The response to the pandemic, a missed opportunity to address inequalities in Quebec and around the world

Two years after the Covid-19 pandemic, we know that certain populations have been disproportionately affected by Covid-19.

We also know that social inequalities in health (SSI) can be exacerbated if they are not taken into account when designing public health interventions.

That’s why we launched HoSPiCOVID, an international study on the resilience of healthcare and public health systems in several countries in the face of the Covid-19 pandemic. The research is conducted by a research team composed of international specialists in the fields of epidemiology, medicine, public health, social sciences and geography.

The authors – researchers, research professionals and students – were involved in the public health component of HoSPiCOVID because of their expertise on ISS. This section looked at the consideration of ISS in the planning of screening and contact tracing for Covid-19 in Brazil, France, Mali and Quebec. If we compare the data, the conclusion is clear: the issue of ISS has been largely forgotten in the initial response to Covid-19. However, it should be a priority in a pandemic context.

Responses adapted to the needs of the population

According to the World Health Organization (WHO), health equity is defined as the absence of systematic health disparities between social groups. SIHs correspond to differences in health status between different population groups due to their social position (eg gender, age, socioeconomic status, place of residence).

The WHO recognizes SIH as unfair and avoidable. However, they can be reduced by government policy.

Screening and contact tracing interventions play a central role in fighting infectious diseases, such as Covid-19. They enable the detection, isolation and monitoring of infected cases. The success of these interventions depends on their ability to reach all populations, at the risk of failing to contain the spread of the virus on the one hand, and increasing SIH on the other. Adopting a proportional universalist approach may be beneficial in a pandemic context.

Dozens of patients rest in beds in a temporary hospital dedicated to Covid-19 patients in Brazil.
Sebastiano Moreira/EPA

Proportional universalism makes it possible to deploy interventions for the whole population, together with extra efforts in proportion to the disadvantage of the different social groups. This approach is more equitable, as the hardest-to-reach groups are often the ones most in need.

In the context of Covid-19, a proportionate universalist approach could have also included population-based testing and contact tracing interventions, combined with concerted efforts to make them more accessible to disadvantaged populations. While this approach has often been identified as the preferred approach for improving health equity, our research shows that it does not appear to be prioritized.

No consensus on inequalities

The public health component of HoSPiCOVID is based on qualitative case studies comparing the public health response to the Covid-19 pandemic during the first wave (in spring 2020) with the adjustments made during the following waves (until the end of 2020). The study covers four locations on different continents: the Amazonas state in Brazil, the Île-de-France region in France, the city of Bamako in Mali and the city of Montreal in Quebec.

The perception of ISS by actors and their organizations varies in each of the sites. In Montreal, respondents from different sectors (hospital, public health, community, etc.) claim that reflection on SIH is well integrated into their organization’s mandate, to varying degrees. In Île-de-France, Amazonas and Bamako, this reflection seems less formalized.

Nevertheless, during the first wave, actors in Montreal and Île-de-France quickly identified several groups as more vulnerable to Covid-19. In particular, they cite the disparate effects of the pandemic on racialized and migrant populations, which several studies have ultimately shown. In Bamako and Amazonas, most of the actors who met previously believed that the pandemic has not aggravated the SIH, as the virus does not affect one social group more than another.

A woman carries her child in Bamako, the capital of Mali. In the study, most of the actors who met previously believed that the pandemic has not exacerbated inequalities, as the virus does not affect one social group more than another.

At the four locations, the various actors therefore do not have a consensus about SIH, which could harm their attention in screening and contact tracing interventions. Moreover, the observation that certain groups are more affected by the pandemic than others does not directly translate into these interventions.

A climate of urgency

In Montreal, Bamako and Île-de-France, several actors claim that the emergency climate linked to the pandemic is overshadowing the issue of the ISS. It is reserved to prioritize the deployment of population-wide interventions, with the aim of containing the spread of the virus.

This population-based approach is seen as necessary in a pandemic context, so that the entire population has equal access to interventions. Equality and justice are therefore sometimes confused. However, some respondents emphasize the importance of tailoring interventions to reach the most vulnerable subgroups.

In Amazonas, screening — not open to the entire population — instead targets subgroups considered high-risk, initially including healthcare professionals, essential workers and hospitalized patients. This screening process aimed at risk groups, carried out during the first wave by the Amazonas authorities, will be continued in subsequent waves.

A more appropriate answer over time

Contact tracing and tracing interventions have evolved over time. While the issue of SIHs is little considered in the initial planning phase of interventions, there is more interest in their implementation during the first wave. Faced with the reality on the ground, the actors involved in the planning of the interventions adapt the interventions for the following waves.

To varying degrees across sites, facilitating the accessibility of interventions is becoming a priority to reach marginalized populations. These adaptations are particularly aimed at rural populations in Bamako, migrants, racialized and allophonic populations in Montreal, populations of low socioeconomic status in Île-de-France and indigenous populations in Amazonas.

Men dressed in white lab coats stand in front of a pharmacy
In this photo, taken on Thursday, May 21, 2020, a delegation led by Malian Health Minister Michel Sidibe, right, visits the isolation tent for coronavirus patients in Timbuktu, Mali.
(AP Photo/Baba Ahmed)

Among the adjustments that have been made, we note the use of mobile clinics, the establishment of new screening clinics and help with the isolation of vulnerable people who have tested positive. The screening and follow-up of the contacts were therefore gradually adapted, which makes it possible to better respond to the different needs of certain population groups.

A historical overview

While the testing and contact tracing interventions implemented to tackle Covid-19 do not appear to have considered ISS a priority in their planning, the current pandemic is no exception. Rather, it seems that this oversight is historical. Two literature reviews conducted by our team effectively demonstrate that during past epidemics in different countries (sexually transmitted diseases, HIV, Ebola, tuberculosis), the vast majority of screening and contact tracing interventions are not based on strategies that promote their equitable deployment.

For decades, calls for equity and social justice in public health interventions have grown. Several groundbreaking public health documents—from the 1978 Alma-Ata Statement to the 2008 Commission on the Social Determinants of Health, including the 1986 Ottawa Charter—emphasize the importance of reducing SIH as a priority and the basis of any public health intervention.

The response to the Covid-19 pandemic then seems like a missed opportunity, highlighting the insufficient political focus on public health mandates.

Our study therefore invites us to focus on evaluating the ability of health interventions to account for SIH so that public health professionals and political leaders can draw lessons from it. This is essential so that future public health interventions do not aggravate SIH, and so that the climate of urgency created by pandemics – the multiplication of which seems inevitable – no longer serves as a pretext for the world’s lack of political will.

We thank our colleagues Raylson Emanuel Dutra da Nóbrega and Sydia Rosana de Araújo Oliveira for their significant contribution to the HoSPiCOVID study and their support in the writing of this article.

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