Almost unnoticed in the uproar of the U.S. election and the worsening COVID-19 pandemic, Dr. Theresa Tam, our chief public health officer, published the 2020 report from the Public Health Agency of Canada. It is an important document, potentially a revolutionary document. But it is likely to go unnoticed until future governments study it to see what went so wrong with our response to the pandemic.
“From Risk to Resilience: An Equity Approach to COVID-19” is based on a concept novel to most of us: “the health of Canadians is dependent on a set of fundamental social determinants.” This isn’t news to health-care workers: the World Health Organization even has a website about it.
In other words, your place in society plays a large part in determining how healthy you are, and even how long you will live. It’s understood that every social class is healthier than the classes below it, and sicker than the classes above it. The COVID-19 pandemic has sharply emphasized these differences.
From the start, we’ve been assured that “we are all in this together.” Dr. Tam knows better. Some of us are well-insulated from COVID-19, while others can’t escape it. For poor people and other marginalized groups, they make this a syndemic, far more dangerous than for those better off.
Dr. Tam points out that we have differential exposure to the virus: some of us can work from home, while others must work side by side in meat-packing plants, or face hundreds of customers in supermarket checkout lines every day.
We also have differential susceptibility: poverty means poorer general health, worse nutrition, and more stress. Others have compromised immune systems, or pre-existing conditions like diabetes and hypertension. Some of us, longtime beneficiaries of Canadian health care, have lived so long that our immune systems have grown weaker with age. Those of us with such susceptibility simply can’t put up adequate defences against COVID-19 or even influenza.
And we have differential treatment. The homeless, the racialized, Indigenous people and immigrants all tend to be poorer than most Canadians. They have less access to health care, and it can be lethally worse when they do get it, as the case of Joyce Echaquan recently showed us.
Without quite saying so, Dr. Tam makes it clear that these differences are not really inborn, dooming us to illness or death. They are the result of policy. Democratically-elected politicians, obeying their voters, have enacted laws and created institutions that serve the privileged but consign the rest of us to poverty, sickness, and an early grave. They are even tactless enough to publish the public-health statistics that prove this.
And why not? The unprivileged don’t vote in enough numbers, or with enough focus, to change this state of affairs. By comparison with the U.S., Canada looks pretty good, both in public health and in pandemic numbers. Last year, we even scored first in health out of 151 countries evaluated, while the U.S. came in at 37.
But other high-ranking countries, notably in Europe, are currently battling a new resurgence of COVID-19, despite their excellent health-care systems.
On Nov. 8, Canada reported a total of 264,113 cases. That same day, the Czech Republic had 414,828 cases, and France had 1,787,324 cases. The United Kingdom’s National Health Service was staggering under the impact of 20,572 new cases, making a total of 1,192,013 cases.
It appears that even the universal health-care systems are incapable of dealing with this pandemic: for all their genuine service, they are over-praised and underfunded. Even in the best of times they can offer only a little remediation to marginalized people; prevention is far beyond them. From the point of view of most governments, they are as much theatre as real care.
The backstage crew who run this theatre understand this. Every health-care system, including agencies like the Public Health Agency of Canada, the Centers for Disease Control and the World Health Organization, is at the mercy of its political masters. We have seen Trump cripple the CDC because he thought he could provide a better show. WHO dares not criticize the UN member states who decree its budget. And when Canada’s politicians thought our Global Public Health Intelligence Network was too expensive, they axed it, and it went silent in the spring of 2019 — just months before COVID-19 began spreading in Wuhan.
Of course, it’s possible to speak truth to power in the back rooms of government, but only in the most technical terms. And those are the terms that Dr. Tam uses.
Consider this paragraph: “This pandemic has demonstrated that inequities in our society place some populations — and ultimately, all Canadians at risk. No one is protected from the risk of COVID-19 until everyone is protected. While learning from this pandemic is an iterative process, to go forward stronger, there are areas of collaborative and cross-sectoral action that can better prepare Canadians for future public health emergencies and their consequences, while ensuring that everyone has the opportunity to achieve their best health and well-being....”
Dr. Tam uses the passive voice (“No one is protected... until everyone is protected”) to excuse any person or agency from responsibility for protecting us. She mixes opaque phrasing (“iterative process,” “cross-sectoral action”) with banalities (“go forward stronger”). And she ends the paragraph not with genuine “best health and well-being” but with the mere “opportunity” to “achieve” it.
The senior heights of the Canadian civil service are full of highly educated, even erudite officials. They can read such prose and nod sagely. But Dr. Tam’s arguments are — to use another political buzzword — aspirational. The civil service and the deputy minister of health can agree that removing “health inequities” would be just lovely, but neither they nor their political masters are under the slightest pressure to start the removal process.
After all, that would mean dismantling much of our present economic and political system and replacing it — to the benefit of the poor and marginalized, but at the expense of the rich and influential. The politicos and their mandarins might even agree that in theory, Dr. Tam is on the right track to ending this pandemic, and preventing or mitigating the next one. But it’s not going to happen because the pressure on both provincial and federal governments is to get back to business as usual, with as many deaths as it takes to restore the lost golden age of 2019.
If Canadians really want to be as healthy as possible, they need to insulate public health from purely political influence. This would mean politicians ceding some power, at least in emergencies, to unelected health experts, and enforcing the experts’ recommendation for the duration. Dr. Tam’s recommendations in her 2020 report, if they were phrased in plain English for ordinary Canadians, might at least start a debate over such a goal.
But her report as it is seems doomed to gather dust — at least until some future government, facing another health disaster, dusts it off and regrets that her wise advice had gone ignored.