Rethinking the Social State: The COVID-19 humanitarian crisis

Article by PhiLab’s Quebec Hub on how the COVID-19 crisis is leading us to question Quebec’s welfare state.

As was the case with the H7N9 flu (2013) and Ebola virus (2014), COVID-19 has presented us with enormous challenges regarding public health, humanitarian emergency management and response transparency and speed. In fighting against the coronavirus, monumental economic plans were deployed. Incredible amounts were mobilized:  US$ 2 000 billion in the United States^[1] along with an announced additional US$ 500 billion^[2], US$ 1200 billion in Germany^[3], US$ 1000 billion in Japan^[4], US$ 256 billion in India^[5], US$ 108 billion in France^[6] and US$ 107 billion in Canada^[7].

Notwithstanding the impressive mobilization of financial resources, we are also witness to the weaknesses of states said to be ‘strong’^[8]. In fact, the crisis has revealed marginalized zones, abandoned by development, where inequalities have historically accumulated and are being reinforced under the present conditions. These zones have been particularly affected by the current health and socioeconomic crisis. Be it the Bronx, Queens or Brooklyn in New York, where the majority of its inhabitants are from Hispanic, Afro-American or immigrant communities; Seine-Saint-Denis (93) in France^[9] or even Montreal-North in Quebec where there is a significant concentration of elderly people, single-parent families, immigrants and low-income households.

Despite efforts made to fight against the pandemic in the North, these were insufficient and revealed markers of a humanitarian crisis generally found in countries of the South. These markers take on many forms: from the intervention of Doctors without Borders in the United Kingdom and Germany, or even, the deployment of healthcare resources from the Red Cross and Canadian Armed Forces in Quebec.

When the number of frontline professionals became insufficient to face the situation and were exhausted^[10], the Canadian Red Cross lent a hand by installing a field hospital in one of Montreal’s boroughs. Both Canada and Quebec were faced with a paradox: having the capacity to make tough political decisions likely to exacerbate existing structural inequalities by shutting down the economy and confining the population, and watching as the markers of a humanitarian crisis arose, requiring the mobilization of actors less recognized by the State, such as many civil society organizations, and resources usually dedicated to international aid. How do we address such an unusual situation for Canada and Quebec, one in which structural inequalities, unrecognized expertise and humanitarian needs collide?

This article will cover the three aspects of the health crisis that reveal the significant flaws of Quebec’s welfare state and signal the presence of a humanitarian crisis within its borders. The two first sections focus on the implementation of extraordinary measures following the healthcare system’s difficulty in curbing the spread of the virus. The third section takes Montreal-North as a case study to illustrate the State’s failure in reversing social inequality structures that have accumulated within the same territory. These structures help explain why some portions of the population find themselves more at risk during the pandemic.

A temporary Red Cross hospital in Quebec: Indicator of the Quebec healthcare system’s fragility

The COVID-19 epidemic has unveiled the weaknesses of both Quebec’s healthcare system and social services. Even with its many hospitals, competent healthcare professionals, emergency services (911), a helpline (211) and a free and confidential helpline (811), we are witness to the many gaps in  the public health system. The curve representing the cumulative evolution of the number of deaths continues to rise, and is higher in Quebec than elsewhere in Canada^[11]. This significant difference is marked by a recent explosion of cases in residential and long-term care centres (CHSLD)^[12]. We find ourselves in a situation where those living in long-term care homes represent 80% of COVID-19 victims. To help face this situation, the Canadian Red Cross was requested to set up a field hospital in the Jacques-Lemaire arena in Lasalle, Montreal. A dozen tents of four beds^[13] were installed to respond to the needs of the long-term care facilities of the area. The personnel deployed stemmed from the CIUSSS de l’Ouest-de-l’Île-de-Montréal, but also from a bank of volunteers of the “Je contribue”^[14] and ”La force du nous^[15]” programs. These volunteers were trained by the Red Cross^[16].

What makes the Red Cross’ mobilization so special?

When disaster strikes, the International Red Cross and Red Crescent (IFRC) intervene at the concerned State’s request by rapidly deploying its Emergency Response Teams^[17] (ERT). These ERTs are part of the IFRC global intervention system. They are used when global assistance is necessary and the National Red Cross cannot intervene alone. Thanks to the support of the Canadian government, the Canadian Red Cross counts on two “medical” ERTs, ready to be deployed anywhere at any time: a mobile emergency clinic and an emergency hospital. An ERT mission can last up to four months, during which the Canadian Red Cross’ personnel works in tight collaboration with the healthcare personnel in place and local Red Cross volunteers^[18]. It is important to note that it is the only mechanism through which a field hospital can be set up throughout the American continent^[19]. Despite its rarity, the Canadian Red Cross ERT hospital, notably deployed in Haiti following the 2010 earthquake^[20], in Nepal following the 2015 earthquake^[21], in Mozambique following cyclone Idai in 2019^[22], was now deployed in Quebec for the first time since its inception^[23]. Why in Quebec and not elsewhere in the world, where healthcare systems are less developed or almost nonexistent?

Privilege: the power to keep humanitarian resources on home soil

The Coronavirus continues its global spread, sparing no one, not even those already going through prolonged humanitarian crises. The latter face a double penalty: Coronavirus and armed conflict or even Coronavirus and chronic political instability. Large humanitarian aid organizations^[24] deplore the catastrophic implications of its spread for states said to be fragile, who are not prepared to face a pandemic due to insufficient local healthcare infrastructure.

The deployment of the Red Cross ERT in Quebec draws our attention for two reasons. For one, the dichotomy of strong versus fragile states seems to be blurred during this global pandemic. Second, it becomes difficult to maintain ones attention directed towards others when in danger ourselves. Canada, with its privileged developed healthcare system and an ERT on its soil, is more likely to use it first for itself, despite the many actions launched^[25] to assist States considered as more fragile.

The Canadian Army deployed in Quebec’s CHSLDs

Given the significant number of deaths in long-term care homes and a lack of caregiving personnel, Prime Minister François Legault made a call for volunteers to support caregiving personnel. On April 22nd, confronted with a worsening situation, the Quebec government asked the Federal government to deploy Canadian Armed Forces (CAF) personnel in CHSLDs. After an initial hesitation from Canada’s Prime Minister, 1020 members of the FAC were finally deployed in Quebec under Operation Laser^[26]. This operation was spread over twenty CHSLDs, concentrated in the Greater Montreal area^[27]. This military contingent included 670 soldiers with medical training, the others received a quick training by the Red Cross’ personnel^[28] to support logistics: serving meals, cleaning buildings, distributing moist towels, etc. Another contingent of 350 soldiers should arrive within a few days, as of the time of writing of this article. In addition, 200 rangers were sent in support of communities in the North of the province.

What makes this deployment of the Canadian Army special?

First off, it is exceptional to see the army supporting Canadian public authorities around public health issues. They are usually mobilized during natural disasters, and mainly abroad. For example, they intervened in 2014 during the Ebola virus outbreak in Western Africa. In addition to significant financial aid to the United Nations Mission for Ebola Emergency Response (UNMEER)^[29], the Canadian government also deployed Operation SIRONA^[30], aimed at administering “medical treatment to local and international healthcare workers admitted as patients at UK’s Kerry Town Treatment Unit in Sierra Leone”^[31].

The fact that the CAF were mobilized for health reasons on Canadian soil not only reveals the gravity of the situation, but also that the virus had overwhelmed the measures put in place by local authorities. Theoretically, in Canada, the healthcare system and social services should have a level of efficiency and efficacy that should protect against the need to use soldiers to take care of the elderly.

What lessons can we draw from this situation?

Following the deployment of members of the Canadian army in long-term care centers, it makes sense to reconsider Prime Minister Justin Trudeau’s hesitations. The CAF are not trained for this kind of operation. While we must collectively reflect on how we got to this point, it is also relevant to examine the soldiers’ intervention and draw lessons on the actual capacity of soldiers to properly protect the population within local humanitarian missions.

Let us explain. We must remember that if the army is this maladapted to help civilians administer treatments, it is in part due to a series of political decisions made by the Harper government, who was in favor of a more “warrior” vision of the CAF. As a special edition of Nouveau Projet published in 2014 points out, Canada’s foreign strategic approach is increasingly replacing “soft power” by “power”^[32]. This shift was felt in the restructuring of the CAF. This being said, while the purchase of sophisticated military materials now represents an important portion of the army’s budget (fighter jets and warships for example), its medical division has suffered cutbacks and its members have found themselves integrated into civilian hospitals^[33]. Ironically, we are now facing the consequences of this political decision, one that distances Canada from the fundamentally humanitarian role given to the CAF. The current situation might allow for a revision of the Canadian military strategy towards one more focused on keeping the peace and taking care of civilians.

Montreal-North: Most affected borough

In a recent study, Pierre Tircheret and Nicolas Zorn^[34] (2020), of the Observatoire québécois des inégalités, summarize the effects of the current health and socioeconomic crisis on the most vulnerable social groups^[35]. According to their analysis, based on surveys recently conducted in China and the United-States on those most affected by the pandemic, “women, the elderly or those living in poverty, certain ethnocultural groups such as Asian communities, remote Indigenous communities, as well as those living with respiratory or chronic illness and immunodeficiencies” are the groups most at risk of being affected, of going through health or socioeconomic complications or, unfortunately, of dying (p.1). Social determinants of health^[36], in other words, the factors that influence a person’s health – such as their level of education^[37] – tend to lead to concentrations of people sharing similar characteristics on micro-territories.

Source : Tircheret et Zorn (2020, p. 3)

Since the current crisis negatively affects certain groups of people more than others, and that these groups are unevenly concentrated in urban areas, Montreal’s neighborhoods, for example, are affected differently, and do not have the same capacities or resources required to face them.

In Montreal, the East-end^[38] has a higher concentration of individuals belonging to the social groups most affected by the pandemic. Other than the “remote indigenous communities” category, the other five categories are represented in greater numbers than elsewhere in Montreal^[39]. As an indicator, a recent study by Ghaffari, Klein and Fontan (2018), on the sociodemographic and socioeconomic characteristics of the Montreal-North borough, demonstrates how this borough has more elderly people (3 percentage points (%pts)), women (3%pts), single-parent families and young children (10%pts), immigrants (7%pts), including a high number of visible minorities^[40], and people living in poverty: there is a 20 000$ difference between the borough’s average income and that of the City. Finally, Montreal’s East-end population has more health problems than the West-end (as an indicator, 2%pts more for obstructive pulmonary disease)^[41]. By adding up these differences, the life expectancy of certain social groups in some of the East-end’s boroughs is “up to nine years less than those living in the West-end”^[42].

During a pandemic, keeping one’s job could be considered as a mitigating factor, on the condition that the job’s activities are safe. This is the case for the many workers working from home. However, it is not the case for every job. The personnel of healthcare or social service institutions in charge of administering treatments are more at risk of contracting the virus and spreading it through community contagion. The majority of health workers are recent immigrants, including Haitian asylum seekers^[43]. This is a situation present in many of Montreal’s boroughs, including Montreal-North, where a significant number of workers are at work in CHSLDs, now considered outbreak zones, where the virus has a significant stronghold.

Conclusion: the COVID-19 pandemic and the need to reinvest and rethink the Welfare State

When analysing vulnerability, a reflex might be to think that a strong state must be more resilient. In fact, the level of resilience within all state space is inconsistent. For example, there are varying levels of resiliency within the same territory (Alalouf-Hall & Fontan, 2020). Some regions, some cities, some boroughs and some activities recover faster than others. We regularly witness this phenomenon after natural disasters. In the COVID-19 context, territorial resilience is just as relevant. Areas with less socio-territorial capital are highly disadvantaged by the crisis and the eventual recovery process. We are thus witness to a territorial disadvantage, adding to the existing disadvantages, which led to the deployment of a humanitarian response (massive testing, support of the Red Cross and international delegates, the army’s intervention, all with the aim of protecting the population.) Thus, for Canada, the increase of social inequalities leads to territorial inequalities that can be observed at the provincial level for starters, and later at the municipal level.

The cross-border COVID-19 crisis leads us to question the actual resilience capacity of countries said to be strong. By exploiting various analytical angles, this article attempts to highlight the fact that the state apparatus has proven itself to be deficient in several ways when faced with the present crisis.

Interestingly enough, this is nothing new. Talk of a society running at two speeds and using some of its characteristics to illustrate the effects of the pandemic^[44] might be useful to mention, but is not a revelation in itself. What is interesting about the current crisis can be found at another level: it reveals an increased awareness about the importance and value of certain forms of work, such as the caregiving that is required for the elderly in long-term care. The crisis also forces us to reevaluate the borders between work that is highly valued and over-recognized and work that is under-valued and unrecognized. The crisis demands a reattribution of value to work that is deemed as essential to the wellbeing and functioning of our society. In this sense, we were reminded of the importance of food sovereignty, local economies and the centrality of being sovereign regarding the production of essential medical equipment. The pandemic is shifting our focus away from globalization, and more toward the importance of the slow movement^[45], of everything local, and of relational proximity.

Finally, this crisis can not be contained by any one actor, unlike the stock market crash of 2008, where the state appeared as the great saviour of a failing financial market. In the current case, the centrality of the state is evidently pushed to the forefront, but so are its weaknesses and the need to mobilize all sectors, including philanthropic organizations. At the heart of proximity work, we find a diversity of community organizations and volunteers who offer services to the homeless, who distribute food baskets^[46], who offer services to those suffering from mental illness and who keep shelters open for abused women… At the heart of the storm, grantmaking foundations are revisiting their granting strategies to give organizations at the frontlines access to a much-needed cash flow^[47].

Want more PhiLab content on the COVID-19 pandemic? Check out our COVID-19 Special Edition of The PhiLanthropic Year