key: cord-0933120-o7tjhy35
authors: Combden, Shianne; Forward, Anita; Sarkar, Atanu
title: COVID‐19 pandemic responses of Canada and United States in first 6 months: A comparative analysis
date: 2021-09-12
journal: Int J Health Plann Manage
DOI: 10.1002/hpm.3323
sha: d57e745118d4c1c7d0b7ae6731e8e57c22993541
doc_id: 933120
cord_uid: o7tjhy35

INTRODUCTION: Canada and the United States have distinct health care and social policies, and it is important to see how they had been responding to the ongoing COVID‐19 pandemic. METHODS: The study period was limited to the first 6 months of the pandemic and aimed to explore the responses by public health authorities, media, general population, and law makers during the initial phase of pandemic. RESULTS: Social disparity, underfunded pandemic preparation, and the initial failure to act appropriately have resulted in the rapid spread of infection in both countries. In the United States, prevailing social inequalities and racism, inaccessible health care, higher rates of preexisting medical conditions and disputed political leadership have further deteriorated the situation and enhanced public suffering, particularly for the black and Indigenous communities. In Canada, its poorly regulated services of long‐term care facilities, initial restriction of testing and lack of access to epidemiological data have helped spread the infection and increased casualties in vulnerable populations. CONCLUSION: Analysis of the pandemic responses of the United States and Canada has revealed how existing social disparity, underfunded pandemic preparation, and the initial failure to act appropriately have resulted in the rapid spread of infection.

People dealing with certain underlying medical conditions (such as cancer, diabetes, chronic obstructive pulmonary diseases (COPDs), obesity, and chronic kidney diseases [CKD]), advanced age (>65 years), and poverty are at increased risk for COVID-19. 12 Table 1 shows a comparison between the two countries with regard to socioeconomic and population health indicators. Life expectancy and the proportion of the elderly population (>65 years) are higher in Canada. Although the poverty rates of both countries are almost the same, children and the elderly population are more disadvantaged in the United States, and overall income inequalities are also more prevalent in the United States. According to the Organisation for Economic Co-operation and Development (OECD), the United States is in the bottom third (Gini coefficient) of the list of all member countries (only better than Mexico and Chile). 19 While the US population is disproportionately unhealthy with regard to obesity, diabetes, and CKD, Canada has higher rates of cancer and COPD. The United States is the only OECD country that does not offer universal healthcare, yet it spends more per capita on healthcare than other member COMBDEN et al. 3

Population age over 65 (%) 13, 14 16. 3 17.5 Life expectancy (years) 15 78. 5 82.2 Poverty rate (%) 16 Prevalence of chronic obstructive pulmonary disease (per 1000) 28 , 29 64 100 Practicing physicians (density per 1000 population) 30 2. 61 2.74 Health care spending (US$) per capita 31 Canada has been criticised for its lack of investment in pandemic preparedness and the poor upkeep of the Global Public Health Intelligence Network (GPHIN). The GPHIN is a secure internet-based multilingual early-warning tool developed by Health Canada in collaboration with the WHO and is a significant source of information for detecting novel infections and outbreaks. 34 In December 2019, as early reports of a novel coronavirus were coming out of Wuhan, China, the GPHIN system was receiving technology upgrades. Since the initial reports did not come from the trusted GPHIN system, there was speculation that early warnings were not taken seriously, thereby slowing the response. 34 Moreover, Canadian provinces and territories are required to provide detailed COVID-19 case report forms to the Public Health Agency of Canada (PHAC) within 24 h of identifying a positive case. Unfortunately, the transfer of these sensitive data relied on antiquated methods such as facsimile and email. 37 Similarly, the United States received criticism for its lack of a national reporting system. Health data collection across the country is fragmented, as its health care systems work in silos and there is a lack of communication between county and state facilities. This deficiency of collaboration hampers the ability to acquire, process, share, analyse, and communicate data to inform a timely outbreak response. 38 

Canada and the United States were not fully prepared to address COVID-19 testing, and neither country met national testing benchmarks. Based on their population sizes and the responses from proactive OECD countries (such as Germany, New Zealand, and Denmark), Canada should be testing a few hundred thousand people and the United States should be testing 2.5-30 million people per day. 39 Table 2 shows a timeline of the United States and Canada's COVID-19 responses.

