As any general will tell you, simulations and war games will only take you so far in preparing for battlefield conditions but any preparation is better than no preparation. Dr. Tim Evans, Inaugural Director and Associate Dean of the School of Population and Global Health at McGill University and member of the COVID-19 immunity task force announced by the prime minister on April 23, provides us with an invaluable assessment of what we know so far, what we need to find out and how we can better prepare for future pandemics.

Dr. Tim Evans

As a veteran of the global health frontlines, I have become an advocate for simulations or table-top exercises as helpful in preparing for pandemics. In October, 2019, I participated in a pandemic simulation hosted by the World Economic Forum in New York City. With a small group of public and private sector leaders representing diverse interests and industries globally, we were confronted with an unsettling pandemic scenario: a novel coronavirus breaking out in Asia causing atypical pneumonia and escalating rapidly to become a crushing pandemic that kills millions over a six-month period and brings the global economy to a standstill.

Less than two months later, there was evidence that this simulation in New York had hit the ground in Wuhan. And now, as we reach the peak of the first wave of the SARs-CoV-2 pandemic in Canada, it is all-to-clear that despite preparations including simulations, we were massively ill-prepared for such a crisis. The magnitude of this pandemic and its devastating impact on our loved ones, our lifestyles and our livelihoods cannot be overstated. Nor can it be written off as a one-off or short-lived. Already, there are reasons to be concerned about subsequent waves of the SARs-CoV-2 infection together with the spectre of prolonged economic contraction and depression-levels of joblessness.

While a formal report card on Canada’s response thus far is premature, there are several areas where reflection may be helpful moving forward: 

First, it’s deeply troubling that four months into this pandemic, our data on infections remain so incomplete. To date, testing has followed the epidemic rather than getting on top of it. The initial focus on testing symptomatic travellers returning from high-risk areas underestimated the potential for asymptomatic and community transmission. To date, due to a wide range of problems including the availability of testing equipment or personnel to perform and analyze tests, there is still no population-based testing that is shedding light on asymptomatic and community transmission. We know from South Korea, Taiwan, Hong Kong and Singapore that well-managed systems for testing are the way to get on top of the epidemic. Canada and many other countries need to take stock of these countries’ testing capabilities as best practices and learn to do much better.

Second, with the advent of blood tests that check for an immune response, there is an opportunity to understand the total numbers infected by the novel coronavirus. This information is critical as it will help not only determine more accurate assessments of the true magnitude of the epidemic but will begin to provide insights on levels and trends in immunity. Should large numbers of the population show signs of immunity for example, it is likely that a second wave of infection will be less severe. In addition, knowing the immune status for essential workers like health professionals will be helpful in their deployment in terms of minimizing risks that they will either transmit infection or get the infection themselves. Canada has an important opportunity to get antibody testing in much better order than the molecular assay testing. A new Canadian consortium aims to ensure rapid and reliable rollout of surveys to assess rates of infection as well as the immune status in high-risk groups such as health workers. Provided high quality tests and concerted attention to the evolving state of science on COVID-19 immunity are central to the consortium, it has tremendous potential to help get Canada truly on top of the epidemic and to inform the re-opening of the economy. 

Third, the sourcing of key commodities critical to responding to the pandemic such as masks, protective gowns, ventilators and tests has been sloppy and slow. National stockpiles were severely underpowered virtually everywhere to meet the crescendo demands arising from staff working in hospitals and long-term care facilities. Likewise, efforts to procure these life-saving commodities in the global markets have been especially difficult given the concomitant flood of demands from many countries much larger than Canada that, in aggregate, vastly outdistanced global supply capacity. A major re-think is required moving forward to develop more road-worthy strategies for stockpiles and tapping global supply for essential pandemic commodities. 

