by COVID-19. Ultimately, strong public backlash prompted the revision of this police power the day after its announcement.
Throughout the pandemic, the Ontario government has had to make difficult choices to ensure the overall safety of its citizens. Some of these choices, while effective at the time, lacked a critical, equity-informed assessment. There wasn’t an informed analysis of the differential impacts these restrictive measures could have on the long- and short-term health of various populations, particularly racialized populations.
To learn from these mistakes and refine mitigation approaches for the next pandemic, several things must be considered.
First, structural factors (for example: inadequate income, limited access to affordable housing) have driven higher risk of COVD-19 infection and transmission in racialized communities and neighbourhoods with low income. All levels of government must work together to continue addressing these structural factors in a sustainable way that builds capacity in community members.
Second, variations in the social determinants of health can make it difficult for individuals to get and stay healthy. Although addressing these determinants will require more than just government intervention, governments must work alongside health care, educational institutions and more to provide individuals with the support they need to live successful, healthy lives.
Third, pandemic measures must be viewed through an equity lens to determine if these measures may do more harm than good and individuals are getting the support needed for their physical and mental health. These lenses already exist in the form of the Ontario Ministry of Health’s health equity impact assessment tool (HEIA) and the Public Health Agency of Canada’s 2020 pandemic equity model. The HEIA can help decision makers limit avoidable heath inequities between populations and help enhance the targeting of health-care investments. The pandemic model can help explore the varied effects of public health measures on diverse populations. Actively using these tools would have identified potential inequities in pandemic measures and helped governments develop more equitable measures.
Finally, rather than only focusing on public health policy to direct pandemic measures, federal and provincial laws must be created that require all instituted measures undergo formal equity assessments. Any variations in the intended impact of these measures must be reported to the public. These four aspects must be considered when planning the pandemic responses of today and tomorrow.
The author thanks Dr. Adalsteinn Brown and Emily Verghis for their help in shaping the contents of this article.