Andreas Laupacis is Editor in Chief of CMAJ.
The coronavirus has done a great job of highlighting the obvious. The poor and disadvantaged always get screwed.
A headline in the Guardian recently asked, “If coronavirus doesn’t discriminate, how come black people are bearing the brunt?” Writing about the UK, Afua Hirsch pointed out that 35% of people who died early in the COVID-19 pandemic were black, Asian or from another ethnic minority, more than double the UK prevalence. Although there were no studies examining the ethnicity of health care workers dying from COVID-19, the first four physicians who died were Muslims of African or Asian heritage.
I am not aware of Canadian data that shows how COVID-19 is affecting different groups of Canadians but I’d be shocked if we are any different from the UK or the United States, where blacks are much more likely to die from COVID-19 than whites.
It is pretty clear that the frail elderly living in Canadian long-term care (LTC) homes are more likely to die from COVID-19 than the elderly living in the community. I’d be surprised if staff working in those homes don’t have a higher risk of getting infected with coronavirus than staff working in hospitals. And almost none of the clinical staff caring for my mother in her LTC facility are white.
Today I am reading about residents in a LTC home in Quebec apparently being abandoned and something similar in a home for persons with disabilities in Ontario. When this pandemic is done, I think we’ll see a higher death rate among the homeless too. To my knowledge a coronavirus outbreak in an isolated indigenous community has not occurred yet, but it would likely be devastating.
This shouldn’t be a surprise. We know poverty and disadvantage kill through a variety of mechanisms such as unhealthy food options, insecure housing, psychological and social isolation and poor access to health care. But because coronavirus kills more quickly than other diseases, it makes the inequities in our society that lead to death much more starkly visible than usual.
We can’t address the underlying structural causes of inequity in the middle of a pandemic. However, we can make sure that the response to the pandemic is equitable – for example providing those working in LTC facilities and homeless shelters and indigenous communities the same access to personal protective equipment and testing as those working in hospitals. And doing everything we can to allow the homeless to practice social distancing.
The question that is depressing me this Easter weekend is whether we will learn from this disaster.
When this is over, will there be a Marshall Plan to deal with our society’s inequities or will we go back to the world as usual? I fear the latter. Post coronavirus, I think we (me included) will retreat to our own parts of society and make well-intentioned but self-serving arguments about how better funding of our sector (e.g. hospitals) would have made us better prepared, without addressing the root causes.
I hope I am wrong. Just maybe we will all be so embarrassed by how we have funded our long-term care sector that we’ll seriously address that, and maybe other areas of inequity too. But I am not optimistic.
Culture plays a role as well in the spread of Covid. Many communities (such as Asian or Middle-Eastern) live in a multi-generational setting (grand-parents live with their adult children, grandchildren).
Also not addressed here is the ‘health equity’ or ‘health inequality’ currently endured by the non-Covid population who may not be given the attention they need because they are told to stay home and/or are too afraid to come to the hospital (eg. new diabetic, mental health patient), or their ‘non-essential procedures/surgeries are postponed.
Thank you for saying this. I would, however, disagree that “[w]e can’t address the underlying structural causes of inequity in the middle of a pandemic”, We don’t need more studies to confirm that poverty leads to poor health outcomes. Unemployment is surging, and it may stay high. The Managing Director of the International Monetary Fund has warned that the COVID pandemic may plunge the world into ” a global recession we have not seen in our lifetimes” (1). Now is the time to prepare.
We have options. In her analysis of the 1974 Manitoba MINCOME experiment Evelyn Forget gives a fine potted history of Canada’s “long flirtation” with a guaranteed income, including the 2009 Senate recommendation that we go that route, and explores the benefits to health (2). I was working on Parliament Hill in 1986 when the Macdonald Commission, best known for its call for a North American free trade agreement, also called for universal income support. For half a century governments around the world have toyed with the idea of universal income support, but were too cowardly to go there. Now COVID has prompted at least one government to grab the bull by the horns. Spain intends to implement a universal guaranteed income program as soon as possible (3).
The federal government has reacted with admirable speed to economic stresses, but with a set of ad-hoc, short-term palliatives. Now is the time for structural reform. If the IMF is right, we’ll need it. And if the IMF is wrong, it’s still the right thing to do.
(1) Ben Winck, The IMF says its forecast for the COVID-19 recession might now be too optimistic. World Economic Forum. https://www.weforum.org/agenda/2020/04/imf-economy-coronavirus-covid-19-recession Accessed 20 April 2020
(2) Evelyn L. Forget, The Town with No Poverty: The Health Effects of a Canadian Guaranteed Annual Income Field Experiment. Canadian Public Policy Volume 37 Issue 3, September 2011, pp. 283-305. https://www.utpjournals.press/doi/full/10.3138/cpp.37.3.283. Accessed 20 April 2020.
(3) Rodrigui Orihuela, Spanish Government Aims to Roll Out Basic Income ‘Soon’. Bloomberg News, April 5 2020. https://www.bloomberg.com/news/articles/2020-04-05/spanish-government-aims-to-roll-out-basic-income-soon. Accessed 20 April 2020.
Thank you for sharing your timely valuable thoughts Dr. The points made in this article cannot be emphasized enough and the governments, businesses, civil society and health care community need to take urgent, coordinated action to address the widespread inequity in our communities. Society cannot afford inaction on health inequalities and health equity is a social justice for all of us (1).The Royal College of Physicians and Surgeons of Canada and the Canadian Medical Association encourage physicians to engage in advocacy to address healthcare inequities (2, 3).
COVID pandemic is a once in our life time golden opportunity to sincerely address this burning social and public health disparities. But if our society looks the same after the post Covid-19 era, it would be the most disappointment and the regret in our lives. The evil Covid-19 would be conquered one day and the health care community should prepare well in advance to cease this golden opportunity to take a lead role to transform this one in life time moment to a sustainable movement. We need to push harder to bring sustainable solution for these long neglected social disparities. This should be important agenda item in the post recovery plans and should be placed high in the agenda and integral part of well coordinated Canada’s post Covid 19 response.
According to WHO, the governance required to act on social determinants is not possible without a new culture of participation that ensures accountability and equity. Facilitating participation can help safeguard equity as a principle and ensure its inclusion in public policies. These long neglected inequities have significant social and economic costs both to individuals and societies (4).
(1). Marmot M: The Lost Decade, How Austerity put back England’s health gains. BMJ 2020; 368:m693.
(2). Canadian Medical Association. CMA position statement: ensuring equitable access to care: strategies for governments, health care planners and the medical profession. In: Policies and research 2014. https://www.cma.ca/Assets/assets-library/document/en/advocacy/PD14-04-e.pdf. Accessed 12 April 2020.
(3). Frank JR, Snell L, Sherbino J. CanMEDS 2015 Physician competency framework. In: Framework CanMEDS 2015. http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf.