The global community – including world leaders, national governments such as Canada, decision-makers and researchers – all failed to deliver on equity during the COVID-19 crisis. More specifically, we were not sufficiently accountable for the negative impact it had on vulnerable people. 

To date worldwide, almost seven million people have died, with more than 760 million affected since the pandemic began more than three years ago.  

Yet, what did we actually learn, and how did it affect population health research? This is exactly what we sought to learn by interviewing 35 global and public health experts across disciplines, research centres and research funders in Canada, as well as international actors including some from the World Health Organization (WHO). 

Some key conclusions include the need for: 

  • Improved training in university public health schools; 
  • Reforms to the Canadian Institutes of Health Research Act to make equity an explicit priority; 
  • Provision of adequate funding to achieve equity and accountability goals. 

All three of these actions are vital to ensuring that fewer people are further disadvantaged, and stay alive and healthy, during the response to the next pandemic. 

Designing policies around the concept of equity is central to improving population health. The WHO defines health equity as “the absence of unfair, avoidable or remediable differences among groups of people.” Equity also underpins population health research. It is at the heart of the 2021-31 Strategic Plan of the Canadian Institutes of Health Research (CIHR), the main health research funding agency in Canada.  

Equity was not a priority  

Our results show that equity was not prioritized during the first waves of COVID-19 in high-income countries, including Canada. Instead, the focus was on urgently containing the virus’ rapid spread and addressing the high number of COVID-19-related deaths 

The negative impact of the pandemic was exacerbated for people living and working in conditions of vulnerability or marginalization, such as front-line workers, seniors, women and children, racialized people, Indigenous communities, LGBTQ+ communities, homeless people and people with disabilities.  

Because of strict COVID-19 physical distancing measures and the temporary halting of home service delivery, children with disabilities and their parents lost access to essential support that would have enabled these children to receive adapted services and their parents to pursue their livelihoods, the researchers reported. 

Racialized front-line workers were also disproportionately affected by being more exposed to the virus through their occupations in places such as long-term care facilities and the service sector. They also had fewer opportunities to follow public health measures, such as physical distancing, if they lived in smaller lodging spaces. 

Moreover, Canada did not deliver on health equity globally. Rather than promoting global vaccine solidarity, the federal government decided not to support the patent waiver (TRIPS) that would have promoted global vaccine equity in countries that needed it most. 

According to respondents to our study, addressing equity and providing clear funding considerations for global and national health governance processes are crucial and should be done systematically. This approach will help prioritize population health research, ensuring accountable health outcomes, both at home and globally. Equitable and accountable health outcomes cannot be achieved without adequate funding. 

Respondents also reported the urgency to investigate the COVID-19 pandemic had negative consequences for other research because it shifted focus away from ongoing work on non-communicable diseases, such as chronic diseases, mental health or research on the health of people in vulnerable situations.  

Researchers, especially women, also mentioned being overbooked due to a high volume of COVID-19-related research proposal writing and management. They felt overwhelmed by working from home, dealing with household chores, and managing home-based schooling for their kids. These factors also affected their mental health. 

A few positive consequences 

However, not all consequences of COVID-19 were negative. Many respondents reported that both the government and the general public rediscovered the importance of population and public health, including studying the impact of COVID-19 and how to respond to it at a population level. 

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In this context, given the different emerging challenges generated by COVID-19 on social, health, economic and equity levels, researchers, funders and decision-makers had to work more collaboratively across disciplines and sectors.  

COVID-19 “enabled much more engagement between social science perspectives, epidemiological, clinical and public health perspectives, and mathematical modelling,” as one study respondent noted. 

Canadian experts also shared that federal and provincial/territorial levels were not operating with the same definitions and criteria for the collection of COVID-19 data, and their respective databases did not “speak” to one another.  

Worse, the availability of data was sub-optimal and did not allow for real-time analysis to help understand what was driving inequitable health outcomes among marginalized populations. Given that all data are not readily available for evidence-oriented leadership, policy and programs, this could further jeopardize accountable health outcomes for different population groups. 

Reflecting on all these negative, positive and unintended consequences of COVID-19 on the research ecosystem, key lessons have been learned.  

Although the COVID-19 pandemic is relatively recent, we have experienced several other epidemics affecting our entire planet, or parts of it, including HIV, SARS, H1N1, avian flu and Ebola. All these infectious diseases are known to be linked to an animal source of transmission (zoonotic). COVID-19 is also thought to be a zoonotic disease.  

Recommendations 

Study respondents underscored the need to adopt a “One Health” approach that promotes an interdisciplinary and intersectoral collaboration at the interface of human, animal and environmental health to address current and future pandemics.  

Another important lesson is to conduct more systematic health-equity impact assessments of any global and national health decisions and processes to avoid inequities within and across population groups as occurred during COVID-19. 

Finally, to redress the COVID-19-related challenges and inequities raised above, study respondents shared actionable solutions and recommendations for global and national health.  

  • For equity to be seriously considered from training and policy to practice, university schools of public (and global) health should better train future generations of global and public health leaders, researchers, practitioners, policymakers and decision-makers on what equity means, how it is measured and operationalized, and what are its health impacts for all population groups.  
  • The federal government should review the Canadian Institutes of Health Research Act to explicitly address health equity beyond improving population health. This amendment would mean specific downstream changes to clarify the pivotal role of equity in improving the health of all population groups considering their gender, age, disability, wealth, education, geography and other social identities.  
  • For the above two recommendations to be effective, adequate and sustainable funding is necessary for population health research priorities to be not only equity-oriented in intent, content and outputs, but also so that accountable health outcomes occur across population health research areas. Study respondents stressed that without adequate funding (in the form of dedicated resources), health researchers will continue to struggle to conduct projects that take into account health equity and its impact in the long run. 

It is our collective duty to address equity considerations in both global health governance and population health research in Canada and beyond. Failing to do so will lead to a repeat of what the COVID-19 pandemic revealed: that vulnerable and marginalized populations face greater risks requiring more robust research and measures to ensure equitable protection. 

Related reading: 

First Nations, federalism and lessons from the fight against COVID-19 

How federalism failed Canadian cities during COVID-19 

New data provide insight into pandemic inequalities 

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Muriel Mac-Seing
Muriel Mac-Seing is an assistant professor of global health at the Université de Montréal. She is one of the co-founding members of Women in Global Health Canada. 
Erica Di Ruggiero
Erica Di Ruggiero is the director of the Centre for Global Health and an associate professor in global health with the Institute of Health Policy, Management and Evaluation at the Dalla Lana School of Public Health. X: @ed4socialchange

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