The Inside Story - COVID-19 and health care in Canada...

From tipping point to turning point?

Now that the COVID-19 pandemic has passed the one-year mark, we thought we’d take a retrospective look at how it has impacted health care. Surely these unprecedented times can provide important lessons learned regarding unprecedented issues. So what new lessons for health care are emerging from the pandemic? Turns out, the more we looked for new lessons, the less we found. Instead the pandemic seems to be bringing old lessons learned to a tipping point; lessons we’ve been failing for years. In a desperate cry for help, is the pandemic telling us (screaming in fact) that numerous well-documented issues in health care can no longer go ignored? If these issues go from tipping point to turning point, hopefully the catastrophic effects of the pandemic will act as a strong catalyst for change.

Vulnerable people falling through the health care cracks

Although you may feel like you’ve been living under a rock, your head would literally have had to be in the sand, not to have witnessed how the pandemic has disproportionately affected vulnerable populations.¹ Indeed, a recurring theme is that COVID-19 has exposed how our health care system fails marginalized people. Exposed? Really? Or did it just illustrate what we already knew? Let’s take a look…

Of course, any discussion of health care lessons learned from the pandemic would be highly remiss if it didn’t cover the devastating impact on older adults, especially those living in communal environments like long-term care facilities and retirement residences.² But this impact should come as no surprise, as it just confirmed what we already knew—that older adults are more vulnerable to health risks. For example:

• Age: Before the pandemic’s variants emerged, statistics revealed that as age increases, the risk of serious COVID-19 health effects increases.³ But given that COVID-19 is a contagious virus that causes respiratory illness, wasn’t it safe to assume that age is likely a risk factor? Regarding the flu, another contagious respiratory illness, age as a risk factor is a dominant public health message especially urging older adults to get the flu shot.⁴
  
  
• Underlying health conditions: Studies suggest that underlying health conditions put people at higher risk for COVID-19.⁵ But it’s already well documented that pre-existing conditions increase risk regarding other health issues.⁶ And it’s also well documented which population has the highest incidence of pre-existing conditions (hint: it’s not children, young adults, or middle-aged people).⁷
  
  
• Environment: Communal living promotes the spread of COVID-19.⁸ But didn’t we already know that infectious diseases are more easily transmitted in confined group living because it can be difficult to maintain physical distancing?⁹ And didn’t we know that Canada has one of the highest rates worldwide of people living in institutional care and, therefore, at higher risk? (Answers: yes and yes.)¹⁰
  
  And specifically, regarding long-term care facilities, the federal government has identified overcrowding, poor ventilation, and chronic understaffing as contributing to the spread of COVID-19.¹¹ Sounds eerily familiar. Turns out we have heard it all before—in fact, 150 times before.¹² In discussing his new book that is a call to action for reform, longtime health columnist, André Picard explains, “There’s been 150 reports about this since Medicare’s advent, how to fix the Canadian health care system. Every one of them talks very prominently about long-term care.”¹³ Echoing this, Ontario’s recently released Long-Term Care COVID-19 Commission report finds “years of neglect,” with advocacy group responses saying the report is “both a call to action and a horror. It is not, however, a surprise.”¹⁴

All talk—and task forces—and (almost) no action

Seniors are not the only vulnerable population that fell through the health care cracks, as the federal government explains, “Some populations, already experiencing poorer health and fewer opportunities to achieve good health, faced the pandemic at a greater risk of direct impacts (i.e., illness and death) and carried a greater burden of the public health measures.”¹⁵ Some populations—as in well-documented vulnerable populations such as people suffering from substance abuse and/or mental health issues, lower-income people and those experiencing homelessness, Indigenous peoples, and front-line workers whose choices are often limited due to low wages, no sick pay, and no job security.¹⁶

Clearly, rather than acting as an exposé revealing existing health inequity issues, the pandemic is acting more like an investigative report—unearthing a lack of preparedness to address long-standing issues and in many ways, exacerbating them. Now with the pandemic’s spotlight directly on health inequity issues, how do we address them (finally) so that everyone has the same opportunities to be healthy no matter who they are or where they live?

The primary way to tackle health inequity is to address the social determinants of health.¹⁷ As described by the World Health Organization (WHO), the social determinants of health “are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”¹⁸ Everything from gender, race, and disability to education, income, and housing (to name a few) influence health equity due to varied access to resources, privilege, and power.¹⁹

Best case scenario: the pandemic brings long-standing health inequity issues to a tipping point. Ideally, this triggers a long-overdue turning point in addressing the social determinants of health by making systemic changes. Changes that will make us a lot more pandemic ready than we were. And bigger picture, changes that aim to protect and promote everyone’s health—pandemic or not. Let’s take a look…

Adopt widespread virtual care

Pre-pandemic: Although virtual mental health support had certainly taken off before the pandemic, not many health care professionals had followed suit with virtual care options. Despite benefits like increasing access and decreasing cost, virtual care had its share of detractors citing issues regarding quality standards, training, licensure, payment models, and a digital divide between technology “haves” and “have nots.” Likewise, questions concerning its effectiveness and impact on the patient/provider relationship seemed to
stall uptake.²⁰

• Pandemic experience: Seemingly overnight, virtual health care ramped up—or rather, zoomed—from what was more or less a rarity to now commonplace. By the end of March 2020, national physician associations launched a Virtual Care Playbook to help Canadian doctors introduce virtual care into their practices.²¹ Likewise, health benefits providers aided uptake by offering coverage for services from virtual providers.²² And it turns out that adoption barriers are surmountable. Several regions expanded public health care billing codes to ensure compensation for care included a range of digital mediums.²³ Also, broadening virtual care—to for example, telephone, email, text, video, apps, and wearables—should help address the digital divide.
  
  
• Post-pandemic predictions: Word on the street is that virtual care is here to stay and that even the term “virtual” will disappear as “virtual modes of delivering care will be seen as just another tool in the toolbox.”²⁴ Indeed, some proponents are downright zealous that if a condition is treatable, virtual care can tackle it. This glass-half-full perspective may be buoyed by the ever-growing list of health conditions virtual care has been effectively addressing.²⁵ A more tempered approach is that “we’ll learn where virtual care is most useful, where it’s superior, and where it falls short. And we’ll fine tune over time.”²⁶

"Widespread adoption of virtual care has certainly helped reinforce the importance of leveraging technology to broaden access to care."

Leverage digital innovation

• Pre-pandemic: Canada’s track record of using digital innovation to its full ability to enhance data collection and distribution, as well as improve communication and patient access to care, could be described as rocky with bumps and barriers (and even a scandal or two) along the road. For example, implementation of electronic health records (EHRs) has been in the works for over 20 years.²⁷ Also, perhaps no two words more aptly characterize the state of Canada’s digital affairs than fax machine (so antiquated you may have to give it a google). Archaic, yes, but nevertheless, faxing remains the cornerstone of how important and confidential patient information is communicated among doctors’ offices, pharmacies, and hospitals.²⁸
  
  
• Pandemic experience: Nothing like a pandemic where accurate, real-time data is critical to making sound policy and health care to put our digital capabilities to the test. So how did our systems do? It became increasingly difficult to make sense of the data as more questions arose than answers. For instance, is there no centralized coordination of data? And aren’t data collection methods standardized so we are comparing apples to apples? The result: confusing and questionably accurate COVID-19 case counts, testing totals, and contact tracing.²⁹ Certainly humans rather than technology need to take some of the blame, but should we be surprised that the fax machine just wasn’t up to the digital challenge? This nurse practitioner explains to the media, “During the COVID-19 pandemic, fax technology failed spectacularly across the health care system. Providers who were cut off from their fax machines couldn’t communicate. A massive shift to e-faxing caused overloaded fax servers and system failures with estimates of 15% to 25% of faxes sent not being received.”³⁰
  
  
• Post-pandemic predictions: Widespread adoption of virtual care has certainly helped reinforce the importance of leveraging technology to broaden access to care. In addition, the pandemic’s unclear messaging has highlighted the importance of systems that enable efficient, accurate and up-to-date data collection, analysis, and reporting (although obviously necessary even in non-pandemic times).³¹ Maybe we’ll even finally pull the plug on fax machines. There is a movement afoot by a variety of health care professionals, as well as Ontario’s finance minister, to finally “axe the fax.”³²

Prioritize mental health and substance abuse issues

• Pre-pandemic: As the Centre for Addiction and Mental Health (CAMH) explains, “Canada was already in the midst of a mental health crisis prior to COVID-19.”³³ In any given year, one in five Canadians experiences a mental illness, including addiction.”³⁴ Mental illness is a leading cause of disability in Canada, and substance abuse issues are also prevalent.^{35, 36} How to tackle these issues is the focus of a large body of research.
  
  
• Pandemic experience: Although over the past year there were some upward fluctuations, overall, the mental health of Canadians has declined. And now, not surprising—having endured the pandemic for over a year and facing the threat posed by the new variants—the mood is well, depressing. Levels of anxiety, depressive symptoms, and loneliness are almost as high as they were back in May 2020. Binge drinking is also nearly as high as it was then, and the opioid crisis has continued to worsen.³⁷ In response, a wide range of organizations—employers, insurers, social service groups, and federal and provincial governments—have launched free virtual mental health and substance abuse supports.³⁸
  
  
• Post-pandemic predictions: Eighty per cent of respondents of a recent Ontario poll by the Canadian Mental Health Association believe there will be a serious mental health crisis after the pandemic subsides.³⁹ Perhaps more likely, it will be a compounded version of the crisis that is already occurring; an “echo pandemic” of mental illness.⁴⁰ Compounded by what the experts describe as people “coming to terms with what they’ve lost” and for many, the anxiety associated with returning to so-called regular
  routines in a post-pandemic reality.⁴¹

Implement national physician licensure

• Pre-pandemic: The ideal of leveraging digital innovation points to another long-standing issue: physician mobility.42 Physician licensing exams are national, but each province and territory has unique licensing requirements, documentation, and fees. As a result, to treat patients in other regions, physicians must become licensed in those regions. For physicians, this is a costly time drain. For patients, this limits access, especially in remote or rural areas.
  
  
• Pandemic experience: COVID-19 is indifferent to regional borders. And like all frontline health care professionals, physicians are disproportionally at risk of infection, and their services have been stretched thinly in many parts of the country. These issues make a strong argument for physician deployment to areas in greatest need. Provincial/territorial regulators started fast-tracking emergency licences enabling physicians to work across regions during the pandemic. Medical-legal protection is now also being extended beyond a physician’s usual region of work.⁴³
  
  
• Post-pandemic predictions:The British Columbia Medical Journal reports that “the needle has moved on the historically entrenched issues of national physician licensure.”⁴⁴ However, the issue requires more movement: “Fast-track and portability agreements are valuable stepping stones, but neither offers the same degree of provider mobility and administrative efficiency as national physician licensure.”⁴⁵

Use health care professionals to their full capacity

• Pre-pandemic: Doctor shortages, long wait times, and patient-centred care—just a few of the issues highlighting the need to use health care professionals to their full capabilities. An example close to our hearts is, of course, pharmacists and their quest to leverage the expertise within their scope of practice and even expand that scope.

• Pandemic experience: Clearly the round-the-clock nature of the pandemic has required an all-hands-on-deck approach. Redistribution of staff and high workloads have added even more stress due to staffing shortages. Fortunately, as the pandemic’s heroes, health care professionals have gone above and beyond by performing additional duties in keeping with practice guidelines. For instance, pharmacists have ramped up digital and telephone medication management and patient education.⁴⁶ Similarly, personal support workers (PSWs) have stepped up by donning many caring and compassionate hats.⁴⁷
  
  
• Post-pandemic predictions: Hopefully, the capabilities demonstrated during the pandemic will not only continue, but also spark further expansion of roles. For instance, will pharmacist-delivered COVID-19 testing pave the way for other kinds of pharmacist testing, like for influenza, strep, and cholesterol? And move over flu vaccine, what if pharmacists became the primary source for all kinds of vaccines? Similarly, the health care system will ideally start to fully leverage the potential of PSWs while implementing much-needed reform (keep reading).⁴⁸

Introduce paid sick leave legislation and job protection

• Pre-pandemic: Many front-line workers fall into a sick-at-work trap. When sick—with symptoms that could be COVID-19—they can’t afford to take a sick day due to issues like hourly, part-time, or contract work that is often low paid and doesn’t include sick pay or job protection (think: many PSWs, and grocery store and factory workers).⁴⁹ Approximately 58% of Canadian workers don’t get paid sick leave through their employers; this jumps to 70% for those making less than $25,000 a year.⁵⁰ Only two provinces provide a little sick leave and the rest only offer unpaid sick days.⁵¹
  

"Approximately 58% of Canadian workers don't get paid sick leave through their employers; this jumps to 70% for those making less than $25,000 a year."

• Pandemic experience: The dire consequences of the sick-at-work trap have become reality as front-line workers proved among the pandemic’s most vulnerable. Close proximity fuels transmission, and front-line workers—often also low-wage workers—typically work and/or live in communal environments. Plus, they often have to get to and from work via public transit. Although it is our public duty to “if sick, stay home,” this isn’t an option for many. To encourage workers who don’t have sick pay to stay at home when sick, the federal government introduced a temporary income support program called the Canadian Recovery Sickness Benefit. As the pandemic drags on, issues with the program continue to emerge, strengthening calls for paid sick days and job protection—pandemic times or not.
  
  
• Post-pandemic predictions: Definitely a tipping point acutely illustrating how paid sick days and job protection promote the greater good by helping protect public safety. However, a turning point seems doubtful without a fight—many fights in fact. The federal government is pointing to the provinces, saying it’s their responsibility to mandate employers to provide paid employee sick leave. Meanwhile, provincial in-fighting means some regions and parties are pushing for this kind of legislation while others are trying to shut it down. And some employers are balking as, for example, the Canadian Federation for Independent Business thinks paid sick days will impose unmanageable costs on small employers.⁵² But there has been some movement as Ontario and British Columbia are now both promising change with the details still emerging.⁵³

From crisis to catalyst…

Maybe we had to reach rock bottom to prompt change. Regardless, perhaps going forward rather than re-building from the pandemic, our focus should be on finally ushering in long-overdue change regarding pre-pandemic issues. Addressing these well-documented—and for the most part, fairly stagnant—issues should help improve health care for all Canadians.

But how? Canada’s “go to” is typically more commissions… more studies… more reports. However, given the long-standing nature of these issues—and in many cases, the resulting long-endured suffering—the less commissioning, the better. Let’s make the “new normal” less navel gazing, more action.

And now, buoyed by the idea that perhaps change on many of these issues is (finally) in the air, we thought we’d end on a positive note. Here is a rapid-fire list of some pandemic health care highlights. Yes, highlights!

PANDEMIC HEALTH CARE HIGHLIGHTS

• Innovative drug dispensing models are ensuring patients remain adherent and, in turn, stay as healthy as possible.
• Hospitals are continually and rapidly re-designing processes and spaces and reallocating staff resulting in flexible, patient-centred care.
• Health care experts are becoming household names as they share their expertise and turn into trusted voices.
• Whether epidemiologist, virologist, or infectious disease specialist, many people have a new-found understanding and appreciation for various health care professions.
• Super-fast vaccine development—with new technology to boot.

And, most positively positive, so far vaccine uptake is winning the war against the vaccine hesitant.

Sources

¹ “The Social and Economic Impacts of COVID-19: A Six-month Update,” Statistics Canada, October 20, 2020. Retrieved May 2021:https://www150.statcan.gc.ca/n1/pub/11-631-x/11-631-x2020004-eng.htm.

^{2, 12, 13, 14} “‘Neglected No More’ exposes deplorable state of senior care in Canada,” Pamela Fieber, CBC News, March 11, 2021. Retrieved May 2021: https://www.cbc.ca/news/canada/calgary/wordfest-book-neglected-no-more-exposes-deplorable-state-of-senior-care-in-canada-1.5946420.

^{3, 5, 8, 9, 10, 11, 15, 16, 48} “From risk to resilience: An equity approach to COVID-19,” Public Health Agency of Canada, October 2020. Retrieved May 2021: https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/from-risk-resilience-equity-approach-covid-19.html.

⁴ Government of Canada website, Flu (influenza): Prevention and risks. Retrieved May 2021: https://www.canada.ca/en/public-health/services/diseases/flu-influenza/prevention-risks.html.

⁵ Government of Canada website, People who are at risk of more severe disease or outcomes from COVID-19. Retrieved May 2021: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/people-high-risk-for-severe-illness-covid-19.html.

⁶ “Individual diseases or clustering of health conditions? Association between multiple chronic diseases and health-related quality of life in adults,” David Alejandro González-Chica et al., December 21, 2017. Retrieved May 2021: https://pubmed.ncbi.nlm.nih.gov/29268792/.

