The Pandemic and Public Health

Even before the new Coronavirus had a name, one thing was certain: A human being wasn’t entirely in control of whether they would get it.

In those first months, geography mattered most of all. On December 31, 2019, China reported a cluster of cases of unusual pneumonia in Wuhan, Hubei province. The illness didn’t have a formal name or a treatment or a known cause, only an epicentre. The first dozens of known cases occurred in the same region. Over the next few weeks, reports of patients with similar conditions began to pop up around the world, often tied to travellers from Wuhan: in Japan, South Korea and Thailand. On January 20, 2020, physicians in the US reported a confirmed case in a 35-year-old man who had presented to an urgent care clinic in Washington state with a four-day history of cough and subjective fever and a history of recent travel to Wuhan. Public health officials in Canada reported this country’s first presumptive case on January 25, 2020, a man in his 50s who’d flown home to Toronto from Wuhan three days earlier. He’d experienced mild symptoms on the flight.

By March, another certainty: How governments responded to this infectious illness would make a difference in slowing its spread and saving lives. Those that acted quickly—by initiating lockdown, shoring up health systems and gathering testing kits and personal protective equipment—buffered their population against COVID-19. Germany, where Chancellor Angela Merkel has a doctorate in quantum chemistry, went into lockdown by mid-March, while, in the UK, Prime Minister Boris Johnson stuck to a wait-and-see approach until March 23, when high infection rates made lockdown imperative. Two months later, about 44,000 residents in the UK had died from COVID, compared to 8,500 residents of Germany—or more than five times as many, despite Germany’s larger population.

Today, the virus is still making its way around the globe, including here in Canada. It’s doing so by exploiting the vulnerabilities that always put people at higher risk for disease and early death, disproportionately affecting those who are older but also who are poorer, marginalized or employed as essential workers.

There are ways to slow pandemics—and there are ways to blunt their impact in the first place. Over the first half of 2020, the pandemic illustrated in real time what public health experts have argued for decades: Government policies, even those seemingly unrelated to health, are a matter of life and death.

A government creates a resilient society by investing in things other than just health—making sure people aren’t poor, are educated, have housing.” DR. JIA HU, CALGARY MEDICAL OFFICER OF HEALTH

According to the Canadian Institute for Advanced Research, only 25 per cent of population health is determined by the healthcare system—things like doctors and medications and hospitals. About 15 per cent is determined by a person’s biology and genetics; another 10 per cent by one’s physical environment, including pollution, water quality and civic infrastructure.

That still leaves half, which portion is driven by a person’s social and economic environments: early childhood development, education, social inclusiveness, the social safety net, gender and racial equality, employment, income, housing, access to safe and nutritious food. These social determinants of health are conditions people have little control over—where they are born, grow up, live, work and age—and they’re much more important in health outcomes than many of the lifestyle choices we make every day.

Most major maladies, including heart disease and mental illness, parallel the social gradient: People in the lowest socioeconomic groups have the highest rate of illness, even in a country with publicly funded healthcare. The poor are more likely to have unmet health needs, suggesting they have difficulty accessing the public health system, and they’re more likely to suffer from cancer, chronic illnesses and diseases affecting the heart. When someone is born into poverty in Canada, they’re at increased risk for disease and addiction throughout their lifetime.

Chronic illnesses weren’t always so closely tied to poverty. In fact, midway through the 20th century, heart disease and diabetes were diseases of affluence—most common among the wealthiest quartile of society, and decreasing incrementally thereafter. The poor suffered ill health, certainly. Tuberculosis, for one, struck much more frequently among less privileged populations. Cancer had no consistent trend, because the disease was generally evenly spread across socioeconomic groups. But by 1991–1993 the pattern had changed: Heart disease and diabetes, along with cancer and tuberculosis, were now more prevalent, and dramatically so, among the lowest income quartile of society. These findings are based on data from the UK, where, as in Canada, a public health system delivers healthcare regardless of ability to pay. But the system did not equalize health outcomes: Wealth also means health.

This is true too for COVID-19, an infection that, early on, was said to select victims indiscriminately. In the late spring of 2020 Canada’s top health policy researchers gathered—virtually—for the annual meeting of the Canadian Association for Health Services and Policy Research. Dr. Amélie Quesnel-Vallée, Canada Research Chair in policies and health inequalities at McGill University, showed that, within a space of a few months, COVID-19 shifted from a disease of affluence to one of deprivation. People with lower incomes, more-vulnerable housing and less-lucrative employment were disproportionately affected.

