The pandemic recovery period presents an opportunity to address health inequities that have led to an unfair distribution of the burden and harms of COVID-19.
New guidance for policy published in CMAJ proposes 13 practical ways to address inequities exposed and worsened by COVID-19 in the pandemic recovery period, based on evidence that was accumulating before the pandemic.
In this special episode of the podcast, CMAJ interim editor-in-chief Dr. Kirsten Patrick talks to Dr. Nav Persaud, lead author on the new guideline, about its genesis, the evidence underpinning its recommendations, and the importance of positioning equity at the centre of policy-making as Canada emerges from the pandemic.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
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Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
The pandemic recovery period presents an opportunity to address health inequities that have led to an unfair distribution of the burden and harms of COVID-19.
New guidance for policy published in CMAJ proposes 13 practical ways to address inequities exposed and worsened by COVID-19 in the pandemic recovery period, based on evidence that was accumulating before the pandemic.
In this special episode of the podcast, CMAJ interim editor-in-chief Dr. Kirsten Patrick talks to Dr. Nav Persaud, lead author on the new guideline, about its genesis, the evidence underpinning its recommendations, and the importance of positioning equity at the centre of policy-making as Canada emerges from the pandemic.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Kirsten Patrick:
Welcome to this special episode of the CMAJ podcast. Regular listeners will notice that I'm neither Blair nor Mojola. I'm Dr. Kirsten Patrick, interim editor and chief of CMAJ. Our new podcast hosts will be back as they promised on the next episode. This episode, along with occasional future ones, we'll follow our old style to focus on a new guideline published in CMAJ.
Dr. Kirsten Patrick:
Today, I'm talking about the article entitled Recommendations for Equitable COVID-19 Pandemic Recovery in Canada, which is co-authored by Dr. Nav Persaud. Dr. Persaud is a staff physician at St Michael's hospital in Toronto and a Canada research chair in health justice at the university of Toronto. He also works sometimes as an associate editor for CMAJ. Welcome, Nav.
Dr. Nav Persaud:
Thank you, Kristen.
Dr. Kirsten Patrick:
So let's start by having you tell readers why this guidance, why now, what problem do we have that needs to be solved at this point?
Dr. Nav Persaud:
Inequities that were present before the pandemic were exacerbated and exposed during the spread of COVID-19. And there's also been increased attention to inequities or unfairness in society. So there's an opportunity to make changes now.
Dr. Kirsten Patrick:
Let's explore the equity angle a little bit more. Why is it so important to use an equity lens for pandemic recovery policy making, rather than say, let's restore the economy lens, like the build back better programs seem to imply?
Dr. Nav Persaud:
Society was unfair before the pandemic. And things are unfair now. And during the pandemic, we all experienced harms related to those inequities. During the pandemic, the spread of COVID-19 among personal support workers or residents in long-term care facilities or shelters for people experiencing homelessness threatened the health of everyone. As the virus was spreading, we were all at risk. So I think we were able to see the problems caused by inequities when they directly put everyone's health at risk.
Dr. Nav Persaud:
Of course, inequities are primarily a problem for those who are disadvantaged. And when a person who's experiencing homeless has a heart attack or a stroke, that doesn't necessarily cause a problem for others, but it helps to underscore the fact that inequities threaten health. And so we have an opportunity now, I think to address these inequities that can put us all at risk and also disproportionately impact those who are disadvantaged.
Dr. Kirsten Patrick:
And I think the COVID-19 pandemic has really highlighted these inequities, even for people who may not have wanted to see them before. Because although nobody could say that they've come out of the pandemic unscathed, it's pretty clear to just about everybody now that folks who are socially disadvantaged or disabled or racialized have definitely had worse health outcomes with this pandemic.
Dr. Nav Persaud:
Yeah. I think you first were asking about why we want to focus on equity versus restoring the economy or building the economy back better. Yeah. I mean, I think the economy that we had before and have now has inequity baked into it and is based on the fact that people will agree to work in dangerous jobs, like in meat processing plants. And so I'm not sure that we want to build that back better. What we'd want to do is first address basic.
Dr. Nav Persaud:
So make sure that everyone has a living income, for example, so that if someone is being pressured to work in a place that's not safe, be it a meat processing plant or a long term care facility where personal protective equipment is not provided, that person has some options and can say, "No, see if you can find someone else to do this, or if not, maybe try and make this job safer and more appropriate."
Dr. Kirsten Patrick:
Absolutely. I mean, that idea of, I think sometimes we fall into this trap of when we talk about building back better, we're building back an economy in the image of the pre-pandemic approach to economic growth. And that's not sustainable. That's been very clear during the pandemic.
