Navigating inequities: a roadmap out of the pandemic

The COVID-19 pandemic has necessitated physical gaps between individuals with distancing, and exposed unjust gaps of disparities between populations. Without a thoughtful roadmap for the equitable allocation of vaccines, this pandemic will lead to the exacerbation of inequities between and within countries. Like SARS-CoV-2, the affliction of the ‘social gradient’—where those at lower socioeconomic positions have inferior levels of health—infects all countries regardless of level of wealth.1 The SARS-CoV-2 virus is novel, but disparities are not. It is no longer sufficient to don a ‘single vision’ equity lens to examine some disparities, some of the time. A comprehensive investigation of all health inequities and the complex reasons for these inequities is urgently needed for the implementation of fair, restorative interventions. Here, we present the first validated, successfully used equity framework applied to COVID-19 (table 1). Unlike anything in the literature to date, this framework illuminates the spectrum of health inequities, navigates their sources and intersections, and helps avoid deepening disparities through ethically just policies. Such a roadmap is critical to steer global leadership towards the mitigation of the unfair burden of this pandemic on marginalised populations who systemically experience greater obstacles to health.

Equity Matrix: a validated tool to help fix complex issues

The Equity Matrix is the first peer-reviewed, published tool that comprehensively outlines how to methodologically assess and respond to critical equity issues in a timely, practical way. It is part of a broader framework that also integrates ethics, feasibility and acceptability to ensure appropriate implementation of public health recommendations.2 The resources and time taken to develop this overall framework through 5 years of environmental scans, stakeholder consultations, surveys and literature reviews have reduced the resources and time taken to implement it. The evidence-informed equity tool supporting the overall framework has been validated for its utility and comprehensiveness, and successfully used for vaccines in recent years. Traditionally, most vaccine guidelines rigorously assess clinical factors such as efficacy and safety. While equity is increasingly considered conceptually, it is not explored systematically or transparently. The Equity Matrix has been fundamental in guidance on COVID-19 immunisation by Canada’s National Immunization Technical Advisory Group (NITAG), the National Advisory Committee on Immunization,3 4 and may be valuable to other NITAGs and organisations around the world hastening to develop recommendations on COVID-19 health products based on principles of equitable access and fair allocation.5–7 Application of this matrix for the development of recommendations on the use of interventions such as SARS-CoV-2 vaccines will be critical to reduce, rather than exacerbate, inequities.

The pursuit of health equity has become a worldwide public health objective.1 The Equity Matrix, though initially developed for vaccine guidance, can be applied across a broad spectrum of policy and programme interventions to pursue this objective. While complex in nature, health inequities share common features: they are systematic, avoidable and unfair.8 They arise because of the circumstances in which people grow, live, work, age, and the systems put in place to deal with illness.1 They can be modified through altering institutions, policies and practices that cause inequitable distribution of power and resources.9 The Equity Matrix provides a roadmap to navigate health inequities with interventions that uphold the ethical principle of justice with the socially just distribution of limited resources. It can be applied within and between countries and regions so that scarce initial supplies of SARS-CoV-2 vaccines are effectively distributed globally based on a gradient of risk rather than a gradient of wealth. It is also an inclusive tool to direct surveillance and research and unveil epidemiological uncertainties and evidence of yet undiscovered inequities of novel diseases like COVID-19.

Table 1 reflects the Equity Matrix we populated with emerging evidence for COVID-19 in consultation with other experts and stakeholders. It was used to inform guidance for the efficient, effective and equitable allocation of SARS-CoV-2 vaccines in the context of limited initial supplies in Canada4 as well as research priorities for clinical trials.3 The table incorporates results of a rapid review of risk factors for severe outcomes in Organisation for Economic Co-operation and Development member countries.10 Technical experts and policy-makers, in consultation with stakeholders across sectors, can populate the Equity Matrix with evidence relevant to the country or countries for which policies are being made. The completed tool can be adapted over time to succinctly and comprehensively summarise up-to-date evidence, and guide research and surveillance where evidence is lacking. The first column summarises biological and social factors that may contribute to health inequity. This allows the identification of groups at high risk, for whom reduced access to a public health intervention may further exacerbate the inequity. For each group identified, the sources of the inequity are explored (second column) to aid in the process of reviewing interventions that could address the inequity and improve access (third column).

While experts acknowledge that inequities must be taken into account when considering government interventions, there is no scientific consensus on how to effectively take action to reduce these inequities.11 Evidence on interventions aimed at individual determinants of health and on the impact of intersectoral action on health equity is limited.12 13 This should not be interpreted as a lack of effect, but rather insufficient rigour in evaluations of these interventions.13 A systematic review conducted to inform the Equity Matrix found limited evidence on the effects of interventions on hospitalisation for or mortality from vaccine-preventable diseases, and the evidence from these trials was uncertain.14 Randomised trials of immunisation aimed at improving health equity (with control groups not offered recommended vaccines) is unethical, and measuring the outcome of health inequities related to many vaccine-preventable diseases requires long-term follow-up. Well-conducted, scientifically rigorous, ethical studies of interventions evaluating the impacts on health equity would be valuable to populate this tool. However, a paucity of such evidence should not preclude the implementation of ethically just interventions. Therefore, the third column of table 1 was completed with stakeholder and expert input on interventions that could address inequities.

The Equity Matrix supports the inclusion of multi-sectoral interventions for structural, systemic changes needed to address inequities. However, given the urgent need for equitable health policies in this pandemic, table 1 focuses on short-term actions within the health sector with examples for immunisation specifically. The information summarised in this matrix is critical to ensure equity issues are appropriately addressed and integrated into expert health guidance, including recommendations on the optimal use of SARS-CoV-2 vaccines.

Illuminating the spectrum of health inequities

Evidence linking severe COVID-19 disease to biological risk factors such as advanced age and pre-existing conditions is well-established.15 16 Evidence continues to emerge separately about the links between COVID-19 and factors such as ethno-racial background.17–19 The Equity Matrix comprehensively illuminates an array of overlapping factors that compound health inequity.

The spectrum of factors included in the first column of this matrix was adapted from the PROGRESS-Plus model of health determinants and outcomes.20 We expanded the categories captured in PROGRESS-Plus and added important health equity factors that were not explicitly included in the existing model, such as having pre-existing conditions, racialisation (including immigration or refugee status), age, and behaviours such as drug or alcohol use and smoking. The categorical inclusion of these factors ensures that they are unequivocally considered. These additional factors are all critically relevant to COVID-19 epidemiology and infectious diseases in general, and were among the most commonly investigated factors in a systematic review on health inequities related to vaccination.14 The resulting ‘P²ROGRESS And Other Factors’ framework was used to guide a rapid review on COVID-19 which included studies using multivariate analyses to adjust for potential confounders.10 Using this framework, the review illuminated independent biological risk factors (eg, advancing age and certain high risk conditions) and independent social risk factors (eg, racialisation, low income, homelessness) where evidence exists, as well as potential risk factors for severe outcomes of COVID-19 where evidence is sparse (eg, immigration or refugee status, living with a disability, substance use disorders). Disregarding potential inequities due to the absence of disaggregated data, such as in migrant workers differentially exposed to SARS-CoV-2, could undermine an effective pandemic response. Using the Equity Matrix to recognise that inequities may exist where evidence does not (yet) exist is important for ethically just interventions where people are treated with equal concern and respect.

Navigating the sources and intersections of health inequities

Public policies should unravel inequities to avoid perpetuating them. The second column of the Equity Matrix outlines reasons why an inequity may exist, including differential access to healthcare, or, as outlined in the Quinn and Kumar framework,21 pathways through which various factors can influence the differential exposure, susceptibility, severity and consequences of infectious diseases. The matrix also illustrates how different factors converge to produce inequities. For example, inequities due to socioeconomic status intersect across multiple factors. Populations living in deprived areas, as well as visible minorities and immigrant populations, seem to be disproportionately affected by COVID-19 with differential severity in the USA,17 England18 and parts of Canada where data exists.19 The rapid review of evidence summarised in table 1 found that low income and ethno-racial background were important independent risk factors for severe outcomes of COVID-19.10 This review also found that diabetes is an important independent risk factor for severe outcomes of COVID-19. The association between low income, ethno-racial background and risk of type 2 diabetes is well-established in many countries.22–24 Though found to be independently associated with increased risk of severe COVID-19, the intersection between these factors is important to acknowledge. The negative association between racism and physical health, mental health and health risk behaviours is well-established.25 Even in countries with universal healthcare policies, evidence on differential access to quality healthcare among racialised populations exists.25 Such intersections are especially important to note because the direct effects of genetic or biological host factors on disproportionately higher rates of severe COVID-19 in racialised groups remain unknown, and research into the contribution of policy, healthcare system and society-level determinants to the roots of such inequities is needed.26

Male sex has been found to be an independent risk factor for severe outcomes of COVID-19,10 even though cases of COVID-19 appear to be equally distributed between the sexes worldwide.27 Biological or immunological differences may contribute to this inequity,28 but gendered differences in occupations and behaviours, such as differential access to healthcare before progression of disease, may also explain observed differences. While direct evidence on differences in severe outcomes due to male sex exists, indirect and direct impacts of the pandemic due to gendered differences in caregiver roles, gender-based violence and socioeconomic instability cannot be ignored.

Disproportionate rates of infections with devastating consequences have occurred in previous epidemics among Indigenous Canadians,29 and are being observed in the current COVID-19 pandemic among Indigenous Peoples in other countries.30 31 Differential disease exposure and severity in these populations are not only linked to differential access to quality healthcare, but also systemic racism in society and the healthcare system, inequities in the social determinants of health such as adequate housing,32 and an underlying history of colonialism.33 Similarly, migrant and ethnic minority populations have been disproportionately affected by infectious diseases and epidemics in the midst of economic crises in the past due to lack of access to healthcare and poor living conditions.34 In the current pandemic, these populations are also subject to differential exposure to SARS-CoV-2 due to disproportionate representation and precarious occupations in sectors such as food and healthcare, deemed essential and not subject to lockdowns.35 Reduced access to paid time off and personal protective equipment (PPE) or other infection prevention and control (IPC) measures in congregate living and work settings perpetuates transmission of infection within communities. Recognising the intersectionality of the social determinants of health in predisposing systemically marginalised populations to inequitable health outcomes is critical to changing the course of this pandemic.

