Letter from Canada: A pandemic that has humbled us?

When the coronavirus disease 2019 (COVID-19) pandemic became a reality in March 2020, the world shut down and governments furiously put plans in motion for how to deal with this potential health crisis, and what a crisis it turned out to be. Countries with well-oiled government-funded national healthcare systems, such as Canada, were expected to cope the best with this type of national health crisis. In general, but with a couple of exceptions, this has turned out to be correct 11 months into the pandemic. However, a major failure in Canada's response was to the most vulnerable in society, the elderly and specifically those in long-term care (LTC) facilities. Among wealthy (OECD) nations, Canada has the worst record for COVID-19-related deaths in LTC facilities, which is perceived by many Canadians as a national disgrace. During the first wave of COVID-19 in Canada, about 80% of all COVID-19-related deaths were elderly people in LTC. Notwithstanding numerous reports, investigations, committee meetings and good intentions to implement change, 6 months later, when the second wave of COVID-19 swept through the country, very little has changed and LTC facilities remain highly prone to outbreaks and deaths from COVID-19. As of January 2021, LTC and retirement homes reported 11% of the Canadian totals of COVID-19 cases and 73% of total deaths. The reason(s) for this blatant failure are numerous and therefore more complex to tackle in a systematic fashion. Canada's national healthcare system is federally controlled but the provinces and territories are responsible for the day-to-day care of patients. This disconnect makes a national effort to provide a synchronized and coordinated response more problematic. COVID-19 outbreaks and deaths in LTC facilities were particularly abysmal in the two most populous provinces of Ontario and Quebec. At the height of the first wave, the army was called in to assist in these facilities. COVID-19 outbreaks in care facilities in Quebec have killed nearly 4000 residents, with large numbers of staff also infected, significantly compromising the ability of these facilities to provide proper care to their residents. In addition, all family and friends who usually provide a significant amount of both physical and mental care to these residents were barred from these facilities. Other issues identified were poor infection control practices, poor training of personnel and lack of proper personal protective equipment (PPE). The fact that many of the workers provided services at several different facilities further promoted the spread of COVID-19. The combination of all these circumstances provided the elements for a ‘perfect storm’. COVID-19 has already killed more than three times as many LTC residents in Canada's second wave than the first wave, with COVID-19 deaths to date in LTC facilities in Canada tallied at 10 450, including ~7000 from facilities in Quebec and Ontario. Several lines of evidence point to historical decisions more than 30 years ago to exclude LTC facilities from Canada's 13 provincial and territorial public healthcare systems as contributing to Canada's dismal record of deaths due to COVID-19 in LTC facilities. This has resulted in substandard and ageing facilities, under-training and poor treatment of workers and overcrowding, all contributing to poor infection control capabilities and practices. Although nurses are the primary regulated healthcare professionals in LTC facilities, nurses provide little direct care to residents with up to 90% of direct resident care provided by unregulated and unlicensed care aides or personal support workers. Furthermore, recent reports also point to a lack of government oversight and accountability to residents, especially in privately owned, for-profit LTC facilities—which account for about 50% of all Canadian facilities. Highlighting the devastating effects of these outbreaks in LTC facilities is a recent (January 2021) outbreak in the Roberta Place facility (Barrie, Ontario) where within a couple of weeks 214 people (residents and staff) were infected with 50 deaths, nearly all LTC residents. Although these problems were well known before the pandemic, long-standing, widespread and pervasive deficiencies in this sector were exposed with devastating effects. Although all these factors have significantly contributed to high infection and death rates of the elderly, they are not the only explanation for the high mortality rate in this population. Clearly, there is some underlying immune mechanistic reason why the elderly are so vulnerable to infection and death from COVID-19. Children are usually one of the main sources of spread of respiratory viruses, but children made up <1% of all COVID-19 cases and even fewer deaths. This scenario provides a unique opportunity to explore changes in our immune responses as we age, potentially revealing how the COVID-19 takes advantage of these deficiencies. In the 1980s and 1990s, the human immunodeficiency virus (HIV) pandemic caused an explosion of our knowledge and understanding of the adaptive immune responses and lymphocyte biology. The hope is that COVID-19 will deepen our understanding of the ageing immune system and reveal immune pathways to support it. When the COVID-19 pandemic struck, Canada was already fighting an opioids overdose crisis. Since March 2016 when the crisis was declared in British Columbia (BC), to March 2020, Canada had already had 16 364 deaths from illicit drug overdoses with the west of the country being the epicentre of this crisis. The victims are predominantly younger males, who experience poverty and homelessness and frequently have other underlying comorbidities. These people were also at higher risk to contract COVID-19 due a limited capacity to physically distance and self-isolate, which put them at higher risk for severe COVID-19 due to their associated co-morbid conditions. Death rates due to drug overdoses spiked shortly after the COVID-19 lockdowns in March 2020 (Fig. 1) and increased from 984 to 1548 (2019–2020 in BC) which is significantly higher than deaths for COVID-19 over the same period.1 Similar to the crisis in LTC facilities, the COVID-19 pandemic unmasked this health crisis and highlighted the deficiencies in all levels of healthcare governance (federal, provincial and local) to address this pressing health issue. As a respirologist/pulmonologist, the COVID-19 pandemic was a trying time. Lung involvement is the predominant feature of severe COVID-19 infection and also the leading cause of death. It was a steep learning curve for most of us, but in some aspects, also an opportunity to tackle a ‘new’ disease from the basic science to clinical practice. The major receptor for entry of the virus into cells (predominantly epithelial cells) was identified in March 20202 and our laboratory (Centre for Heart and Lung Innovation, Vancouver) described the expression of the ACE-2 receptor in lung tissues3 showing that smokers and chronic obstructive pulmonary disease (COPD) subjects have higher expression, making them more vulnerable to severe disease. Our clinical respirology practice also had to make major adaptations including developing new protocols to conduct lung function studies, bronchoscopies and bronchial challenge tests, all procedures that generate aerosols that could potentially spread COVID-19. We had to severely restrict our ‘in-person’ clinical practice but digital platforms allowed us to do the majority of our clinical consultations virtually. The downstream effects of these major changes in clinical practice still need to be determined. With the roll-out of COVID-19 vaccines, the projections are that the pandemic will be over by the end of 2021, at least in the developed world. New genetic variants of the virus may change this outlook. The COVID-19 pandemic has had devasting effects on human physical and mental health with already ~104 million infections and 2.3 million deaths worldwide by the end of January 2021. The local and global financial impacts of the pandemic are still evolving and will most likely linger on for years to come. We can just hope that the saying ‘What does not kill (destroy) you, makes you stronger’ will be true, looking back on these trying times. It was a steep learning curve, but we can all agree that certain aspects of the pandemic could have been managed much better; for example, early recognition and declaration of the pandemic will allow appropriate steps to contain the spread of the disease; base all containment decisions on scientific data and, although difficult, keep politics out of the equation (the main reason why a highly developed country such as the United States did so poorly managing the pandemic); apply all and the most stringent measures available for early contact tracing and containment (pandemics are mostly a race against time and countries such as Taiwan demonstrate the effectiveness of this approach); and support the most vulnerable in society as the well-to-do can most of the time support themselves. Lastly and most likely the most difficult to address, pandemics are global events and a globally unified approach is necessary to efficiently contain and manage these events. These lapses in responding to the COVID-19 pandemic are concerning, but humans tend to have short memories as similar issues were identified in previous pandemics. We can just hope that when the next pandemic comes around (and it will), we will do better.

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