In the COVID-19 era, Canada needs to better understand the relationship between identity and health. To do that, we need to use intersectional analysis, the study of the way identity categories such as gender, race and ability interconnect to create discriminatory systems that impact individuals in different ways. Fortunately, we have a policy tool in our policy toolbox for precisely this purpose, and it can and should be deployed by provincial ministries of health across this country: Gender-Based Analysis plus (or GBA+). Our federal government has been using GBA+ for years across many departments, though it is not mandatory for all federal departments. But it is in use at the Privy Council Office, Finance, the Department of National Defence and Health Canada. There is therefore a wealth of Canadian policy experience with this tool, and we need GBA+ now more than ever.
The GBA+ tool was developed by the federal Department of Women and Gender Equality (WAGE), formerly Status of Women Canada. It is an approach to understanding sex and gender alongside other identity factors such as race, ability and age, to assess how various groups experience policies, programs and initiatives. The aim of GBA+ is the creation of equitable policies, programs and initiatives — equitable from inception to execution. Awareness of the differential impacts that government policies and actions have on different identity groups is central to that goal.
There are no hard and fast rules on how GBA+ should be done; in fact, it is perhaps best thought of as a competency rather than a methodology. In other words, there is no set formula to achieve equity in all situations; rather, progressing toward equitable change requires the continued cultivation of knowledge about various groups, the challenges they face and potential avenues for change. Nevertheless, GBA+ consistently relies on the use of disaggregated data, in addition to other forms of research, to gain insights into policy. Reliable data are essential to effect change, especially with identity-based issues. Showing patterns of discrimination is more compelling than anecdotal accounts in documenting a need for policy change. GBA+ also requires the monitoring and evaluation of the effects of policies on Canadians. It is not enough to enact change; change must be equitable.
Properly applied to the government’s COVID-19 response, GBA+ would have directed policy-makers to draw on fine-grained differentiated data to evaluate equity considerations. In asking whether policies are equitable, GBA+ analysts ask whether policy outcomes track a range of identity factors, including race, ethnicity and socio-economic background. Thus, if GBA+ had been applied to provinces’ public health response to COVID-19 from the start, requisite data would have been collected from the outset. These data, as the trickle of international evidence is making increasingly apparent, are key to targeting necessary medical supplies, policies and programs to those most affected, and hence helping to curb the spread of the virus.
GBA+ directs policy-makers to include identity-based considerations in the formulation, deployment and evaluation of their policies. Of course, GBA+ is not perfect: critics sometimes charge that it is too abstract, offering little actionable guidance to policy-makers. While its goals may be commendable, it is not always readily apparent how GBA+ should influence decisions within a specific portfolio or policy. This is why proponents of GBA+ argue it is a competency rather than a methodology. Policy-makers need to develop the ability and experience needed to make equitable decisions. Whether or not this response satisfies critics, it is true that GBA+ has clear implications in the context of COVID-19. If it had been employed in the appropriate offices before the pandemic, it would have helped policy-makers see and act upon considerations of identity in the making of health policy, including in their collection of data. Even at this later stage, the deployment of GBA+ would significantly improve our understanding of the virus and our response to it.
Several Western countries have discovered that factors linked to social determinants of health, most notably race, ethnicity and socio-economic status, are closely related to infection, hospitalization and death rates In Canada, however, we are flying blind, as COVID-19 data collection has been limited so far to age and sex.
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Our obliviousness to the potential relationship between race, ethnicity and socio-economic status and infection, hospitalization and death rates will negatively impact our ability to control the spread of the virus in the short term and impair our understanding of how this virus impacts societies’ well-being in the long term. In response to criticism about this gap in data collection, Ontario’s chief medical officer of health, Dr. David Williams, for example, has said that statistics based on race aren’t collected in Canada unless certain groups are found to have risk factors.
Frankly, this position just does not align with mounting international evidence that race, ethnicity and socio-economic status have an impact on health outcomes related to COVID-19. A recent study released by a United Kingdom think tank, the Institute for Fiscal Studies, finds that minority groups are overrepresented in hospitalizations and deaths from the virus, with Black Britons nearly twice as likely to die from COVID-19 as the white British majority. Similar patterns have emerged in the United States, where the Centers for Disease Control confirmed that current data suggest a disproportionate burden of illness and death among racial and ethnic minority groups. New York City, for example, has recorded a disproportionate death rate among African-Americans (33.2 percent) and Hispanics (28.2 percent), and a Washington Post analysis shows that American counties that are majority-black have three times the rate of infections and almost six times the rate of deaths as counties where white residents are in the majority.
There is further reason to apply a GBA+ lens to race, ethnicity and socio-economic data of those infected, hospitalized or succumbing to COVID-19. Academic studies have noted that racial discrimination, specifically when directed against Canada’s Black and Indigenous people, may itself be a determinant of chronic diseases and their underlying risk factors. Clearly, racial and ethnic inequalities in health outcomes are found throughout Canada, but the severity of these inequalities varies across racial and ethnic groups, further illustrating the importance of intersectional analysis. Moreover, academic evidence notes that a failure to distinguish between Canadian-born visible minorities and visible minorities who are immigrants to Canada is a key gap in Canadian health data of racialized individuals. This further indicates the importance of taking intersectionality into account when collecting health data.
When policy-makers truly embrace GBA+ as a lens for equitable policy-making, we can then better assess the toll of the pandemic. Only with an intersectional lens on the impact of COVID-19 on society will we see the differentiated impact of this virus on individuals and communities. Thus far, we have been flying blind, but it may not be too late to make a course correction in our COVID-19 policies.
This article is part of the The Coronavirus Pandemic: Canada’s Response special feature.