Canada remains ill-prepared for the next pandemic or national health emergency

Canada still needs to fix multiple serious problems in the country’s health emergency response system to be prepared for the next pandemic or national health emergency, researchers and health experts say.

They pointed to problems ranging from a lack of coordinated research and centralized scientific advice, to “inappropriate” human health resources and little resiliency in the health system, to paltry investment in public health and drug distribution challenges.

One thing that hasn’t changed since the first SARS (severe acute respiratory syndrome) outbreak in Canada in 2003 “is that we undervalue and underinvest in public health,” Dr. Allison McGeer (photo at right), professor in the Department of Laboratory Medicine and Pathobiology at the University of Toronto, said in a presentation of online talks.

Canada’s public health budget amounts to only about 1.5 percent of the country’s health care budget, said McGeer, who’s also a senior clinician scientist at the Lunenfeld-Tanenbaum Research Institute at Sinai Health.

“Investing in public health more than anything is what we need,” she said.

McGeer also served as a member of the Expert Panel for the Review of the Federal Approach to Pandemic Science Advice and Research Coordination, which produced a report (the “Walport report”) with recommendations.

People working in public health are focused on preventing infectious diseases, she noted. “If we doubled their budget, that would be the single most important thing we could do about pandemic preparedness.”

The COVID-19 pandemic was the greatest mass mortality event in Canadian history, said Dr. Fahad Razak (photo at right), Canada Research Chair in Data Informed Healthcare Improvement at the University of Toronto.

More Canadians have died of COVID-19 in the past five years than died in the First World War, said Razak, who’s also an internist at St. Michael’s Hospital, Unity Health Toronto.

The distribution of deaths was extremely unequal, with catastrophic impact on vulnerable groups such as people in long-term care, he said.

The pandemic caused huge disruptions in the workforce, with unemployment doubling during the first few months and particular damage to lower-income and less-educated Canadians. “Many small businesses closed, losing a generation of wealth and effort,” Razak said.

Canada’s pandemic measures kept children out of school much longer than most other countries, with Canada having the second-highest rate of school closures in the G10 group of industrialized nations.

“Critically, this was a whole-of-society crisis with impact well beyond health and the health system,” he said.

Considering that Canadian governments and public health experts had to make decisions during the COVID pandemic, often without options and with limited information, there is much to be proud of in Canada’s response, Razak said.

During the first two years of the pandemic, Canada had the second-lowest mortality rate and the highest rate of COVID vaccination for the initial doses among G10 industrialized nations, he noted. “If we had followed the U.S. pandemic trajectory on a per capita basis, 70,000 more Canadians would have died in those first two years.”

The lesson from COVID is that “health emergencies can be far-reaching in their consequence and can fundamentally change society,” Razak said.

Need to act now on three of the Walport report’s recommendations

The Walport report made 12 recommendations, three of which Razak said are the most actionable and urgent.

The first recommendation is to create a national risk register, a systematic and continuously updated review of risks that can impact health, which helps guide preparedness and response.

The second action is for Canada to create a consolidated, centralized science advisory structure to advise government before, during and after pandemics and national health emergencies.

Razak noted that during the COVID-19 pandemic, as the pandemic accelerated, causing fear and social disfunction and putting intense pressure on institutions, nearly 40 new ad hoc science advisory bodies were created across Canada in response to the pandemic.

“Many of these [advisory bodies] had overlapping mandates and drew on the same small pool of expertise,” he said. “This building of the plane as it was being flown is exactly what you would like to avoid in any future crisis.”

The third action is to take steps immediately to maximize the use of research and innovation funding during a pandemic or national health emergency, Razak said.

Canadian funding for research and innovation on a per capita basis is now the second-lowest in the G7, and Canada spends roughly half on R&D per capita compared with the U.S. or Germany.

“Given these deficits, especially in a crisis, it’s crucial to coordinate what existing [research funding] resources we have,” he said.

