A Syndemic of Suffering: The Racialized and the Marginalized in Ontario’s Long-Term-Care Crisis, 2020-2021, by Sandria Green-Stewart

The coronavirus SARS-CoV-2 (Covid-19) pandemic has been unforgettable for many reasons: leaders’ ineptness, grieving survivors, and vulnerable global populations. In Canada, where the pandemic cut a relatively modest swath through the population by world standards, what will likely remain etched in long-term memory are the tragedies that unfolded in long-term-care facilities (LTCs).

The first three waves of the Covid-19 pandemic between March 2020 and June 2021 were devastating to older Canadians and healthcare workers in Ontario’s long-term care facilities and community home care. The temptation will be to look at the losses of older Canadians and healthcare workers separately, but a complete picture of their suffering cannot emerge unless they are related to each other.  Social and political dynamics (neoliberal underfunding, corporate downsizing, official mismanagement) were  intertwined with systemic racial and socioeconomic inequalities to shape the outcomes of the pandemic as a whole. The syndemic framework offers us a different way of seeing how the tragic outcomes resulted from the interaction of multiple symbiotic factors.^[1]  

The term “syndemic” denotes “a set of closely intertwined and mutually reinforcing health problems that significantly affect the overall health status of a population” within the context of complex social conditions.^[2] There is an overlapping “synergy” between interacting diseases and underlying social conditions (i.e., comorbidity/multimorbidity, on the one hand, and marginalization/exploitation, on the other). Racialized and marginalized groups suffer the most in such situations because of the intersection of systemic discrimination, social inequalities, and biomedical factors. The parallel intersectionality approach championed by legal scholar Kimberlé Crenshaw also offers us precious insights into how racial, class and gender discriminations work together to create and maintain disadvantages for certain groups.^[3] 

In this article, I combine the syndemic and intersectionality approaches to ask: why did Canada’s LTCs become such death traps, both for residents and staff? Following in the footsteps of Pat Armstrong and André Picard in the third issue of Syndemic, I explore how the pandemic revealed systemic racial inequalities among Indigenous, Black and People of Colour (IBPOC) both worldwide and in Canada. These groups suffered disproportionately, not because they were biologically more prone to the disease, but because our social order, proceeding on the basis of narrow conceptions of human economic worth, relegates many of them to vulnerable and dangerous positions in society and the labour market. In a capitalist society, social determinants of health count heavily against the racialized and marginalized “others.”

**

That older (65 years+) adults were more likely to be hospitalized and die from Covid-19 was hardly unique to Canada. Similar crises erupted in the US, UK, Spain, and Italy, among other countries.^[5] As scientists and pharmaceutical companies worldwide rushed to develop a vaccine to reduce hospitalization and deaths from Covid-19, the pandemic raged globally during the first and second waves. In the interim, many seniors succumbed to the infection.

And so did many of the people caring for them, a disproportionate number of them racialized frontline workers. Many of these working-class women soldiered on without job security and benefits and were, therefore, more likely to work out of necessity, even when experiencing symptoms of Covid-19.^[6] From January to July 2020, health care workers across Canada made up 19.4 percent of Covid cases.^[7] In Ontario, Personal Support Workers (PSWs) make up 58 percent of the staff of long-term care facilities, comprising 90 percent female and 41 percent are people of colour (people of colour make up 26 percent of Ontario’s population).^[8] Half of PSWs working in LTCs are between 35 and 54 years of age, and 25 percent are 55 and older.^[9] This racialized and gendered workforce is aging, putting them at risk for Covid-19 because of biomedical factors, occupational hazards, and socioeconomic status.

Black feminists argue that the theory and practice of labour segmentation based on race, class and gender perpetuate the racialization of women of colour in precarious jobs.^[10] The over-representation of women of colour in the lowest stratum of healthcare supports the narrative that due to systemic racism and the legacies of colonialism and slavery, Black women’s labour is undervalued and deemed inferior. As essential workers, PSWs’ duties expose them to infection because their work is “high-touch and intimate” and cannot be done remotely.^[11] The double jeopardy of race and lower socioeconomic status – a dangerous “intersection” indeed – contributed to higher risk factors (precarious frontline work and occupational hazards), resulting in adverse Covid-19 outcomes for racialized healthcare workers.

