key: cord-0949984-scoglf3e
authors: Whalley Hammell, Karen
title: Building back better: Imagining an occupational therapy for a post‐COVID‐19 world
date: 2021-07-22
journal: Aust Occup Ther J
DOI: 10.1111/1440-1630.12760
sha: 081c26c79dac9e8b23b3ec91abb53f485b4a068a
doc_id: 949984
cord_uid: scoglf3e

INTRODUCTION: The COVID‐19 pandemic, which has disrupted occupations and lives of people around the world, has simultaneously exposed deeply rooted social inequities and structural injustices that have negated the facile claim that “we're all in this together.” But the pandemic has also opened up opportunities to imagine other ways of living and doing in the future. This paper imagines some possibilities for shaping occupational therapy's future practices and seeks to illustrate why it is both timely and necessary to re‐imagine occupational therapy in 2021. METHODS: Drawing from epidemiological research, the paper explores the inequitable impacts of COVID‐19, environmental degradation, and multiple social determinants on people's real opportunities for health, wellbeing, and occupational engagement. FINDINGS: Evidence presented in this paper challenges occupational therapy's individualised approach towards wellbeing and contests the limited parameters of occupations “that matter” that are prioritised and promoted within the profession. In response, the paper seeks to expose the specific, political, economic, and ableist ideology that has effectively shaped the occupational therapy profession's assumptions, models, theories, and the practices these inform. CONCLUSION: Drawing from the “Build back better” approach to post‐disaster recovery—with its dual attentions to wellbeing, equity, and inclusivity and to physical, social, cultural, economic, and environmental vulnerabilities—this paper imagines an occupational therapy for a post‐COVID‐19 world; an occupational therapy that takes seriously the premise that occupations and people are inseparable from their environments; a profession that no longer colludes in individualising problems that are inherently social or in depoliticising the systemic social and economic inequalities that create stress and illness; an occupational therapy that no longer promotes the values of neoliberal ableism; and an occupational therapy dedicated to expanding people's just and equitable opportunities to engage in meaningful occupations that contribute positively to their own wellbeing and the wellbeing of their communities.

Introduction: The COVID-19 pandemic, which has disrupted occupations and lives of people around the world, has simultaneously exposed deeply rooted social inequities and structural injustices that have negated the facile claim that "we're all in this together." But the pandemic has also opened up opportunities to imagine other ways of living and doing in the future. This paper imagines some possibilities for shaping occupational therapy's future practices and seeks to illustrate why it is both timely and necessary to reimagine occupational therapy in 2021.

Methods: Drawing from epidemiological research, the paper explores the inequitable impacts of COVID-19, environmental degradation, and multiple social determinants on people's real opportunities for health, wellbeing, and occupational engagement. Findings: Evidence presented in this paper challenges occupational therapy's individualised approach towards wellbeing and contests the limited parameters of occupations "that matter" that are prioritised and promoted within the profession. In response, the paper seeks to expose the specific, political, economic, and ableist ideology that has effectively shaped the occupational therapy profession's assumptions, models, theories, and the practices these inform. Conclusion: Drawing from the "Build back better" approach to post-disaster recovery-with its dual attentions to wellbeing, equity, and inclusivity and to physical, social, cultural, economic, and environmental vulnerabilities-this paper imagines an occupational therapy for a post-COVID-19 world; an occupational therapy that takes seriously the premise that occupations and people are inseparable from their environments; a profession that no longer colludes in individualising problems that are inherently social or in depoliticising the systemic social and economic inequalities that create stress and illness; an occupational therapy that no longer promotes the values of neoliberal ableism; and an occupational therapy dedicated to expanding people's just and equitable opportunities to engage in meaningful occupations that contribute positively to their own wellbeing and the wellbeing of their communities.

The COVID-19 pandemic, which has disrupted occupations and lives of people around the world for more than a year, has simultaneously exposed deeply rooted social inequities and structural injustices that have negated the facile claim that "we're all in this together." But the pandemic has also opened up opportunities to imagine other ways of living and doing in the future. The aim of this paper is to articulate some possibilities for shaping occupational therapy's future practices and to illustrate why re-imagining occupational therapy in 2021 is not only timely but also necessary.

Building on knowledge concerning the social determinants of health and occupation and drawing from epidemiological research, this paper examines the status quo into which the novel coronavirus emerged to provide context for the assertion that occupational therapy needs, not solely to build back better but to build back fairer.

Because the paper addresses injustice and inequity, it is necessary to acknowledge the author's position as a White, Anglophone, class-privileged, straight, cis-female, and with neither physical impairments nor mental health challenges. "Cis-gendered" means that the gender the author was assigned at birth is the gender with which she has always self-identified. It is another component of her identity-like her white skin and her able body-from which she derives material benefits, occupational advantages, and social privileges that she has never sought and has not earned. But this is how privilege works.

She also enjoys the advantages of dual citizenships, as an immigrant and citizen of a colonised territory-Canada-and as a citizen of Britain: a nation that invaded, occupied, and influences vast regions of the world as part of its colonial agenda. For half the year, she writes from Vancouver, British Columbia, on the traditional, ancestral, and unceded territory of the Tsleil-Waututh people and for the other half, from the Souris River valley in Saskatchewan, on Treaty 2 land, which is part of the traditional territory of the Blackfoot Niitsítapi Cree people, and the homeland of the Métis nation. The author recognises the unjust history and problematic present enabling her presence on these stolen lands and will return to the shameful subject of colonialism later in this paper. Injustice shapes all our lives-advantaging some and disadvantaging others-as it is intended to do, yet injustice is often invisible to those of us who unfairly enjoy its benefits.

As a resident of Canada, the author is accustomed to using the terms "First Nations people" or "Indigenous people" to refer to the original people who have belonged to these lands for millennia and will also interchange these terms to refer to Aboriginal and Torres Strait Islander peoples. Please know that each term is employed with deep respect. I know that words matter, and if I get them wrong, I request forbearance and forgiveness.

The term "Global South" is used in this paper to refer to those regions of the world that continue to endure inequalities of power, wealth, and cultural influence due to the dominance and ongoing impact of European colonialism and North American imperialism. Although obviously located in the Southern hemisphere, Australia is included within the parameters of the Global North due to its power, wealth, and Anglophone privilege, because this term addresses power, not geography. But Núñez (2019) reminds that "in each North there is a South and in each South there is a North" (p. 672). Structural inequalities ensure that some in the Global South enjoy extreme wealth and unlimited opportunities, whereas numerous people in the Global North endure poverty, food insecurity, lack of access to clean water, safe housing, quality education and employment, negation of cultural traditions and spiritual practices, and limited occupational opportunities. Australia, then, is geographically south and wields the power and wealth that characterises the Global North yet has a significant population of people enduring the injustices and vulnerabilities that epitomise the Global South.

This was the profoundly unjust world into which COVID-19 emerged.

Since the first weeks of 2020, measures taken to limit the spread of the COVID-19 virus have disrupted the lives of billions of people around the world. In the early days of the pandemic, as we shared the collective experience of unpredictability and uncertainty, and constraints on the abilities and freedoms many of us had viewed as rights and entitlements, politicians assured us that "we're all in this together." But we were not.

From the earliest days of the pandemic, it was apparent that members of poor, racialised communities in the Global North were significantly more likely to die from COVID-19 than White people enjoying more privileged economic circumstances (Marmot et al., 2020; Yancy, 2020) . First Nations and Indigenous people, Black people, and other people of colour have suffered the consequences of a constellation of systemic factors that have significantly increased their risk of death. Inequitable access to health care resources; overcrowded, poorquality housing that afforded few opportunities to enact physical distancing; severe economic disadvantages that led to difficulties obtaining masks, hand sanitiser, clean water, and healthy food; limited economic resources that offered no alternative to the use of public transportation; and precarious employment or employment in poorlypaid, yet essential jobs servicing those enjoying the privilege of working from and staying at home all conspired to significantly raise the risk of exposure to and death from the coronavirus (Marmot et al., 2020; Yancy, 2020) . Social injustice has killed people, and of course, we knew it would. Decades of epidemiological research into the social determinants of health had already held up a mirror to the inequities and injustices deeply embedded in our societies, and epidemiologists had been insisting for years that "social injustice is killing people" (Marmot et al., 2008 (Marmot et al., , p. 1661 ).

Long before the current pandemic, researchers in Australia had documented unfair disparities between different social groups, with specific social determinants of health inequity affecting both the material and psychosocial aspects of people's daily lives (Baum & Friel, 2017) . Understanding that social determinants produce health inequities is of fundamental importance for occupational therapists, not just because our profession is concerned with human health but because occupation-our central domain of concern-is also socially determined. The paper will return to the idea that occupations are socially determined but will first focus briefly on the social determinants of health.

The social determinants of health are the conditions in which people are born, grow, live, work, and age. These "determinants" include such things as early childhood development, education, employment, food security, housing, transport, economic status, social support, and access to health care (Marmot et al., 2008 (Marmot et al., , 2012 . The inequitable distribution of these determinants contributes to inequities in physical and mental health throughout the lifespan, inequities that are reproduced and compounded from one generation to the next. Words matter; and the word "inequity" is used to indicate differences that are not solely unequal but unfair. Health inequities are avoidable differences in health status and, as such, are manifestly unfair (Marmot et al., 2008) .

Critical epidemiologists, who have researched the impact of social determinants on health, have demonstrated the existence of a social gradient, such that each socio-economic group experiences worse health and lower life expectancies than the group immediately above it (Marmot et al., 2008) . Incidences of diabetes, heart disease, respiratory disease, stroke, diseases of the digestive tract, kidney disease, tuberculosis, HIV-related diseases, mental illnesses, suicide, and accidental and violent deaths all follow this social gradient, such that those who are lower in the socio-economic hierarchy have higher risks: the lower the status, the higher the risk (Marmot et al., 2008) .

Differential exposure to the social determinants of health leads to life expectancies in some Canadian cities being 20 years longer in wealthy neighbourhoods than in poor neighbourhoods within the same city (Canadian Medical Association, 2013) . Clearly, this is unfair and unjust; life should not be a by-product of privilege.

It has already been emphasised that health inequities are avoidable differences in health status. The social determinants of health are not unfortunate quirks of happenstance; they reflect specific political choices and the health, social, educational, and environmental policies derived from these choices. This should prompt us to ponder the ways of thinking that inform these choices; why are injustices baked into the policies that govern our lives? Reading (2018) has offered the metaphor of a tree to depict the relationship between the social determinants of health and their ideological underpinnings. The visible leaves represent the proximal social determinants that have already been outlined, like food security and education. The trunk represents the intermediate-or mediating-factors that impact the social determinants, such as access to health care and embeddedness within networks of social support, and the root system represents the foundation that nourishes all the other determinants. To understand the "leaves," it is necessary to expose and examine the "roots."

To situate the contention that re-imagining occupational therapy in 2021 is not only timely but necessarywhy returning to "normal" is neither appropriate nor acceptable-the paper will briefly explore colonialism and its more recent off-shoot, neoliberalism. Using the tree metaphor, these are the roots supplying ideological nutrients to the iniquitous social determinants of both health and occupation.

Australia, like Canada, continues to manifest the ongoing impact of colonialism: "one of the most important, destructive and lasting forces in human history" (Grech, 2015, p. 7) . Motivated by greed and entitlement and justified by a perverted sense of racial and religious superiority, colonialism-in the past and in the present-involves the systematic use of power to exert control over other people; appropriate and commodify their territories, waters, and resources; settle their lands; exploit their labour; erase their cultural and spiritual practices and languages; and establish and preserve inequitable access to opportunities and services (Hammell, 2022) . Colonialism constructed hierarchical classificatory systems that positioned White people as superior to all others, imposed binary genders and positioned men as superior to women, and established class hierarchies that ranked groups according to their proximity to capital (Pihama, 2019) . These constructed hierarchies continue to determine occupational opportunities in settler-colonial nations, unfairly advantaging straight, able-bodied White people (and especially cis-men) from middle and upper classes while disadvantaging poor people, Indigenous people, people of colour, people with disabilities, queer, trans and gender diverse people, and people from a diversity of religious, ethnic, and cultural traditions.

In the 21st century, colonialism remains the fundamental determinant of Indigenous people's health in countries where settler-colonial power dominates (de Leeuw et al., 2018) . For Aboriginal and Torres Strait Islander people, deep, spiritual connections to sacred and traditional lands and waters, cultures, ancestors, communities, and languages are known to be significant determinants of health and wellbeing (Kingsley et al., 2013) . Engagement in the collective, sacred, traditional, and land-based occupations that support the wellbeing of Indigenous peoples has required-and continues to demand-significant resilience due to colonialism's historic and ongoing process of cultural genocide (Fogarty et al., 2018) .

Regrettably, and despite considerable evidence that within colonised and settler countries, such as Canada and Australia, Indigenous people continue to experience significantly more social and occupational disadvantages, diminished wellbeing, and ill health than non-Indigenous people as a direct consequence of colonialism (de Leeuw et al., 2018; Nelson, 2007) , the uncomfortable topic of settler colonialism is rarely mentioned in the occupational therapy profession's dominant Anglophone literature. Yet, as Chelsea Vowel (2016) has observed, "If you don't understand the history of relations between Indigenous people and settlers, then you aren't going to believe that current conditions faced by Indigenous people aren't self-imposed" (p. 230). This understanding is important for a profession that so consistently promotes the neoliberal premise that people-all people-are able to make wise occupational choices that will contribute positively to their health and wellbeing.

Fundamental to colonial ideology is the Judeo-Christian belief that humans are entitled to dominion over nature and that the natural environment is a commodity, or "resource" that people are entitled to subdue, manage, and exploit (Pihama, 2019) . This deeply rooted belief is visible within the occupational therapy literature, wherein Anglophone theorists have portrayed all people as having an innate and irresistible urge to achieve mastery and superiority over the environment (for discussion, see Hammell, 2020a) . The lasting impact of a colonial agenda focused on exploiting nature as if it is a "resource" is evidenced both in the current climate crisis and in the aetiology of the current pandemic.

However, for more than a year, the near-total international preoccupation with COVID-19 has effectively diverted attention from the significantly greater threat to global health of environmental degradation, biodiversity loss, and climate change. In 2009, a Lancet commission declaring climate change as the "biggest global health threat of the 21st century" (Costello et al., 2009 (Costello et al., , p. 1693 recommended that the health effects of climate change should be placed high on the agenda of every academic journal, scientific and professional conference, and university curriculum. Even before the pandemic, there was scant evidence to suggest that occupational therapy had risen to this challenge, and there has been little apparent interest within the profession on understanding the natural physical environment as a determinant of occupation.

Despite recognition that occupations inevitably occur within environments, occupational therapy research has only rarely sought to understand how occupations are shaped or dictated by the demands of the natural environment and how occupations are impacted by environmental degradation and climate change, on the specific places within nature in which people may wish to undertake their occupations or of the meaning of these natural places and spaces to the motivations, responsibilities, and rewards inherent to specific occupations (Hammell, 2021) .

