As the COVID-19 pandemic enters its 10th month in Canada, public attention is focused on the rollout of a massive vaccination program. Reviewing the volume of information from the last countrywide pandemics – H1N1 in 2009 and SARS in 2003 – it doesn’t look like Canada has learned its lessons. These learning failures raise serious concerns about policy-makers’ ability to draw on history to plan for the future.
Looking back and remembering differently?
Nearly two decades before the COVID-19 pandemic, the 2003 SARS pandemic overwhelmed hospitals and stunned unprepared public health agencies in Toronto. Today, SARS is referenced as COVID-19’s dress rehearsal. However, leading Canadian experts in pandemic planning disagree as to whether Canada learned much from it.
Mario Possamai, a former senior advisor to The SARS Commission, argues that Canada failed to adequately prepare for and respond to COVID-19. In a recent report for the Canadian Federation of Nurses Unions, Possamai highlights how the SARS final report developed a roadmap for future pandemics that was ignored during the first wave of COVID-19, specifically its recommendations to protect health-care workers. These conclusions are supported by Linda Silas, president of the Canadian Federation of Nurses Unions and Sandy Buchman, past-president of the Canadian Medical Association.
In contrast, David Naylor, a leading expert on pandemic planning and lead author of the 2003 Learning from SARS report released by Health Canada recently stated that Canada’s response to COVID-19 benefited greatly from our experience during SARS. Naylor believes that the Canadian government addressed 80 per cent of the recommendations from Learning from SARS. Naylor notes his report was a prime force behind the creation of the Public Health Agency of Canada, the renovation of emergency departments to meet the minimum infection-control standards and the construction of sufficient negative pressure rooms for treatment of patients with infectious disease.
Experts disagree about whether we are using the lessons of past pandemics effectively. This lack of consensus is in itself an indication that learning may be imperfect. There is a clear divide with non-government stakeholders raising concerns and those more closely aligned with government expressing confidence. This divide sparks a larger debate about who should evaluate and what evidence should be considered when determining if learning occurred.
One way to address this is to consider what occurred between the two most recent pandemics before COVID-19: SARS and H1N1.
The broken link between SARS and influenza pandemics in Canada
The H1N1 influenza pandemic hit Canada in the spring of 2009, and unlike SARS, there were confirmed cases in every Canadian province and territory. Federal and provincial governments produced numerous reports as a result of H1N1. The majority of these provincial reports failed to reference SARS and the public-health lessons that were learned less than a decade earlier. Alberta, British Columbia, Manitoba, New Brunswick and Nova Scotia were the provinces that did not reference the recommendations of either SARS report. As well, a national guide on a potential fall 2009 wave of the H1N1 from the Public Health Agency of Canada made no mention of the recommendations from those reports.
In contrast, national health-care provider associations, including the Canadian Medical Association and the College of Family Physicians of Canada, published a report on H1N1 that included direct references to SARS and the previous lessons learned. Ontario, Saskatchewan and Prince Edward Island reports referenced the SARS pandemic as the rationale for preparing for and reporting on H1N1. In fact, Ontario’s pandemic reports appear to be among the more prescient about our current challenges, which is an important area for future research.
Ontario’s H1N1 pandemic report, written by the former Ontario chief medical officer of health Arlene King in 2010, concluded with a strong recommendation for improvements to Canada’s immunization delivery system. Five years later, Ontario’s Ministry of Health released an immunization report and roadmap that noted that the province’s immunization coverage still fell short of national targets.
Expectations and evidence of learning
Canada’s previous experience with pandemics might suggest that Canadian policy-makers should have a wealth of policy lessons to draw on in responding to COVID-19. However, when trying to determine whether and how learning is occurring, we are confronted with a series of challenges and contradictions.
First, we have a body of research that suggests that learning from past policies is not necessarily a rational evaluation of successes and failures, and tends to be complicated and difficult. Policy learning is often shaped by cognitive shortcuts that can lead to biased conclusions, especially in moments of crisis and in situations where there is expected to be a high degree of institutional amnesia, or forgetting lessons drawn immediately after past experiences. Australian researchers Alastair Stark and Brian Head have argued, « When ‘why’ rationales fade or get reinterpreted because of amnesia, important aspects of policy can become vulnerable, particularly if their worth is not immediately apparent in relation to an organization’s core business.”
We have theoretical reasons to expect learning may be difficult, and the real-time experience of experts disagreeing about whether we have learned from the past. It is perhaps not surprising that experts working with non-government stakeholders like medical associations and nurses’ unions take a more critical view than experts who are more closely associated with government.
However, when this disagreement is juxtaposed with the stark lack of references to SARS in most Canadian H1N1 reports outside Ontario, there is reason for concern about how learning is occurring. We need specific, systematic information about who is learning, what is being learned, and how and whether these lessons are being applied. Without this information, we risk attempting to plan for the future without a clear understanding of the past.
After H1N1, experts reviewed what had gone wrong and made extensive recommendations to help with the next pandemic, including how to handle mass vaccination. When H1N1 hit in 2009, it’s unclear whether policy-makers made meaningful connections to the lessons of SARS six years earlier. The different viewpoints of leading Canadian experts need to be explored to understand if and why Canada is currently failing to understand lessons from previous pandemics. This is particularly important now as we have begun in a limited way the rollout of the COVID-19 vaccine. There is an emphasis on getting an immunization plan in place quickly, with opposition politicians criticizing government for a perceived lag.
However, if we do not consider potential pitfalls and barriers to learning, we risk leaving critical lessons from past pandemics on the table. As we continue through the current crisis, we can’t let hard-won information go unused. Lives may depend on it.