Our current health-care disaster could have been averted

April, 2020: The world had just counted its millionth case of COVID-19.

The virus was just beginning to spread like wildfire in Canada. Politicians were scrambling to secure their health-care defences against the fast-moving virus.

Ontario Premier Doug Ford was the most bullish.

“Thanks to the hard work and relentless preparation of our hospital staff to build capacity in our hospitals, we are in a position to better allocate resources to sectors that are in critical need and respond to any potential surge in cases,” he said in a statement. It would, he said, give Ontario a “fighting chance against this deadly virus.”

By the end of April, he promised, Ontario was adding thousands of new beds to its hospital system. “The province has added 1,035 acute care beds and 1,492 critical care beds and taken steps to ensure hospitals have the staff available to care for a sudden surge in patients,” a government press release reads. Whatever your opinion of the premier, it was a comforting vow as we stood in the shadow of the worst modern public health crisis.

Every province faced the possibility that, as people fell ill with the new coronavirus, there would simply not be beds available for them in hospital: Not just the physical bed, but the hospital space, the staff support, the oxygen, the ventilator and the necessary equipment. For much of the next year, the Ford government fired out press releases lauding the new ICU beds it had added to the system, preparing the province for the next wave of the virus that was sure to hit.

Ford’s consistent efforts to bolster health-care capacity have been an indication of how seriously he understands the problem facing the province.

It was also complete and utter nonsense.

Before the virus hit, Ontario had 2,012 adult ICU beds. As of October 31, 2021, according to the province’s independent scientific advisory board, there were 2,343.

Two years of the worst health disaster in modern Canadian history and its largest province managed to add 331 beds to its intensive care units.

That story has been repeated straight across the country—albeit without Ford’s trademark ability to make up numbers.

Nearly every province has seen its health system pushed to the breaking point in recent weeks due to the Omicron variant. All the promises that we’ve heard for two years about using the ebb between waves to prepare have turned to sand.

ICUs are full. Surgeries are being cancelled. Lockdowns and curfews are being implemented because governments fear even a modest rise in cases could lead to deaths—not due to COVID-19, but due to a lack of care. The only exception is in the territories and Atlantic Canada, where leaders have—at least compared to their colleagues in the rest of the country—actually shown themselves capable of handling crises. (Admittedly, their geography helps.)

This is not a new problem. Canada has long lagged behind other rich nations in terms of its hospital capacity: Canada’s ICU capacity is less than half of that of the United States and just over a third of Germany’s. (Or, we think so, anyway: Canada’s most recent survey is from 2014. A 2015 study distressingly found “our overall national critical care capacity is unknown.”)

While ICU capacity is not necessarily a sign of the overall quality of a health system—an efficient health-care system can run on fewer ICU beds by diverting patients before they need critical care, and by load-balancing between hospitals and health networks—a modern health system absolutely needs significant surge capacity.

Canada has famously been unable to do surge capacity well, and there appeared to be a general indifference to fixing that problem. When the H1N1 pandemic hit in 2009, hospitals were routinely turning away patients and rescheduling surgeries in order to handle the influx.

“To mount a response to H1N1, public health units pulled human resources from other programs, and many critical services were delayed, suspended or cancelled altogether,” Jeffrey Turnbull, the president of the Canadian Medical Association, told a Senate committee in 2010. “The resources of our critical care infrastructure were stretched to their limits in many hospitals.” Turnbull noted that his organisation has been warning about the lack of surge capacity for over a decade.

“If H1N1 had been the severe pandemic that was expected, and for which Canada had been preparing, our health-care system would have been brought to its knees,” he warned.

That warning was, unfortunately, prescient. 

***

Early in 2021, a team from McMaster University in Hamilton embarked on a study to understand how the pandemic has affected frontline health workers across the country.

Their study interviewed hundreds of the pandemic’s unsung heroes: Respiratory therapists. While they can work in a variety of settings, they are some of the most critical staff in ICUs. Respiratory therapists, for example, are the ones performing the intubations for patients who are no longer able to breathe unassisted. They have often been the ones holding the hands of patients as they die from complications caused by COVID-19.

