by Levonne Abshire and Tenny King, MAR Healthcare Advocacy Team members.
Levonne (she/her/hers) identifies as a second-generation Filipinx-Canadian who lives on the traditional, ancestral and unceded territories of the Coast Salish Peoples, colonially referred to as East Vancouver.
Tenny (she/her/hers) is a first generation Canadian of European and Armenian descent, who lives on the ancestral and unceded territories of the Lekwungen-speaking peoples in what is now known as Victoria, BC.
We are all in this together, but we don’t all experience the pandemic in the same way. We are told to follow public health orders but whose lifestyles do the orders most consider? When in crisis, what set of rules does our society fall back on, and who do these rules protect?
The one year mark of COVID has come and gone, and with it another set of public health orders. Although ‘Bubble’ talk feels familiar now, it makes me reflect on how our public health orders have been inherently white upholding. Throughout this pandemic, it has felt like the recommendations were based on the typical white family; nuclear and living in separate households because they can most often afford to. I feel that the white privilege I hold has made it easier for me to follow the public health orders than for others and, consequently, my family and I are more protected from COVID. I only live with my partner and children, so we have not had to worry about exposing our elders to COVID. I have paid sick leave and the financial security to manage childcare without having to rely on relatives. I am an English-speaking Registered Nurse and can therefore access the virtualized healthcare system as easily as a person can. It has been straightforward for me to follow the rules and access judgement-free health care. But I know this is because the system is designed for me, a white person.
It’s undeniable that our public health leaders have had an immense challenge on their hands for the last year. I am grateful to be benefiting from the evidence-based approach to health that is guiding public policy. But I wonder who these recommendations are leaving out and at what cost? Without appropriate data, and without an anti-racist lens, the government (as a colonial system) is not fully capable of understanding the implications of public health orders on non-white families, nor can it set a path for those families so they can keep just as safe as white families.
Race, on its own, is not a risk factor for COVID-19. Societal structures, however, place some individuals at a higher risk than others. Data from the United States proves that Black, Indigenous, racialized, and marginalized individuals bear the greatest impact of this pandemic. Here in Canada, we don’t know exactly how the virus is magnifying racially-based health inequities because the government doesn't collect data on the ethnicity of individuals infected by the virus. Instead, we collect data at the neighborhood level. In the absence of race-based COVID-19 data, grassroots organizations have been sounding the alarm: in Canada, non-white families are at higher risk of becoming infected with COVID than white families.
Levonne’s observations and experiences
As a Filipinx-Canadian, I have seen how Covid-19 and the responses of our public health officials have disproportionately impacted the Filipinx community, specifically those who work on the front line and live in multi-generational households. Early in the pandemic, a CBC news article highlighted how Filipino-Canadian care aides are disproportionately affected by the COVID-19 pandemic, citing that “many front-line workers — including food services employees, health care aides, grocery store clerks, and custodial staff — are people of colour. They are at the low end of the earning scale, but are at high risk of being exposed to COVID-19 and spreading it.” Cora Mojica, a union hospital member at one of BC’s largest hospitals estimates that 90 percent of food service workers are women of colour and most are immigrants from the Philippines. In an interview with Stephen Quinn of the The Early Addition, Lenora Angeles, an associate professor with UBC's Institute for Gender, Race, Sexuality and Social Justice, shared that a disproportionate amount of care aides in long term care homes and assisted living facilities are Filipino and as a result of federal immigration and labour laws, such as the Live-in Caregiver Program, many Filipinos are kept working in low-wage sectors such as domestic child care and seniors' care. She suggests that many Filipino people who are working in such positions cannot afford to speak up to demand greater protection and increased wages for fear of losing their jobs. Many are supporting families here in Canada and back home in the Philippines.
This is just one example of how race, ethnicity, nationality and income determine one’s experience of health and wellbeing. These identity markers are known as the social determinants of health. The social determinants of health (SDH) are the non-medical factors that influence health outcomes and include: income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviours, access to health services, biology and genetic endowment, gender, culture and race/racism (Government of Canada). They are 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. Research has shown that SDH can be more important than health care or lifestyle choices in influencing health outcomes. (World Health Organization).
Another area we have seen where IBPOC families are disproportionately impacted, or more so forgotten, is in the specific public health measures communicated by the Ministry of Health. In an interview with CBC, Satwinder Bains, director of the South Asian Studies Institute at the University of the Fraser Valley, criticized the Ministry of Health for focusing on cultural gatherings and multigenerational households as causes for Covid-19 spikes. This resulted in what she called a “pathologizing of culture" which then resulted in the development of stereotypes and fear towards certain racial groups. Why is it we have not criticized the normative culture of placing the elderly in care homes? The images of families having to see their elderly loved ones from two stories below or through a glass window is heartbreaking and maybe pause for reflection on how we must respect the diversity of cultures in our community such as multigenerational households.
I have lived in a multigenerational home during various stages of my life. Grandparents in multigenerational homes play a significant role in the lives of both their children and grand-children, especially during this pandemic; yet no specific health measures or directions were provided for these types of families and households. There was lots of information about how to interact with older adults and the elderly in care homes throughout this pandemic but, when it was time for school age children to go back into class, there was no information about how to keep one’s family safe if you lived in a multigenerational household. This is a clear example of how public health measures are, and continue to be, developed with a specific population in mind.
