Canada’s lost months: When COVID-19′s first wave hit, governments and health officials were scattered and slow to act

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Between Jan. 26 and Jan. 30, Monir Taha, an associate medical officer of health with Ottawa Public Health, wrote a series of increasingly agitated e-mails to high-ranking Ontario health officials, outlining concerns about the federal response to the emerging threat of the novel coronavirus.

On the day before Dr. Taha’s first message, Ontario’s chief medical officer had announced a Toronto hospital was treating Canada’s first case of COVID-19. In subsequent media conferences, provincial and federal officials stressed the health care system was well-equipped to contain cases if more appeared. “The risk of an outbreak in Canada remains low,” tweeted Theresa Tam, Canada’s Chief Public Health Officer on Jan. 25.

But Dr. Taha - and other health experts dotted across the country – weren’t so sure. “Canada’s goal of containment has a considerable probability of failure given the current strategy,” he wrote in a Jan. 28 e-mail that was obtained by The Globe and Mail.

In another, he warned the new pathogen appeared to be less deadly but more contagious than SARS, the virus that infected more than 400 people in Canada in 2003. If the disease got loose, “sheer numbers of severe cases will overwhelm ordinary health care capacity – as we are seeing in China.”

He continued: “Flights from China should be prohibited now until the epidemic is under control,” but given that this was unlikely to happen, hospitals should start looking at “ICU and respirator availability” and the public should be educated on “interventions that will help flatten the epidemic curve.”

Dr. Taha declined to comment on his e-mails, but when asked whether he ever reached out directly to the Public Health Agency of Canada, he said he believed he was following the proper channels in reporting his concerns to officials with Ontario’s Ministry of Health, Public Health Ontario and the Council of Medical Officers of Health, all of whom he understood to be in regular consultation with their federal counterparts.

The lack of clarity over where to raise these dire warnings speaks to the wider dysfunction within the Canadian health care system. The communication breakdown was felt most acutely in Ontario where, according to more than 15 senior medical officials – including individuals in hospital leadership positions, infectious-disease specialists and microbiologists – some of the most important doctors in the province were so frustrated and perplexed by the province’s lack of action that, by mid-February, they were holding secret strategy sessions to brainstorm ways to get through to decision makers. On testing guidelines, on laboratory capacity, on protective gear, on the need to start watching for community spread – Ontario’s health care system was lost. Apoplectic with fear and frustration, senior doctors sent messages and petitions to the ministry. Tensions finally culminated with a March 13 letter to Premier Doug Ford from the Ontario Hospital Association, imploring the government to take action.

The frustration of Ontario doctors reflects a concern expressed by experts across the country during this pandemic; a feeling that the scientists and doctors most qualified to craft a public health response went largely ignored.

Over the past two months, The Globe and Mail has interviewed more than 50 individuals involved in Canada’s pandemic response to understand how the outbreak unfolded through the eyes of the scientific community compared with the government perspective. From epidemiologists, microbiologists, virologists, physicians and hospital executives, to public health officials, elected representatives and their staff, many also provided access to e-mail correspondence between groups of experts and government.

The common thread among their stories is that Canada’s response was mounted not as one country, but in silos. Each province charted its own course, resulting in dramatically different outcomes.

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Most frustrating for experts was that many of these shortcomings were the same ones that hampered Canada’s response to the severe acute respiratory syndrome (SARS) outbreak 17 years ago.

In the aftermath of SARS, both the federal government and Ontario launched large-scale reviews of what needed to be done to fix the system.

Both found that the government would benefit from an arm’s-length agency to manage serious public health threats with scientific expertise, not unlike the Centers for Disease Control and Prevention in the United States. This was the genesis of the Public Health Agency of Canada (PHAC).

Above all other findings, there was an understanding that in the face of the next outbreak, public health bodies should follow the “precautionary principle.” When faced with a little-known pathogen, it is better to err on the side of caution. Hesitation can cost lives. Overreacting is better than the alternative.

In those first pivotal months of the outbreak, the opposite occurred.