As it turned out, older Canadians and frontline healthcare workers are vulnerable to Covid-19 because race, class, gender, and age inequalities intersect with the social determinants of health to determine outcomes for these populations. And, beyond merely intersecting, such determinants interacted in a destructive new synthesis: a syndemic.

The concept of syndemics emerged in the early 1990s as researchers on the HIV epidemic struggled to understand why North America’s poor, Black and other communities of colour were particularly ravaged by the disease, above and beyond the levels expected of its usual targets – gay men, hemophiliacs, drug addicts. Merrill Singer introduced the novel term syndemic to the world. Singer argues that while it is conventional in social sciences to separate coextensive issues as distinct entities, in the case of “substance abuse, violence, and AIDS,” such problems are mutually reinforcing and sustained by complex socioeconomic disparities resulting in a syndemic health crisis.^[12]  

Clarence Gravlee concurs with Singer.  She argues that HIV grows dramatically  in populations already threatened by correlated endemic and epidemic conditions, such as “HIV, TB, STDs, hepatitis, cirrhosis, infant mortality, drug abuse, suicide, homicide, etc.”  These health challenges are perpetuated by political-economic and social factors.^[13] Communities confronting health crises can often be considered vulnerable, but new epidemics often coexist with old ones. The crucial point of the syndemic framework is that not only are there discrete forms of oppression, but they are shaped by underlying socioeconomic forces that dynamically interact with one another. Disease concentration (the clustering of epidemics particular to socioeconomic conditions) and disease interaction (the overlapping of epidemics) are both strongly influenced by both biological and social processes.^[14]

While the Covid-19 pandemic directly or indirectly affected everyone worldwide due to widespread lockdowns, worldwide travel bans and such mitigation strategies as quarantines, studies have shown that racialized and marginalized groups were most likely to be hospitalized or die from the pandemic because of syndemic factors. The social determinants of health (occupational hazards, ageism, racism,  gender biases, crowded living arrangements, and lack of support and work benefits) intersect with biomedical factors (such as age-related comorbidity) to structure the Covid-19 experience in different ways for different groups.

Between March 2020 and May 2021, Canadians 65 and over, most living in LTCs, accounted for 93 percent of Covid-19-related deaths.^[15] Older age, comorbidities, and congregate living arrangements ranked among the top risk factors for Canadians 65 and older.^[16] According to one important study in the US, “diabetes, respiratory diseases, cancer, cardiovascular problems, arthritis, hypertension” are more common chronic medical conditions in older than in younger populations.^[17] The study demonstrates that chronic diseases are typically related to an older age.  An Ontario study of the comorbidity risk factors for Covid-19 outcomes reports that 43.8 percent of Covid-19 related cases had at least one preexisting comorbidity such as “organ transplant, dementia, chronic kidney disease, severe mental illness, cardiovascular disease (CVD), hypertension, Chronic obstructive pulmonary disease (COPD), cancer, diabetes, rheumatoid arthritis, HIV, and asthma.”^[18]

Between March to July 2020, Quebec and Ontario accounted for 95 percent of all Covid-19-related deaths in Canada.^[19] Quebec and Ontario reported 38 and 36 percent, respectively, of individuals who died from Covid-19 with such preexisting diagnoses as dementia and Alzheimer’s disease. In addition, 13 percent of Quebecers listed renal failure as comorbidity compared with 10% of Ontarians, while 14 percent of Ontarians and 11 percent of Quebecers recorded diabetes.^[20] Comorbidity and age were prime Covid-19 risk factors for older Canadians.

The syndemic model holds that overlapping epidemics constitute something more damaging than the sum of their toxic parts. The interactions between the social and economic manifestations of the social determinants of health are factors that make syndemic theory especially pertinent to the Covid‐19 pandemic.

It can be misleading and even dangerous to imply that particular populations – racialized, stigmatized, and marginalized – are themselves prone to disease. The coronavirus, or other infectious diseases that prey upon humans, do so without regard to their race, class, or national identity. However, populations that experience a confluence of racial and socioeconomic disparities (overcrowded living arrangements, low wages and occupational hazards) and old age are more likely to suffer the adverse outcomes of disease.

