Syndemic Connections: Overdose Death Crisis, Gender-Based Violence and COVID-19

Abstract

This article will use syndemic theory to identify and analyze overlapping health and social conditions, focusing specifically on how gender-based violence is systemically interconnected with contemporary public health issues. The overdose death crisis that continues to afflict Canadian populations is not an isolated health issue. Across Canada, it is intertwined with mental health, HIV/AIDS, COVID-19 and structural violence—the chronic and systemic disadvantages affecting those living in poverty and oppressive circumstances. Opioid use is an often-avoidant coping strategy for many experiencing the effects of trauma, relentless fear, pain, ill health and social exclusion. In particular, Indigenous and non-Indigenous women’s experiences with opioid addiction are entangled with encounters with gender based-violence, poverty and chronic ailments within structurally imposed processes and stressors shaped by a history of colonialism, ruptured lifeways and Western ways of knowing and doing, leading to disproportionate harms and occurrences of illness. While biomedical models of comorbidity and mortality approach substance misuse, gender-based violence and major infectious diseases such as HIV/AIDS and COVID-19 as distinct yet compounding realities, this article argues that these conditions are synergistically interrelated via the critical/reflexive lens of syndemic frameworks. Through secondary research using academic, media and policy sources from the past decade in Canada, complemented by prior ethnographic research, the synergistic connections among opioid addiction, gender-based violence and the effects of the COVID pandemic on diverse women will be shown to be driven by socio-structural determinants of health including poverty, intergenerational trauma, the legacy of colonialism and Western optics. Together, they embody a contemporary Canadian syndemic necessitating coordinated responses.

1. Introduction

Biomedical models of comorbidity and mortality approach currently pressing issues in local and global communities, such as mental health, substance misuse, HIV/AIDS, COVID-19 and gender-based violence (GBV), as distinct yet compounding realities. Generally, biomedical practitioners view infectious diseases as biological dysfunctions caused by organic pathogens such as viruses, bacteria or parasites that must be treated with curative interventions such as pharmaceuticals and vaccines [1,2]. Similarly, substance misuse and mental health issues are often approached by clinicians as biological phenomena resulting from biochemical brain imbalances that require medical and psychological initiatives [3,4]. A biological explanation also underlies biomedical perspectives of GBV in terms of testosterone or hormonal levels in men that contribute to violence toward women or that neuroanatomical differences including biological factors in men predispose men’s tendency to be violent toward women [5,6,7]. However, biomedical professionals do not typically address GBV as a medical issue unless they are confronted by its health impacts when victim–survivors, including other family members, disclose their personal injuries and physical, emotional and psychological harms [8] or are diagnosed with HIV/AIDS as a result of unprotected sex or sharing contaminated needles [9,10,11].

GBV comprises different forms of violence including childhood sexual abuse, intimate partner violence (IPV), non-partner assault and trafficking [12]. Our Canadian federal government connects it specifically to violence against one’s “sex, gender, gender identity, gender expression, or perceived gender” that can take many forms including “physical, sexual, psychological, emotional, and financial abuse, as well as technology-facilitated violence” [13]. While GBV can affect diverse genders and occur within same-sex contexts, women and girls have been disproportionately impacted due to longstanding imbalanced gender relations and power dynamics that continue to devalue women and girls in many societies [14,15].

Since GBV is not directly caused by a biological micro-organism such as a virus or bacteria, biomedical professionals and even our own federal and provincial governments, likely influenced by the biomedical dominance1 in society, fail to notice GBV as a public health issue.

To date, HIV/AIDS, COVID-19 and opioid overdose deaths in Canada have been publicized as “epidemics” demanding immediate public health responses. In contrast, despite GBV’s alarming incidence rates in this country, its federal and provincial governments have not declared GBV an epidemic. According to recent media and community-based reports, 850 women and girls have been killed in the past 5 years in Canada (2018-2023), which is equivalent to one woman or girl killed every 48 h [18,19,20]. In addition, 44% of Canadian women report some form of IPV in their lifetime [21,22], and 6.3 million women and girls will experience sexual violence or IPV in their lifetime [20].

Although our Ontario government has refused to declare GBV an epidemic because it claims that an epidemic, by definition, must be an “infectious disease” [23], it stated in April 2024 that it would support a bill tabled by the provincial New Democratic Party (NDP) to declare IPV an epidemic [24]. As of June 2024, 95 out of 444 Ontario municipalities, including Toronto, Ottawa and Windsor, have made their own formal declarations [25].