“I don’t know if it’s denial or not … it’s like you never think that someone in your family is actually going to have cancer or be shot or have a fatal car accident,” said Canada’s Chief Science Advisor, Mona Nemer. “But I don’t know what the Public Health Agency of Canada was doing during that time and they certainly didn’t reach out to me to ask for advice.”

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JANUARY

When Danuta Skowronski woke up on Dec. 31, 2019, she began her day the way she always does: scouring the internet to see if any new respiratory viruses had flared up overnight. Dr. Skowronski is the lead epidemiologist for influenza and emerging respiratory pathogens at the B.C. Centre for Disease Control (BCCDC). It’s her job to sound the alarm on threats such as COVID-19 as early as possible. On that morning, that’s exactly what she did, before almost anyone else in Canada.

Multiple websites, including two of Dr. Skowonski’s go-tos – ProMED and FluTrackers.com – were reporting that a strange pneumonia in Wuhan, China, had sickened 27 people. Respiratory virus outbreaks aren’t uncommon in the infectious-disease world, especially during flu season, but something about the news made her uneasy. “You have a gut feeling,” she said. “SARS arose in a very similar fashion.”

Dr. Skowronski hammered out a draft of a bulletin, then sent it to some colleagues, including British Columbia’s Provincial Health Officer, Bonnie Henry, for feedback before distributing more widely. Though details were scant, Dr. Henry was also immediately alarmed. Both women had been on the front lines of Canada’s response to the SARS outbreak – Dr. Skowronski in British Columbia and Dr. Henry in Toronto, where she was the city’s operational lead in the crisis.

In February, 2003, a doctor from Guangzhou who was unknowingly infected with SARS travelled to Hong Kong and checked in to the Metropole Hotel. The following day, a 78-year-old tourist from Toronto who had been staying at the same hotel boarded a flight home. Canada ultimately recorded 438 probable and suspect cases of SARS cases, the majority of which were in Ontario.

“We took it seriously from the very beginning,” Dr. Henry said of COVID-19. “To be frank, part of it was the sensitives that I had – and some were at the time telling me I was overreacting – but the sensitivities I had and that Danuta shared … about what happened in Toronto during SARS.”

On Jan. 8, Dr. Skowronski issued a bulletin. All of the province’s health officers, infectious-disease specialists, microbiologists, emergency-room physicians and airport authorities, received the same bold-faced warning: “BE VIGILANT.” (PHAC sent its first warning to the Canadian Network for Public Health Intelligence on Jan. 9.)

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All along, British Columbia’s approach was to err on the side of caution. When BCCDC microbiologists began developing a test for COVID-19, they did so with the worst-case scenario in mind. Testing for viruses is a delicate science, as evidenced by the fact that in the United States, the Centers for Disease Control and Prevention botched its first rollout. Accuracy isn’t the only concern. In a pandemic, being able to process large numbers of tests quickly can be just as important.

“What we did from Day 1 was design a test that could be ramped up and automated,” said Mel Krajden, the medical director for the BCCDC’s public health lab. They were able to run 96 samples at a time, meaning labs could process thousands in a day.

Ontario’s provincial public health lab actually developed a successful test before B.C., but it was more cumbersome to perform and difficult to scale, according to three sources with knowledge of Ontario’s testing. This didn’t matter much in the first two months, when volumes were low. But by the middle of March, the province was no longer able to keep up with the number of tests coming in.

(A spokesperson with Public Health Ontario (PHO) said the problem wasn’t scalability, it was a lack of reagents to mix the tests. Ontario’s test took “approximately the same amount of time to perform” as the one developed by B.C.)

Ontario had another disadvantage when compared with Canada’s other most populated provinces. Unlike B.C., Alberta and Quebec, Ontario’s system of laboratories isn’t integrated. Public health labs, commercial labs and hospital labs all report to different parts of the ministry. There was no process in place to share the load.

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The days ticked by and more news came out. On Jan. 13, Thailand reported that a tourist from Wuhan had tested positive and was now in hospital. She’d taken a direct flight from the epicentre to Bangkok on Jan. 8 and was caught at the border through thermal surveillance at Suvarnabhumi Airport.

For Kamran Khan, the founder and CEO of BlueDot, a Toronto AI company that uses machine-learning to identify disease-outbreak trends, that event was a warning that China’s numbers could not be trusted.

“There are about 11 million people in Wuhan and what we’re told is there are about 27 cases … the probability that someone would actually get on a plane infected is really low,” he said. “The outbreak has to be bigger.”

Bluedot had been analyzing flight data patterns out of Wuhan to predict which cities were most at risk of seeing cases. (Bangkok topped their list.) Canada was not a particularly popular destination for Wuhan travellers, but of those who were coming to Canada, 80 per cent would be heading to Toronto or Vancouver.

But still, in those first several weeks, few of the experts who spoke to The Globe were overly worried.

“To be honest, with the information coming out, I didn’t think it was that big a deal,” said Darryl Falzarano, a lead investigator with the VIDO-InterVac’s laboratory at the University of Saskatchewan in Saskatoon. His team is leading the hunt for what may be Canada’s best hope at a vaccine. “It sounded like it was containable.”

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Some of the scientists who spoke to The Globe conceded they felt Canada would be able to handle the new virus, having learned the lessons from SARS. The country had spent 16 years getting ready since that time. Policies and procedures had been put in place that did not exist in 2003. And in those early weeks, the threat of a novel respiratory virus triggered a series of new protocols and responses, even though there was doubt.

Hospital infection-control specialists went through screening procedures and safety best practices with emergency-room staff. The chief medical officers of each province and Canada’s Chief Public Health Officer, Theresa Tam, began regularly discussing the situation in Wuhan.

Despite his skepticism, Dr. Falzarano began working on a vaccine. His team was already far-along in developing a vaccine for COVID’s close coronavirus cousin, Middle East Respiratory Syndrome. MERS emerged in 2012 and while individual outbreaks have always been contained, it periodically resurfaces because it can jump from infected camels to people.

(Dr. Falzarano’s lab was eventually the first in Canada to isolate and grow COVID-19, a step needed before researchers can work with and study the virus.)

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With the scientific community mobilized, doing what they were supposed to be doing, the novel coronavirus landed on the radar of the Prime Minister’s Office the weekend of Jan. 18 during a cabinet retreat in Winnipeg.

Over the next seven days, the information coming out of Wuhan shifted in a way that started to scare some experts.

On Jan. 22, the World Health Organization (WHO) finally confirmed that COVID-19 was spreading between people. China had officially reported 309 confirmed cases, but, through informal channels and relationships in the medical community, word leaked out that thousands were likely sick. In the ensuing days, the Chinese government shut down all travel into and out of Wuhan, a city of bigger than New York.

For Kevin Katz, the doctor in charge of infection prevention and control at North York General Hospital in Toronto, the grim moment of realization that the situation was out of control came on Jan. 24, when construction crews in Wuhan broke ground on one of two temporary hospitals that would have a combined capacity of about 2,300 beds. This Herculean undertaking was to be completed in about 10 days.

“That was it for me,” said Dr. Katz. “You don’t build two massive hospitals in a week if there isn’t a very big problem.”

Dr. Katz persuaded his hospital to spend six figures stockpiling reagents, a substance needed to conduct tests. He was convinced that COVID-19 was not going to spare Canada. Toward the end of February, Dr. Katz placed another order for more supplies and protective gear.

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Then came confirmation of Canada’s first case on Jan. 25. A 56-year-old man with a cough, fever, and recent travel history to Wuhan had arrived at Toronto’s Sunnybrook Hospital two days earlier.

Sunnybrook staff had been bracing themselves for that moment. During the SARS epidemic, nine health care workers had contracted the lethal virus while caring for a single patient. This time, when the patient arrived, protocols that didn’t exist in 2003 were put into action, including placing the man into an isolation room.

Samira Mubareka, a microbiologist and infectious-disease specialist at Sunnybrook, was on call that weekend. She remembered vividly entering the same room as the virus. “It was a real moment for pause: It’s with us now,” she said. “It was pretty obvious at that point that this is the beginning and we have it and it’s coming in a big way.”

With the news of Canada’s first case, public health officials across the country held news conferences to reassure the public that things were under control and that the risk of an outbreak in Canada was low. The Prime Minister’s Chief Science Advisor, Dr. Nemer, felt differently. In an interview with The Globe, Dr. Nemer said she saw the developments in China as clear signals that the situation was gravely serious. “This is a viral infection that can travel the world and there was no reason to believe that anybody would be spared or that the impact of the infection would be easier in different countries than in China,” Dr. Nemer said.

In the final days of January, Dr. Nemer reached out to the deputy minister of health to convey her concerns.

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On Jan. 29 in the House of Commons, Edmonton MP Matt Jeneroux asked: “Other nations are stopping flights in and out of China and introducing more rigorous screening processes. Is the Prime Minister satisfied with the actions of his government?”

Prime Minister Justin Trudeau responded: “We are taking all necessary precautions to prevent the spread of infection.”

Srinivas Murthy, an infectious disease specialist with the University of British Columbia who co-chairs the WHO’s clinical research committee on COVID-19 (he notes he does not speak for the WHO), said there was good reason for not closing borders.

“All of those things lead to stigma and lead to worsening of relationships across borders … . Those kinds of messages aren’t the ones that are going to help us solve this,” he said. A mandatory 14-day quarantine with strong and clear public health messaging about the severity of the situation would be more effective policies.

Except quarantines weren’t enacted either.

Instead, air travellers from China arriving in Toronto, Montreal and Vancouver were asked to self-identify if they had any flu-like symptoms.

This was less effective than temperature screening, which had been implemented in a number of countries, according to John Conly, one of Canada’s leading infectious-disease experts and the lead author on a 2014 WHO report on control of pandemic-prone respiratory infections.

“Do you want to get hung up with answering questions? You answer ‘Yes’ and get pulled to the side,” Dr. Conly said. “That’s just human nature.”

Meanwhile, Alberta Health Services (AHS), which is responsible for the province’s health care, placed a bulk order for personal protective gear. The agency’s head of procurement, Jitendra (J.P.) Prasad, had heard rumours about a strange illness in Wuhan earlier in December. Before Christmas, AHS officials were inquiring with vendors about availability.

Months later, when other provinces struggled to keep health care workers in proper masks, gloves and gowns, Alberta shipped excess supply to other provinces.

So why was that intelligence not relayed to the rest of the country?

Tom McMillan, a spokesman with AHS, said Alberta was regularly sharing and receiving information from counterparts in other jurisdictions during this period. “PPE was among the topics regularly discussed,” he said.

At least two Ontario hospitals – including Dr. Katz’s institution – began stockpiling medical equipment around this time. Clearly, any warnings went ignored, because by March most provinces were panicking about the lack of supplies.

January, as it turned out, had been a crucial window to stock up.

Rodin Lozada, a sales director at Wayne Safety, a wholesale seller of safety supplies, says in the first few weeks of January, there was a line-up outside his office that was two to three hours long. GTA residents were hearing about the situation in Wuhan from relatives and they were buying up masks by the crate to ship back to their family or hometowns in China.

Provincial health bodies didn’t start calling until March, he said, but by then, the supply was long gone.

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FEBRUARY AND MARCH

February began well enough, but it was the month when things unravelled.

Public health labs in Quebec, Ontario, B.C. and Alberta had developed their own successful test for COVID-19, as had the National Microbiology Lab. The chief medical officers were regularly discussing the evolving situation. Hospitals began running elaborate pandemic simulations to test their protocols and train staff.

What happens when someone suspected of COVID-19 walks through the emergency room door? What protective gear is needed? What happens when someone’s heart stops or when a patient needs to be intubated?

“We developed a checklist that is designed to be like a pilot landing a plane. Do you have this? ‘Yes.’ Do you have this? ‘Yes,’ ” said emergency and trauma physician Andrew Petrosoniak, a simulation lead at St. Michael’s Hospital in Toronto.

