​Diabetes, heart disease, arthritis, and cancer are all examples of chronic diseases in which environmental and/or individual factors promote the development of health conditions that are present for extended periods of time (Earle, 2011). It is commonly known that practicing healthy habits such as eating nutritious foods, getting enough sleep, and regularly exercising contributes to healthier outcomes and reduces the risk of developing chronic diseases and illnesses. Sounds easy enough, right? For many Indigenous people, however, the reality is that there are numerous social barriers to engaging in healthy behaviours. In the first-ever Indigenous Services Canada Annual Report to Parliament in 2020, Indigenous Peoples, especially First Nations living on-reserve, reported lower incomes, less education, reduced employment rates, worse housing conditions, and decreased life expectancy compared to non-Indigenous counterparts. They also reported greater likelihood of being in foster care and higher infant mortality rates, as well as  higher rates of violence, victimization, and incarceration. This exemplifies the magnitude of the inequities experienced by this population, and it is understandable why Indigenous Peoples are at greater risk for developing disproportionate rates of disease, illness, and even deaths. Conversely, a study conducted by Anand et al. (2019) found that First Nations communities with higher incomes, better education, increased access to healthcare services, and robust social support mechanisms displayed fewer risk factors for cardiovascular disease compared to communities with overall lower socioeconomic status. Moreover, other research indicates that socioeconomic and lifestyle factors contribute to the high proportion of First Nations who suffer from diabetes (Halseth, 2019). These findings support the position that the social determinants of health play a significant role in contributing to the subsequent development of chronic disease amongst First Nations and other Indigenous groups.

So, how does colonization and its legacy effects tie into chronic health disparities? According to one article, there are proximal, intermediate, and distal social determinants at play. Proximal determinants are those that directly impact healthy behaviours (e.g., physical environment), intermediate determinants are institutional or system-specific (e.g., education level and health care accessibility), and distal determinants are the bigger-picture issues from which many of these factors stem, such as colonialism and racism. Colonialism has been defined as the exploitation, control, and settlement of one country by another (Blakemore, 2019). In Canada, this involved removing autonomy from Indigenous Peoples and using assimilation strategies such as Residential Schools, separating children and families through the Sixties Scoop, and continues today by disproportionately placing Indigenous children in the Child Welfare System (Hobson, 2022). For many Indigenous families, the proximal effects of these initiatives resulted in broken-family dynamics and unstable living situations, depression and overall poor mental health, a loss of sense of self, and substance use. Furthermore, intermediate effects such as a lack of access to, or affordability of, adequate treatment services for these outcomes have ultimately led to intergenerational traumas, and high rates of suicide (Bombay et al., 2014), and we are now seeing higher prevalence rates than ever of chronic diseases like diabetes amongst First Nations youth (Halseth, 2019). If we know that colonialism has shaped both the social determinants and direct health outcomes of Indigenous Peoples (i.e., increased chronic diseases), why do these issues continue to persist? 

​In 2015, the Canadian Government accepted the final report released by the Truth and Reconciliation Commission of Canada, which outlined 94 Calls to Action targeted at improving Indigenous health, education, and other domains. Although efforts have been made towards addressing these Calls, colonialism persists through current Westernized structural and governance frameworks, policies, and practices that continue to perpetuate the disadvantages and inequalities experienced by Indigenous Peoples in Canada (Blanchet Garneau et al., 2021; Czyzewski, 2011). Prime examples of this can be seen with policing issues, the overrepresentation of Indigenous People in the Canadian criminal justice system (Clarke, 2019), and insufficient culturally sensitive health educational programming, which can result in discrimination and harmful stereotyping (Blanchet Garneau et al., 2021). Increased collaboration and open communication between different levels of government and Indigenous leaders are needed to act on the chronic health disparities we know disproportionately affect Indigenous Peoples. Targeting the social determinants that impact this population, by increasing employment and educational opportunities and guaranteeing equitable access to basic necessities such as adequate healthcare and clean drinking water, is needed in order to ensure better health outcomes for future generations.

As we are reminded of the horrific truths about the history of the Residential School system and the effects of colonialization through continued media reports of more unmarked graves, remember that the effects of colonialism are not a thing of the past. In fact, we still see the legacy effects on Indigenous health today, if we are willing to look.

​Living in downtown Ottawa means never being far from a demonstration. The nation’s capital is the ideal venue for protests against invasions or displays of solidarity for climate action and social justice. A different kind of demonstration, however, was organized here in early 2022. Stepping outside my apartment near Bank Street dropped me into the “Freedom Convoy.” The Convoy first labelled itself as a protest against a COVID-19 vaccine mandate for truckers crossing the border into the United States but shifted almost immediately into an unlawful occupation of Ottawa streets set on ending all COVID-19 vaccine mandates and removing public health restrictions.
 
The Convoy occupation rallied against undeniably lifesaving measures. There have been significantly fewer deaths due to COVID-19 in individuals who have been vaccinated. Moreover, public health measures (PHMs) for masking, social distancing, and isolation of positive cases have reduced COVID-19 infection. Combined, vaccines and PHMs have spared many from both mild symptoms and severe months-long disabilities that could come from COVID-19 infection.
 
Individuals with ties to and involvement in hate groups organized and participated in this Convoy. However, of interest to this post, some Convoy occupants were more focused on simply opposing PHMs. This subset of participants demonstrated a fundamental misunderstanding of science guiding the pandemic response in Canada during their displays of opposition. Despite aiming to highlight perceived issues with vaccine mandates and PHMs, occupants instead highlighted that some Canadians may not have strong enough knowledge of science and health.
 
Jordan Klepper’s interview with occupants of Rideau St, for example, includes one unvaccinated man who was bewildered that his status means “[he] can’t go to the restaurants, can’t play hockey, and can’t go watch the [Ottawa Senators].” He seemingly views vaccination simply as a method to bar certain individuals of the population from public spaces without acknowledging the science informing these policies. Other knowledge gaps in science and health were seen in Convoy propaganda. Signs questioned scientists' motivations, discounted the value of PHMs, and drew unsupported concerns about deaths from surgeries delayed by COVID-19.

​These individuals displayed low health literacy during their participation in the Convoy. Health literacy is defined by the World Health Organization as:
 
People’s knowledge, motivation, and competences to access, understand, and appraise health information in order to make judgments and take decisions in every-day life concerning health care, disease prevention, and health promotion to maintain or improve quality of life during the life course.
 
Equipping Canadians with skills in health literacy can enhance one’s ability to understand their health status and improve it. Health literacy is displayed, for example, when one can collect and understand information surrounding the risk of COVID-19 to then take steps to mitigate infection. The ability to do this, though, varies among Canadians. Estimates from 2008 show that 60% of Canadian adults are unable to obtain, understand, and act upon health information shared with them. This alarming statistic is more problematic with no national update to this estimate since 2008.
 
Granted, the number of participants in the Convoy was minimal compared to the entire population of Canada. However, the occupation made it obvious that there are still Canadians who have not achieved sufficient health literacy. Convoy propaganda showed that low health literacy continues to be a significant problem in Canada into 2022. Some occupants who rallied against PHMs, for example, may not have the knowledge to take in the evidence showing that these measures increase safety for an entire population. The unvaccinated man interviewed by Klepper may not have been exposed to accessible health messaging describing that entering high-risk environments without being vaccinated puts himself in much higher danger of being infected with and dying from COVID-19. Shifting from a mindset that lacks concrete health and science-related knowledge to a more informed viewpoint would demonstrate improved health literacy.
 
Health literacy, though, is not an issue of solely individual level factors. It is a social determinant of health (SDoH). This term refers to the unique living conditions one experiences that shape their health. SDoH are often influenced by systemic issues (e.g., socio-economic status, education level, etc.) that cause general societal inequities. Health literacy falls in line with this. Lower-income Canadians, for example, tend to have lower health literacy skills. A similar trend has been seen in Canadians with no post-secondary education. Individuals with little educational background are more likely to have insufficient health literacy skills. Children, even, receive most of their knowledge related to COVID-19 from parents, suggesting that one’s health literacy may be influenced by and sustained through generations. In total, research has demonstrated how engrained health literacy is as a SDoH.
 
Importantly, gaps in health literacy have direct effects on the health of an individual and the population. Individuals who have both chronic obstructive pulmonary disorder and low health literacy skills, for example, tend to have a lower quality of life. Other general findings show that individuals with combined chronic illness and low health literacy skills have higher rates of mortality from their illness. These findings are especially troubling knowing that the proportion of older adults in the Canadian population will increase in the coming years. Improving national health literacy could therefore reduce the burden on the Canadian health care system for the care of chronic illnesses that will become increasingly prevalent in an aging population. Improving health literacy across a population could also empower individuals in subsequent pandemics to understand public health messaging and incorporate it into health behaviours that keep all members of society safe.
 
Many existing definitions of health literacy do not adequately acknowledge the very real influence of the SDoH. As a result,  interventions to improve health literacy may be too narrowly focused on individual factors. The Convoy shows, instead, that population-level interventions guided by the SDoH make more sense. The occupants did not exist solely within themselves but were members of diverse families, earners of varying incomes, and with varied educational backgrounds. These factors are large-scale SDoH that influence health literacy levels and overall health. This may be why previous attempts at improving health literacy in a one-on-one clinical setting have largely failed to make great impacts on health outcomes; issues influenced by large systemic factors cannot be fixed by small-scale individual level interventions.
 
Community-based interventions have been suggested as a possible method by which to bolster skills in health literacy. Attempting to improve the health literacy skills of entire communities aligns with the knowledge that health literacy is a SDoH and addresses previously stated concerns. Research suggests that programs should be tailored to the unique SDoH of each community. This would require developing intervention tools that are specific to the community’s culture. This could include pairing health literacy skill workshops, for example, with programs that aim to improve other influential SDoH like education and income. Population-level interventions like these could have a much broader effect on the health of Canadians because they would inherently account for the large systemic influences that dictate skills in health literacy.
 
Downtown Ottawa continues to be a stage to discuss current issues in Canadian society. Though the Freedom Convoy occupants may have felt they were putting on a performance solely to rally against pandemic-related issues, they were, in fact, bringing a different fundamental Canadian issue to the spotlight. The Convoy showed that we must improve the health literacy of Canadians. Doing so is imperative because health literacy is a SDoH with definite influence over the general health of individual Canadians. Health literacy must be addressed if we wish to improve the health of Canadians. Taking action on this issue could even prevent future disruptive occupations during public health crises. The exasperated residents of Ottawa and those occupying the city streets could both be helped by viewing such issues through the lens of health literacy. Though, I admit, this is a difficult mindset change to make, speaking as one of those exasperated Ottawa citizens living in the middle of the occupation. That being said, my background in health sciences has taught me that addressing issues at the systemic level is often the best way to bring about meaningful change.

​The COVID-19 pandemic has changed the way we think about a lot of things including the way we travel, how we shop, and even where we live. Early on, as the pandemic containment measures were announced, it seemed that those who could were trading in their urban lives for the peace and tranquility of their rural cottages. Inspired, perhaps, by the wish to escape the higher transmission rates in urban centers but also the increasingly strict restrictions on public space. Those who longed for nature were encouraged to seek rural areas and homes with private backyard space in place of their urban apartments. Given that this is not an accessible option for most people, the role of urban development in the promotion of resilience and well-being has been brought into sharp focus. 

​The thought of urban development might elicit images in our minds of new apartment buildings with large windows and rooftop patios, and while this is not the extent of urban development, it does make up an important part. The architectural features of our living space contribute to our mental health and wellbeing, particularly when we face restrictions on our ability to leave these spaces. The loss of daily routine, social gatherings, and the amalgamation of home and workspace have had a significant impact on mental health and wellbeing, all of which are compounded for those in densely packed urban areas. 

 A study conducted in Northern Italy, a region that experienced severe lockdown restrictions due to COVID-19, looked at the impact of features of built living spaces on university students found that living in small apartments, lacking a functional balcony, and having a poor view were each associated with moderate to severe depression symptoms (1). These living features are not uncommon as we experience a global trend of movement to urban centers where space is limited. 