Dr. Nav Persaud:
Yeah. Another thing that I've sometimes heard is that we can have the benefits of the economy you had before, and then take some of the lessons that we learned during the pandemic and make the economy better. And one of them is about working remotely, we're meeting for virtually. And obviously, there are some benefits of that and people have explored the pros and cons of virtual care.
Dr. Nav Persaud:
There are other examples though. One that came to my attention recently was around the landlord tenant board meetings being entire virtual now in Ontario. And some of the implications and the asymmetries that can sometimes lead to bad decisions where a landlord might be better positioned to attend using video conference. Whereas, a tenant may not have the ability to do that. It might be phoning in and there's an asymmetry there.
Dr. Nav Persaud:
And as Douglas Kwan, the director of the Advocacy Center for Tenants of Ontario has explained to me, the stakes for the tenant can be much higher. So after one of these hearings at the landlord tenant board, the outcome for the tenant could be that they don't have anywhere to live the next day. Whereas, for landlords, the implication is usually for their income and that night they'll have somewhere to sleep.
Dr. Nav Persaud:
So if there was an important decision like that being made about you and your housing, you'd want to be on equal footing with the other party. But that is not necessarily what's happening now. So I think there can be a tendency to get carried away with this building back better and this assumption that things are going to get better after the pandemic, because we would've learned from it. In many ways, it seems like there's a tendency among leaders to ignore the lessons that should have been learned in the early part of the pandemic now.
Dr. Nav Persaud:
And I can easily see us return to an unfair status quo after the pandemic. And in fact, it won't even be returning to an inequitable or unfair status quo. There's talk about this K shaped recovery, where those who are advantaged now will improve their status and their wealth and income after the pandemic. And those who are disadvantaged, have a low income or experiencing other forms of oppression like racism or sexism are going to see their wealth and income decline further. And so there'll be a wider disparity years after the pandemic is over.
Dr. Kirsten Patrick:
That makes huge sense. The idea that they'll just be widening inequalities. We know from work on disaster politics that that happens every time there's a crisis. And why should this one be any different, I guess? So let's go into the guidelines themselves, the nitty gritty. Who was involved in producing these recommendations?
Dr. Nav Persaud:
A group of scientists based at the MAP Centre for Urban Health Solutions at St. Michael's hospital in Unity Health Toronto came together in the summer of 2020. And we scanned the literature and looked at the inequities that were exposed and exacerbated during the pandemic based on reports, for example, from the public health agency of Canada.
Dr. Nav Persaud:
And then we started thinking about potential interventions that could help address these inequities going forward. And we consulted with people with lived experience of inequities and came up with a set of candidate topics to perform systematic searches of the literature for. And that's what led us towards these recommendations.
Dr. Kirsten Patrick:
And you've had some interactions with folks beyond the MAP center, right? So you've had stakeholders from across Canada, I thought, and endorsement from various groups. Could you explain what those are?
Dr. Nav Persaud:
Sure. That's right. We contacted a list of around 20 national organizations, including organizations like the Canadian Medical Association, the black positions of Canada, Canadian doctors for Medicare, who've all endorsed the recommendations. We also shared the recommendations with the College of Family Physicians Canada, who support these recommendations. And we con contacted many others for input and feedback on the recommendations.
Dr. Nav Persaud:
In some cases, members of those national bodies suggested potential changes to the recommendations and we adjusted them based on those suggestions. There were also other topics that some organizations suggested. For example, there's a suggestion to explore youth mental health. And we considered those and did some informal searches of the literature. But ultimately, decided that based on what we saw, we wouldn't necessarily be able to make a useful recommendation in all of the important topics that were highlighted by the stakeholders we contacted.
Dr. Kirsten Patrick:
So I'll come back to that issue about what you are including in your recommendations and not including and why a little bit later. But first tell us about the recommendations themselves. What are they first of all?
Dr. Nav Persaud:
So the recommendations are in six areas, income, housing, intimate partner violence, childhood, access to healthcare and racism. And we recommend for example, a living income for everyone living in Canada. We also recommend unemployment insurance and paid sick leave. Additionally, in the category of income, we recommend access to affordable credit or loans as a replacement for payday loans that typically have high rate of interest. In-housing for people experiencing homelessness who have mental health problems. We recommend access to permanent supportive housing.
Dr. Nav Persaud:
In childhood, we recommend expanding access to publicly funded childcare and the distribution of healthy foods. And that's been studied in several early childcare settings and schools. For intimate partner violence, we recommend legal advocacy and other supportive interventions for victims that have been shown in a number of trials to improve a number of outcomes and reduce the likelihood of violence. For access to healthcare, we recommend expanding access to opioid substitution therapy, expanding access to HIV and Hepatitis C screening.
Dr. Nav Persaud:
We also recommend including medicines in our publicly funded healthcare system. And we recommend bringing the healthcare that people who are incarcerated receive up to standards seen by people who are not incarcerated. Our recommendation for racism is different from the others. Here rather than reviewing the primary literature and talking about the effects of various interventions seen in clinical trials or other study types, we instead recommend that action be taken on previous recommendations that have been written over the last several decades about addressing racism, especially anti indigenous racism and anti-black racism.
Dr. Kirsten Patrick:
Thanks, Nav. So looking at those categories, hugely important, and we could unpack them all in quite some detail. I noticed there's congruency between your recommendations and those of another reports, the marmots report in the UK, which also highlighted the importance of early life and addressing childhood poverty. Did some of this international guidance inform your guidance in that area?
Dr. Nav Persaud:
Certainly this work was informed by work that's been going on over the last several day on the social determinants of health. And that report you referenced, I think was applying that social determinants of health lens to the COVID pandemic. And was, I think, intended to start thinking about how we can address the social determinants of health going forward in the pandemic recovery period. So those sorts of reports and other related reports from the public health agency of Canada definitely informed our approach.
Dr. Nav Persaud:
And what we sought to do that I think was a little bit different from other reports or other resources that were available is to look at the existing literature on interventions and policy changes that can address inequities and think about how we can use those previous studies to inform policy changes right now, or during the pandemic recovery period. So I hope that this will be a contribution. And I think often when we're talking about big policy changes like a living income or even changes related to whether or not a daycare or childcare is publicly funded.
Dr. Nav Persaud:
I think ideology plays a large part of those discussions and partisan is in politics would obviously play an important role in determining whether or not those changes were actually made. And part of our contribution, I hope will be to say we don't just have to talk about what we think might happen if people receive a living income or speculate about whether or not people will be dis-incentivized to work or seek employment, because these types of interventions have been studied. And we know what happens in other places when people are given access to a living income.
Dr. Kirsten Patrick:
Thanks for highlighting that, that's really important is these recommendations come out of work that is well done, long established and accumulating. For example, with living income, which I think in some forms takes the name universal basic income. These things have been studied even in Canada and as well as in other places in the world. And what you're doing is presenting a good summary of what's been shown to work that policy makers could use.
Dr. Kirsten Patrick:
They're sort of in a way, no brainer interventions that really with little political will could be instituted right away. I wanted to focus just briefly on the paid sick leave recommendation. Interestingly, that wasn't mentioned in the recent speech from the throne, but there has been a federal bill tabled for the institution of paid sick leave for federally governed businesses.
Dr. Kirsten Patrick:
But that to me seems like the most obvious thing that we could do right now in terms of preventing harms that we've seen happen in the pandemic where workers who were not able to forego their wages or would be fired if they didn't show for work, went to work sick during the pandemic. And that's going to be a thing that would help us in future crises, which are very likely to come including climate crises. So those income protection recommendations seem to me to be really solid.
Dr. Nav Persaud:
Yeah. So I completely agree. And while we were focused on the pandemic recovery period, I think it is important to note that during this pandemic of a virus that causes a cough, very little progress was made on paid sick leave. And we still don't have an adequate system that would ensure appropriates paid sick leave for everyone who has a job in Canada.
Dr. Nav Persaud:
And so it does point to some of the structural problems here where there might be employers or corporations that would benefit from keeping employees in a precarious position. And you could understand how an employer would want to prevent people from staying home when they want to and when it's appropriate to do so. So I think there are some really big structural challenges going forward in making some of these changes. And the fact that we made little progress on paid sick leave during this pandemic helps to illustrate them.
Dr. Kirsten Patrick:
Sure. So let's go back to this idea of how you chose the categories that you chose. In the main, you've already explained that you chose to make recommendations in areas that there already exists a fair bit of evidence. And you've pointed out that there was a suggestion that you consider youth mental health. Other readers of the guideline might say, "Why are you not mentioning elderly social care at all?" Perhaps you could explain why you chose the particular categories you chose?
Dr. Nav Persaud:
Sure. And I think that all of the topics that we chose are important. I hope no one takes the message that if a topic was excluded, it was because we thought it was unimportant. And I think there were a number of really important topics that are not addressed by these recommendations. I think youth mental health that was suggested is an important example. I think the health of people who come here under these temporary foreign worker programs or migrant farm worker programs, that's an extremely important issue.
Dr. Nav Persaud:
I think that the catastrophe that unfolded in the long-term care is facilities across Canada during the pandemic points to big systemic issues in the way that older adults are cared for in this country. And a lack of support for long term care facilities. In particular, I think also the serious threats to health of people working in long term care facilities, such as personal support workers points to another big problem. And these are all extremely important topics that we didn't address. And I think if we had an unlimited amount of resources and time to formulate these recommendations, we likely would've addressed additional topics like these really important ones.
Dr. Kirsten Patrick:
And those extra topics that you've mentioned really underscore the idea that it's important to be looking at structures and with an equity lens going forward to recover properly from this pandemic. Let's talk about the ranking of the recommendations or the strength. How did you come to rank your recommendations?
Dr. Nav Persaud:
We use the grade system where we make strong or weak recommendations based on the balance of benefits and harms. And then we also grade the certainty in the estimate. So provide an assessment of the degree to which we think the benefits or harms observed in the studies will match with what actually happens if these changes are implemented in Canada. And in some cases, for example, the studies were primarily done in low and middle income countries. And so that would decrease our certainty in whether or not the estimates would match with what's actually observed if these changes are implemented.
Dr. Nav Persaud:
But I think in many of the cases, regardless of where the studies were done or the sizes of the studies, we were able to determine that the benefits would clearly outweigh the harms. And so we were able to make a number of strong recommendations. I think it's also important to point out that we also don't want to send a message that the weak recommendations that we make or we actually use the terms just strong recommendation or strongly recommend and recommend in the document. So it's not that we think the recommendations that are not strong recommendations are less important or less urgent to implement.
Dr. Kirsten Patrick:
Let's talk about the recommendation to reflect and act on racism. It's an ungraded recommendation, but you and your co-authors explain why you think it's an important one. Tell me about that?
Dr. Nav Persaud:
At first in general, I think while there's been a lot of attention to inequities during the pandemic, and there've been reports written about racialized people disproportionately experiencing harms during the pandemic, I think a lot of the discourse from leaders has given the impression that these inequities were just discovered and that they just found out about them during the pandemic, or just before the press conference.
Dr. Nav Persaud:
In fact, these inequities have been around for a long time and their reports certainly going back to the 1990s when there was substantial amount of attention put towards anti-black racism and anti indigenous racism. But even those reports in the 1990s refer to reports done decades before them. So I think it's important to view these proclamations about the importance of addressing racism now in the appropriate context.
Dr. Nav Persaud:
And to remember that people made similar proclamations decades ago. So that's why we recommend reflection on the fact that these previous recommendations exist. And I think in large part were not acted upon. And while some things have changed and there have been improvements, I think many of the structural inequities and the structural racism that was addressed in the reports from the 1990s are also present today. And we saw them in full force during the pandemic.
Dr. Kirsten Patrick:
Yeah, we certainly did. So Nav, before I kind of end this off, is there anything that we haven't discussed that you really thought was important to discuss?
Dr. Nav Persaud:
Sure. First of all, just on that last point, I think it's also one of the reasons that we pointed to the previous reports is because we want to pay respect to all of the people who have contributed to this area of racism and health. And our contribution obviously during the pandemic is mostly based on work that others have done previously.
Dr. Nav Persaud:
That's true in general, but specifically in the topic of racism, I think there are a lot of indigenous scholars and black scholars who have done work that is in many ways, much more important than our work. And so we want to signal that this article appearing in the CMAJ in 2021, it isn't the product just of work that we've been doing for the last year, but it is based in work that indigenous people, black people, and other racialized people have been doing for a long time.
Dr. Kirsten Patrick:
Yeah. And it's not been easy work or always well received. It's probably been frustrating. So yeah. Thank you for raising that issue and acknowledging the work that's underpinned your guideline. Nav, what would you like listeners to take away from this discussion?
Dr. Nav Persaud:
Yeah, if there's time, maybe just one last point. Potentially to end on a, what I would view as an optimistic note. And it's that I think that the inequities that we're experiencing now during the pandemic are the result of decisions that we have made collectively and that our leaders have made. And the implication of that is that we can collectively decide to make society more equitable and fair.
Dr. Nav Persaud:
And I think we've seen during the pandemic that there were changes that brought us closer to fairness, like there were income supports that were quickly implemented during the pandemic. There were moratoria on evictions during the pandemic. So we can do these things if we choose to. And I hope that this document, these recommendations will help inform good decisions going forward.
Dr. Kirsten Patrick:
Nav, thank you for joining me today for this interesting discussion.
Dr. Nav Persaud:
Thank you very much.
Dr. Kirsten Patrick:
I've been talking to Dr. Nav Persaud, a staff physician at St. Michael's hospital in Toronto and a Canada research chair in health justice at the university of Toronto. You can find the article that he co-authored at cmaj.ca. And we'll put a direct link to it in the show notes. I'm Dr. Kirsten Patrick, interim editor and chief for CMAJ. Thank you for listening.