It should not be surprising that the negative impacts of climate change and environmental degradation on occupations, health, and wellbeing disproportionately impact rural people, farmers (Stain et al., 2011) , Indigenous people (Green et al., 2009) , and those living in economically disadvantaged areas (Costello et al., 2009; Marmot et al., 2012) . For many Indigenous Australians, occupations undertaken to care for the land are of enormous importance to individual and collective wellbeing; the ability to enact occupations that connect Aboriginal people with "country" is a key determinant of their health (Green et al., 2009) . Inevitably, as ecosystems change through environmental degradation, extreme weather events, and climate change, the traditional owners of the land are likely "to face increased physiological, psychological, economic and spiritual stress as it becomes more difficult to 'look after their country'" (Green et al., 2009, p. 5) . Environmental injustice is interleaved with occupational injustice.

Clearly, environmental policies and social practices reflect specific political choices. These choices are rooted in the dominant economic and political ideology that has been promoted within the Global North and imposed on the Global South since the 1980s: neoliberalism. Neoliberalism is a particular form of globalised capitalism that prioritises free markets, private businesses, and the consumerism that fuels private profits. In the service of this neoliberal agenda, governments cut taxes for corporations and the wealthy, reduce spending on the social programmes that assist those forced to the margins, privatise public resources and services, depress wages and worker benefits, and slash the regulations and oversights that constrain the ability of private businesses to maximise profits (Esposito & Perez, 2014; Hammell, 2020a Hammell, , 2020b . Neoliberalism is regarded by scholars as being a form of covert colonialism (e.g., Gruber & Scherling, 2020; Pihama, 2019 ) that effectively entrenches existing inequities of power and perpetuates White dominance. In so doing, it has simultaneously widened existing economic inequalities both within and between nations and has had a catastrophic impact on the natural environment, which is viewed by colonialists and neoliberals alike as a resource to be exploited for private profit.

Critical disability scholars have sought to expose the ableism at the heart of neoliberalism (Goodley et al., 2014; Harris et al., 2014) . The term ableism refers to social practices that centre and privilege able-bodied forms and that preserve unfair and unearned advantages and opportunities for those without illnesses or impairments. Use of this term indicates an awareness that inequity is not a consequence of impairment per se but of an ideology that marginalises people who do not conform to dominant "norms" (Hammell, 2020a) . Within a neoliberal ideology, people are valued according to their independence, productivity, and contribution to economic growth (Gruber & Scherling, 2020) , prompting the contention that "neoliberalism provides an ecosystem for the nourishment of ableism" (Goodley et al., 2014, p. 981) .

Betraying its ableist orientation, neoliberal ideology promotes individualism, independence, and self-reliance; devalues states of dependency; portrays individuals as "free, calculating and rational agents" (Block, 2018, p . 577) who seek (or ought to seek) to improve their abilities and become more employable; advocates individual choice and personal responsibility for one's circumstances; and blames people for the social problems, ill health, and economic woes that are deemed to be the products of their irresponsibility and poor choices.

This listing of the features of neoliberalism may sound familiar to occupational therapists, and it should, because this ideology has effectively shaped occupational therapy in the Global North. If neoliberalism is the root, as this paper contends, then occupational therapy's models, theories, and practices are its leaves, blossoms, and fruit-the visible manifestations of an ideological agenda.

Echoing neoliberal ideology, occupational therapy has prioritised productivity-especially in work and has enthusiastically promoted independence-especially in self-care, thereby contributing to an oppressive ableist narrative-that dependence on others is unacceptable. This narrative devalues the lives of disabled people and negates the interdependence that Indigenous people and researchers insist is integral to human wellbeing. Through a preoccupation with individualistic, selffocused occupations (self-care, productivity/work, and leisure/play) and with individualistic, self-fulfilling notions of doing, being, and becoming, the profession has missed or dismissed the fundamental importance of all other occupations.

Examples of the occupations missed or dismissed by our dominant models include, but are not limited to occupations that foster connections with families and communities, ancestors and ancestral lands, gods and spirits, cultures and nature; occupations undertaken to care for country; resource-seeking and survival occupations, restorative occupations, occupations undertaken to contribute to the wellbeing and future of others, to enact reciprocity, enrich relationships, strengthen social roles, and fulfil duties, responsibilities and obligations to others; shared and collective occupations, occupations that foster self-worth, occupations undertaken to engender hope and a sense of life continuity, occupations chosen to assert gender identities or foster creativity, and occupations enacted as acts of resistance (Hammell, 2020a) . By declaring clearly which occupations we believe to be occupations that "matter"-doing self-care and being productive-occupational therapy has also indicated which occupations we believe do not matter. This is what occupational injustice looks like.

Congruent with its neoliberal underpinnings, occupational therapy reinforces the notion of clients as consumers, asserting that individuals autonomously choose and shape their everyday occupations and that occupational choice is the product of individual volition and rational deliberation (for discussion, see Hammell, 2020b ). Yet, research evidence makes clear: opportunities to choose and to act are inequitably distributed, and inequities that constrain the occupational choices of some groups of people effectively enhance the occupational choices and advantages of privileged group members, as they are intended to do (Frier et al., 2017; Hammell, 2020b) . Inequities are not a consequence of happenstance, and because they are avoidable, inequities are manifestly unfair.

Consistent with occupational therapy's neoliberal orientation, considerable profession attention has focused on identifying and modifying individuals' dysfunctions, in-abilities and deviations from ableist norms, and with neoliberal modes of governance that prioritise "standardised" assessments and quantitative outcome measurements (Hammell, 2019) . Critical disability scholars contend that through practices of categorising, classifying, assessing, measuring, and adjusting individuals towards social "norms," occupational therapy acts as an agent of the state, actively sustaining the economic and political status quo (Hammell, 2006 (Hammell, , 2020a .

The social determinants of occupation have received little attention from occupational therapy's researchers and scholars. However, Brenda Beagan (2020, p. 2) contends that "occupation simply cannot be adequately understood without attending to oppression and privilege. Everything we do and don't do, the expectations we face, the encouragement or discouragement we receive, the meanings we attribute to occupations, the impacts of our occupational engagements, the barriers to occupation all are affected by our membership in social groups both oppressed and privileged." In short, occupations are socially determined.

Despite the undeniable impact of neoliberal ideology on occupational therapy's priorities, practices, and proclamations, neoliberalism is rarely named and seldom critiqued within our profession's literature (for exceptions, see Clouston, 2014; Gerlach et al., 2018; Hammell, 2017 Hammell, , 2019 Hammell, , 2020a Hammell, , 2020b Kristensen et al., 2017) . Our profession is drowning in an ideological ocean, yet we have avoided talking about the water.

So, why has so much space in this paper been utilised in discussing the ableist, colonial, and neoliberal ideologies that have so effectively structured the way we think and act? It is because these unexamined ideologies have led to naïve, individualistic, ableist, and unjust theories, models, and practices that have obscured the inequities unfairly limiting people's occupational rights. It is also because these ideological systems have to be deliberately noticed and consciously contested and "unlearned" if we aspire to build back a better occupational therapy postpandemic. As occupational therapy starts to understand the toxic legacy of settler colonialism and its reproduction through neoliberalism, we can begin to understand the imperative to decolonise occupational therapy, to expose its ableist ideological roots, liberate ourselves from its toxic tendrils, and imagine new ways of thinking and doing.

The COVID-19 pandemic has provided occupational therapy with an opportunity to reassess our priorities and rebuild our profession in ways that align with the values we espouse. The inequities and injustices so starkly exposed by the pandemic should not allow us to return to business as usual, tacitly supporting an unjust status quo.

In thinking about future possibilities, this paper draws from the Build Back Better approach to postdisaster recovery that emerged following the 2004 Indian Ocean Tsunami, and that has been implemented following more recent disasters, such as Australia's devastating bushfires (Mannakkara et al., 2014) . The Build Back Better approach focuses on enhancing human wellbeing through reducing physical, social, cultural, economic, and environmental vulnerabilities. Central to this approach is a focus on improving inclusiveness and reducing inequality, thereby placing human wellbeing within a context of social justice and ecological health. Indeed, epidemiologists have advanced the idea of Building Back Fairer after the COVID-19 pandemic, asserting that "to build back fairer, society needs to deal both with inequalities and with the climate crisis" (Marmot et al., 2020, p. 65) .

This paper embraces Ryff and Singer's (1998, p. 2) premise that "human wellbeing is ultimately an issue of engagement in living." In recent work, Hammell (2020a) identified six dimensions of human wellbeing that have cross-cultural relevance and that are all significantly impacted by occupational engagement. Briefly, these are surviving and thriving; taking care of self and others; experiencing a sense of belonging and connectedness; experiencing a sense of self-worth; experiencing pleasure, purpose, and meaning through engagement in roles and accomplishment of occupations; having the opportunity for choice and for the control to enact one's choices; and having hope and a sense of life coherence and continuity.

Wellbeing is not an individual concern but rather a collective phenomenon (Hammell, 2020b) . Belonging is central to wellbeing, such that the wellbeing of families, communities, and cultures is integral to individual wellbeing. Moreover, it is becoming ever more apparent that human wellbeing is indivisible from the wellbeing and health of the natural environment.

Occupational Therapy Australia (2021) states that "occupational therapists use a whole person perspective to work with individuals, groups and communities to achieve optimal health and wellbeing through participation in the occupations of life." Through its discussion of ideologies, injustices, and inequities, this paper has been building towards suggesting, respectfully, that a "whole person" approach is inadequate to achieving the goal of achieving optimal health and wellbeing through occupational participation.

Responding to the global reality of inequity and injustice, the World Federation of Occupational Therapists (WFOT, 2019) has offered an expanded vision for the profession, declaring that "occupational therapists around the world are obligated to promote occupational rights." WFOT has defined occupational rights as being "the right of all people to engage in the occupations they need to survive, define as meaningful, and that contribute positively to their own wellbeing and the wellbeing of their communities." This has clear resonance with the Build Back Better approach and its focus on enhancing human wellbeing through reducing physical, social, cultural, economic, and environmental vulnerabilities, improving inclusivity and reducing inequality, an approach that places human wellbeing within a context of social justice and ecological health.

To build the occupational therapy profession back better and fairer will demand solid roots-a foundation of our own choosing and not one absorbed uncritically from our hegemonic ideological context. Occupational therapy could be rebuilt as a profession that has broken free from the ideas and practices shaped and derived from colonialism and neoliberal ableism and that has interrogated and dismantled their combined impact on the way we think and act.

Occupational therapy could be deeply rooted in a commitment to expanding people's just and equitable opportunities to engage in meaningful occupations that contribute positively to their own wellbeing and the wellbeing of their communities; and by "people", this paper is referring, not to "people with impairments and illnesses", but to people; any people. Contrary to the Occupational Therapy Australia (2021) declaration of occupational therapy's mandate, our literature reveals a profession preoccupied with assessing and addressing the occupational performance deficits of people with impairments or ill health, with little attention paid to promoting their wellbeing and even less attention directed to promoting wellbeing among the wider population (Hammell, 2020b) .

Rebuilt, the occupational therapy profession might focus clearly on equity and justice, attuned to environmental vulnerabilities and committed to "structural competency" (Metzl & Hansen, 2014) , the ability to look beyond the individual to discern-and address-the impact of social and structural conditions on health inequalities. Roberts (2019, p. viii) claims that for the medical profession, "structural competency is revolutionary. It not only addresses the negative impact of structural inequalities on health but forges a path to undo medicine's support for an unjust social order … It radically rejects the exclusive focus on individual responsibility for one's own health outcomes and replaces it with public responsibility for creating the conditions needed for health and well being." Occupational therapy could join this revolution. Structural competence could-and should-be one of the leaves on our tree.

