September marks six months since the World Health Organization declared a global pandemic of COVID-19. We’re using this milestone to take stock of the policy response so far and consider next steps as Canada continues to move from reaction to rebuilding. As part of this, First Policy Response is speaking to several policy experts to gather their thoughts on the key policy developments of these past six months, and what they think our next priorities should be.
This interview with Dr. Samir Sinha, director of health policy research and co-chair of the National Institute on Ageing at Ryerson University, is part of a series of interview transcripts. You can read the full series here. This transcript has been edited for clarity.
First Policy Response: As of May, the National Institute on Ageing was reporting that more than 80 per cent of COVID-19 deaths in Canada were in long-term care homes. Is that still accurate at this point?
Dr. Samir Sinha: Yes. Towards the end of March, we launched what we call our NIA Long-term Care COVID-19 Tracker. It’s available online and we continue to update it to this day. By May, or at the height of the pandemic, if you will, we were even up as high as 82, 83 per cent of Canadian deaths that occurred in long-term care settings. By the time the Canadian Institute for Health Information did an analysis towards the end of May looking at our data, they confirmed about 80 to 81 per cent. Right now that number is about 77 per cent of Canadian deaths that have occurred in long-term care homes. So the number is decreasing a little bit, but it’s staying around the 80 per cent mark, and this reflects that more younger people are now becoming infected. And certainly younger populations, with the second ripple or second wave that’s starting to develop across the country, we’re starting to see more deaths occurring outside long-term care homes in the general population, as well.
But the bottom line is that Canada still holds this record of 77 per cent or close to 80 per cent of its deaths occurring in our long-term care homes. And that’s about double what we’re seeing on the international stage.
FPR: Why do you think that is?
I think there are two fundamental reasons why we’ve actually been seeing such a high proportion of our deaths occur in long-term care homes. The first part is good news: Canada did a really, really good job early on in the pandemic, as cases were starting to climb in Canada, to actually take some definitive public health measures to lock us all down, essentially, and limit our ability to travel and interact, and close our borders as well. And by doing that, we helped to significantly limit the rate of community spread that could potentially occur, that we had seen become real issues in places like the U.K., Spain, Italy, etc. And so, because we had fair warning compared to some European countries, for example, we were able to heed those warnings and close our borders, create our lockdown situation early, which helped to limit the amount of community spread and the number of cases and deaths. And overall we’ve seen only about 1 per cent of Canadians in total have actually been infected, probably, with COVID-19.
The challenge is that, when it came to the way that we were preparing ourselves in our health-care system, a huge amount of focus was placed on our hospitals at the expense of our long-term care and our retirement-home systems, which really in the end were not well equipped and well supported enough to deal with COVID-19. So even though COVID-19 was circulating in the communities, we weren’t making sure that all of our long-term care homes were fully equipped with personal protective equipment. While we assumed that our staff in these homes knew how to follow IPAC [Infection Prevention and Control] procedures and use their PPE, this wasn’t quite the case.
And then we already had a system that was plagued with staffing shortages and issues. And as COVID got into homes and spread easily – because we weren’t aware early on of the possibilities of asymptomatic spread and transmission – staff weren’t equipped with enough PPE and we already had severe staffing shortages to begin with. As soon as COVID started taking effect in these homes, this just exacerbated all these problems even further, and especially in provinces like Ontario and Quebec, really set us off on a wrong foot overall.
FPR: What does that tell us about the long-term care system in Canada?
I think what it really exposed to us is that, when we think about how Canada did compared to the rest of the world, we could say, yes, some of our high case numbers or rates of deaths in these settings was partly related to the fact that we actually had done a reasonably good job of limiting the amount of general community spread. But you know, when you’re double the international rate of deaths in long-term care homes, it also speaks to the fact that COVID-19 exposed how vulnerable our long-term care system was to begin with. So when you look at OECD [Organisation for Economic Co-operation and Development] countries, in general, which experienced half the rate of deaths in its care homes that we did, what we see is that we spend 30 per cent less on providing long-term care services in Canada compared to other OECD countries. We’re already funding significantly less as a proportion of our GDP compared to other countries, only 1.3 per cent versus 1.7 per cent on average. So that’s the first challenge.
