Dr. Sandor Demeter
The Fine Art of Muddling Through – COVID Pandemic Management in Canada
Updated: Nov 17, 2020
Wild and Wooly by Mandy Stephen (Edmonton)
Remember when Manitoba went 13 days without a COVID case? What happened?
It is a given that no matter what governments, or health care systems, do there will be criticism that they either acted too late, or too early. However, there is room for improvement on how to proceed as we are going to be in this soup until an effective vaccine comes on the scene.
Charles Linblom, who published "The Science Of 'Muddling Through'" (1959) and “Still Muddling, Not yet through” (1979), described a policy decision style where policy makers take small incremental steps without necessarily going in any particular direction. This is the Canadian way.
The figure below (Demeter, 2016) illustrates incremental, rational and a blend of the two policy decision models.
“Incrementalism” appears to be driving how the federal and provincial governments are managing the current COVID pandemic.
We have a virus for which the strain may be novel but the virus itself is not. Considering varying population risk factors, which may influence disease severity, the virus has the same incubation period and is transmitted the same way across the country. Fortunately, COVID treatment has improved, and hospital/ICU death rates are improving. However, there is patchwork quilt approach to outbreak management including when, and what, preventive measures are recommended or mandated.
Another important fact is that after we “flatten the curve” we will, as a population, remain as susceptible to multiple future waves of infection until we either reach herd immunity or an effective vaccine becomes available. Expecting a different result post every lock down" is wishful thinking or, as Einstein bluntly put it; "Insanity is doing the same thing over and over again and expecting different results."
Outside of international travel (under the federal Quarantine Act), the federal government does not have jurisdiction for health care and they primarily play an advisory role to the provinces and territories. However, they act as an important pandemic information conduit to international bodies such as the Word Health Organization. The feds rely on accurate and timely reporting by the provinces and territories to feed into the global COVID pandemic picture.
The pubic is being bombarded daily with high level COVID information (cases and deaths) and evolving prevention advice.
For the public:
Do not wear masks,
Wear a mask,
Wear a multiple layer mask, or,
as Mayor Bowman as put it:
[just] “wear a friggin mask”.
The disease is droplet spread, like TB,
Perhaps the droplets are smaller than we thought,
Perhaps the droplets are small enough to be “respiratory” spread which has significant impact on the utility of non-medical masks.
Thresholds for progressive preventive actions are moving targets whether they be: test positivity rates, daily cases/rates, daily deaths/rates, impact on hospitals and ICU or impact on long term care or personal care homes.
Manitobans have been through all of this before and we “flattened the curve” which resulted in low case counts over the summer. Now we are facing a devastating second wave, especially for personal care homes (PCH). We are limping along with incremental broad stroke prevention orders.
It does not help when the Premier shames and blames Manitobans about the current situation citing anecdotal late night “house parties” without providing any evidence of such “parties”, or if they are at all related to current COVID case loads.
The government, not the people, not public health, is responsible and accountable for current, past, and future pandemic related public health and emergency orders. The government is also responsible for monitoring all the impacts, positive and negative, of their orders as well as when such orders are “loosened”.
It also does not help when the Minister of Health, Cameron Friesen, accused front line Docs of having an alternate agenda when they publicly raised concerns about COVID’s impact on acute care capacity. It added insult to injury when he, and I would say arrogantly , quipped that “the people in charge got this”. (CBC ref 1, ref 2)
As a front-line health care provider I can tell you that things have to get pretty bad before physicians band together (i.e. 200+) to publicly voice their concerns that their patients, or the public, are at significant risk unless something is done.
You may say it is easy to criticize how the pandemic has been handled, especially since hindsight is 20/20. However, there is always room for improvement and constructive feedback should be welcomed and not brushed off.
Here are some suggestions, which are framed in a Public Health Ethics framework (Upshur ,2002) on how to make the situation better.
Mill's Harm or Liberty Principle
You can only compel an individual to do, or not do, something, against their will to prevent demonstrable harm to someone else. As long as the individual is capable of making decisions for themselves you can not compel them to take, or not, take actions which may only harm them personally.
Or as the cliché goes: “Your right to swing your fist ends where my nose begins.”
This dovetails with the Canadian Charter of Rights and Freedoms rights of mobility, association, peaceful assembly, and speech.
Quarantine (14 days), isolation (10 days), indoor and outdoor group size caps, travel bans and mandatory mask use are examples where the state has to demonstrate that impositions on individuals is directly linked to preventing or reducing risk to others.