Fourth, Canada’s hospitals appear to be standing up quite well to the challenge of the acute surge in hospitalizations and needs for intensive care. This may reflect a lower-than-expected peak in the numbers requiring care due to the impact of physical distancing measures or that the models predicting hospital needs were simply exaggerated. Less clear, but equally important is how the health care needs above and beyond COVID-19 are being managed given the widespread cancellation of elective procedures and the reluctance that people feel toward going to health care facilities. 

More worrisome is the performance of long-term care facilities for the elderly and infirm where infection appears to be rampant and mortality rates very high. Media reports of massive understaffing together with unconscionable living conditions of residents points to an urgent need to develop options to improve long-term care in the setting of pandemics.

Fifth, Canadians appear thus far remarkably compliant with the severe physical distancing measures that have been imposed now for close to a month. Sustaining these will become increasingly difficult as the first peak of infection declines, the weather warms and the imperative to restart the economy grows. More nuanced options for managing public health risk in a re-opened economy need to be assessed as a matter of urgency. Chief among them is to tailor appropriate responses to communities with disproportionate risk including First Nations, the homeless and the swelling numbers of unemployed. 

Sixth, fast-moving pandemics require a commensurate ability to surge or grow the response quickly in order to avoid getting overwhelmed. Surge capacity is not only constrained by slow decision making but more fundamentally by assets that can’t be mobilized easily without advance preparation such as a qualified workforce. The severity of workforce shortfalls is starkly felt system-wide: in elderly care centers, among hospital workers whose prolonged use of masks has resulted in facial scars, and also amongst critical public health workers who lack the time to fill out vital information on persons newly detected with infection. It is imperative to explore innovative solutions that bring appropriately trained persons in the numbers needed to these clinical, long-term care and public health front-lines. 

Finally, the current pandemic makes it clear why the health of anyone anywhere matters to everyone everywhere. In this regard, Canada’s response to the pandemic must be considered not only within its borders but also beyond. One of these areas relates to global efforts to find a SARs-CoV-2 vaccine. In the wake of the Ebola crisis in West Africa in 2014, many of the reviews of lessons learned pointed to the need for a proactive and ongoing vaccine development capacity for pathogens with pandemic potential. This led to the creation of the Coalition for Epidemic Preparedness and Innovation (CEPI) in 2017, a global NGO with a mission to advance development of vaccines for pandemic pathogens. Among CEPI’s initial priorities is the development of vaccines for coronavirus and investments over the last two years on this front have provided an important head start for many of the vaccine candidates that are currently being tested for SARS-CoV-2. Canada’s participation in CEPI allows it to leverage the best science globally to accelerate vaccine development with a very modest investment. 

Creating new public good institutions like CEPI to shore up gaps or enhancing the performance of existing institutions is critical to better management of global pandemics. Canadians should not forget that it was the SARS epidemic in 2003 that exposed many shortfalls in Canada’s epidemic readiness and led to the creation of the Public Health Agency of Canada (PHAC). 

We tend however to lose sight of the importance of these institutions. As Jeffrey Lewis pointed out in his recent book Fifth Risk, the biggest risk we face is undervaluing these public assets by either under-investing in their growth and further development, or worse, by co-opting them for short-term political gain. While PHACs integrity has not been questioned thus far in the pandemic, the same cannot be said of other institutions like the World Health Organization (WHO), the essential work of which has been the focus of misguided and misplaced attacks. Canada’s public efforts to stand up for and support WHO at this time are important and appropriate. 

Nevertheless, no institution should escape scrutiny and accountability, and at an appropriate time, WHO and other multilaterals like the World Bank as well as PHAC and its provincial/territorial equivalents should be duly assessed regarding their institutional performance during the pandemic with appropriate measures taken to address any shortfalls. Fostering a culture of improvement and learning across all institutions will mean more lives saved in the future.  

Dr. Tim Grant Evans is former Senior Director, Health, Nutrition & Population at the World Bank. He has been Inaugural Director and Associate Dean of the School of Population and Global Health at McGill University since September 2019.