September 02, 2023 – The British Medical Journal (BMJ) has published a series of peer-reviewed articles entitled Accountability for Canada’s covid-19 response.
The series is a scathing and sobering read, especially given the gathering storm clouds about another wave of the usual fall and back-to-school flu, colds and garden variety covid-19 (of which there have recently been cases reported in QB) — plus the warnings of a new variant of the covid-19 virus that may be on the horizon.
Published on July 24, 2023, the unflinching findings of the BMJ panel expose inadequacies in all three pillars of public health service — competency, transparency and accountability.
The world expected more of Canada
BC Health Minister Adrian Dix’s repeated platitude throughout the pandemic was, “We’re all in this together.” Members of the BMJ review panel rejected that notion. “In every epidemic in history, there was inequality. Covid-19 was never going to be different and we were never “all in it together,” Mishra said.
Sharmistha Mishra, Associate Professor, Infectious Disease Epidemiology, University of toronto
For her introduction to the series, Jocalyn Clark, the BMJ’s international editor based in London, UK, chose the title, The world expected more of Canada.
Clark concluded her introduction saying, “There are lessons to learn from Canada’s covid-19 response to ensure accountability for decisions and actions, and to build confidence in the country’s health leadership, which faltered during the pandemic and created a strain on its already beleaguered public health and healthcare systems.”
Nowhere has this been more apparent than in our long-term care homes, not only in BC but across Canada.
In the appropriately titled BMJ article entitled The predictable crisis of covid-19 in Canada’s long term care homes, author Sharon Straus, Physician-in-Chief, St. Michael’s Hospital in Toronto, and her colleagues examine the many ways in which “residents, families, and staff in long term care homes in Canada were failed by governments during the pandemic.”
How bad was it?
In mid-April 2020, teams from the Joint Task Force of the Canadian Armed Forces (CAF) were deployed — at the request from the province of Ontario — to “provide humanitarian relief and medical support” for residents in long-term care facilities in Ontario that were experiencing uncontrolled covid-19 outbreaks.
The commander in charge of the mission, Brigadier General C.J.J. Mialkowski, wrote that the CAF Joint Task Force observations were made “from the perspective of our medical and non-medical personnel in situ” and were “strictly factual in nature…”
In just their first two weeks onsite, Joint Task Force teams observed and documented horrific mistreatment in long-term care facilities. Here are just a few of the numerous incidents reported:
- “Aggressiveness when changing incontinence product, not stopping when resident complained of pain.
- “Forceful and aggressive transfers, little/no regular turning of patients leading to increased number and complexity of pressure ulcers.
- “Patient meals often mixed up, with incidents of inappropriate meals being fed to residents with swallowing difficulties (increases likelihood of choking or aspiration).
- “Forceful feeding observed by staff causing audible choking/aspiration, forceful hydration causing audible choking/aspiration.
- “PSW [care aides] often rushed and leave food on table but patients often cannot reach or cannot feed themselves (therefore they miss meals for hours).
- “Degrading or inappropriate comments directed at residents.
- “Medications are being reported/documented as being given but in fact they are not.
- “PSW and Nurses aren’t always sitting residents up before feeding/hydrating/giving meds; choking/aspiration risk high; includes observation of incident that appeared to have contributed in patient death (code blue due [to] choking while feeding while supine – staff unable to dislodge food or revive resident).
- “Most residents were reported to not have received 3 meals per day. Poor nutritional status due to underfeeding.
- “Resident complaining of chest pain. RPN [Nurse] advised on call physician. Physician ordered Nitroglycerin. Patient’s BP was 95/62, thus contraindication was communicated to physician who insisted on the treatment using Nitroglycerine. RPN withheld drug related to safety reasons.
- “Not assisting residents during meals (staff would rather write the resident refused to eat, rather than helping them.
- “Expired medication. Patients sleeping on bare mattresses.”
Brigadier General Mialkowski, in his report to the federal and provincial governments summarizing the observations of the Joint Task Force teams stated, “The purpose of this letter is to ensure that these observations do not go unnoticed by our chain of command, the Province of Ontario, and most importantly at the individual long-term care facilities…”
Public health agencies failed to respond to community interests
Tania Bubela, Dean of Health Sciences at BC’s Simon Fraser University was a contributor to the BMJ series.
Bubela and her colleagues noted the “absence of a coordinated pandemic planning authority,” and found that “the supporting evidence and rationale for different rules in different places were often unclear” — even though public officials claimed they were following the data.
“Data were in short supply to support public health decision making during covid-19,” they wrote. “This situation will persist without major reform.”
A golden opportunity to provide a framework to enable major reform was squandered by federal and provincial authorities. “Eight years and $130 million of investment [had] failed to establish a pan-Canadian solution for public health data,” Bubela wrote, referring to the widely-acknowledged mismanagement of the Panorama project funded by Infoway Canada, and led by the BC Ministry of Health, that relied heavily on IBM Canada Ltd. for software development.