In fact, even our Federal Justice Minister, Arif Virani, in response to the 2022 public inquest into the 2015 deaths of three women by the same perpetrator in Renfrew County, outside of Ottawa, declared in an open letter on 14 August 2023 that GBV is an epidemic [23].However, our federal government did not express strong commitments or declarations after this inquest concluded with 86 recommendations along with the 3000-page Mass Casualty Commission Final Report (MCCFR) released in March 2023 [26]. The latter made 130 recommendations on how to prevent future violence after the mass shooting of 22 people in Nova Scotia in 2020 by a man with a long history of IPV [21,23]. Our federal government has supported the MCCFR and implemented some of its recommendations including establishing an independent body to monitor progress on implementation. A significant government response to the MCCFR recommendations was to create a possible law on coercive control, a form of IPV intended to isolate, intimidate and control victims [23]. Notwithstanding, the most significant federal response to date is the release of its National Action Plan (NAP) to End Gender-Based Violence in November 2023 [13], which consists of the following five pillars:

• Support for victims, survivors and their families through social, health and community services;
• Prevention to address the root causes of GBV and to stop violence before it occurs in different private, public, community and workplaces as well as educational and online settings;
• A responsive justice system to promptly and proactively address allegations and complaints;
• Implementation of Indigenous-led approaches building upon coordination with Indigenous governments, partners, non-governmental organizations (NGOs), provinces and territories; and
• Social infrastructure that offers health, social programs and services that support parents, children, families, seniors and communities, including housing as well as culturally and socially relevant trauma- and violence-informed support.

Furthermore, this plan includes a foundation that is based on three components: leadership; coordination; and engagement linking data, research, knowledge mobilization, reporting and monitoring across the individual, community, research and government sectors to make Canada free of GBV [13]. While this policy initiative is much needed and long overdue, one could argue that it may have been a reactionary move towards the MCCFR since its previous plan—Canada’s National Action Plan on Women, Peace and Security [27] was mainly geared towards addressing sexual and gender-based violence perpetrated in conflict and post-conflict settings, advocating for greater participation of women in conflict prevention, resolution and post-conflict state building as if GBV were primarily an “Other’s” problem exclusive to conflict zones, and thus signalling Canada as a leading model of citizenship and human rights. In this earlier National Action Plan (2017–2022) [27], there is a one-paragraph acknowledgement that Canada has its own challenges regarding the issue of murdered and missing Indigenous women and girls, without recognizing that GBV is a broader societal issue demanding close attention and national responses.

While femicide rates are on the rise in Canada, Indigenous people in Canada are at greater risk of being targeted [22]. The Canadian National Inquiry on Missing and Murdered Indigenous Women and Girls [28] has found that Indigenous women and girls are 16 times more likely to be slain or to disappear than non-Indigenous women. This shows that GBV is intertwined with systemic racism, wherein the harm and exploitation of Indigenous bodies through violence is rooted in Canada’s colonial legacy. Historical and persistent traumas related to colonization, residential school experiences, poverty, child apprehension and involvement in child welfare systems [29]; gender-based determinants including family violence and the demands of single parenthood [30]; and violence against Indigenous women and girls [28] continue to challenge Indigenous communities across Canada. Additionally, over-policing and higher rates of incarceration of Indigenous and other racialized populations represent socio-structural drivers of health inequities that contribute to disproportionate harms among equity-denied groups [10,29,31,32].

Although both the biomedical and government sectors recognize each co-occurring condition (GBV, HIV/AIDS, COVID-19 and opioid overdose deaths) as distinct but compounding events, this article argues that these issues are synergistically interrelated via the critical/reflexive lens of syndemic frameworks [10,33,34]. Syndemic theory, originally proposed by medical anthropologist Merrill Singer [33], offers a framework to analyze overlapping health and social conditions. Through secondary research using academic, media and policy sources alongside participant voices from the author’s previous ethnographic research with opioid users undergoing harm reduction interventions in Toronto, the synergistic connections between GBV, mental health, infectious diseases and substance misuse will be shown to be driven by socio-structural determinants of health as well as by Western ways of knowing and doing. Together, these conditions embody a contemporary Canadian syndemic in which health and social conditions overlap, thus rendering GBV a syndemic rather than a cumulative epidemic.

