Since 2020, the SARS-CoV-2 virus—which causes the COVID-19 disease—has caused a world-wide pandemic and put a spotlight on many of the pre-existing social and economic inequalities that are pervasive in society [1, 2]. Previous pandemics have taught us that infectious diseases have the strongest impact on marginalized groups due to the often higher exposure to vulnerability factors (e.g., substandard housing and working conditions) by these groups . As a result of additional vulnerability factors (e.g., lack of permanent residence status) experienced by migrant populations, this population represents some of the most marginalized groups . The literature suggests that the COVID-19 pandemic has disproportionately affected migrant populations across a range of socio-economic and health outcomes, including a heightened risk of infection, worsened mental health, interrupted immigration processes, and increased challenges in access to health and social services and support resources [5–9]. Moreover, several categories of migrants, like refugees, asylum seekers, and migrants without status, have been more affected by the pandemic than others [10, 11]. We suggest an intersectoral response is necessary to reduce the vulnerability factors experienced by the most marginalized migrants.
The value of intersectoral collaboration
The concept of “intersectorality” builds upon the health in all policies movement. It suggests that improving population health requires the collaboration (i.e., coordinated efforts) of different sectors of society (e.g., communities, local governments, etc.) [12, 13]. Crucially, intersectorality requires a re-framing of values away from health as a superseding goal towards promoting equity as an overarching goal. In doing so, the concept of intersectorality seeks to ensure equality between the diverse partners of such collaborations, through valuing and promoting the equal contribution of these different sectors of society .
There is evidence that collaborations between public health and health care organizations with community-based organizations (CBOs)—that go beyond the mere referral of patients to health care services—significantly enhance access to services for marginalized populations . Intersectorality is also considered a “best practice” in response to pandemics because when CBOs have direct communication links to public authorities, public health messages are swiftly conveyed as CBOs have closer access to underserved populations, thereby reducing the risk of infection in these population categories . For example, in the United States, during the H1N1 outbreak in 2009, organizations serving Latino-American migrant and seasonal farm worker communities successfully communicated key information from the US Centers for Disease Control and Prevention. The proximity of CBOs to these communities was successfully leveraged through daily emails to key resource persons, such as migrant health center chief executive officers and migrant health clinicians, to ensure that the information quickly reached the intended populations. They also designed bilingual patient education tools which were transmitted to diverse migrant networks .
However, despite the above example, there is little research on the development of intersectorality during crises [17, 18]. The present research intends to fill this research gap. Indeed, across the globe, the start of the COVID-19 pandemic acted as a catalytic event, spurring the emergence of new intersectoral initiatives in response to increasingly diverse migrants’ needs .
Migration categories and vulnerabilities
Through this research, we are particularly interested in migrants who have experienced cumulative vulnerabilities as they are the ones who express the most need for health and social intervention [20–22]. Three migrant categories are considered the most vulnerable (see also Table 1): migrants without status, asylum seekers, and refugees. Migrants without status are mostly – in the Canadian context – persons who reside in the host country after their temporary permit has expired. Asylum seekers are persons who, upon entry or during a temporary stay, seek the protection of another government. Refugees and asylum seekers are persons forced to flee their home country in order to escape persecution, violence, or war.
Three categories of vulnerable migrants in the Canadian context
Migrants without status
Persons who remain in the host country after their temporary permit has expired (e.g., student permit or temporary work permit).
Persons who, upon entry or during a temporary stay, seek the protection of another government. After a lengthy application process, they may or may not obtain refugee status.
Persons who were forced to flee their country in order to escape danger. In Canada, whether they are privately-sponsored of government-assisted, refugees are admitted to the country with permanent resident status. Those who are recognized in Canada also eventually obtain permanent residence.
|Note: The limited space for the present manuscript compels us to provide ‘simplified’ definitions. We indeed acknowledge the complexity of these categories, as well as the diversity of people’s situations within each category – most particularly, the diverse situations of migrants without status.