In the United States, limited access to testing reagents, inadequate testing capacity at the national and community levels, and fragmented funding have prevented the development of accurate and reliable tests, resulting in a significant number of undiagnosed cases. 60, 61 Additionally, the initial test kits released by the Centre for Disease Control (CDC) were flawed and took weeks to correct, squandering a critical month during which aggressive and widespread testing might have reduced the speed and scale of the pandemic in the country. 62 Similarly, in Canada, shortages of testing supplies led to backlogs and delayed diagnosis, isolation, and contact tracing. 63 The scarcity of supplies meant that health care professionals had to prioritise testing and, therefore, were less likely to detect community transmission. 11 Despite these limitations, Canadian provinces were able to ramp up testing quickly, and by the end of February, the province of British Columbia alone had tested more people than all of the United States. 64 Canada failed to heed warnings from the WHO regarding asymptomatic viral transmission. Thus, asymptomatic

contacts of cases were not tested or isolated and therefore contributed to widespread community transmission. 63 Testing criteria at the federal and provincial levels were also criticised for being too restrictive, leading to missed cases. 65 Later, various government sectors collaborated to enhance the surge capacity as recommended by the PHAC (2018). As a result, federal employees have been trained as contact tracers to support jurisdictions with inadequate human resources. Statistics Canada provided 1700 interviewers with the capacity to make 20,000 calls per day to help with contact tracing efforts in any province or territory requiring assistance. 66 In the United States, the testing criteria were much more liberal, with testing available to symptomatic and asymptomatic individuals with known exposure to COVID-19. 67 The United States lacks a national strategy for contact tracing, which has led to a patchwork approach with uneven implementation across the country. Many states are understaffed and ill-prepared for the task. 68, 69 To achieve appropriate staffing, 100,000 additional contact tracers are required, with an estimated cost of US$3.7 billion to local, state, territorial, and federal public health agencies. 69 Chronic underfunding and a lack of federal financial support resulted in a loss of 25% of these agencies' employees over the last 10 years. 69 

While Canada's universal health care program provided free testing and treatment access to all citizens and residents, unprecedented levels of unemployment in the United States left many without health insurance and, therefore, made them less likely to seek testing and care due to the cost. 61, 64 In response, a new aid package, the Families First Coronavirus Response Act, which included provisions for free testing and paid sick leave for a portion of the population, was developed. 64 Unfortunately, the act was not implemented until March 18, nearly a month after the United States had documented widespread community transmission (Table 2) . 42 The response to improved access in the United States was slow, delaying diagnosis, isolation, and contact tracing and contributing to widespread community transmission. 61 and ultimately discarded, highlighting the lack of pandemic planning. 71 Additionally, Canada was dependent on international supply chains for PPE procurement, leaving the country vulnerable to inadequate supply amidst global pandemic demands. 72 The lack of PPE supply left healthcare workers susceptible to exposure to COVID-19 and led hospitals to appeal to the public for PPE donations. 73 

Notably, the turning point for Canada's response was the united decision to physically distance and outstanding compliance with stay-at-home orders from the public. 63 Consistent communication between provincial and territorial government leaders and public health officials allowed provinces to gain insights from one another and employ stayat-home orders. 87 Conversely, early communication from federal officials in the United States was noted to downplay the seriousness of the virus. Throughout February, President Trump repeated the message to various media outlets and state governors that COVID-19 would disappear on its own as the weather gets warmer. 88 The misinformation and influence of the president contributed to a false sense of security and sentiment that public health measures were unnecessary. 49 On 26 March 2020, the president released national social distancing and stay-at-home guidelines entitled '30 Days to Slow the Spread'; however, stay-at-home orders were inconsistently implemented among states, and public non-compliance levels were high. 49 Dr Fauci's statement supporting stay-at-home orders was in stark contrast to President Trump's message that some states were too harsh with closures and stay-at-home orders, contradicting his own guidelines. It has been noted that the US federal government's hesitation in supporting state stay-at-home orders was rooted in the desire to avoid disruptions to business and the economy. 49

Communities experiencing pre-existing social vulnerabilities are at an increased risk of exposure to infection and psychological distress in the context of a pandemic. Such groups include LGBTQ+ persons, racialized populations, longterm care residents and staff, and people living in poverty. 89 

Public health measures such as physical distancing and shelter-in-place orders pose unique challenges for LGBTQ+ communities in both countries, negatively impacting their health and safety, and they have received minimal attention during the COVID-19 response. 90 

LGBTQ+ people in the United States lack federal employment protections from being fired because of their sexual orientation, making them more susceptible to employment loss during the pandemic. 92 In the United States, 17% of the LGBTQ+ population lacks access to health insurance versus 12% of the general population. 90 With the loss of service industry jobs and subsequent employer insurance, the health insurance gap is increasing for LGBTQ+ populations in the United States, thereby limiting their access to healthcare. 92 Both Canada and the United States have developed online mental health resources to support the general public with the psychological stress associated with COVID-19. These resources, however, failed to consider that intersectionally marginalised populations such as LGBTQ+ groups with low income may lack access to digital technology, further perpetuating health inequities in these vulnerable populations. 90 

A growing body of evidence suggests that racial and ethnic minorities and socioeconomically disadvantaged communities bear a disproportionate burden of illness and death due to COVID-19. 93 The infection rate in black counties in the United States is three times higher, and the death rate is six times higher than in predominantly white counties. 94 African American patients had 2.7 times the odds of hospitalisation, even after adjusting for age, sex, income, and comorbidities. 93 Moreover, several underlying medical conditions known to increase the risk of COVID-19 (such as certain types of cancer, diabetes, COPD, obesity, and CKD) are more prevalent among black, Indigenous, and ethnic minorities. For example, compared to Caucasians, end-stage kidney disease prevalence is about 3.7 times greater in African Americans, 1.4 times greater in Native Americans, and 1.5 times greater in Asian Americans. 26

Existing social, economic, and health policies and systems that underpin health disparities for racial and ethnic minorities and socioeconomically disadvantaged communities are magnified during times of crisis. As income is strongly correlated with health, economic status matters profoundly for reducing the risk of exposure to COVID-19. In 2018, for every dollar of household income that white workers earned, black workers earned 59 cents, and Hispanic workers earned 72 cents. 95 African American individuals also had higher rates of un-insurance and under-insurance compared to white individuals, thereby limiting their access to healthcare and contributing to delays in seeking appropriate testing and care for COVID-19 symptoms. The segregation of healthcare services further limits access to care. COVID-19

testing centres were more likely to be located in higher-income, mostly white neighbourhoods versus low-income racialized black neighbourhoods, contributing to racial disparities in health. 95 COVID-19 has exposed the deeply entrenched history of health care inequity based on underlying racism. Studies from 2015 to 2017 indicated a majority of healthcare clinicians had an implicit bias against African Americans associated with poor patient-clinician communication and quality of care. COVID-19 testing data from several states revealed African American patients reporting COVID-19 symptoms were less likely than white individuals with the same symptoms to receive testing. 95 Thus, members of racialized communities lacked access to testing, thereby delaying diagnosis and further increasing the risk of complications and deaths from COVID-19.