“But in the pandemic, we had the disheartening situation of research funding in some instances supporting competing studies, making each [study] too small and too slow to have an impact that matched the furious pace of the pandemic.”

Razak pointed out that someone who was critically ill from COVID-19 in the U.K. was five to 10 times more likely to be enrolled in a live-saving COVID-19 clinical trial compared with someone in Canada who was similarly ill.

One of the main reasons for this was the U.K.’s coordinated research approach, he said. “As we prepared our [Walport panel] report, it was striking to see the gaps identified 21 years ago in the SARS-1 report still plague us today.”

Canada also needs to step away from its “cult of efficiency” approach to its health system, said Dr. Brian Golden (photo at right), director of the global executive MBA for health care and life sciences in the Rotman School of Management at the University of Toronto.

During the COVID-19 pandemic, a Canadian health system designed for efficiency and with little redundancy was caught flat-footed without sufficient personal protection equipment and vaccine capacity, underdeveloped supply chains, too few nurses and other shortfalls, he said.

“We had a shockingly high number of hospitals at 100-percent capacity pre-COVID,” and there are even more hospitals in this situation today, Golden said. “We should be embarrassed by that.”

Canada has under-invested in health emergency preparation across several domains of its health system, he said. “We need massive investments in health – not health care – to build resiliency.”

Golden said in his view, Canada also has an “inappropriate mix of health human resources” in its health system. Physicians are critical to the system, but there are too many of them and not enough other health professionals who are also essential to the system and who require less training that’s less costly, he said.

“We need to get the mix right, and we can look to other health systems that are less reliant on physicians,” he added.

At a minimum, Canada should focus on the value Canadians get for health care spending rather than just the amount of money that’s spent, Golden said.

“We spend plenty in Canada, just on the wrong stuff often,” he said. “We need to make it financially attractive to invest in redundancy [in Canada’s health system].”

Canada’s drug distribution supply chain is “stretched thin”

Another challenge Canada faces, especially during a potential pandemic or other health emergency, is the country’s drug distribution system.

That system is federally regulated, with the price of distribution fixed as a percentage of drug prices which are also set by the government, said Angelique Berg (photo at right), president and CEO of the Canadian Association for Pharmacy Distribution Management.

Prices for generic drugs – the most commonly used products – have dropped by 70 percent since 2007, reducing funding for distribution by the same amount, or an estimated $50 million per year, she said. “As governments reduce drug prices, distribution funding is reduced also.”

Newer, high-cost medicines typically go directly from the manufacturing facility to where patients are undergoing treatment, Berg noted. But for drugs that do move in the supply chain, the funding percentage is capped.

“That’s [distributors’] income line. The costs have soared,” she said.

Regulatory and operating costs have increased at least 2.5 times faster than drug distribution volumes during the past decade, Berg said. At the same time, inflation has driven up fuel prices and warehouse and labour costs.

“The result is a supply chain that’s stretched thin, with little room for investment in critical infrastructure or innovation,” she said.

The number of drug distribution centres in Canada has fallen from about 50 across the country to approximately 30 today, which means the drug products have to travel much farther to get to patients – a challenge for people especially in rural and remote communities.

During the COVID-19 pandemic when the mRNA vaccines became available, drug distributors had to buy new fridges and freezers to meet new regulations on frozen storage of vaccines. Distributors then had to deploy this equipment across 9.9 million square kilometres of mostly rural land over roads – just 40 percent of which are paved – amid temperature fluctuations of up to 50 degrees C.

 “The pandemic exposed our weakness,” Berg said. “It showed us that safety stocks of critical drugs are needed to withstand product production disruptions.”

Looking at the issue through the narrow lens of lowest-cost drugs today has unintended impacts across the supply chain, she said. “It could create inequities in drug access in normal times and [leave Canada] ill-equipped to withstand further crises.”

Good news on some fronts in pandemic preparedness

Amid the problems still to be addressed in Canada’s health emergency response system, there is some good news.

The Emerging and Pandemic Infections Consortium (EPIC) now connects researchers and experts at the University of Toronto (U of T) and across the Toronto Academic Health Science Network to combat infectious diseases and prepare for future pandemics, said Dr. Leah Cowen (photo at right), vice-president of research, innovation and strategic initiatives and professor of molecular genetics at the U of T.

 EPIC houses a high-containment facility in Toronto, the only facility in the Greater Toronto area used by hospital and industry researchers to study high-risk pathogens and viruses. The facility was the first lab in Canada and one of the first in the world to isolate the new coronavirus COVID-19 in March 2020.

“We are currently working to modernize the facility to advance made-in-Ontario therapeutics,” Cowen said.

For example, Markham, Ont.-based Edesa Biotech is conducting a phase 3 clinical trial for a drug to treat acute respiratory distress syndrome, a common complication from COVID-19 as well as influenza infections.

That clinical study, however, is happening at U.S. health centres and is being funded by the U.S. government – not Canada. Leading the effort is the Biomedical Advanced Research and Development Authority, part of the Administration for Strategic Preparedness and Response within the U.S. Departments of Health and Human Services.

Another initiative in Canada is the Canadian Hub for Health Intelligence & Innovation in Infectious Disease, or HI³, which has 90 partners – including hospitals, universities, colleges, community organizations and industry – that are developing health threat surveillance platforms and next-generation precision interventions, Cowen said.

However, to build a rapid-response, made-in-Ontario therapeutic strategy “we need to attract capital” she said. “Most importantly, we need stable investment in discovery research – fundamental research.”

At the federal level, the government in January 2022 created the Centre for Research on Pandemic Preparedness and Health Emergencies, with an ongoing investment of $18.5 million per year, housed within the Canadian Institutes of Health Research. The goal of the centre, which currently has seven fulltime staff members, is to fund and coordinate research across Canada related to pandemic preparedness and health emergencies.

Ottawa in September also announced the Health Emergency Readiness Canada (HERC) initiative, which is overseen by Innovation, Science and Economic Development Canada. The goal of HERC, which is not yet operational, is to coordinate the development of new technologies for therapeutics and diagnostics for all types of emerging infectious diseases.

In another forward-looking development, First Nations are taking charge of health emergency management for more than 200 First Nations across B.C., including 41 communities in isolated or remote areas.

This effort is led by the First Nations Health Authority (FNHA) and encompasses the full spectrum of stages in emergencies, said Jessica Hill (photo at right), director of health emergency management for FNHA.

First Nations in B.C. are seeing hazards and emergencies such as drought, wildfires, floods, landslides, marine spills, pandemics and ecological changes due to global warming, Hill said. This is impacting food security for First Nation communities.

FNHA’s work is community-driven and embeds cultural knowledge and teachings within health emergency management practices and processes, she said.

“FNHA helps provide health-focused preparedness and planning. We walk through response and mitigation alongside communities and we also partner with them in recovery phases,” Hill said.

Researcher and internist Razak said the time to act on pandemic preparedness is now, given that the World Health Organization has declared a global public health emergency three times just in the last five years – for Ebola, COVID-19 and Mpox.

“Right now, we’re on the cusp of a potentially extremely worrying breakthrough event with avian influenza, as more and more animals are impacted,” he noted.

Also, in the past few weeks, a severe infection has occurred in an otherwise healthy B.C. teenager without a clear exposure event.

“Whether a breakthrough mutation of avian influenza occurs, one that allows transmission between humans and sets off a devastating new pandemic, is simply out of our control,” Razak said.

“That is why, in an uncertain world, I believe the only responsible approach is to act on what we can control – that is, to be prepared.”

The online talks were presented by The Walrus, in partnership with pharmaceutical multinational Johnson & Johnson and the Rotman School of Management at the University of Toronto.

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