​To combat these negative psychological effects, people took to parks and local greenspace. A study that analyzed data from the Google Community Mobility Report found an increase in park visitation from February to May 2020, by over 100%, compared to the same time period the previous year, in Canada, Denmark, and the United Kingdom. Similar increases were found in Spain and Italy once the most strictest lockdown restrictions were lifted (2).

​Time outdoors appears to be an important coping strategy. Nature provides an escape from confined living quarters and a time of relaxation to release the stress and anxiety felt most acutely by those in urban centers. Urban greenspaces are not only places to enjoy nature and physical activity but are also places to enjoy social connection. Community gardens and parks help foster social ties that can be maintained safely during social distancing measures to further reduce feelings of isolation and loneliness and foster resilience in a community. 

​A survey of Tokyo residents explored the relationship between mental health scores, outdoor experience, and lifestyle factors to further understand their interaction amidst the increased psychological stress of the coronavirus pandemic. They found that greenspace use and view were both individually associated with higher life satisfaction, happiness, and self-esteem scores.  ​Greenspace use and view were also both independently associated with lower loneliness, depression and anxiety scores (3). This supports the importance of greenspace in maintaining our mental health and wellbeing through periods of significant stress.

​However, greenspace is not equally accessible. Data from the Google Community Report found that park visitation and access were correlated with economic, cultural, and social dimensions. Higher socio-economic status communities experienced greater park access and visitation rates, while poverty and unemployment were correlated with reduced park access and visitation (2). Wealthier areas tend to have a greater diversity of species, higher tree cover, and are therefore, less susceptible to environmental changes (4). This inequality in greenspace access could compound the negative effects felt by disadvantaged populations due to COVID-19.

​Recognizing these data is important in our understanding of the impact of urban development on our wellbeing, especially as we prepare for future pandemics where quarantine measures may again be necessary for preliminary containment. Architectural design should include consideration of living features that have been found to be correlated with positive mental health and wellbeing such as a livable balcony, increased natural lighting, and larger and more functional space, all of which are a function of access to resources and socio-economic status. In addition, urban nature protection and development should be a priority as they have been shown to protect mental wellbeing and foster resilience in communities. Focus should also be brought to increasing equity in the distribution of urban nature development to benefit lower socio-economic communities who are at an increased risk of experiencing negative impacts to wellbeing.

​The COVID-19 pandemic has changed the way we think about a lot of things, including how we appreciate urban greenspaces. They are no longer simply spaces that we enjoy individually, but have become crucial to maintaining our mental health and wellbeing. Urban greenspaces are places for physical activity, stress relief, and community interaction, all of which are key to combatting feelings of loneliness and isolation during lockdown restrictions. As we prepare for future pandemics, urban development that prioritizes greenspace is fundamental to fostering resilience in those who live in urban centers.

Hilary Ziraldo, Carleton University Student
​
On the day I wrote this, exactly one year had passed since the World Health Organization declared COVID-19 a global pandemic. Like every other day that year, I was at my home in Toronto, only leaving to get groceries or to exercise outside. When I ran into my mom as she headed down the stairs to her basement work-from-home setup, she liked to joke that there was “heavy traffic” on her morning commute. Joking aside, COVID-19 has changed how we interact with our physical environments. We have become increasingly dependent on our homes and neighbourhoods to support our physical and mental health needs, and this has intensified health disparities between those living in adequate and inadequate conditions. 
​
​The impacts of housing on health are numerous. Overcrowding can increase the spread of communicable infections, while chronic diseases, such as asthma, are associated with substandard heating, insulation and dampness (1,2). Unsafe or unaffordable housing is also a source of chronic stress and can lead to social isolation and poor mental health (2,3,4). 

​Despite these broad consequences, 15.3% of Ontario households live in unsuitable, inadequate or unaffordable conditions, and affordable housing has been consistently de-prioritized by the provincial government (5). I find this alarming because housing is an essential human right, yet continues to be treated as non-essential by government decision-makers and the voting public.