But understanding how such populations came into harm’s way through systemic socioeconomic inequalities demands a realistic assessment of the political, social and economic worlds in which we all live. Data collection is one way to recognize and quantify disparities for different oppressed groups in order to challenge systemic inequalities. Canada did not collect race-based data until four months into the first wave of the pandemic. Still, those collected in Ontario between 26 June 2020 and 21 April 2021 mirrored the findings in the US and UK. They revealed that the pandemic was highly racialized. Blacks, South Asians and Latinx reported higher rates of infection, hospitalization, ICU treatment, and deaths from Covid-19 than whites in Ontario.^[23] However, data for the Indigenous peoples of Ontario, especially for the large numbers (75 percent) living in urban centres, remain lacking.^[24] Such data can help pinpoint the systemic inequalities stemming from the lived experiences of oppressed people. One lesson of the pandemic has been that we need more comprehensive data in order to analyze and remedy systemic inequalities.

**

For several years before the Covid-19 pandemic, long-term care facilities and community home care grappled with the long-standing shortages of frontline staff and the need to safely deliver adequate care to residents in long-term care facilities and the community. In 2018, Eileen E. Gillese, a justice of the Court of Appeal for Ontario, commissioned a public inquiry into the Safety and Security of Residents in the Long-Term Care Homes System. Her 91 Recommendations went to the Ministry of Long-Term Care. In turn, the government took up at least one of her recommendations (no. 85)  and launched an investigation of the staffing question.^[25] The report on this issue came out in the early days of the pandemic.

By that point, Covid-19 had created something of a panic in Toronto’s LTCs, where the Ministry of Long-Term Care presides over the sector. Government officials and LTC leaders felt called upon to respond to a crisis that risked overwhelming the system. Staffing shortages had become so acute in LTCs that in April 2020, approximately 1,650 trained Canadian Armed Forces (CAF) personnel were deployed to care homes in Ontario and Quebec. The CAF reported that five of them in Toronto were in dire straits, plagued by staffing shortages that resulted in residents being left unattended and without adequate meals and personal hygiene. The soldiers compiled stark lists of the enormities (cockroaches, bed bugs, dangerously crowded facilities, cases of near-starvation and avoidable deaths) that made Covid-19  a hellish experience for so many seniors and the health care workers ministering to them.^[26]

Between March and July 2020, Ontario reported 2,770 deaths from Covid-19, of which 63.7% were among long-term care residents and staff, 65.5 percent of whom were females, and 88.1 percent 70 years of age and older.^[27] The crisis worsened because of the warehousing of hundreds of frail elderly Canadians in congregate settings within proximity to other residents, sharing indoor spaces without adequate ventilation and facilities for quarantining the sick. And as it became more and more apparent that Covid-19 often spreads through direct person-to-person contact, often through aerosols contained in an infected person’s cough or sneeze,^[28] these deficiencies became all the more glaring.

A particularly harsh face of the pandemic was the enforcement of social distancing, even in the case of dying seniors hoping for one last glimpse of loved ones. Although social distancing and masking were meant to reduce the spread of infection, mitigation policies could be cruel in practice, violating comforting conventions to lessen the suffering and loneliness of a human being’s last hours.  

Yet, even under such regimes of isolation, residents in LTCs were at risk of infection. Those living in larger facilities (250-456 beds) were exposed to multiple healthcare workers (physicians, Registered Nurses (RNs), Registered Practical Nurses (RPNs), PSWs, and Physiotherapists, among others). Contact with all these professionals meant increased risks of exposure to the disease, especially when proper infection precautions, such as personal protective equipment (PPEs), were often not forthcoming in the early pandemic wave. Sometimes the equipment was not available. Sometimes employers did not want to pay for it.  

Ontario’s long-term care facilities employ over 100,000 health care workers to support a “medically complex population” of approximately 78,000 residents. Personal support workers comprise the largest group of employees, representing almost 60 percent of the staff of LTCs in Ontario. RNs (including RPNs and nurse practitioners) make up 25 percent, and allied health professionals and programming support (such as activity assistants, dieticians, occupational and physical therapists, and social workers) make up 12 percent of the long-term care labour force.^[29] 

The media and government officials focused on the residents in LTCs. But seniors and persons with disabilities in their own homes were often not noticed, despite their vulnerability to Covid-19. Community home care represents a significant part of the long-term care sector, serving vulnerable populations in their homes. An estimated 34,000 PSWs (about a third of PSWs in Ontario) work for community and home care agencies.^[30] PSWs and visiting nurses make home visits to deliver essential support to older Canadians, persons with disabilities and patients recuperating in their homes. According to the Visiting Homemakers Association (VHA Home Healthcare), a service provider of nursing and PSW services in Toronto, PSWs are the “backbone of home care.” They are essential workers providing support to clients in their homes.^[31] Despite the high percentage of PSWs in home care, the media hardly paid any attention to the impact of Covid-19 on this sector.

**

Women of colour are over-represented among PSWs, in the lowest strata of Canada’s healthcare system.^[32] PSWs perform manual labour assisting older adults, patients and individuals with disabilities in various settings. Their duties include performing non-clinical activities of daily living (ADLs), such as personal hygiene, grooming, mobility and feeding in long-term care facilities, hospitals and home care settings.^[33]

Although PSWs perform essential work, their earnings ($17.30 to $25 per hour, depending on worksites and experiences) do not reflect the value of their work.^[34] Ninety percent of PSWs are women, 41 percent are women of colour, and nearly half work part-time without benefits. Part-time work means that many PSWs work at multiple jobs to earn enough wages to support their families.^[35] Working at several locations during a pandemic increased PSWs’ risk of exposure to Covid-19, thereby heightening the possibility of infecting the residents they support.

Katherine Zagrodney and Mike Saks have argued that PSWs number among Canada’s new class of precarious workers, the precariat. Unlike earlier forerunners, such as Caribbean domestic workers in Canada in the 1950s and 1960s, contemporary PSWs’ occupational lives offer them some scope for collective action on the basis of  “a potential class consciousness.”^[37] For Zagrodney and Saks, writing within a Marxist framework, the way forward for PSWs should encompass strong unions capable of resisting their precarity.^[38] PSWs are represented by some well-known unions, such as SEIU Healthcare, Unifor, and CUPE, representing 175,000 healthcare workers across Ontario. Although unions have questioned the Ontario government’s responses to the plight of PSWs, they have not been as effective in organizing for, and agitating on behalf of, the lowest strata of the healthcare system.^[39] However, the voices from these devalued frontline workers are getting louder, especially from people with vivid memories of the horrors of the Covid-19 pandemic of 2020-21.

These problems – disregarded older adults and undervalued racialized workers – can be analyzed separately in evaluating how Covid-19 affected vulnerable populations in our society. But a syndemic framework suggests that such issues must be directly related to each other to grasp the full impact of the pandemic.

Older Canadians and racialized frontline workers in long-term care homes coexist in a dynamic synthesis of suffering. Such suffering did not arise from biology alone, i.e., from humanity’s age-old susceptibility to viruses. The biological outbreak of the virus in LTCs can be directly related to the socioeconomic realities of staffing the homes, which are disproportionately made up of a racialized and precariously positioned class of workers with diminished bargaining power. The sufferings of both residents and workers did not arise primarily from particular biological agents, i.e., viruses. They emerged from the ways in which the pandemic forced a brutal “synthesis” of multiple crises onto those least able to withstand them.

The Covid-19 pandemic exacerbated staffing shortages and retention challenges at LTCs. Many staff were absent. The onerous demands of the situation stressed out some, and others were misled by pandemic misinformation. In the first wave, many healthcare workers worried about access to adequate PPEs, about testing for themselves and family members, and about childcare at a time of widespread institutional lockdowns.

Covid-19’s harsh effects on frontline workers had a cumulative, indeed syndemic effect. Increased workload due to sicker residents, frequent cleaning and disinfecting of surfaces, and reduced staff rosters all meant that many long-term care staff suffered severe burnout.  

The “great resignation” ensued. Some healthcare workers decided to retire early to avoid contracting Covid-19. As many as 43 percent of healthcare workers left the sector due to burnout from overwork and being short-staffed, aggravating an already severe problem.^[40] While other healthcare workers, such as RNs, were short-staffed, the most significant proportion of missing shifts was among PSWs, with one home reporting as many as 60 vacant PSW shifts daily. One LTC with accommodations for 128 residents reported that ten registered nurses were missing per day.^[41]

