The COVID-19 pandemic exposed notable weaknesses in Ontario’s public health system. In this podcast we hear from experts Dr. Michael Finkelstein, Dr. Joyce Lock and Dr. Paul Roumeliotis on the necessity of actively preparing the system for the inevitability of future pandemics.
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Georgia Balogiannis: In this podcast the Ontario Medical Association looks at current issues of interest in health care. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association.
COVID-19 revealed gaps in Ontario's public health care system. On this podcast, we speak to experts about strengthening public health and pandemic preparedness. We hear from Dr. Michael Finkelstein, a public health and preventive medicine specialist, Dr. Joyce Lock, the medical officer of health for Southwestern Ontario Public Health, and Dr. Paul Roumeliotis, medical officer of health and CEO for the Eastern Ontario Health Unit.
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Dr. Michael Finkelstein: What we've done well, I think, is that local public health infrastructure in the province was able to respond at a local level to the differences in the pandemic across the province. So, because of the highly variable nature of the province in both its concentration of populations and the type of people that are in different places, this was a real strength of the public health system in Ontario, because we had that local level.
In the first part of the pandemic, when cases escalated quickly, we didn't have the infrastructure to collect information that quickly on that many cases. So, we were using an information system that was a bit dated and hadn't been updated for modern times, and it was unable to collect information on all those cases quick enough to provide good data for our response. So, there was a little lag in some communities, knowing how many cases you had.
We didn't have good access to hospital records of people who were in hospital for COVID. How are they doing? Were they getting into ICU? We had to build that stuff really quickly, rather than it having been already there. See, the last thing we want to do is place hurdles between doctors and being able to care for their patients. I think we can do better. There are still choke points of medical information from hospitals, labs, and other parts of the system where information could flow better. We’re part of the way there, but we still have a ways to go to make it seamless. We're getting there, like, I think we're getting there.
We need better collaboration across the health system. Each public health unit gets to choose its own course — we all plan with different assumptions, we plan with different actors, and so we need a way of having both some common language and a framework and then having local flexibility to match to our local stakeholders.
Whole genome sequencing, new technology where you can sequence the entire virus, so you can know which — you've probably hea … heard of delta versus alpha, speaking of variants; we still don't have, for instance, the infrastructure to do all of that type of whole genome sequencing. And so, there we need more infrastructure at the laboratory level, being able to test all of those blood tests for the type of virus they had. That is of public health importance when you're having these changes in the virus. We've seen that when it's needed it's sometimes needed quickly.
Another part that has shown a weakness is the public health workforce. We went into the pandemic under-resourced because there were a lot of vacancies in our public health units because of the budget constraints that the province had imposed just before the pandemic. And I think that that was an error, and I think the pandemic exposed that error, to say, "Geez, this system is an important component of our Emergency Response Network, and we let it decay a bit."
The system was underfunded coming into the crisis, our funding was going down. Public Health Ontario's budget hadn't increased for five years, and it was being decreased in the year before the pandemic. The whole point of my job is to prevent people from getting sick. The measles cases that didn't happen or the outbreaks of syphilis that are on the way down or fill in the blank. So, that's not very popular at election time. "Oh, look, during my time in office, we had no measles cases!" That's probably not going to get you re-elected.
We're kind of right at the bottom, right at — “oh, at the end of the day, if we have some funds left over, well we'll give it to public health.” And we — this has proven that that may not be a good strategy when these things come along. Because then we have to stop your economy for a couple months and cost you a couple trillion dollars.
It's very hard for — for us to get ongoing funding. Ongoing, stable, or even increasing funding as the population increases is essential. We're talking about a communicable disease crisis that has hit us and the world. There's going to be another one sometime in the future. Influenza pandemics occur between every about 30 years. So, we had one in 2009, 20 years from now we're going to have another one. It's inevitable actually.
After SARS in 2003, we came up with plans. And then after the pandemic in 2009 —because remember, we had a pandemic in 2009 — they never updated the plan really well. What we should have had, is a basic set of assumptions on how we plan for these events. We didn't drive that out with enough detail so everybody knew how things were going to start. When the thing started, we had to learn who was going to do what. We were stuck in the planning cycle in the eight years before the pandemic.
You know, there's lots of things going on, always, and planning sometimes gets pushed to the back. There needs to be ongoing resources attached to that kind of planning, and so that we can continue to refresh the assumptions and then use that to get to specific plans that are flexible and reflective of everybody's community.
We need the ability to have those basic planning assumptions so that we're ready the next time. That's fundamental to what we do. We need those common ways of accessing data throughout the system so that it's efficiently capable of being summarized for action and decision making. If we don't understand what's going on, how can you make good decisions?
And so, we have to continue to invest in the expertise We have, probably, too few people in our field, so that we can call on. There's a dearth of public health specialists, we need to train more people in public health. And this all comes back to funding.
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Dr. Joyce Lock: Although we were prepared, our health system colleagues didn't have the administrative infrastructure or the operational infrastructure in order to be coordinated and respond quickly. I pulled together key decision makers from the cross section of healthcare organizations in our region, and then we had a coordinated response right from the get go. I think there was a bit of a lag between developing the effective functional connections between the acute healthcare system and ourselves.