There are multiple data gaps on the health and wellbeing of these populations in Canada. The most vulnerable and underserved categories – migrants without status and asylum seekers – are the least documented in the literature. In Canada, government-assisted refugees are admitted with permanent resident status, granting them access to public services, community services, and financial aid. Privately-sponsored refugees are also admitted as permanent residents, but their access to services and public financial aid may be limited . Given the temporary or non-status nature that asylum seekers and migrants without status face, these individuals not only have reduced access to services, but they also face significant uncertainty, increasing their vulnerability (e.g., for asylum seekers, the uncertainty about the ability to obtain permanent residence, and for migrants without status, the uncertainty in seeking health and social services for fear of being turned away or being reported to authorities) [24, 25]. Our population of interest therefore includes a heterogonous group of migrants who have very different circumstances. Given the limited data, our study will be a welcome addition to the literature as it will document differences of service experience across these three categories.
In Canada, public service providers aim to support all migrants benefiting from permanent residence, however, there are multiple barriers to service access (e.g., discrimination, delay of care due to a mandatory three-month waiting period, complexity of the health system) . CBOs that receive public funding from the provincial and/or federal government are officially mandated to deliver certain services (e.g., food security and employment assistance) to facilitate the integration of refugees (for Quebec), or all services necessary to facilitate their integration, ranging from orientation, to housing and employment (e.g., in Ontario and most other Canadian provinces). These services are primarily accessible to refugees, and to a much lesser extent, to asylum seekers. For instance, in Quebec, certain CBOs were mandated to only provide diverse services to government-assisted refugees. Only recently were housing assistance services extended to asylum seekers in Quebec. On the other hand, the impetus falls on other (im)migrant-serving community-based and non-governmental organizations to offer temporary housing, food, psychosocial support, health care, language classes, professional training, legal and employment assistance as a complement to, and sometimes instead, of public organizations, especially for migrants lacking government support (e.g., migrants without status).
Recent studies have highlighted that despite the availability of these diverse sources of support, migrants without status and some migrants with temporary status, experience poorer self-perceived health and more unmet health needs than Canadian citizens and economic immigrants [24, 27–29]. With many of the aforementioned services closing during the pandemic, these issues were further exacerbated [30, 31].
Impacts of the pandemic on migrants’ physical and mental health
Health data on refugees, asylum seekers, and migrants without status is scarce in Canada . The pandemic did not improve this situation due to the fact that data regarding migration status was not systematically collected in relation to COVID-19 infection, hospitalization, or mortality . For this reason, we are extending our review of the consequences of COVID-19 beyond the aforementioned three population categories, to include other categories of migrants (e.g., economic immigrants, who have a permanent status), although we acknowledge the limitation associated with the differences in circumstances .
Ecological studies have shown that the interaction between race, socio-economic, and occupational status resulted in an increased risk of infection and excess-mortality [34–37]. Migrants without status and other vulnerable categories of migrants may be particularly at risk for severe COVID-19 symptoms given the prevalence of 1) undiagnosed diseases and health conditions that remain untreated, and 2) comorbidities in this population (e.g., cardiovascular disease, hypertension, hepatitis B and C) . In Canada, available studies suggest that refugees, asylum seekers, and migrants without status are at increased risk of contracting COVID-19 given their precarious living conditions (e.g., living in crowded housing with potentially dysfunctional ventilation systems, shared bathroom facilities, multi-generational housing, etc.) and working conditions (e.g., working as essential workers, for example as orderlies in long-term care facilities, who often have a status of asylum seekers) [39–41]. A growing body of evidence based on surveillance data indeed indicates that COVID-19 cases in large Canadian cities have been disproportionately concentrated in areas with a higher proportion of visible minorities, recent immigrants, high-density housing and essential workers – all interrelated risk factors for refugees, asylum seekers and migrants without status [42, 43]. In addition, the implementation of COVID-19 policies have exacerbated other vulnerability factors (i.e. employment loss, mistrust of institutions, barriers to healthcare access, etc.) further deteriorating their health  and leading to an even greater risk for infection. Statistics Canada data from late 2020 showed recent immigrants (which includes refugees), and particularly those who have been in the country for less than five years, have poorer self-perceived mental health since the pandemic started (2, 55): 28% of recent immigrants reported fair or poor self-rated mental health, compared to 20% of long-term immigrants and 24% of Canadian-born people . Similarly, recent immigrants who were financially affected by the pandemic had higher levels of anxiety (21%) than the other two categories (11%) .
