Module 1: Pandemic Histories

Introduction

Those who fail to learn from history are doomed to repeat it. There are still some — a very few now — people alive today who remember the 1918 (Spanish) Influenza Epidemic: 500 million sick, 50 million dead. Of course, we didn’t have GIS systems and Johns Hopkins maps on the internet to track all this, so these are likely underestimates, and there was also a World War going on at the same time. What we experience with respect to COVID-19 is not that dissimilar from what happened then — a US president who refused to acknowledge the pandemic, anti-mask rallies, economies faltering, and families being torn apart by sickness and death. History also tells us that the 1918 flu was not necessarily the first pandemic that “took down” a society. Some historians believe that the fall of the Roman Empire was due to a widespread deadly disease (Wazer, 2020).

Learning Outcomes

Upon completing this module, you should be able to demonstrate an understanding of the role of history and the lessons learned that can help us contextualize the present and future of pandemics.

Module Activities

There is no lecture for Module 1. Students read Viboud & Lessler’s 2018 article on the 1918 influenza pandemic and Little’s 2020 piece on “mask slackers” and “deadly spit” campaigns to shame people into following public health rules during the Spanish flu.

Watch:

*'Be lazy, save lives,' young Germans urged in comic COVID video (Reuters, 2020)*

Listen: This Podcast Will Kill You: Episode 1 — Influenza Will Kill You (56:27)

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Module 2: Pandemic Epidemiologies

Introduction

Epidemiology is critical to the management of public health crises and drives many policy decisions. During COVID-19, epidemiology led to the implementation of public health measures such as social distancing and mask wearing. In this module, we go over key terms in epidemiology and discuss how epidemiology is used in the management of pandemics.

What is Epidemiology?

Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations and the application of this study to control health problems. Put simply, it is the study of the health of populations. Its various objectives help us answer questions like how a disease spreads in populations and why.

First, epidemiology aims to identify the etiology — the causes or determinants of disease. When we talk about distribution, epidemiology helps us determine the extent of disease found in a community through the exploration of the frequency of and patterns of disease: what is the frequency of disease, and how does it differ in different geographical locations?

By populations, epidemiologists could be talking about people living in a specific neighbourhood in Waterloo, a city or town, a province, country, or even the world. Epidemiologists apply their knowledge to develop preventative and therapeutic measures and to develop policy to address public health concerns. They study a whole range of diseases and outcomes: environmental exposures (such as air pollutants that contribute to asthma), infectious diseases, injuries, non-infectious diseases like cancer and cardiovascular disease, and the possible health impacts of natural disasters and climate change.

Determinants of Health

Epidemiologists study the determinants of disease — the causes and other factors that influence the occurrence of disease. They assume illness does not occur randomly in a population, but when certain risk factors or determinants exist. These determinants are strongly linked to the environments in which we live, work, and play.

The economic environment contributes to whether we have access to shelter, food, and water. The cultural environment encompasses factors such as gender, social norms, and accepted patterns of behavior. The political environment — who is in power in your country, province, or municipality — impacts your health through policy decisions. The physical environment, including access to green space, can improve wellbeing and encourage physical activity. Finally, access to healthcare — whether you live in an urban or rural setting — impacts your proximity to services such as specialists or family doctors.

These determinants help us understand why different groups experience different rates of disease. The social determinants of health can include income, education, employment status, early childhood development, food security, social exclusion, social capital, access to social support, and stress. In Canada, for example, there is a clear relationship between socioeconomic status and life expectancy — data from the Public Health Agency of Canada shows that both males and females living in the richest neighbourhoods have higher life expectancy than those in the poorest neighbourhoods.

Disease Transmission

Understanding disease transmission is important to determine what public health interventions can reduce spread. Infectious diseases can spread in a number of ways: through direct contact with others carrying a virus or airborne transmission (COVID-19, influenza); through indirect contact such as touching a contaminated surface before washing hands; through animal vectors (Lyme disease from blacklegged deer ticks); and through consumption of contaminated foods or beverages (E. coli from undercooked beef; cholera from contaminated water).

Key Epidemiological Terms

Mortality refers to death; the mortality rate is the number of deaths in a certain group over a certain time. Morbidity refers to the amount of illness within a population. Prevalence is the number of people with a disease at any one point in time or over a specified period — it includes all cases, both new and pre-existing. Incidence is the number of new cases of illness in a given time interval expressed as a proportion of people at risk. Incidence is different from prevalence because it includes only new cases.

Epidemiology and the COVID-19 Pandemic

In a globalized world with prominent air travel, people and the diseases they carry can be in any city on the planet within a few hours. Epidemiology is therefore an essential tool in our toolbox to fight public health crises.

In late December 2019, the WHO’s office in China picked up a media statement from the Wuhan Municipal Health Commission about viral pneumonia cases of unknown cause. By January 5th, the virus had infected 59 people; by January 20th, Chinese authorities reported more than 200 infections and three deaths. Even early in the pandemic, epidemiologists were modelling how case numbers might progress.

These studies helped estimate the reproductive rate (R₀), which describes the number of people an infected person will pass the virus onto on average if allowed to spread uncontrolled. If R₀ is greater than one, the number of infected people will likely increase exponentially; if less than one, the outbreak will likely reduce on its own. The first estimate for COVID-19 ranged from 2.0 to 3.1, similar to SARS 2003.

Epidemiology also helped us understand the incubation period — the time between infection and onset of symptoms — estimated by the WHO at five to six days on average, up to fourteen days. Even early on, it was evident that the risk to those over 60 was substantially higher than for younger age groups.

Non-Pharmaceutical Interventions

With no vaccines or medications in the early months, epidemiologists modelled the effectiveness of non-pharmaceutical interventions. A study published in Nature in November 2020 ranked the effectiveness of worldwide COVID-19 government interventions. The most agreed-upon effective interventions included: small gathering cancellations, closure of educational institutions, border restrictions, and increased availability of personal protective equipment. At the peak of US lockdowns in 2020, more than 83% of the population was under statewide stay-at-home orders, accompanied by long-term closures of schools, restaurants, and recreation areas.

Social Determinants and Disparities

The social determinants of health and geographical factors also contribute to how populations experience COVID-19. Major disparities emerged in access to testing, pandemic messaging, and virus exposure. The mortality rate was found to be higher in cities and towns with higher poverty, household crowding, and higher percentages of populations of colour.

