COVID-19 in Canada and the United States: Comparting the Social Protection Responses

COVID-19 did not, at least at first, appear to prefer one side of the 49th parallel. In early March, Canada and the United States had virtually identical daily rates of confirmed deaths from the virus. Nor did the virus seem to discriminate in wreaking economic havoc. In April 2020, unemployment rates in Canada and the US surged dramatically to 13 and 14.7 percent, respectively. Yet the United States’ tepid public-health response has created a stark divide between the two countries. As of late July, the confirmed rate of COVID-19 deaths (1 in 2,814) there is now twice as high as the Canadian rate (1 in 4,185).

This gap in public-health measures is mirrored by a similar divide in the realm of social policy. As the economic crisis took shape, federal and subnational governments in each country enacted temporary social policy measures to mitigate the dire, unprecedented socio-economic consequences of the global pandemic. While social scientists tend to group Canada and the United States together as examples of the “liberal” welfare state (characterized by weak state provision), a closer look reveals a number of startling differences in how each country used the tools of social policy to ensure health and economic security for their populations during the pandemic.

Put simply, Canada acted both more boldly and more rapidly than the United States. In Canada, the policy response has been more centralized despite provinces having jurisdiction over most social policy issues. The federal government quickly adopted emergency economic responses on March 25 and April 11 and has continued to build on them. These include the easy to access Canada Emergency Response Benefit (CERB), which provides income support to affected workers, and employer subsidies under the Canada Emergency Wage Subsidy (CEWS). Together, the government has spent over $69 billion CAD on these policies by the end of June. The federal government also increased federal transfers and funding for vulnerable populations as well as families and students. The pandemic exerted important pressure on provinces which are responsible for healthcare provision. Contrary to the US, Canadians maintained their healthcare coverage under the country’s universal structure. However, the number of cases and, significantly, deaths was disproportionate in public and private long-term care facilities. The cost of these emergency measures and slowed economic growth have created record deficits in the modern era at the federal and provincial level.

In comparison to Canada, the United States acted more slowly and less boldly to respond to the social protection challenges of COVID-19. There were important and potentially expensive measures put in place, but the impact of some of these actions was slowed by existing institutional fragmentation. The problem did not initially lie in Washington DC as Congress enacted, and President Trump signed into law, measures that both created new policy instruments and significantly expanded existing ones. A one-off payment of $1200 per adult and $500 per dependent child was made to people who earned less than $75,000 in their 2019 tax filing. The Unemployment Insurance (UI) program was temporarily adjusted to cover categories of workers losing their jobs who would have ineligible for UI under the existing rules and the federal government added an extra $600 a week to the standard benefits. For many recipients this meant that they were receiving more in UI benefits than they had previously been earning. One piece of legislation, the CARES Act, had an estimated cost of $2.3 trillion, amounting to 11% of GDP. In addition, were the Paycheck Protection Program, which was costed at $483 billion, and the Families First Coronavirus Response Act at $192 billion. But if this upstream action was decisive by the standards of modern Washington DC, the downstream implementation was more problematic. The huge numbers of newly unemployed stretched many states’ administrative capacity delaying payments. This was especially so in states such as Florida that had deliberately made the UI application process to be opaque. Further, Republican opposition in Washington prevented the inclusion of extra federal funding directly to the states in the relief legislation. This was especially problematic for states, nearly all of which are required to balance their budgets, at a time when their expenditures on programs such as Medicaid were rising.

There are three basic reasons for the divergence between these two so-called liberal welfare states. First, as shown in the cases of unemployment protection and health care, Canada possessed a social policy architecture that enabled a quicker response to rapidly emerging conditions. Canada’s universal single-payer system, for example, meant that massive unemployment did not translate into historic waves of health insurance losses, as it did in the United States. Second, even when Canada had to adapt its policies in response to the emergency, its parliamentary system enabled a faster response than in the US, where checks and balances slow down policymaking, when different parties control the House and the Senate. The immense power of the executive in Canada isn’t without its problems, however, as the Liberal government undergoes an ethics investigation for benefit administration. Ultimately, this slowed down benefit delivery for student volunteers. Third, the intense polarization of American political parties relative to their Canadian peers has accentuated the gridlock caused by the separation of powers, and has further frustrated the development and maintenance of emergency relief programs in the US.

While long-term trends in both countries are difficult to predict, the social policy divide between the two countries is already great. If anything, that means the gap between the two countries on major indicators of income inequality and health disparities is likely to grow.

No place like home: Changing relationships of private and public space during COVID-19

Most of us have been stuck at home for the duration of the COVID-19 pandemic. This has underlined a longstanding image of home as a safe haven and a retreat. While “cocooning” typically brings on a cycle of intense consumption, buying stuff and doing house renovations have been difficult. Instead, we’ve turned to hoarding groceries (Fig. 1), re-arranging the furniture, editing our closets, solving puzzles (Fig. 2), cultivating house plants (Fig. 3) and baking bread (Fig. 4). As the weather improved, we gardened.

Fig. 1: Weekly grocery hauls for our family of four were much larger than usual. When lockdown began, on March 13, there was still snow on the ground.

Many Montrealers live in buildings constructed before World War I. These Victorian and Edwardian houses and apartments are set up well for both sickness and work-from-home. Pre-modern houses typically have discreet rooms arranged around circulation systems like corridors and stairways. Victorian rooms were single purpose and designed for particular family members. The parlour, for example, was for the wife and mother; the dining room, was for the husband and father. The house was an extraordinary ordering system, clearly communicating each person’s place in the universe through design. A key to its magic was its capacity for isolation.

Fig. 2: The Adams-Gossage family fridge scrabble is restricted to terms related to COVID-19.

By contrast, many homes since the 1920s, and especially after World War 2, have open plans. Modern rooms are often multi-purpose, with sight lines into other multi-purpose rooms. The postwar family room is a great example, often connected to a combination kitchen-dining room. It’s not a place where it’s easy to quarantine. The post-war kitchen, for example, was a kind of technological command centre, designed so that a single worker, the wife and mother, could cook, clean, and care for kids simultaneously.

Fig. 3: House plants are our companions, including refugee plants from our university departments.

As more people get sick (knock on wood), will the home become a container for sickness, rather than a retreat from COVID-19? For many of us, our work lives now occupy our bedrooms, dining rooms, family rooms, and basements. My own work space (Fig. 5), for example, is in a corner of our bedroom, a spot that I transform every morning for work; and take down every evening, for sleep. Post pandemic, how will we separate work and life? On Zoom we can use different backdrops to frame our work spaces, but what is the backdrop for real life? Is a new style of home with dedicated and separate spaces for work on the horizon?

Fig. 4: Our bread standards went way up and we even started to experiment.

I’ve been thinking a lot about the Victorian sick room, where family members were nursed back to health without risk to other family members. Another recurring image is the home library/office for the man of the Victorian household, which sometimes had a separate entrance. Similarly, doctors’ offices in houses (this was common in the 20th century) is an interesting precedent for the accommodation of work at home, where pocket doors or changes in décor would indicate a clinical section of the house plan, allowing a separation of medical practice and family life. Will those with the means to renovate adapt their houses in these retro modes?

On the flip side, the pandemic has illuminated “the workplace” as somewhat unnecessary and as a potential source of contagion. If we all work from home, what will happen to our city centres? Where will business-people meet clients, in public parks and squares? Surely not in homes. What is the post COVID-19 “public sphere”? We’ve all seen the images of futuristic offices with separate bubbles for each employee. How one gets to a bubble, however, is unresolved.

Fig. 5: My improvised home-office is a little-used dining room table, moved to a corner of our bedroom, with an ever-changing Zoom backdrop as smokescreen.

The pandemic has illuminated the hospital as a source of contagion, and thus a place to avoid. How will hospitals change after COVID-19? I suspect hospital architects will focus on preparing for the unexpected. I’ve watched with some amusement the return to the so-called “pavilion plan” for emergency hospitals in cities like London. Pavilion-plan hospitals maximized ventilation; its hallmark feature was the Nightingale ward, where 30-36 patients occupied beds interspersed between often-open windows. These spaces resembled barracks. Montrealers may know it from the old Royal Vic, in use until 2015 (Fig. 6). This type of hospital-as-shed, we have learned, is better than nothing, but might it also be better than the purpose-built hospital with its inflexible circulation and single-purpose planning?

Additionally, the pandemic has revealed long-term care institutions as sources of contagion. One might even say that long-term care is our new image of hell. Few speak about the architecture, beyond the need for single rooms. The architectural problem is much larger than density. Long-term care is a very low prestige building type among architects. There is next to no encouragement in schools of architecture to take on buildings that solve social problems, let alone “warehouse” old people. There are few design awards for long-term care; housing in general rarely gets published in the glossy magazines and websites. What incentive is there for innovation? Sometimes I think it should be called Long-term Not-care.

Fig. 6: The now empty Royal Victoria Hospital wards once housed 32-36 patients, separated by open windows. The pavilion-plan hospital maximized ventilation in order to minimize contagion.

My theory about why the long-term care nightmare of COVID-19 has been so shocking is because it de-stabilizes our image of home as a safe haven.

On the bright side, and to conclude, I like the way the pandemic has brought new admiration to older, low-tech systems like the Victorian house, the sick room, and the pavilion-plan hospital.  Relatedly, I embrace all the hand-drawn signs and optimistic, crooked rainbows (Fig. 7). I think they are evidence that what we design post COVID-19 will have a more human touch.

Fig. 7: Delightful, hand-drawn rainbows, with the optimistic message ça va bien aller, decorate windows all over Montreal.

Graphic advice by Anaik Fortier and David Theodore. Photos and bread by Annmarie Adams. Rainbow by Katie Adams-Gossage. Fridge scrabble mostly by Peter Gossage.

Some recommended readings on changing notions of home and work:

Annmarie Adams (and others), “Field notes on pandemic teaching: 5,” Places (April 2020)

Kyla Chayka, “How the Coronavirus will reshape architecture,” New Yorker (17 June 2020)

Harriet Little Fitch, “Will our homes look different after the pandemic?” Financial Times Magazine (6 June 2020)

Edwin Heathcote, “Between dreams and delirium: reflections on illness, Financial Times Magazine (20 June 2020)

Joe Moran, “Out of office: has the homeworking revolution finally arrived?” The Guardian (11 July 2020)

Annalise Varghese, Maram Shaweesh, “Rethinking ‘home’ post pandemic,” Parlour: women, equity, architecture (29 April 2020)

Enabling Cities: Lessening the impacts of Covid-19 on the urban poor.

Reference to Covid-19 as ‘the great leveller’ was short-lived. As critics foresaw, the pandemic has brought societal inequalities into sharp focus. Privileges of the wealthy and middle classes reduce the risk of not only contracting the virus, but also dying as a result of infection and suffering the pandemic’s longer term social and economic effects. This is most evident in cities where the poor and rich live in close proximity and the urban poor and working classes carry a disproportionate burden of the Covid-19 pandemic.

Racial disparities in Covid-19 incidence and outcomes, as seen in the U.S. and U.K., are a reflection of long-standing inequalities acting to exclude Black, Asian, Indigenous and Minority Ethnic people from privileged positions, and place them among those most vulnerable to Covid-19 infection and death.

The pandemic response can and should prioritise equity
The examples that follow demonstrate the capacity to prioritise equity in the pandemic response. As cases continue to rise in some regions and localised outbreaks have seen cities re-shutdown, cities and local governments must use their structures, powers and assets to go further in championing equity and engage with community members to address local needs. Fast and definitive action from decision makers, ‘out-of-the-box’ ideas, and new partnerships between government, private sector, and civil society remain essential to mitigate the pandemic’s impacts on cities’ vulnerable communities.

Secure safe housing. The stay-at-home orders – used around the world to limit spread of the virus at the root of the current pandemic – prioritised the need for universal housing. Emergency legislation to temporarily suspend evictions, freeze rents and ban foreclosures gave residents in countries including Spain, the U.K., the U.S. and Canada some security against the threat of eviction, when incomes declined or stopped amidst business closures and job losses, especially in the gig-economy services. Several cities across Canada temporarily suspended deadlines for municipal property taxes and utility payments.

Cities needed to rapidly and safely house their homeless. The U.K. provided an emergency fund of £3.2 million for accommodation to support self-isolation of people without permanent housing, establishing facilities to separately house and monitor those infected. Overcrowding in homeless shelters led to outbreaks in many places. In response, thousands of homeless people considered most likely to require hospitalisation or die as a result of infection were placed in the vacant hotel rooms of cities, including Los Angeles and Toronto, where social distancing could be more easily practiced.

Maintain urban mobility for essential travel. Major cities, including London and New York, reduced public transport services to minimise non-essential travel. To promote alternatives to mass transit for people needing to access and deliver essential services, road driving charges were suspended during lockdown in London, U.K., and public bicycles were made free to use for healthcare workers. ‘Tactical urbanism’ projects improved walking and cycling infrastructure overnight.

Some regular services were maintained for those without cars needing to travel longer distances. Increased cleaning frequency, reduced station counter services, entrance/exit of buses restricted to doors furthest from drivers and mandatory face covering were among the policies implemented to optimise the safety of riders and providers on operational routes.

Enable continued learning for poor children. In March, 85% of the world’s students were out of school due to pandemic closures. Many schools began distance-learning through online platforms. Many students in low-income households without the necessary resources to participate faced additional hardship. Chromebooks and iPads were distributed to students without devices in cities in the U.S, Canada and Australia. The U.S. government coordinated the ‘Keep America Connected’ pledge among broadband service providers to keep people connected, regardless of payment, and to provide free or low-cost service to low-income homes.

Address growing food insecurity. Demand for foodbank assistance soared, forcing the scale up of existing infrastructure with financing and personnel to meet the growing need. The U.S. national guard was deployed to help cities cope with an up to eightfold increase in food bank demand. Urban charities have set up “drive-through” distribution points for food and essential supplies and organised volunteer meal delivery to elderly and vulnerable populations. Many supermarkets limited essential item purchases to prevent stockpiling by those who could afford to do so. Quito, Venezuela, used a food system map to target assistance to vulnerable neighbourhoods and supported home delivery of produce from local urban and peri-urban gardens.

Over 850 thousand students in England and 30 million students in the U.S. participate in free or discounted school meal programs. Schools in the U.K. were mandated to continue providing meals during closures. Furthermore, a voucher program allowed schools to issue supermarket gift cards to carers of children that qualify for free meals. Cities like Baltimore opened up emergency food distribution sites with grab-&-go breakfasts and lunches for any child.

Support for victims of domestic abuse. Heightened anxiety and home confinement were linked to surges in calls for assistance to Women’s advocacy groups and emergency hotlines in many places. Several governments exempted abuse victims from fines that were in place to enforce stay at home regulations. Paris established a code word alert system for victims’ use in pharmacies. France additionally paid for 20,000 nights of hotel accommodation to relocate people away from abusive situations. Safe-guarding practices in some U.K. schools had teachers make weekly calls to students during school closures.

Support for mental health services. The communities carrying the disproportionate burden of Covid-associated ill-health, loss and uncertainty are most risk of suffering the pandemic’s mental health impacts. To offer free support to those in need, Toronto developed a pandemic support strategy in partnership with local organisations to complement existing services. The London mayor worked with ThriveLDN to coordinate mental health support through healthcare, charity, education and business organisations.

Many cities under lockdown have allowed residents to leave homes for daily exercise and maintained the access to nature provided by local parks, particularly important for families lacking outdoor space at home.

Moving Forward

These strategies have not been without criticism. Some fell short of their stated goals and left needs unmet; for others the implementation timelines left people at risk for lengthy periods. As countries reopen, any short-term policies and programs should be replaced with longer term efforts to address the urban inequalities exasperated by the pandemic. Investment in a green economic recovery, for instance, would reduce urban environmental hazards that are too often concentrated in poor neighbourhoods.
Dealing with the challenge of urban inequalities requires coordinated action across multiple sectors including housing, transport, education, health and wellbeing. It is cities and local government who have learned over-and-over how to deliver services efficiently and can address local needs. It is local government and local organisations that have demonstrated their efficiency in this crisis. It is time that national governments should pass resources and jurisdictions to them in order to better support the urban poor.

CHSLDs in Court: Thoughts on Government’s and Managers’ Liability.

The COVID-19 pandemic is revealing the extreme vulnerability of elderly people. The situation being relayed by the media, the Canadian military, and many other witnesses is grim. Our current understanding will be supplemented by the Quebec Ombudsperson’s upcoming investigation, which will no doubt help to better identify the various factors behind this tragic state of affairs.

Liability lawsuits (including class actions) are one response to the pandemic, and its effects on the elderly, that is currently emerging. At this time, there are two class actions against private care homes in Quebec and seven in Ontario. The affected families’ feelings of helplessness and anger may indeed lead them to blame individual actors within the “CHSLD system”, when it is perhaps the system itself which is failing. To understand everyone’s responsibility for the current tragedy, it is essential to ask ourselves: What system are we referring to? What failures are we talking about? Who is involved?

What system are we referring to?

Three types of long-term care facilities (CHSLDs) exist in Quebec: public, private, and private under agreement. Public CHSLDs are part of the Quebec health and social services network and are operated by Integrated Health and Social Services Centres (CISSS) as well as Integrated University Health and Social Services Centres (CIUSSS), which are both public organizations. Private administrators manage private CHSLDs, as well as private CHSLDs under agreement, which are funded by the government. It is essential to distinguish these categories of CHSLDs because they entail important differences in the extent of the harm experienced by our seniors, the mode of the CHSLD’s administration, and the legal framework for the liability of the CHSLD’s managers.

What failures are we talking about?

The law of civil liability (tort law—or responsabilité civile in Quebec) deals with the allocation of responsibility and the compensation of victims for an injury that has been suffered on a case-by-case basis. It is therefore difficult to generalize about the possible outcomes of legal proceedings instituted in response to the tragedy experienced by our seniors. For example, the chronic underfunding of long-term care homes or the low salaries for employees that have been the subject of discussion for years would not be treated in the same way as the contamination of personal protective equipment during the pandemic. Failures within CHSLDs to respect infection prevention and control guidelines would not be considered similarly to the government’s decision to transfer seniors to CHSLDs in order to open beds in hospitals at the start of the crisis. Some issues are individual, others are organizational; some involve political decisions, others manifest themselves on the ground.

Who is involved?

Finally, the criticisms of CHSLDs target three very different categories of actors: the Minister of Health and Social Services (the government), the entities that operate CHSLDs, and employees of CHSLDs. Can victims demand that the courts hold each of these actors accountable? Let us leave aside the situation of employees and discuss claims against the government and CHSLD managers.

Immunity shields many government decisions from liability lawsuits. The Quebec Public Health Act grants immunity to the government, the Minister of Health or “another person” for acts performed in good faith in the exercise of powers held under a declaration of public health emergency aimed at protecting the health of the population (s. 123 PHA). Bill 61 provides for a similar immunity (s. 51). As for government decisions that precede or fall outside this declaration or the ambit of Bill 61, partial immunity protects those decisions that deal with the allocation of resources and the determination of health priorities, unless they are made in bad faith or are irrational (see e.g., Cilinger v. Quebec (A-G) and Khoury 2016).

What about CHSLD managers? Will the CIUSSS/CISSS operating a public CHSLD be immune from liability proceedings as “another person” exercising powers under a declaration of public health emergency? The answer to this question is far from clear. If not, the CIUSSS/CISSS will be subject to the ordinary rules for liability, just like the managers of private CHSLDs and private CHSLDs under agreement. Their liability will depend on having committed negligence that caused the injury a victim has suffered (art. 1457 CCQ), for example, having failed to put in place reasonable infection prevention and control measures.

When evaluating negligence, judges will have to disentangle the roles and obligations of all the actors involved. They will have to establish how they are going to take account of the exceptional circumstances these actors faced, the lack of resources to which they had access, the urgency with which they were required to make decisions, and the changing and incomplete scientific knowledge that underpinned their pandemic management. Judges will also have to rely on public health experts to define what the reasonable standards are for curtailing a pandemic, given the novelty of the situation, taking into account the uncertainty that existed at the relevant time (see e.g., ter Neuzen v. Korn).

Finally, in addition to the existence of negligence, liability is conditional on the existence of a causal link between this negligence and the injury (the death of residents, for example). Tracing the transmission path of an extremely contagious virus whose carriers are often asymptomatic is not an easy task; assessing the causal link between organizational failures and the deaths of our seniors will be equally difficult (Khoury 2012).

Research funded by the McGill Emergency COVID-19 MI4 Fund / MUHC Found

 

 

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