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Chevonne Xue
Product Designer & Entrepreneur based in Toronto.
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Race and COVID-19:
An In-Depth Analysis  
Chevonne Xue, Hibo Roble,  Celeste Ranmarnine, Caroline Wang



IntroductionSince the beginning of the pandemic, public health data from multiple countries appears to indicate that racial/ethnic minorities are more highly represented in COVID-19 case counts, hospitalizations and mortalities than their White counterparts. Unfortunately, this precedent also occurs in the city of Toronto as Toronto Public Health was able to report that people of color make up more than 80% of COVID-19 cases despite only accounting for approximately 50% of the population (Cheung, 2020). 

This report will discuss why these disparities occur by highlighting key socio-demographic factors that play a role in determining why racial/ethinic minorities are overrepresented in COVID-19 cases. This paper will also discuss the race data collected by the City of Toronto in relation to COVID-19 cases and also provide a more detailed view on the representation of East Asians within this data. 

In addition to this, this paper will also reveal some of the underlying issues concerning the race data collection in Toronto and will examine the experiences of Indigenous people during this pandemic. Lastly, this paper will also examine the efforts the city of Toronto has made towards marginalized groups during  COVID-19 and make suggestions for improvements.


 Sociodemographic Factors At the beginning of the pandemic, COVID-19  was previously thought to be an equal opportunity virus, which led to the nickname “The Great Equalizer” (Mein, 2020). However, as time has gone on, multiple studies have postulated that socio-demographic factors such as race/ethnicity, socio-economic status, housing situations and several others can result in some individuals having a higher risk of contracting COVID-19 (Abrams & Szefler, 2020). 

In fact, one study situated in New York City, which was an early epicentre for the COVID-19 pandemic in the United States found that rates of hospitalizations and deaths were highest in the Bronx, the borough with the highest proportion of members of racial/ethnic minority groups and households living in poverty (Karmakar, Lantz & Tipirneni, 2021). A more detailed look into the city’s hospitalization data showed that Hispanic and Black patients make up 34% and 28% of  city-wide fatalities despite comprising 29% and 22% of the population (Mein, 2020). These statistics in combination with the racial disparities outlined by Toronto Public Health indicate  that the underlying reason for these inequities is not the result of race but rather systemic racism that continues to permeate into today’s society. Due to the long history of systemic racism and racial/ethnic stratification within post-colonial, multi-ethnic countries such as the United States, United Kingdom and Canada, factors such as educational attainment, income level, type of employment, home ownership and others which comprise an individual’s socio-economic status (SES) are strongly correlated with race (American Psychological Association, 2021). 

Multiple studies have shown that ethnicities with darker skin tones are strongly correlated with lower incomes than their lighter skinned or white counterparts (Bailey, Saperstein & Penner, 2014). Additionally, US census data has shown that race/ethnic stratification can often determine an individual’s socioeconomic status (American Psychological Association, 2021). Furthermore, neighbourhoods are often segregated by SES, often resulting in low-economic development and poor environmental conditions, which can exacerbate health and educational inequities (2021). The subsequent section will examine one key aspect of socio-economic status: employment and its effect in increasing the representation of racial/ethnic minorities in COVID-19 health data in further detail. 



EmploymentTo shed some light on the issue of employment, minorities are more likely to be employed in low paying work that has been classified as “essential” during the pandemic (Olding, Barker, McNeil & Boyd, 2021). This is in contrast to individuals with higher SES who have been able to easily transfer to “work from home” employment, thus limiting their exposure to COVID-19. Some of these “essential” roles include: post office workers, retail staff, janitors and cleaners ( 2021). In addition to this, lower paying, more exposed healthcare positions such as registered practical nurses and personal support workers are also more likely to contract COVID-19 than their other healthcare counterparts (2021). 

Given that these positions are lower paying, often minimum wage work, missing work can mean losing much needed income which can leave people choosing between making rent and buying groceries. This all too frequent scenario often results in the difficult choice of taking a sick day, which can hinder any progress in the fight against COVID-19. This issue has been highlighted by Chief Medical Officer of Peel Region, Dr. Lawrence Loh who has said: 

  •              “Insufficient paid sick days, financial/income supports, and sick leave protection are known barriers to compliance to COVID-19 control measures, including testing and self-isolation. Paid sick day supports for workers who have COVID-19 or need to isolate because they may have been exposed to the virus will help support workers to follow public health guidance and support our essential businesses to operate safely, reducing community transmission of COVID-19.”  (Peel region, 2021)  

These comments are reflective of a Peel Public health study that looked at 7,784 people with symptoms that could be associated with COVID-19 between August 2020 and January 2021 and found that 25% of the study population reported to their jobs. More shockingly, eighty of those individuals continued to go to work even after testing positive for COVID-19 (Aguilar, 2021). These statistics clearly highlight the need to have paid sick leave for all, a privilege that those who have higher SES may not fully recognize as universal. As of today, the federal government has introduced the Canada Recovery Sickness Benefit, a paid sick leave benefit which provides up to 14 days of paid sick leave for anyone who is experiencing COVID-19 symptoms and needs to miss work (2021). However, there have been calls by various groups, including Mayor John Tory, for paid sick leave at the provincial level, something Premier Ford has and continues to reject (2021). This rejection continues to put racialized, low income workers in danger of contracting COVID-19. 



Data from the Province of Ontario and the City of TorontoIn June 2020, the Ontario Ministry of Public Health released a report entitled “COVID-19 in Ontario - A Focus on Diversity” (Public Health Ontario, 2020). This report includes data from Integrated Public Health, Toronto Public Health Coronavirus Rapid Entry System and Ottawa Public Health COVID-19 Ottawa Database while also providing an analysis of the data to compare COVID profiles across communities. The report’s results appear to indicate that ethno-culturally diverse communities are far more affected by COVID-19 than communities that are less ethno-culturally diverse (2020). The report’s findings also note that these ethno-culturally diverse communities, which are primarily concentrated in large urban areas have a COVID-19 prevalence that is three times higher than less diverse communities, even after adjusting for differences in age structure (2020). Individuals living in these ethno-culturally diverse communities were worse off, with far more hospitalizations, intensive care unit admissions, and deaths than those living in less diverse communities. The following sections will outline some of the key figures from this report and highlight some key insights concerning racialized Ontarians and Torontoians’ representations in the COVID-19 health data. 


Figure 1. Cumulative number of confirmed cases of COVID-19 for each quintile of ethnic concentration: Ontario, January 15, 2020 to May 14, 2020 (n=16,169 case), Public Health Ontario, 2020



Figure 1 above shows the cumulative number of confirmed cases of COVID-19 for each quintile of ethnic concentration. The investigators divided the different ethnic communities into five quintiles, Q1 to Q5. Where Q1 is the least diverse, and Q5 is the most diverseThe graph shows that the overall number of cases peaked on April 15 after an outbreak on March 4, and then leveled off and declined. However, regardless of the stage, the number of illnesses in Q5 far exceeds that of several other communities, highlighting the association between the spread of COVID-19 and race/ethnic background. 



Figure 2. Share of COVID-19 cases among ethno-racial groups compared to the share of people living in Toronto,City of Toronto, 2021



Figure 2 displays the share of COVID-19 cases among ethno-racial groups in comparison  to the share of people living in Toronto. This data was collected via ongoing Toronto Public Health surveys on Ethno-Racial Identity (City of Toronto, 2021). These surveys also collect information on ethnicity, income as well as family status from individuals testing positive for COVID-19. Although, close to 21% of COVID-19 cases do not have their ethno-racial identity and other related information documented for unknown reasons, this figure indicates that Black, Latin American, South Asian or Indo-Caribbean, Southeast Asian and Arab, Middle, Eastern or Western ethno-racial groups are overrepresented in COVID-19 cases in comparison to their representation in Toronto’s population. This is in contrast to East Asian and White ethno-racial groups as they are underrepresented in COVID-19 cases. 




The formation of the third space
In Beauvoir's work The Second Sex, she introduced the concept of the "other". (Beauvoir, 2010) She argues that in a patriarchal society, men would be seen as "exemplary" and "standard", while women would be seen as "others", and this group of people would be marginalized and become subordinate. The concept of "other" also applies to issues of race and ethnicity. In a white-dominated world, minority or non-white groups would be seen as "others. Therefore, when it comes to migration to predominantly white European (Caucasian) countries, immigrants from all non-white ethnic groups face a problem. How should they deal with the high cultural walls? Should they integrate into the local culture, or should they try to preserve their own culture? How should immigrant communities choose between their native culture and the culture of their homeland?

Shuyu Kong proposes the concept of a "third space" through his study of Chinese-language television programs produced in Canada. (Kong, 2013) This concept of third space prevents Asians from falling into the dichotomy of "standard" and "other" mentioned above. They gradually find a new cultural space in the "home country" and the "host country". In this space, new immigrants can choose information according to their own cultural background and needs. In addition, the one-way media communication is gradually changed by the two-way and multiple communication of Internet media. People can even be encouraged to express their own opinions and views.

Shuyu Kong suggests that the "third space" opened up by ethnic media shows a sense of belonging to multiple regions, a new "localness" that transcends the polarized perceptions of birthplace and residence. Overseas Chinese media have created a cultural strategy to cope with capital accumulation, namely "mobile citizenship. " They are also guiding new immigrants to break away from old socio-cultural habits and adapt to new value standards. (Kong, 2013) In the face of the cultural barriers erected by the mainstream media, local Chinese-language media create an opportunity and space for new citizens to actively participate in the discussion of local public issues, to make their voices heard, and to express their identification with multicultural citizenship in this safe space.



A Unique Case: East Asian CommunityWhen the pandemic first broke out, many people called it the "Chinese" virus, with more bigoted and misinformed individuals inaccurately thinking that interactions with the Chinese community would increase their chances of catching this unknown and deadly virus. However, it should be noted that in addition to Whites, East Asians are underrepresented in COVID-19 cases, contradicting the stereotype that COVID-19 has a special relationship with the East Asian community ( see figure 2, City of Toronto, 2021). The unique under-representation of East Asians in COVID-19 health data can be further understood by looking at income disparities within COVID-19 health data, a concept the following figures will explore more thoroughly. 

Figure 3. Share of COVID-19 cases by household income in comparison to the share of people living in Toronto by income group, City of Toronto, 2021


Figure 4. Chinese-Canadian Incomes Vs. All Canadians, Statistics Canada, 2017




Figure 3 displays the share of COVID-19 cases by household income in comparison to the share of people living in Toronto by income group. This figure clearly shows the over-representation of COVID -19 cases in low-income groups ($0 -29,999 and $30, 000 - 49,999), highlighting a strong correlation between poverty and contracting COVID-19. 

This is especially interesting as Figure 4, a graph showing the differences between Chinese-Canadian incomes and those of the general Canadian population indicates that Chinese-Canadians are overrepresented in high-income brackets when compared to the general population (Wong, 2017). The lack of East Asian representation in the city’s COVID-19 case counts appears to be the result of high incomes, which confirms the idea that socio-economic status plays a large role in determining COVID-19 risk. 





Who's Missing?There are several issues with the Toronto race data which can be uncovered by analyzing the modes of data collection. First, data was collected on a voluntary basis and required participants to respond to various socio-demographic questions. Therefore, there were  individuals who were not included in the data, chose not to respond, or responded inaccurately - leading to skewed data. Second, data collection spanned from May to July 2020, meaning the data does not reflect the beginning of the pandemic, the second wave that occurred during fall 2020 or currently. Third, the data does not include counts from those in long term care homes, prisons or in Indigenous Communities (Cheung, 2020, Dalla Lana School of Public Health, 2020).



The Indigenous Experience 
Among the COVID-19 race data for Toronto, Ontario and across Canada, there is a resounding absence of information about Indigenous communities. Dr. Marcia Anderson, of the COVID-19 Response Coordination Team, noted this statistic: “First Nations people currently make up 73% of all presumed active cases, 50% of hospitalizations, and 52 % of ICU admissions” (Sound & Jones, 2021). This is one of the few statistics provided for the Indigenous community during the pandemic, and as the pandemic has gone on for almost a year, it is clearly outdated. As well, not much is known about this statistic or the origin of these numbers. Without accurate and transparent information about data collection and analysis for Indigenous COVID-19 related data, their wellbeing or what supports they need cannot be fully understood (Patel, 2020). However, it is clear that Indigenous peoples, like many other racialized communities, are unequally affected by COVID-19. The Indigenous experience during COVID-19 is so vast, thus this section can only summarize a handful of the issues faced by Indigenous communities across Canada. 

On reservations, conditions are poor; there are issues with access to potable, clean water which affects hygiene, nutrition and ultimately the spread of disease (Mendleson, 2020, Dalla Lana School of Public Health, 2020). The result of this can lead to further disease spread like the COVID-19 outbreak seen in northern Saskatchewan, on the La Loche residence which accounted for the majority of the province’s cases (Patel, 2020). As well, the majority of reservations are experiencing a housing crisis (Patel, 2020, Dalla Lana School of Public Health, 2020). This crisis is described as overcrowding (i.e. not enough homes for all) and poor housing conditions (i.e. not well maintained). Indigenous reservations are the responsibility of the federal government, which is one of the redeeming factors during the pandemic because Indigenous case numbers, testing, vaccinations and supports are monitored on reservations, even if they are not well maintained (Patel, 2020). However, an important consideration is that there are still many Indigenous peoples that live outside of reservations and in urban centres, who are not accounted for in reservation based monitoring and thus do not receive the same federal services including vaccines and testing (Kennedy, 2021). Indigenous individuals living off of reservations must rely on community led programs to circumvent their increased risk of contracting COVID-19 (Kennedy, 2021).

One aspect to consider is the impact on local Indigenous service providers. With the economic disparities experienced during COVID-19, many of these services are unable to support Indigenous communities (Mendleson, 2020). $15 million dollars in federal funding has been provided to help Indigenous communities and services cope, though as suggested by Indigenous Services Minister Marc Miller this amount is not nearly enough (Mendleson, 2020). Again, without robust data collection and analysis we will never know what is enough to support our Indigenous people through COVID-19.



Trust and Healthcare for Racialized People

The idea of trust is a huge issue to consider when discussing racialized communities and COVID-19. Ethnic communities that are at a higher risk of contracting COVID-19 are refusing to get the testing and vaccinations that can save their lives because of their lack of trust in the public health system (Barned, 2020, Cooper & Crews, 2020). This mistrust and associated behaviours are justified when the histories of institutionalized racism in public health are considered (Barned, 2020, Boulware et al., 2003). For example, in 1932, four-hundred African-American men were subjected to the U.S. Public Health Tuskegee Syphilis Study in Tuskegee, Alabama (Barned, 2020, Boulware et al., 2003). They were unknowingly enrolled in a 40-year syphilis study and left untreated (Barned, 2020, Boulware et al., 2003). Black women were exposed to similar treatment when James Marion Sims improved the design of the speculum ( a medical tool used in obstetric and gynecological treatment) on them, without anesthesia (Barned, 2020). As well, Henrietta Lacks, another black woman, has also been taken advantage of by the North American healthcare system (Barned, 2020). Her cancer cells were used, without consent, to create the first immortalized human cell line (HeLa cells), which contributed to medical advances like the polio vaccine, without any attribution to Lacks (Barned, 2020). Sterilization experiments also occurred in women of colour across North America (Barned, 2020). Canada is also guilty of applying the same treatment to Indigenous peoples (Barned, 2020). Through the 1930s - 1970s, Canada tested novel medical research on Indigenous people including skin grafting, vaccinations, nutrition experiments and dental procedures (Barned, 2020). Specifically, a class-action lawsuit was filed against the Canadian government on behalf of Indigenous communities that were subjected to trials of tuberculosis vaccines during the 1930s, when it was reported that government officials were supposed to be in these communities to attend to their poor living conditions (Rodriguez, 2020). Aboriginal children in residential schools were tested on to find successful medicine to treat children; when a solution was found, it was distributed to children across Canada, except those that were Indigenous (Barned, 2020, Rodriguez, 2020)). Even today, people of colour do not see themselves well represented in healthcare - as clinicians, as public health leaders and decision makers or by research studies, which further reinforces their feelings of mistrust (Cooper & Crews, 2020). 

In order to truly support the health of racialized people, public health systems must start from the ground up - healing the relationship with trust, understanding and cultural sensitivity before implementing wide-spread, one-size-fits-all clinical systems (Barned, 2020, Boulware et al., 2020, Cooper & Crews, 2020). There are two approaches identified in Cooper & Crews (2020) to enhance trust among people of colour and health systems: relationship-centred care (RCC) and structural competence. RCC is a lens to apply to healthcare which places the emphasis on relationships, primarily the physician-patient relationship but also physical-self (i.e. self-reflection), physician - physician (i.e. with colleagues) and physician-community (Cooper & Crews, 2020).  RCC can look like improved communication, partnership, mutual respect, knowing, shared values and trust (Cooper & Crews, 2020). Structural competence describes the process of remodelling the current public health system to include the experiences and expertise of people of colour, such as putting funding toward the health issues that affect them, including racialized groups in more medical studies, having more diverse leadership and implementing topics such as structural racism into medical curricula (Cooper & Crews, 2020). In addition, to these two approaches, organizations in Ontario report that the best way to heal the relationship of trust with people of colour is to simply listen to them (Rodriguez, 2020). This can look like conducting focus groups with ethnic groups, providing information and literature that is culturally sensitive and language inclusive, holding question and answer sessions that are accessible such as in places of worship, community hubs or on online meeting groups, and also checking in with community leaders such as religious leaders (Rodriguez, 2020).


Current Applications of Race Data - Implementation and SolutionsToronto has provided generalised intentions for how they plan to apply the findings of their COVID-19 race data. They want to work with community groups that serve those unequally affected by COVID-19, improve health promotion messaging by targeting marginalized, ethnic groups, increase the number of testing sites in communities with marginalized people, increase opportunities for out of home isolation for those who cannot safely do so in their own homes and engage in long-term planning for a more equitable health system (City of Toronto, 2021).

These goals have begun to be implemented by both the government and community organizations, such as: 
  • The Black Community COVID-19 Response Plan - this effort was created by the government of Toronto to support black communities during the pandemic which include prevention, awareness, testing and funding supports (Wilson, 2021) 
  • The South Asian COVID Task Force - this is a community led organization that brings awareness to COVID-19 rules and information via culturally sensitive means (Marwaha et al., 2020) 
  • The #FaceRace Campaign - this campaign was created to target anti-Asian racism seen during the COVID-19 pandemic and includes the East-Asian community sharing their stories to promote healing and understanding (Neustaeter, 2021)
  • Anishnawbe Health Toronto: Mobile Health Unit - this health unit is composed of nurses, administrative assistants and social workers who travel to Indigenous communities across Canada in an RV, to provide COVID-19 testing and hot meals. (Jabakhanji, 2020) 
  • Operation Remote Immunity - this effort was created to deliver COVID-19 vaccinations by airplane to remote Indigenous communities across Ontario (Sound & Jones, 2021). 
  • In response to remarks made by Indigenous minister Marc Miller and the community about insufficient funding for Indigenous support, Ottawa has pledged $250,000. This additional funding will be used for improved data collection efforts that would lead to more accurate modelling of the virus's spread in Indigenous communities and thus, better inform the government's response (Mendleson, 2020).  

What Else Can Be Done?Though there are so many great efforts currently being implemented, there is so much more that can be done to support racialized communities during COVID-19. As seen in the previous section on trust, there are many social initiatives that need to be included as part of the COVID-19 treatment efforts such as listening to racialized voices who are the experts of their own experience (Dalla Lana School of Public Health, 2020, Rodriguez, 2020). In terms of data collection, Canada, Ontario and Toronto can improve and increase their race-based data collection efforts at all levels of government (McKenzie, 2020), which include those who have been identified as missing in current data. Structural and institutional changes are also very important. One obvious solution is creating and improving equity based public health plans for system reform (McKenzie, 2020). Second, increasing funding for community, people-of-colour led services (McKenzie, 2020. Lastly, more research and published literature about race and COVID-19 in Canada is needed.






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