Learning Lessons from COVID-19 (the Canadian way)
Or, How are we Doing? Part 1
Calls for a public inquiry into Canada’s COVID-19 response have been growing, following the release of a series of articles by Canadian authors in the prestigious British Medical Journal (BMJ) on July 24, that characterised flaws in the government’s handling of the pandemic.
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Contributors to the BMJ called attention to fragmented decision-making and poor data access, failures to take health inequalities into consideration, the shameful tragedies that occurred in long-term care homes, and Canada’s poor performance on the global stage in terms of vaccine access, especially for the global south. These are four important issues, though they probably only scratch the surface.
The BMJ authors conclude that:
“The picture that emerges is an ill prepared country with outdated data systems, poor coordination and cohesion and blindness about its citizens’ diverse needs. What saved Canada was a largely willing and conforming populace that withstood stringent public health measures and achieved among the world’s highest levels of vaccination coverage. In other words, Canadians delivered on the pandemic response while governments faltered.”
This seems right to me, even with the undertone that we are sheep.
The BMJ advances five arguments for an “independent, national inquiry” in Canada. They are:
To learn lessons to better prepare for the future, with an emphasis on “positive” ones, rather than scapegoating
To have an authoritative accounting in the face of much misinformation, disinformation and polarization
To help deliver on Canada’s ambition to be a global leader in health security
To suggest measures of reform (an “actionable framework”)
To deliver accountability to Canadians in the face of the losses inflicted by COVID-19.
Probably most of us have lost count of the count. It is truly staggering—53,000 direct deaths and close to five million cases of COVID in Canada. With accountability should come remembrance. I will never forget the sight of the long stretch of memorial names tagged to the wall on the south bank of the Thames River In London. Where is Canada’s equivalent?
But do we have the appetite for such an inquiry? The “we” in the question breaks down into two parts—we the people; and we the government. There is good reason to doubt both. We the people would likely like to move on and the prospect of a future pandemic probably seems a distant concern to most. We the government inevitably fears the political consequences of an inquiry and would much prefer business as usual, which means incremental change conducted invisibly behind bureaucratic walls.
My hands-down favourite political commentator these days, Paul Wells, has had some interesting things to say about a COVID inquiry in Canada. He is emphatic that he doesn’t want a public inquiry under the Inquiries Act, as he put it “with witnesses and Judge Rouleau and an organized right of rebuttal for the counsel for the Canadian Association of There Never was a COVID.” Nice. Elsewhere in the same substack column, Wells suggested that a public inquiry “would be as likely to turn into a circus as a real circus.”
BMJ experts, yes an inquiry. Paul Wells, no circus please, but lessons learned, yes.
Who, in this day and age, would be content with allowing a learning process from COVID to be conducted entirely within the walls of government. What, no hands? But--buyer beware--this may be the only outcome (until next time).
We may not have an appetite for what the UK is undertaking in their COVID-19 Inquiry. The terms of reference of that inquiry are vast and its time-scale beyond the patience of any conceivable (current) Canadian (minority) government. The UK inquiry was initiated in June 2022, held its first set of hearings in July 2023 and is scheduled to conclude its public hearings in, wait for it, summer 2026. A final report might follow in 2027 or so.
I don’t think Canada is going down that road, but who knows what list of aspirational commands will turn up in the new Minister of Health’s (Mark Holland’s) mandate letter, coming in the mail any day now (or September).
By whatever means, IF we eventually set off down the road to a public-facing exercise in learning from the experience of COVID-19, there is a part of the story that threatens to go unacknowledged and untreated. This concerns the fundamental and related issues of early warning and risk assessment. Without early warning linked to authoritative risk assessments, pandemic preparedness plans, no matter how good, are likely to be thrown overboard by reactive, ad hoc, even panicky measures. Does that sound familiar? It should, because Canada suffered a tremendous failure of early warning and assessment of the pandemic threat in the early months of COVID-19, a failure that we have yet to fully appreciate. Not least, as paradoxical as this sounds, because we had ample warning. Describing early warning and risk assessment failures is not a matter of retrospective wisdom. The signs were all around us, and some were generated by our own institutions.
The value of early reporting of the threat posed by a major disease outbreak should be so clear as to hardly deserve argument. If early warning can be delivered, and actioned, it allows for important preparatory measures prior to the arrival in force of a pandemic—everything from readying health care systems for impact, taking extra precautions in long term care homes, and bolstering strategic stockpiles of essential medical supplies, to public messaging and education, consideration of travel restrictions, and mandatory health care measures (masking etc). Early warning is all the more important in a federated state like Canada, where cooperation between federal, provincial and territorial, and even municipal jurisdictions is so important to battling a pandemic. Early warning buys time to try to get all levels of government to align on policy responses.
