People who identified as Arab, Middle Eastern, West Asian, Latin American, South East Asian or Black were 6-9 times more likely to test positive for COVID-19 than the White population according to new figures from Toronto Public Health covering the period from mid-May to July.
Similar results were reported from Peel Regional Public Health Unit for the period mid-April to July. South Asian, Black and Latin American origin residents were over represented in COVID-19 cases and White residents were under represented compared to their proportion of the population.
Both public health units should be congratulated for being the only ones to collect and publicly report their data in Canada. Because they decided to collect data before the Province of Ontario they have a head start trying to improve their pandemic response.
The results are both predictable and concerning.
They are predictable because disparities in infection rates have been reported in previous pandemics. For instance, in the H1N1 influenza pandemic in Ontario South East Asian groups were 3 times more likely, South Asian 6 times more likely and our Black populations were 10 times more likely to be infected than the rest of the population.
They are concerning for two reasons: first the size of the increased risk of COVID-19 for racialized groups looks larger than the USA and UK; second, these disparities may have been preventable or at least made smaller if Ontario had considered equity when setting its pandemic plan and it had altered its systems so that it could collect race-based and socio-demographic data to identify disparities.
Ontario has systematically failed to equitably protect its racialized communities.
Public health units have also reported on other social determinants of health and COVID-19. Toronto Public Health data show that COVID-19 test positive rates increased as household income decreased. The infection rates were 24 per 100,000 in those living in households with more than 150K income and 160 per 100,000 in those with household incomes less than 30K. The Unit has also said that there are associations between over-crowding and rates of COVID-19. Peel Public Health Unit reported occupation; 64 per cent of people who tested positive were in industries that could be seen as essential.
This extra information may help focus our attention on possible new strategies to improve the equity of our pandemic response. But much more information will be needed. It makes sense that income, overcrowding and being and essential worker are factors in the increased rate of COVID-19 in racialized groups, but there is likely to be more reasons that we have not uncovered. Both public health units have said that they are going to speak with communities to better understand what is putting them at higher risk. Moving on from quantitative data to hearing directly from people in communities and people who work in communities may help public health to identify ways to improve the impact of current public health measures and also identify new interventions to decrease the risk and impact of COVID-19.
The figures and the reaction of the public health units underline the need for a shift from focusing on flattening the curve to also thinking about who is under the curve. It also underlines the importance not just of collecting data, but using it to promote action.
One way of focusing on who is under the curve is to take an equity lens to pandemic planning. If we had done that then we may be able to decrease disparities in the risk of getting COVID-19 and dying from it. The Province has a great health equity impact assessment tool. Using that may have identified possible ways that the pandemic response would have unequal impact. By using this assessment to work directly with all stakeholders the Province could have fashioned mitigation strategies to ensure equity in the public health response.
But we will have to go further and all levels of Government will need to be involved. The equity lens should not be limited to working out how to enable people to get tested and socially isolate; it should be used on all the economic and social aspects of the pandemic plan and our recovery strategy.
COVID-19 is not a great equalizer, it discriminates. It exacerbates existing social inequalities. The Canadian Medical Association – 60 per cent of our risk of illness is linked to social determinants of health and another 25 per cent is because of variations in access to health and social care. There are many social determinants of health and they intersect so that some groups end up at much greater risk than others. Racialized groups are more likely to be exposed to all of the social determinants of health because of the systemic nature of racism.
An equitable pandemic strategy would base itself on this knowledge. Effective action on the social determinants of health is the true cornerstone of a pandemic response which works for all.
We do not need just to protect communities, we need to but to build resilience. We need to decrease the inequities that make specific communities vulnerable. We need to move away from the old normal which made us weak and move to a new normal where we put people first, we increase affordability, equity, inclusion and we embrace anti-racism. This means we need: good jobs, employment rights and wages which ensure that people thrive; a revitalized benefits system which ensures that we never again allow people to live in government sponsored poverty; and, a housing strategy that makes homes affordable.
The importance of improving housing affordability has been underlined by Toronto Public Health’s reports on overcrowding. And Dalla Lana School of Public Health has added more evidence. It has shown that the ability to physically distance is one of the most important factors in COVID-19 risk and spread. Toronto’s housing market is so hot that the average family cannot afford a downtown condo. Low-income families and racialized families are more likely to live in over-crowded housing which decreases their ability to protect themselves and their families from COVID-19.
The City of Toronto have said they will make hotel rooms available so low-income and racialized people who test positive or who are exposed can socially isolate if they need to. This is welcome but, with a significant asymptomatic transmission and with some arguing that only a minority of people with COVID-19 ever get tested, this may not have as big an impact on COVID-19 risk as we may think. Fundamentally, we urgently need more affordable housing to be in place that offers enough space for people to protect their health.
And Peel’s report brings into focus the importance of worker protections. Workers in essential areas are still at high risk so we need to offer them better legislated protection and we need to enforce these protections. We can also decrease the infection rate by improving other social determinants that intersect with their occupational risk of COVID-19. We can decrease COVID-19 disparities by paying essential workers a thriving wage.
Understanding the reasons for disparities and producing systematic policy solutions to deal with them will improve our pandemic response. We need an equitable public health response because there is an urgent need to focus on here and now solutions that will save people from infection and will save lives. We should systematically try to build policies to decrease social determinants which increase risk. Wellesley Institute has offered a comprehensive set of recommendations to the Standing Committee which would improve the pandemic response. But we should not lose sight of what creates these significant disparities in the first place. COVID-19 is telling us that our social system is breaking.
In our aim to be competitive and get inwards investment we are mimicking the USA. We have increasing income inequality, decreased protections for people in society and widening social divisions. COVID-19 loved that. It exploits differences between communities in the social infrastructure, their power over their environment and their work, their control over government, their access to resources and access to information. It uses these cracks in our system to get in, take hold and maintain its position. It came from richer international travellers but when they started following public health measures it moved to long-term care. As long-term care changed practices, it moved to other congregate settings and now is infecting and remaining in low-income and racialized populations, though it has been all but controlled in the rest of the population. COVID-19’s foe is social justice. A new normal based on social justice will be fundamental to defeat COVID-19 and make society more resilient.