Ontario’s Exploitation of Healthcare Workers – A Health Equity Perspective

In the ominous shadow of the global COVID-19 pandemic, another largely ignored parallel health crisis has intensified to a near breaking point – the occupational health crisis for Ontario’s healthcare workers.

Thinking beyond traditional occupational wellness strategies focused on influencing individual behaviours, ETR’s Health Equity Framework (HEF) explores spheres of influence contributing to risk and protective factors furthering health disparities for HCW’s throughout the COVID-19 pandemic. The HEF emphasizes three core concepts: equity at the core of health outcomes, multiple interacting spheres of influence, and a historical and life-course perspective - all of which can be fundamentally tied to the systemic circumstances resulting in the current crisis within Ontario's healthcare community.

Equity at the Core of Health Outcomes: The HEF’s definition of Health Equity as “having the agency and fair access to resources and opportunities needed to achieve the best possible physical emotional and social wellbeing” is well aligned with The World Health Organization’s definition of health as “a state of complete physical, mental and social well-being and not just merely the absence of disease” (WHO, 1946).

Conversely, health inequities are health differences that are considered preventable and are linked to social, economic and environmental conditions. The emotional and psychological impact of the COVID-19 pandemic has disproportionately affected healthcare workers (HCW’s) when compared to the general population (Giess et al. 2021). In Ontario, healthcare workers courageously battled the first waves of COVID-19 in the absence of validated evidence about how the virus spread, and without adequate protections including personal protective equipment (PPE) or application of other hierarchy of hazard controls fundamental to occupational health and safety. As a result, by July of 2020 Ontario HCW’s were disproportionally infected with COVID-19 making up nearly 20% of all cases – a significantly higher rate than the estimated 14% global rate for HCW infections (Brophy et al. 2021).

Multiple interacting spheres of influence: HEF outlines four spheres of influence closely interrelated with the more widely recognized Social Determinants of Health, highlighting the explicit, implicit and interrelated interactions of multilevel influences on health outcomes that create the conditions and context for health: systems of power, relationships and networks, individual factors, and physiological pathways.

Systems of Power include macrosystems such as the broader healthcare system, as well as smaller organizational systems and policies. The COVID-19 pandemic thrust Ontario’s already struggling and chronically underfunded healthcare system into the limelight. According to a report prepared by the Ontario Health Coalition, "Ontario has the fewest hospital beds and lowest nursing hours per patient of any province in Canada” (Brophy et al, 2021). Ontario was also embarrassingly unprepared to face the challenges of the COVID-19 pandemic after failing to apply critical lessons learnt in the 2003 SARS outbreak.

The Ontario Governments COVID-19 response was torturous for health care providers who suffered through unpredictable, constantly changing and sometimes nonsensical Ministry Directives, often in direct contradiction to the well-established keystone concepts of Infection Prevention and Control. Ontario’s Minister of Health and Minister of Long-Term Care enforced measures inconsistent with the evolving science and ever-changing risk of COVID-19 and its variants. Healthcare workers were left fearful they were not being adequately protected - especially when the protocols implemented by Doug Ford’s conservative government were repeatedly proven unreliable. There remains an overarching sense amongst the healthcare community of being disrespected, neglected, and exploited. An overall feeling of mistrust in the very government accountable to its citizens under Canada's Health Act “to protect, promote, and restore the physical and mental well-being of residents, and to facilitate reasonable access to health services without financial or other barriers” (Canada Health Act, 1985).

Ontario healthcare workers were left to tow the COVID line as Ford’s government irresponsibly and repetitively caved to public pressures - prematurely easing COVID restrictions resulting in repeated “waves”, overwhelming an already drowning health workforce. Adding insult to injury, the Ontario government refused to repeal Bill 124 – wage suppressing legislation passed in 2019 that caps increases in salaries or benefits to a maximum of one percent for public sector healthcare workers – which has arguably not only been a key factor in Ontario’s unprecedented nursing and HCW shortage, but is also overtly discriminatory as it disproportionately impacts female-dominated professions.

Relationships and Networks include mesosystems such as interactions, relationships, interactions and networks around us such as family, friends, peers, co-workers and neighbours. These systems are often a source of support that mitigate the negative impacts of systems of power, or in contrast, can also serve to reinforce bias and unhealthy habits (maybe sometimes a little of both). For healthcare workers, this sphere of influence for was also significantly and disproportionately impacted by COVID-19.