2. Methodology

This article is mainly based on secondary research data collected via three main sources: (1) academic literature, (2) media and (3) government policies retrieved from scholarly, mainstream news and policy databases: Google Scholar, Sociological Abstracts, Social Sciences and Humanities Index, PubMed, CBC, Global and CTV News, The Guardian and the Government of Canada’s Health Canada and National Action Plans’ websites. The following keywords were used: gender-based violence; epidemic/pandemic/syndemic; public health and Canadian government responses to GBV, COVID-19 and overdose death crisis. A purposive sample of 10 citations per year was selected according to the scope of the problems arising within a decade (2013–2023) for in-depth reading to determine which issues would undergo a critical thematic analysis. The literature review was updated by consulting additional sources during the writing process, resulting in a total of 125 secondary sources analyzed in depth, and 75 (or ~60%) of them were included in this article.

Additionally, the secondary research data were complemented by ethnographic data collected from field research projects between 2005 and 2021 with staff and clients at two harm reduction-oriented centres in Toronto, Ontario—a community health care centre offering a needle exchange program and its satellite methadone treatment program. The purpose of this ethnographic component is to shed light on client perspectives in select clinical settings regarding their experiences with GBV as they recounted their stories about opioid use and drug treatment interventions. In-depth interviews with a total of 40 clients (25 males and 15 females) were conducted during two phases of fieldwork (2005 and 2009). Twenty males and ten females were interviewed in the first phase of field research, and five males and five females were interviewed in the follow-up period. To ensure participants’ confidentiality, all individual names that appear in this article are pseudonyms.

After completing the content analysis of textual and ethnographic data using Nvivo 12, the findings were situated within social science theorizing drawn from various disciplines including anthropology, gender studies, health studies, history, social work and sociology to illuminate a key argument: GBV in Canada epitomizes a syndemic by synergistically interacting with contemporary epidemics such as mental health, infectious diseases (HIV/AIDS and COVID-19) and the opioid overdose death crisis, all driven by structural violence. As part of this analysis, issues of social justice, social inequities and the biomedical dominance of health care are foregrounded as major lacunae in Canadian government policies addressing GBV. Overall, this critical analysis aligns with a qualitative methodological approach that explores power in social practices by understanding, uncovering and endeavoring to transform conditions of inequity [35].Quantitative content analysis is valid to systematize large quantifiable data from statistical analysis and controlled experiments; however, it remains limited in capturing deeper meanings of broader socio-cultural developments and thematic relationships.

3. Syndemic Connections: GBV, Substance Use and HIV/AIDS

Singer identified the first syndemic in the mid-1990s as the interaction between substance abuse, violence and AIDS or SAVA:

“From the syndemic perspective, AIDS, drug use and violence in particular contexts are so entwined with each other and each is so significantly shaped by the presence of the other two that if one tries to understand them as distinct things in the world, it is hard to conceive of them accurately” [33].

Downe [10] illustrated a similar position in the ethnography of the Saskatchewan HIV syndemic, which explained that the HIV/AIDS epidemic plaguing Indigenous populations in the Canadian prairies at eleven times the national average was a result of structural violence—the chronic and systemic disadvantages of those living in impoverished and oppressive contexts. However, Downe added that the HIV/AIDS epidemic in Canada was not an independent health issue but was linked with the hepatitis C virus (HCV), a blood-borne virus that infects the liver; similar to HIV, it can be transmitted through shared needles and injection drug use [10].

Likewise, many scholars [36,37,38] have demonstrated that substance misuse is a form of structural violence, driven by social factors beyond individual control. Consequently, self-medication with psychoactive drugs becomes an avoidant coping strategy that is often employed by those living in precarious and oppressive conditions. Structural violence extends general definitions of violence beyond physical, emotional and psychological harms, leading to severe injuries and loss of life as highlighted in Canada by the systematic oppression of Indigenous Peoples. Lacking access to fundamental resources itself constitutes a form of violence.

Unquestionably, structural violence against women is a main driver of GBV, which is exacerbated when alcohol and other psychoactive substances are involved [32]. GBV affects disproportionately women who use psychoactive drugs and exacerbates their risk of HIV infection [34].Despite limited population-level data quantifying GBV that affects women who use psychoactive substances, international studies based on national surveillance estimates suggest that women substance users experience IPV and other forms of GBV five to twenty-four times more often than the general female populations [34,39,40].