The US Navajo Nation reported the highest per capita COVID-19 rate in the US — 2,304 cases per 100,000 people — compared with 1,806 in New York State and 605 in the US overall. The reservation’s unemployment rate is approximately 40%, and many live below the poverty line, with chronic conditions like diabetes and heart disease making individuals more vulnerable. Across 71,000 km², there are only 13 grocery stores, and medical facilities have a combined 200 hospital beds — a third of the national rate. A third of households have no access to running water or electricity, making it difficult for thousands of people to wash their hands regularly. In Memphis, data indicated that the most COVID-19 testing occurred in well-off suburbs rather than lower-income neighbourhoods.

Ongoing Questions

COVID-19 variants emerged in early 2021 due to virus mutations. Epidemiologists continue to investigate: how do these variants respond to interventions like social distancing? How do vaccines contribute to increased immunity? What are the longer-term public health impacts of stay-at-home orders on mental health, chronic disease, and cancer? And what are the lasting impacts for those directly infected by COVID-19?

Watch:

*How Pandemics Spread (TED-Ed, 2012)*

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Module 3: Pandemic Politics

Introduction

Politics refers to the activities associated with the governance of a country or area — especially the debate or conflict among individuals or parties having or hoping to achieve power. When one achieves power, one has the responsibility to take care of the people who put them there, whether a president, prime minister, premier, or mayor. When trouble hits — an earthquake, economic crisis, or global pandemic — politics is part of the equation.

Who Has the Power?

In most of the world, in democracies, people give power to those they elect — people who share the same belief systems, who will represent their interests. We’re interested in jobs, the economy, healthcare, education, equity, and the environment. You can tell a lot about a country by the people they vote into power.

When the COVID-19 pandemic hit, three vastly different leaders were in power: in the United States, a neo-conservative right-wing leader with no universal healthcare system; in Canada, a mid-range liberal government with universal healthcare; and in New Zealand, a very progressive, social democratic female leader. How did these countries differ in their response?

The World Health Organization

Politically, pandemic management starts with the World Health Organization (WHO), founded in 1948 — the United Nations agency that connects nations, partners, and people to promote health, keep the world safe, and serve the vulnerable. Working with 194 member states across 6 regions and 150 locations, the WHO mobilizes every part of society to advance health and security.

The WHO gets funding from two main sources: assessed contributions (membership dues proportional to each country’s GDP) and voluntary contributions. When US President Donald Trump withdrew US support from the WHO in early 2020, it was a significant blow to both the organization’s credibility and budget. The pandemic was declared by the WHO on March 11, 2020.

The United States

The USA is a federation of states. Power exists at the national level, but also significantly at the state level, and — uniquely compared to Canada — at the local level where mayors are members of political parties. At the national level, there was profound tension between the President and the Head Medical Officer, Donald Trump versus Tony Fauci: politics versus science. Masks became political tools.

The status of statewide face-covering laws mapped almost perfectly onto political party lines: states with Republican governors were more likely to have lifted mask requirements; Democratic governors more likely to maintain them. This politicization of a public health measure was unprecedented.

New York State was among the first in the US to experience overwhelming death tolls — refrigerated tractor trailers were brought into hospital parking lots to store the dead. New York became the first major US city to introduce COVID-19 vaccine passports and was also the first state to mandate vaccination for healthcare workers, generating legal battles over religious exemptions. Florida, by contrast, had its governor appeal rulings on masks in schools, threatening to fire those who insisted masks were required.

Canada

Canada often speaks of having a national healthcare system, but in reality has ten parallel provincial healthcare systems. Pandemic responses therefore varied dramatically across the country.

Atlantic Canada took it very seriously from the start, creating the “Atlantic Bubble” — a zone within which the four Atlantic provinces (Newfoundland, Nova Scotia, New Brunswick, and Prince Edward Island) could move freely, but from which no one could enter or leave from other parts of Canada. They had relatively good outcomes for a long time.

Quebec implemented curfews, requiring 12 million people to be home by a certain hour each night — a sweeping measure unmatched elsewhere in Canada. Alberta initially downplayed the pandemic, lifted restrictions early, and then suffered a new wave that prompted the Premier to publicly apologize. British Columbia had the “Bonnie Henry effect” — Medical Officer of Health Dr. Bonnie Henry’s mantra of “Be kind, be calm, be safe” became internationally famous; she appeared on the front page of the New York Times and became the inspiration for special merchandise including tea towels and shoes designed by John Fluevog.

Ontario was characterized by a “tango” — constant vacillation between opening and closing, gym access on and off, in-person learning announced and then cancelled. At the time of recording, vaccine mandates were beginning, first through the private sector, then through vaccine passports.

New Zealand

In New Zealand, power is concentrated at the national level. The response was total and absolute lockdown early on, with borders shut and intense contact tracing — easier to implement given New Zealand’s island geography. At time of recording, the country had only about 4,000 cases and 27 deaths out of a population of 5 million. When the Delta variant arrived, New Zealand went into lockdown again for 31 days.

Watch:

*Trump & the Coronavirus — Last Week Tonight with John Oliver (HBO, 2020)*

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Module 4: Pandemic Economics

Introduction

In 2015, Bill Gates predicted that a global pandemic would cost the economy 3 trillion dollars. What actually happened? The economic impacts of COVID-19 rippled through every level of society, from individuals and families to communities, states, and the global economy.

Individual Impacts

Three major things happened to individuals: many had to move their work home; many lost their jobs entirely; and many had to pivot — a keyword during the pandemic — to entirely new careers. Working from home went from 4% of the employed population to 30% during the pandemic. These were disproportionately higher-income workers — professors, lawyers, accountants, policy makers — who simply moved their work to basements and spare rooms.

According to Statistics Canada (April 2020 to June 2021), 45% of dual-earner salaried couples in the top 10% of the earnings distribution had both spouses working from home — nine times the rate of 5% observed in the bottom 10%. This is the core inequality: a minimum-wage bus driver, taxi driver, restaurant worker, or coffee shop employee simply cannot work from home.

Regional variations were significant. Of Ontario workers, 37% worked from home; in Quebec, 30%; in Atlantic provinces, only 17–23%. In Saskatchewan, 20%. The hollowing out of downtown Toronto’s financial district meant that all the ancillary economic services — restaurants, dry cleaners — that downtown workers depended on were devastated.