Across Canada, COVID-19 started with travellers. In Montreal it initiated with Quebeckers returning home from spring break; many, like Quesnel-Vallée and family, had visited Europe and returned to their homes in high-income areas in the city centre. The first known case of COVID-19 in Montreal was reported February 27 in a woman who had recently returned from Iran. Over the next two weeks, cases appeared in more affluent neighbourhoods in the city. But as time passed, even with lockdown in place, COVID-19 surged and spread into high-density, low-income areas—a pattern that suggests people who do not have the space to physically distance or the luxury to work from home were defenceless against the novel virus.

“Physical distancing is a privilege,” said Quesnel-Vallée. “[COVID] is playing out along those social determinants in a way that wasn’t seen before in the extent of the spread and the speed of the spread.”

The same pattern repeated in Alberta. The province had its first presumptive case on March 5, a Calgary-area woman in her 50s who had been a passenger on the Grand Princess cruise ship. The next few cases were also travellers: an Edmonton man on the same cruise ship and a man who had travelled to the US for work. By March 24, Calgary’s northwest zone was hardest hit, with 29 cases, while the densely populated centre had only two. Six weeks later the picture looked dramatically different, with outbreaks in high-density residential areas, long-term care homes and poorer, rural areas. More than 1,500 cases and three fatalities were eventually linked to Cargill Inc.’s meat processing plant in High River. Twenty-three long-term care facilities and supportive living sites also had outbreaks.

By mid-July the Alberta regions with the highest per capita rates of COVID-19 were the lowest-income areas of the province. In Calgary the upper northeast quadrant had the highest incidence, with 41.7 active cases per 100,000 population. Here, according to Alberta Health Services data, 24 per cent of residents are sometimes or often worried about running out of food before they can afford to buy more, 28 per cent are immigrants and the average family income is roughly $30,000 below the provincial average. An outbreak arose in the County of Warner, just north of the US border, with 347.9 cases per 100,000. There, the average family income is some $34,000 less than the provincial average. Clear Hills County, in the province’s northwest, had 133.4 cases per 100,000, and 13 per cent of its residents are low-income. These data provide a limited perspective because they reflect outbreaks at a moment in time and, in rural communities, a smaller population. But they demonstrate the path that an infectious illness took throughout the province.

Calgary medical officer of health Dr. Jia Hu confirmed that social determinants are playing out in real time over the pandemic. “Usually it takes years, decades even, but here it took months,” he says. After the outbreak at Cargill, contact tracing helped unveil the factors contributing to the rapid spread of the virus: carpooling, low health literacy, crowded housing, people who kept working despite symptoms, due to fear of unemployment or need for income.

 “If you really want to deal with an outbreak, you need a resilient society,” says Dr. Hu. “A government creates a resilient society by investing in things other than just health—making sure people aren’t poor, are educated, have housing. You need that in addition to the acute response.”

People in homelessness often have really complex health issues. And if we think that isn’t a public health issue, then we’re mistaken.” KATRINA MILANEY, UNIVERSITY OF CALGARY SOCIOLOGIST

What might this look like? If, for example, physical distancing from other people is the best prescription for protection from the novel coronavirus, housing must be part of our government’s health strategy. From early March, staff at homeless shelters across Calgary tried to reduce risk for clients. At Alpha House, staff asked clients to sleep in a head-to-foot configuration in an attempt to get more space between faces during a cold snap in March. Shelters began screening clients by checking their temperatures and requiring anyone entering to sanitize their hands. The Telus Convention Centre was turned into an emergency shelter with capacity for 350 people to sleep, and a hotel was reopened for people who needed somewhere to isolate. Even so, at least two-dozen people at Calgary shelters tested positive for COVID before the end of spring.

“If you look at people who have no home, they are automatically at a really strong disadvantage,” says Dr. Hu. “They are told to self-isolate and to wash their hands, wear a mask. Where do you wash your hands if you don’t have access to a bathroom? And how do you self-isolate if you don’t have a home to self-isolate in?”

