Advancing an inclusive approach to pandemic policy co-design
Well before the COVID-19 pandemic, Canada, like many other parts of the world, was grappling with challenges related to health equity. For decades, there was growing awareness that the Canadian health system and public health infrastructure were not providing adequate and equitable support to some of Canada’s most vulnerable and marginalized citizens.
Years of cuts to healthcare, decreased public health funding and a massive blind spot on access to mental health care were already taking a toll when the pandemic hit. In response, many Canadian health leaders have been covering their eyes with one hand and pointing south of the border to the United States with the other.
Fortunately, many Canadian jurisdictions are beginning to collect data to measure and address the disproportionate toll the pandemic is taking on populations that have been structurally marginalized for much of Canada’s history. These groups are at risk of both contracting the virus and, if they get sick, have considerably worse outcomes due to these inequities. There is also no doubt that the economic fallout from the pandemic will disproportionately impact these same populations.
Effectively addressing the disproportionate impacts of the pandemic requires an appreciation for the breadth and depth of structural inequities. An equity-centered response goes beyond simply collecting data or investing in research. Thinking upstream requires us to take an inclusive approach to co-designing pandemic policy with the public we purport to serve.
Throughout the pandemic, health organizations have been rapidly developing policies relating to testing, distribution/allocation of personal protective equipment and redeployment with an emphasis on acute care settings. But have we determined which voices are missing from this discussion? Are decisions being made with attention to those who are most vulnerable? Bringing an equity lens to policy design may help analyze the impact of policy decisions on underserved and marginalized individuals and groups.
Although Canada has a longstanding history of assessing the health equity impact of decisions, Canadian organizations and institutions have been criticized for not going deep enough. For example, a 2012 study explored how public health standards across Canada conceptualize health equity. Researchers found that provinces identified health inequities because of unfair or unjust structural conditions. Many provinces also identified limits to the accountability of public health offices to reduce health inequities. Missing was an analysis of systemic factors and deeper analysis regarding the roots of health inequity.
Given the stunning spread and speed of COVID-19, an inclusive approach to pandemic policy would not slow the process but rather mitigate our lived experiences. An example of successful inclusive pandemic policy can be found in Seattle, Wa., where one of the earliest outbreaks in North America occurred. Communities in this region worked to ensure public health directives were designed with input from community leaders and included customized messaging. Attention was paid to social stigma toward Asian communities. Pandemic management in Seattle and King County included a Pandemic Community Advisory Group as part of the command structure.
Another example is data ownership and sharing. Although collecting information about COVID-19 and sharing it with the public is an important aspect of pandemic planning, failure to centre Indigenous communities in all aspects of data collection and ownership is problematic for several reasons. Data that are not meaningful to Indigenous communities continue to be collected without meaningful action and perpetuate further inequity. In addition, health data can be misused in ways that perpetuate structural oppression. For example, in Manitoba, pandemic data is collected and held by Indigenous leaders, while decision-making and policy creation regarding care and the downstream impact of the pandemic are held within Indigenous communities. Indigenous leaders also have a seat at the provincial pandemic planning table.
An inclusive approach to pandemic policy does not assume or expect that every policy will be completely equitable. Rather, it provides proactive ways to consider the impact of inevitable policies such as those related to physical distancing; equity shines a light on issues such as inadequate or unsafe housing and food insecurity.
Meaningful engagement, co-creation and partnership with individuals from the communities most disproportionately impacted by a pandemic does not simply lead to more equitable policy. Inclusive policy design allows organizations focused and strategic guidance to develop and implement better policy overall. Improving health equity is a complex undertaking, therefore no single change can achieve this objective. Yet, an equity-centred approach ensures that a crisis does not detract from our ongoing progress toward justice.
The COVID-19 pandemic has redefined what it means to be vulnerable. As large numbers of Canadians apply for social assistance and seek government support to survive, will we forget about those Canadians who were struggling before the pandemic?
Our shared vulnerability must provide a springboard for collective action.
Javeed Sukhera, MD, PhD, FRCPC is Associate Professor, Departments of Psychiatry/Paediatrics; Scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University.
Ming-Ka Chan, MD, MHPE, FRCPC is Co-Director, Office of Leadership Education, Rady Faculty of Health Services; Associate Professor, Department of Pediatrics and Child Health, University of Manitoba.
Jerry M. Maniate, MD, MEd, FRCPC is Vice President of Education, The Ottawa Hospital; Associate Professor, Faculty of Medicine, University of Ottawa.
Lisa Richardson, MD, MA, FRCPC is Strategic Lead in Indigenous Health, Faculty of Medicine; Associate Professor, Department of Internal Medicine, University of Toronto.