About 95,000 healthcare workers in Canada became infected with Covid-19 between March 2020 and June 2021.^[42] While all categories of healthcare workers were in danger, PSWs had a higher risk of contracting Covid-19 than other healthcare workers. The provinces of Ontario, Manitoba, and British Columbia reported that PSWs had a 3.3 times higher risk of contracting Covid-19 than physicians and 1.8 times more than registered nurses.^[43] Between January and June 2021, the number of Canadian health care workers infected with Covid-19 increased from 65,920 to 94,873 nationally. As of 15 June 2021, forty-three health care workers died from Covid-19 in Canada.^[44] Ontario reported 5,815 confirmed cases of Covid-19 among healthcare workers as of 22 June 2020, of whom 81 percent were female, and 18.7 percent were male. RNs comprise the largest proportion of cases representing 22 percent of Covid-19 instances among healthcare workers overall. Ontario’s long-term care homes had 69.1 percent infections among healthcare workers and 13 deaths, with an overall fatality of 0.2 percent during the first two waves of the pandemic.^[45] Although one could look at healthcare workers and note their comparatively low fatality rate (compared with older Canadians), still as many as half of them were off sick as the early waves crested. Such high absenteeism revealed a system in deep crisis, exacerbating the risk to residents in LTCs.

The Covid-19 pandemic has provided tangible proof that marginalized and racialized groups suffer not just from diseases but from the complex of socioeconomic forces that render such illnesses more dangerous. The rates of infection, hospitalization and mortality among Indigenous people living in urban centres like Toronto, for example, are three times higher than those in the general population.^[46] Yet, Ontario’s demographic data do not always include an aggregate of Indigenous people living in urban centres affected by Covid-19.

The first two waves of the pandemic reveal that older Canadians and racialized essential workers were most affected by the adverse outcomes because of the synergy between systemic inequalities (race, class, gender and age) and the social and biological determinants of health. Older Canadians are especially vulnerable to a higher risk of hospitalization, health complications and death from Covid-19 because of a syndemic health crisis, with multiple complex social, political, economic and biological factors that create and sustain disadvantages for individuals or groups in our society.  Older Canadians past the prime of their labouring lives are seen as consuming rather than contributing to the political economy; therefore, some may see them as less valuable to the economy. Similarly, racialized individuals and groups, such as PSWs in LTCs,  endure the double jeopardy of racial inequalities and lower socioeconomic status. Their labour is both undervalued and underpaid, while they themselves are often overworked.

As we steel ourselves for the next instalment of this ‘Age of Pandemics,’ we should attend to the voices of those who learned, often at great cost, that this crisis has constituted a syndemic. Seemingly separate problems – viral infections, understaffing, overwork – are best seen as elements in a dynamic, often fatal synthesis. Averting similar suffering in the next pandemic demands learning from those who paid such a steep price just to survive this one.

[1] Clarence C. Gravlee, “Systemic racism, chronic health inequities, and COVID-19: A syndemic in the making?” American Journal of Human Biology: The Official Journal of the Human Biology Council 32, 5 (2020), 2, e23482, Link to source; Christopher Williams and Sten H. Vermund, “Syndemic Framework Evaluation of Severe COVID-19 Outcomes in the United States: Factors Associated With Race and Ethnicity,” Frontiers in Public Health, 9, Article 720264 (20 September 2021), 1-7;Rachel Herron, Christine Kelly, and Katie Aubrecht, “A Conversation about Ageism: Time to Deinstitutionalize Long-Term Care?” University of Toronto Quarterly 90,  2 (spring 2021), 182-206.

[2] Merrill Singer, “A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the SAVA syndemic,” Free Inquiry in Creative Sociology 24,2 (1996), 99.

[3] Kimberlé Crenshaw, “Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics,” University of Chicago Legal Forum, Issue 1, Article 8 (1989), 139-167, Link to source.

[4] “COVID-19 and deaths in Older Canadians: Excess Mortality and the impacts of age and Comorbidity,” Government of Canada, Link to source.

[5] “Percentage of COVID-19 cases in the United States from February 12 to March 16, 2020, resulting in death, by age group,” Statista, Link to source; Anna Schultze et al., “Mortality among Care Home Residents in England during the first and second waves of the COVID-19 pandemic: an observational study of 4.3 million adults over the age of 65,” The Lancet Regional Health – Europe, 14 (March 2022), 100295; “Percentage distribution of coronavirus deaths in Spain as of May 18, 2020, by age and gender,” Statista, Link to source; Maria Dorrucci et al., “Excess Mortality in Italy During the COVID-19 Pandemic: Assessing the Differences Between the First and the Second Wave, Year 2020,” Frontiers in Public Health (July 2021) Link to source.