Although public health measures such as physical distancing and stay-at-home orders are effective strategies known to reduce COVID-19, the ability to comply with these measures is not equal among all populations. The privilege of physically distancing at work and working from home are not available in many low-income jobs. 94 Additionally, racial minorities are overrepresented among essential service workers who are required to work outside the home when stay-at-home directives are issued. Many must travel to work on buses and subways, increasing the risk of exposure and consequent infection. 94 Canada's Pandemic Plan cites the need for robust data collection to identify populations disproportionately impacted in order to address specific needs through tailored interventions. 89 The report recognises priority populations,

including Indigenous people, black people, LGBTQ+ communities, and people living in poverty. For Indigenous communities, special attention was paid to appropriate communication, restrictions on entry for outsiders to reserves, and access to essential pandemic responses. 96 Incidence and mortality rates of First Nations individuals living on reserves reported one-fourth and one-fifth of the rates found in general population. 97 However, in the United States, in the first 5 months, the cumulative incidence of laboratory-confirmed COVID-19 among non-Hispanic American Indian and Alaska Native persons was 3.5 times higher than among non-Hispanic white persons. 98 A notable weakness of Canada's pandemic response is the lack of race-based and socio-demographic data collection. 99 On 5 June 2020, Canada's federal, provincial and territorial human rights commissions issued a letter calling on the Government of Canada to develop and implement a nation-wide strategy for the collection of disaggregated health data focused on race and indigeneity. 100 The Commission is advocating for policy and decision makers to engage racialized communities as partners and co-owners in race-based data collection to ensure appropriate use and to identify inequities. 99 Canada was slow to recognise that healthcare workers employed across multiple sites were contributing to the rapid spread of infection. As such, measures to restrict employment to one single facility were implemented too late. 103 Early data from the United States clearly showed that long-term care workers were spreading COVID-19 between facilities; this discovery led all provinces in Canada to restrict the employment of healthcare workers to one facility. 103 For most health care workers in Canada, long-term care setting employment is part time at lower wages and without benefits such as sick leave. Because of this, health care providers have to work across multiple sites to earn a living wage. 103, 106 Similarly, in the United States, workers receive low pay and do not have employer health insurance. 107 The low pay in both countries forces many to work shifts in several care homes to earn a living wage, contributing to the spread of COVID-19 across facilities. 106 

Analysis of the pandemic responses of the United States and Canada has revealed how existing social disparity, underfunded pandemic preparation, and the initial failure to act appropriately have resulted in the rapid spread of infection. In the United States, prevailing social inequalities and racism, inaccessible health care, higher rates of preexisting medical conditions and questionable political leadership have further deteriorated the situation and enhanced public suffering.

Not surprisingly, 6 months after first case was reported, the incidence and death rates of COVID-19 in the United States were much higher than in Canada (Table 2) . However, Canada's inadequate services of long-term care facilities, initial restriction of testing and lack of access to epidemiological data have helped spread the infection and increased casualties in vulnerable populations. Study also shows that scarce scientific evidence is a challenge for initial fight against novel pandemic and therefore, preemptive additional protection for socially vulnerable population and effective coordination between the law makers and scientific experts are paramount to reduce early morbidity and mortality.

The lessons learned from this research can be used to inform future planning, management and the response to any novel pandemic. Successful pandemic management and response requires: (a) a robust public health surveillance system, (b) accessible mass testing, (c) the rapid collection, collation, analysis, and dissemination of testing data, (d) the domestic supply and production of PPE, (e) the early implementation of public health measures (social distancing and masking) and (f) clear and consistent communication from government and public health leaders.

The major limitation of the study was the non-availability of peer-reviewed research articles on this novel coronavirus within the first 6 months of the pandemic period. Although we attempted to retrieve all available research articles, our main sources were grey literature and media.

For future research, we suggest to conduct in-depth retrospective global study of managing early phase of COV-ID-19 pandemic. Sharing such database will help finding gaps in the health system and taking corrective measures before any novel pandemic strikes in future.

Future pre-pandemic planning should focus on addressing inequalities and inequities, the mobilisation and capacity building of human resources, the preemptive assessment of the required surveillance supplies and self-reliance in their production, and strengthening the existing demographic database by adding racial profiles of the population.

The political establishments and technical experts should work in tandem in planning and management of pandemic.

Not applicable.

No conflict of interest.

Not applicable.

The manuscript is based on literature review (no primary data). All the sources were cited in the text and listed in the reference.

Atanu Sarkar https://orcid.org/0000-0003-1797-4971

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