Consequently, Bubela explains, “as the 2020 covid-19 pandemic progressed, public confusion arose from jurisdictional inconsistencies in advice and case reporting.
“Most jurisdictions routinely reported the raw number of covid-19 cases. More detailed information about the demographics or location of cases was often more guarded because of privacy concerns, meaning that public health agencies did not respond to community interest about local risk, and tailoring of implementation strategies to mitigate covid-19 risks was slow or non-existent.
“Lack of local data contributed to a lack of understanding of local transmission dynamics and contributed to loss of public trust over time.”
Applying homogeneous measures was a tactical failure
Another contributor to the British Medical Journal’s series of articles entitled Accountability for Canada’s covid-19 response is Sharmistha Mishra, associate professor of infectious disease epidemiology at the University of Toronto.
Mishra and her colleagues examined “how pandemic research contributed to a homogenized public health and clinical response to covid-19 in Canada and how it could have done better.”
Public health officials claimed they were priorizing at-risk groups, primarily the elderly and the immuno-compromised.
But in practice, officials applied restrictive prohibitions to everyone universally, inflicting family separation, business closures, lost income, and social isolation on millions, young and old, who weren’t necessarily at-risk of anything more than a few days of discomfort, and who were reasonably capable of minimizing their own risk of CoV-2 transmission to others.
BC Health Minister Adrian Dix’s repeated platitude throughout the pandemic was, “We’re all in this together.” Mishra’s team emphatically rejects that notion.
“In every epidemic in history, there was inequality. Covid-19 was never going to be different and we were never “all in it together,” she said.
“Communities and connected researchers called early attention to the need to design a more nuanced public health response — detailing structural solutions, prioritized allocation, and tailored programmes to address differences in risks.
“In Canada, communities and individuals experiencing social and economic marginalization and systemic racism shouldered the greatest burden of the covid-19 pandemic. The highest rates of cases and deaths were among racially minoritized people, recent immigrants, lower wage essential workers, and those living in higher density and multigenerational households.”
For example, in Ontario “Rates of covid-19 hospital admissions and deaths remained threefold higher in the lowest income neighbourhoods compared with highest income areas in each pandemic wave.”
“Faulty research produced ineffective data that “may have contributed to homogenizing public health responses to a heterogeneous epidemic. … Research could have been used to shape more tailored health policies and implementation effort.”
Canada’s health care agencies didn’t learn from past mistakes, independent inquiry needed
Twenty years ago, the CoV-1 (SARS) epidemic was a wake-up call. Or, rather, should have been.
As Tania Bubela, Dean of Health Sciences at BC’s Simon Fraser University, and contributor to the BMJ series summarizes: “SARS brought international attention to shortfall in the Canadian public health system. After the 2003 outbreak, the country’s handling of SARS was described as an “international embarrassment.”
The chair of the National Advisory Committee on SARS and Public Health, David Naylor, described “squabbling among jurisdictions, dysfunctional relationships among public health officials from the three levels of government (federal, provincial/territorial, and municipal), an inability to collect and share epidemiological data, and ineffective leadership” – which, taken together, held hostage the health of Canadians.”
“[P]ublic health agencies did not respond to community interest about local risk, and tailoring of implementation strategies to mitigate covid-19 risks was slow or non-existent.”
T. Bubela, dean of health sciences, Simon fraser university
Accepting the scathing analysis in Naylor’s report, authorities reacted quickly, particularly to remedy the fragmented leadership and glaring deficiencies in data management.
Bubela recounts that “Canada’s public health system was reformed after its 2003 severe acute respiratory syndrome (SARS) outbreak, which was the worst outside of Asia with 438 cases and 44 deaths. Ensuing national and provincial inquiries led to the creation of the national Public Health Agency of Canada (PHAC) to coordinate Canada’s preparation for and response to public health threats. Subnational [provincial and territorial] public health agencies were also created or strengthened to function as regional centres for disease control [such as BC’s Centre for Disease Control].”
While “these actions should have put Canada in a good position to respond to the covid-19 pandemic,” Bubela concludes that, “Despite these reforms, Canada experienced serious failures during the covid-19 pandemic.”
This is disappointing to hear, but also a refreshing antidote to the empty blandishments of BC’s Public Health Officer Bonnie Henry and BC Minister of Health Adrian Dix who perpetually laud themselves and their decisions and edicts, wrapped in an impermeable cloak of infallibility.
The BMJ’s panel of experts concluded that “an independent, national inquiry is needed in Canada, with accountability for implementation of recommendations.”
“We need political will to call an independent inquiry that is inclusive of a diversity of voices, accountable to communities and with a mandate to implement change. Reforms to data generation, access and uses are essential in preparing for the next public health emergency.”
Related information sources:
- British Medical Journal series Accountability for Canada’s covid-19 response.
- Joint Task Force (JTFC), Canadian Armed Forces – Observations in Long-term Care Facilities in Ontario, 2020: