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Editorials

The world expected more of Canada

BMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p1634 (Published 24 July 2023) Cite this as: BMJ 2023;382:p1634

Read the full collection: Accountability for Canada’s covid-19 response

  1. Jocalyn Clark, international editor1,
  2. Sharon E Straus, director of knowledge translation programme2,
  3. Adam Houston, health advocate3,
  4. Kamran Abbasi, editor in chief1
  1. 1BMJ, London, UK
  2. 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Human Rights Research and Education Centre, University of Ottawa, Ottawa, Canada
  1. Correspondence to: J Clark jclark{at}bmj.com

A BMJ series examines Canada’s covid-19 response and calls for an independent national inquiry

Canada is among the healthiest and most diverse nations in the world, with free universal healthcare and multiculturalism protected in national law for its population of 40 million people, of whom about a quarter are foreign born and two million are Indigenous peoples. Compared with the shambolic UK response12 and the chaos and divisiveness of its southern neighbour, the US,34 Canada may seem to have risen to the occasion of covid-19. We wouldn’t know because no pandemic inquiry has been established by its federal government. This is a mistake. There are lessons to learn from Canada’s covid-19 response to ensure accountability for decisions and actions, and to build confidence in the country’s health leadership, which faltered during the pandemic and created a strain on its already beleaguered public health and healthcare systems.

How good was Canada’s covid performance? An evaluation two years into the pandemic5 said the country had lower covid case and death burdens and higher vaccination coverage than most other G10 countries, despite Canada’s low hospital and critical care capacity and its vast geographical area that makes care delivery challenging. But this overall impression of adequacy masks important inequalities by region, setting, and demography. A more in-depth and critical analysis is required, to which a new BMJ series on Canada’s covid-19 response contributes (www.bmj.com/canada-covid-series).67891011 As the series sets out, beneath the surface of a general sense of satisfaction lie major pandemic failures.

Probing pandemic failures

Canada’s emergency response during covid-19 was impaired by longstanding weaknesses in the public health and healthcare systems, including fragmented health leadership across the federal, provincial, and territorial governments. Pandemic performance varied widely across Canada’s 13 provinces and territories, hampered by inconsistency in decision making, inadequate data infrastructure and sharing, and misalignment of priorities.6 Early on, research was used to build an all purpose response when tailored interventions were needed.7 Science advice filled a vacuum in areas where coordinated federal and provincial leadership was deficient, but this too was composed of varying advisory committees with no clear or consistent mandates or accountability, and at times conflicting messages.

Equity worsened. Despite ostensibly universal healthcare, the highest rates of covid cases and deaths in Canada were among people already disadvantaged: racialised ethnic groups, migrant workers, essential service workers, and those living in crowded housing. For some Indigenous peoples in Canada living on reserves, appalling lack of access to basic needs such as clean water rendered early covid hygiene advice impracticable. A particular disgrace is Canada being at the top of wealthy nations for covid related deaths in care homes for older people, despite more than 100 reports foreshadowing a nursing home crisis.8 In much of the world, covid-19 exacerbated existing inequalities. But it is no less an indictment that an abundantly wealthy country’s response to a public health emergency failed to protect its most vulnerable citizens.

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 its governments faltered.

Internationally, Canada contributed to devastating covid losses by not sharing enough covid vaccine and disrupting global supply,912 and it was named the world’s chief hoarder.13 Canada was judiciously ungenerous and unsavvy in its global behaviour, despite repeated pledges by its prime minister to deliver global solidarity during covid-19.14 Instead, Canada squandered opportunities to show how local and global health security are interlinked, and to extend its health leadership within collective and multilateral efforts.

Canada survived a previous coronavirus outbreak, that of SARS-CoV-1, and its health authorities were reprimanded by independent experts in the aftermath for squabbling … dysfunctional relationships among public-health officials … an inability to collect and share epidemiological data, and ineffective leadership, which, taken together, held hostage the health of Canadians.”5 And yet this new series provides a déjà vu of missed opportunities and fragmented and unclear leadership. Were lives lost as a result of the broken systems? Were decisions by governments taken appropriately and equitably? Will Canada be better prepared for the next public health emergency?

A covid inquiry is essential

There are at least five reasons why an independent, national inquiry is needed in Canada, with accountability for implementation of recommendations.

First, failing to look to the past will ensure an unchanged future. Undoubtedly, lessons can be drawn to inform new health investments and preparedness, and much learning comes from decisions and actions that failed or faltered. Positive lessons can also pave a way to a better future—from high vaccination coverage that built on traditional Canadian values of community, caring, and compliance to the First Nations pandemic management strategy in Manitoba showing how to overcome geographical barriers to testing and treatment, as well as how important and effective culturally informed responses are.11

Second, lacking an independent, federal inquiry allows others to step into the frame. The so called national citizens’ inquiry, for example, appears fuelled by vaccine safety misinformation and ideological concerns with government public health measures15 and is far from the full, national, and public inquiry led by independent experts that Canada’s pandemic performance deserves. A disturbing covid fallout is the growing social and political divisiveness, which is ignored at Canada’s peril.

Third, an inquiry would help deliver on Canada’s ambition to be a global leader.161718 Any review and examination of Canada’s pandemic response cannot be domestic alone because domestic and global health security and equity are linked.10

Fourth, it must provide an actionable framework for reforming Canada’s healthcare and public health systems, which were struggling pre-pandemic and are currently on life support. For health workers, the post-pandemic feeling is exacerbation—even rage—about the inertia of governments, health authorities, and professional medical associations and their failure to tackle the depth of the dysfunction in Canada’s healthcare landscape. For the public health system, which receives just 5% of the country’s health spending, continued functioning with such poor investment is unfeasible. For research, the pandemic further exposed Canada’s inadequate support for delivering science and innovation. Much of the core technology underpinning the mRNA vaccines was developed in Canada then never capitalised on, resulting in the Canadian government spending billions of dollars acquiring vaccine to protect its citizens during covid from an innovation it had helped develop.19

Fifth, and most important, is accountability for losses: the 53 000 direct deaths and close to five million cases of covid in Canada20 have devastated families and left a legacy of long covid in their wake. A million lives in 2021 alone might have been saved in poorer countries had rich nations such as Canada shared more covid vaccine.

We commissioned this series, modelled on the UK covid inquiry series,21 with the aim of bringing multidisciplinary and diverse perspectives to bear on Canada’s covid-19 response. The authors are experts across clinical and research areas including humanitarianism, Indigenous peoples’ health and rights, law, medicine, nursing, patient advocacy, policy, and public health, and they represent 13 institutions from across Canada. We hope their work informs and advances an independent, comprehensive, and probing review of Canada’s covid-19 response to ensure transparency and accountability from governments and health authorities, and to commit leaders to actions that support and sustain preparedness for current and future health needs.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that JC is a member of the 2023 joint Royal Society of Canada and Canadian Academy of Health Sciences expert panel reviewing Canada’s global health role. ARH is an employee of Doctors Without Borders/Médecins Sans Frontières (MSF) Canada but is writing in his personal capacity. SES and ARH are authors of some of the articles in the BMJ series.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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