On the federal side, finance staff had taken notice of the virus. During a budget meeting with Finance Minister Bill Morneau, officials flagged the potential for a huge spike in employment insurance claims if the coronavirus were to reach Canada. They suggested the government find a way for public servants to process claims from home in case they were unable to go to work.

Meanwhile, Ottawa repatriated hundreds of Canadians caught in locked-down Wuhan and took them to the Canadian Forces Base in Trenton, Ont., to be quarantined for two weeks. The move raised eyebrows among some in government, who supported the decision but wondered why commercial travellers from China were not being forced to do the same? Instead, PHAC still told travellers to voluntarily self-isolate.

“We feel that this is the right message,” Dr. Tam told a news conference on Feb. 6. Many of the experts who spoke to The Globe agreed with the approach, given the information available at the time, especially as related to people without symptoms.

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Even though the numbers were climbing – there were just shy of 50,000 confirmed cases worldwide mid-month – officials monitoring the trend lines were cautiously optimistic. Two dozen countries had seen cases, but 99 per cent of the confirmed infections were in China. And the rate of new cases was trending downward, suggesting the virus may be on its way to resolving.

On Feb. 14, Nick Ogden, Director of Public Health Risk Sciences with the agency’s National Microbiology Laboratory, gave a presentation at the Fields Institute in Toronto. He displayed a graph of the case counts and pointed to the downward slope. “It looks a little bit like the epidemic has peaked,” he said, although cautioning that things could change.

By then, Canada had recorded seven confirmed cases of COVID-19, four in British Columbia and three in Ontario.

The cases had all been contained, but the two provincial governments were functioning very differently, and the flaws in Ontario’s system and approach were starting to show.

In B.C., Dr. Henry had made it clear that, while the focus was on symptomatic people who had been to China, clinicians could test anybody they were concerned about, regardless of travel history. This was a huge break from the federal guidelines and Ontario doctors wanted that same flexibility. If the virus had managed to escape China and was spreading elsewhere undetected – which many experts believed was likely – those cases would be missed.

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Some of the big hospitals in the Greater Toronto Area decided to go rogue and start testing more broadly. They appeared to have the support of PHO, which released a memo on Feb. 14, which indicated the provincial lab would accept any samples, even if the patient did not meet ministry guidelines.

But then three days later, the Ontario Hospital Association sent a bulletin to hospital executives stating that the ministry had expressed concerns that some facilities were planning to ignore the federal and provincial guidelines. Any “misalignment” with the provincial and federal guidelines “could lead to inconsistencies and possible confusion” and “create difficulties in laboratory testing,” read the memo, which was obtained by The Globe. (Several hospitals ignored this edict.)

The structure of Ontario’s health care system exacerbated tensions. For COVID-19, there were five big players: the Chief Medical Officer, the Ministry of Health, the Ministry of Long-Term Care and then two agencies, Public Health Ontario – which is the equivalent to the BCCDC – and Ontario Health, a new entity that was supposed to try to co-ordinate the province’s disparate system. That work got going in earnest just before the outbreak. On top of all that, there are 34 public health units and then all the hospitals.

By contrast, Alberta’s health care system – including the hospitals – are all under one umbrella, which Geoffrey Taylor, the Senior Medical Director of Infection Prevention and Control with Alberta Health Services, says was a huge asset. “Sometimes an integrated system can have drawbacks, [but during a pandemic] it’s an advantage,” Dr. Taylor said.

Quebec and B.C.’s health care systems are also more centralized. In Quebec, there are 18 health regions, but they are co-ordinated by the ministry. B.C. has five health authorities, but even though they operationally report to a local board, they too report to the ministry, which directs policy. Many of the province’s top infectious-disease experts are connected to the BCCDC, which reports to the provincial health officer, Dr. Henry. It was always clear that Dr. Henry was steering the response in B.C.

In Ontario, the chain of command was unclear to the experts, meaning when problems arose they weren’t even sure where to direct complaints.

