Equity, a key indicator in monitoring COVID-19

The D^D Nakia K. Lee-Foon (Ph.D.) is a postdoctoral fellow at the Dalla Lana School of Public Health at the University of Toronto. His work ranges from examining equity in health care systems to exploring the sexual health knowledge of young men who identify as black and have sex with other men in Toronto.

The D^r Adalsteinn Brown is Professor and Dean of the Dalla Lana School of Public Health at the University of Toronto. His research focuses on health policies, measuring the performance of health systems and improving training programs for doctoral students.

The COVID-19 pandemic has profoundly challenged the ability of governments to effectively combat public health threats. A careful analysis of what happened and what should have happened will no doubt reveal problems ranging from gaps in disease surveillance, to limited supplies of personal protective equipment, to difficulties in communication and the use of emerging evidence by researchers and policy makers.

It is undeniable that at the start of the pandemic, many authorities failed to take into account the inequitable effect of infectious diseases on societies, a widely recognized fact.

At the start of the health crisis, Canada was not prepared for the rapid spread of SARS-CoV-2 or its consequences on health systems. Once the contamination became indisputable, the responses of many provinces were brutal, with the sole objective of reducing contact between people and, therefore, the transmission of the virus. Although these measures have reduced infection rates and likely saved thousands of lives, some researchers and public health officials early on advocated emphasizing the inequitable effect of the pandemic, highlighted evidenced by statistics from virtually every jurisdiction that consistently show an overrepresentation of racialized or low-income populations and other marginalized groups among COVID victims. These populations constitute an important part of the essential workforce that directly or indirectly affects the lives and health of all members of society. This over-representation has highlighted the disconnect between governments’ goal of diminishing the effects of COVID and the disruption to society it has brought.

There is no universal definition of health equity. We therefore define it here as the reduction of avoidable health disparities and their drivers in groups based on the social determinants of health or privilege arising from socioeconomic status, gender identity, race, education and other types of distinctions. In Canada, some researchers have adopted a health equity lens to analyze and treat COVID. However, there are differences in how disease reduction is viewed from this perspective. Diverse approaches and frameworks complicate efforts in this direction, despite the link between improving social determinants and health.

These variations have resulted in a concentration of the disease in racialized and low-income neighborhoods. Many governments at all levels have been slow to put in place policies to address these inequalities. For example, at the start of the pandemic, in January 2020, Ontario made COVID a reportable disease. He also instituted sweeping public health measures in the spring.

Although researchers found disparities across socioeconomic strata in the early months of the health crisis, provincial equity-focused responses did not begin until the middle of the second wave, with the exception of a moratorium. on tenant evictions announced during the first wave. These belated and inconsistent responses have prompted groups such as hospitals and health centers and community organizations to develop their own interventions to address inequities within the communities they serve.

Canadian data on COVID cases unequivocally shows that health equity approaches and frameworks must consider the factors that make racialized and low-income populations more vulnerable to exposure to COVID and death that may result.

The Toronto example

The need for such an angle is evident in Ontario, the province with the highest number of COVID cases in the country.

In the absence of standardized province-wide rules for collecting reliable data on social factors, some public health departments have taken it upon themselves to extrapolate the effect of COVID on vulnerable populations. For example, the province’s largest public health service, Toronto Public Health (TPH), collects data on some of the major social determinants of health (e.g. racial identity, income, household size) . The axes of data collection (particularly socio-demographic questions) draw on disease data collected in other localities, and these axes greatly influence other health outcomes. The submissions are intended to inform TPH, the City of Toronto, and City Health Services and community collaborators on efforts to address COVID-related disparities, particularly among populations and in communities. neighborhoods hardest hit by the virus.

The data revealed startling, but not surprising, trends in disease. For example, most COVID cases (72%) are found among racialized populations and 44% among low-income households. Racialized communities and newcomers are often overrepresented in low-wage essential services and face-to-face with the public. They therefore expose themselves to a higher risk of transmission due to the need to continue their (essential) work and the difficulties in accessing essential resources such as personal protective equipment, not to mention their cramped accommodations. These factors, combined with comorbidity, racism, social exclusion and neighborhoods underserved by services of all kinds, increase their risk of contracting COVID.

In the fall of 2020, TPH was tasked with creating a set of COVID equity indicators that were incorporated into the City’s Pandemic Watch Dashboard. This coronavirus dashboard appears to be one of the few in Canada to explicitly present data on equity and race. It also includes indicators on: virus spread and containment, laboratory testing, health care system capacity and public health. It provides information on the current state of the pandemic and tracks changes in disease rates across the city. The “equity” category aims to flag income, race and neighborhood inequalities in vaccination and COVID case rates. These indicators can highlight areas that require additional attention, review, and action. Additionally, they help researchers, policymakers, officials, and community members closely track populations at increased risk of exposure, progress in the fight against the coronavirus, and disparities in infection rates. infection.

These data may have strengthened the equity of public health interventions and helped reduce COVID rates in these populations. For example, the first sociodemographic data analysis conducted by TPH in July 2020 found that blacks and Latinos had 6 to 11 times higher rates of COVID than whites. This data led the City to quickly implement various interventions in hard-hit areas and to organize community consultations in order to respond more equitably to the diseases. Actions ranged from multilingual public health announcements to free emergency childcare services.

Recognition of inequality has shaped the City’s COVID policies and helped protect the lives of populations at heightened risk of disease exposure and infection. This effect again confirms the need to move away from aggregate data collection, a method commonly used in Canadian healthcare settings. By making disaggregated data easily accessible, we ensure that health resources can be distributed in a way that better meets the needs of populations. As a study assessing health equity-focused COVID reporting in Canada noted, the lack of data related to risk settings or social markers may mask larger disparities around COVID.

A model to follow

The Toronto Dashboard provides municipal and national healthcare facilities with a model for integrating equity into their COVID reporting and planning. This can be done mainly in two ways:

First, include equality indicators in COVID dashboards. It is not enough to state that equity is a component of the fight against COVID, it is necessary to specify how it is evaluated, measured and implemented. This information can help health facilities better understand the spread of disease and, potentially, identify and address underlying inequities. To gather meaningful information, researchers must critically examine pre-existing factors that aggravate health problems and use these to augment their indicators.

The indicators must also be used to assess the equity of the care provided by the health establishments. This metric is important because the City of Toronto says its inequality indicators cannot determine strategies to address it, but the data can be used to assess the degree of equity between different strategies. This helps to ensure that strategies are scrutinized for their ability to deliver quality, effective and accessible services that meet the needs of the population.

Second, we need to collect disaggregated health data. While this suggestion is not new, and some Canadian scientists in the field have been calling for a concerted effort for years, COVID has further underscored the need for it, as well as revealing other major gaps. and preventable in health care knowledge. If collected properly and put into context by community organizations or trained stakeholders, data can be used to improve health care as a whole.

As healthcare facilities continue to be pressured to better address COVID, having a dashboard that shows emerging inequities related to the coronavirus in real time is vital. This type of chart can not only reveal trends, but also help save the lives of those who are often overlooked by traditional disease surveillance approaches.