The present research focuses on Ontario and Quebec, which are Canada’s most populous provinces and are the two Canadian provinces that receive the larger share of refugees, asylum seekers, and migrants without status . Studies from Quebec and Ontario demonstrate the disproportionate risk of infection for migrant populations compared to the general population [46–48]. More specifically, a 2020 Ontario report indicates that while economic immigrants, refugees, and other migrants make up 25% of the province’s population, they accounted for 43.5% of the total number of COVID-19 cases during the first wave . While rates of testing amongst this group were generally lower, amongst those tested, refugees tended to have the highest percent positivity rate (10.4% vs. 7.6% in migrants with permanent status and 2.9% in Canada-born and long term residents) .
Research in metropolitan areas of both provinces have shed light on numerous difficulties experienced by migrant groups since the start of the pandemic. In Toronto, the rate of COVID-19 was 923 cases per 100,000 in immigrants, refugees, and other recent health insurance cards (OHIP) registrants, while for Canadian-born and long-term residents the rate was 565 COVID-19 cases per 100,000. The proportion of positive tests was higher in immigrants (6.1%), refugees (9.6%), and recent OHIP registrants (5.9%) in comparison with Canadian-born and long-term residents (2.8%) . A Montreal study pointed out that 1) migrants with temporary status or without status had encountered many difficulties in accessing COVID-19 testing, and 2) several reports were made of working conditions that did not comply with health regulations in companies employing migrants without status . Acknowledging these issues, in a key report on the future of public health post-COVID, Canada’s Chief Public Health Officer highlighted the importance of coordinated responses by working collaboratively with all levels of government and key stakeholders . By analyzing the development and implementation of promising intersectoral initiatives to meet the diverse needs of refugees, asylum seekers, and migrants without status, the present project is directly in line with these public health recommendations.
Impacts of the pandemic on intersectoral services for refugees, asylum seekers and migrants without status
Enhancing intersectoral action is a major lever in the response to pandemics . Community mobilization, as a pillar of intersectoral action, is an essential instrument for pandemic responsiveness [50–52]. As shown in a peer-reviewed rapid review by Loewenson and colleagues (2021), CBOs play a pivotal role in implementing solidarity- and equity-driven public health interventions that extend beyond the usual risk communication strategies (as described below) . More evidence is needed to document how CBOs adapt and transform their actions in the context of health crises. Indeed, while public health restrictions to contain and slow the spread of COVID-19 changed the functioning of public service providers, these restrictions also significantly affected the actions of CBOs. A US report highlights the strong pressure (notably due to significant staffing shortages) exerted on CBOs assisting migrants during the pandemic, which reduced access to support services . In Quebec and Ontario, CBOs reacted by adapting their practices, offering additional services, and switching to remote forms of support . CBOs played a pivotal role in both infection prevention (i.e., by raising awareness and providing access to reliable, multilingual information on COVID-19) and social protection (i.e., by centralizing data on the availability of food aid, psychosocial support, screening and access to healthcare related to COVID-19) [50, 55, 56]. It is essential to learn from both the community sector and the public sector who implemented promising initiatives during the pandemic with a specific focus on the needs of migrants to better prepare for future health crises , and to sustain the initiatives that may be considered promising from a health systems responsiveness perspective and by all research partners – from funders, policymakers and service providers, to migrant service users.
Using the Canadian case, and by applying a theory-informed, and unique participatory approach through which migrants participate in the governance of our research project, we will highlight the lessons learnt from the implementation of promising initiatives that mobilized unprecedented forms of intersectoral collaboration between public and community actors.