The data is clear, and has been for months: Ontarians who are poor, under-housed and racialized are disproportionately attacked by COVID-19.
And yet, deep into the second wave, this central feature of the pandemichas not been central to our pandemic response, health experts say. The current “one size fits all” restrictions have so far failed to protect the vast majority of people getting infected by COVID-19. As a result, lockdowns in hot spots like Toronto and Peel are on track to be longer, harder and more devastating for everyone.
“If we don’t tackle this problem, we will continue to struggle through the winter. I can guarantee you that right now,” says Dr. Peter Juni, scientific director of the Ontario COVID-19 Science Advisory Table, which provides evidence to inform the province’s pandemic response.
In the first wave, lockdowns worked instantly in richer, whiter Toronto neighbourhoods but failed to flatten the curve in the poorest, most racialized ones, Star analyses showed.
Experts fear the same thing is happening again. Over a recent four-week period, the 20 Toronto neighbourhoods with the highest proportions of visible minorities recorded more than 3,300 cases. The 20 whitest neighbourhoods reported just 360. This racialized tilt is not a function of race itself, research shows, rather of who performs essential but low-paying work and is more likely to live in sub-standard housing.
“This is really about the people who do all the work for us and who allow you and me to stay home,” says Juni.
“The restrictions work very nicely in my neighbourhood, Moore Park,” an affluent area in North Toronto, Juni adds. “In some other neighbourhoods, they don’t. Why? Because we do not support people to actually be able to decrease the amount of contact they have.”
Summer offered a reprieve from the virus — a chance to reflect on the first wave of the pandemic and prepare for the second. And perhaps the harshest lesson from the spring was that COVID-19 predominantly impacted poor and racialized Torontonians, especially from Black and South Asian communities.
According to Toronto Public Health data released in July, racialized residents accounted for 83 per cent of cases despite making up 52 per cent of the population. People in the poorest households accounted for the largest share of cases of any income group.
Many of the worst-hit neighbourhoods were in the city’s northwest and northeast. And while the rest of Toronto — particularly whiter, more affluent downtown neighbourhoods — enjoyed a relatively pandemic-free summer, residents in these areas continued to see transmission simmer along at low levels.
As the second wave took off, the same first-wave patterns quickly took hold: the downtown Waterfront neighbourhood initially emerged as a hot spot, then infections began to spike in neighbourhoods more densely populated by poor and racialized residents.
The province and the city began a series of interventions over the fall that escalated in severity — all of which have been too lax, many epidemiologists have argued. In late September, capacity limits were imposed for indoor dining and bars. In early October, indoor dining was nixed entirely along with fitness classes, and gathering sizes reduced.
These measures did have an impact — but most dramatically in downtown neighbourhoods like Little Portugal and the Waterfront. In the northwest and northeast corners especially, cases continued to climb.
“Rates in some of those downtown communities have dramatically decreased. You can see the direct effects of the intervention on those neighbourhoods, and you can hypothesize that (restaurants and indoor dining) were a very big driver for the cases in those neighbourhoods,” says Dr. Vinita Dubey, an associate medical officer of health with Toronto Public Health.
Dubey acknowledges that the inequalities of the first wave are repeating. “We are still seeing some of the same patterns that have actually persisted,” she says. “We’re doing more, we’ve learned more, we’re working with the communities more. But some of those systemic inequalities or disparities haven’t (been) fixed between the first and second wave.”
In an emailed statement, a health ministry spokesperson said the provincial government has had “an explicit focus on equity issues” with respect to the pandemic’s impact and cited several steps it’s taken to address these, including: public-health marketing efforts in more than 18 languages; a relief fund of $510 million for food banks, shelters and other organizations; and working with community groups to improve testing access in hard-hit areas.
If the lockdown that began Nov. 23 has had any effect on the hardest-hit neighbourhoods, it is not yet apparent. But while the inequities underlying differences in COVID risk may be deep-rooted, they can still be tackled, health experts say.
“We’ve set up a response, I think, at the extreme … it’s been only for the rich, or at least with the rich in mind first,” says Dr. Stefan Baral, an epidemiologist at the Johns Hopkins School of Public Health, who provides clinical care in homeless shelters in Toronto.
“There were very specific and tangible things that I think could have been done to prepare for what was going to be a very difficult winter.”
In early October, the Star obtained provincial data showing that some Toronto neighbourhoods had alarmingly high positivity rates, suggesting that pockets of the city were in worse shape than previously known.
Provincial health officials admitted they first saw this data in the newspaper, and Premier Doug Ford cited mobile testing as part of what the province was doing to support marginalized communities.
But just days earlier, community health organizations in some of Toronto’s hardest-hit neighbourhoods were pressured by the province to stop offering pop-up testing, those involved say.
The province was transitioning to an appointment-only testing system as the backlog of unprocessed specimens ballooned. But community groups knew that easier-to-access pop-up testing sites were critical for reaching residents at highest risk of COVID-19.
The community groups pushed back, and “highlighted that without their pop-ups, there would be nothing available for (their) communities,” says Sané Dube, with the University of Health Network’s social medicine program, who was working in the community at the time.
It was “disturbing and concerning,” she adds. Though the province “backtracked” and the pop-up sites happened as planned, she says, “it raised serious questions about how decisions were being made.”
The health ministry says “there was absolutely no plan or proposal to ever cancel testing” in the neighbourhoods in question.
“Ontario Health Regions are working with high priority communities to offer additional testing sites.”
Many advocates describe a chronic inability to reach people in marginalized communities, where the need for COVID-19 testing is most dire.
In September — when testing volumes peaked in Toronto and the second wave started taking off — there was no pop-up testing in Scarborough and just three sites in the city’s northwest corner, two regions with high densities of poor, racialized communities that have been hardest hit by the pandemic.
But people in the richest and whitest neighbourhoods were likely being overtested. In late September, testing rates in Toronto’s whitest neighbourhoods were double that of the most racialized communities, according to a Star analysis of public health data.
After the province overhauled its strategy in late September, including restricting access for those with no symptoms, testing rates fell dramatically in the richest, whitest neighbourhoods. Today, they are more or less in line with rates in the city’s poorest, most racialized neighbourhoods — even though testing rates in the latter neighbourhoods “should be through the roof” given the soaring infection rates in those areas, says Dr. Sharmistha Mishra, a scientist with the Li Ka Shing Knowledge Institute and a member of the province’s modelling consensus table.
In response to the Star’s questions about testing access in northwest Toronto, the health ministry spokesperson cited the dozens of testing sites across the larger region that encompasses these neighbourhoods — but also acknowledged that uptake was still too low, and that the “expansion planning is underway.”
“Next efforts focus on mobilizing increased uptake of testing within targeted communities and providing culturally relevant and community tailored messaging addressing the social determinants of health, such as income, food security, and housing, that make it difficult for some people to seek or access care.”
Coun. Joe Cressy said that though COVID-19 testing is the province’s purview, the city recently ramped up supports for testing in targeted neighbourhoods. All city facilities — from fire stations to libraries — are now available for pop-up testing, he said. The city also recently kicked off a $5 million program in partnership with 11 communities agencies that have played a crucial role in supporting marginalized neighbourhoods.
Cressy said community involvement is key to increasing testing rates in the hardest-hit areas. Dube agrees, noting that many people are understandably mistrustful of a health system that has long excluded their needs.
“The failures we have with testing are actually linked to the failures of our pandemic strategy in general,” she says.
The province’s science table has begun referring to something called the “prevention gap” — the observation that “light touch” restrictions will flatten the curve in mildly affected areas, but allow large amounts of transmission to carry on in the hardest-hit regions.
Different tools are needed to meaningfully protect people at highest risk of COVID-19, experts say — for example, paid sick leave or a moratorium on evictions. Both measures would allow people to self-isolate without worrying about losing their job or home, and are now being formally requested by the City of Toronto in forthcoming letters to the provincial and federal governments.
Low-wage earners, who are the most likely to contract COVID-19, are also the least likely to have paid sick leave, according to data from the Labour Force Survey. Among Torontonians who make $17 an hour or less, only 17 per cent of workers who took a week-long sick leave between March and September were paid to take that time off.
This statistic almost certainly underestimates the problem, since it only captures workers who took an entire week off; low-wage workers are much more likely to only take a few days off at most, according to Dr. Kate Hayman with the Decent Work and Health Network.
Hayman, an emergency room physician in downtown Toronto, says paid sick leave is “a concrete tool for behavioural change that the government is underutilizing.” She frequently sees patients with COVID-19 who would benefit from paid sick leave; the food services worker whose employer wouldn’t allow her to self-isolate without a doctor’s note, for example, or the construction worker who continued working to pay the bills, even though he lives with his mother who had the virus.
“This is actually an intervention that has the (biggest) potential to benefit people who need it the most,” Hayman said. “Which is completely different from a lockdown, which might benefit people who can work from home the most.”
The ministry spokesperson said the Ontario was the first province to sign onto the federal Liberals’ Safe Restart Agreement, which provided $1.1 billion for paid sick leave. The province had earlier changed labour laws to provide unpaid, job-protected emergency leave, a requirement to receive the federal funding.
“No one should have to choose between their job and their health, which is why our legislation ensures those who stay home to self-isolate or care for loved ones will not be fired.”
Hayman says the federal program — $500 a week, for two weeks maximum — is both onerous and insufficient, with too many barriers, exclusions and delays to meet many workers’ needs.
Hayman notes there is good evidence paid sick leave can be a powerful tool for outbreak control. American researchers recently found that states with paid sick leave had a statistically significant reduction in COVID-19, according to a paper that will be published in an upcoming issue of the journal Health Affairs.
A COVID-19 research survey from Israel also suggests that when pay was available, workers’ compliance with public health measures was 94 per cent. When pay was removed, compliance dropped to less than 57 per cent.
And following the H1N1 flu pandemic in 2009, a U.S. study estimated that up to eight million workers did not take time off despite being infected — leading to an estimated seven million additional infections.
Without paid sick leave, precarious workers are both less likely to get tested — because being forced to self-isolate can have devastating financial consequences — or make use of the city’s voluntary isolation centre, experts say. Toronto Public Health did not respond to questions about how many admissions there have been at the city’s 140-person isolation centre, which opened in September.
Failing to take targeted, meaningful steps to stop the spread in hardest-hit communities — those primarily populated by Black and other racialized people — is just another example of “how systemic racism actually moves,” says Dube.
“Because the truth is we value some lives over others.”
Multicultural Meanderings 