The Canada Recovery Sickness Benefit — An Emerging Public Health Intervention and the Social Determinants of Health
Photo by Isaac Quesada on Unsplash
Photo par Isaac Quesada sur Unsplash
Meron Gidey
(FR) L'émergence mondiale du coronavirus (ou la COVID-19) a déclanché une pandémie et a donné naissance à de nombreuses mesures de santé publique, telles que des vaccins et des mesures d'état d'urgence dans le monde entier pour réduire la transmission du virus et baisser le nombre de cas necessitant des soins intensifs . Les communautés médicales, sociales et celle de la santé publique ont créé des mesures et des interventions afin de réduire et potentiellement éliminer les risques pour la santé et les fardeaux produits par la pandémie. Cet article examine la Prestation canadienne de maladie pour la relance économique (PCMRE ou CRSB en anglais), une allocation fédérale disponible pour les Canadiens éligibles durant la pandémie, mise en œuvre du 27 septembre 2020 jusqu'au 25 septembre 2021. L’objectif de cette analyse est de mieux comprendre les actions de l’agence de santé publique pour adresser les déterminants sociaux de la santé et les inégalités en matière de santé qui se sont aggravés pendant la pandémie.
Cet article est divisé en deux parties. La première section offrira du contexte sur des cadres réglementaires et des concepts importants: la COVID-19, la corrélation entre les déterminants sociaux de la santé (SDH en anglais) et les inégalités associées avec la COVID-19, ainsi que ses causes, qui donneront aux lecteurs les outils requis pour comprendre l’analyse d’intervention offerte dans le texte qui suit. La deuxième section étudiera l’analyse d’intervention et les sujets suivants: la PCMRE, les déterminants sociaux de la santé par rapport au PCMRE, les effets de la PCMRE à l'échelle de la population et élaborera sur la pauvreté.
Ensuite, cet article se conclura avec une discussion à propos de la nature à plusieurs facettes de la PCMRE. La pandémie a mis en évidence les inégalités chroniques sociales et économiques que notre société a maintenu à long terme. En fin de compte, un mélange de modifications institutionnelles systémiques et de politiques publiques qui concernent les déterminants sociaux de la santé, telles que les politiques natalistes, les droits de travail equitable, les congés de maladie, les syndicats de travailleurs de secteurs essentiels, les salaires viables et les logements abordables et de qualité sont tous nécessaires pour adresser les injustices concernant les inégalités en matière de santé, mais aussi pour augmenter l'efficacité des mesures associées avec la COVID-19.
The worldwide emergence of the Coronavirus (COVID-19) has led to a pandemic and multiple emerging public health measures, such as vaccines and international lockdowns, to reduce the transmission of the virus and to slow down ICU capacities. The medical, policy, and public health community produced measures and interventions to help reduce and eliminate the health risks and burdens of the pandemic. This article examines the Canadian Recovery Sick Leave Benefit (CRSB), a federal-level benefit available to eligible Canadians during the pandemic that was implemented on a national level on September 27, 2020 until September 25, 2021. The purpose of this analysis is to better understand what public health is doing to address the social determinants of health and health inequities on a population level that have been further exacerbated during the COVID-19 pandemic. This paper has two sections. The first section will provide context on important concepts and frameworks: COVID-19, the interrelationship between the SDH framework and COVID-19 inequities, and the fundamental causes of COVID-19 inequities that will equip readers for the intervention analysis. The second section will explore the intervention analysis and the following topics: CRSB, SDH in relation to CRSB, population level impact of CRSB, and framing poverty. This paper concludes that the discussion of CRSB is complex and nuanced in nature. The pandemic has revealed chronic social and economic inequities that our society has sustained over time. Ultimately, a combination of systemic institutional changes and public policies that address social determinants on health, such as pro-natalist policies, equitable labour laws, provincial sick days, unionized essential workers, liveable wages, and affordable/quality housing for all, would not only help eliminate population level inequities, but also increase the effectiveness of COVID-19 measures.
Coronavirus
As cited by WHO, Coronavirus (COVID-19) is a novel infectious disease caused by Severe Acute Respiratory Syndrome (SARS-COV-2). Originating from Wuhan, People’s Republic of China, COVID-I9 began as an epidemic that was first reported to the WHO on December 31, 2019; it has since been declared a pandemic as of April 2020 [1]. COVID-19 symptoms vary from mild to severe and are spread through direct and indirect airborne modes of transmission (respiratory droplets and physical surface contact) with asymptomatic individuals also being capable of virus transmission [2]. COVID-19 has prompted international lockdowns (including facility and school closures) and face mask ordinances to reduce the transmission of the virus and to slow down ICU capacities.
SDOH Framework and COVID-19 Inequities
Social determinants of health (SDOH) refer to the social, economic, political, and environmental factors that individuals grow, work, and live in that ultimately shape health and well-being over the course of life [3]. It is a framework that illustrates how distal, intermediate, and proximal causes of health shape overall health in dynamic ways. Distal causes of health are the contextual aspects that shape societal circumstances that people live in, including socio-historic context, cultural values, and policies [3,4]. It constructs and reinforces the intermediate and proximal determinants [3,4]. Intermediate determinants refer to the community factors and to relationships that define individuals’ immediate social environment [3,4]. Proximal determinants refer to individuals’ capacities, behaviours, and personal factors that have a direct impact on health and well-being [3,4]. This framework is necessary to increase our understanding of the conditions that predict COVID-19 inequities. It reveals that not everyone is affected equally by the pandemic. Distal determinants of COVID-19 inequities include sexism (gender segmented labor markets), structural racism, ageism (inadequate support for elders in long term care homes) and neoliberalism (i.e., nominal wages and lack of benefit protection) [3,4]. Intermediate-level determinants include psychosocial stressors (such as social isolation) and material conditions (such as housing and neighborhood quality) [3,4]. Proximal determinants include COVID-19 measures: mask-wearing, hand-washing, social-distancing, and staying at home [3,4]. These determinants work together to shape an individual’s risk level of exposure to COVID-19 and its transmission in their household and community.
Unfortunately, tactics such as “stay at home” measures, whereby individuals are asked to work from home or self-isolate, are not effective for essential workers due to the nature of their job and housing circumstances [5]. Essential jobs include, but are not limited to, personal support workers, manufacturing workers, live-in caregivers, grocery store clerks, truck drivers, and harvesters. Essential workers maintain a functioning level of operation within our communities at the expense of their own health and safety. Nevertheless, they are one of the least protected workers even amidst a pandemic. These jobs are characterized by nominal wages, precarity, no labour law protections, little to no benefits, long hours, and demanding labour. Additionally, these individuals are more likely to be low income and have smaller living quarters with more people, which makes self-isolation less effective and increases transmission in the household and community. Therefore, COVID-19 inequities reflect the limited agency held among socially and economically disadvantaged individuals.
Fundamental Cause of COVID-19 inequities
Structural racism is the main fundamental cause of social, economic, and COVID-19 inequities. Structural racism refers to the racism that is embedded in institutions, policies, laws, practices, and performances that provide differential opportunities and access to social and economic resources that are fundamental to health and well-being [6,7]. Structural racism operates alongside other inequities: sexism, ageism, and neoliberalism. COVID-19 has been declared a “virus that does not discriminate,” however the distributional inequities of COVID-19 between subgroups demonstrate otherwise [8]. COVID-19 discriminates along the intersecting social locations of race and gender identity, job type, age, SES, and migrant and immigrant populations. According to the City of Toronto, almost 85% of individuals with COVID-19 reported that they identify with a minority group [9]. Race-based COVID-19 data is important as it reveals that COVID-19 disproportionately burdens the working-class Black community in Toronto [10]. The city’s predominantly Black neighbourhoods carry the worst infection rates compared to white, wealthy neighbourhoods [5]. These neighbourhoods are associated with greater rates of chronic disease, low-income, and low levels of post-secondary education [7]. It is important to note that Black people are subjected to immense discrimination, social and economic sufferings, and lack of governmental support [11].
Intervention Analysis
Canadian Recovery Sick Leave Benefit
The Canadian Recovery Sick Leave Benefit (CRSB) is a federal-level benefit available from September 27, 2020 to September 25, 2021. CRSB provides up to $1000 to workers that are unable to work for more than 50% of the week as a result of falling ill, contracting COVID-19, or as part of the high-risk population with underlying conditions [12,13]. There are stringent endpoints (the benefit lasts for two weeks) and eligibility requirements and financial thresholds that individuals must meet to be entitled to CRSB (minimum earning of $5000 in previous year). Individuals are not eligible for CRSB if they are sick or self-isolating at home for more than two weeks, become re-infected or need to self-isolate again, or are migrant workers [13]. The objective is to mitigate the spread of COVID-19 by ensuring that individuals have a temporary income if they become ill and are unable to work while they quarantine [12].
SDOH and Canadian Recovery Sick Leave Benefit
CRSB is better than the absence of such benefits, but the magnitude and extent of these benefits are insufficient in producing a population-level impact. CRSB attempts to address the intermediate SDOH (lost or reduced income) and the proximal SDOH (self-isolation for no more than two weeks) in a way that is decontextualized from the social and economic realities of at-risk individuals. Therefore, individuals are more likely to return to work ill because they cannot afford to self-isolate. Furthermore, CRSB does not mediate the SDOH that predict conditions for virus exposure and transmission such as housing, job (in)security, inadequate access to testing sites in COVID-19 burdened communities, public transit, working conditions, and food insecurity [12]. The intervention veers away from the fundamental cause (structural racism) and upstream factors that maintain and reproduce COVID-19 inequities.
Population Level Impact of Canadian Recovery Sick Leave Benefit
CRSB will likely not have a population-level impact because it is a reactive, targeted based intervention that is only eligible to a limited population for a temporary period of time. A targeted approach aims to protect susceptible individuals, whereas a population approach aims to control the causes of incidence [14]. CRSB falls under a targeted approach that fails to provide adequate support for its intended risk group: individuals that are sick or have underlying conditions. The intervention's narrow approach cannot produce population-level impacts. CRSB fails to consider the intersecting social and economic risk factors of essential workers, and thus considers the health of individuals in a manner that is removed from its context and lived experiences [6, 15]. A SDOH framework would be useful to develop a targeted approach for high-risk essential workers.
Framing Poverty
Poverty doesn’t happen in a vacuum; it is a result of structural inequities and factors that shape unequal distribution, access, and ownership to resources that are fundamental to health and well-being. CRSB provides income support based on stringent eligibility criteria and thresholds [6]. It fails to recognize that individuals experiencing poverty fall along a continuum, not in binary outcomes (poor vs. rich), as we have seen with the increase in the working poor. Therefore, individuals that fall short of these eligibility criteria will not receive the financial support they need to support themselves and/or their families during a pandemic. An employment lawyer framed the benefits as a handout that Canadians would certainty abuse [12]. This demonstrates how neoliberal framing narratives work to frame poor living circumstances that have been further exacerbated by the pandemic as an individual responsibility rather than a result of existing structural, social, and economic inequalities, in addition to framing subsidies as a public burden that disincentives workers. In essence, this framing criminalizes poverty. Ultimately it redirects attention to poverty, veering away from the transnational processes that reproduce global inequality that have direct and indirect impacts on nations’ micro-level working conditions that can either facilitate or hamper access to resources that are fundamental to health and quality of life.
This intervention analysis demonstrates that the discussion around public health interventions is more complex and nuanced in nature. The advent of COVID-19 holds a mirror to the social and economic inequities that our society has sustained over time. There is ample research on the SDOH and the necessary policies to address them that would allow measures like national lockdowns to be more successfully implemented at a population level, including pro-natalist policies, equitable labour laws, provincial sick days, unionized essential workers, liveable wages, and affordable/quality housing for all [3]. It requires changes to policies that keep structural racism in place. The more important question is, why have we not adequately moved forward in this direction?