And then, when you underfund an entire long-term care system, it means that we have staff who aren’t paid as well as those who are generally working in our hospitals, for example. And we also have the challenge where more people tend to work part-time in these settings than, say, in other health-care settings, and as a result, to try and make a full-time salary, people are working multiple jobs in multiple settings. All of this means that if you have infection in one home, when staff are working between multiple homes, they could inadvertently become vectors to transmit this virus from one home to the other. So when you underfund the system, it affects the level at which we staff these homes.
It also affects the resources we actually provide these homes to provide the care that residents need. And it really just exposed the fact that we had these systemic vulnerabilities – that not only were we having challenges staffing and making sure that homes have the resources they did, but we also see this phenomenon in Canada, compared to many other countries, where in Ontario, for example, a large portion of the rooms happened to be two-, three- or four-bedded rooms, where in many other jurisdictions, they moved to an all-single-room format. The problem is, if you move to all single rooms, that’s a much more expensive home to build than packing people two or three or four to a room. And so again, when you underfund the system, you’re going to have poor-quality facilities and many older facilities that are vastly in need of redevelopment, but also a system that can’t actually even attract the basic staff it needs to keep these homes properly staffed and supported, especially during a pandemic.
FPR: Was it a surprise to you, how much higher the rate was in Canada compared to the rest of the world?
It was. I mean, the data doesn’t lie. And when you see that Canada has such a high rate of death in long-term care settings, especially when we had other countries that had significant community spread but their long-term care settings seem to fare better, we started realizing what other countries were doing and what we weren’t doing, and it reinforced how our approaches were not well balanced in Canada. For example, other countries, realizing that their long-term care homes or settings were highly vulnerable settings, were making sure that they actually increased the staffing in those settings. They were making sure that homes had adequate supplies of PPE. They were making sure that staff in those homes were having their skills augmented in terms of how to use PPE, and making sure that they were well versed in their infection prevention control efforts. And in some jurisdictions, they had developed early response teams, so that if a home did go on outbreak, it would actually have extra resources deployed almost immediately. Yet we didn’t have a lot of those mechanisms in place or those considerations in place. I think so many people were concerned about our hospitals getting overwhelmed at the beginning; we were concerned about conserving PPE for these settings at the expense of our long-term care settings. So while we were masking all the staff in our hospital settings, we weren’t doing that for staff in long-term care homes for even weeks after we started mandating this in our own hospitals. This really just showed that we almost created a bit of a double standard, and ironically, a double standard in environments that had the most to lose if COVID-19 got in.
“Fundamentally, as a society, we’re ageist.”
FPR: How do you think we ended up in this position where the long-term care homes were so much less prepared than hospitals?
I think part of it was just the fact that what we were seeing around the world was that countries that were really struggling had hospitals that were utterly overwhelmed. And so I think a lot of people just naturally felt that if we shore up our hospitals, then the rest of the system will be OK. But what we weren’t hearing about was the fact that in countries like Spain or Italy, people weren’t even getting the opportunity to be sent to hospital for care from a long-term care home. Because the hospitals were so overwhelmed, they kind of left long-term care homes on their own. And it’s only after the fact that we found that thousands of additional people were dying in these settings, weren’t even being tested and weren’t even being given the chance of going to a hospital.
And I think part of it is because fundamentally, as a society, we’re ageist. And we’re more focused on maybe protecting the shinier and more expensive parts of our health-care system that we can all relate to, versus the more underfunded and forgotten parts of our system that tend to a group of people towards the end of their lives, who no longer have as much relevance in our society as, say, children and adults in general. So when you think that these homes basically housed hundreds of thousands of Canadians who are in their last few years of their life, 70 per cent of whom have dementia, I think that sometimes the attitude is, “Well, if they get COVID and die, they were going to die in a few years anyways, so is this really a loss?”
We see the utter hysteria right now happening at this time around schools reopening, and parents really worried about their children and protecting the children. If we imagine these homes being boarding schools, and all of these victims, the thousands of Canadians who have died in these homes, were actually young children, I wonder if we would have even more of a visceral response as Canadians, feeling that if these were young lives, that they would have mattered more, because they lost the lives that were completely ahead of them. But because these were older people towards the end of their lives, did their lives matter as much as others?
And we saw these attitudes and these issues play out in places like Italy. When they ran out of ventilators, for example, they would just simply say, “If we have to choose between two people, we’re going to choose a young person over an older person, because frankly, that older person has probably less of a chance of surviving on a ventilator and they have fewer years of life ahead of them.”