⁷ “Aging and Chronic Diseases: A profile of Canadian seniors,” Public Health Agency of Canada, December 2020. Retrieved May 2021: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/aging-chronic-diseases-profile-canadian-seniors-executive-summary.html.

¹⁷ Centers for Disease Control and Prevention website, NCHHSTP Social Determinants of Health, Frequently Asked Questions. Retrieved May 2021: https://www.cdc.gov/nchhstp/socialdeterminants/faq.html.

^{18, 19}  World Health Organisation website, Social Determinants of Health. Retrieved May 2021: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1.

²⁰ “Telemedicine benefits: For patients and professionals,” Zawn Villines, Medical News Today, April 20, 2020. Retrieved May 2021: https://www.medicalnewstoday.com/articles/telemedicine-benefits.

²¹ CMA launches how-to guide to help physicians introduce virtual care services, Canadian Medical Association, March 31, 2020. Retrieved May 2021: https://www.cma.ca/news/cma-launches-how-guide-help-physicians-introduce-virtual-care-services.

²² “COVID-19 Virtual care is here to stay,” Deloitte, 2020. Retrieved May 2021: https://www2.deloitte.com/content/dam/Deloitte/ca/Documents/life-sciences-health-care/ca-covid-19-digital-health-and-virtual-care-aoda-en.pdf.

²³ Canadian Institute for Health Information website, Physician billing codes in response to COVID-19, May 18, 2021. Retrieved May 2021: https://www.cihi.ca/en/physician-billing-codes-in-response-to-covid-19.

^{24, 26} “From a distance: COVID-19 puts more of a spotlight on virtual care’s potential,” Stuart Foxman, eDialogue, June 12, 2020. Retrieved May 2021: https://dialogue.cpso.on.ca/2020/06/covid-19-raises-profile-of-virtual-care/.

²⁵ “The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence,” Elham Monaghesh and Alireza Hajizadeh, BMC Public Health, August 1, 2020. Retrieved May 2021: https://dialogue.cpso.on.ca/2020/06/covid-19-raises-profile-of-virtual-care/.

²⁷ “Electronic Health Records: Then, Now, and in the Future,” R.S. Evans, US National Library of Medicine - National Institutes of Health, May 20, 2016. Retrieved May 2021: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5171496/.

²⁸ “Ontario to (finally) pull the plug on fax machines in public service,” Thomas Daigle, CBC News, March 19, 2021. Retrieved May 2021: https://www.cbc.ca/news/science/ontario-fax-machines-1.5955753.

²⁹ “Is more testing behind the record numbers of COVID-19 cases in Canada? Your testing questions answered,” Emily Chung et al., CBC News, October 28, 2020. Retrieved May 2021: https://www.cbc.ca/news/health/ask-covid-testing-questions-1.5777576.

³⁰ “Axe the fax: A primer on fax tech in the 21st century, an Ontario’s healthcare system perspective,” Beth Gerritsen, 2021. Canadian Healthcare Network. Retrieved May 2021:https://www.canadianhealthcarenetwork.ca/axe-the-fax-a-primer-on-fax-tech-in-the-21st-century-an-ontarios-healthcare-system-perspective.

³¹ “Informing Canada’s Health System Response to COVID-19: Priorities for Health Services and Policy Research,” Meghan McMahon et al., US National Library of Medicine - National Institutes of Health, August 2020. Retrieved May 2021: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435075/.

³² “We need to axe the fax in health care — now,” Parminder Singh and Sachin Aggarwal, March 24, 2021: Retrieved May 2021: https://www.thestar.com/opinion/contributors/2021/03/24/we-need-to-axe-the-fax-in-health-care-now.html.

³³ “Mental Health in Canada: Covid-19 and Beyond,” CAMH Policy Advice, CAMH, July 2020. Retrieved May 2021: https://www.camh.ca/-/media/files/pdfs---public-policy-submissions/covid-and-mh-policy-paper-pdf.pdf.

³⁴ Centre for Addiction and Mental Health website, Mental Illness and Addiction: Facts and Statistics. Retrieved May 2021: https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics.

³⁵ Center for Addiction and Mental Health website, The Crisis Is Real, Retrieved May 2021: https://www.camh.ca/en/driving-change/the-crisis-is-real.

³⁶ Canadian Mental Health Association of Canada website, Substance use and addiction. Retrieved May 2021: