Lower-income Ontarians continue to die of COVID-19 at much higher rates than those with higher incomes — a troubling pattern repeated in each of the province’s six pandemic waves, new data shows.
In yet another indication that COVID is not an equal-opportunity illness, researchers at the University of Toronto have found that death rates from the virus in Ontario’s lowest-income neighbourhoods have been roughly double those in the province’s richest areas throughout the pandemic.
That COVID deaths remain disproportionately concentrated in lower-income neighbourhoods even after the rollout of vaccines, antiviral medications and COVID treatments — in addition to seemingly endless calls for equitable access to public health resources — illustrates that for many the pandemic is far from over.
“It begs the question: Among whom are we flattening the curve?” said Dr. Sharmistha Mishra, an infectious disease physician and mathematical modeller at Toronto’s St. Michael’s Hospital. Mishra heads a research team that analyzes COVID mortality data. She shared the sixth-wave analysis with the Star; the team’s analysis of the other five waves has been previously presented by the Ontario COVID-19 Science Advisory Table.
With another wave of the virus expected this fall, Mishra and other experts are calling for the province to further fund tailored prevention and treatment strategies for the most vulnerable, including older Ontarians and communities with the lowest income brackets.
Mishra, whose team at Unity Health Toronto has analyzed COVID deaths and illness data throughout the pandemic, said the same pattern of inequity remains for hospitalizations and ICU stays, even when accounting for underlying health conditions. The team used COVID data from Ontario’s Case and Contact Management System overlaid with income-level data from Statistics Canada that accounts for cost of living within regions, Mishra said.
The analysis found the pattern of inequity is true across the province, Mishra said, with low-income areas — many with high numbers of essential workers — seeing a disproportionate number of COVID deaths, including in regions of Peel, the northwest corner of Toronto, parts of Ottawa and northern Ontario, including Thunder Bay. People who are underhoused or who are experiencing homelessness also continue to be disproportionately impacted by COVID, she said.
Research conducted over the past two years has shown that in every wave of the pandemic, Ontario’s working poor, racialized and immigrant populations have not only suffered disproportionate rates of infection but also have had inequitable access to testing, treatment and vaccines.
In April 2021, after the first doses of the COVID vaccine had been rolled out, postal code data showed that many areas hit hard by the virus were simply not getting the shot. Toronto’s Jane and Finch neighbourhood, for example, home to many multi-generational households and essential workers, had the lowest vaccination rates at that time. Conversely, the wealthy Moore Park neighbourhood had the highest vaccination rates.
Last spring, research conducted by the Gattuso Centre for Social Medicine and University Health Network found that people who lived in Toronto and Peel COVID hot spots were, on average, about twice as likely to be racialized and about four times more likely to be employed in manufacturing and utilities compared to residents of other neighbourhoods in the regions.
When it comes to booster shots, as recently as this past January, data showed that less than 20 per cent of residents in northern Peel region and Toronto’s hard-hit northwest corner had received third doses.
“The pandemic has sadly reinforced what we have seen for so many other illnesses in human history: that they are concentrated among the poorest and the most vulnerable,” said Dr. Fahad Razak, scientific director of the Ontario COVID-19 Science Advisory Table.
“The burden of COVID-19 in lower-income neighbourhoods and among racialized groups highlights the need to focus our protective strategies with the widest possible lens: considering for example workplace exposures, poor housing, and schools.”
Ministry of Health spokesperson W.D. Lighthall said the province continues to employ a variety of strategies to connect with communities with lower vaccination rates, including offering more diverse clinic locations, focused communication across traditional and social media channels, providing data to primary care about their rostered patients and providing information in over 300 languages through the Provincial Vaccine Contact Centre.
Whitehall added the province’s GO-VAXX fleet is still active and prioritizes vulnerable communities with low vaccine uptake, including hosting clinics at seniors and community centres, schools, shelters and places of worship.
“The Ontario government will continue to offer COVID-19 vaccines to all eligible individuals that want to receive their first, second or booster doses, and continues to focus outreach and engagement efforts on vulnerable and elderly populations that are not up to date on the vaccines,” Whitehall said in an email.
While the province last summer tailored the vaccine rollout of first and second doses to communities with high infection rates, Mishra said ongoing research by her team is trying to understand why the inequities in deaths and hospitalizations persisted.
“Could it be that the third-dose approach wasn’t as tailored? Is it that we weren’t fully addressing exposure risks based in structural elements, including paid sick leave and housing supports — and was this something that vaccination alone wasn’t able to overcome? Does there need to be a more tailored distribution and access to the therapeutics that decrease COVID severity?”
Sophia Ikura, executive director of the Health Commons Solutions Lab, a publicly funded, not-for-profit organization at Sinai Health in Toronto, said the province’s efforts to work with communities has helped close the gap on COVID inequities, though more needs to be done.
“We’ve seen a tremendous loss of life in these communities,” said Ikura, calling the disparity in COVID death rates across neighbourhoods “a tragedy.”
The Health Commons Solutions Lab works with a team of nearly 200 community outreach ambassadors that work in priority neighbourhoods, offering information and helping support the distribution of COVID vaccines and treatments, including the antiviral Paxlovid.
Ikura said ambassadors are reporting a growing hesitancy among residents about getting boosters, though she hopes ongoing education and distribution efforts will help encourage residents to feel safe taking antivirals.
“These communities have always gotten the short end of the stick … and it continues to contribute to this lack of trust,” she said. “It’s become a very difficult cycle.”
The “structural realities” facing residents of lower-income neighbourhoods, such as housing that doesn’t allow for physical distancing and the need to take public transit for work, has contributed to higher rates of COVID infection throughout the pandemic, Ikura said.
These same structural inequities, including the lack of safe, stable housing, food insecurity and fewer employment paths, also lead to an increased risk of chronic illness, such as diabetes and heart failure. This in turn raises risk for COVID illness and death, she said.
Dr. Mustafa Hirji, acting medical officer of health for Niagara Region, notes that one of the reasons those with lower incomes tend to have worse outcomes from COVID is that they can’t afford to be off work when sick.
“Otherwise they’re not going to be able to pay their bills or put food on the table. So they go to work and they spread that infection around to everybody else,” said Hirji, who is calling for an extension for at least another year of the three subsidized temporary paid sick days, known as the Worker Income Protection Benefit, that the province introduced in April 2021.
He is also calling for a study looking at how to make these sick days permanent and also increase to 10 the total sick days workers would be entitled to in a way that doesn’t harm the economy.
Just last week, a group of more than 160 physicians, nurses and health-care workers sent an open letter to Premier Doug Ford calling for 10 permanent sick days to be legislated for all workers, but particularly those who are racialized in low-wage and precarious jobs.
“Paid sick days are partly about helping build that culture where we stay home when we’re sick and control infectious diseases long term,” Hirji said. “But it’s also particularly about equalizing the ability for people to stay home so that those who are lower-income who don’t have that option start to get that option.”
Ikura acknowledges many people are tired of COVID, including masking and keeping up with public health recommendations. But she hopes people don’t become numb to the fact that people are still dying of the virus — and that those deaths are disproportionately higher in vulnerable communities.
“We should never get tired of hearing about the loss of life — and the lack of justice around it. We should not allow ourselves to grow callous around the number of people who have died in these communities, and how totally unjust this is.”
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie
Kenyon Wallace is a Toronto-based investigative reporter for the Star. Follow him on Twitter: @KenyonWallace or reach him via email: firstname.lastname@example.org