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Four months after the first outbreak in a Canadian nursing home, over 7000 long-term residents have died of COVID-19. But if you look at the news or social media or our political debates, it seems like we’ve already moved on. Maybe that’s because it feels like this kind of tragedy was inevitable during a pandemic. It wasn’t. And we know that because in some places in Canada, politicians and public health officials made decisions that saved hundreds, if not thousands of lives.
COMMONS: Pandemic is currently focusing on how COVID-19 is affecting long-term care in Canada.
Featured in this episode: Samir Sinha, Isobel Mackenzie, Michael Schwandt, Kieran Moore
To learn more:
“If you can get your relatives out of seniors’ homes, try to do so as fast as you can” by André Picard in The Globe and Mail
“With an early focus on seniors’ residences, Kingston has so far avoided the brunt of COVID-19” by Karen Howlett in The Globe and Mail
Luck and timing: How B.C. has managed to avoid the worst-case COVID-19 scenario by Briar Stewart in CBC News
This episode is sponsored by Rotman’s MBA Essentials Online
Additional music from Audio Network
“Clean Soul” by Kevin Macleod, adapted.
TRANSCRIPT:
EPISODE 11 – “IT DIDN’T HAVE TO BE LIKE THIS”
COLD OPEN
[ARSHY MANN]
Samir Sinha is a rare breed of doctor. He’s a geriatrician. Doctors that focus on older patients are scarce.
[SAMIR SINHA]
There’s 10 times as many pediatricians in Canada as there are geriatricians, and partly because we still have medical schools that don’t teach geriatrics, even though we now have older people outnumbering younger people.
[ARSHY]
And in this select group, Sinha stands out. He’s a Rhode’s scholar who also did a fellowship at Johns Hopkins’ prestigious medical school. In 2012, the Ontario government chose him to overhaul the province’s senior strategy. He was only 36 years old. The Toronto Star, understandably, labeled him a wunderkind. Today he’s the director of geriatrics at Sinai Health System and the University Health Network in Toronto, the director of health policy research at the National Institute on Ageing and easily one of the most respected doctors in his field.
And over the last decade, he’s been happy to see interest in the medicine of ageing grow among his peers and policymakers.
[SINHA]
We’ve been able to start, you know, changing the mold a bit, attracting more people into the specialty. You know, making some headway, showing what we could do in Canada and starting to kind of bend the needle a bit and make progress.
[ARSHY]
But then, this year, the novel coronavirus hit
[SINHA]
The last four months have been perhaps some of the toughest professionally and personally I’ve ever had. This virus was just kind of like the geriatric nemesis, where every one of my older patients now is basically in the line of fire. They’re all at increased risk of dying, and not by an insignificant amount, but in a significant amount.
[ARSHY]
When the first reports about the coronavirus were coming out of China, Sinha wasn’t too worried. But then it spread to Iran and to Italy.
[SINHA]
Being in a hospital where we often hear about SARS or we talk about SARS, you kind of then wonder, “Is… Is this that SARS thing again?”
[ARSHY]
Sinha watched aghast as older Italians died because ventilators went to the young. He saw Spanish long-term care residents die from neglect as workers abandoned the facilities. And by the time there were outbreaks and deaths in American nursing homes, he knew that Canada wasn’t ready.
He remembers the day he started ringing the alarm.
[SINHA]
I remember it was on April 2nd. It was the day before, I think it was the Thursday. André Picard from The Globe and Mail called me. He was distressed. You know, he was following what was happening in long term care.
[ARSHY]
André Picard is the Globe’s health columnist.
[SINHA]
And he basically said, “I don’t know if anybody really cares about all these people and what’s actually happening. Like we’re watching the carnage unfold before our eyes. And I don’t know if people get it and why people aren’t doing the things that we know we should be doing.”
[ARSHY]
And Picard asked him the kind of question that so many people had asked Sinha in the past. “What if it was your family?” “What would you do if your mother was in a long-term care home?”
[SINHA]
And I said, “I’d pull her out right now.” But, my God, that was the headline, you know, piece of his story the next day. That was the—the opening statement. And do you know how much hate mail I received immediately? My professional society put an open letter to all the members basically saying, “We think Dr. Sinha is alarmist and we don’t agree with his view.”
I got people that, you know, I thought were relatively supportive, saying, “Why are you being so alarmist and trying to be an attention whore?”, really, is what they were kind of saying. You know, “You’re trying to grandstand and you’re being so callous with your words. You’re putting families under unnecessary distress.”
And, really, I said, “Did you read the article?” Because the article actually exquisitely details what are the problems and what are the solutions. It was a call to action.
[ARSHY]
For a decade, Samir Sinha had been the wunderkind, the guy that everyone in Canada turned to when they needed a geriatrician. But at this crucial moment, he wasn’t just ignored, he was denounced.
[SINHA]
I want to remind you that, at that time, we had a few dozen homes that were in outbreak, okay? Two weeks later, by the time Ontario finally followed my recommendations, we had hundreds of homes in outbreak.
[ARSHY]
I’m Arshy Mann and from CANADALAND, this is Commons.
PART ONE
[ARSHY]
If I’m being honest, doing this reporting about the COVID-19 pandemic the last few months has been incredibly frustrating. When we started this series in April, the scale of the crisis in long-term care was just coming into focus. But months later, we know what happened.
Here are some numbers. Over 7,000 people have died in long-term care. That’s more than 80 percent of all Canadian who died during this pandemic. Canada has, by far, the greatest proportion of long-term care deaths of any OECD country. And part of that is because we’ve done a pretty good job of limiting the number of deaths in the rest of the community.
But if you think about these deaths in long-term care as a single event, they constitute one of the worst catastrophes to have taken place on Canadian soil since the Spanish Flu a century ago. And if you look at the news or at social media or at the political debates, it seems like we’ve already moved on. I feel like I’ve been screaming into the void. Thousands of people have died. Most of them died alone, away from their families, not understanding what was happening around them. We’re unwilling to actually look this horror in its face.
And there’s a lot of reasons for that. Ageism and ableism are certainly a huge part of it. But I think there’s something else at play. A feeling of… inevitability. That we didn’t know. That there’s nothing we could have done. That we did our best.
Well, in many cases, that’s just not true. Decisions were made, by elected officials and public health leaders. And the reason we know that this incredible loss of human life wasn’t inevitable is because some of them made the right decisions and saved hundreds, maybe thousands, of lives.
This is the second-to-last episode of our season investigating long-term care, and we’re going to use this as an opportunity to take stock, and to try to understand exactly what happened. To distill some lessons on how to prevent this tragedy from happening all over again in a few months. And to call out the politicians who made the wrong decisions.
And the obvious place to start is in B.C..
[ISOBEL MACKENZIE]
B.C. did not have the first case of COVID-19, but we were pretty quick to, I think, be about the second case.
[ARSHY]
That’s Isobel Mackenzie, the Seniors Advocate for the province of British Columbia.
Looking back, B.C. had the odds stacked against it. Vancouver has the strongest ties to China of any Canadian city, the Lower Mainland is densely populated, and it’s nestled right next to Washington State, where the pandemic surged early.
[MACKENZIE]
We thought we would be an epicenter, and so we reacted not in naiveté or denial. We reacted with, “We could very well become northern Italy.”
[ARSHY]
And, at the beginning of the year, that’s exactly where it looked like B.C. might be headed. The first institutional outbreak took place at the Lynn Valley Care Centre in North Vancouver on March 6th.
[MACKENZIE]
We are deeply saddened to, uh… To hear that, uh, one of the residents of the Lynn Valley Care Home, who was infected with COVID-19, passed away last night.
[ARSHY]
Lynn Valley was a galvanizing moment For Michael Schwandt..
[MICHAEL SCHWANDT]
Within our team at Vancouver Coastal Health and, uh… And with that long term care home, it was really all hands on deck from an early stage, I think, because there was such a high level of concern.
[ARSHY]
Schwandt is a public health officer with Vancouver Coastal Health, which covers much of the Lower Mainland including North Vancouver.
[SCHWANDT]
It wasn’t a case where just one or two people got involved. Really, the whole team of medical health officers, our communications and patient relations… All of those sorts of people did get activated and involved.
