Letter from Canada: A pandemic that has humbled us?

Abstract

When the coronavirus disease 2019 (COVID-19) pandemic became a reality in March 2020, the world shut down and governments furiously put plans in motion for how to deal with this potential health crisis, and what a crisis it turned out to be. Countries with well-oiled government-funded national healthcare systems, such as Canada, were expected to cope the best with this type of national health crisis. In general, butwith a couple of exceptions, this has turned out to be correct 11 months into the pandemic. However, a major failure in Canada’s response was to themostvulnerable in society, theelderlyandspecifically those in long-termcare (LTC) facilities.Amongwealthy (OECD) nations, Canada has the worst record for COVID19-related deaths in LTC facilities, which is perceived by many Canadians as a national disgrace. During the first wave of COVID-19 in Canada, about 80% of all COVID19-relateddeathswereelderlypeople inLTC.Notwithstanding numerous reports, investigations, committee meetings and good intentions to implement change, 6 months later, when the second wave of COVID-19 swept through the country, very little has changed and LTC facilities remain highly prone to outbreaks and deaths fromCOVID-19. As of January 2021, LTC and retirement homes reported 11% of the Canadian totals of COVID-19 cases and 73% of total deaths. The reason(s) for this blatant failure are numerous and therefore more complex to tackle in a systematic fashion. Canada’s national healthcare system is federally controlled but the provinces and territories are responsible for the day-to-day care of patients. This disconnectmakes a national effort to provide a synchronized and coordinated response more problematic. COVID-19 outbreaks and deaths in LTC facilities were particularly abysmal in the twomost populous provinces of Ontario and Quebec. At the height of the first wave, the army was called in to assist in these facilities. COVID-19outbreaks in care facilities inQuebechave killednearly 4000 residents,with large numbers of staff also infected, significantly compromising the ability of these facilities to provide proper care to their residents. In addition, all family and friends who usually provide a significant amount of both physical andmental care to these residents were barred from these facilities. Other issues identified were poor infection control practices, poor training of personnel and lack of proper personal protective equipment (PPE). The fact that many of theworkers provided services at several different facilities further promoted the spread of COVID-19. The combination of all these circumstances provided the elements for a ‘perfect storm’. COVID-19 has already killed more than three times as many LTC residents in Canada’s second wave than the first wave, with COVID-19 deaths to date in LTC facilities in Canada tallied at 10 450, including ~7000 from facilities inQuebec andOntario. Several lines of evidence point to historical decisions more than 30 years ago to exclude LTC facilities from Canada’s 13 provincial and territorial public healthcare systems as contributing to Canada’s dismal record of deaths due to COVID-19 in LTC facilities. This has resulted in substandard and ageing facilities, undertraining and poor treatment of workers and overcrowding, all contributing to poor infection control capabilities and practices. Although nurses are the primary regulated healthcare professionals in LTC facilities, nurses provide little direct care to residents with up to 90% of direct resident care provided by unregulated and unlicensed care aides or personal support workers. Furthermore, recent reports also point to a lack of government oversight and accountability to residents, especially in privately owned, for-profit LTC facilities—which account for about 50% of all Canadian facilities. Highlighting the devastating effects of these outbreaks in LTC facilities is a recent (January 2021) outbreak in the Roberta Place facility (Barrie, Ontario) where within a couple of weeks 214 people (residents and staff) were infected with 50 deaths, nearly all LTC residents. Although these problems were well known before the pandemic, long-standing, widespread and pervasive deficiencies in this sector were exposed with devastating effects. Although all these factors have significantly contributed to high infection and death rates of the elderly, they are not theonly explanation for thehighmortality rate in thispopulation. Clearly, there is some underlying immune mechanistic reason why the elderly are so vulnerable to infection and death from COVID-19. Children are usually one of the main sources of spread of respiratory viruses, but children madeup<1%of all COVID-19 cases and even fewer deaths. This scenario provides a unique opportunity to explore changes in our immune responses as we age, potentially revealing how the COVID-19 takes advantage of these deficiencies. In the 1980s and 1990s, the human immunodeficiency virus (HIV) pandemic caused an explosion of our knowledge and understanding of the adaptive immune responses and lymphocyte biology. The hope is that COVID-19 will deepen our understanding of the ageing immunesystemandreveal immunepathways to support it. When the COVID-19 pandemic struck, Canada was already fighting an opioids overdose crisis. Since March 2016 when the crisis was declared in British Columbia (BC), to March 2020, Canada had already had 16 364 deaths from illicit drug overdoses with the west of the country being the epicentre of this crisis. The victims are predominantly younger males, who experience poverty and homelessness and frequently have other underlying comorbidities. These people were also at higher risk to contract COVID-19 due a limited capacity to physically