Two reviews in Canada—early lessons-learned exercises—have already pointed out problems in our early warning system. The first was an important performance audit conducted by the federal Auditor General and tabled in Parliament on March 25, 2021. The audit covered pandemic preparedness, surveillance and border control issues.
Among its findings were that the unique web surveillance system created by Canada in 1997 and known as the Global Public Health Intelligence Network (GPHIN) had not been used to its full potential. GPHIN had not mobilised one of its reporting channels, known as “alerts,” to issue warnings to its (then) 520 global service subscribers, which included the WHO and entities in China, about the onset of the COVID-19 pandemic or about the discovery of initial cases in Canada.
GHPIN was not asleep at the switch. Its web surveillance capacity was activated and caught news of a viral pneumonia outbreak of unknown origins in China on December 31, 2019. But that warning was disseminated only through one channel of reporting, called “daily reports,” whose circulation was limited to domestic public health officials. The Canadian warning was kept to itself, a significant departure from the global role that GPHIN had played in the face of past significant disease outbreaks.
In fact, the GPHIN international alert reporting system had been side-lined in the years immediately prior to COVID-19 by management decree, partially at least owing to nervousness about diplomatic blowback from GPHIN warnings to foreign subscribers, such as China. Bureaucrats seemingly also didn’t relish the idea that some GPHIN alerts might prove to be false alarms, something that goes with the business. So GPHIN’s international reporting was seriously throttled back.
This finding was not new to the OAG report. Previous media coverage had already pointed to serious problems with GPHIN.
The exposure of these problems not only attracted the attention of the OAG by also led the then-Minister of Health, Patty Hadju, to establish an independent expert panel in September 2020 to examine and report on the work of GPHIN. I will come back to the findings of that panel later in this piece. The Auditor General’s report gave generous space to the still uncompleted work of the independent panel and limited its recommendation on GPHIN to a form of encouragement:
“The Public Health Agency should appropriately utilize its Global Public Health Intelligence Network monitoring capabilities to detect and provide early warning of potential public health threats and, in particular, clarify decision-making for issuing alerts.”
While this recommendation signaled the importance of early warning and the value of GPHIN’s capabilities, it did not represent any deep-dive into the problems that bedevilled the unit or make any assessment of the value of the kind of reporting that GPHIN did deliver (to Canadian authorities only) from the onset of the pandemic, or raise red flags about the ways in which the undercutting of GPHIN had also detracted from the World Health Organization’s own independent monitoring of global disease outbreaks. On a charitable reading (why not), the superficiality of the OAG’s report on GPHIN was a product of a belief that the independent panel would be better positioned to produce a more in-depth evaluation.
In response to the OAG’s recommendation, the Public Health Agency of Canada promised to:
“continue to use the GPHIN as Canada’s global event-based surveillance system, relying on the full scope of its capabilities to provide early detection and warning of potential public health threats.”
Where the OAG did not pull its punches, knowing there was no follow-on study in the wings, was in regard to the COVID risk assessments produced by the Public Health Agency of Canada. As the OAG found, the risk assessments produced by PHAC relied on an untested methodology that was still under development, despite years-long efforts, and were not really risk assessments at all, in that they failed to be forward looking and determine the threat that a pandemic outbreak could pose to Canada. The risk assessments that were produced were incredibly complacent and completely wrong in their judgements on the low risk that COVID-19 presented to Canada. If this was not damning enough, the Auditor General discovered that senior decision makers, operating through pandemic response committees, paid little to no attention to these risks assessments. Risk assessments were clearly not embedded in decision-making.
Although a series of five PHAC risks assessments were produced between January and March 2020, it was not until the Chief Public Health Officer of Canada questioned the “low risk” rating contained in them on March 15, that the assessments were altered (and then subsequently abandoned altogether). In short, the Government of Canada was provided by PHAC with no usable, reliable or authoritative risk assessments in the crucial two-and-a-half month period between first knowledge of an outbreak in Wuhan, China and the institution of a series of emergency public health measures in mid-March 2020, by which time Canada already had 401 confirmed cases—a number that would soon skyrocket.