Age and Gender at the Individual Level

Workers aged 15 to 24 were at least half as likely to work from home than older workers: 16% of women aged 15–24 worked from home compared with 36% of women aged 45–54. The young woman at the grocery checkout counter was going out to work and facing exposure to the virus every day. Regardless of marital status and whether they had children, men worked from home to a lesser extent than women: 30% of married men with children worked from home, compared with 39% of their female counterparts. Overall, 27% of men worked from home versus 35% of women.

Unemployment

Ontario’s unemployment rate rose to 13% between April 2020 and April 2021. The labour force participation rate decreased significantly, bringing Canada’s participation rate to almost 60% as more than one million people dropped out of the labour force entirely. Of the roughly 400,000 Canadians who lost their jobs during the pandemic, one quarter completely changed their career path. A memorable local example: airplane pilots in Guelph, with no planes to fly, pivoted and became coffee roasters, founding Lost Aviator Coffee.

Families

Families were hard hit. With children being schooled at home and both parents working remotely, households needed enough space, enough computers, enough broadband, and enough time. As one study noted: “While women were already doing most of the world’s unpaid care work prior to the onset of COVID-19, emerging research suggests that the crisis has resulted in a dramatic increase in this burden.” Women who were at home caring for children while their partner also worked from home were providing the foundation of the care economy — cooking, raising children, managing schooling — without recognition.

Housing

Housing prices increased astronomically during the pandemic. People living in dense urban condominiums, now working from home with no backyard, started moving outward and buying up houses in surrounding areas. Stories of houses selling sight unseen, for twice the asking price, filled the press. In Hamilton-Burlington, a townhouse that was under $500,000 in January 2019 had climbed well over $600,000 by January 2021; two-storey houses approached $900,000 to a million dollars.

With rental accommodation becoming extremely scarce, homeless encampments proliferated in public parks across Toronto. The City noted that encampment sites had increased at a concerning rate since March 2020. The CDC guidance was stark: “If individual housing options are not available, allow people who are living unsheltered or in encampments to remain where they are. Clearing encampments can cause people to disperse throughout the community and break connections with service providers.” An estimated 1,000–2,000 people lived in encampments across Toronto, with an over-representation of Indigenous persons among them.

Government Supports and Global Impacts

At the state level, Canada created the Canadian Emergency Response Benefit (CERB) for those who lost jobs due to COVID-19, the Canadian Emergency Student Benefit for students who couldn’t work, and small business loans. The total amount spent by the Canadian government by August 2021 was approximately 350 billion dollars. The total cost to the Canadian economy: more than $1.5 billion per day.

At the global level, shortages of basic supplies like toilet paper and hand sanitizer were dramatic. Supply chain disruptions caused tariffs and boycotts. The US exerted power to limit Canada’s access to face masks. Early estimates predicted that most major economies would lose at least 2.9% of their GDP over 2020 — a number revised to 4.5%. With global GDP estimated at around $87.55 trillion USD in 2019, a 4.5% drop represents nearly $3.94 trillion USD of lost economic output.

Watch:

*Covid-19: What Will Happen to the Global Economy? (The Economist, 2020)**Covid-19: How to Fix the Economy (The Economist, 2020)*

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Module 5: Pandemic Geographies — the Statistics

Introduction

In the context of a pandemic, we are overwhelmed with data and maps that portray patterns of disease and how disease varies spatially. But how can we interpret this data, and why is it important? This module discusses the theories and quantitative methods that geographers use when designing research, collecting data, and displaying their findings — and how we can use these approaches to interpret pandemic data and inform policy making.

What is Research?

Research is the search for an answer to a question. To answer a question, we need first a research question that outlines what we want to study. We then need to think about the way the researcher views the world — what even counts as data or facts? Only experiments that collect numbers, or can data also be someone telling you about their feelings or experiences? Finally, we need methods — what you actually do to collect data — which must be consistent with your theoretical approach and research question.

Positivism and Quantitative Methods

Positivism is a theoretical approach used to study and detect areal patterns or to model the way in which health outcomes or disease incidence varies spatially. A positivist map from Public Health Ontario in early 2021, for example, showed COVID-19 case rates across the province — darker red areas indicating higher rates — 104.4 cases per 100,000 province-wide, with significant regional variation. This is useful for seeing how outcomes vary spatially, but people appear only as numbers. Place and the meanings associated with spatial locations become incidental.

Positivistic approaches often use quantitative or statistical methods to develop universal laws of human behaviour. In a pandemic context, researchers might model spatial patterns to predict future impacts. Positivist researchers often use a biomedical perspective: if you are exposed to a pathogen in your environment, you may experience a typical outcome. They also aim to draw samples — ideally random — from specific populations to develop generalizations.

What can we measure that might help determine risk to individuals or populations? Understanding prevalence, incidence, morbidity, and mortality rates related to specific illness; mapping how health outcomes vary spatially or over time; and tracking how rates impact different populations based on sociodemographics. These all fall within a positivist approach.

Quantitative data sources include: observations (COVID-19 case counts), secondary data (hospital data, the census), and surveys (self-reported illness or symptoms). An interactive map of Toronto’s cumulative COVID-19 cases by neighbourhood, for instance, allows users to see which neighbourhoods have been hit hardest, distinguish long-term care home cases from community cases, and track how inequities map onto the city’s geography.

Limitations of Quantitative Approaches

Criticisms of quantitative methods include that they can tell us what is happening but provide little context about why or how. They provide a snapshot in time rather than explaining how things change. Additional considerations: whether the sample size is large enough, what statistical tests to employ, and whether results are generalizable.

Early in the COVID-19 pandemic, in the absence of mass testing, we were relying only on hospital data. Without testing asymptomatic individuals or those with mild symptoms, numbers were almost certainly under-represented. In all likelihood, rates in Canada were much higher than we knew in the first few months of 2020. Quantitative data also does not capture human behaviours or the characteristics of individuals — the lived experiences and context are missing.

Data Transparency and the Case of Rebekah Jones

The collection, analysis, and dissemination of health data must be publicly available, transparent, and accessible to inform individual decision-making and help us understand who is most at risk.

In Ontario, Ryan Imgrund — a high school teacher and former biostatistician — updated a COVID-19 dashboard every day, colour-coding important variables and tracking the R₀ value across regions. Dr. Jennifer Kwan, a family physician, released daily case, death, and resolved-case counts with graphs tracking the pandemic’s waves over time.

