“This virus could hit any one of you or your loved ones, because this virus doesn’t discriminate,” a Canadian Premier recently declared. “It doesn’t care about your race, religion or creed. It doesn’t care about your age. Anyone and everyone is at risk.”
While there is some truth here – viruses themselves don’t discriminate – the stark reality is that social and economic inequities have left some at greater risk of getting seriously ill with COVID-19, while decreasing their ability to fight it. “COVID-19 has undeniably affected all of us, but it is extremely important to recognize that it is not the “great equalizer,” explains Mohammad Karamouzian, a PhD Candidate at University of British Columbia (UBC)’s School of Population and Public Health (SPPH) who studies and writes about health equity.
Health outcomes, including how long people live and if they are affected by chronic illnesses, vary by different demographic groups and even between neighbourhoods. Within Vancouver, those living in the area that includes UBC and the Westside have a life expectancy six years longer than those living in parts of East Vancouver. How can a few kilometres make such a big difference?
Evaluating the underlying reasons for health inequities has long been a foundation of public health research. Dr. Brenda Poon, an Assistant Professor within SPPH’s Human Early Learning Partnership (HELP) and Research Division Lead at the Wavefront Centre for Communication Accessibility, studies ways that community structures and systems influence health inequities. She explains “the conditions where we live and work – which are known as the social determinants of health – like housing, education, income, work arrangements, physical and social environment, and access to care, impact our health. Effects from these can accumulate both directly and in combination to affect families through channels that include childhood development, stress, our biology, and our coping resources.”
Health discrepancies between communities largely mirror differences in income and education, which snowball into affecting other social determinants. One’s level of education affects the type of job they can find, the security and safety of that job, and how much money they make. Economic security affects the type of housing they can afford, and the quality of the food, schools, services, and infrastructure in their neighbourhood.
Dr. Poon explains that health outcomes often follow the pattern of the social gradient, meaning that “those who are in the most socioeconomically disadvantaged situations have the highest rates of [illness], and it goes down in a stepwise manner. So as the conditions for socioeconomic well being improve, we also see improvements [in health].”
The social determinants also interact with one another by contributing to chronic illnesses like diabetes, obesity, hypertension, or chronic obstructive pulmonary disease (COPD), which are health risks on their own but also make someone more susceptible to complications from other diseases or infections. “The conditions that we experience have a way through biological pathways and systems to truly get ‘under the skin’ and show the inequities and health disparities we observe across chronic health conditions,” notes Dr. Poon.
These chronic conditions are frequently distributed along socioeconomic lines. In the case of COPD, one report found that there could be a “45% overall reduction in the rate of COPD hospitalizations for those younger than 75 if Canadians in all income levels experienced the same rate as those in the highest income level.” In the context of the pandemic, many chronic conditions are linked to more severe illness and higher rates of death due to COVID-19 than the general population. There are two parts to this: First, people with an underlying condition are more likely to have a worse disease course – meaning severity of disease – and thus are more likely to be hospitalized or die if they contract COVID-19. Secondly, people with low socioeconomic status may not have the same access to health care, paid sick leave, or other support they need to fight the illness.
As with many other chronic conditions, obesity is a risk factor for several diseases including worse COVID-19 outcomes. A recent publication from SPPH Professor Dr. Jerry Spiegel and former graduate student Ashleigh Domingo looked at food insecurity in First Nations communities and found that rates of obesity were highest for those in marginally food-insecure households, in comparison with food-secure households. Food insecurity followed a distinct pattern, associating with lower levels of income and education.
Indigenous people in Canada experience a significant gap in health outcomes, driven by social determinants of health including racism and discrimination. Similar to income or education, racism finds a way to impact other social determinants and exacerbate their effects. Among residents of Canada’s remote northern communities, these factors compound and contribute to the lowest life expectancy in the country.
For Indigenous people, colonialism is itself is also a social determinant. In addition to creating intergenerational trauma and separating Indigenous people from their culture, family, and land, colonialism also created distrust of the systems that caused harm, which can deter people from seeking help when they need it.
“It can be personal experiences that deter you from going back to seek services – if you had a bad experience or racist experience yourself – but it also doesn’t have to be personal experience,” explains SPPH PhD Candidate Chenoa Cassidy-Matthews. “There is a lot of historical and intergenerational trauma that makes people feel distrust of the system and makes them not want to encounter the system in any way, whether that is the police, paramedics, or having to go to the hospital.” The disproportionate effects of disease are exacerbated when those experiencing them are not comfortable seeking care, placing them further at risk.
Within SPPH, the Centre for Excellence in Indigenous Health (CEIH) was formed to advance the health of Indigenous people through education, research, and traditional practice. The Centre works to boost the participation of Indigenous people in the health sciences, address long-ignored research questions in Indigenous health, and educate UBC medical and health sciences trainees in the social determinants and cultural safety. It operates with the understanding that equity will only be reached when Indigenous people are empowered to identify and implement solutions to the health disparities that affect their communities, and that the systems and institutions responsible for creating these issues will not be the ones to solve them.
The inequities being exacerbated by the pandemic are not new to scholars of public health, but SPPH Associate Member Dr. Farah Shroff notes that there is a positive trend towards broader awareness within society. “The current social movements that are bringing ethno-racial justice to the forefront are very positive. Re-imagining institutions, including policing, in a way that centres the needs of Black, Indigenous and communities of colour will go a long way towards creating genuine safety, which is a critical determinant of health.”
Given that racialized people often experience lower socioeconomic status due to discrimination, and lower socioeconomic status is associated with health disparities and chronic disease, it comes as little surprise that in the United States and Canada, COVID-19 is disproportionately affecting communities of colour. In Toronto and Montreal, the hardest hit neighbourhoods are those that are also the poorest, and the most racialized. In the United States, communities of colour are disproportionately bearing the COVID-19 burden compared to their white counterparts.
COVID-19 likely won’t be the last pandemic we experience. If we want to be better prepared to fight the next one, we need to be concerned about the social determinants of health. As a society, this means taking the opportunity to reimagine programs to address safe and accessible housing, clean drinking water, nutritious food, educational and employment equity, health care, and community infrastructure to support families and connect them to the services they need. If we want to get serious about health disparities, we need to address the damage done by Canada’s colonial history and institutions, focus on eliminating discrimination, and improve equity for all.
By Elizabeth Samuels