Global lessons in accountability from The BMJ report on Canada’s Covid-19 response
A call for an independent, national inquiry into Canada’s response to Covid-19
The prestigious medical journal BMJ collaborated with a number of Canadian medical researchers to prepare and publish a series of articles analysing and evaluating the Canadian response to the Covid pandemic. The focus of the report was holding Canadian institutions accountable for what they could have done better. The conclusion is that there is enough worth investigating to warrant a public, independent, national inquiry into Canada’s pandemic response.
I don’t have much to add here other than to emphasise that the mistakes that Canada made were probably not that much different from other countries. Areas such as vaccine procurement, long term care impact, and overall pandemic preparedness are ones that virtually any country should look at in terms of their own response. Introspection is good for the soul. Public, independent inquiries are something every country should consider calling.
While Canadians may have been mostly happy with what happened during the pandemic, there’s plenty of room for improvement. I completely support the call for an inquiry from the BMJ authors.
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Here’s the main series of articles from The BMJ, each with a short excerpt. There is one introductory post, two editorials, one op-ed and four articles. I’ll present them in that order.
Accountability for Canada’s covid-19 response / BMJ
Covid-19 led directly to 52750 deaths in Canada with more than 4.6 million reported cases as of mid-2023. This cumulative covid-19 death rate of 1372 per million exceeds the global average of 855 per million. Despite a universal healthcare system, communities experiencing social and economic marginalisation in Canada were hardest hit in each wave of the pandemic. Those living and working in long term care homes were particularly affected, which was a cause of national shame. Canada achieved high vaccination coverage domestically, but its hoarding of vaccination doses and failure to fully support multilateral efforts to share vaccination doses globally led to global vaccine inequity. Lessons from a previous outbreak of, SARS-CoV-1 — which in 2003 impacted more Canadians than anywhere else outside of Asia— went unheeded and left the country’s governments and health authorities ill prepared for covid-19. An independent, national inquiry is needed to review Canada’s covid-19 response, draw lessons, and ensure accountability for the past and future pandemic preparedness.
Modelled after the UK Covid Inquiry Series, The BMJ's Canada Covid Series comprises articles by Canadian experts that critically review topics such as: data sharing and access; research use and misuse; jurisdictional coordination; fitness of healthcare and public health systems; and surveillance; and the ways in which Canada’s enormous geographic, linguistic, social, ethnic and other diversities were supported by an ostensibly universal but fragmented system. This series offers a reflection and analysis of what worked and didn’t in Canada’s covid-19 response, what a national inquiry should address, and pathways for the future.
The world expected more of Canada by Jocalyn Clark, Sharon E Straus, Adam Houston, Kamran Abbasi / BMJ
The picture that emerges is an ill prepared country with outdated data systems, poor coordination and cohesion, and blindness about its citizens’ diverse needs. What saved Canada was a largely willing and conforming populace that withstood stringent public health measures and achieved among the world’s highest levels of vaccination coverage. In other words, Canadians delivered on the pandemic response while its governments faltered. …
There are at least five reasons why an independent, national inquiry is needed in Canada, with accountability for implementation of recommendations.
First, failing to look to the past will ensure an unchanged future. Undoubtedly, lessons can be drawn to inform new health investments and preparedness, and much learning comes from decisions and actions that failed or faltered. Positive lessons can also pave a way to a better future—from high vaccination coverage that built on traditional Canadian values of community, caring, and compliance to the First Nations pandemic management strategy in Manitoba showing how to overcome geographical barriers to testing and treatment, as well as how important and effective culturally informed responses are.
Second, lacking an independent, federal inquiry allows others to step into the frame. The so called national citizens’ inquiry, for example, appears fuelled by vaccine safety misinformation and ideological concerns with government public health measures and is far from the full, national, and public inquiry led by independent experts that Canada’s pandemic performance deserves. A disturbing covid fallout is the growing social and political divisiveness, which is ignored at Canada’s peril.
Third, an inquiry would help deliver on Canada’s ambition to be a global leader. Any review and examination of Canada’s pandemic response cannot be domestic alone because domestic and global health security and equity are linked.
