Pan­demic Lessons for Fix­ing Canada’s Health Care Sys­tem

Policy - - In This Issue - Ge­off Norquay

As with all crises, the COVID-19 pan­demic has ex­posed strengths and weak­nesses in Canada’s health care sys­tem at all lev­els: pub­lic health, ac­tive treat­ment and physi­cian ser­vices. While our ju­ris­dic­tional ar­chi­tec­ture has proven both good and bad dur­ing the cri­sis, gov­ern­ments at all lev­els will need to col­lab­o­rate to close all the other ca­pac­ity gaps.

Cana­di­ans are right­fully proud of their health care sys­tem; the vast ma­jor­ity of our cit­i­zens value it as a defin­ing fea­ture of our ci­ti­zen­ship. The cur­rent pan­demic has re­sulted in un­prece­dented pres­sures be­ing placed on Cana­dian health care, so how has the sys­tem fared, how is it hold­ing up and what have we learned so far?

Like much else in the COVID-19 odyssey, the re­port card is mixed. In some re­spects, Cana­dian health care has held firm and per­formed ad­mirably; in oth­ers, such as long-term care for se­niors, the out­comes are abysmal. In terms of pan­demic plan­ning, Canada was caught flat-footed, but so was ev­ery other coun­try in the world.

At times, Canada’s fed­eral-provin­cial-ter­ri­to­rial di­vi­sion of pow­ers has caused real chal­lenges in cre­at­ing

timely and co­or­di­nated re­sponses. In the wide­spread take-up of tele-health prompted by the pan­demic, the sys­tem has adopted new ap­proaches that are likely to rev­o­lu­tion­ize the de­liv­ery of health care in the fu­ture.

At the broad­est level, there are three sides to health care in Canada: pub­lic health, ac­tive treat­ment and the pro­vi­sion of physi­cian ser­vices. Pub­lic health has al­ways placed a dis­tant sec­ond to the im­por­tance of acute care and doc­tors in the health care sys­tem. It has a broad man­date—the pro­mo­tion of pop­u­la­tion health—and its nor­mal con­cerns are such threats as sea­sonal flus, oc­ca­sional out­breaks of measles, the opi­oid epi­demic, obe­sity and sex­u­ally trans­mit­ted dis­eases.

The re­spon­si­bil­ity for pan­demic plan­ning is sub­ject to peaks and val­leys in po­lit­i­cal de­ci­sion-mak­ers’ in­ter­est— high im­por­tance in the face of events like SARS and H1N1—but re­ced­ing as a top of mind is­sue as time passes and mem­ory fades.

This re­al­ity, plus Canada’s fed­eral-provin­cial struc­ture, is what caused this coun­try to be un­pre­pared for the need for per­sonal pro­tec­tive equip­ment (PPE) gen­er­ated by COVID-19. Sev­eral months into the pan­demic, Canada is still strug­gling to en­sure ac­cess of front-line work­ers to es­sen­tial PPE. This oc­curred for two rea­sons: first, the prov­inces al­lowed their stock­piles to dwin­dle and be­come out of date; and sec­ond, the fed­eral gov­ern­ment took a lack­adaisi­cal ap­proach to main­tain­ing the na­tional emer­gency stock­pile of this equip­ment.

At both lev­els of gov­ern­ment, there were lapses in on-time re­place­ment of PPE that had reached its best-be­fore date. In ad­di­tion, when the pan­demic struck, the sys­tem ex­pe­ri­enced chal­lenges re­lated to dis­tri­bu­tion of sup­plies. In April, CBC dis­closed that in 2019, the fed­eral gov­ern­ment threw out two mil­lion N95 masks and 440,000 med­i­cal gloves when it shut down an emer­gency stock­pile warehouse in Regina. The masks had ex­pired five years be­fore in 2014. The ab­sence of an ad­e­quate sup­ply of PPE has led to a mad scram­ble by both the fed­eral gov­ern­ment and the prov­inces to source crit­i­cal sup­plies in a chaotic and highly com­pet­i­tive mar­ket.

Now that the prov­inces are re-open­ing their economies stage by stage, Cana­di­ans are crit­i­cally de­pen­dent on the im­ple­men­ta­tion of mas­sive “test, trace and iso­late” mea­sures across the coun­try. These mea­sures are es­sen­tial to the coun­try’s abil­ity to de­tect pos­si­ble spikes in com­mu­nity trans­mis­sion of the virus if the pace of re­turn­ing to nor­mal is too fast. Tes­ti­fy­ing be­fore the House of Com­mons health com­mit­tee on May 19, Dr. Theresa Tam, Canada’s Chief Pub­lic Health Of­fi­cer, said that the 30 test­ing labs in Canada have a daily ca­pac­ity for roughly 60,000 tests, but on av­er­age, only 27,000 are cur­rently be­ing per­formed by prov­inces and ter­ri­to­ries. On­tario and Que­bec have faced al­most con­stant chal­lenges in com­plet­ing suf­fi­cient num­bers of tests.

If an army marches on its stom­ach in a time of war, in a pan­demic, pub­lic health of­fi­cials and epi­demi­ol­o­gists march on ac­cu­rate and com­pre­hen­sive data. They need to see the spread of the virus in real time to form ef­fec­tive re­sponses and mo­bi­lize re­sources. This means timely data on pos­i­tive cases and their lo­ca­tion, the num­bers of deaths and where they are oc­cur­ring, the num­ber of re­cov­ered cases and how many tests are be­ing per­formed. On data col­lec­tion and its de­pend­abil­ity, Canada’s ex­pe­ri­ence in 2020 is that the whole is not greater than the sum of the parts.

In re­al­ity, Canada has no na­tional pub­lic health data sys­tem; once again our creaky fed­eral/provin­cial/ter­ri­to­rial struc­ture gets in the way. As Dr. Tam told the Com­mons health com­mit­tee in May, “We ac­tu­ally have na­tional case def­i­ni­tions, but it’s up to the prov­inces and ter­ri­to­ries to…re­port to us ac­cord­ing to the def­i­ni­tions, but some­times that does vary and we do have cer­tain data gaps that we must ad­dress.” In post-pan­demic Canada, the ab­sence of de­pend­able data is a chal­lenge that must be over­come.

In the early stages of the pan­demic, sig­nif­i­cant con­cern was ex pressed that vic­tims of the virus might flood this coun­try’s ac­tive treat­ment ca­pac­ity and col­lapse it, as oc­curred in such coun­tries as Italy and Spain. With 57,000 hos­pi­tal beds, Canada’s com­par­a­tive rank­ing in beds per 1,000 peo­ple is the low­est of all Or­gan­i­sa­tion for Eco­nomic Co-op­er­a­tion and De­vel­op­ment (OECD) coun­tries and our oc­cu­pancy rates tend to­wards be­ing the high­est. Even in nor­mal times, the per­sis­tence of “hall­way medicine” is a ma­jor chal­lenge for provin­cial health sys­tems.

Likely due to the shut­down of the econ­omy and the suc­cess of self-iso­la­tion and so­cial dis­tanc­ing in flat­ten­ing the curve, the much-feared run on acute care never hap­pened in most prov­inces. There was one no­table ex­cep­tion. Be­cause of the vir­u­lence of the out­break in Que­bec, that prov­ince came the clos­est to catas­tro­phe. In early May, an as­tound­ing 11,600 of its front-line health care work­ers were miss­ing from the sys­tem—sick, quar­an­tined or afraid to go to work. That sit­u­a­tion per­sisted for weeks.

When the pan­demic took hold in mid-March, prov­inces can­celled elec­tive surg­eries to pro­tect their hos­pi­tal ca­pac­i­ties in the event of an in­flux of COVID-19 pa­tients. As a re­sult, thou­sands of Cana­di­ans can now be counted as the col­lat­eral dam­age of our chron­i­cally low num­ber of ac­tive treat­ment beds. Based on an ex­trap­o­la­tion of On­tario and British Columbia’s share of the pop­u­la­tion, the re

In the wide­spread take-up of tele-health prompted by the pan­demic, the sys­tem has adopted new ap­proaches that are likely to rev­o­lu­tion­ize the de­liv­ery of health care in the fu­ture.

sult is a back­log of as many as 189,000 de­layed surg­eries na­tion­wide. These de­fer­rals now need to be cleared, and B.C. es­ti­mates that it will take as long as two years.

On the pos­i­tive side of the pan­demic, in just three months Canada has seen a sea-change in the use of telemedici­ne—the de­liv­ery of med­i­cal care and in­for­ma­tion us­ing telecom­mu­ni­ca­tions tech­nolo­gies. With peo­ple warned away from hos­pi­tal emer­gency de­part­ments and many physi­cians’ of­fices closed or re­strict­ing vis­its, doc­tors and pa­tients quickly em­braced ac­cess to and de­liv­ery of med­i­cal care through on­line plat­forms.

With the boom in the use of tele­health ap­proaches, apps for doc­tor-to-pa­tient in­ter­ac­tions such as ZOOM, GoToMeet­ing and have pro­lif­er­ated. Pa­tients with­out a physi­cian can ac­cess one through Cloudmd, and Med­imap now pro­vides quick ac­cess to vir­tual ap­point­ments with walk-in clin­ics. The good news is that provin­cial fee-for-ser­vice re­im­burse­ment sys­tems are be­gin­ning to catch up with these new re­al­i­ties. In April, British Columbia changed its physi­cian pay­ment mod­els to ac­com­mo­date vir­tual medicine.

The apoca­lypse that has be­fallen Canada’s frail el­derly liv­ing in long-term care fa­cil­i­ties stands as the great­est fail­ure of our health care sys­tem in the cur­rent pan­demic. It is also a sear­ing na­tional shame. Roughly 400,000 Cana­di­ans live in these fa­cil­i­ties and as of late May, ac­cord­ing to the Na­tional In­sti­tute on Age­ing (NIA), 80 per­cent of all COVID-19-re­lated deaths in Canada—5,324 out of a to­tal of 6,599 deaths—were res­i­dents in long-term care set­tings.

With stun­ning pre­science, a late-2019 study by the NIA counted the ways that long-term care homes were court­ing dis­as­ter with con­di­tions that would spread in­fec­tions: peo­ple liv­ing close to­gether in res­i­dences that suf­fered from chronic staff short­ages, and low­paid em­ploy­ees forced to work part­time in sev­eral dif­fer­ent fa­cil­i­ties.

These long­stand­ing is­sues are com­pli­cated by Canada’s ju­ris­dic­tional struc­ture: 13 sep­a­rate and of­ten pro­tec­tion­ist po­lit­i­cal and ad­min­is­tra­tive sys­tems; dif­fer­ent standards from ju­ris­dic­tion to ju­ris­dic­tion; mixed pub­lic, pri­vate and phil­an­thropic own­er­ship, con­founded by the lack of in­clu­sion of these fa­cil­i­ties un­der the Canada Health Act. When the pan­demic is over, there will be a reck­on­ing on long-term care in Canada; it will be painful and com­plex…and very ex­pen­sive.

Epi­demi­ol­o­gists and pub­lic health plan­ners are quite cer­tain that COVID-19 is far from done with Cana­di­ans and our health care sys­tem. A re­cent pa­per by the Cen­ter of In­fec­tious Dis­ease Re­search and Pol­icy (CIDRAP) at the Univer­sity of Min­nesota ar­gues that the best com­par­a­tive model for pre­dict­ing what comes next can be learned from the in­fluenza pan­demics that oc­curred in 1918-19, 1957, 1968 and 2009-10: “Iden­ti­fy­ing key sim­i­lar­i­ties and dif­fer­ences in the epi­demi­ol­ogy of COVID-19 and pan­demic in­fluenza can help en­vi­sion­ing sev­eral pos­si­ble sce­nar­ios for the course of the COVID-19 pan­demic.”

Based on the ev­i­dence from pre­vi­ous in­fluenza pan­demics and what is known about COVID-19, the re­searchers con­clude that there are likely three pos­si­bil­i­ties for the fu­ture progress of the virus:

Sce­nario 1, in which the cur­rent peak is fol­lowed by “a se­ries of repet­i­tive smaller waves that oc­cur through the sum­mer and then con­sis­tently over a 1- to 2-year pe­riod, grad­u­ally di­min­ish­ing in 2021.”

Sce­nario 2, where the Spring 2020 wave is fol­lowed by a larger wave this com­ing fall or win­ter and smaller waves in 2021.

Sce­nario 3, in which the cur­rent ini­tial wave is fol­lowed by “a ‘slow burn’ of on­go­ing trans­mis­sion and case oc­cur­rence, but with­out a clear wave pat­tern.”

What this means is that we are now in a race be­tween the de­vel­op­ment of herd im­mu­nity and the dis­cov­ery of a vac­cine against the virus. Un­til a vac­cine be­comes avail­able, suc­ces­sive waves of in­fec­tion will con­tinue to sweep through the pop­u­la­tion, build­ing to­wards the achieve­ment of herd im­mu­nity. Only a vac­cine can put a stop to the virus.

The pos­si­bil­ity of con­tin­u­ing stops and starts to eco­nomic ac­tiv­ity to stem the spread of fu­ture out­breaks is a daunt­ing prospect for both gov­ern­ments and the na­tional psy­che. At the very least it means the ne­ces­sity of re­dou­bling cur­rent ef­forts to put in place test, trace and iso­late mea­sures that are com­pre­hen­sive and ro­bust, as well as se­cur­ing de­pend­able sup­plies of per­sonal pro­tec­tive equip­ment to pre­pare for the next wave.

Among the top-tier lessons we’ve al­ready learned: pre­pare for the worst.

Con­tribut­ing Writer Ge­off Norquay, a prin­ci­pal of the Earn­scliffe Strat­egy Group, is a for­mer so­cial pol­icy adviser to Prime Min­is­ter Brian Mul­roney and com­mu­ni­ca­tions di­rec­tor to Stephen Harper in op­po­si­tion.

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