A shortened version of this blog post was published in the Ottawa Citizen on Mar 13, 2020, under the title, “Coronavirus shows the urgent need to invest in health infrastructure.”
by Raywat Deonandan, PhD
Epidemiologist & Associate Professor
Assistant Director, Interdisciplinary School of Health Sciences
University of Ottawa
One of the open secrets shared by population health scientists is that for decades humanity has been long overdue for a particularly virulent pandemic of some flu-like respiratory illness. Bill Gates himself recently speculated that COVID-19 could be that “once in a century” disease whose spread and severity rivals that of the 1918 Spanish Flu. That disease’s global impact was so dire that it likely played a role in ending World War I, having removed so many healthy young men from the battlefield.
With COVID-19, we are in the early days of a global outbreak of a respiratory virus that has already seen profound economic, psychological, and even climatic impacts. With over 100 years to examine and learn from the Spanish Flu, how prepared is this country, and how resilient is the world’s health infrastructure against the stressors of this and future pandemics?
Last year, the Nuclear Threat Initiative (NTI) published their “2019 Global Health Security Index”, which quantified and ranked 195 countries according to their abilities to Prevent, Detect, and Respond to biological threats like pandemic disease. Overall, the world scored a disappointing 40.2 out of a possible 100 points, with the USA ranking as the most secure nation with a score of 83, and Canada ranking a respectable 5th with a score of 75.3.
Canada’s comparatively high score is based mostly on our Detection capability, due in large part to our excellent laboratory facilities and well-trained epidemiology workforce, both of which received perfect scores. Our ability to respond to an existing epidemic, though, was not as well rated at 60.7.
The capacity to Respond is less of a scientific endeavour and more of a systems management issue. To respond effectively to pandemics, a nation needs a robust health care system with the ability to treat people at scale and to quickly isolate carriers. In coordination with other nations, we also need an integrated biopharmaceuticals industry that can develop, test, manufacture and deploy vaccines and antiviral treatments with rapidity. And this all hangs together with an effective communications infrastructure for accurate dissemination of information and the assuagement of unnecessary panic.
The recent announcement by the Prime Minister’s Office of the creation of a federal cabinet committee to oversee Canada’s COVID-19 response is a new addition to our pantheon of systems responses. Helmed entirely by politicians, it seems likely that this committee is partly a symbolic show of leadership and partly an attempt at monitoring and managing the economic implications of the epidemic, though one hopes that their mandate will include managing the flow of resources and expertise between provinces and territories.
Beyond the creation of new oversight and decision-making bodies, our government would be well advised to enhance our disease surveillance capabilities. Knowing when and where new cases of diseases occur is a comparatively inexpensive way to guide resource distribution. In the era of planet-wide instantaneous communication and our stupendous capacity for data storage and transmission, getting accurate real-time information on incident cases should not be an impediment to managing a pandemic.
And yet globally surveillance is fundamentally weak, with many countries having almost non-existent abilities to detect and identify novel outbreaks. Since diseases do not respect borders, other nations must therefore rely ever more so on their own native health information systems.
In Canada, scores of diseases are actively and passively monitored by their own dedicated surveillance programs. We have a very good grasp of our influenza burden, for example, because of our national surveillance system for that disease, called FluWatch. The inclusion of COVID-19 into the FluWatch paradigm would help us track and manage the new disease’s spread.
Surveillance and related data tools also allow us to draw relationships between clusters of cases, making instances of “community transmission” less mysterious and scary. Absent such tools, cases can appear to manifest almost magically without a clear transmission route, fomenting panic and confounding our efforts to contain an outbreak. In Canada, we have world-class expertise in such data analytics at the highest levels of quality. What we need are the resources, leadership, and political will to deploy that capability onto the field at scale.
Scale is indeed the magic word when discussing pandemic response planning. I would argue that all nations’ outbreak plans assume relatively low numbers of cases. But if many hospitals become overwhelmed with sufferers needing isolation, quarantine, and specialized care, how do we provide distributive care at a national level? And do we have the legislative power, ethical oversight, and political cover to enact more restrictive isolation policies should that need arise?
These are many of the same questions asked during the SARS crisis almost 20 years ago. And while remarkable adjustments were made in the shadow of that epidemic, our health system remains unable to scale up its high-intensity response over a prolonged period and over many urban areas.
While NTI ranks Canada highly in preparedness, the one category in which we received a score of zero was in our failure to exercise our response plans. In the wake of SARS and the creation of the Public Health Agency of Canada, much thought and hand-wringing went into building our Maginot Line against the next viral assault. Yet that bulwark remained truly untested until now.
So even if COVID-19 is not the “once in a century” disease Bill Gates warned us about, we can nevertheless consider it a working test of our pandemic resilience systems, which will no doubt be challenged repeatedly and at greater intensities in decades to come. We can choose now to invest in the appropriate infrastructure to keep Canadians safe from pandemic disease now and in the future.