By Nicole Spence, Tasha-Aliya Kara, Katrina Plamondon, Barbara Astle, and Ngozi Joe-Ikechebelu
Summary: Adopting and applying a health equity lens onto policies is essential to reducing disproportionate impacts on populations and creating a more sustainable and equitable approach to disaster management.
Canada’s citizens are some of the healthiest in the world, but the benefits of good health are not enjoyed equally by all. As the frequency and severity of extreme events increase in direct relation to climate change, globalization, and industrialization, vulnerable populations are disproportionately impacted. While these inequitable health burdens have been well explored, equity considerations in disaster management are not particularly well examined.
Some provinces have frameworks for health equity in disaster and emergency management; however, there is no national equity-based emergency management framework. And although equity and fairness are guiding principles in Canada’s National Disaster Mitigation Strategy, there is a divide between policy and practice, imploring the question: How can we ensure well-intended policies are equitably informed?
Equity considerations are essential to reducing disproportionate impacts on populations and creating a more sustainable and equitable approach to disaster management. Otherwise, the increase in extreme events threatens to widen the existing health gap, in Canada and beyond.
Health inequities and disasters: A global perspective
Disasters come in many forms, however, what is not often understood is the inequity of the health of those affected. In the past couple of decades, some scholars have begun to acknowledge that the assessment of those affected by post-disasters should address the inequities for the needs of socially vulnerable populations (Emrich, Tate, Larson & Zhou, 2019). What is clear however, is that the roots of vulnerability during disasters such as the social, economic and health disparities endure.
It is commonly understood that action taken outside the health sector can have health effects much greater than actions taken within it. To better address the health of a population, the inclusion of the social determinants of health – the economic and social conditions in which people live, learn, work, and play – is required. These factors are inequitable when they disproportionately advantage some groups over others, and can be avoided through policy or collective action (Stronks, Toebes, Hendriks, Ikram, & Venkatapuram, 2016; CCGHR, 2015).
More importantly, a social justice and human rights framework identifies the need to go beyond the immediate conditions of health burdens and focus on the causes of the causes: the fundamental structures of social hierarchy and social conditions. Through this lens, there are five drivers of health inequity: structural discrimination, income inequality and poverty, disparities in opportunity, disparities in political power, and governance that limits meaningful participation (ChangeLab Solutions, 2019, p. 9). By framing these structures and conditions as political determinants of health, it recognizes that the social determinants of health include historical and ongoing political injustices, and that health is ultimately determined by political decisions.
The inverse relationship between disasters and deaths
Examining the inverse relationship between extreme events and deaths exemplifies that the roots of inequities endure in a disaster. While extreme events have increased, disaster-related deaths from natural hazards have fallen significantly in the past century (see Figure 1). The observed decrease in deaths is a direct result of preparedness; however, it is not observed equally across all populations (see Figure 2). While higher-income countries experienced the majority of recorded disasters (56%) since 2000, lower-income countries suffered 68% of the disaster death toll (CRED, 2015). Of course, these differences are not only observed between countries, but exist where there is high variability within countries, regions, and municipalities – including Canada.
Climate change and inequities
Climate change has recently been declared as a health emergency by national and international governing bodies, panels, and committees. Climate-related disasters alone have increased by 44% from the 1994-2000 average and more than doubled the level in 1980-1989 (CRED, 2015), apparent in its domination of headlines in the media. However, it is also ebbing away at communities’ capacity and resilience. Critical infrastructure such as schools, health facilities, and roads, are increasingly damaged by seemingly small-scale weather events. This results in economic losses that undermine the ability of communities to invest in poverty reduction, health and education (UNDRR, 2019).
As environmental changes challenge the health and economy of many nations, an increasing global trend is emerging: rural and underserved communities are the most vulnerable to these risks and exacerbating present non-climatic inequities. The injustice of this issue is underlined by the fact the regions experiencing the greatest increase in climate-related diseases and events are the communities that are the least responsible for the increase in greenhouse gas emissions. Worse, these communities often have the least amount of resources to adapt, become prepared, withstand, and recover from extreme events (Levy & Patz, 2015; Patz et al., 2007).
The implication of this is that development has helped increase preparedness for some, but that very development creates disaster risk and threatens development for others. It follows that efforts to protect vulnerable population groups not only serve ethical purposes but also facilitate economic growth and development, thereby decreasing regional inequities (Levy & Patz, 2015; Patz et al., 2007). Therefore, climate change is a critical component of any equity discussion and vice versa.
Equity challenges and opportunities in Canada
Canada has often aspired to be a socially progressive force at home and abroad, and its history of nation building has been translated into an approach to global health that is focused on equity and global citizenship (Nixon et al., 2018). Yet there are certain populations and geographic areas in Canada with similar conditions and health burdens to developing nations.
These conditions are particularly observed amongst those with lower socioeconomic status as well as First Nations, Inuit and Métis peoples. The inequities are rooted in colonial history and perpetuated by income inequality, gender identity, and racism, amongst other factors. For example, in pre-contact times (i.e. before settlers arrived), First Nations benefited from a strong health care system with ceremonial, spiritual, and physical elements, including a connection to nature and maintaining a healthy balance with the ecosystem. When the churches and government exerted control during colonization, traditional health systems were eradicated or repressed. Western medicine that was availed was sporadic or segregated and was highly associated with residential school experimentation on children. Furthermore, it only contained one of the three historical elements of First Nations health systems, often leaving people feeling neglected or emotionally distraught, and with low trust in the system (FNHA, 2019). These issues persist today, resulting in lower life expectancy and household food insecurity, and higher infant mortality and unintentional injury mortality. In some cases, these existing inequities are worsening (PHAC, 2018).
Exacerbating this, many parts of Canada are warming much faster than the rest of the world, particularly in areas with geographical barriers. Between 1900 and 2013, the average temperature in British Columbia increased faster than the global average (Abbott & Chapman, 2018), with an observed increase in duration and severity of wildfires. Aligned with the global trend, remote and Indigenous communities are often the first and foremost affected (PHAC, 2018; Abbott & Chapman, 2018; Krishnaswamy, Simmons, & Joseph, 2012). For those living in coastal and remote settings, rapid evacuation may not be possible due to a lack of road access, limited ability to land large planes, or lack of access to safe waterways (Public Safety of Canada, 2019a, para. 1; Maguet, 2018).
Wildfires in BC
The increasing threat of extreme events became evident when a provincial state of emergency was declared in British Columbia for two consecutive years. Evacuations prompted by wildfires set record levels, with the total number of people displaced estimated at 65,000, with nearly 48,000 people evacuated on July 15, including 12,400 people from Williams Lake and surrounding area (Maguet, 2018). The following summer, evacuation orders and alerts and poor air quality throughout the summer impacted a significant number of people, as illustrated in Table 1.
During these events, First Nations communities were disproportionately impacted. The Tsilhqot’in communities in Williams Lake alone consisted of nearly two thirds of the total area affected by wildfires in British Columbia (Verhaeghe, Feltes, Stacey, 2017, p. 7). Following these events, an interview with the Tsilhqot’in Nation highlighted how the unnecessarily complicated bureaucratic system and lack of funding disadvantaged the community and many other First Nations communities.
Table 1 – Wildfire Season Summary (2017 and 2018)
Source: Wildfire Season Summary, Province of British Columbia (2019)
|Hectares Burned||1.2+ million||1.3+ million|
|Fire Suppression Costs||$649 million||$615 million|
|Total Days On Provincial State Of Emergency||71 (July 7 to Sept 15)||24 (Aug 15 to Sept 7)|
The aftermath of these events extended far beyond immediate displacement. During the 2017 wildfires, the rurality and distinctiveness of the Tsilhqot’in nation meant that the physical and mental health needs of the community were not adequately addressed through conventional services (Verhaeghe, Feltes, Stacey, 2017, p. 14). Personal health impacts such as poor air quality were compounded by the closure of multiple health facilities, canceled or rescheduled appointments and procedures, and a lack of health staff and physician availability due to evacuations. To make matters worse, public health issues such as water quality and food security posed significant challenges for re-entry once the immediate threat had resolved. Given these factors, the mental health impacts were far reaching, from evacuees to first responders (Verhaeghe, Feltes, Stacey, 2017, p. 33).
The situation faced by Tsilhqot’in communities in Williams Lake was not unique; in fact, it has been the case for the past thirty years. Those living on a First Nations reserve face a 33 times greater chance of being evacuated due to wildfires, as opposed to those living off-reserve (HazNet, 2018, p. 10). Many experts agree that the effects of climate change can be linked to these extreme weather events of 2017.
Indeed, there is no lack of evidence about the causes of inequities; but rather a lack of responsive research (Raphael et al., 2011), practice, and governance mechanisms (Lee, 2010) to support equity-informed solutions. This brings forward a critical question: how do we practically and meaningfully integrate equity considerations into disaster management in Canada?
Where we came from, and where we’re going
From a macro perspective, emergency management in Canada has been led by the Emergency Framework in collaboration with the Federal, Provincial and Territorial locations. Introduced in 2007 and updated in 2017, it now addresses how emergencies are managed through four interdependent components: prevention and mitigation; preparedness; response; and recovery, which are the shared responsibility by all sectors, when dealing with various emergencies (Emergency Management Policy and Outreach Directorate Public Safety Canada).
In 2009, Appleyard, described a framework for health equity in Ontario’s Emergency Management programs in Ontario’s health system, with those most vulnerable needed to be recognized, and supported through more research and policy. Public sector leaders are considered essential to ensure that a “health equity objective and analysis must be part of emergency management programs” (Appleyard, 2009, p. 10).
Canada has also been a signatory to all three international frameworks on disaster risk reduction, including the Sendai Framework which supported the development of a national platform on disaster risk reduction in 2009. It highlights that reducing risk has been proven more economical than the cost of response and rebuilding, and that a whole-of-society approach will increase the overall resilience of communities (Public Safety Canada, 2018). Despite the policy recognition and the preliminary groundwork, a health equity lens still has yet to be systematically applied to emergency management programs.
Frameworks are necessary, but not the entire solution
While the Emergency Disaster Framework provides a logical approach, it does not delve deeply into social inequities for those in the Canadian population who are structurally vulnerable, and how they would be best served (Labonté & Rukert, 2019). More importantly, what is missing from these types of framework is how to actively reduce the inequities experienced by many in the Canadian population who are as most risk when immersed in a disaster situation.
An example of a more responsive framework is the well-known independent review examining the 2017 flood and wildfire seasons conducted by George Abbott and Chief Maureen Chapman that calls for emergency services to be available and provided to First Nations in a way that is comparable to other communities of similar size and location, stating that “equity must be the norm, not the exception” (p. 82). This guiding document provides recommendations on four themes (partnerships and participation, knowledge and tools, communication and awareness, and investment) that prioritize First Nations. Given that most projections expect an increase in extreme events, determining the unique needs and circumstances of specific populations is critical to managing emergencies in Canada.
This highlights a clear opportunity to transform its commitments to equity and global citizenship into stronger leadership on the global stage. Better coordination of efforts, increased funding, and addressing the infamy of Canada’s colonization of Indigenous Peoples would strengthen the potential for Canadian policy makers, researchers, practitioners, and health leaders to make meaningful contributions to the improvement of health equity (Nixon et al., 2018). Policies are thus required to ensure these types of recommendations are adopted into research and practice.
Practical tools to achieve equity-centred solutions
If health equity is reached when individuals are able to reach their full health potential and are not disadvantaged by social, economic, and environmental conditions, what tools are available for policy makers and professionals to help reach this goal?
Equity-centred principles to guide action
The CCGHR Principles for Global Health Research (“the CCGHR Principles”) (CCGHR, 2015; Plamondon & Bisung, 2019) support the exploration of equity considerations in global health activities, and could be adopted through the four phases of emergency management to promote equity informed practice and identify equity options. The Principles include authentic partnership, inclusion, shared benefits, commitment to the future, responsiveness to causes of inequity, and humility (Figure 1) and are already integrated into training modules for the Canadian Institutes of Health Research (CIHR) College of Reviewers as a national standard. The principles apply well beyond global health, with people finding these principles resonate in many fields, facilitating a multi- disciplinary and sectoral approach that helps examine norms and values that have become invisible to researchers, policy makers, and practitioners.
Figure 1 – CCGHR Principles for Global Health Research
Tools to adopt the Principles
A health equity lens becomes paramount with individuals or groups susceptible to harm: that is, marginalized, vulnerable, and under-served populations (Piggott & Orkin, 2018, p. 13). However, associating challenges of labelling must be recognized and considered to avoid losing potential health benefits, as well as to effectively ascertain differences in outcomes associated with certain vulnerable realities of these diverse populations. It is also critical to recognize and critically reflect on the implications of language that problematizes or naturalizes health and climate inequities (see Figure 2). This process facilitates assessing alignment between action and root causes of inequities and can identify ways to move toward more productive actions for equity and climate justice (Plamondon et al., 2018).
