What’s wrong with public health in Ontario?

April 30, 2020

If there’s been one bright spot in this pandemic saga, it’s the way it has been managed in British Columbia. They’ve been proactive right from the start, taking a lot of measures early. They recommended against all non-essential travel outside of Canada during spring break. They put in an early measure to prevent health care workers from working at multiple care homes. They flattened the curve while Ontario and Quebec were still struggling with soaring numbers. They quickly coordinated their communication and procedures across the province. And every day, their provincial health officer, Dr Bonnie Henry, steps before the cameras and delivers the latest update calmly, clearly, honestly, and compassionately. In British Columbia, a scientist is leading the charge with integrity and courage. The rest of us can just watch with awe and envy. Because look at what’s been happening in Ontario.

Following the SARS epidemic of 2002 – 2003, Ontario created a stockpile of personal protective equipment (PPE): some 55 million N95 masks, respirators, face shields, needles and more. But the budget covered only the cost of storage. There was no budget to manage, distribute or replace the equipment. When a 2017 auditor general’s report found that most of the equipment had passed its expiry date, the government simply destroyed most of it and didn’t order replacements. So as the coronavirus spread, Ontario was caught short, dependent on a highly competitive, cut-throat, unreliable international market. When we could get N95 masks, they went first to front-line hospital staff. Other front-line workers, like paramedics and long-term care staff, were often left to scramble. Sometimes they were told to use the less effective surgical masks, sometimes home-made masks, and sometimes they were not issued any masks at all. Some had to use green garbage bags as gowns. Now one in seven Ontario residents who have tested positive for COVID-19 is a health care worker. That puts Ontario at one of the highest rates of health care worker infection in the world.

We didn’t have enough swabs, reagents, or lab capacity either, so that may help explain why Ontario’s approach to testing has been so slow and narrow. Insufficient testing has been one of Ontario’s major failures. We persisted in testing only travel-related cases for weeks, long after we had clear evidence of community spread. Later we allowed testing of people in contact with a diagnosed case. But people with coronavirus symptoms who did not meet these criteria were refused a test and told to stay home, so that community spread could not be recorded and tracked. Faced with a lack of capacity and a mounting backlog, Ontario narrowed its criteria even further, restricting testing mainly to sick front-line health care workers and patients sick enough to be admitted to hospital. Additional labs were hastily brought on board, increasing capacity to 13000 a day by the beginning of April, but by then the testing criteria were so narrow, they were down to just over 2500 tests on April 7. That provoked an angry response from Premier Ford, who demanded more testing. So what did they do? They changed the way they count the tests. Instead of reporting the number of patients tested, they simply report the number of tests per day. One patient may receive multiple tests, so now it’s harder to know how many patients there are and it’s harder to track the spread. But Public Health Ontario can look as if it’s ramped up the testing. Before we are ready to ease restrictions, we need to know how much coronavirus is out in the community, being spread by people with mild symptoms or even no symptoms. So we need to do massive testing in the community. Where is the huge army of health care workers going to come from who will do all that testing and contact tracing?

Robust reporting and clear communication aren’t just nice to have. Without them, we can’t move forward safely. In this pandemic, they’re a key to life and death. But Ontario’s public health system has not been up to the job. It is made up of a group of agencies which vary widely in size and sophistication, many of which try to get by on precarious funding. Their Integrated Public Health Information System (iPHS) is antiquated and selective about which data it reports. In frustration, the City of Toronto built their own COVID-19 database, the Coronavirus Rapid Entry System (CORES). Dr Eileen de Villa, Toronto’s public health chief, said that CORES would speed up her department’s efforts to trace people who came into contact with infected Torontonians, and yield better data on the local spread of COVID-19 to share with the public. The new system also tracks test results, hospitalizations and deaths, and uploads information to iPHS. In response to the ongoing nightmare in long-term care, the Toronto Star built a database too, to provide up-to-date information about COVID-19 outbreaks and deaths in long-term care and retirement homes. The Star had found that the data reported by Public Health Ontario vastly under-reported the true number of people dying in these settings, and failed to include any information about where the deaths were occurring, and which homes were experiencing outbreaks. And it’s not just Public Health Ontario that has let us down; it’s the scientific and political leadership too. They have been very slow to respond to the evolving evidence. As recently as early April, Dr David Williams, Ontario’s Chief Medical Officer of Health, announced that asymptomatic nurses and care workers could keep going to work in long-term care, even if they tested positive for COVID-19. It wasn’t until April 14 that Christine Elliott, Minister of Health, reported that she had “recently learned” that asymptomatic COVID-19 carriers can spread the virus. This information has been reported repeatedly in the medical literature since January. Ontarians are being asked to trust the scientists, but we will do that only if they act with scientific integrity.

They say that the COVID-19 pandemic has been a great revealer. In Ontario’s case, it has revealed a fragmented, dysfunctional public health system that has broken down after years of cost-cutting, downloading, and short-term thinking. This pandemic is reminding us what governments are for. What a civics lesson we’re getting. What will we learn from it?

Comments

Comment: 
I think of all the university students who cannot get their regular summer jobs and wonder if a large number could be trained to do testing and contact tracing over the summer. Having said that, I do not know what such training would involve. A subset of those students would be nursing and other healthcare students; maybe some already have sufficient knowledge or experience to help. Then there are retired and repurposed clinical staff to tap into. The government would know this … I wonder what a stockpile means when its product expires soon. You have a plan to replenish it continuously. You maintain national supply chain partners. You budget for it like insurance. Surely the government has this sort of procedure for other products. So I wonder what value and priority is assigned to this pandemic readiness need. Hopefully, this will be raised now ... As one of the articles you quote says, "how and why it was allowed to happen” … “who is in charge of the coordination.” They are referring to the information; it also applies to the stockpile. Will they learn and make changes for the long, long term …