[ARSHY]
Lynn Valley quickly turned into a disaster. Fifty-two residents came down with COVID-19, and 20 of them died.
[MACKENZIE]
It was effectively ground zero and patient zero, in terms of our learning about exactly how the many fault lines that exist in our fragmented long-term care system in British Columbia are going to have an impact on our ability to manage this outbreak.
[ARSHY]
The Lynn Valley outbreak seemed to confirm the worst fears of the authorities in B.C.. The province was destined to be a hotspot.
[MACKENZIE]
But that tragedy, because it was early on in the pandemic… We learned from that and prevented further tragedy down the road in other care homes
[ARSHY]
It helped that right next door in Washington State, similar outbreaks had been ravaging nursing homes. But B.C. was paying attention.
Here’s Samir Sinha again.
[SINHA]
The United States actually came to our rescue, courtesy of the CDC. They actually traced what they called the epidemiology of COVID-19, you know, in the first nursing home. And they showed everything. Everything we know now, they were able to document in a beautiful study, and a series of studies, that were coming out by mid- to late-March.
And they were telling us that there are key things that we now know we need to do, masking of all staff, for example, in these settings. We can’t have people working between multiple homes. We need to make sure that we are recognizing asymptomatic, pre-symptomatic presentations and atypical presentations. And that means that you don’t just simply test those people who look sick, but you actually make sure that anybody who is a positive contact gets isolated and tested as well.
[ARSHY]
On March 27th, Sinha’s team at the National Institute of Ageing put out what they called their “Iron Ring” document, that made recommendations drawing upon the CDC study.
[SINHA]
And immediately, B.C. took those actions. All of those things we were doing, they didn’t hesitate. They simply locked down their homes, they made sure they actually masked everybody, they prevented people from working in multiple places. Or frankly, they “enabled people,” is a better way to just stay in one home by putting everyone on a full-time salary and actually giving them full-time work.
Like, they just solved issues that had been lingering for years in a matter of days.
[ARSHY]
In retrospect, B.C.’s single-site order certainly prevented the virus from spreading into even more long-term care homes. And it was a logistical feat.
[MACKENZIE]
There were 48,000 staff in about 500 different locations that had to be identified, organized, scheduled… All the rest of it.
[ARSHY]
But it was only one part of the approach. What distinguished B.C. from almost every other province is that they took a centralized, coordinated approach to dealing with outbreaks at long-term care facilities. If a worker or a resident at a B.C. long-term care home tested positive for COVID-19, a public health team would be there on the ground to help immediately.
Here’s Michael Schwandt again.
[SCHWANDT]
The rapid response teams, or SWAT teams, as they were often called, evolved quite organically from our earliest outbreaks.
[ARSHY]
Medical staff, infection control specialists, communication experts and administrative leaders would all be at the home within the same day.
[SCHWANDT]
And because that seemed to be successful and because the homes were well supported by that team, we very quickly formalized that structure and provided basically the same set of personnel, almost as a package, anytime a new outbreak came up.
[ARSHY]
Because of that approach, B.C. was able to limit many of its long-term care outbreaks to only a handful of people infected.
[MACKENZIE]
When you look at Ontario and Quebec, a number of the cases, the most horrendous cases that we are seeing in the media and hearing about, you also will find that public health didn’t get in there for several days, if not weeks. So by the time we got into the care home, it had was already out of control.
[ARSHY]
And B.C. took a similar approach when it came to personal protective equipment.
[MACKENZIE]
When it became clear that this PPE issue was significant, in part because we’re not accustomed to using it in long-term care and in part because of the global disruption of supply chains, the province said, “OK, we’re going to take over. If you are a care home and you need PPE, you call us, we will get it to you.”
[SCHWANDT]
So we would often tell sites to please let us know if they were running low, that we didn’t want them to see the bottom of the box or even think about the bottom of the box, uh, to be confident that there would be masks, that there would be gowns and, uh… And face shields when it was needed.
[ARSHY]
And then there’s the fact that B.C.’s hospitals and long-term care homes were able to work together. In past episodes, we’ve talked about how governments focused heavily on acute care early in the pandemic, at the expense of the long-term care system.