Rebekah Jones was a geographer and data scientist who essentially single-handedly created and ran the Florida Department of Health’s COVID-19 dashboard — highly regarded by the scientific community and lauded by the White House Coronavirus Task Force for its transparency. After being fired in May 2020 for refusing to use unreliable data that would minimize the perception of the COVID-19 threat, she founded her own Florida COVID dashboard. The Florida Governor led personal attacks against her credibility, and in December 2020 police raided her home, seizing computer equipment as part of an investigation into an unauthorized message sent through the Department of Health emergency messaging system — a message urging recipients to “speak up before another 17,000 people are dead.”

Jones’ story is about data transparency and the public’s right to make informed decisions. Her dashboard was more comprehensive than the state’s official version, including higher case counts and hospitalizations for all individuals in Florida regardless of legal address — unlike the state’s dashboard, which excluded non-residents, potentially underestimating case counts significantly given Florida’s large winter tourist population.

The Power of Maps

The way we display data tells a story and influences how we interpret it. Cartograms — maps where countries are displayed proportional to their number of cases rather than land area — can dramatically shift our perception of the pandemic. A cartogram from March 7, 2020 versus January 1, 2021 shows how radically the global burden of COVID-19 shifted over those ten months.

Watch:

*Geographic Information Systems (GIS) — Dan Scollon at TEDxRedding (TED, 2013)*

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Module 6: Pandemic Geographies — the Stories

Introduction

Geographers use a variety of approaches and techniques to understand our world. In this module, we discuss the qualitative theories and methodologies applied by geographers and review how qualitative approaches can help us understand not just the what, but the how and the why — the meanings, stories, perspectives, and experiences of individuals and populations in the context of a global pandemic.

What Counts as Data?

While the previous module addressed positivist approaches using quantitative methods that collect numbers, data can also include subjective meanings, experiences, stories, and perspectives from individuals and populations. Such data addresses different kinds of research questions, using different methods.

Consider the richness of peer-reviewed work already published: Lived Experiences of COVID-19 Intensive Care Unit Survivors; Experiences of Home Healthcare Workers in New York City During the Pandemic; Spanish Influenza Remembered by Survivors. Each of these studies recognizes that numbers alone cannot capture the full human experience of illness.

Social Interactionism

Social interactionism is a theoretical approach focusing on individual experiences of health and illness in which meanings are constructed out of our interactions with others in day-to-day life. The major goal is to uncover and interpret meanings from an individual’s specific point of view. For a social interactionist, individual meaning, subjectivity, and how things are constructed socially count as evidence — not just numbers.

Social interactionists use qualitative data: words, pictures, photos, videos, audio recordings, conversations, and other documents. They conduct interviews, focus groups, or perform textual analysis, where the data include the lived experiences of research participants themselves. They use small sample sizes to emphasize deep understanding of meaning, rather than generalizing to a broader population.

In pandemic contexts, social interactionism can be useful in many ways: understanding the lived experiences of different populations in a pandemic; seeing how experiences vary in different geographical locations; exploring the factors that contribute to how people experience illness; or amplifying powerful stories to drive government action or policy change.

Structuralism

Structuralism focuses on the social, political, or economic factors that explain health outcomes. In this theory, explanations come not from the individual level but from the broader structures that influence our lives — capitalism and power, federal, provincial, or municipal policies, social structures related to gender, race, and ethnicity.

Structuration theory seeks a middle ground, recognizing the dualism of both structure and agency: these broader structures shape human social practices and actions, but in turn, these practices can create and recreate societal structures. When we study pandemics, it’s important to consider how embedded structures — gender, race, ethnicity — influence exposure to COVID-19 and shape social expectations at home and in the workplace.

A CBC News headline from the pandemic captures the structuralist dimension perfectly: “If you’re sick, stay home, is a non-starter for many Canadians.” For workers in jobs where paid sick leave doesn’t exist, the choice between potentially spreading the virus and being able to pay rent or buy groceries is untenable. One cannot simply tell someone earning minimum wage with no sick pay to stay home. The structures of employment can profoundly shape individual decisions and experiences of the pandemic.

Mixed Methods: An Example

A study from the University of Waterloo explored how the infodemic — the spread of misinformation during COVID-19 — impacted patients with lupus. The pandemic was especially concerning for people with lupus because at the start, no one knew if they were more vulnerable to severe outcomes, and they depend heavily on hydroxychloroquine, which was falsely reported (including by President Trump) to treat COVID-19. This led to panic buying, shortages, and profound stress for lupus patients.

In this study, patients from around the world completed an online survey between June 2020 and March 2021, reporting frequency of access to different health information sources, their preferred sources, their trust levels, and how they felt impacted by accessing health information through social and news media. Results showed that 9.1% of Canadian participants and 14.6% of international participants reported adverse impacts from news media; 8.2% and 11.1% respectively reported adverse impacts from social media.

Three themes emerged: (1) health information in news and social media impacts mental health — “I believe that health information in news media has increased my stress, anxiety, and depression. It is overwhelming and inconsistent”; (2) it impacts decisions to access healthcare — “Because of the craziness of corona and the news outlets, many of us were too scared to go to the doctors”; (3) people made health decisions based on online information — “People speak without knowing what they’re talking about and it can be harmful. Somebody told me to use a cream on my face for my lupus rash and I listened to them. My face is now scarred and infected.”

Storytelling as a Research Method

Storytelling as a research method is an effective way to engage decision-makers and drive change in government action. When you hear a story, it may resonate and help you understand someone’s lived experiences in a way that numbers alone cannot. Stories also keep a time capsule of a situation, ensuring we remember and learn from the lived experiences of those impacted.

A 95-year-old survivor of the 1918 pandemic, Elmer Kretzschmar (who was six years old at the time), recounted: “I am now 95 years old and I currently reside in San Antonio, Texas. In 1918, I was six years old and living in Strawberry Point, Iowa, with my parents and my seven year old brother, Clarence. My father, Otto Kretzschmar, owned a shoe store, and my mother, Minnie, was a homemaker. My father was also a violinist and one of my fondest memories is that of listening to him play during Christmas programs at the church. Later that year, I was home from school because I had an earache. My father was at home too, because he was sick with the flu. A registered nurse from Charles City, Iowa, came to live in our home to help care for my father. The nurse was with us for two weeks and then she left. My father died the next day.”

