The ongoing COVID-19 pandemic has challenged our current health care system. The global pandemic has exacerbated existing health inequalities and has provided ‘’an unprecedented illustration of the determinants of health and their importance’’ (Government of Canada, 2020). Responsible for a wide range of health and quality of life outcomes, the social determinants of health are defined as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life" (World Health Organization, n.d.). The negative impacts of COVID-19 have been experienced more by marginalized and vulnerable groups and recent emerging trends show that this can be explained by the social determinants of health (Abrams & Szefler, 2020).
A big part of my role as a registered respiratory therapist has been treating and managing the care of COVID-19 patients in the intensive care unit. It wasn’t long into the first wave of the pandemic that my colleagues and I quickly perceived the pandemic’s disproportionate burden on ‘non-white’ individuals in the intensive care unit. Ontario Health would later confirm our suspicions that ‘’white Ontarians have experienced the lowest crude per capita rates of COVID-19 infection. Latino and South Asian communities have been particularly impacted” (Ontario Health, 2021). Following early reports of social inequities in COVID-19 outcomes, jurisdictions in Ontario started to collect social determinants of health data as part of COVID-19 surveillance. Quebec and Manitoba followed suit.
The current synopsis for the province of Ontario concludes that social determinants of health such as gender, socioeconomic position, race/ethnicity, occupation, indigeneity, homelessness and incarceration, plays an important role in the risk of Covid-19 infection, ‘’particularly when they limit ability to maintain physical distancing’’ (Public Health Ontario, 2020). Increased prevalence of underlying medical conditions, or decreased access to health care also contribute to increased risk of severe Covid-19 outcomes (Public Health Ontario, 2020).
Just as we perceived it in our ICU, white Ontarians have experienced the lowest rates of hospitalizations, ICU admissions and death (Ontario Health, 2021). Latino and Middle Eastern communities have experienced the highest rates of hospitalizations, 7-9 times higher than those of white Ontarians, and Latino and South-East Asian communities have experienced the highest rates of COVID-19-related critical care admissions, ten times higher than for white Ontarians (Ontario Health, 2021). In Toronto, the lowest income group had higher rates of COVID-19 cases and hospitalizations compared to the highest income group (Public Health Ontario, 2020). Areas with the highest percent of people from racialized communities, immigrants, people with lower education levels, and unemployed people had higher COVID-19 case and hospitalization rates compared to groups with the lowest percent of each (Public Health Ontario, 2020).
Pre-existing social inequities in health may increase the risk of severe COVID-19 outcomes, such as hospitalization and death (Abrams & Szefler, 2020). First Nations people, Metis, and Inuit populations are overrepresented among Canadians with low socioeconomic status, with issues of overcrowded housing and food insecurity. Health issues such as diabetes, hypertension, cardiovascular disease and chronic respiratory disease are associated with low socioeconomic status in Canada (Public Health Ontario, 2020). COVID-19 exacerbates these issues of poverty, lack of adequate housing, and lack of nutrition and unemployment. “How can you self-isolate in a house that is already overcrowded or does not have potable water?’’ (Government of Canada, 2020). Difficulty in accessing medical care, including preventative medicine, can further be complicated by geographic location or geographic isolation (Public Health Ontario, 2020).
Data with respect to race, ethnicity and Indigeneity was collected in 2020 by the government of Manitoba, in an effort to further understand why COVID-19 infections in Manitoba were not evenly distributed throughout the population and also as a means of addressing health equity (Government of Manitoba, 2021). The report shows racialized groups, particularly Africans, Filipinos, North American Indigenous, and South Asian are over-represented in COVID-19 case counts. Similarly to the province of Ontario, the burden of disease is lowest for White Manitobans. While the data in the report is incomplete with respect to occupation, income and housing, the report contextualizes the data and it finds that Black, Indigenous, and People of Color are over-represented in the manufacturing labor sector, which has the highest rates of COVID-19 cases (Government of Manitoba, 2021)
COVID-19 driven inequalities in digital communication have also come to the forefront (Viswanath et al., 2020). Social determinants such as education, race, income and employment have impacted different social groups in accessing, processing and using digital information. (Viswanath, 2020). Current evidence suggests that upper socioeconomic groups acquire information at a faster rate than others, reinforcing existing inequalities between different socioeconomic groups (Viswanath et al., 2020). In low-income countries, ‘’there is no universal experience of growing up in a digital world’’ (The Lancet Digital Health Editorial,2021).
The global pandemic has exposed the best and worst of system structures as well as vulnerabilities in these systems (Government of Canada, 2020). The COVID-19 pandemic has exacerbated the pre-existing health disparities in our country and their impact on patient outcomes. Therefore it is appropriate that as Chief Public Health Officer, Dr. Tam’s strategic goal in her five-year mandate was to undertake a comprehensive approach to public health challenges to address the social determinants of health and their resulting health inequities. On a more individual level, as I endeavor to champion for improved health equity for the patients I care for, and advocate for patient centered care, I recognize the influence of social determinants of health and their impact on patient health outcomes.
Abrams, E. M., & Szefler, S. J. (2020). COVID-19 and the impact of social determinants of health. The Lancet Respiratory Medicine, 8(7), 659–661. https://doi.org/10.1016/S2213-2600(20)30234-4
Government of Canada. (2020). From Risk to Resilience: An Equity Approach to COVID-19. Supplementary report for the Chief Public Health Officer of Canada’s Report on the State of Public Health in Canada 2020. https://www.canada.ca/content/dam/phac-aspc/documents/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/from-risk-resilience-equity-approach-covid-19/best-brains-exchange-proceedings-report/bbe-eng.pdf
Government of Manitoba. (2021). COVID-19 Infections in Manitoba: Race, Ethnicity, and Indigeneity External Report. https://www.gov.mb.ca/health/publichealth/surveillance/docs/rei_external.pdf
Ontario Health. (2021). Report: tracking COVID 19 Through Race-Based Data. https://www.ontariohealth.ca/our-work/equity-inclusion-diversity-and-anti-racism/report-covid-19-race-based-data
Public Health Ontario. (2020, May 24). Covid-19 – What We Know So Far About…Social Determinants of Health. https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/2020/05/what-we-know-social-determinants-health.pdf?la=en
The Lancet Digital Health Editorial. (2021). Digital technologies: a new determinant of health. The Lancet Digital Health, 3(11). https://doi.org/10.1016/S2589-7500(21)00238-7
Viswanath, K., Lee, E., & Pinnamaneni, R. (2020). We Need the Lens of Equity in COVID-19 Communication. Health communication, 35(14), 1743–1746. https://doi.org/10.1080/10410236.2020.1837445
World Health Organization. (n.d.). Social Determinants of Health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
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