​Due the high rates of poor-quality and unaffordable housing in Ontario, stay at home orders during the COVID-19 pandemic confined many Ontarians to unhealthy living conditions. Essential workers are also impacted because income is a determinant of housing quality, and the reality is that many frontline jobs are poorly compensated (6). For essential workers living in crowded or intergenerational households, continuing to work puts themselves and their families at greater risk due to both workplace exposures and their household conditions.

Beyond housing, our neighbourhoods can have a large impact on health. Residents are more likely to be physically active in safe, walkable neighbourhoods and to choose healthy foods when they are easily accessible (7,8). In neighbourhoods designed to facilitate gatherings, residents perceive greater social support and a stronger sense of community belonging (8). Due to the impact of neighbourhood features on health, vast disparities in health may occur between otherwise geographically close communities.
​
Like quality of housing, quality of neighbourhoods is largely determined by income (6) and this cannot be fixed by simply investing in the development of low-income neighbourhoods. When lower income neighbourhoods are revitalized, gentrification may occur. Gentrification refers to the transformation of the social, economic, cultural, physical and demographic features of a neighbourhood, and often leads to the displacement of long-term and socially marginalized residents (9). In a neighbourhood impacted by gentrification, property and rental values are inflated, pushing vulnerable populations to relocate. 

​However, there are ways to break the cycle of revitalization and displacement caused by gentrification. The City of Ottawa is incorporating public health concepts into urban growth strategies by creating ‘15-minute neighbourhoods’ (10). A 15-minute neighbourhood is one in which all (or most) daily needs can be accessed within a 15-minute walk from one’s home. The goal of a 15-minute neighbourhood is to reduce reliance on vehicles, increase social connections, and promote equity through improved access to daily needs (10). 

​At the provincial level, Ontario has tried to combat income-based disparities in access to healthy built environments through inclusionary zoning regulations (11). Inclusionary zoning is a strategy to increase affordable housing in desirable neighbourhoods. Under an inclusionary zoning system, every new housing development must be mixed income, meaning that a range of income levels can afford to live in high-quality housing within updated neighbourhoods. Inclusionary zoning has shown some success in the United States, but there is concern that provincial actions will be ineffective at the municipal level. Under the current system, the power to enforce inclusionary zoning lies with municipal governments, that will need to implement bylaws and regulations surrounding the construction of affordable housing units (12). By leaving decisions on inclusionary zoning to municipalities, substantial changes are not guaranteed. 

​When we understand the magnitude of Ontario’s housing crisis, it is easy to support policy action, like inclusionary zoning. But, take a moment to consider your perspective if affordable housing was proposed in your own neighbourhood? As is too often the case, such a policy might be easy to support until you are personally affected. For residents living near areas allocated for affordable housing, the “not in my backyard” (NIMBY) phenomenon is both common and predictable. The NIMBY phenomenon refers to the opposition of new developments by residents when they believe the development will negatively impact their neighbourhood or property value. Classical examples of the NIMBY phenomenon include responses to safe injection sites and homeless shelters, but affordable housing is similarly affected (13). NIMBY responses are often founded in stereotypes and stigma and serve to perpetuate social inequities. One method governments and developers can use to fight the NIMBY phenomenon is to engage and inform residents throughout the planning process. Importantly, we can individually work against NIMBY-ism by discussing the value of diverse communities with family, friends, and neighbours and being leaders for social equity within our own neighbourhoods.

As I sat at my desk in Toronto with the entire province under stay at home orders, I couldn’t help but appreciate how much I relied on my home and neighbourhood over the past year. But, for many Ontarians, hiding away at home has not been a refuge from the dangers of COVID-19. Improving access to healthy homes and neighbourhoods is a complex battle involving political priorities, revitalization and gentrification, and local sentiments. As we move forwards in the COVID-19 pandemic and into its aftermath, we must do more to ensure that “home” is a healthy environment for all Ontarians. 