I think there were a lot of different issues that came into play. This was a less well-known part of our system. It’s always been, traditionally, a less well-supported and funded part of our system, and I think that partly reflects societal attitudes and views. And then when it came to an overall response, I think that many people were just feeling that if we just better support our hospitals and make sure that our efforts are focused on them, then the rest of the system will follow. But what we really saw is that by having poorly coordinated and under-supported responses early on for our long-term care homes, especially as COVID was spreading in communities in Ontario and Quebec, we saw what the consequences ended up being. And in provinces like B.C. that actually took much more definitive action early – perhaps because they were next to Washington state, which was seeing some of the first major outbreaks occurring in their nursing homes – I think B.C., frankly, gets top marks so far because they recognized quickly how vulnerable these homes were. I think they really focused on making sure that they were particularly well supported with the right policies, staffing solutions and PPE supplies. By doing those things early and definitively, our work has shown that only 12 per cent of B.C. homes ended up in outbreak. You compare that to the province next door of Alberta, where 24 per cent of its homes in a less populous province ended up in outbreak; then you go to Ontario, and you see 35 per cent of Ontario homes, 27 per cent of Quebec homes in outbreak. You see that B.C., as one of Canada’s most populous provinces, by definitively taking earlier and more direct actions to support their long-term care homes, saw only 12 per cent of their homes ever end up in outbreak.
FPR: What policy interventions so far do you think have been helpful?
Universal masking, for example – making sure that all the staff in these care settings and all visitors to these settings are wearing masks. Especially when we realized that COVID-19 can have such a high rate of asymptomatic transmission and spread. By universally masking – what we’re asking citizens to do in their everyday lives now, as well – we knew that putting that in place had a significant level of impact. But B.C. did this fairly early on. They did this towards the end of March, for example, where this still wasn’t implemented in other provinces, like Nova Scotia, Ontario and Quebec, until well into April.
We also know that COVID-19 can be rather asymptomatic in its presentation and spread. Traditionally when there’s an influenza outbreak, it’s pretty easy to tell who has influenza and who doesn’t, but with COVID-19, because a person could look perfectly well and actually have COVID-19, it became really important to start changing our approaches to testing and isolating residents. So, making sure that we don’t simply just isolate and test people who look symptomatic, but we also think about people who possibly could have been positive contacts and making sure that we test and isolate them, as well. It was quickly adopting more advanced testing and isolation strategies that also recognized the rates of asymptomatic transmission.
And then also making sure that we could actually support staff or enable staff to not have to work in multiple care settings, because when you have a lot of foot traffic occurring between different settings, we have a risk where these staff can inadvertently start transmitting this virus between homes. That was an early lesson learned in B.C., where the very first outbreak led to the second outbreak, when it was staff working between two homes who actually introduced it to a second home.
“We’re trying to be open and transparent about what the data actually shows to better inform better policy responses.”
FPR: I am also struck by the fact that the NIA is collecting data on this. Does that identify a gap in the system, that nobody else has been doing this?
Yeah. I think certainly at the start of the pandemic, did we think this was something that needed to be done? Absolutely. Did we think we needed to be the ones doing it? Certainly not. I think what we anticipated early on was that there would be some kind of national system to help, just as we would hear in the daily news brief – how many cases, how many deaths, etc. What we were seeing was the most vulnerable part of the system wasn’t really getting a lot of air time, other than hearing stories about significant outbreaks occurring in parts of Canada, but not necessarily seeing the data being reported. We would hear number of cases, deaths, how many people are hospitalized, how many people are using ICUs, but never how many homes are in outbreak across the country? How many residents have been infected? How many staff have been infected? How many residents and staff have died? And because we didn’t see this being collected, first of all, at a national level – or at least being reported publicly at a national level – and then we were seeing provinces collect information in different ways and not collecting it in a systematic way that would allow us to compare and learn from different provincial experiences, we clearly saw a gap here that nobody else seemed to be filling. And that’s why I think the NIA decided to step in and actually start collecting this information in a robust way that we could present in an open way back to the public, with a goal to fill in a clear data-collection gap that nobody else seemed to be focusing on in Canada at the time. And we certainly have seen over time that certain provinces have improved some of their reporting systems, but we’ve seen some provinces that have kind of backed away from being so public in the way they’re reporting things and even becoming a bit more, I think, secretive in the data that they’re even willing to share.
