Public Health Interventions: A Critical Analysis of Paid Sick Leave and COVID-19
Tionné Polin
(FR) Il est apparent que les déterminants sociaux de la santé mènent à des protections accrues pour certains et des risques sanitaires élevés pour d’autres. Malheureusement, ces inégalités en matière de santé qui ont comme racines des problèmes sociostructurels, comme l’inégalité de revenus, ne sont qu’aggravées par la pandémie de COVID-19. Plus précisément, le congé maladie rémunéré est considéré comme une intervention de santé publique favorable dans les efforts pour atténuer la propagation du COVID-19, et pour réduire les disparités sanitaires. Par conséquent, en octobre 2020, le gouvernement fédéral canadien a commencé à accepter les demandes de Prestation canadienne de maladie pour la relance économique (PCMRE). Toutefois, ces interventions a posteriori ne sont pas suffisantes pour traiter les inégalités préexistantes, qui se sont aggravées en conséquence de la crise sanitaire. Les décideurs politiques devraient plutôt réfléchir de façon proactive à des approches en amont inclusives qui adressent les causes qui mirent à risque certaines populations.
The social determinants of health are ubiquitous within our society, leading to increased protections for some and heightened health risks for others. Specifically, they refer to individuals’ social, economic, and environmental circumstances that influence access to resources and opportunities that bolster health, on the basis of social factors, such as race and income (Office of Disease Prevention and Health Promotion, 2020). These factors pose serious consequences which can manifest in the form of increased morbidity and mortality (Ontario Agency for Health Protection and Promotion, 2013). Unfortunately, public policies have failed to address these inequities at both the distal and proximal levels, which have exacerbated the impact of the COVID-19 pandemic on specific populations. Consequently, this analysis will focus on low-income workers and income inequality to demonstrate the reality that current interventions, such as the federal government’s paid sick leave (PSL), are not sufficient in addressing the pre-existing inequities, which have worsened due to the pandemic.
The Problem
It is evident that structural and social factors reinforce health inequities within Canada. Unfortunately, certain populations are overrepresented in low-income and precarious employment. According to the Ontario Ministry of Labour (2017), single parents, recent immigrants, women, and Black people, as well as other marginalized racial groups, account for the majority of these workers. Additionally, these people tend to have low wages and minimal employment benefits, such as PSL. This is concerning, as low income can restrict access to resources that buffer against the poor health and chronic stressors that elevate health risks (Toronto Public Health, 2015). Thus, pre-existing inequities present additional concerns, with regards to the COVID-19 pandemic. For instance, Black communities in Toronto, and especially its northwest region, have been overrepresented in COVID-19 cases, as many are essential workers, disallowing them from remote work options (City of Toronto, 2020; Yang et al., 2020). Across Canada essential workers are at a heightened risk of exposure to COVID-19, as well as financial hardship if sickness does occur. Consequently, this could discourage test uptake, time off from work, and reduce one’s ability to protect loved ones. Therefore, it is apparent that the social determinants of health are involved at the proximal and distal levels, yet, it appears as though this has not been accurately addressed at the federal level of government.
The Intervention
In October 2020, the Canadian federal government began to accept applications for the Canada Recovery Sickness Benefit (CRSB) in response to the overwhelming concerns of Canadians who lacked PSL throughout the pandemic. The benefit includes up to 2 weeks of PSL valued at $1000 for workers who are unable to work at their normal capacity due to self-isolation requirements, COVID-19 infection, or health conditions that increase personal risk of contracting the disease (CBC News, 2020). Specifically, eligible applicants receive approximately $500 for a 1-week period, which would require an additional application for further assistance. Moreover, the benefit cannot be received in addition to Employment Insurance and only covers a maximum of 2 weeks between September 27, 2020 and September 25, 2021 (Canada Revenue Agency, 2020). Therefore, while the government intended to make this intervention accessible to millions in hopes of reducing inequities and mitigating the spread of COVID-19 infection, this downstream approach does not remedy the root, ongoing causes of the issue: income inequality and precarious employment.
Usefulness in Addressing the Social Determinants of Health
At first glance, the CRSB is appealing because low-income workers typically have less access to PSL. For instance, in 2019, only 14% of individuals who earned $16,000 or less had PSL covered by their employer, compared to 74% of those who earned $96,000 or more (Macdonald, 2020). Additionally, PSL has the ability to reduce all-cause mortality. Thus, outside and within the context of COVID-19, the public health benefits clearly outweigh the economic costs (Heymann et al., 2020; Vazquez et al., 2020). Therefore, the intervention does aim to target those who are particularly disadvantaged, due to their socioeconomic status and social location, yet it still lacks suitability. Essentially, this intervention provides support for essential workers who would face increased financial hardship, due to COVID-19-related time off. However, it is inherently flawed; it does not truly alter the inequitable circumstances of the disenfranchised, which will fail to establish long-term improvements beyond COVID-19.
Limitations
PSL is essential in mitigating the spread of COVID-19, although, the CRSB arrived months late and does not address the underlying inequities that existed prior to the pandemic, which put precarious and low-income workers in jeopardy. Causes of this heightened risks are rooted in distal ongoing factors, including the unequal distribution of wealth and discrimination on the basis of race, immigrant status, and gender, which are further influenced by socio-structural forces, including policies and societal norms that widen gaps in health outcomes (Lynch, 2020; Marchand et al., 2020). Consequently, at the proximal level this manifests in the form of low-wage, essential workers, who are more susceptible to COVID-19 infection, due to inequities that reduce access to healthcare. This can include barriers to testing and time-off for income-related reasons, such as access to transportation and inability to afford time off from work.
In addition to this, there are two additional limitations inherent to the intervention. First, the intervention is temporary. Despite the unpredictability of the pandemic, it only provides individuals, such as essential workers who cannot work remotely, with 2 weeks of PSL until September 2021. Consequently, there is a need to create a permanent solution because the health inequity will persist following the end of the benefit period and the COVID-19 pandemic. Second, the CRSB may support many, but it still lacks true inclusivity. For instance, the CRSB has extensive requirements; it cannot be collected alongside Employment Insurance and a minimum of $5000 must have been earned at least 12 months prior to the application date (Canada Revenue Agency, 2020). Therefore, these requirements limit the eligibility of newcomers and low-income Canadians experiencing financial hardship. The CRSB and its conditions fail to consider the social determinants of health that are at the core of the issue, and have excluded particular groups from upward social mobility and opportunities to better their health.
The CRSB is a reactive intervention, which works downstream, rather than upstream, which is a limitation in itself. Thus, the conditions of the CRSB reduce the ability to truly rectify the pre-existing roots of the health inequities, which have been exacerbated by COVID-19. While the CRSB has short-term benefits, it is inadequate in addressing income inequality, which continues to reinforce poorer health outcomes in low-income communities. Instead, the government needs to create evidence-based interventions that are both long-term and upstream through discussions with those most affected by COVID-19. These limitations of the CRSB demonstrate that policy changes need to occur in order to ensure that distal circumstances are improved and that particular groups are not overrepresented in COVID-19 infection and death.
Conclusion
In conclusion, while the CRSB will help many, it is not entirely sufficient in mitigating the spread of COVID-19 because it fails to address the root causes that have put particular populations at risk. Thus, policymakers need to think both proactively and beyond COVID-19 to amend inequities within the social determinants of health that have existed prior to the pandemic, otherwise, interventions will continuously fail to correct the unequal distribution of wealth and its associated health inequities. Health equity advocates argue that policymakers should consider bottom-up approaches, such as a livable wage or universal basic income (Lynch, 2020). Policies such as these could truly alter the social circumstances of those who have been repeatedly failed by socio-structural barriers, allowing them to thrive within and beyond the pandemic.