References:

1. Brown, K. A., Jones, A., Daneman, N., Chan, A. K., Schwartz, K. L., Garber, G. E., … Stall, N. M. (2021). Association between nursing home crowding and COVID-19 infection and mortality in Ontario, Canada. JAMA Internal Medicine, 181(2), 229–236. https://doi.org/10.1001/jamainternmed.2020.6466
2. World Health Organization. (2018). WHO housing and health guidelines. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK535293/
3. Pevalin, D. J., Reeves, A., Baker, E., & Bentley, R. (2017). The impact of persistent poor housing conditions on mental health: A longitudinal population-based study. Preventive Medicine, 105, 304–310. https://doi.org/10.1016/j.ypmed.2017.09.020
4. Tomaszewski, W. (2013). Living environment, social participation and wellbeing in older age: The relevance of housing and local area disadvantage. Population Ageing, (6), 119–156. https://doi.org/10.1007/s12062-012-9077-5
5. Government of Ontario. (2020). Community housing renewal: Ontario’s action plan under the National Housing Strategy. Retrieved March 13, 2021, from https://www.ontario.ca/document/community-housing-renewal-ontarios-action-plan-under-national-housing-strategy/housing-needs-ontario
6. Raphael, D., Bryant, T., Mikkonen, J., & Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Retrieved from https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf
7. Krieger, J., & Higgins, D. L. (2002). Housing and health: Time again for public health action. American Journal of Public Health, 92(5), 758–768.
8. Public Health Agency of Canada. (2017). The Chief Public Health Officer’s Report on the State of Public Health in Canada 2017: Designing healthy living. Retrieved March 14, 2021, from https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/chief-public-health-officer-reports-state-public-health-canada/2017-designing-healthy-living/PHAC_CPHO-2017_Report_E.pdf
9. Cole, H., Anguelovski, I., Baró, F., García-Lamarca, M., Kotsila, P., Pérez del Pulgar, C., … Triguero-Mas, M. (2020). The COVID-19 pandemic: Power and privilege, gentrification, and urban environmental justice in the global north. Cities & Health, 1–5. https://doi.org/10.1080/23748834.2020.1785176
10. City of Ottawa. (2020). Big 5 Moves. Retrieved from https://engage.ottawa.ca/the-new-official-plan/news_feed/the-5-big-moves
11. Government of Ontario. (2018). O. Reg. 232/18: Inclusionary zoning. Retrieved March 16, 2021, from Ontario.ca website: https://www.ontario.ca/laws/view
12. Government of Ontario. (2020). Citizen’s guide to land use planning: The Planning Act. Retrieved March 3, 2021, from https://www.ontario.ca/document/citizens-guide-land-use-planning/planning-act
13. Ontario Human Rights Commission. (n.d.). Human rights and not-in-my-back-yard (NIMBY). Retrieved March 15, 2021, from http://www.ohrc.on.ca/en/human-rights-and-not-my-back-yard-nimby

Link References:

1. Talwar Kapoor, G. (2021, April 3). Successive budgets show affordable housing is clearly not a priority for Ontario. Retrieved April 25, 2021, from the Toronto Star website: https://www.thestar.com/opinion/contributors/2021/04/03/successive-budgets-show-affordable-housing-is-clearly-not-a-priority-for-ontario.html
2. Wellesley Institute. (n.d.). Ontario announces evidence-based inclusionary zoning regulations and action shifts to the municipal level for implementation. Retrieved March 16, 2021, from https://www.wellesleyinstitute.com/ontario-announces-evidence-based-inclusionary-zoning-regulations-and-action-shifts-to-the-municipal-level-for-implementation/
3. Keenan, E. (2016, January 2). The good and bad of Toronto NIMBYism. Retrieved April 26, 2021, from the Toronto Star website: https://www.thestar.com/news/gta/2016/01/02/youre-a-toronto-nimby-now-what.html

Picture References:

1. Archibald, A. (2019). Liberals for inequality: NIMBYism and affordable housing In American cities. Retrieved March 16, 2021, from Pax on both houses website: http://paxonbothhouses.blogspot.com/2019/08/liberals-for-inequality-nimbyism-and.html
2. Government of Ontario. (2021). Ontario Ministry of Health. Retrieved March 17, 2021, from https://www.facebook.com/ONThealth/photos/a.546566125392952/3516644231718445
3. Ottawa Public Health. (2020). Health and the built environment. Retrieved March 17, 2021, from https://www.ottawapublichealth.ca/en/public-health-topics/health-and-the-built-environment-.aspx