Previous public health outbreaks have taught us what we should do—if we listen
Every crisis is also an opportunity. The question is whether we learn from the past or repeat our mistakes. We have seen evidence of both during this pandemic.
In the aftermath of the 2003 SARS outbreak, for instance, our health system took some important steps forward. We created Public Health Ontario, redefined the role of the chief medical officer of health, and updated the governance of local public health agencies. All of that has paid dividends. Public Health Ontario has behaved brilliantly during the pandemic, and the lab system has been robust and responded appropriately. We learned a lot about infection prevention and control through SARS, and applied it well, particularly in the hospital sector.
Later, the 2009 H1N1 pandemic emphasized that we need a strong immunization strategy at a population level. We have put into practice some of the lessons around phasing in vaccinations and bringing in partners to support the distribution.
Yet there are many lessons we haven’t heeded as well. For one, we didn’t necessarily apply in a consistent way what we know about infection prevention and control to long-term care, retirement home and other congregate settings. Nor did we continue to invest as we should have in public health and emergency preparedness. We let our guard down, and can’t afford to do that again.
In the wake of past epidemics, we have carried out large-scale reviews of the health-system performance. It’s instructive to look back on what they told us. For example, the Lac Tremblant Declaration of 1993 looked at emerging infectious disease issues. The report talked about the importance of having an independent immunization production capacity, a federal quarantine capacity and border protection. These have clearly been weak points in our response to COVID-19. We are dependent on others for vaccine supplies and haven’t kept pace in Canada with vaccine innovations such as mRNA and non-replicating virus technologies.
As a nation, we also should have been much better, from the start, at identifying cases upon entry to Canada, testing before people returned to the community, and quarantining appropriately. Some things that should have happened in March 2020 were only ramped up a full year later. Australia and New Zealand did a much better job at locking down, controlling entry and preventing community spread. Perhaps part of the reason is that they are island nations. Even so, they had stricter measures in place regarding travel within the country. In Canada, we did have some success with the Atlantic bubble. But overall, you pay the price when you don’t implement stringent quarantine and isolation rules.
The 2003 report on “Learning from SARS: Renewal of Public Health in Canada” (commonly known as the Naylor Report), also highlighted a great many systemic inefficiencies and shortcomings:
Sound familiar? So much still resonates today. It’s frustrating to see how history repeats itself. When it comes to pandemics, we should be preparing annually, using a hazard identification and risk analysis process. What are the probable events and possible outcomes? And what are the less probable but most impactful events? Why not treat every influenza season as our pandemic preparedness? If we do it right, the same principles and tools can be applied to many infectious disease situations.
We also need to hold chief medical officers of health accountable to their respective legislatures, annually, on the state of pandemic preparedness—locally, provincially and nationally. Nobody has a crystal ball to see all the specifics of events. But pandemics are absolutely predictable, and they can be mitigated. But we need a better pandemic playbook.
How can we improve? More consistent (and just plain more) funding for public health would help. We saw a boost after SARS, but it didn’t last. There is heavy competition for health-care dollars. In an ideal world, everything is worthy. When we decrease investments in public health, however, we do so at our own peril. We need those investments to not only be better prepared for the next pandemic but also to better protect the health of all citizens, all the time.
Proper investments in public health require a long-term vision. It calls on us to look five, 10, 15, 20 years ahead. That’s how long it takes for many efforts to bear fruit. It’s the old an ounce of prevention is worth a pound of cure saying. For practical reasons, governments do not always have that vision. They operate in shorter election cycles and have to balance many interests when it comes to health-care budgets. That’s even more of a reason to set aside a fixed amount for public health, guaranteed not to erode over time. Funding is critical to help us prepare for future pandemics. So is heeding some broader lessons from previous public health crises. Past reports highlight the importance of focusing on communications, collaboration and coordination.
In a pandemic, a major role of public health is to provide clear and concise communications, so that the public understands what’s required of them to decrease the risk. Too many voices or fuzzy messages get in the way. Having one expert spokesperson from the health-care side helps to drive trust. One area where we can always improve is understanding the knowledge, attitudes, beliefs and behaviours among the public. That differs between groups and might change over time. All of it affects how we need to tailor and adjust our messaging. That’s a science too.
How we engage with the public is one piece of the puzzle. The way we engage with health-system partners is critical too. Right now, that collaboration is voluntary. We don’t have a governance structure mandating it. Strong collaboration is essential to breaking down some of the silos that can interfere with a comprehensive and timely response. Should we change our governance to make sure we are collaborating? Will we move into a regional health authority model? Coming out of the pandemic, we will have to reflect on our separate accountabilities. Co-ordination is also part of collaboration. If we don’t do it well, we will be grossly inefficient in our approaches.
Despite not having a governance structure to compel it, I think we have had some great examples of collaboration and coordination during this pandemic. At my own local level, I’ve seen effective partnerships between primary care, acute care, paramedicine, long-term care and pharmacy partners, for example. It wasn’t formalized; it just happened.
There are many things we can do better next time. But one area where I think we have done well is putting data over politics. For public health measures to work, we need to prioritize data-driven decisions and take politics out of decision-making. We have come a long way in doing so over the past few decades and in making those decisions and what went into them, transparent.
The time will come to study how we fared during this pandemic, to get us ready to handle another. It will surely come, just as the SARS outbreak of 2003 was followed by H1N1 in 2009, MERS in 2012, and now COVID-19. We don’t know what the next one will look like. But we do know there will be a next one. When it does, we should reflect on how health-care organizations and physicians have worked well together with the clear goal of protecting the health of their communities. Let’s build on that.
Dr. Kieran Moore is medical officer of Health for Kingston, Frontenac and Lennox & Addington, and is a member of the Ontario Ministers’ COVID-19 Vaccine Distribution Task Force.