[6] Denise N. Obinna, “‘Essential and Undervalued: Health Disparities of African American Women in COVID-19 Era,’” Ethnicity & Health, 26, 1 (2021), 69, Link to source; Elliot Clissold, Davina Nylander, and Cameron Watson, “Pandemic and Prejudices,” International Journal of Social Psychology, 65, 5 (2020), 422, Link to source.

[7] “COVID-19 Cases and deaths in healthcare workers in Canada,” Canadian Institute of Health Information, Link to source.

[8] Ontario, Ministry of Long-Term Care, “Ontario Demographics,” Long-term Care Staffing Study, 30 July 2020, 9, Link to source, Link to source.

[9] Long-Term Care Staffing Study, 9.

[10] See, for instance, Dionne Brand, “Black Women and Work: The Impact of Racially Constructed Gender Roles and the Sexual Division of Labour,” in Enakshi Dua and Angela Robertson, eds., Scratching the Surface: Canadian Anti-Racist Feminist Thought (Toronto: Women’s Press, 1999), 83–96; Tania Das Gupta, Racism and Paid Work (Toronto: Garamond Press, 1996),7–10;Agnes Calliste, “Canada’s Immigration Policy and Domestics from the Caribbean: The Second Domestic Scheme,” in Jesse Vorst, ed., Race, Class, Gender: Bonds and Barriers (Toronto: Garamond Press, 1991), 136-168.  These scholars have argued that, in Canada and the US,  immigrant women of colour (from the Caribbean, the Philippines, and West Africa) were overrepresented as manual labourers in domestic service, retail, manufacture, and low-level health service. Black women are over-represented in poorly paid jobs because the division of labour along race, gender, and class lines positions them in precarious jobs. Their labour is systemically undervalued.

[11] “Homecare Personal Support Worker Experiences Working During the COVID-19 Pandemic: A Qualitative Study,” VHA Home Healthcare, Link to source.

[12] Singer, “A dose of drugs, a touch of violence, a case of AIDS,” 99, 109. See also Merrill Singer, Nicola Bulled, and Bayla Ostrach,  “Whither syndemics? Trends in syndemics research, a review, 2015–2019,” Global Public Health, 15,7 (2020), 943–955, Link to source.

[13] Gravlee, “Systemic racism, chronic health inequities, and COVID-19,” 1.

[14] Ibid., 2.

[15] “Impact of the COVID-19 Pandemic on Canadian Seniors,” Statistics Canada, 2021, Link to source.

[16] Erjia Ge, et.al., “Association of pre-existing comorbidities with mortality and disease severity among 167,500 individuals with COVID-19 in Canada: A population-based cohort study,” PLOS ONE (5 October 2021), Link to source.

[17] Rosemary Yancik, et al., “Report of the National Institute on Aging Task Force on Comorbidity,” Journal of Gerentology, Series A 62, 3 (March 2007), 275–280, Link to source. The interdisciplinary task force report was issued by the National Institute on Aging (NIA) Geriatrics and Clinical Gerentology (GCG) program.  

[18] Erjia Ge, et.al., “Association of pre-existing comorbidities with mortality and disease severity among 167,500 individuals with COVID-19 in Canada: A population-based cohort study,” PLOS ONE (5 October 2021), Link to source.

[19] Kathy O’Brien, Marylène St-Jean, Patricia Wood, Stephanie Willbond, Owen Phillips, Duncan Curie and Martin Turcotte, “COVID-19 Death Comorbidities in Canada,” Statistics Canada, 16 November 2020,  Link to source.

[20] Ibid.

[21] Magesh, et al, “Disparities in COVID-19 Outcomes by Race,” 1;  L. Ebony Boulware, “Race Disparities in the COVID-19 Pandemic­ – Solutions Lie in Policy, Not Biology,” JAMA Network Open 3, 8 (18 August 2020), 1-3:e2018696. Link to source; Gravlee, “Systemic racism, and COVID-19,” 1.

[22] Shirley Sze, et.al., “Ethnicity and clinical outcomes in COVID-19: A systematic review and meta-analysis,” EClinicalMedicine 29-30 (2020), 3-9; Elliot Clissold, et.al., “Pandemics and prejudice,” International Journal of Social Psychiatry, 66, 5 (2020), 421–423.

[23] Tracking COVID-19 through Race-based Data, 8-9.

[24] Well Living House, “Our Health Counts: Urban Indigenous Health Database Project,” Link to source; Brendan Kennedy, “Indigenous people in Toronto have much higher rates of COVID hospitalization than general population, new data shows [sic],” Toronto Star, 26 April 2021, Link to source; Heather A. Howard-Bobiwash, Jennie R. Joe and Susan Lobo, “Concrete Lessons: Policies and Practices Affecting the Impact of COVID-19 for Urban Indigenous Communities in the United States and Canada,” Frontiers in Sociology (23 April 2021), 1-14, Link to source.

[25] See Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System, commissioned by Hon. Eileen E. Gillese, Commissioner, 31 July 2019. This inquiry was commissioned in the wake of the crimes of Elizabeth Wettlaufer, a RN who was convicted of eight counts of first-degree murder, four counts of attempted murder, and two counts of aggravated assault of residents in several southern Ontario long-term care facilities between 2007 and 2016. Long-Term Care Staffing Study, Link to source.

[26] Jan Malek, “Military Report on Long-Term Care Homes Reveals Long-Known Truths,” The Council of Canadians, 2021, Link to source; Benjamin Rempel “‘There was a lot of death and suffering’: How soldiers turned the tide in Ontario’s long-term care homes,” healthydebate (Sept 2020), Link to source.

[27] Jeanne M. Sorrel, “Losing a Generation: The Impact of COVID-19 on Older Americans,” Journal of Psychosocial Nursing and Mental Health Services 59, 4 (April 2021), 9+; Ilya Kashnitsky and Jose Manuel Aburto, “COVID-19 in Unequal Ageing European Regions, Elsevier Public Health Emergency Collection (August 2020), Link to source.;“Public Health Ontario: COVID-19 in Long-Term Care Homes in Ontario: January 15, 2020 to February 28, 2021,” 1, Link to source.

[28] “How does COVID-19 spread between people?” World Health Organization, 23 December 2021, Link to source.

[29] Long-Term Care Staffing Study, 8.

[30] Janet Lum, Jennifer Sladek, and Alvin Ying, “Ontario Personal Support Workers in Home and Community Care: CRNCC/PSNO Survey Results,” InFocus (Toronto: Ryerson University, 2010), 6.

[31] Visiting Homemakers Association.

[32] Long-Term Care Staffing Study, 9; Lum et. al, “Ontario Personal Support Workers in Home and Community Care, 3-5.

[33] Long-Term Care Staffing Study, 2-10;  VHA Home Healthcare, “Homecare Personal Support Worker Experiences Working During the COVID-19 Pandemic: A Qualitative Study,” VHA Home Healthcare, Link to source.

[34] Long-Term Staffing Study, 10.

[35] Sandria Green-Stewart, “Transition to Health-Care Work: The Narratives of Caribbean Immigrant Women in Toronto, 1970s­–1990s,” Histoire Sociale / Social History (forthcoming, 2022), 27.

[36] Long-Term Care Staffing Study, 8-10; “Ontario Extending Temporary Wage Enhancement for Personal Support Workers,” Ontario Government, 28 October 2021, Link to source.

[37] Katherine Zagrodney and Mike Saks, “Personal Support Workers in Canada: The New Precariat?” Healthcare Policy/Politiques de santé 13, 2 (November 2017),  31-9; Link to source; Green-Stewart, “Transition to Healthcare,” 13-15.

[38] Zagrodney and Saks, “Personal Support Workers in Canada,” 35.

[39] SEIU Health Care, “Ontario government PSW regulation short on details raises more questions than answers and absent urgent support workers need today,” Unifor, 27 April 2021, Link to source.

[40] Approximately 40 percent of PSWs leave the health care sector within a year of graduating.Annually about 25 percent of PSWs who have two or more years of experience exit the sector. Long-Term Staffing Study, 8-9, 10-11.

[41] Long-Term Staffing Study, 16.

[42] Canadian Institute of Health Information, COVID-19 cases and deaths in health care workers in Canada, 31 March 2022, Link to source.

[43] COVID-19 cases and deaths in health care workers in Canada.

[44] COVID-19 cases and deaths in health care workers in Canada.

[45] Public Health Ontario, “Enhanced Epidemiological Summary, COVID-19 in Health Care Workers in Ontario,” June 2020, Link to source.

[46] Janet Smylie, “Our Health Counts Toronto linkage to Institute of Clinical and Evaluative Sciences (ICES) COVID-19 data holdings,” Link to source.