It is not the role of the Auditor General to lambaste government departments, but to unearth poor performance and encourage improvement. Here is the relevant recommendation on risk assessment from the March 2021 audit:
“The Public Health Agency should strengthen its process to promote credible and timely risk assessments to guide public health responses to limit the spread of infectious diseases that can cause a pandemic…”
In response, here is how PHAC took its knocks:
“The Public Health Agency of Canada…recognizes the importance of having a robust risk assessment process in response to public health events, including pandemics such as COVID-19.
The agency will conduct a review of its risk assessment process and incorporate lessons learned from the COVID-19 pandemic to support timely decision-making by senior officials…This review will be completed by December 2022 (COVID-permitting).”
Time to ask--was this lesson-learned review completed? I am told by a senior PHAC official that the review process was completed but no formal review report was compiled. The absence of a formal review report of course inhibits any detailed public scrutiny of the changes made by PHAC, and limits accountability as well.
PHAC annual departmental plans, one potential window into the Agency’s reform efforts, provide little substance on the work that has been undertaken to improve risk assessments and early warning.
The 2022-23 plan states that the Agency is working to improve GPHIN and to “strengthen early detection and warning of potential public health threats by improving existing systems and developing new ones…”
The 2023-24 plan contained this bromide: “the Agency aims to strengthen the early detection and warning of potential health threats by establishing mechanisms to connect GPHIN information and classified intelligence signals to PHAC’s broader monitoring activities for further verification, risk assessment and response.” It also noted a steep decline in future expenditures and personnel in part owing to “the expiry of budgetary authorities for the surveillance and risk assessment initiative in 2024-25.” That is a red flag with worrying implications for the long-term sustainability of whatever changes have been engineered internally at PHAC.
While PHAC has not publicly trumpeted any of the work undertaken in the aftermath of the OAG audit and the independent GPHIN panel report, some digging on its website provides insights into the “strengthening” measures.
Intrepid navigators of the PHAC website (try this route—PHAC website—Emergency Preparedness and Response—Risk Assessments for public health professionals) will learn that PHAC created a new Centre for Integrated Risk Assessment (CIRA), launched in 2022, and headed by an epidemiologist, Dr. Eleni Galanis, hired away from the British Columbia Centre for Disease Controls. A brief news bulletin sent out to all employees in Health Canada and PHAC stated that CIRA “has further enhanced PHAC’s risk assessment capabilities by providing a process, methods and governance for infectious disease rapid risk assessment.”The bulletin mentioned a June 2022 launch of coordinated public health assessment and a PHAC weekly threat report. It specifically cited this work as addressing recommendations from the OAG and the GPHIN independent review.
The PHAC website provides more details on the steps have been taken to improve risk assessment reporting and its underlying methodology. PHAC, through its new risk assessment centre, has now developed three distinct streams of reporting: risk profiles; rapid risk assessments; and pandemic risk scenario analysis. This replaces the singular and poorly developed rapid risk assessment product available to PHAC when COVID-19 struck.
Risk profiles are described as “a detailed characterization of a possible public health risk that may impact people living in Canada or Canadian abroad.” Rapid risk assessments utilize available scientific evidence and other data to understand the “likelihood of a public health threat occurring and its impact.” Pandemic risk scenario analysis looks to the future to examine plausible health security threats.
CIRA has forged ahead in 2023 with the production of all three categories of risk reports:
risk profiles (published on syphilis and wildfires)
rapid risk assessments (published on Avian influenza and SARS-CoV-2 variant XBB.1.5)
pandemic risk scenario analysis (published for Influenza A (H5Nx) and related future novel viruses
Clearly PHAC has upped its game significantly in terms of risk assessments and understood the need to make major improvements in light of the poor performance on risk assessment during the early months of COVID-19. This seems to be one lesson in the bank.
The agency has also abandoned the home-grown pre-COVID risk-assessment methodology that was the subject of intense criticism in the 2021 OAG audit and instead adopted the "Joint Risk Assessment Operational Tool" developed by a trio of UN agencies (WHO, Food and Agricultural Organization and the World Organization for Animal Health). Second lesson in the bank. Don’t try to invent something better invented by someone else—and save some cash on consultants in the bargain.
But a few things worry me.
First off, these risk assessments are described as "for public health professionals." The 2023 rapid risk assessment for Avian Influenza, an issue of growing concern, is 28 pages long (with endnotes). (For the latest WHO bulletin on Avian influenza, see):
Lengthy and scientifically oriented reporting products such as the PHAC “rapid risk assessment” would be of little use to senior decision-makers, especially in non-health portfolios. In that respect, PHAC continues to work in its silo. I am told by a senior official at PHAC that “there are other avenues through which PHAC informs decisions across the federal government.” The risk assessments themselves are clearly not designed to perform this function. What these “other avenues” might be and what form the risk reporting might take is unknown.