Katrina Milaney, a sociologist at the University of Calgary, says homelessness puts people at risk for many diseases but also stems from poor health. Illness hinders a person’s ability to make the kind of living that can pay for safe, spacious housing. The result is a population doubly susceptible to COVID-19: They’ve no place to isolate but are especially vulnerable to severe illness and death from this infection. “People in homelessness often have really complex health issues, chronic physical and complex mental health issues,” Milaney says. “And if we think that isn’t a public health issue, then we’re mistaken.”

She is concerned that a worsening economic crisis will drive more people into homelessness. “We need a spectrum of affordable housing options for everyone that needs them. That would be really good public health policy, and we’d see a decrease in strain on emergency services and healthcare.”

Likewise, the physical spaces around us directly affect our health all the time. Unsafe water and lack of hygiene facilities—a problem especially for Canada’s Indigenous communities—contribute to diarrheal disease. Polluted air and second-hand tobacco smoke cause cancers. Lack of open, green and public spaces worsens mental health.

Indeed, COVID demonstrated that people need green spaces where they can go without overcrowding. This is especially important in neighbourhoods where people live in tight quarters or multi-family dwellings without private yards. They need space to recreate. In Calgary the City closed several roads or lanes to cars to generate more safe space for walkers, runners and cyclists who had been packed onto pathways—an indication that the existing system isn’t enough.

“Some neighbourhoods have no local green spaces, parks or easy ways to get around on foot,” says Dr. Raj Bhardwaj, a family and urgent care physician in Calgary. “That affects people’s health directly during the pandemic, but when you look at the mental and physical health benefits, outside of the pandemic as well.”

Dr. Roman Pabayo, a social epidemiologist at the University of Alberta, says inequality has contributed to worse outcomes during the pandemic. He pointed to three ways that inequality leaves a population vulnerable to COVID-19.

First, inequality erodes social cohesion. “Social cohesion is like the trust and glue that keeps members of society together, leads us to care and to have compassion for each other,” he says. Cohesion matters when social distancing is the recommended prescription for a viral outbreak. The success of this treatment depends on the commitment of the population to faithfully adhere to what is a mentally, physically, emotionally and economically exhausting plan. Inequality makes it difficult for a community to share a sense of common fate. Social psychology research has shown that the sustained effectiveness of public health measures depends on a population’s willingness to make changes and sacrifices, but this momentum of solidarity slows in the presence of inequality. That makes it difficult to convince people of the value of an act such as mask-wearing to keep others safe. 

Second, says Pabayo, in more unequal societies the population is less likely to support social programs to protect the most vulnerable—thereby narrowing the buffers for people already at greater risk of getting and dying from the novel coronavirus.

And finally, inequality alone contributes to worse health outcomes. A 2019 study published in the Journal of the American College of Cardiology found that as income inequality increases, so does the rate of cardiovascular-related deaths and hospitalizations. Income inequality is associated with higher infant deaths and reduced healthy life expectancy. In the US, one of the world’s wealthiest countries, life expectancy is shorter than in less affluent but more equitable places. Inequality adds fuel to mental health problems. In more unequal societies, people compare themselves to each other, resulting in anxiety and depression. Societies with greater inequality have lower levels of interpersonal trust and greater class conflict.

[Inequality erodes] social cohesion, the trust and glue that keeps members of society together, leads us to care and to have compassion for each other.” ROMAN PABAYO, UNIVERSITY OF ALBERTA SOCIAL EPIDEMIOLOGIST

The pandemic has magnified existing inequalities. In June, Statistics Canada reported that income inequality across Canada is likely to worsen with COVID-19, as work interruptions related to the pandemic fall disproportionately on financially vulnerable families. Social divides deepened; in July, Alberta’s chief medical officer of health, Dr. Deena Hinshaw, said she had received reports that some Siksika Nation members were discriminated against at local businesses because of COVID-19 cases in the community. Hinshaw also noted earlier reports that Albertans of Chinese or other ethnic heritage and some religious groups were also singled out and discriminated against. “All Albertans of every heritage deserve better than that,” she said.

Government affects the social determinants of health, notes Dr. Lindsay McLaren, the senior editor of the Canadian Journal of Public Health and a professor at the University of Calgary’s O’Brien Institute for Public Health. They have levers to reduce poverty, for example. The fed and provinces long ago set up programs to support low-income families, including child tax benefits and a minimum wage. But these measures have not gone far enough to reduce income inequalities. Taking inflation into account, minimum wage in Canada peaked in 1976, at just over $11 an hour, according to Statistics Canada. In 2017 economists with the Institute for Research on Public Policy found that inequality had increased significantly in Canada since the early 1980s, although the situation stabilized after 2000, mainly as a result of a resource boom. The largest increases in inequality occurred in Ontario, BC and Alberta.

During the pandemic, governments announced additional income assistance programs for people in need, notably the federal Canada Emergency Response Benefit (CERB) to support workers who lost income as a result of COVID-19. Federal and provincial governments mobilized large amounts of money in a very short time to support citizens during the pandemic, says Dr. McLaren. “It was just to allow people to survive this time, to pay their rent and to pay their bills. That’s all part of public health.” She wants more supports such as CERB throughout the pandemic and after.

Dr. Mike Paulden, a health economist and assistant professor of public health at the University of Alberta, says the people who stand to benefit most from greater public health measures and social programs are marginalized populations. But these people don’t often look like the people who make policy, he says, and so “they get less attention. When we spend new money on a new technology, drug, diagnostic or whatever it is, those who stand to benefit from it are much
more identifiable.”

Is an ounce of prevention really worth a pound of cure? One large study from the University of York in the UK found that spending on public health improves overall health even more than spending on health systems does. The authors said that moving resources from the National Health System into public health initiatives—for example, creating more public housing—would be likely to improve overall health outcomes.

No similar study has been done in Canada to look at overall public health spending. And politicians aren’t always swayed by the cost-effectiveness of individual public health measures. A 2010 economic analysis of Vancouver’s Insite supervised injection facility demonstrated that, based on conservative estimates, the site prevented 35 new cases of HIV and almost three deaths per year—a societal benefit in excess of $6-million annually. A recent study from the University of Calgary’s Dr. Jennifer Jackson showed that supervised consumption sites have saved Alberta nearly $2.3-million in reduced ambulance and ER costs. These are the kind of savings “health economists would regard as a kind of no brainer,” says Dr. Paulden. But supervised consumption sites remain controversial here.

And when it comes to government spending on social programs that improve determinants of health, again the people most likely to benefit are those with the lowest incomes, who are often those with the worst health. But governments rarely prioritize social spending. A 2018 study published in the Canadian Medical Association Journal reported that, based on data from provincial reports from 1981 to 2011, a one-cent increase in social spending per dollar spent on health was associated with an 0.1 per cent decrease in potentially avoidable mortality and a 0.01 per cent increase in life expectancy.

The study’s lead author, Dr. Daniel Dutton, an assistant professor of community health and epidemiology at Dalhousie, says social assistance spending makes a real difference to individuals at highest risk of deep poverty. He worries that the people we already overlook will “be completely ignored as COVID sucks up all our available attention.” So far, governments have put more importance on the reopening of bars and golf courses than on handling problems most relevant to the other end of the income spectrum, he says. “I hope COVID causes us to critically reassess how we structure supports for those in society who are extremely vulnerable or whom we rely upon for critical services, such as grocery store employees,” he says.

 This pandemic shows no signs of waning. The main tools of protection remain the same as back in March 2020. Wash your hands, yes. Don’t touch your face, certainly. Wear a mask. But ultimately your risk for getting COVID-19 has a lot to do with things outside your control.

All Albertans of every heritage deserve better than being singled out or discriminated against.” DR. DEENA HINSHAW, CHIEF MEDICAL OFFICER OF HEALTH

COVID-19 is a political challenge as much as a scientific one. The same was true with the early years of the AIDS epidemic, says the U of A’s Dr. Pabayo. Government officials repeatedly ignored alerts from physicians about a new kind of illness, a kind of Kaposi’s sarcoma with unusual features that was affecting, initially, young gay men or intravenous drug users. These warnings were dismissed. If governments around the world had listened to public health experts, especially in the US, where 1,292 people had died by the end of 1983, far fewer people would have succumbed to AIDS, Pabayo believes.

The same principle is at play in any public health crisis, he says. “A virus is not political, but the environment in which a virus takes hold is political.”