I am not arguing that these measures are not needed, or that they do not necessarily work. I am arguing that in a free and democratic society the state should provide compelling information and data to back up their orders. If the latter was provided compliance may significantly improve. This links to the second principle of Transparency.
Releasing information should go beyond the frequent justification for release, i.e. - only “if needed for public safety”.
Transparency helps individuals link restrictions on their freedoms to tangible protection of the broader community.
For example, there has been no systematic ongoing release of information about where people are being infected. If individuals knew the evolving breakdown of disease transmission (e.g. worksites, acute care, PCH, community, “house parties”, unknown etc.) it may help them make risk aversion decisions better aligned with current public health orders.
Cynically I worry that public health is so overwhelmed and under resourced that they may not be able to adequately collect, provide, and package this information to the public in a timely or meaningful manner.
In addition, transparency helps to establish trust in the government. The paternalistic “we got this” or “trust us” platitudes have no place in a 21st century democracy, especially during a pandemic.
As I have written before, the government’s refusal to release provincial PCH inspection reports is a prime example of lack of transparency. Prior to the pandemic family and friends could visit their loved ones in PCH and directly observe how well, or not, they were being cared for. Now they are locked out I cannot imagine the angst and fear they are feeling as they watch the media reports on what is happening at multiple Revera PCH (e.g. Maples and Parkview).
Use the Least Coercive Means Possible
This is self explanatory. Start with education and information and move to progressive measures to achieve compliance to justified impositions on individual freedoms.
Fixating on “flattening” the curve at all costs avoids the uncomfortable reality that such preventive measures can cause harm, especially to vulnerable and marginalized groups and individuals such as the homeless, low income families, PCH residents, those living with disabilities, and those with mental health challenges, to name a few.
This sentiment has recently been echoed by the Public Health Agency Canada’s publication: From Risk to Resilience: AN EQUITY APPROACH to COVID-19
While the COVID-19 pandemic affects us all, the health impacts have been worse for seniors, essential workers, racialized populations, people living with disabilities and women. We need to improve the health, social and economic conditions for these populations to achieve health equity and to protect us all from the threat of COVID-19 and future pandemics. (Chief Public Health Office of Canada)
Here is a list of potential COVID-19 preventive measures fallout which the government is responsible, and accountable, for mitigating and communicating to the public:
Social isolation impact on Seniors
“lock down” institutionalization
end of life scenarios
Impact on mental health – e.g. crisis line calls, attempted suicides, suicides, social decompensation etc.?
Impact on domestic abuse/violence?
Impact on homelessness?
Impact on street drug use and over doses?
Unemployment and other economic sequelae?
Impact on Child and Family Services cases?
Impact on elective care services?
Impact on preventive health services such as vaccination?
Reciprocity or Adequate Resources
The last principle states that the government should provide individuals and communities with the resources and means to achieve compliance with PH directives.
Salary, rent, small business and other monetary compensation programs are good examples of attending to this principle. Maintaining essential services such as for groceries, gas and day care are other good examples.
Concerns raised about lack of adequate PPE in health care settings and worker “burn out" due to short staffing are examples where resources may not be adequate.
There is a risk of stigmatization of those who have not had COVID or the vaccine when it is available. This may lead to a “COVID passport” system where those who are felt to be immune are treated differently. This may seem far fetched but check this out:
Monday's news that pharmaceutical company Pfizer's early results on a new COVID-19 vaccine showed a 90% efficacy rate on an initial clinical trial have given concert professionals hope that the business can start mounting a return in 2021. As part of that preparation, Ticketmaster has been working on a framework for post-pandemic fan safety that uses smart phones to verify fans' vaccination status or whether they've tested negative for the coronavirus within a 24 to 72 hour window….Here's how it would work, if approved: After purchasing a ticket for a concert, fans would need to verify that they have already been vaccinated (which would provide approximately one year of COVID-19 protection) or test negative for coronavirus approximately 24 to 72 hours prior to the concert. (Billboard)
For those who are interested the Canadian Civil Liberties Association has published a dedicated article on this topic (Immunity Passport).
I close with a quote from Abdu'l-Bahá (eldest son and successor of the founder of the Baha’i faith) in hopes that Manitobans, health care leaders and the government can transparently work together to persevere through these tough times.
The shining spark of truth cometh forth only after the clash of differing opinions.