This links to a second concern. There is no clear indication that PHAC risk assessment products will be integrated with other reporting from elements of the national security and intelligence system to give a more holistic picture of a global health security threat.
Third, there is no indication whether GPHIN reporting is a source for these PHAC assessments. As the GPHIN independent panel report of May 2021 found: “if GPHIN’s early signals are not being fully incorporated into the risk assessment continuum, then its intelligence is not being fully leveraged.”
Fourth, the PHAC departmental plan for 2023-2024 anticipates deep budgetary and personnel cuts going forward to 2025-26 planned spending. Have a gander at these figures.
Planned spending 2023-24 for Health security branch:
Planned spending for 2025-26 for Health security branch:
Human resources (FTE) for Health security branch for 2023-2024:
Human resources (FTE) for Health security branch for 2025-26:
Wow, that is more than the proverbial government “haircut.” These drastic reductions, according to the Departmental plan, are:
"mostly due to the gradual reduction of funding for the management of medical supplies and equipment, including PPE related to the COVID-19 pandemic and the expiry of budgetary authorities for the surveillance and risk assessment initiative in 2024-25."
If there is a take-away on lessons-learned about risk assessments, it is that significant governance and reporting improvements have been made through an internal process, but the work has lacked transparency, remains siloed, and may not be sustainable given projected cuts. The much-needed bridge between work on health security undertaken by PHAC and the national security and intelligence system remains to be built.
What about GPHIN? Did the independent panel set up GPHIN for readiness for the next pandemic and what has come of its recommendations?
The independent review panel’s report on GPHIN, commissioned by the Health Minister, was issued in late May 2021. Its four chapters (sixty pages) comprise the most extensive account available on GPHIN, its nature, history, challenges, and reform needs.
GPHIN is an effort to “scrape” the web for formal and informal news stories from global sources that might indicate anomalous disease outbreak events, possibly before they are reported officially by state parties. To use a radar analogy, it “scans the horizon” for emerging public health threats. GPHIN operates in nine major languages and uses AI capabilities, including machine learning and natural language processing. It is known as an “events-based” surveillance system (EBS). In a wider intelligence context, it is a prime example of the use of open-source intelligence. When it was created in 1997 it was ground-breaking and it remains the only example of a state-organised web surveillance system for health security. But the information environment and technology have changed dramatically since 1997 and GPHIN is challenged to keep pace.
A key point that the Independent panel report makes is that for GPHIN to be effective it has to be a contributor to a risk assessment process within PHAC. GPHIN has an important role to play in verifying its open-source raw intelligence, but it does not do assessments. Pointedly, the panel argued that PHAC must ensure that “GPHIN’s signals are able to initiate the risk assessment that decision-makers require.” (p. 31)
The panel said that GPHIN needed to be “plugged in” to an organised assessment process that existing PHAC structures and internal silos did not facilitate. To that end, it recommended the creation of a “risk assessment office.” Hey, presto, PHAC responded by building its new Centre for Integrated Risk Assessment, discussed above. The panel also recommended that the Chief Public Health Officer be formally made responsible for risk assessment through changes to the PHAC Act—one way of ensuring that risk assessment reporting is paid attention to at senior levels and that there is clear accountability. That hasn’t happened yet—legislative changes take time.
In addition to calling for internal improvements to the PHAC assessment process, the panel report also recognized the importance of trying to ensure that PHAC was able to use classified intelligence from the national security and intelligence agencies in its work. This would involve improved engagement, access to shared reporting, and a cadre of employees with the necessary top secret security clearances.
Beyond this lay the higher-level question of the extent to which health security should be integrated into national security policy. Here the panel clearly felt that political decisions were required, given the long history of separation between the spheres of health security and national security. It expressed an optimism that “the lessons of COVID-19 will set the stage for re-prioritized objectives that link public health and public safety.” But the panel report declined to try to set the stage itself and offered no recommendations on this score other than saying that a government decision would be needed on “how to incorporate public health intelligence into national security priorities.”
This disappointing squib at least got the fundamentals right. Identifying health security as a key component of national security would necessitate a cultural change in approach on the part of the Canadian national security system. That change would require political will, direction, leadership and accountability. One obvious staring point would be to incorporate health security into the Cabinet-mandated bi-annual setting of intelligence priorities.
But the panel report failed to reflect on any lessons from the last time Government direction was issued on integrating health security into national security policy. The 2004 National Security Policy, issued by the Martin government in April 2004, urged this integration, with the experience of the SARS crisis fresh on its mind. It wanted to ensure that intelligence community threat assessments incorporated health security reporting. The newly created Integrated Threat Assessment Centre (subsequently renamed and repurposed as the IntegratedTerrorism Assessment Centre—you see what happened) was meant to take on this work. But it didn’t, and nobody showed up to play. And, two decades later…here we are back at the same problem.
The lesson is this. A published national security strategy is a key element of government leadership and public accountability. Governments must return to creating and releasing them on a regular basis. It is shameful that there is no current national security strategy and that none has been produced since 2004. But on their own they are not enough. The changes they signal must be followed up on, properly resourced, and paid attention to, including by accountability through independent channels. Learning lessons is not a one-stop paper exercise.
One major change that has occurred between the 2004 national security policy and today is that we now have a robust architecture of independent external review bodies, in particular the National Security and Intelligence Review Agency and the National Security and Intelligence Committee of Parliamentarians. Neither has yet to conduct any studies of the role of health security in the national security function. Its time they did.
Overall, the independent panel report had important things to say about the need to sustain and strengthen the role of GPHIN and its “event-based surveillance” within the Public Health Agency of Canada. Critically, it recognized that GPHIN must not be treated as a peripheral entity within PHAC, disconnected from other parts of the Agency and looking outward. Its ability to send signals to an enhanced risk assessment centre within PHAC and to serve an assessment reporting “continuum” was recognised. Staying abreast of technological change and finding ways to incorporate social media sources into the GPHIN information universe were tagged as key issues for the future. As in other uses of social media scraping by elements of the national security and intelligence system, the challenges of meeting privacy requirements lessen with an international focus. Working with private sector entities with existing and developing expertise in the field of social media monitoring will be vital for GPHIN. A government organization that was once a leader in open-source intelligence has a chance to be a pioneer again.
But amidst these important findings of the GPHIN Independent panel, one major issue was left unresolved. How GPHIN and PHAC should serve a wider national security function in government was left on the table.
Score—one important set of lessons learned about the need to ensure GPHIN viability within PHAC; one more set still to learn on the integration of health security and national security, where GPHIN and PHAC risk assessment could be key elements.
One last thing to note. Parliament and our political parties have been mostly silent on the issue of learning lessons from COVID-19. The Conservative party promised a full COVID inquiry in their 2021 election campaign platform, but it doesn’t seem a current priority of the Poilievre leadership. There is no media clamour. There is nothing like the red-hot (excuse the terrible pun) attention given to demands for a public inquiry into Chinese state election interference, though in the scale of things someone should be asking which constitutes a greater national security threat (or, more crassly, how many people have died from Chinese officials’ intended schemes and boasts to meddle in our elections).
It has been left to a lone and sometimes maverick backbench Liberal MP, Nate Erskine-Smith, to try to move Parliament in the direction of a lessons-learned exercise through tabling of a private member’s bill (usually a quixotic enterprise). Mr. Erskine-Smith’s bill (C-293) is masterfully short and to the point. It would set in motion four things:
An advisory committee, with diverse representation, to the Minister of Health to “review the response to the COVID-19 pandemic in Canada”
The review to be used to inform a new pandemic prevention and preparedness plan
To create a governance mechanism—in effect a pandemic preparedness ‘czar’—at the Public Health Agency of Canada to oversee the review and its implementation in a new strategic plan.
To require the Minister of Health to table the pandemic plan in Parliament and to provide updates to the plan at least every three years.
Its neat and needed and avoids the circus that Paul Wells fears.
It could be done. First reading of Bill C-293 took place on June 17, 2022. And that’s where the story of Parliamentary action becomes stale-mated. Opposition members on the Health Committee opposed Erskine-Smith’s idea of an advisory committee, fearing that it would be an inadequate substitute for a full public inquiry. A Conservative MP called it a “shield” for the government. MP Erskine-Smith countered by saying that he was looking for ways to avoid politicising any lessons-learned exercise.
Does all this sound a familiar game? If and when the bill goes to third reading in the House (maybe in the Fall of 2023) it is likely that the advisory committee approach will be deep-sixed. That’s all folks (For now).
A future instalment of this investigation into learning lessons from COVID-19 will look outside our borders, to some key studies and strategic plans. It won’t be comprehensive. The focus will be on early warning and risk assessment and what these studies and strategies might have to teach Canada.
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