The study found that at least one-in-five respiratory therapists, the vast majority of whom are still on the job, exhibited the symptoms of post-traumatic stress disorder. What’s more, the effects of the stress placed on these workers corresponded to a significant impairment in their ability to work—the therapists who participated in the study reported they were unable to work, on average, one-and-a-half days out of 30, and had had to cut back on work responsibilities for another four days.

This is, unfortunately, the reality in many high-pressure jobs, especially in times of crisis. But there’s a factor that is magnifying this problem: Moral distress.

Moral distress, in essence, is the psychological response to being unable to do the right or ethical thing because it is either impossible or disallowed. It’s not hard to imagine such distress: Picture yourself in an over-crowded hospital. You’ve got to decide who gets the just-opened ICU bed—the person awaiting critical heart surgery, or the unvaccinated person suffering from COVID-19 whose chances of survival look dire. You’re wearing only a surgical mask, because the hospital doesn’t believe you require an N-95. Your colleague down the hall is proudly unvaccinated, bragging about how they’ve forced the premier to back down on a mandate for health-care workers. You’ve been working double shifts all week because so many of your colleagues are off sick, and you know your performance is suffering. Your floor is half staffed, and the ones who are working are straight out of medical school and in way over their heads. You’re doing your best, but the health-care system is not working as designed.

How could you not be distressed?

The researchers administered an established test to measure moral distress. They presented the respiratory therapists with 27 statements—like ”[I] experience lack of administrative action or support for a problem that is compromising patient care,” and “[I am] required to care for more patients than I can safely care for”—and asked them to rank the statements in terms of how frequently they experience the situation, and how distressing it feels.

The scale goes between 0, meaning the health-care workers feel no real stress at all, and 432. The McMaster study found those respiratory therapists reported an average score of over 133, with those working on COVID-19 wards averaging 141. By way of comparison, a 2019 American study found that an average score of 96 for a random sample of physicians and 112 for nurses. The Canadian health-care workers, in other words, were 50 per cent above the baseline. (Although the comparison is imperfect, given the United States’ for-profit health-care model.)

What is galling about that metric is that it is avoidable. It is not a measure of how difficult the job is—it is a metric of how the health system makes the job difficult. It is a measure of how much our health-care workers feel abandoned and unsupported.

“Categorically, that comes out in the interviews,” says Margaret McKinnon, who led the study. She’s a professor of psychiatry and behavioural neurosciences at McMaster, and has worked as a frontline health-care worker.

“You feel distressed by an institution.”

***

For the past two years, we have heralded our frontline health workers as heroes. We have clanged pots and pans from our windows and put up posters promising “ça va bien aller.” Our politicians have been effusive in their praise of our health-care staff, who form the only bulwark between our delicate status quo and utter tragedy.

Yet, in real actions, what have they done to support those staff?

I asked one health-care worker, a nurse in British Columbia, if she had received any kind of pay bump during the pandemic—certainly, I know my friends on Bay Street have received bigger-than-usual bonuses in recent years, in recognition of their difficult work-from-home arrangements. Why not health-care workers?

She laughed and thought for a second. There was a modest pay bump near the beginning of the pandemic, she said, thanks to a $3 billion federal fund. Nothing since then. 

While money can’t fix the trauma visited upon those health-care workers, it sure doesn’t hurt. It’s a way of recognizing the sacrifice made by those workers. Some provinces, like Alberta and Ontario, topped up the federal program in 2020 but have done next to nothing since then. (Governments in Nova Scotia, New Brunswick, and Manitoba, to varying degrees, have provided more compensation for frontline health-care workers, to their credit.)

On the other side, low pay and wage caps have done the opposite: They have sent the message, as one nurse told me, that these health-care workers don’t matter. “They feel like they’re expendable,” she told me.

In Ontario, Doug Ford’s Bill 124, introduced in 2019, limits wage increases for nurses to one percent per year. More recently, Quebec has cancelled nurse’s vacation time and will force COVID-positive health-care workers back on the job. Alberta actually tried to cut nurses’ wages during the pandemic.

In January, the Registered Nurses Association of Ontario launched a damning indictment of the Ford government—which could readily be applied to governments across the country—accusing him of “turning a pre-pandemic nursing shortage into a full-blown nursing crisis.”

Respiratory therapist positions, meanwhile, are some of the lowest-paid in the health-care sector. They regularly make seven or eight dollars an hour less than nurses. In some provinces, including Ontario, they had to fight to be included in the Ottawa-financed pay bump. Respiratory therapists are also excluded from Ontario legislation designed to provide paid leave for those experiencing PTSD.

The magnitude of the pressure facing these frontline workers can be hard to convey.

Carolyn McCoy, Director of Accreditation and Professional Practice Services at the Canadian Society of Respiratory Therapists, told me that, in normal times, a respiratory therapist can expect to look after five ventilated patients each. “Well, now, they’re looking after eight, nine, 10 ventilated patients,” McCoy told me. Despite their critical role in the pandemic response, she says, respiratory therapists “have not felt recognized or valued.”

“There’s a systemic staffing problem,” the B.C. nurse told me. Whenever there’s a shift change, the job assignment board in the hospital “is like the New York Stock Exchange,” they told me.  “They’re trying to reassign patients and trying to reassign nurses. And then, halfway through the shift, the whole thing happens again. So it’s a very chaotic situation.”

Sometimes, staff feel unable to show up and handle COVID-19 cases. The nurse said that one trick hospital administrators pull is to call up health-care workers and tell them they’ll be working a non-COVID-19 ward—when the nurse shows up, however, they find themselves reassigned to the COVID floor.

Not having the bandwidth to handle COVID-19 patients is understandable. Today, the vast, vast majority of seriously ill patients with the coronavirus could have averted getting sick but chose not to: They opted to not get vaccinated. While health-care workers try and find compassion for those people, sympathy has its limits. What’s more, many of the critically-ill, unvaccinated, patients have a faint hope of survival. “Many feel like they’re providing futile care,” McKinnon told me.

Jonathan Lee is a critical care pandemic with Ornge, the not-for-profit company tasked with providing air and land health transport services in Ontario. Part of his job is trying to balance the load of patients between hospitals and health authorities around the province.

“The hospitals are a disaster,” he told me. “It is not uncommon to walk in and there’s just no staff, there’s just no nurses, there’s an emergency department that normally would run with six or eight—it’s down to one or two.”

We are in a vicious cycle. The past two years have pushed many health-care staff to their breaking point: The stress of fighting this cursed virus has wrecked the lives of doctors, nurses, paramedics, and support staff. Rather than stepping up to support those workers, our governments have systematically signalled that they are expendable. Many have left for more normal, 9-to-5 jobs in public health, or administering vaccines. Others have left for the United States or further afield, where their expertise is rewarded adequately. Others have gone on unpaid, indefinite leave. Still others have just quit.

For every health-care worker who quits, it compounds the work of everyone else in the system. One fewer nurse on shift means the workload, and the stress, is distributed to their remaining colleagues—increasing the likelihood that one of them will walk as well.

On top of that, fewer staff doing more work makes it nearly impossible to do adequate on-the-job training. That means students are either not graduating, further decreasing the overall capacity, or are entering the hospital without the same standard of training they ought to have—that only leaves them unprepared for the work, making them further likely to experience that moral distress, and increases the workload on their new colleagues. The problem is so acute that some of the shiny new ventilators, purchased early in the pandemic as a splashy way for the government to show their commitment to the health sector, have gone unused because there is simply no time to train staff on the new gear.

“There’s a lot of nights where we’re short,” Lee told me. “And, you know, that means we have to drive extra. And that means, because when the hospitals are short—and they’re all short—then they transfer more patients because they can’t take care of them.”