And there could be other leaves: other visible manifestations of our rootedness in equity and justice. Occupational therapy could become a profession committed to needs-based resource allocation, such that occupational therapy services are equitably available throughout rural areas and in every corner of our cities and targeted to those most oppressed by the inequities of the status quo.

Occupational therapy could become a profession whose assessments are able to identify environmental resources and constraints, assessments able to identify strengths as well as dysfunctions, resilience as well as vulnerabilities. Standardised assessments informed by the norms of straight, middle class White people living in urban areas of the Global North would be replaced by less oppressive tools with the understanding that using these assessments among diverse groups is unethical and unjust.

Occupational therapy does not exist in a political vacuum but within systems of social power that promote conformity and acceptance of the ideas that support the status quo (Hammell, 2006) . Bailliard (2016, p. 13) contends that "if students become habituated to critically assessing how power structures and systems of oppression shape clients' situations, then they will become sensitive to how everyday professional practices are issues of rights and justice." If we are to build back better, occupational therapy education will need to foster the critical thinking skills that students require to resist conformity, question the assumptions and ideologies that are presented as "truth," and discern the systems of oppression that shape clients' occupational lives. These are abilities they will need if they are to practice in ways that promote occupational rights and justice.

If the occupational therapy profession is going to have an evidence-informed, actionable knowledge base from which to educate students, our research will need to be sophisticated in its capacity to identify the social determinants of occupation and the impact of inequities on people's unconditional occupational rights (Hammell, 2020b) . Moreover, by studying the interconnectedness of occupations, health, wellbeing, and the health of the natural world, occupational therapy will be positioned to contribute a valuable, occupational perspective to global initiatives on human rights, environmental degradation, and climate change (Hammell, 2021) .

The intent of this paper has been to imagine an occupational therapy for a post-COVID-19 world, a rebuilt profession committed to fairness and equity and dedicated to expanding people's just and equitable opportunities to engage in meaningful occupations that contribute positively to their own wellbeing and the wellbeing of their communities.

An occupational therapy that takes seriously the premise that occupations and people are inseparable from their environments will no longer collude in individualising problems that are inherently social, will no longer collude in depoliticising the systemic social and economic inequalities that create stress and illness, and will no longer promote the values of neoliberal ableism.

• The COVID-19 pandemic exposed profound social inequities and structural injustices, but also provided the opportunity to imagine possibilities for rebuilding occupational therapy. • Current occupational therapy practice is deeply rooted in a colonial-neoliberal-ableist ideology committed to promoting independence, productivity, and individualism. • The "Build back better" approach, with its dual attentions to wellbeing, equity, and inclusivity and to physical, social, cultural, economic and environmental vulnerabilities, provides the inspiration for imagining a renewed occupational therapy profession, a profession dedicated to expanding people's just and equitable opportunities to engage in meaningful occupations that contribute positively to their own wellbeing and the wellbeing of their communities.

ACKNOWLEDGEMENT This paper is based on a keynote presentation at the 2021 Occupational Therapy Australia National Conference. No funding was received for this paper.

There are no conflicts of interest to report.

KWH is the sole author of this paper.

Data sharing not applicable to this article as no data sets were generated or analysed during the current study.

Karen Whalley Hammell https://orcid.org/0000-0001-7946-2862

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Colonization and the importation of ideologies of race, gender, and class in Aotearoa

Determinants of Indigenous Peoples' Health; Beyond the social

Structural Competency in Mental Health and Medicine: A Case-Based Approach to Treating the Social Determinants of Health

The contours of positive human health

The psychological impact of chronic environmental adversity: Responding to prolonged drought

Indigenous writes: A guide to First Nations, Métis and Inuit issues in Canada

Position statement: Occupational therapy and human rights (Revised)

Building back better: Imagining an occupational therapy for a post-COVID-19 world