COVID-19, structural racism, and migrant health in Canada

As the COVID-19 pandemic continues to unfold, questions of who has been most affected and where interventions should be targeted increasingly recognise the disproportionate and long-standing health inequities faced by racialised communities (a social construct describing groups that have racial meanings associated with them that affect their economic, political, and social lives) and migrant communities in many settings.¹ By migrants, we refer to a broad diversity of people born in other countries, including long-term and recent arrivals, refugees, asylum seekers, economic migrants, and undocumented migrants. Although evidence from some countries shows heavily racialised effects of COVID-19, there has been scarce discourse and intervention addressing the manifestation and role of structural racism in shaping the pandemic's pattern and toll among migrants.² Unpacking the role of structural racism (the macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities faced by racialised communities) remains crucial for understanding the effects of COVID-19 and pandemic responses among migrants in high-income countries.²

In high-income migration destinations, such as the USA, Italy, France, Spain, and the UK, high rates of COVID-19 have had a disproportionate impact on racialised migrants.³ Migration, economic, and labour policies result in over-representation of migrants in so-called essential, low-paying, and precarious work.⁴ These policies and their outcomes represent structural racism as applied to immigration,⁴ and COVID-19 cases have clustered within these occupations, which are typically more crowded and often offer limited workplace protections and benefits.⁴ Using Canada and other high-income contexts as exemplars, we argue for the need for increased attention to these inequities in high-income migration destinations.

Canada is a large global economy, with universal health care and a high proportion of migrants.⁵ Canada has a long history of racism and colonial violence, dispossession, and oppression of Indigenous peoples and communities that has been linked to a plethora of health and social inequities, including racist treatment within health care, and intergenerational trauma.⁶ While data on race and migration status are scarce within COVID-19 surveillance and public health research nationally, we know that migrants in Canada faced barriers to health care before the pandemic,⁷ and data from some settings in Canada show inequities that reflect findings from the USA and elsewhere. In Ontario, migrants represent just over 25% of the population but 43·5% of COVID-19 cases, mostly racialised visible minorities.⁸ In Toronto, racialised newcomers are over-represented in hospital admissions for COVID-19,⁸ and migrants in British Columbia who are waiting for their applications to be processed are, alarmingly, slated to be excluded from receipt of public health care in early 2021.⁹ These crucial gaps in Canada's COVID-19 response highlight a need to consider and intervene in structural racism as a core part of the pandemic response and recovery process.

Most countries, including Canada, have signed up to global and national policy instruments (eg, the Global Compact for Safe, Orderly and Regular Migration)¹⁰ that affirm the need for countries to take steps towards advancing the human rights of refugees and migrants, including access to basic services, yet few have implemented sufficient policy and programmatic changes to realise these aspirations. In Canada, structural racism manifests in ways that include severe gaps in health-care access among racialised migrants; these gaps are more closely linked to factors such as limited health insurance eligibility, concerns about negative immigration consequences (eg, medical repatriation, requirement to present proof of status at point of care), and scarce culturally and linguistically appropriate care.⁵ To affirm racialised migrants' human rights to health care during and beyond the COVID-19 pandemic,¹⁰ federal and provincial governments in Canada and authorities in other destination countries must make health care accessible and safe for all, including universal health coverage for all residents (regardless of immigration status), culturally and linguistically appropriate health care, policies that allow access without fear, and anti-oppression training for providers.

Labour and immigration policy interventions are also needed globally to address precarious conditions for migrants and affirm their human and labour rights, which are closely connected. For example, workers with precarious immigration status or status tied to a sole employer (eg, agriculture, domestic work) are much more likely to report precarious conditions, including workplace exploitation and safety concerns. To advance human and labour rights during the pandemic, and beyond, it is incumbent upon governments and policy makers in migration destination contexts to implement intersectoral, equity-oriented immigration and labour interventions. In Portugal, for example, all migrants were temporarily regularised (ie, able to secure temporary legal status) to ensure access to health care and social security during the pandemic.³ The continuation and scale-up of such actions after the COVID-19 pandemic are needed to ensure that these gains are not lost. Such changes are particularly needed within sectors that rely heavily on migration.¹¹

All interventions and decision-making must be informed by the lived experience and voices of affected communities.¹² Migrant communities and community-based organisations, such as the Migrant Rights Network in Canada, have mobilised and demonstrated tenacity and dedication, and above all, have clear insight into their own needs and priorities. Listening to and amplifying these calls is one of the most powerful ways that decision makers, researchers, and others in positions of power and privilege can advance the rights of migrant communities. The current toll of the COVID-19 pandemic on racialised migrants represents an urgent call for action to prioritise dismantling structural racism within and beyond the health-care sector.

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