Fourth, it must provide an actionable framework for reforming Canada’s healthcare and public health systems, which were struggling pre-pandemic and are currently on life support. For health workers, the post-pandemic feeling is exacerbation—even rage—about the inertia of governments, health authorities, and professional medical associations and their failure to tackle the depth of the dysfunction in Canada’s healthcare landscape. For the public health system, which receives just 5% of the country’s health spending, continued functioning with such poor investment is unfeasible. For research, the pandemic further exposed Canada’s inadequate support for delivering science and innovation. Much of the core technology underpinning the mRNA vaccines was developed in Canada then never capitalised on, resulting in the Canadian government spending billions of dollars acquiring vaccine to protect its citizens during covid from an innovation it had helped develop.
Fifth, and most important, is accountability for losses: the 53 000 direct deaths and close to five million cases of covid in Canada have devastated families and left a legacy of long covid in their wake. A million lives in 2021 alone might have been saved in poorer countries had rich nations such as Canada shared more covid vaccine.
Canada’s pandemic response and future preparedness by Kelley Lee / BMJ
Yet despite irrefutable evidence of how inequities hindered the pandemic response, meaningful commitment to equity as a core principle remains a key sticking point for many governments in current negotiations for a global pandemic treaty. This includes what can be gleaned so far about Canada’s proposed amendments to make it voluntary to provide access to medical technologies and waive intellectual property rights during a pandemic, which would entrench the inequitable status quo. This goes against Torreele and colleagues’ conclusion that “market-based systems cannot deliver essential epidemic countermeasures in a timely, fair, equitable, and sustainable manner.”
We can learn from the covid-19 pandemic management strategy of First Nations communities in Canada by Marcia Anderson, Melanie MacKinnon / BMJ
The pandemic response shows the effectiveness of honouring Indigenous leadership (political and clinical) and self-determination, collaborative approaches led through agile and trusted clinical service delivery organisations, and shared decision making and resources, and these lessons present a path for future public health emergency resources. First Nations clinical leaders bring clinical and contextual expertise in building bridges across complicated jurisdictional settings, and the Manitoba response shows that using this expertise strengthens public health service delivery.
How Canada’s decentralised covid-19 response affected public health data and decision making by Tania Bubela, dean of health sciences, Colleen M Flood, Kimberlyn McGrail, Sharon E Straus, Sharmistha Mishra / BMJ
Key messages
Canada’s public health system was insufficiently prepared for the covid-19 pandemic
Public health decisions and outcomes varied across jurisdictions and were hampered by outdated health information systems and lack of integration
Decentralisation of public health decision making has benefits such as tailoring interventions to local constituencies, but during a crisis, governance structures need to pivot to enable coordination and systematisation of data collection and analyses
Gaps in data and decision structures created a vacuum, filled by science advisory committees with disparate roles, responsibilities, and accountabilities within different jurisdictions
A shift to a culture of data access and shared analysis is needed to enhance health system learning and population health benefit, and for future crisis and pandemic preparedness
Use and misuse of research: Canada’s response to covid-19 and its health inequalities by Sharmistha Mishra, Jennifer D Walker, associate professor, Linda Wilhelm, Vincent Larivière, Tania Bubela, Sharon E Straus / BMJ
Key messages
Early in the pandemic, Canada largely applied public health measures universally with little focus on reaching those most at risk
Research, and its use, failed to challenge these universal policies, especially early in the pandemic
Existing infrastructure for patient engagement was critical to reshape research priorities, but patient engagement was left behind in early research
Relationships with communities need to be built before the next emergency to avoid repeating the same failures
The predictable crisis of covid-19 in Canada’s long term care homes by Carole A Estabrooks, Vivian Ewa, Janice Keefe, Sharon E Strau / BMJ
Key messages
Canada’s long term care homes (LTCHs)—including residents, their family and friend caregivers, and staff—experienced among the highest proportion of deaths among all covid-19 deaths worldwide
This crisis was predicted in more than 100 reports and inquiries over the 50 years preceding the pandemic
Three contributors to Canada’s poor performance in LTCHs during the pandemic were inadequate attention to growing resident complexity; longstanding failure to support the LTCH workforce; and a lack of integration within health and social systems
Fragmented LTCH, health, and public health systems led to variable responses across provinces and territories
Unprecedented coordination and collaboration at federal and provincial or territorial levels are needed to create an integrated health system with funding and accountability
Canada’s role in covid-19 global vaccine equity failures by Adam R Houston, Joanne Liu, Roojin Habibi,Srinivas Murthy, Madhukar Pai / BMJ
Key messages
Canada exemplified the tensions between domestic and international priorities in access to covid-19 vaccines, failing to follow through on its pledges and stated principles
Canada hoarded vaccines during the most critical phase of the pandemic, while not supporting measures intended to increase global supply
Lack of domestic vaccine production and subsequent reliance on importation left Canada vulnerable to pressures that directly affected its actions around global vaccine equity
Canada’s renewed domestic capacity can be harnessed to help it reinvigorate its role as a global health ally
And here’s most of the commentary I’ve been able to find, with a few excerpts as well.
