Economic, health plans not in sync, critical care doctor says
Michael Warner worries. He’s a critical care doctor, so maybe he is used to seeing emergencies, but he also sees solutions. He spearheaded a wildly successful drive for personal protective equipment in the COVID-19 crisis. His hospital, Michael Garron, has been proactive in protecting long-term-care homes. There’s excellent work being done there.
But right now one of Toronto’s leading doctors is worrying Ontario’s public health infrastructure might have wasted our COVID-19 lockdown. And that without solutions it could cost us, now and later.
“Everyone that we know has sacrificed,” says Warner, Michael Garron Hospital’s medical director of critical care. “We’ve been blowing our brains out in the ICU preparing for an onslaught, we’ve been so careful with our current patients, and I’ve been relying on the preventative health-care people to kind of take that time to figure out what they need to do, tell us what the plan is.
“The public health plan has to be in lockstep with the economic plan. They have to come together. And I haven’t seen that.”
Ontario is in Stage 1 of reopening. Some retail stores are open again. Golf courses, marinas, and bizarrely, nannies and housecleaners are among those back in the game. Toronto opened up some park amenities Wednesday, with a thicket of specific rules attached. Life is an experiment now.
Meanwhile, Ontario is testing far below its capacity, and completed tests dipped precipitously over the past few days, even as daily new cases continue to plateau; the province is only now helping newly reopened businesses test. We aren’t doing proactive testing in the community.
Even if cases were dropping, contact tracing and isolation are keys: as Warner says, “Sure, you can wear masks when you go to the car dealership, but that has nothing to do with testing, tracing, isolating, and supporting people.”
And Warner isn’t seeing that yet, even though the hospital level is where we can best respond to community outbreaks. Warner offers an example: when he sees a patient now, he can tell within 10 minutes whether they have COVID. But hospitals have no way of sending that information to Toronto Public Health, which could launch immediate investigation of the patient’s contacts.
Michael Garron’s infection prevention and control team contacts household contacts of COVID patients at the hospital. Warner says of the 500 they have chased, Toronto Public Health beat them there once.
Toronto Public Health says it chases contact information after getting the result from the lab, which creates a delay of between one and two days, or more.
“I don’t pretend to know how to contact trace, but I can tell you who has COVID,” says Warner. “And when I call family members, they ask me when public health is going to call them. When I’m talking to them two of three days later about life support, or ventilators or decisions, they will ask me, when is public health going to call me? And then I’m doing the education on the phone. Which I can do, but come on.
“And (Ontario Public Health is) aspiring for 90 per cent contact tracing within 24 hours. So that’s aspiring for mediocrity. We need to blow this out of the park. We need to be so good at this. That’s the only way we’re going to get ahead of this. And then we set a mediocre standard we aspire to that we’re not even reaching. It’s inexcusable.
“And that’s the only way the economy will get going, if we get rid of this thing, not just let it linger in the community.”
In a pandemic often driven by clusters and super-spreaders, the hospital often sees clusters in families and apartment buildings, often from Thorncliffe Park and Crescent Town. There is no self-isolation in shared apartments with one bathroom and no publicly funded hotels to go to.
“People are saying it’s indiscriminate, but it is discriminate,” says Warner. “I’m seeing socially disadvantaged people with medical comorbidities being preferentially affected by this, who don’t have the ability to protect themselves from contacts where they live or potentially work. And that’s not fair. “We know where the hot spots are. We can identify them before public health. And we are reaching out to those communities. We want to help public health do their job. It’s not that we want to throw them under the bus; we want to be an asset.
“I should have some way of informing them what I see, because I see where all these people live. I know their address. I can see if they’re in the same building. We need to go to the fire. We can’t wait for the fire to come to us.”
But Ontario half-assed the lockdown and now Ontario has begun to reopen, and that means behaviours will change. It will be difficult to pull back, if public health — which, remember, is an underfunded public good — isn’t ready.
“The physical distancing was really a community-based effort,” says Warner. “But in some ways, the physical distancing camouflaged the inherent challenges within public health. It gave them time, at least we thought, to shore up their infrastructure, their organization, their leadership. They had 10 weeks to get their house in order.
“But as we open things up now, which I think people are really desperate to do, I’m concerned that the major cracks in public health will show through, and instead of having this onslaught of Italy and New York that we avoided, we’re going to have a steady burn of COVID for months and even years. Which I think will be really, really difficult for people to handle emotionally, economically, and will hold the health-care system back from caring for people who don’t have COVID illness.
“We have to do the work. We haven’t done the work yet.”
The province isn’t in step with the city. The city isn’t in step with its hospitals. It’s not at all clear the system is built for the moment, which is the moment of the pandemic so far. Michael Warner worries. Maybe you should, too.