The syndemic connections between GBV, substance use and HIV/AIDS can entrap individuals in an unending vicious cycle: structural violence predisposes vulnerable populations to GBV, who may turn to psychoactive drugs as a coping mechanism to relieve and escape from their painful experiences. However, temporary relief from their immediate struggles through substance use may lead to long-term unintended negative consequences by deepening their experiences of structural violence through drug addiction, exposure to infectious diseases and escalation of GBV that may culminate with victims’ violent deaths.

Substance use can also heighten feelings of irritability, jealousy and paranoia among perpetrators of GBV as well as impair women’s judgement when faced with a potentially risky situation in which they lack the ability to negotiate for condom use with an intimate partner or when engaging in sex work to support their families or drug needs [34,41]. In cases when women’s intimate partners provide them with drugs, power differentials can also be intensified whereby women may be compelled to have sex in exchange of drugs or money. Below, Tracy, a client at the methadone treatment program where this study’s field research was conducted, shared a similar dilemma:

When I started out (doing sex work), men would basically threaten me, I needed a place to sleep, I had got myself in a lot of positions that I couldn’t or had trouble getting out of, where it would be really cold outside and a man would be threatening me pretty much, but I would be stuck with him all night, because I needed the money…

Dependencies on male partners for drugs are further associated with increased risks of HIV/AIDS and drug overdoses among women [39,42]. In the context of our patriarchal society where toxic masculinist norms are pervasive, they may shape drug use, especially when drug supplies are limited. For example, women are reportedly second to use syringes after their male partners inject their drugs first. As such, sharing potentially contaminated needles predisposes women to HIV/AIDS and other infections [39,43]. Further, criminalization of drug use and sex work can marginalize women, driving them away from health and social services for several reasons: fear of arrests; fear of child welfare services’ involvement, with the possible removal of children under their care; and harassment by law enforcers or even by staff and clients attending harm reduction services such as drug consumption sites [34,44]. Recent research [45,46] has confirmed the author’s previous studies that males predominantly utilize harm reduction facilities. Resultantly, women have been sexually harassed by male clients and even by staff members when accessing harm reduction services that still lack a gender-informed approach. As Sheila another participant in the methadone treatment program explained:

If you look nervous when they’re taking your blood, they (staff members) say ‘what’s the matter with you? You’re used to shooting, this shouldn’t be a problem!’ Well, this is hurting, and I think to myself, if I was sticking the needle myself, I’d be doing a better job…I’d find the vein right away…

These cited staff comments illustrate structural barriers that may deter women from seeking help for their drug addiction or securing protection from violent partners through institutional settings, thus increasing their risk of GBV, drug overdoses and re-victimization by service providers.

4. Syndemic Connections: GBV, Mental Health and Substance Misuse

There is substantial multidisciplinary research evidence indicating that women substance users are more likely to have experienced sexual and physical assault and abuse as children or as adults and to continue being disproportionately exposed to IPV, which demonstrates structural inequalities between men and women who use psychoactive drugs [4,32,40,47,48].

Throughout a long career span, psychiatrist Van der Kolk [48] has studied the impacts of different forms of trauma on one’s mental health, noting that many contemporary health issues such as anxiety, depression, ADHD, PTSD, obesity, cardiovascular conditions, substance misuse, HIV/AIDS and others are rooted in developmental trauma shaped by adverse childhood experiences (ACEs). The latter is a term coined by medical researchers Vincent Felitti, Robert Anda and other colleagues in their study conducted at the CDC-Kaiser Permanente’s Department of Preventive Medicine in San Diego, USA [49]. This 1995–1997 study was one of the largest investigations on the impacts of childhood abuse, neglect and household challenges toward later-life health and well-being. In short, Felitti’s team found that adverse experiences are interrelated even though they are usually studied separately. Drawing from this research, Van der Kolk poignantly writes:

People typically don’t grow up in a household where one brother is in prison but everything else is fine. They don’t live in families where their mother is regularly beaten but life is otherwise hunky-dory. Incidents of abuse are never stand-alone events. And for each additional adverse experience report, the toll in later damage increases [48].