Quebec is one of those classic examples. I think, as things were getting really bad in Quebec, for example, there wasn’t really clear, definitive information on what was actually happening in its long-term care homes. And then I think by April, the Quebec government started releasing a daily list showing what the size of the outbreaks were, which homes were in outbreak, etc. But then they abruptly stopped reporting that data on April 30. They said there was some kind of accounting or technical error that they would fix and start reposting that information back within a few days. But then it was literally about two weeks that, that information system was down. When it got re-posted, it was even, I would even argue, a little bit less transparent than it was before, and it made it really hard for people to understand exactly what was happening. So even with our tracker data in Quebec, we know that we’re probably under-reporting the total number of resident cases and staff cases and overall [cases]. And that’s a concern because, again, without accurate data, we’re making assumptions about what happened in Quebec that may actually be under-reporting the issue there, and maybe [affecting] how accurately we can interpret the Quebec situation in a way that can be helpful for other provinces and territories not wanting to make some of the same mistakes.
We’ve had real problems trying to get clear, definitive answers towards our data in both Nova Scotia and Quebec, whereas other provinces like B.C. and Alberta have been incredibly transparent and supportive of our work and helping us to make sure that we have good quality, accurate data, because they appreciate that what we’re trying to do is just be open and transparent about what the data actually shows to better inform better policy responses.
FPR: At this stage, as we’ve kind of gone through the first six months of this, what kind of policy responses do you think are needed as we’re going forward over the next few months?
I think right now, the good news is that we have learned a lot during the first six months that helped us to understand why long-term care homes are particularly vulnerable and what potentially makes them particularly vulnerable. And I think through provinces that have been particularly hard hit, like Ontario and Quebec, they’ve started to appreciate the resources and mechanisms that they didn’t have in place before. They now better understand what the virus is, how it operates, the things that we can do that can effectively prevent its introduction and spread, and again, mimicking some of the good policy decisions that B.C. made early on. I think now other jurisdictions are starting to increasingly emulate that. The key is that we haven’t fundamentally changed any of the underlying staffing problems that we had prior to the pandemic, so there still remains significant issues that relate to the staffing of care homes and what we need to be doing that way.
So I think we’ve come away with a lot of lessons learned, both internationally and locally. And I think that will hopefully stand us in better stead. But it also reminds us how vigilant we need to be, not just saying, “Oh well, we appreciate that we needed to have adequate supplies of PPE.” We actually have to make sure that all of our staff are really well trained in infection prevention and control strategies, as well. So I think all of these sorts of things have been good lessons learned. The question is, only time will tell how well we’ve actually learned those lessons.
For example, more recently, we’re seeing new outbreaks occur in places like B.C., in places like Manitoba and Alberta, as well. So we’re seeing new outbreaks that are actually developing. And in some of these cases, people are saying, “Well, when we look at it, we certainly were making sure staff are trained in PPE, we thought we were doing all the right things, but we also realized that we have to maintain a high level of vigilance.” And in places where we see right now that they still haven’t resolved their staffing issues overall, it’s going to make them particularly vulnerable yet again if there’s another outbreak in that setting.
I think the other challenge has been, in homes that remain understaffed, they’re finding it increasingly difficult to try and do things like even permit homes to reopen to visitors. So for family caregivers and families and friends who want to visit their loved ones in care, a lot of people have just been shut out of these homes because the staffing situation of the home remained below the level where they can provide the basic care that they need to be providing, let alone actually provide additional staffing resources to facilitate families and friends wanting to come and visit their loved ones in care.
So I don’t think we’ve resolved a lot of the core, underlying, fundamental issues that were the problems related to long-term care in the first place. I think we’re still just kind of grappling and thinking about what needs to be done.
But I think what COVID-19 is done is exposed, certainly, a lot of the vulnerabilities within the system. I think it’s really shaken a lot of Canadians’ trust and confidence in the system, whether that be residents, whether that be family members and friends, whether that be members of the general public thinking about their own future. I think a lot of individuals and a lot of staff who were working in the system have probably lost a lot of faith in it – lost faith in it to be able to protect the residents, but also protect the staff who work in these systems, as well. So there’s going to need to be a lot more work done to further figure out what the future of long-term care needs to look like in Canada, and how do we actually advance that.