And while that over-focus on hospitals also happened in B.C., the structure of the province’s health care system meant that they were able to act nimbly.
[SCHWANDT]
Within the structure in B.C., the long term care sector is closely associated with the, with the hospital system. So the regional health authorities are funding most of long-term care and are also running the hospital system as well. So, there’s some continuity in that way, and that the people who are giving directions around infection prevention and control in hospitals are also supports for the long term care system, too.
PART TWO
[ARSHY]
Now remember, much of this was taking place in B.C. in March, early in the pandemic. So what were the other provinces doing?
Well, let’s start with B.C.’s neighbour.
[SINHA]
You just look at the province next door. You look at Alberta, not as populous as B.C., not where COVID-19 landed, but when you actually look at the number of homes that were affected in Alberta—the number of cases, the number of deaths overall—Alberta did far worse than B.C
But then, when you actually look at when Alberta started taking action by implementing them—weeks, weeks later after B.C.—resulted in about 18 percent of their homes being infected, compared to only 10 percent of British Columbia homes.
[ARSHY]
Deena Hinshaw, the chief medical officer for Alberta, announced on April 10th that long-term care workers would be limited to one facility. But the policy wouldn’t go into effect until April 23rd, and the guidance was so confusing that they had to extend that date and roll out the order in waves.
[SINHA]
Then you venture over to Ontario and Quebec, for example, where, really, their long-term care systems largely collapsed.
[ARSHY]
The first outbreak at a long-term care home in Ontario was declared on March 18 at the Pinecrest Nursing Home in Bobcaygeon. The next day, Dr. David Williams, Ontario’s chief public health officer recommended that long-term care workers returning from international travel over spring break should self-isolate. But he didn’t make it mandatory. And, on March 22nd, he recommended that long-term care homes limit the number of locations that they work in. Again, not mandatory.
And over the next two-and-a-half weeks, the Ford government started to take measures that they said would free up staff and resources for long-term care homes. But it wasn’t until April 8th that David Williams made it compulsory for all long-term care workers to wear masks at all times.
And as for the single-site order? Well, that didn’t come until April 15th. By that point, almost 2,000 long-term care residents and staff had tested positive. And within another week, by April 22nd, 125 nursing homes were in outbreak, and the military had to be called in to help.
[SINHA]
And you see that 32 percent of Ontario homes, 26 percent of Quebec homes, and then, even in the small province of Nova Scotia, 10 percent of their homes ended up getting infected. And you realize these things shouldn’t have gotten as bad as they did. But when you actually look back at the chart and you actually compare every province and territory, you see that Ontario, Nova Scotia, Quebec all took weeks, if not even a month, after B.C. to implement the same recommendations.
And that’s what really pained me, when I see that we have nearly 7,000 dead now in these homes, and it really was the result of delayed implementation of things that the CDC—that the U.S., of all places—actually told us what we need to do, and things that B.C. took to heart and got right. And we dithered for various reasons.
[ARSHY]
Because of chronic underfunding and the fragmented nature of the long-term care system, it was almost a certainty that some people would die of COVID-19. But the premiers and chief medical officers of those four provinces—Alberta, Ontario, Quebec, and Nova Scotia—made the wrong choices.
They didn’t act on the information that was available at that time. The workers spread the coronavirus within homes and between facilities, that asymptomatic spread is real and poses a major risk. And because of that, hundreds, if not thousands, of people died unnecessarily as a result.
PART THREE
[ARSHY]
But even in the provinces that hesitated to take the necessary steps, there were bright spots, places where public health leaders had been preparing for a moment like this. And Kingston is one of those places.
[KIERAN MOORE]
My name’s Kieran Moore. I’m the medical officer of health of Kingston, Frontenac, Lennox and Addington Public Health, which is a local public health agency in Ontario. Of note, a quarter of our population is over 60 years of age.
[ARSHY]
Like B.C., Kingston and the surrounding area have attributes that should make it especially vulnerable to COVID-19.
[MOORE]
Very early on, we were worried about our community, given that we have a high proportion of retirees. We are worried about our patients and community members in our congregate settings.
[ARSHY]
Moore has been expecting a pandemic for a long time. But he was anticipating something different: influenza. Moore is a little bit obsessed with influenza.
[MOORE]
I do think our approach to influenza locally is unique. We work very hard for influenza preparedness. I’ve always believed that if you can prepare your health system well for influenza, that will pay off in dividends for any other viral threat.
[ARSHY]
Every year his office does preparation exercises and education on how to detect and respond to flu outbreaks, how to do proper testing. And, back in the summer of 2019, Moore and his team were closely monitoring the particularly brutal flu season that was happening in Australia. So in August, he brought together around 100 people from long-term care facilities, retirement homes and other stakeholders for a full-day exercise on how to prepare for the fall.
When he realized that COVID-19 was coming, he was ready.
[MOORE]
We had already practiced and rehearsed how to respond to a severe viral threat. It was influenza in August of 2019, but we knew who to call. We knew the partnerships. They knew they could trust us in terms of our outbreak management and response.
[ARSHY]
Moore quickly recognized how deadly the novel coronavirus could be for older people.
[MOORE]
So, when we saw this threat and saw COVID-19 had a predilection for the elderly, it was my biggest nightmare was that the virus would get into any of our facilities.
[ARSHY]
And like Samir Sinha and B.C.’s public health leaders, Kieran Moore was watching what was taking place in Washington State.
[MOORE]
We learned from what was going on in Washington that you just didn’t test the case. You had to test everyone around that initial case within the facility and isolate them quickly.
[ARSHY]
When the province of Ontario shut down on March 17th, closing down all the bars and restaurants, Kingston took their food inspectors, paired them with nurses and immediately sent them into long-term care homes and retirement homes to make sure everything was up to snuff.
[MOORE]
And I’m happy to say we had one outbreak of one health-care worker within one long-term care facility that was caught on the first day of symptoms of this health-care worker. There was no transmission anywhere in KFL&A to any patients within our long term care facilities or retirement homes.
[ARSHY]
Because of their preparation, their quick thinking and, honestly, a little bit of luck, there hasn’t been a single death from COVID-19 in a Kingston long-term care home.
OUTRO
[ARSHY]
It feels like Canada is already trying to turn the page on the disaster in long-term care.
[SINHA]
I think now the government’s completely embroiled in this whole WE scandal and stuff. So the headlines, if you will, have actually already shifted already. And so now the question is, “Is this government gonna be judged by an ethics scandal or Canada’s track record in long term care?”
[ARSHY]
But a second wave of the coronavirus is coming. And the lingering question is if the long-term care system is ready for that.
[SINHA]
I don’t think we’re really ready for a second wave. If “wave two” was to hit tomorrow, at least we’d now recognize the importance of training staff and, and doing that. But have we filled up all the staffing gaps, especially in places like Ontario and Quebec? No, we haven’t. Do we have incredible contact tracing mechanisms and testing capacity ready at the go? No, we don’t. And if anybody tells you we do, we don’t.
I think we’re really deluding ourselves if we think we’ve actually, uh, you know, that we won’t have many more deaths occurring in these homes.
[ARSHY]
And if it comes this autumn, it won’t only be COVID-19 that we have to worry about. Influenza and other viruses will be circulating as well.
[MOORE]
It’s something we’ve never had to deal with. Two circulating severe pathogens that will need early testing, identification and cohorting of the patients within hospital settings, within long-term care settings. And we’ll have to start making room for that cohorting of these patients.
[ARSHY]
We know what we have to do. The question is if we have the will to do it.
CREDITS
[ARSHY]
That’s your episode of Commons for the week. If you want to support us, click on the link in your shownotes or go to commonspodcast.com. This episode relied on reporting from Karen Howlett at the Globe and Mail, Briar Stewart at CBC News Vancouver, Nora Loreto and many others. If you want to get in touch with us, you can tweet at us at @COMMONSpod. You can also email me, Arshy@canadalandshow.com. This episode was produced by me and Jordan Cornish, with additional production by Tiffany Lam. Our managing editor is Andréa Schmidt, and our music is by Nathan Burley.