***

This feeling like health-care workers aren’t really valued is highlighted to a sickening degree in provinces’ refusal to provide the best personal protective equipment to health-care workers.

In 2020, the Quebec nurses union had to go to an administrative tribunal and to court repeatedly to force the government to provide N-95 masks to their members in hospitals and other COVID-19 hot spots.

“The public health bureaucrats, far away from what’s happening in the hospitals, long-term care homes, and other health units in the [COVID-19] hot zones, are taking a hard line and maintaining an order that limits access to N-95 masks,” wrote representatives from two of Quebec’s largest health unions, cosigned by dozens of their regional colleagues in the Journal de Montreal last January. They warned: “Our members have simply had enough!”

The Ontario Nurses Association has had a similarly miserable fight, trying to force the Ford government to do the right thing. Even as scientists were publicly admitting that COVID-19 is primarily spread through the air, the Ford government was arguing in court that the virus spread through droplets and, therefore, health-care workers only needed good masks in certain circumstances.

A court ultimately sided, rightly so, with the nurses and ordered the province to stop withholding masks. But even today, access can be limited for workers in long-term care homes and other high-risk environments.

Even if access has improved, obtaining the masks can still be a struggle in some settings. In British Columbia, where the courts haven’t weighed in, it’s a nightmare.

Public health nurses were visiting communities where COVID-19 was rampant—spending significant time in tight spaces with poor ventilation. “They were being told…you don’t need N-95s,” one nurse told me. During the summer, some of their surgical masks were literally dissolving in the heat. 

“They’re dealing with incredibly sick people in very unstable conditions and all of a sudden, you’re also having to have a huge fight about access to N-95s,” they told me. Even in the hospitals, staff are regularly denied N-95s. 

A core piece of the moral distress that McKinnon identified as being endemic in our hospitals right now is the feeling that they’re not just struggling against a naturally-occuring virus, they’re struggling against their own government and employer.

“We’re essentially on war-time footing,” she told me. “And one does not want to go into war without armour.”

In some cases, it feels like health-care workers are struggling against their own colleagues. Ontario and Quebec, in particular, announced plans to mandate vaccines for health-care workers, only to stage a hasty retreat.

“It is very difficult to not become resentful of it, especially health-care workers who don’t [get the vaccine],” Lee told me. Working alongside someone who refuses to adopt the countermeasure that is scientifically proven to reduce the likelihood of transmission of COVID-19 is frustrating as hell, he told me. “If you are a health-care provider and you refuse—or you don’t believe that, or you can’t interpret that, the same way as everybody else—are you a competent health-care provider?”

It would be like refusing to perform CPR on the basis of a “personal belief that CPR makes my wrist hurt, so I’m not going to do it,” he said. Pulling someone off the frontlines to do a desk job, while collecting a full salary, isn’t a solution either, he adds.

British Columbia is a rare province that forged ahead with its vaccine mandate for health-care workers. “I didn’t notice anyone leaving,” the B.C. nurse, who was not authorised to speak to journalists, told me.

British Columbia reported in November that just over 3,000 health-care workers, about 2.5 percent of the health sector, are on unpaid leave due to refusing the vaccine.

Certainly, 3,000 is a sizeable number. But consider the risk of tens of thousands of other workers quitting in disgust. The SEIU healthcare union found that more than half of their members in Ontario are considering quitting altogether. “Poor wages and working conditions are 20 times more likely to be the reason for health-care workers leaving the system than vaccine mandates,” they reported.

Lee recently got an email from his employer that highlighted the absurdity of it all.

“They emailed me, in the middle of this entire nonsense saying: ‘You need to get your tetanus shot updated, or you will not be eligible to work.’” (Lee, obviously, got his tetanus.)

***

Someday we will have a taxonomic accounting of where our slothful and lazy governments declined to act, and how dearly we paid for it. Because governments have been unable to build that surge capacity in our hospitals, schools have closed, businesses have shuttered, and we have all taken enormous hits to our personal life and mental health. Some of that was inevitable, but not all of it.

Those measures have all been done in the name of protecting our health-care system, but that is misdirection. Because governments have shown themselves incapable of preparing, there are scores of doctors and nurses who have to worry about their children’s virtual learning, even as they work tirelessly in a system on the brink. Mobs of angry protesters are channelling their anger over lockdowns and curfews towards those health-care workers who had tried hard to buy us time to avert such miserable policies.

Retrospectives are for later. For now, we need to focus on what must be done immediately.

For one, being unvaccianted must become untenable. Vaccine mandates need to be implemented for health-care workers: Forcing doctors and nurses to work alongside colleagues who refused to take the shot is insulting. 

We need to speed up booster doses—just 16 per cent of British Columbians have received their third dose. Dropping the eligibility requirements and allowing non-health-care personnel to administer those doses would be a way to boost demand and supply at the same time.

More importantly, we have to stop accepting that being unvaccinated is a personal choice without consequences for the rest of us. Much like piloting a plane without a licence or playing with dynamite on a busy highway, reckless actions have the clear potential to hurt the rest of us: Not just by transmitting the virus, but by slamming the hospitals where the rest of us need to be treated.

Quebec has forged the right direction there by first requiring a vaccine passport to enter alcohol and cannabis stores, and by vowing to tax unvaccinated people higher. The other provinces would be wise to follow suit. We already tax risky behaviour that strains our health-care system, through tobacco and alcohol taxes, and this should be no different.

Vaccines, one way or another, need to be mandatory.

But the benefit of vaccines takes some time to be seen. What provinces need to do immediately is show health-care workers they are valued, instead of cogs that are expected to keep turning. And, in the process, avoid the further hollowing-out of the entire health system. Immediate pay increases and an explicit policy to make N-95 masks for all staff at all times is a bare minimum. Provinces should, further, endeavour to work between each other to better share resources to try and more quickly offer surge capacity when one needs it more than others. 

Recognizing the health-care credentials obtained abroad (which Ontario is doing) is also one way to boost capacity quickly, but it is not necessarily a fix for immediate staff shortages: Someone still needs to train those new staff.

There has been a lot of talk about protecting health-care workers from the irate protesters and conspiracy theorists who have targeted their workplaces. This can’t be done fast enough. Health-care workers aren’t just facing danger from the hordes of unvaccinated on the sidewalk outside, they’re facing threats and harassment from patients and their families who continue to labour under paranoid delusions about this virus.

There also needs to be considerably more mental health support for health-care workers. Offering pablum from the podium isn’t good enough: Provinces need to pony up the money to hire those resources. “Social support is the single greatest predictor of PTSD,” McKinnon told me. There needs to be mental health support on every unit in the hospitals.

It’s clear the federal government needs to stop watching from the sidelines and get more involved. Ottawa has been ready to transfer money to the provinces without much hesitation. But the federal government has played a passive role, offering up support only when called—relying on the premiers to act, as we’ve all learned, is a dicey proposition. Ottawa dispatched mobile health units to beef up ICU capacity early in 2021, but haven’t during this Omicron wave. A spokesperson for the health minister told me their current status is “stand-by.” Quebec has had the good sense to take up the Canadian Forces on their offer to help administer vaccines—other premiers should follow suit.

While the federal government has hardly been a paragon of competency through the pandemic (vaccine procurement excepted) it’s time it steps up. Ottawa has tests, N-95 masks, money and trained mental health professionals: If the provinces won’t make those things available, perhaps Ottawa should find a way to provide them directly to its own citizens.

Things are bad right now, but there are things our leaders could do right now to make them better.

After this current crisis is over, we need to have a long, difficult conversation about what our health-care system looks like. If we want it to remain public and universal, we will need to figure out how to pay for a resilient and effective system without bankrupting other parts of it. If not, then it’s time to start talking seriously about how to get private industry more involved.

Quite honestly, we should not trust any premier west of Bay of Fundy or south of the 60th parallel to join us in that conversation because they clearly have no idea what the hell they’re doing.

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