“I do think it’s been challenging. It’s been hard to know what tables are responsible for certain decisions. There’s a lot of overlap,” said Susy Hota, the Medical Director of infection Prevention and Control at University Health Network in Toronto. “My bottom line would be you need to have the right experts at the table speaking and helping you to make the decisions.”

In an interview, Ontario’s Chief Medical Officer David Williams acknowledged that the structure of the province’s health system presents communication challenges. For example, public health units are managed by local municipal boards. “While I work with them, they do not report to me,” he said.

One senior hospital official said that it is absolutely true that the government appeared incapable of taking significant action in February and early March but, in fairness to them, there was no consensus about what should be done between the scientists and doctors. Different groups were pushing for different, sometimes conflicting, policies.

Perhaps the single most important development in the outbreak happened in the third week of February – a moment that was a line in the sand for every expert who spoke to The Globe. From that point on, the question was not if COVID-19 would spread within Canada, it was whether the country could prepare itself in time.

On Feb. 20, B.C. announced that a woman who had recently travelled to Iran was positive for COVID-19. She had no connection to China. Dr. Henry told The Globe that the emergency-room physician who ordered the test didn’t actually think the person was positive, since Iran had not reported any cases at that point.

“That first Iran case in one emergency room in B.C. told you: game over,” said David Fisman, a physician and professor of epidemiology at the University of Toronto’s Dalla Lana School of Public Health.

Dr. Fisman, who specializes in modelling infectious diseases, and his collaborator, Ashleigh Tuite, an epidemiologist, did a back-of-the napkin calculation: if Iran was exporting cases at least 19,000 people were likely infected in a country with no infrastructure to contain an outbreak.

Ben tenOever, a Canadian-born virologist based in New York who now runs one of the U.S. Department of Defence’s COVID studies, said Iran was his “brace-for-impact” moment.

“It was bona fide community spread. And then Italy happened. And then it was clear as day that this was going to circle the planet. And it was going to be bad,” he said.

(Doctors in Ontario pointed out that had B.C. followed the advice of PHAC or their own Ministry of Health, this important case would not have been caught.)

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Before Feb. 20, Dr. Fisman said that it was not an unreasonable position to think that COVID-19 would play out like previous influenza scares. He was among those who thought COVID-19 was going to go the same way that SARS had in 2003 and H1N1 had in 2009: serious health events, but not a global crisis.

But he and those like him were operating with two big blind spots.

First, before the Iran case, the virus seemed contained within China, where new infections were steadily decreasing, Dr. Fisman said. Second – the big one – scientists did not understand how COVID-19 spread. Well into March, the thinking was that infected people without symptoms were not significant vectors. But scientists now suspect that infected people can spread the virus before they show symptoms.

Every doctor and scientist interviewed by The Globe without a connection to government said that by the last week of February, they were convinced that COVID-19 would be coming to Canada and that it would be bad. But still, most of the country’s public health bodies appeared paralyzed.

In fact, top scientists, doctors and hospital executives had spent the previous month trying to convince provincial decision makers that Ontario was not properly preparing for a pandemic. Their lobbying efforts began as polite e-mail exchanges and conversations, but when things didn’t change, they resorted to writing petitions.

At the end of February, 36 senior doctors in Ontario – the Medical Directors of Infection Prevention and Control at some of the largest hospitals, as well as senior microbiologists and hospital leadership – signed the letter to Dr. Williams, imploring him to make a series of changes to the province’s laboratory network. The current system would not be able to handle high volumes of COVID-19 tests, they wrote.

(Toward the end of February, Vanessa Allen, the Chief of Medical Microbiology at PHO’s lab, ended up reaching out on her own to colleagues to cobble together an informal network of sharing. Ontario Health eventually stepped in, bringing KPMG on board to formalize this ad hoc integrated system. This was completed March 20. The backlog peaked at more than 11,300 cases toward the end of March.)

Dr. Hota of the University Health Network in Toronto, was one of the doctors who signed the letter. She did not provide The Globe with the text and declined to comment on that process, but did acknowledge that there were “many letters” written during February and that it was not always clear where to direct them.