The other really challenging thing was that, although we were operationally prepared, our health system was not prepared in that there was no PPE, there were no swab kits, it was difficult to get testing done. They really scrambled to supply our health system partners with simple things like PPE and swabs in the first few weeks.
They learned from this episode that in the early days of a global pandemic there will be resource limitations because every country in the world is looking for similar supplies. And as such, part of the planning preparedness is to develop strategies to address resource limitations and prioritizing the use of resources early on.
We worked with our laboratory partners and our health system partners extensively to set prioritization for the various testing, like who got tested with what test. So, that kind of decision-making had to be formed on the fly, and perhaps some of that could have been better prepared.
At some point, we need to look back and determine lessons learned and use those to constructively enhance pandemic planning moving forward. To a large degree, we built our pandemic plans on the experience of past pandemics.
I think pandemic plans needs to realize that there are a slew of different organisms on the planet. I do think that there has to be ongoing recognition that technology is fundamental, that technology is expensive, that technology needs to be coordinated, and that technology needs to be invested in, realizing that some of these investments only last for a short while because the technology evolved so rapidly, but inevitably, the cost and life savings are worth it.
I think what we've all learned is that pandemic preparedness is important. Perhaps our surveillance system internationally for emerging organisms needs to be re-enhanced with more pre-emptive preparedness before things get out of hand.
It's always good to be coordinated as much as possible. I think that the integration of the health system is also evolving with enhanced integration between in-hospital and out-of-hospital care – improved integration of public health.
I also think that we need to think beyond the box of “health system”. Pandemic planning requires a multi-jurisdiction approach. We were able to pull together our municipal partners, our business partners, our health partners very, very quickly, because we knew each other, and we knew how our communities functioned and worked. And some of that might be lost in a bigger system.
One thing that we benefited from was the local, personal connection. Because it's rural and small, you tend to know people, and that was a real asset in terms of being able to expedite action, as well as to garner trust and responsiveness from the community.
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Dr. Paul Roumeliotis: The pandemic did several things. Number one, it highlighted the inequities that already existed. People who were more vulnerable tended to be sicker, tended to be more hospitalized, tended to be lower working-class individuals, and tended to be under-vaccinated. So, that was one of the things that we saw.
It also caused us to shift our focus exclusively onto that at the expense of other programs. So, for example, our Well Baby programs our Healthy Baby, Healthy Children's programs, our normal school vaccination programs had to be put aside. We maintained only the bare minimum of what our health protection mandate was. So, for example, food, water safety, those type of things were maintained. Working with our hospitals, working with our long-term care — we were really challenged by the long-term care deaths, because most of the deaths occurred there as well. So, that was brought out to the forefront, where long-term care was a vulnerable part of our society.
In addition to that, we also then saw the importance of prevention. And again, this is what we've been doing. A lot of what we were doing was really in the background. We were preventing food and waterborne illness because of our inspections that were not public. We were vaccinating people, but not at the level that you see now.
One of the things that shone the light on us was that, yes, public health are the ones that prevent and protect. We had, as a consequence, been in the spotlight and continue to be in the spotlight, which is a good thing because it increases people's awareness of public health.
Databases need to be a bit more consolidated to make it easier for us. Of course, more integration of the systems — it's not fully integrated at this point, but we're having a semblance of integration. And that needs to continue to be more streamlined where you can have an OHIP card, I can see all the information – respecting privacy and confidentiality and security, obviously.
The expectation now, as we move forward, as we go out of step three, there is not going to be a provincial response anymore, there's going to be more of a local response. However, there are times where you do need to have provincial direction. Yes, we have an emergency, yes, we have to close down. And then either the way you roll it out, or you retract it, may be on regional basis. And they've done that.
If you recall last year, they had different areas. It's like, you go to stage one, you go to stage two and so on. And I think that's the way to do it because it's unrealistic to think that it's a one-size-fits-all approach. I can tell you that I've got areas that are 95% vaccinated, and I've got other areas that are 75% vaccinated, and their rates are different. So, my approach would be even different within my area.
Despite the fact that, yes, there are regional and local complexities and contexts, as much as possible we'd like to have a more of a regional consistency and uniformity. Public Health Ontario is like the CDC, the Centers for Disease Control, so they should be treated as such. They should have ample budget, ample budget for their labs, ample budget for what they do. They provide us at the local level, very importantly, with scientific-backed information, they do all our data – information on a certain issue, they will provide it to us, they will do our epidemiology. They do all the all the mapping, they do all that for us, and they're vital to us. They need to be sufficiently funded to be able to have a surge capacity for future pandemics.
But, public health units themselves need to be funded adequately as well. The point is that public health, in general, public health units have a unique ability in Ontario to be able to work at the local level with municipalities, other partners, to be able to take provincial direction, provincial regulations, and modify and apply it at the local level.
And I think that's the strength of public health in Ontario that needs to maintained, and at the same time ensuring that it’s well funded into the future, so we can have that surge capacity and lessons learned from this pandemic. It's not that we weren't prepared, but we were understaffed, we had to hire more people.
Bottom line is that public health really is the key to health and wellness in the future. It is the key to keeping people out of hospital. For $1 spent in public health, you’re probably saving 20-30 bucks down the road. That should be part and parcel of any health program that's done, to be able to, not only look at cost savings, but also optimizing health of the population.
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Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.
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