Similarly, a recent 30-year study [50] followed people from early life to age 29. It shows that poor-quality care in infancy was, nearly three decades later, associated with a higher volume in an emotionally crucial brain structure—the hippocampus—as well as with an elevated risk of “borderline personality” features and suicidality.

Indeed, many women participants in this ethnographic research described their substance use as a coping strategy to deal with chronic pain and to dissociate from their bodies as they attempted to grapple with past traumas as well as to escape from ongoing extenuating circumstances. For example, Tracy, who was in her 40s at the time of our interview in the mid-2000s, had used illicit substances since she was a teenager, when she left home in a small town in southern Ontario to move to Toronto. Without any income, she ended up relying on sex work to survive. Contrary to popular perceptions, she did not engage in sex work to buy illicit drugs. Rather, in her own words, drugs made her feel “less shy”. She felt that her middle age was both a deterrent to changing occupations and a handicap on the streets as she admitted she could not compete with “younger girls” in her underground sex work. In the following passage, she speaks of the elusive empowerment that she derived from acquiring her own drugs rather than being dependent on men for her drug supply:

Drugs are a great equalizer…and a lot of the users are men. I found that in my life, a lot of people wanted to use me to get drugs or money. Because I was a sex worker, somebody could move in on me and use the drugs or for my money. Now, I’ve managed to call the shots instead of men calling the shots on me and making me have sex with them for a price that they wanted or anything else because they had got me there. I wanted to be able to call the shots, get them out and I’d have the money and I could spend it on anything I wanted! And I’d be able to take that money and go to a male dominated place, because drugs are mostly sold by men and I can buy my drugs and I could decide what to do with my drugs and no man would think to entice me because he had drugs. I had my own!

Contradictorily, despite no longer being dependent on men to acquire her drugs, her dependency on illicit substances to cope with an uncomfortable job entrapped her in a vicious cycle of continuous structural vulnerability: using illicit drugs to facilitate a limiting income opportunity put her at risk of GBV, exposing her to infectious diseases and developing an opioid addiction. At the time of our interview, she had already undergone several unsuccessful drug treatment programs. Throughout the years we had known each other, she had relapsed multiple times even while participating in the methadone treatment program that required her to gradually abstain from illicit substances.

As can be seen from the above ethnographic example, and corroborated by other studies, [10,32,39,40] women often use psychoactive drugs to deal with GBV throughout life, but contexts of drug use expose them to greater economic deprivation, social exclusion, homelessness and substance misuse. Early childhood and adult traumatic experiences predispose women to use psychoactive drugs to cope with emotional, psychological and physical pain, but once they become drug-dependent, they are vulnerable to lifetime GBV occurring in their immediate and/or institutional environments as they navigate different worlds, negotiating between what we could call choiceless choices: avoiding intense drug withdrawal or sharing potentially contaminated needles; relying on precarious work or being financially deprived; supporting their families or dealing with child welfare services; leaving abusive intimate partners or facing unreliable criminal justice, law enforcement and limited community support.

Undoubtedly, both survivors and women’s services advocates have pointed to massive failures of our governments and institutions to address GBV as a systemic issue [51,52]. In a CBC podcast [51] entitled the “Ex-wives Club”, four women recount their harrowing stories of GBV as they were married to the same man in different provinces and territories. They found support with each other through social media after the criminal justice system had failed them by not connecting their perpetrator’s patterns of violent behaviour in different jurisdictions. Instead, either his charges were dismissed or he was released without further warnings about his prior offenses in any of the communities that he had relocated into. His last charges of aggravated assault were dropped after his fourth partner failed to appear in court because of her severe medical issues, caused by his violent assault. Likewise, the perpetrator who committed the mass shooting of 22 people in Nova Scotia in April 2020, had been a wealthy White professional man whose patterns of violent behaviour against his partner of 19 years, neighbours and patients had been dismissed due to implicit bias by police who never followed up on complaints of violence against him [21]. These types of systemic failures demand closer scrutiny of our government, criminal justice and law enforcement approaches to GBV, which must be addressed as a societal issue with coordinated efforts and additional resources for prevention and intervention efforts similar to the rapid public health responses towards the COVID-19 pandemic. The latter has undeniably caused a significant increase in GBV incidence rates [53,54] which have remained unchanged despite significant improvements in COVID-19 outcomes [52,55].

5. Syndemic Connections: GBV, Opioid Overdose Death Crisis and COVID-19

According to the latest government and media sources, nearly 6000 people died of an opioid-related overdose between October 2022 and April 2023 [56,57]. The overdose death crisis that continues to afflict Canadian populations is not an isolated health issue. Across Canada, it is intertwined with HIV/AIDS, COVID-19 and GBV, all shaped by structural violence. First Nations residents are five times more likely to experience an opioid-related overdose event and three times more likely to die from opioid-related causes than non-First Nations residents. Northern Indigenous communities experience higher opioid-related challenges because of inadequate access to health and addiction treatment services [58,59]. In understanding how socio-structural factors can predispose individuals to opioid use and why many Canadians live in chronic pain, are cross-cultural studies of somatization in which individuals in many cultures use personally meaningful and culturally acceptable bodily idioms such as pains and aches to communicate personal distress instead of using psychological affect such as sadness, hopelessness or depression, to describe their mental health. Presenting their symptoms in a somatized rather than a psychologized language may mitigate the stigma often associated with mental illness [60,61]. In this context, opioid use becomes a form of self-medication for personal distress that is mediated through expressed physical rather than psychological symptoms. Even within medical communities, it has been recognized that patients who use pain medication beyond two to three months for their injuries are more likely to be suffering from depression, related psychosocial distress or underlying trauma [62]. Thus, life events rather than inherently biological factors can compel individuals to opioid use. Considering these broader socio-structural underpinnings affirms the importance of a more comprehensive policy framework that approaches the opioid death crisis and other intersecting public health emergencies as societal issues, supporting meaningful prevention and intervention efforts, comprising diverse knowledges and practices for removing structural barriers to quality care.

As communities across North America grapple with increasing rates of opioid overdoses and fatalities, the Canadian Government has attempted to take a coordinated approach to address this national crisis. A substantive policy change occurred in 2017, when the National Anti-Drug Strategy (NADS), which had relied heavily on enforcement action, was replaced with the Canadian Drugs and Substances Strategy (CDSS) [63]. The latter supported a four-pillar model in the addiction field, integrating prevention and harm reduction with treatment and enforcement [64]. The stated focus of this new initiative was a public health approach to substance misuse, underscoring a “collaborative”, “compassionate” and “evidence-based” approach to drug policy [63]. Despite the combined biomedical, legal and bureaucratized harm reduction efforts instituted under the CDSS, the opioid epidemic remains intact and fatal overdoses have increased at an even higher rate prior to and even more so during the COVID-19 pandemic in Canada, being overshadowed by the latter public health emergency. Ning and Csiernik [65], discuss why the opioid death crisis has remained unchanged in Canada despite more concerted federal government efforts to approach it as a public health issue. Here, readers’ attention is drawn to the intersections between GBV, the opioid overdose death crisis and COVID-19 because only the latter two have been addressed nationwide as public health emergencies. As mentioned earlier, both the 2022 public inquest into the triple femicide in Renfrew County and the 2023 MCCFR [26] on the mass shooting in Nova Scotia demanded, to no avail, that our federal government declared GBV an epidemic so that it could be addressed as a public health issue through coordinated efforts and higher allocation of resources for prevention and intervention measures similar to the COVID-19 pandemic.

As the World Health Organization (WHO) declared COVID-19 a worldwide pandemic on March 11, 2020, prompting immediate public health responses that ranged from masking, social distancing to lockdowns that encouraged everyone to stay safely at home, women were disproportionately impacted in what the UN Commission on the Status of Women (CSW) termed the “Shadow Pandemic”, and the WHO called GBV a “Twin Pandemic”. The Ontario Chamber of Commerce [66] reported that women’s labour participation rate had fallen to its lowest in 30 years. At the outset of the pandemic, temporary business shutdowns and layoffs most severely affected occupations and sectors that predominantly employed women such as in the hospitality, retail, service and small business industries. Additionally, restrictions on schools and paid child-care facilities shifted additional hours of unpaid family care onto parents, and this work was largely undertaken by mothers. Further, while women are still dominating the frontline response as health care providers, workers and child or elder caregivers, they have not been widely included in the planning for post-pandemic recovery [54]. Additionally, the long-term impacts of COVID-19 on women in the workforce remain unknown. Worldwide, a major unintended negative consequence of COVID-19 on women was the rise of IPV. Lockdowns put women in abusive relationships more at risk. Research has shown that distress calls from women using helplines in different countries increased between 20–50% [53,67].

The governments’ slogan “Stay Home and Stay Safe” did not resonate with many adults and children living in situations of domestic abuse and family violence. Home is not always a safe place for many as it is where physical, psychological and sexual abuse occurs. During lockdowns and social distancing measures, dynamics of power within households could be distorted by those who abused, without scrutiny from others outside of a couple or family unit. Stringent restrictions on movement resulted in lesser avenues of escape, help-seeking and ways of coping for victim–survivors, as community resources such as women’s shelters were also closed down in response to the public health restrictions. Social distancing measures could grant people who abuse more freedom to act out without scrutiny or consequence, further reinforcing existing social norms surrounding ideas of the sanctity of family life that make it difficult for people to speak out about and leave abusive situations, coupled with feelings of shame and embarrassment [53,54,67].

While public health resources and interventions were quickly channeled to curb the COVID pandemic, lesser efforts have been undertaken to address GBV at a societal level despite its significant increase during the COVID pandemic and its continued higher incidence rates after the pandemic [52,55]. Thus far, the onus has been mainly on the criminal justice system, law enforcement and limited women-run community resources to address this systemic issue that has encountered massive systemic failures. Despite the recent move by our federal government to pass the NAP to End Gender-Based Violence [13], its commitments remain primarily at the discursive level, lacking visible implementation in the form of financial investments such as increasing the availability of women’s shelters as GBV across the country continues to rise without an end in sight [55], and many Canadians are struggling in a post-pandemic, inflationary context of rising food, housing and fuel prices, which are major structural challenges to secure living.

Overall, Canadian public health policy lacks an open discussion of pressing public health issues (overdose death crisis, HIV/AIDS, COVID-19 and GBV) in the context of post-colonialism in which issues of racism, intergenerational trauma and structural violence continue to exclude many vulnerable populations from accessing critical resources such as adequate food, clean water, housing, employment and education. This omission has led to higher morbidity and mortality rates among equity-denied groups [30,37,68]. Biomedical and policy discussions of substance misuse, infectious diseases and GBV are mainly desocialized, with limited consideration of the social context.

In recent years, media, educational and public health sectors have focused on athletes’ concussions or head injuries in the context of contact sports, prompting demands on health and safety via multiple interventions such as improved sports equipment including safer helmets and even policy changes regarding specific sports’ rules and regulations such as restricting body checks [52,69,70]. However, many women who have sustained severe head injuries as a result of GBV suffer alone from long-term physical, emotional and financial adversities as they cannot resume previous work responsibilities that require full concentration, attention, memory and focus. In some cases, their head injuries have been used against them in legal custody battles whereby their former spouses’ lawyers use the women’s cognitive impairments as justification of being “unfit mothers” for their children, thus leading to deeper suffering, re-victimization and personal losses [52]. As well, concussions or head injuries suffered through GBV can generate feelings of shame and stigma for women who may be embarrassed to share that they had been victimized by IPV, when concussions are typically associated with involuntary physical activities such as a fall or a sports accident.

6. Policy Implications of GBV as a Societal Issue

Aside from declaring GBV as an epidemic to be addressed as a systemic issue, a main recommendation by the MCCFR [26] and even by NAP to End Gender-Based Violence [13] is to emphasize prevention rather than reactive measures towards GBV. In this respect, establishing educational programs at schools from elementary to secondary levels up to grade 12 to raise awareness of this pressing issue becomes paramount. Given the deeply embedded socio-cultural and political structures in Canadian society which support and/or ignore multiple forms of GBV and considering the tremendous health implications that this form of violence perpetuates by leading to disproportionate harms to different groups and communities, coordinated prevention and intervention efforts encompassing feasible educational, policy and social awareness initiatives are critically needed. In particular, meaningful initiatives must target the root causes of GBV including misogyny, implicit bias in our institutions, normalization of violence in conflict resolution, gender devaluation and banter in everyday conversations as well as promoting supports for both survivors and perpetrators to unlearn socially constructed and (un)acceptable norms and behaviours.

More importantly, appropriate implementation of resources to address GBV as a systemic issue must involve an effective coordination between health and social services, including multidisciplinary collaboration between diverse ways of knowing, being and doing beyond Western systems of thought. To date, Indigenous ways of knowing, health and well-being including insiders’ voices have been substantially omitted from mainstream policy-making and practices. In the context of Canada’s health care system, a cultural bias exists whereby universal standards derived from biomedical evidence bases become the gold standard and the most pervasive forces for medical and public health professions to establish the efficacy and safety of clinical interventions to address population health, excluding other possibly feasible local practices that lack scientific evidence [38]. Particularly, complementary and alternative medical modalities and Indigenous forms of knowledge have been systematically excluded from mainstream health care delivery because of insufficient biomedical evidence [71,72]. In contrast, emerging social science literature [73,74] has considered the relevance of multiple ways of knowing to evaluate diverse therapeutic outcomes. This analytical approach broadens the meaning of evidence, allowing bioscience and traditional knowledge to co-exist and become integrated in the production of scientific evidence. This epistemological framework creates a space where evidence-informed approaches to policy-making can be embedded in decolonizing approaches, allowing cultural models of health care to become part of public health interventions.

Canada’s colonial history of knowledge production in the health field is well documented with knowledge taken from Indigenous communities without consideration of its cultural significance or meaning outside of Western worldviews [30,59]. As most health research is grounded in an individualistic, Western approach, this perpetuates the legacy of colonialism by denying the validity of insiders’ own personal or cultural understandings of health and well-being. Further, because of historical overemphasis on biomedical explanations of health in mainstream society, the strengths of Indigenous perspectives of health and medicine have been either overlooked or only superficially documented. Locating insiders’ perspectives within the cultural logic of their lived experiences is instrumental because some perspectives of health and healing such as Indigenous understandings revolve around holistic concepts of unity and balance across biological, psychological, social and spiritual aspects of life and not simply the absence of disease, contrary to Western biomedicine [30].

Experts often propose interventions without the voices of the impacted communities including individual sufferers and their peers and families to fully understand their real needs and what they consider as meaningful solutions. Thus far, it is assumed that only biomedical and public health experts hold legitimate evidence bases to demonstrate effective prevention and intervention efforts. While our government policy may discursively endorse GBV as an epidemic and attempts to eliminate it in society, it also fails to affirm key principles that entail destigmatizing people who suffer from GBV and involving them in policy-making. Failure to consider substance users, GBV survivors and HIV/AIDS and COVID-19 sufferers as equity-deserving citizens and capable collaborators with experiential expertise contravenes Canada’s “evidence-based”, “compassionate” and “collaborative” public health orientation in its recent health mandates [65,75].

7. Conclusions

Drawing upon textual and ethnographic data about the interconnections between health and social issues, this article endeavoured a deeper critical analysis of currently pressing issues within our communities such as gender-based violence (GBV), mental health, infectious diseases (HIV/AIDS and COVID-19) and the opioid overdose death crisis by approaching them as synergistically interrelated conditions rather than as isolated incidents. Through the theoretical lens of syndemic frameworks, the underlying structural roots of GBV were uncovered, including its overlapping connections with publicly recognized epidemics, thus showing that they are not divergent or cumulative epidemics, but together, they all amount to a contemporary Canadian syndemic, shaped by structural violence. By critically examining academic, media, government and ethnographic sources, this study provides a more comprehensive understanding of GBV in interaction with other health and social matters, debunking common assumptions about the biological determinants of particular afflictions, while also putting forward appropriate pathways to effectively guide policy responses to a major societal issue.

Given the predominance of biomedical and Western ways of knowing in our society, it was argued that our government responses to GBV lack an encompassing public health orientation as GBV is not confronted as an urgent “epidemic” in the literal sense, being unconnected with any organic pathogen. As demonstrated through its syndemic connections with other public health emergencies, GBV is a systemic issue that requires an effective coordination between health and social services, including multidisciplinary collaboration between diverse ways of knowing, being and doing beyond Western systems of thought. As it disproportionately affects vulnerable populations such as Indigenous women and girls, Indigenous ways of knowing, health and well-being including insiders’ voices must be considered in mainstream policy-making and practices. This epistemological framework creates a space where evidence-informed approaches to policy-making can be embedded in decolonizing approaches, allowing cultural models of health care to become part of public health interventions.