A focus solely on biological explanations of disease is narrow and has been damaging to science and people. Labelling populations as ‘vulnerable’ without understanding the reasons for the increased risk in outcomes causes further stigmatisation and discrimination. The Equity Matrix allows for holistic reflections on biological and social inequities and their origins and intersections, rather than fragmented assessments that could perpetuate harmful misunderstandings, injustices and ineffective public health solutions.

Identifying how to close, rather than widen, the gap of health inequities

Applying an ‘equity lens’ to bring inequities into focus without a vision to alleviate them is short-sighted. In order to be effective, public health actions in a pluralistic society cannot ignore diversity in disparities. Therefore, the Equity Matrix includes a third column, identifying practical interventions to reduce varied inequities. In the face of limited interventional resources such as vaccines and cost-prohibitive population-level programmes or product characteristics where vaccine effectiveness cannot support herd immunity, population-based risk assessments must extend beyond traditional biological risk factors to be successful and fair in immunisation strategies where some groups may get vaccine earlier than others.

To reduce morbidity and mortality of COVID-19 and minimise disruption to society, healthcare systems and the economy, specific strategies to increase access to interventions (such as immunisation) and respectfully engage systemically marginalised populations will be required, as summarised in table 1. Pluralism is a prerequisite for success and respect for the diversity of communities and traditions is the key to open doors rather than a reason to put up walls. This has been evident in the success of Indigenous communities in Canada who, through interventions grounded in their own traditions, self-determination and sovereign collection of Indigenous-specific COVID-19 data,33 have had COVID-19 case rates that are four times lower and fatalities that are three times lower than the general population36 despite systemic inequities. Respectful engagement of diverse populations is paramount in leading us out of this pandemic.

Public health interventions should navigate inequities in order to reduce them through inclusion, rather than exacerbate them with policies of neglect. For example, real efforts should be made to include populations from a variety of socioeconomic, gendered and racialised backgrounds in clinical trials. Unfortunately, an examination of a subset of published studies investigating the effects of COVID-19 treatment found that a third of the studies did not report ethno-racial data, and Black patients were under-represented in all studies relative to the burden of disease among Black communities in which the studies took place.37 Such exclusions in vaccine clinical trials contribute to distrust and vaccine hesitancy.38

While there is a race to develop SARS-CoV-2 vaccines, public surveys indicate that there may not be a race to get one.39–42 Vaccine hesitancy has been deemed one of the top ten global heath threats by the WHO in 201943 and could limit the success of a COVID-19 immunisation programme. In Canada, an examination of acceptability of SARS-CoV-2 vaccines, and coverage rates of existing vaccines, reveals additional issues contributing to inequities in groups already at high risk of severe COVID-19. Visible minorities and Indigenous Canadians appear to be less willing than non-visible minorities to get a SARS-CoV-2 vaccine that is effective and recommended.42 Though significant differences in willingness to get a SARS-CoV-2 vaccine have not been observed by sex or socioeconomic status in Canada,41 42 vaccination coverage rates in general have tended to be lower among men and those in lower socioeconomic groups,44 45 suggesting issues related to decreased access to vaccines. Even among healthcare workers, who tend to have higher vaccine coverage rates, uptake varies by ethnicity.46 Studies have demonstrated protection against infection with the appropriate use of PPE in healthcare workers.47 48 Unfortunately, differential access to, and training in the use of PPE and other IPC measures intensifies inequities.

Key reasons for vaccine hesitancy include complacency, inconvenience in accessing vaccines, and lack of confidence.43 Population differences in access to and trust in vaccines and healthcare, as well as intent to get a safe, effective SARS-CoV-2 vaccine, should influence the direction of effective interventions, as outlined in the Equity Matrix. For example, offering publicly funded vaccines in key high-risk groups, ensuring vaccines are safe and effective in all high-risk groups, and providing mobile immunisation clinics with recall and reminder systems could increase access to vaccines for many populations. Engaging social influencers and leaders of cultural and faith-based groups with community-driven efforts for coordinated public health approaches and immunisation programme planning, and providing culturally sensitive educational materials in appropriate languages, literacy levels and media channels could combat misinformation and mistrust about vaccination in general, and SARS-CoV-2 vaccines specifically. Receiving a recommendation from a healthcare provider is linked to increased acceptance for vaccination in general,2 and trust in doctors is a key factor in willingness to get a SARS-CoV-2 vaccine.41 Empowering healthcare providers and the public with transparent evidence-informed recommendations based on systematic analyses of critical equity issues, in addition to factors such as the safety and efficacy of interventions, is vital. Diverse strategies will be required for diverse inequities (see table 1).