From the height of the third wave in Ontario in April 2021, frontline stories illustrated the human reality: one concerned citizen wrote, “A lack of socializing is destroying my child. Every day, online school gets more impossible for my family.” An essential worker who had been exposed to a COVID-positive colleague was told they did not need to quarantine: “It doesn’t make sense that the largest companies continue to put people’s lives at risk every day.” A nurse in a major hospital described how the ICU had expanded into three different areas of the hospital with staff drawn from every unit: “The other hospital units are facing terrible shortages of staff because of this. I’m scared to go to work that we won’t have the staff that we need.”

Watch:

*1918 Influenza Pandemic Survivor Interview: Mrs. Edna Boone, interviewed 2008 (Alabama Audiovisual Collection, 2021)*

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Module 7: Pandemic Debates

Introduction

Living through a global pandemic is not easy, and we as well as policymakers have had to make a lot of decisions and engage in debates: to lock down or not to lock down; to vaccinate or not vaccinate; to provide paid sick days or not; and so on. In this module, students engage in a range of debates related to the global pandemic.

This week is dedicated to a week-long debate. Student groups are assigned a debate topic and participate in a modified Oxford-style debate in an online forum.

Learning Outcomes

Upon completing this module, students should be able to: demonstrate skills in argument building; think critically about the advantages and disadvantages of different policy directions; and engage in and learn from a modified Oxford-style debate in an online format.

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Module 8: Pandemic Inequalities — Local

Introduction

The world is not fair — it is full of inequalities and inequities. “We’re all in the same boat” became a saying during the pandemic. But we are not all in the same boat. We may all be in the same storm, but some of us are in a yacht, some on a raft, some in a rowboat, and some are just clinging to a piece of wood. In this module, we focus on pandemic inequalities at the local level using two case examples.

Inequality vs. Equity

Before exploring the specific dimensions of local inequality, it is essential to understand the distinction between equality and equity. Equality means we all have the same box to stand on to watch the baseball game over the fence. Equity means we recognize that some people are unfairly disadvantaged and we give them more resources to bring them up to the same level, so we can all watch the baseball game together.

Poverty

The largest numbers of people who lost their jobs during the pandemic were those in low-wage, insecure positions, typically in the service sector — coffee shops, restaurants, dry cleaners, the industries that collapsed when people stopped going out. In the US (from Pew Research, May 2021), roughly four in ten adults said they or someone in their household lost a job or wages due to COVID-19 — that is 40% of the population. By race: 23% of white workers lost their jobs; 29% of Black workers; 34% of Hispanic workers. By age: the youngest groups were hardest hit. By education: those with the lowest levels of formal education fared worst.

In the US, where employment is often tied to health insurance coverage, losing your job means losing your healthcare. By June 2020, there were 18 million unemployed workers in the US, 16 million of whom lost their jobs due to the pandemic — 10% of the pre-pandemic workforce. Among these, about 8 million had lost their health coverage, and with dependents counted, 15 million people went from having healthcare coverage to having none.

An indicator of rising poverty was the dramatic increase in food bank use. In Ontario, about 540,000 people accessed food banks between April 2019 and March 2020 — already up 5% over the prior year. With the onset of COVID-19, food banks saw a 26% increase in first-time visitors between March and June 2020. One out of two food bank visitors reported being worried about eviction or defaulting on their mortgage in the next two to six months; 93% had borrowed money from friends and family, accessed payday loans (at very high interest rates), or used a credit card to pay for monthly necessities.

Evictions were another dimension. The Ontario Landlord and Tenant Board continued to hear eviction applications, but enforcement was postponed during the Provincial Declaration of Emergency. Ontario invested $510 million through the Social Services Relief Fund to protect the health and safety of vulnerable people during COVID-19.

Gender

The COVID pandemic unequally affected women over men. Women are most likely to be engaged in low-income service jobs — the sector that experienced the greatest losses. According to Statistics Canada, from March 2020 to February 2021, women accounted for 54% of year-over-year employment losses.

Women are disproportionately represented in the industries expected to decline the most. Women are also more likely to take on childcare responsibilities — so not only had many women lost their jobs, but with daycares and schools closed, they were simultaneously managing the care and homeschooling of their children.

One of the most serious public health issues revealed during the pandemic was the dramatic rise in domestic violence. Canada’s Assaulted Women’s Helpline fielded over 20,000 calls between October and December 2020 compared to 12,000 over the same period the previous year — a 67% increase. Data from 17 police forces across Canada showed that calls related to domestic disturbances rose by 12% between March and June 2020.

Race

Higher rates of COVID-19 cases and mortality among African Americans and other people of colour emerged starkly. Early speculation about genetic differences was quickly dispelled — this is an infectious disease; the differences were not genetic but reflected differences in access to the social determinants of health. African Americans and other people of colour were already disadvantaged with respect to education, employment, and income; the pandemic simply shone a spotlight on those pre-existing inequalities.

From April to December 2020, cumulative COVID-19 mortality rates per 100,000 by race and ethnicity showed that Black and Indigenous Americans experienced the highest death tolls. Overdose deaths also spiked dramatically after the start of the pandemic, driven by synthetic opioids like fentanyl — and the increase was substantially larger in the Black population than the white population, both in the number of overdoses and in deaths.

Water

Early in the pandemic, the consistent public health advice was: wash your hands, wear your mask. But how do you wash your hands if you don’t have water?

From 2013 to 2017, an estimated 1.1 million people in the United States had insecure access to piped water — with nearly half located in the 50 largest metropolitan areas. Unplumbed households in cities are more likely to be headed by people of colour, earning lower incomes, living in mobile homes, renting, and paying a higher share of gross income toward housing. In inner-city areas where poor households had their water turned off for failing to pay their water bills to privatized water companies, people could not wash their hands to stem the spread of the virus. When the pandemic hit, 90 US cities had to pass legislation to force privatized water companies to turn water back on.