|Ways we naturalize health inequities||Ways we can problematize health inequities|
|● Not referring to evidence about causes||● Explicitly naming causes|
|● Explaining them as mysterious or the result of bad luck||● Describing them as actionable (i.e. human-caused and therefore humans can respond)|
|● Focusing on symptoms||● Stating that they are unfair or tied to unearned advantages and disadvantages|
|● Placing blame (root causes) in individuals||● Shaped by political economy|
|● Blaming culture or ethnicity rather than -isms||● Situate them in social systems of power|
Figure 2 – Implications of language that problematize or naturalize health and climate inequities
Possible actions for an equity-centred approach
When disasters disproportionately affect the ways in which societies function, those responding can consider possible actions for equity. A useful set of guiding questions complementing the table can spark dialogue to an equity-centred approach to all levels of emergency management, specifically mitigation, preparedness, response, and recovery.
- Are we discrediting clear evidence?
- Are we distracting from the root causes?
- Are we overlooking or ignoring the root causes of health inequities?
- Are health inequities recognized without going further to respond?
- Are efforts focused on understanding something new about how health inequities work?
- Do efforts open possibilities for change related to power, privilege, and their distribution in society?
The tool in practice: supporting resilience on a global scale
While it is true that disasters can exacerbate existing vulnerabilities and inequities, it is worth noting that in times of distress, community networks, and organizations continue to foster resilience. Resilience refers to the capacity to build strength following a disaster (Emergency Management Policy and Outreach Directorate Public Safety Canada, 2017). Using the guiding questions above, resilience offers a way to change perspectives related to power and privilege, examining a more equitable approach to community recovery, especially as it relates to gender.
For instance, in gender and disaster literature, two primary themes emerge: women as either powerless and victimized or resilient. Statistics show that cases of rape, human trafficking, and domestic violence rise during and after disasters (Alston, 2013). These outcomes of disasters are rooted in pre-existing inequities. Rather than highlighting women’s resilience or focusing on their portrayal as victims lacking agency (Stromquist, 2015), it is worthwhile examining how both will influence one another following a disaster.
Despite their potential for massive physical destruction, disasters are spaces that allow opportunity to build resilience and challenge existing power dynamics, and can act as a catalyst to progressive changes in gendered relations. A longitudinal study showed that the 2010 Chile earthquake and tsunami in El Morro – one of the most marginalized communities in the region – brought radical change to gendered relations (Moreno, 2018). During the establishment of the El Morro Fisherwomen’s organization women were able to contribute to the family income by fishing and collecting seaweed and mussels, resulting in a significant change to women’s labour role. As fishing was an exclusively male practice prior to the earthquake, women’s productive role adapted and overcame persistent gender-based barriers; the earthquake ultimately leaving women economically empowered. Women-led organizations were vital in creating long-term, sustainable change following one of the most severe earthquakes.
Consulting the guiding questions above forces us to disrupt and question western, patriarchal attitudes to societal development and therefore has potential to tangibly address health inequities globally. Time and again, North American and European countries are deemed the models for progressive and equitable health care systems when in reality, these areas have an opportunity to learn from communities like El Morro. If Canada is just as susceptible to climate-related disasters, it only makes sense to have a global conversation about how disaster risk reduction can be more equitable, better preparing us for the future.
Despite the recognized need for equity centered emergency management, there is little evidence of systematic implementation. There are many frameworks that exist offer tools and approaches, but the many constraints that are placed on populations result in a practice that does not examine norms and values that have become invisible to us.
Canadians advocate for equitable disaster risk reduction, but bureaucratic, political, and socio-economic constraints are still deeply ingrained in research, policies, and practice, worsening inequities and ultimately stunting disaster resilience. As a result, integrating equity considerations in disaster and emergency management requires attention to root causes of inequity. Given that the people most affected by disasters often have fewer resources and power to deal with them, including this kind of framework in emergency management would ensure that equity considerations are not lost in the process of planning.
Adopting an equity lens is therefore essential to not only reducing disproportionate impacts on populations but also for creating a more sustainable and equitable approach within disaster management. Some examples discussed in this article, such as the CCGHR Principles provide a practical tool that enables more critical and collective dialogue that shifts us towards more responsive research, policies, and practice. Overall, local and international populations could greatly benefit from such an equity informed approach. If adopted, it could help transform Canada’s commitments to equity and global citizenship, positioning us as a leader on the global stage.
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