The government’s inability to collect race/ethnic based data during Covid-19, to pay attention to the social determinants of health, it’s “pathologizing of culture” in its Provincial Health Orders, and its disregard for considering the complexity and diversity of our community when providing health information, are all examples of health inequities. Health inequities(1) are health differences between various groups that are defined by social, economic, demographic or geographic terms. These terms are typically unfair and avoidable(2).
Covid-19 has shone a light on the health disparities and inequities that exist and persist as a result of colonialism and systemic racism. Covid-19, the virus, may not discriminate based on one’s race or ethnicity, but colonialism and racism do. They create barriers for IBPOC communities to reach their full health potential, whether as a result of inaccessible information and care, as seen in BCs Provincial Health Orders; the policies that do not protect workers rights, as seen with migrant and temporary foreign workers, and; historical trauma as a result of racism experienced in the healthcare system, as we know from Indigenous communities’ experiences of racism in the health care system.
Health equity means that all people can reach their full health potential and should not be disadvantaged from attaining it because of their race, ethnicity, religion, gender, age, social class, socioeconomic status or other socially determined circumstance. Health equity involves: the equitable distribution of resources needed for health, equitable access to health information, and equitable access to healthcare when people are ill. My hope is that we can learn from these inequities Covid-19 has highlighted and that we can move forward with creating more just ways of providing health information and care.
Pandemic life has forced us to live with constant change which can bring opportunity. We know our systems can be flexible. With a year of struggle behind us, it is imperative that the government respond to this health crisis in a way that actively promotes health equity. As Levonne describes, health equity is about making changes to ensure we all have the same opportunity to be healthy. In the current context of structural disadvantage, a blanket-approach to collecting data and rolling out public health measures is not enough. We need to decolonize our public health response to COVID-19, and other health emergencies (such as the ongoing opioid crisis). What could the steps to decolonizing the public health response to COVID-19 look like?
Well, right now, we can:
Collect detailed, culturally relevant health data and use it with the intention to unmask the barriers that often impede BIPOC from receiving health and medical care. This data can be compared to existing information on social determinants of health (eg. housing affordability, access to clean water, income, job security) to identify risk and target funding efforts to reduce the burden of COVID-19 on affected communities.
Create more space for, and financially invest in, non-white responses to public health. Current examples are BC’s First Nations Health Authority and the Ontario/BC South Asian COVID Task Force. Both are creating culturally appropriate communications and education around access to health care and should be expanded on. We can also push for public health orders that are more inclusive and representative. For example, orders that consider impacts to intergenerational households, and individuals who work in multiple workplaces.
Respect self determination, utilize peer experts, and highlight BIPOC voices. Indigenous communities, for example, have utilized self-determination during COVID-19 by restricting who can and cannot travel into certain communities. In some cases they have also advocated for the collection of, and sovereignty over, Indigenous-specific health data. In the spirit of ‘nothing about us without us,’ BIPOC community leaders should be directly involved in public health planning, analysis, and action at every level.
Develop a mechanism for reporting experiences of racism in health care. This measure, which was cited as recommendation #5 in Dr. Mary Ellen Turpel-Lafond’s 2020 report In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care, is long overdue. We need to collect detailed information on the scope of this massive problem in order to address it and be accountable to change.
Big picture, we need to:
Urgently address the social determinants of health in Indigenous and racialized communities. Social distancing and hygiene practices, the main tools for containing COVID-19, require clean water, adequate plumbing, access to housing, and a certain level of income. Because of colonial history and structural racism, BIPOC Canadians are less likely to have access to these means. In order to address health inequity, money needs to flow directly to the communities in question: to build affordable housing, develop infrastructure, and support education and training programs.
Subvert the patriarchal narrative of healthcare. Our current healthcare system has been built on the norms of a patriarchal society. Health care providers are typically seen as ‘gatekeepers’ to accessing care and knowledge. This narrative is starting to shift with the focus on patient and family-centred health care, but the structures that hold the system up remain inherently colonial. We need to not only invite BIPOC experts and patient partners into all levels of healthcare decision-making, but we must also actively listen to them and make decisions together with our peer experts.
To further address patriarchy in healthcare we need better pay and job security for our so-called ‘pink collar’ workers, like our Health Care Aides, many of whom are BIPOC and have to work multiple jobs to support themselves.
In order to increase BIPOC accessibility to healthcare, we need to vastly increase cultural representation in healthcare professions, healthcare education and, perhaps more importantly, healthcare management. Representation will help turn the tide of white-centering in health care.
We need to develop better, mandatory training for health professionals in cultural humility and safety, and trauma informed care. We can’t rely on the click-through, online modules to uproot deeply-ingrained racist beliefs. We need health professionals to be accountable for their actions; and we need to give our health care workers (and management) the tools to succeed in their deeply personal work of anti-racism.
This pandemic has occurred against the backdrop of a massive societal change. We are seeing the world wake up to racism. The changes outlined above are not new ideas; the good news is that this work is already underway. We need to support and amplify these efforts. Deep work needs to happen at all levels of the healthcare system, and society at large, to address the health inequities that BIPOC face. As MAR advocates, this work needs to start at home. As individuals, we can use our voices to point out gaps and advocate for change in our communities. It is going to be hard work, but if anything, this pandemic has taught us that we are capable of doing hard things.
Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in health: Levelling up part 1. Geneva: World Health Organization; 2006 [cited 2012 Sept 21]. Available from: www.euro.who. int/__data/assets/pdf_file/0010/74737/ E89383.pdf
World Health Organization. “Equity Team” definition. Health and Human Rights and Equity Working Group Draft Glossary Unpublished 2005. 2005. Unpublished Work
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