Watch:

*Ontario's Opioid Crisis is Getting Worse — The Agenda with Steve Paikin (TVO, 2020)**How COVID-19 is Exacerbating Detroit's Poverty and Racial Inequality (PBS NewsHour, 2020)*

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Module 9: Pandemic Inequalities — Global

Introduction

The themes of inequality in Module 8 — poverty, gender, race, and water — apply not only locally but globally. The pandemic shone a spotlight on existing global inequities in a way that was undeniable. Are we all in the same boat? We are not. Some of us are in a yacht, some on a raft, some in a rowboat, some are clinging to a log floating down the river.

Poverty

Existing inequalities in wealth directly impede certain responses to a global pandemic. There are inequalities in access to personal protective equipment, inequalities in available healthcare (no doctors, hospitals, medications, or oxygen), and profound inequalities in access to vaccines — labelled during this period as “vaccine apartheid.”

A vivid illustration: in Uganda, a healthcare centre for seniors operates in a town about one to two hours from Kampala. Many of the patients are women who have spent their lives cooking over open fires, developing chronic obstructive pulmonary disease — their lungs already compromised before COVID-19 arrived. The healthcare facility has two oxygen tanks. When one is empty, a driver takes it to Kampala to be refilled — a 12-hour round trip. While one tank is being refilled, they use the other.

In many countries, large proportions of the population work in the informal economy — as domestic workers, market sellers, or drivers. Statewide lockdowns are extremely difficult in these circumstances. When there is a lockdown and they cannot go to work, they cannot make money, cannot eat. In some cases, this means lockdowns are broken, which has direct implications for the spread of the virus.

Gender — Global Dimensions

The United Nations Foundation documented a “shadow pandemic” — how the COVID-19 crisis exacerbated gender inequality globally. Women, approximately 70%, are employed in the informal sector: looking after someone else’s children, cleaning someone else’s house, cooking someone else’s food. They are the first to go when lockdowns occur, because they are unable to make money but still must feed their families.

Increased stresses from economic deprivation result in increased domestic violence. The pandemic also saw increasing numbers of young girls being sold into early marriage. Some girls were hiding their menstruation from their parents, knowing that once parents knew they were menstruating, they might be sold into marriage for money to feed the family.

Women’s unique healthcare needs also went unmet due to the ravages of the pandemic — with tremendous increases in maternal mortality and decreases in prenatal and antenatal care. The number of children being vaccinated for diseases like polio and measles also decreased, threatening to reverse decades of public health progress.

Race — Global Patterns

In Brazil, Afro-descendants were 40% more likely to die of COVID-19 than white people. In the United States, 22,000 Black and Hispanic people would still be alive today if they had experienced the same COVID-19 mortality rates as their white counterparts. Statistics Canada data showed that COVID-19 mortality rates in Canada’s ethno-cultural neighbourhoods are much higher — where there are higher proportions of new Canadians immigrating from other countries, already disadvantaged in many other ways, the death rates from COVID-19 are dramatically elevated.

The UK’s Office for National Statistics stated: “People from a Black ethnic background are at a greater risk of death involving COVID-19 than all other ethnic groups. The risk for Black males has been more than three times higher than white males and nearly two and a half times higher for Black females than white.” Even adjusting for socioeconomic factors partly explains the increased risk, a twice-as-high risk for Black males and around one-and-a-half times for Black females remains.

Water — Global

In Sub-Saharan Africa, 58% of healthcare facilities did not have access to safe water or adequate sanitation before the pandemic. How do you take care of people in a healthcare setting — how do you wash your hands to stem the spread of a virus — when there is no water?

As Nobel prize-winning economist Joseph Stiglitz observed: “While the pandemic has revealed the enormous cleavages across the countries of the world, the pandemic itself is likely to increase disparities.” The concern is that all the gains made in reductions of child poverty, malnutrition, and infectious diseases like malaria, measles, and polio will be lost. As the UN Secretary General stated: nobody is safe until we are all safe.

Watch:

*The Global Threat of COVID-19 Vaccine Inequality (CBC News: The National, 2021)*

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Module 10: Gendered Pandemics

Introduction

Although pandemics impact all people, each segment of society is affected differently. In this module, we explore the gender dimension of pandemics and discuss why it is important to consider a “gender lens” when studying and developing policies for pandemic management.

Key Terms

Definitions in this module are borrowed from the World Health Organization. As a binary concept, sex refers to the biological characteristics that define humans as female or male — though these sets of characteristics are not mutually exclusive, as there are individuals who possess both. Gender refers to the socially constructed characteristics of women and men — the norms, roles, and relationships of and between groups of women and men — which vary from society to society and can change over time.

As a non-binary concept, gender identity is each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth. Gender identity exists on a spectrum. When an individual’s gender identity differs from their sex at birth, they are commonly considered transgender or gender fluid. When gender identity aligns with sex at birth, they are commonly considered cisgender.

A gender lens means putting on a pair of glasses where one lens shows the participation, needs, and realities of women, and the other shows those of men — while recognizing this should be applied as a non-binary concept across the full spectrum of needs.

Gender mainstreaming is the globally accepted strategy for promoting gender equality — equal chances and opportunities for women and men to access and control social, economic, and political resources. Mainstreaming ensures that all gender perspectives are considered in policymaking, research, advocacy, legislation, resource allocation, and program monitoring.

Intersectionality refers to the way people’s social identities can overlap, creating compounding experiences of discrimination. We tend to talk about gender, race, sexuality, class, or immigrant status separately, but for some people the experience is not just the sum of its parts.

Gender and Health

The social construction of gender — the norms, behaviours, and roles associated with being a certain gender — varies from society to society and can change over time. Geography is key: where you live and the way gender is constructed in that place affects your susceptibility to different health conditions and your enjoyment of good mental and physical health.

Women and girls often face greater barriers than men and boys in accessing health information and services, including restrictions on mobility, lack of access to decision-making power, lower literacy rates, discriminatory attitudes of healthcare providers, and a lack of training on the specific health needs of women and girls. These barriers contribute to greater risk of unintended pregnancies, STIs including HIV, cervical cancer, malnutrition, and elder abuse.

Harmful gender norms related to rigid notions of masculinity can also affect men’s health negatively, encouraging smoking, sexual and health risk-taking, alcohol misuse, and failing to seek healthcare. Such gender norms contribute to men perpetrating violence, as well as being subjected to it themselves.

COVID-19 Through a Gender Lens

Across every sphere — health, economy, security, social protection — the impacts of COVID-19 are exacerbated for women and girls. Women and girls are generally earning less, saving less, and holding insecure jobs or living close to poverty. While more men are dying from COVID-19 directly, the health of women is adversely impacted through the reallocation of resources including sexual and reproductive health services.

Unpaid care work increased dramatically with children out of school, heightened care needs of older persons, and overwhelmed health services. Women spend three times as many hours as men in unpaid care and domestic work, limiting their access to high-quality paid work. The gender pay gap remains stuck at 16% globally, with women paid up to 35% less than men in some countries. Only 65% of women globally have a bank account, compared to 72% of men. These facts link directly to the economic vulnerability of women during COVID.

In the US, one in four working women — 15.5 million individuals — has a child under the age of 14 at home. More than 10 million working women (17%) rely on childcare and schools. School closures disproportionately harmed working mothers, especially low- and middle-income mothers and mothers of colour.

Gender-based violence increased exponentially during the pandemic. Many women were forced to lock down at home with their abusers at the same time that support services were disrupted or made inaccessible.

Women in the Health Workforce

Globally, women make up 70% of the health workforce, rising to 90% with social care workers included. They are more likely to be frontline health workers — nurses, midwives, community health workers — and the majority of health facility service staff: cleaners, laundry, and catering employees. As a result, they are more likely to be exposed to the virus. In Spain and Italy during the first wave: 72% of healthcare workers infected in Spain and 66% in Italy were female. In the USA, Italy, and Spain, 70% of COVID-19 infections in healthcare workers were in women — partly because women and Black women in particular have less access to personal protective equipment and training on how to use it properly.

Policy Recommendations

Gender-neutral policymaking inherently neglects the needs of women and other vulnerable groups. The UN emphasizes three cross-cutting priorities for pandemic policy:

1. Ensure women’s equal representation in all COVID-19 response planning and decision-making. Policies that do not consult women or include them in decision-making are simply less effective.

2. Drive transformative change by addressing the care economy, both paid and unpaid. Formal economy care jobs — teachers, nurses — are often underpaid relative to other sectors. In the home, women perform the bulk of care work unpaid and invisible.

3. Target women and girls in all efforts to address the socioeconomic impact of COVID-19, applying an international gender lens to the design of social assistance programs.

One concrete example: a national health research funder implemented gender policy changes that extended deadlines and factored sex and gender into COVID-19 grant requirements. Following these changes, the funder received more applications from female scientists, awarded a greater proportion of grants to females, and received more grant applications that considered gender and sex in COVID-19 research content.

Watch:

*Sustainable Gender Equality — A Film About Gender Mainstreaming in Practice (SKR Jämställdhet, 2014)**Is Coronavirus Widening the Gender Gap and Disadvantaging Women? (BBC Newsnight, 2020)*

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Module 11: Pandemic Responses

Introduction

On March 11, 2020, the World Health Organization declared a global pandemic related to COVID-19. How did the world respond? How did we respond as individuals, as families, as institutions, as governments? This module reviews as much of that response as possible and asks: Will this pandemic ever end? And what will the next one look like?

The Early Days

For the professor recording these lectures, it all started at a meeting of global health researchers in a hotel in downtown Toronto when the WHO declared the pandemic. These were people who dealt with global health issues all the time — Ebola, malaria, neglected tropical diseases. They were like kids in a candy store: “Wow, this is a really interesting research issue.” None of them realized what the impact would be.

University of Waterloo announced a two-week closure on March 20, 2020. “You will go home today and won’t come back for two weeks.” Everyone thought it would all be over in two weeks. The science kept changing. In summer 2020, there was intense debate about mask wearing — early guidance said masks might not help, then shifted to mandatory mask-wearing. The surface transmission scare had people leaving groceries in their garage for 24 hours to let the virus die. There was a run on toilet paper that, in retrospect, seemed puzzling.

The Vaccine

Then the vaccine came. Scientists and governments made herculean efforts to develop a COVID-19 vaccine in approximately one year. Importantly, they were not starting from scratch — SARS vaccines, also a type of coronavirus vaccine, had been under development since around 2000. The first vaccine was administered on December 8, 2020, in the UK, beginning with seniors and working down by age group.

By time of writing, 74% of Canadians had one dose, 68% were fully vaccinated, and 78% of those 12 years and older were fully vaccinated. Vaccines for children aged 5–11 were approved just weeks before this lecture was recorded.

Herd Immunity

Two words explain why vaccines are critical: herd immunity. When enough people are vaccinated, the infectious disease cannot survive. In Canada, that means 90% of the population vaccinated. However, there are global inequities: as of September 2021, only 3% of the population of sub-Saharan Africa was fully vaccinated while Canadians and Americans were receiving booster shots. This represents a profound moral dilemma.

Vaccine Hesitancy

Vaccine hesitancy was a significant challenge and had historical precedents. In the mid-1950s, Elvis Presley was vaccinated against polio on live television on the Ed Sullivan Show in 1958, demonstrating to young people that vaccines were safe. During COVID-19, Dolly Parton — who donated $1 million to COVID-19 vaccine development funds — receiving her vaccine publicly encouraged many people to get vaccinated. In Alberta, the government offered $100 cash to those who showed up to get vaccinated. In parts of the US, incentives included free tuition, free concert tickets, and free Budweiser beer.

Key terms for this module:

• Pandemic: an epidemic that has spread over multiple countries or continents, usually affecting a large number of people
• Endemic: a disease that is regularly found within a particular geographic area or population group
• Herd immunity: when enough of a community becomes immune to a disease (through vaccination or prior infection) to make its spread from person to person unlikely

Looking Forward

At the time of recording, a new variant — Omicron — had emerged (described by the professor as “sounding a bit like a super villain from a Marvel comic”). Scientists indicated it was highly transmissible but potentially less severe, and that booster shots would provide protection. The professor was uncertain whether they would be able to have Christmas dinner indoors with family. “What’s going to happen? I don’t know.”

Watch:

*The Next Outbreak? We're Not Ready — Bill Gates TED Talk (TED, 2015)*

Additional Resources:

• Risk Of Surface Transmission Of Coronavirus Is Low, CDC Now Says (Today, 2020)
• Dr. Fauci Explains Why Mask Guidance Changed (NBC News NOW, 2020)
• Covid: When Might We Achieve Herd Immunity? (BBC, 2021)
• Vaccine Hesitancy: A Threat to Global Health? (DW News, 2021)

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Module 12: Pandemics and Environmental Change

Introduction

The COVID-19 pandemic has raised important questions about the interactions between humans, the environment, climate, and health. This module explores how humans interact with the physical and natural environment, the impacts of COVID-19 on environmental change, and the lessons learned from this pandemic that can be applied to tackle other environmental and health challenges — particularly climate change.

Environmental Change and Human Health

Human actions are changing many of the world’s natural environmental systems. Environmental change includes deforestation, urbanization, and land degradation due to human agricultural processes, causing ecosystem changes and habitat loss. Climate change and ozone depletion also broadly affect how humans interact with other species.

According to the WHO, air pollution kills 7 million people worldwide every year. Research from Harvard indicates that people living in areas with poor air quality were more likely to die from COVID-19, even accounting for preexisting conditions, socioeconomic status, and healthcare access — consistent with research showing that exposure to air pollution and smoking increase vulnerability to respiratory infections.

Climate Change and Health

Climate change is defined by the Intergovernmental Panel on Climate Change (IPCC) — established by the World Meteorological Organization and the United Nations Environment Program in 1988 — as “a change in the state of the climate that can be identified by changes in the mean and/or variability of its properties, and that persists for an extended period, typically decades or longer.” Changes may be due to natural processes or persistent anthropogenic changes in atmospheric composition or land use.

The health impacts of climate change include:

• Temperature-related death and disease: increased average and extreme temperatures affect the body’s ability to regulate temperature; increased mortality and morbidity especially among those with preexisting conditions or without adequate shelter
• Air quality impacts: changes in climate affect indoor and outdoor air quality, increasing ground-level ozone and particulate matter, altering production of airborne allergens like ragweed, disproportionately impacting those with preexisting conditions and those in urban areas with high vehicle traffic
• Extreme weather events: increased frequency, intensity, or duration of flooding, droughts, and severe storms can damage property and infrastructure, exacerbate poor social and economic conditions, and impact water supply and sanitation — with mental health impacts across affected populations
• Water and sanitation: climate change can lead to loss or contamination of potable water, water scarcity, drought, crop failure, malnutrition, and resource conflict; diarrheal disease — the second leading cause of death in children under five — is exacerbated
• Food and nutrition: food security is anticipated to be impacted as physical and climatic factors link to spoilage and disruption of food access; higher CO₂ concentrations can lower the nutritional value of certain crops
• Mental health and wellbeing: from increased stress and anxiety to clinically diagnosed disorders, certain populations are at higher risk — children, elderly, homeless populations, and communities reliant on the natural environment
• Population and migration: rising sea levels could contribute to population movement and conflict for resources
• Vector-borne diseases: climatic factors influence the seasonality, distribution, and prevalence of vector-borne diseases such as malaria, West Nile Virus, and Lyme disease

Vulnerability is not distributed equally. Vulnerable groups vary by age (children and elderly are particularly vulnerable), socioeconomic status, gender, and health status. Climate change threatens to widen existing gender-based health disparities; women and girls are at higher risk of domestic violence in the aftermath of natural disasters, particularly those with low socioeconomic status.

COVID-19 and the Environment

The emergence and spread of SARS-CoV-2 appear related to a changing physical environment. Both the emergence and spread of COVID-19 are related to environmental factors: urbanization, habitat destruction, the live animal trade, and intensification of livestock farming all affect the nature of how humans and animals interact, increasing risk of zoonotic pathogen transmission.

Animal species host unique viruses adapted to infect specific species. Over time, some jump to humans — zoonotic diseases. More frequent contact with animals we don’t normally interact with creates more opportunities for viruses to jump to humans. Viruses that were not well suited to a new species can evolve in that host and produce variants that spread more easily, and because they are new, humans lack immunity. The zoonotic nature of COVID-19 was demonstrated early; initial reports of infection were linked to a live animal market in Wuhan, China. A bat coronavirus in China suggested a high probability of a bat origin for SARS-CoV-2.

Transmission pathways from animals to humans include: direct contact (through saliva, blood, mucus, or other bodily fluids; bites and scratches); indirect contact (spending time where animals live, touching contaminated surfaces in coops, barns, or on plants); vector-borne transmission (through ticks, mosquitoes, or fleas); through food (undercooked meat, eggs, or raw produce contaminated with feces); and through water.

Ecosystem changes — deforestation, road building, and urban expansion — impact human-wildlife interactions and increase risk of zoonotic disease transmission. Deforestation in particular diminishes biodiversity; while some species go extinct, those that survive and thrive (rats, bats) may be more likely to host pathogens that can jump to humans. Reducing the risk of future pandemics could therefore be linked to controlling deforestation and curbing the wildlife trade.

Environmental Impacts of the Pandemic

The pandemic’s lockdowns also had direct impacts on the environment. A study from the United Arab Emirates found that during the 2020 lockdown, average nitrogen dioxide levels and surface urban heat island intensity declined by 23.7% and 19.2% respectively, due to reduced automobile use and industrial emissions.

Plastics represent another concern: PPE such as masks and gloves generated massive increases in single-use plastic consumption, likely aggravating existing projections of a twofold increase in plastic debris by 2030. Shifting toward sustainable alternatives such as bio-based plastics is increasingly urgent.

Lessons from COVID-19 for Climate Change

What can we learn from COVID-19 to apply to climate change? Most importantly, there are huge parallels related to the spread of misinformation and disinformation.

• Misinformation: information spread online that is incorrect but not spread maliciously — circulated by people who don’t know it’s incorrect
• Disinformation: the intentional spread of false information, sometimes for political reasons

This type of spread is also common in the context of climate change, where some parties wish to distort public perception of the threat. Early in the pandemic, Anthony Fauci’s initial statement that masks would not be helpful — then later reversed — caused many to lose trust in credible information sources, which those spreading disinformation used to fuel conspiracy theories.

Facebook’s fact-checking system missed 90% of COVID-19 disinformation in June 2020 (including claims about miracle cures). We cannot only rely on technology to extinguish disinformation.

As journalist David Remnick has written: there is no vaccine for climate change. While COVID-19 has a singular solution in the form of vaccination, addressing climate change will require true global collaboration, political imagination, and innovative initiatives. Future research will require integrative approaches across disciplines involving a whole range of global stakeholders. Applying lessons from COVID-19 about countering misinformation and disinformation will be critical as we move forward.