Another group sent a petition to Dr. Williams asking for the province to change its protective-gear policy, which they argued was not rooted in science and was wasting preciously-scarce N95 respirators.

There had been other clashes, such as testing criteria. Experts believed the federal and provincial guidelines were too restrictive and would lead to missed cases. For weeks the ministry dismissed their concerns, so some hospitals just ignored the rules.

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On Feb. 28, the WHO’s Bruce Aylward, a Canadian epidemiologist, released a report into China’s handling of the outbreak. The document praised “China’s bold approach” and helped fuel criticism that the WHO had been too trusting of the information coming out of Beijing.

A day earlier, Quebec’s Health Minister, Danielle McCann, confirmed that the province had its first positive patient. Today, it has reported more cases of COVID-19 than all the other provinces combined, but experts within Quebec say that is more a reflection of bad luck than bad policy.

Quebec’s spring break fell in the first week of March, before the rest of the country and at a time when the world was on the cusp of understanding how bad things were going to be. Because of the way exponential spread works, experts within Quebec say the province’s fate was sealed.

Caroline Quach, who heads the infection prevention and control unit at CHU Sainte-Justine hospital in Montreal, said with the benefit of hindsight, the province should have enacted quarantine measures for anyone returning from spring break. At her own hospital, she persuaded her CEO to have any staff who travelled to high-risk areas, such as Italy and Spain, stay home for two weeks.

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In Ottawa, politicians were losing patience with PHAC. The agency tasked with protecting Canada from a pandemic was still reluctant to take bold action, whether it was border closures, mandatory quarantines, banning mass gatherings, or introducing the public to physical-distancing interventions.

Two individuals who were involved in the many policy debates at PHAC said the agency is encumbered by needing to consult with the provinces before moving forward with a policy, since provinces manage health care. Particularly as it concerned the testing criteria, one individual said: “Sometimes it was the provinces dragging their feet and sometimes it was the feds. People were really worried [that a broad definition] would overwhelm testing capacity.”

On March 4, Deputy Prime Minister Chrystia Freeland assumed control of the COVID-19 file. By the weekend of March 7, Ms. Freeland was already firmly in favour of stronger border measures – even though PHAC wasn’t ready to take that step – and developing plans with other cabinet ministers to ensure the move would not create chaos or stop the import of medical equipment and food, federal sources said.

(These sensitive negotiations took weeks. Canada announced it would close the border to non-citizens excluding permanent residents and Americans on March 16. The U.S. border closed to non-essential travel, except for trade and essential workers, on March 21. Health Minister Patty Hajdu announced the Quarantine Act would be used to force anyone coming into the country to self-isolate for 14 days – regardless of whether they had symptoms.)

In those first two weeks of March, the situation around the world unravelled rapidly.

The global number of COVID cases crossed 100,000 in more than 90 countries on March 7, with large outbreaks in Iran, Italy, South Korea, Germany, France and Spain. Canada had 51 cases and confirmed community spread in B.C., but still federal and provincial officials maintained the risk for Canadians was low.

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The dam burst on March 11.

That was the day the WHO finally declared COVID to be a global pandemic, Italy had been put under lockdown, the NBA halted its season and actor Tom Hanks revealed he had tested positive while filming in Australia. On March 12, news broke that the Prime Minister’s wife, Sophie Grégoire Trudeau, had tested positive following a speaking engagement in England.

It was against this backdrop that Ontario Premier Doug Ford told families to “go away, have a good time” over March Break at a news conference.

Those within the Ford government said the comment was made as an off-the-cuff remark in an attempt to ease people’s growing fears about the virus. It was not representative of how seriously the government was taking things at that point. Nevertheless, to hospital leadership and doctors within Ontario, it appeared as confirmation that the people in charge still didn’t get it.

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On March 8 – as Ontario’s Ministry of Health maintained that the risk from COVID-19 was low for residents – an exasperated senior manager at a Toronto hospital had gone directly to Premier Doug Ford’s chief of staff, James Wallace, according to a document viewed by The Globe. The official told Mr. Wallace that the country was facing an “impending” and “unprecedented” national emergency and the government should immediately implement interventions such as social distancing to avoid the health system becoming overwhelmed.

On March 13, the Ontario Hospital Association (OHA) sent the Premier their letter outlining what needed to happen. Among the recommendations: The province should declare a state of emergency, fix its testing guidelines, educate the public on physical distancing and limit or ban large gatherings.

“As a pandemic, COVID-19 has the potential to spread rapidly and overwhelm Ontario’s hospitals, particularly critical care capacity. Decisions made now will have enormous effect on mitigating the impact on people, patients and health care workers,” the document, which was provided to The Globe by the OHA, concluded.

One high-level source involved in the medical community said that in February and early March, the impression was that the Premier’s Office believed the Ministry of Health and the Chief Medical Officer were on top of the situation. Given that, Premier Ford was himself focused on the potential economic fallout from a pandemic.

Hours after the OHA sent its letter, the federal government finally issued a travel advisory.

A little more than a week later, the border was sealed, states of emergency were in affect across the country and Canada started staying home to flatten the curve.

Michael Gardam, the chief of staff at Humber River Hospital in Toronto, said that even though Canada (and Ontario) never became a New York or an Italy, things could have gone much better.

“Just look at British Columbia,” said Dr. Gardam, a former Medical Director of Infection Prevention and Control at the University Health Network.

“Epidemiologists who are not hampered by politics and just see the science for what it is – it’s not surprising we’d be way out ahead of them. The frustrating part is we didn’t feel we were listened to. And to this day, people are still about wondering who is giving the government advice on some of this stuff.”

In response to questions about the challenges health care experts faced dealing with government in the early days of the pandemic, a spokesperson with the Ministry of Health highlighted that compared with similarly sized states in the U.S., Ontario has been doing well, with fewer than 200 new cases a day. Hospitalizations, ICU admissions and the number of patients requiring a ventilator have been on decline.

“Despite these positive trends, there were and continue to be substantial challenges to deal with, not the least of which include inheriting a siloed health system, a neglected long-term-care sector and an irrationally disconnected public health system,” the statement read. It went on to say that had Ontario Health been fully functional at the time of the pandemic, many of these problems would likely not have existed.

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LIFE UNDER QUARANTINE

Different provinces and jurisdictions are now in varying degrees of reopening. But many of the experts who spoke to The Globe said all of this is likely temporary. Most expect a second wave when the weather cools down and people are forced indoors in the fall and they are worried that Canada is repeating its mistakes from the early days of the outbreak.

“Are we ready for [a second wave]? I don’t think so. Are we getting ready for it? I don’t think … there’s three months between now and fall. The clock is ticking,” said Gary Kobinger, the director of the Research Centre on Infectious Diseases at Laval University and a former chief of special pathogens at the National Microbiology Laboratory.

Dr. Kobinger said the government should be preparing to handle a second wave that is 10 times worse than the first. Is the testing capacity there? Can hospitals absorb that traffic?

“If we need field hospitals, how are they going to be built? And what if it drags through December and January. This is Canada. Not China. It’s cold. How are you going to manage that?” he said.

Dr. Kobinger said that he has tremendous respect for those who work in public health and that it is an extremely difficult job. That said, he continued, PHAC was created to better prepare the country for the next SARS. “I think it is fair to say that we can understand that many had higher expectations.”

Dr. Kobinger sits on a scientific advisory panel that Dr. Nemer formed in March. For most of the experts who spoke to The Globe from the panel, Dr. Nemer was the first person connected to the federal government to reach out. Asked why she didn’t create the group sooner, Dr. Nemer said she wanted to let PHAC do its job. “This was not the time to be sending different messages or competing for attention.”

But eventually, she decided she had to act.

Anthony Dale, the OHA president, said there was sincere fear throughout hospitals ahead of the countrywide shutdown. A level of that apprehension remains today, he acknowledged, as there continues to be concern that the province has not prepared for the fall.

“Let’s not sleepwalk into a second wave. Let’s use the time now while there is stability,” he said. “The second wave is inevitable.”

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