In addition to the disconnect felt by all Ontarians due to COVID isolation requirements, Healthcare workers lived in fear of bringing the virus home and infecting their loved ones. There was a sense of societal stigma, where outside of COVID restrictions, healthcare workers and their families were avoided by friends, neighbours, and the public out of fear that they had been occupationally exposed to the novel virus. While many professions shifted to a work-from-home model where parents remained at home working alongside their kids who were participating in on-line learning, essential (predominantly female) frontline healthcare workers were required to work longer hours, with impossible demands both at home and at work and tremendous feelings of conflicting guilt - for not being home to support their children and families - and simultaneously feeling guilt-ridden for not being at work to support suffering patients, and overworked colleagues.

Individual Factors include microsystems such as our attitudes, skills and behaviours in response to the constraints and opportunities of our social and physical environment. These are closely related to our personal experiences and to the identity and values we hold. Targeting individual factors is the easiest and most common way to influence health outcomes, but is rarely an indication of sustainable change or a true shift in health inequities. Holding a leadership role in Long-Term Care throughout the COVID-19 pandemic, this has been one of the more painful struggles to experience both personally and to observe within my teams. With unprecedented strains on health human resources, staff are often working short, bearing constant witness to preventable human suffering, and are unable to provide the level of quality care we want to provide, and that our patients deserve. Healthcare workers formerly passionate about their jobs feel anxious, demoralized, and defeated as they leave lengthy assignments - mourning the good ol' days where they left even the most hectic of shifts still feeling energized - proud of the care they provided, and knowing that they helped and healed. Fulfilled in the knowledge that they made a difference.

Physiological Pathways are the biological, physical, cognitive and psychological abilities and conduits known to contribute substantially to health outcomes. Recognizing that physiological pathways are not always modifiable, the Health Equity Framework focuses on physiological pathways as a means to augment resilience in the other three spheres of influence. Each of the four spheres of influence overlap and interact to create health outcomes - both positive and negative.

Historical and Life-Course Perspective: The third and final concept of the Health Equity Framework is a historical and life-course perspective which explores influences with consideration to developmental and/or life stage including cumulative and generational impacts of historical inequities. Ontario's healthcare system has been habitually deprioritized by provincial governments, negatively impacting the occupational wellness of healthcare providers for decades. Professional associations, unions and statisticians who for years have been warning of the need to take proactive action to address Ontario's aging health workforce, saw their worst-case scenario unfold when the additional strain of working in a health system ill-prepared for the impact of a global pandemic, saw a mass exodus of already exhausted healthcare workers opting for early retirement.

Using the age demographics of Registered Nurses (RN's) in Ontario as a sample population. the Registered Nurses Association of Ontario (RNAO) RN/NP Workforce Backgrounder (2019) reports that as of 2017, 40% of Ontario’s RN’s were aged 50+. By 2022 that cohort would theoretically have increased to 52.5% . This data predicting anticipated mass health sector retirements was readily available - but was largely ignored. The Ontario government had little interest in proactively addressing healthcare shortages, even in the pre-pandemic era.

In their report titled Long-Term Care Systemic Failings: Two Decades of Staffing and Funding Recommendations (June, 2020), the RNAO comprehensively highlights innumerous reports provided to the Ontario government by health policy researchers and advocates over the years highlighting the impending crises - a timeline which clearly outlines how Ontario’s healthcare workforce has been steadily eroded through chronic underfunding, understaffing, and decades of diminished capacity. Reports that unfortunately fell on deaf ears with catastrophic consequence. Rosa Saba of the Canadian Press reported that according to the most recent analysis of the labour force survey data by the Canadian Centre for Policy Alternatives (CCPA) in April of 2022, “retirements in health care in a year almost doubled, with 19,000 excess retirements compared with a year earlier” (The Canadian Press: Wave of retirement hits Canadian workforce as healthcare, education lose workers, September 30th 2022).

For many healthcare workers in Ontario and across the globe, COVID-19 added an additional layer of stress to an already taxing work environment. “While statistics regarding the rates at which HCW’s contracted COVID-19 compared to the general public provides proof of their vulnerability to infection, the numbers do not reveal the emotional toll or personal hardships that result from working a high risk setting”. (Brophy et al 2021). The stress and underlying emotional impact of treating patients during a pandemic, the effort-reward imbalance propagated through Bill 124, in addition to fear of contracting the virus, isolation from family and friends, and an overall sense of unpredictability and appropriately earned distrust towards the Ontario Government all continue to weigh heavily on Ontario's healthcare workers.

Applying the Health Equity Framework to evaluate the current occupational health crisis in Ontario's health workforce calls urgent attention to the need to dig deeper in order to address the complex and interrelated factors that have influenced health inequities for the health community. Specifically the grossly inadequate provincial response to the COVID-19 pandemic, compounded by years of systemic deprioritization, and the chronic exploitation of a female dominated "caring" profession. A deplorable affront that continues to this day, and has brought Ontario’s Healthcare Workforce to the verge of collapse.