Abstract
Introduction:
Equity-oriented efforts to mitigate and prevent COVID-related disparities are hindered due to methodological limitations of the categorization of racial and ethnic groups, including Arabs and Middle Eastern and North African (MENA) communities, which remain invisible in national data collection efforts. This study highlights the disparities in COVID-related outcomes in Toronto, Canada and supports ongoing calls to collect public health data among MENA communities in the United States.
Methods:
Data on racial/ethnic identity and hospitalizations were collected by the Toronto Public Health (TPH) of the Ontario Ministry of Public Health Case between May 20, 2020, and September 30, 2021 from people with a confirmed or probable case of COVID-19.
Results:
The reported COVID-19 infection rate for Arab, Middle Eastern, West Asians (i.e., categories used to self-identify as MENA in Canada) relative to Whites in Toronto was 3.51. The age-standardized hospitalization rate ratio between Arab, Middle Eastern, West Asians and Whites was 4.59.
Discussion:
Data from Toronto highlight that Arab, Middle Eastern, and West Asians have higher rates of COVID-19 infections and hospitalizations than their White counterparts. Comparable studies are currently not possible in the United States due to lack of data that can disaggregate MENA individuals. This study underscores the critical need to collect data among MENA communities in the United States to advance our field’s goal of promoting and advancing equity.
Health equity scholars have explicated how long-standing inequities undergirded by structural racism are at the root of racialized patterns in COVID-19 outcomes (Ford & Amani, 2022; Laster Pirtle, 2020; Wrigley-Field, 2020). In response to the pandemic and recognition of racism as a core determinant of health, public health professionals have committed to going beyond documenting racialized disparities and instead advance approaches toward challenging the insidious racism within our systems, institutions, and practices (Ford & Amani, 2022; Orr et al., 2021; Sharif et al., 2022). Such efforts are limited, however, by racial categories that perpetuate the systematic exclusion of entire communities, including those who face multiple levels of social disadvantage and health inequities.
This study moves us closer to our health equity goals by providing timely empirical evidence on Arab and Middle Eastern and North African (MENA) communities, an understudied heterogeneous subgroup, to (1) demonstrate how they are bearing a disproportionate burden of COVID-19; and (2) support ongoing initiatives calling on the National Institutes of Health (NIH) to broaden their definition of “disparities” populations to include MENA communities (Abboud et al., 2019; Awad et al., 2022). Currently, MENA Americans are counted as White in the US federal race/ethnicity standards and within the NIH, thereby excluding them from discussions on disparities research, practice, and policy. There are increasing calls to disaggregate data on MENA Americans (Abboud et al., 2019; Awad et al., 2022; Maghbouleh et al., 2022), an approach already adopted by the American Medical Association; “MENA” is currently under consideration by the U.S. Office of Management and Budget to be added as an identity category to the federal race/ethnicity standards. Across the border, however, in Canada, members of this community are counted as non-White “visible minorities” in governmental data collection under the terminology “Middle Eastern” and the subcategories “Arab” (by population size, for example, Lebanese, Algerian, or Moroccan Canadians) and “West Asian” (by population size, for example, Afghan, Armenian, or Iranian). Differentiating data on Middle Eastern populations from the White category in Canada reveals distinct social and health disparities experienced by this population (Public Health Agency of Canada, 2018). To better understand who may be invisibilized in health disparities research in the United States, we examined trends in COVID disparities in Toronto, Canada’s largest city.
Method
Data
The data came from Toronto Public Health (TPH, 2022) of the Ontario Ministry of Public Health Case and Contact Management Solution and Integrated Public Health Information System (City of Toronto). Between May 20, 2020, and September 30, 2021, TPH collected data on Indigenous identity, racial identity, income, and household size by matching individuals with a probable or confirmed COVID-19 case with a case and contact investigator. Data are restricted to individuals with a reported probable or confirmed COVID-19 infection, valid data on sociodemographic information, and who were neither hospitalized nor residing in either retirement or long-term care homes. Respondents identifying as Indigenous were excluded as TPH supports Indigenous-led reporting and analyses of Indigenous cases. Detailed information on data collection is available on the City of Toronto’s website (City of Toronto).
Measures
Ethno-racial group was measured using the CORES (The Coronavirus Rapid Entry System) from May 20, 2020, to January 31, 2021, developed by the Toronto’s Data for Equity initiative. CORES measured ethno-racial identity by asking respondents the following question:
“People often describe themselves by their race or racial background. . . . Which race category best describes you?” Respondents could select only one of the following options:
(1) Arab, Middle Eastern, West Asian, (2) Black, (3) East Asian, (4) First Nations, Inuit, or Métis, (5) South Asian or Indo-Caribbean, (6) Southeast Asian, (7) White, (8) more than one race category or mixed race, and (9) not listed. On February 1, 2021, data collection started using the provincial case and contact management system (CCM) developed by the Province of Ontario that provided the following different response options and allowed respondents to select all applicable options including: (1) Black, (2) East Asian, (3) Latino, (4) Middle Eastern, (5) South Asian, (6) Southeast Asian, (7) White, and (8) another racial category (Table 1).
Ethno-Racial Categories in the CORES (The Coronavirus Rapid Entry System) and the Case and Contact Management System (CCM)
Outcome Measures
COVID-19 infection rate was calculated by dividing the total number of cases by the total number of people in that sociodemographic category based on the 2016 Census and multiplying this estimate by 100. Rate ratios were calculated by dividing the infection rate for the Arab, Middle Eastern, West Asian group by the infection rate for the White group. Age-adjusted hospitalization rates were calculated based on existing standardization methods according to the 2011 Canadian population. These figures are derived from estimating the total number of hospitalizations that would be expected in the ethno-racial or income group based on the age-standardized rate. Rate ratios were calculated by dividing the age-standardized hospitalization rate for the Arab, Middle Eastern, West Asian group by the age-standardized hospitalization rate for the White category.
Results
There were a total of 119,018 confirmed COVID cases across all racial/ethnic groups. Middle Easterners were over-represented in the share of COVID-19 cases considering they constituted 7.3% of the cases yet only make up 3.6% of the population in Toronto. In contrast, their White counterparts constitute 27% of the COVID cases but make up almost half (48%) of the Toronto population. The reported COVID-19 infection rate ratio for Arab, Middle Eastern, West Asians relative to Whites was 3.51. Figure 1 depicts the monthly ratio of infection rates between the two groups and shows the consistent disproportionate rates among Arab, Middle Eastern, West Asians relative to Whites between June 2020 and September 2021. Table 2 lists the monthly infection rates of each group. The age-standardized hospitalization rate ratio between Arab, Middle Eastern, West Asians and Whites was 4.59.
Rate Ratio of COVID-19-Reported Cases Among Arab, Middle Eastern, West Asians Relative to Whites in Toronto, Canada (June 2020–September 2021)
Monthly Reported COVID-19 Rate (Per 100,000) for Arab, Middle Eastern, or West Asians and Whites Living in Toronto (June 2020–September 2021)
Discussion
For the last 2 years, COVID-19 has been the third leading cause of death among adults (Ahmad et al., 2022) in the United States, and racialized minorities continue to bear a disproportionate burden of COVID-related outcomes. Accurate and real-time epidemiologic data across COVID indicators are critical for developing effective and equitable mitigation strategies (Ford & Amani, 2022). However, our understanding of COVID-related inequalities and our ability to ameliorate said inequalities are limited by our conceptualization of race/ethnicity and our data collection strategies for understudied and hard-to-reach groups. To overcome data limitations related to Arab/MENAs, an understudied group, this study documented COVID-specific outcomes including infection and hospitalization rates for this group in Toronto, the fourth most populous city in North America. The results demonstrate that Arabs, Middle Easterners, and West Asians are overrepresented across COVID-related outcomes including infection and hospitalization compared with White residents. These data guide Toronto’s governmental COVID responses by prioritizing resources for Arabs, Middle Easterners, and West Asians, as well as other racialized communities at high-risk of COVID-19 infection and hospitalization (City of Toronto).
Such equity-oriented strategies in the United States are limited due to long-standing obfuscation of data collection on race and ethnicity, across federal agencies including the NIH, that systematically invisibilize the MENA community. Although evidence demonstrates that MENA Americans experience significant identity-related discrimination and may not actually identify as White, they remain categorized as non-Hispanic Whites in U.S. administrative data (Maghbouleh et al., 2022). This renders MENA people ineligible or otherwise excluded from the vast majority of health-related and social equity initiatives for ethnic and racial minorities in the United States (Abboud et al., 2019; Awad et al., 2022).
Our findings align with evidence based on community samples documenting the health disadvantage within MENA communities relative to their White counterparts (Abboud et al., 2019; Abuelezam et al., 2018, 2019; Awad et al., 2022), including recent reports from MENA community advocacy groups about disproportionate rates of COVID cases (USA Today). This study also supports mobilization efforts to restructure nationally representative data collection to reflect the “othering” and racialization of Arab/MENA communities (Abboud et al., 2019; Awad et al., 2022). The failure to do so will continue to compromise the scientific rigor of our field including the understanding of, and responses to, health disparities.
The results should be interpreted considering the following limitations: the racial/ethnic response options changed during data collection (Table 1), and analyses were restricted to cases with complete sociodemographic data and that were not from a hospital, retirement, or long-term care facility. The study did not include respondents identifying as “mixed race” nor cases prior to May 20, 2020. Rates could be misestimates based on (1) missing data in the 2016 Census and differences in population sizes between then and now which may produce underestimates in the analyses, and (2) TPH’s inclusion of both probable and confirmed COVID cases may have overestimated, and thereby impacted, rate calculations.
Public Health Implications
Categorization of race and ethnicity remains a contentious, political process fraught with problematic approaches. This has enabled systematic and institutionalized dismissal and erasure of the needs of minoritized ethnic and racial groups, including MENA Americans, within health care and public health settings. This is the first study, to our knowledge, to leverage COVID clinical outcomes among Arab, Middle Eastern, and West Asians in Canada to better understand potential inequalities faced by MENA populations in the United States. The findings substantiate calls to enhance data collection efforts and scientific rigor, particularly within the NIH, to improve health inequity by systematically including data to represent MENA individuals both specific to the pandemic and beyond.