Inquiry must assess how Canada’s fragmented COVID-19 response lost the public’s trust by Tania Bubela Kimberlyn, McGrail, Sharmistha Mishra / The Conversation
It is clear that some public trust in public health, science and government has been lost in Canada and around the world. This does not bode well for future threats, such as emerging pandemics, and current threats from the opioid crisis and climate change.
For these reasons, we call for a different kind of inquiry, agreeing that another expert report packed with recommendations will gather dust and not serve to rebuild public trust.
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 use are essential in preparing for the next public health emergency.
We Need a COVID Inquiry. Here's Why It Won't Happen by Crawford Kilian / The Tyee
Even an inquiry based on firm science would have little chance of being accepted and turned into policy by any future federal or provincial government, or of restoring trust in public health. Canadian governments, like governments around the world, got their worst pandemic scare not from the SARS-CoV-2 virus but from their voters.
Too many people succumbed to disinformation, which had already eroded their trust in government in general and public health in particular. They confronted governments with convoys and border blockades. The economic and political damage of the pandemic drove politicians to relax public health measures, and then, grotesquely, to convert public health itself from “doctor’s orders” to “personal responsibility.”
Governments also learned they could get away with reduced information: fewer medical tests, fewer tallies of confirmed cases, hospitalizations and deaths. Peer-reviewed reports keep coming out about the continuing damage the pandemic was doing, but few people read the medical journals. Even fewer want to be reminded about the pandemic at all.
Canada's gap between rhetoric and reality on global equity of COVID vaccines deserves scrutiny, experts say by Elizabeth Payne / Ottawa Citizen
“Inequitable access to COVID-19 vaccines — as well as tests, treatments, and other tools — has cost millions of lives, prolonged the pandemic, and highlighted tensions between countries’ domestic responses and their collective global responsibilities,” the authors wrote.
Canada, they said, exemplified tensions between domestic and international priorities when it came to access to COVID-19 vaccines.
Not only did they fail to give actual doses when they were needed most, but government procurement practices undercut Canada’s financial contributions by pushing low and middle-income countries to the back of the line for purchasing vaccines, the paper states.
And finally, some additional media commentary that’s worth checking out.
Exposing deep institutional failures in the COVID-19 response in Canada / The Toronto Star
Canada's response to COVID-19 came up short, experts say. What lessons can we learn? / The Toronto Star
Canada’s response to COVID-19 pandemic questioned | CTV News
Opinion: When it comes to a COVID inquiry, we shouldn’t succumb to cynicism - The Globe and Mail
COVID-19 response should highlight what went right in Canada / The Toronto Star
Canada slammed as ‘ill-prepared’ for COVID, amid inquiry call / The Toronto Star
Top medical experts call for national inquiry into Canada's COVID-19 'failures' | CBC New
Une enquête indépendante est réclamée sur la réponse du Canada à la COVID-19 | Le Devoir
Une enquête indépendante est réclamée sur la réponse canadienne à la COVID-19 | La Presse
The COVID papers: What Canada's top doctors say about the country's pandemic response / The Toronto Star
A COVID-19 public inquiry? Canadians seem to think it's a good idea / The Toronto Star
Editorial: Public inquiry needed into our COVID response / Times Colonist
Learning from the last pandemic to get ready for the next one - The Globe and Mail
Public health experts excoriate Canada Covid response and call for inquiry / The Guardian
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