A pandemic sweeps across Canada in one or two months. It is spread not only by the sick, but by people who show no symptoms. There are shortages of medical supplies and the health system struggles to keep up. The peak won’t come for months, and it will be accompanied by a surge in deaths. Soon after, the country will brace for a second wave.
All of this is now true for the COVID-19 crisis, but the aforementioned scenario – a warning – comes from a 2006 federal report on pandemic preparedness. Fourteen years later, its words are eerily accurate.
Long before COVID-19 emerged, top health authorities from across Canada put together a playbook to prepare for a situation strikingly similar to the one the country now finds itself in.
One of the co-authors of that report was Theresa Tam, now Canada’s chief public health officer in charge of the fight against the novel coronavirus.
According to doctors who worked on the 2006 document, which was based on a hypothetical, highly contagious outbreak of influenza, the urgency of the report faded over time, though the threat never did. It is one of several credible warnings that seem to have gone largely unheeded.
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A 2010 federal audit flagged problems with the management of Canada’s emergency stockpile of medical equipment; a 2018 assessment of the H1N1 swine flu outbreak a decade earlier raised concerns about ventilator shortages; and a 2019 study led by a team of global scientists questioned the ability of many countries, including Canada to prevent, detect, and respond to a major outbreak.
Despite the prescience of such warnings, Canada and many other governments around the world significantly underestimated the severity of the coronavirus.
As recently as late January, federal officials, including Dr. Tam, said the threat of a major outbreak in Canada was very low, that measures such as travel restrictions weren’t needed, and that the risk of the virus being spread by people without symptoms was highly unlikely.
“Canada’s risk is much, much lower than that of many countries,” Dr. Tam told MPs in Ottawa on Jan. 29, a month after the government was alerted to the outbreak at a market in Wuhan, China. This was four days after a man had arrived in Toronto from Wuhan and became the country’s first case of the disease.
“It’s going to be rare,” she said. “It doesn’t matter how few those cases are, we are preparing the whole country in the event that you might pick up a rare case.”
Nine weeks later, with more than 19,000 cases and much of the country under virtual lockdown, federal officials have radically revised that position as they confront critical shortages of medical supplies in hospitals, and prepare for devastating peaks in Ontario and Quebec. Hundreds of people have died across the country. And thousands more will follow, according to federal projections.
The stark contrast between the government’s early assessment of COVID-19 a few months ago and the catastrophe it has become is raising uncomfortable questions about the warnings made years ago by health officials. It appears warnings were either played down, forgotten, or ignored by government, putting front-line medical workers at heightened risk and health authorities marshalling every available resource just to catch up.
“Health systems were never designed for this kind of surge,” federal Health Minster Patty Hajdu said last week. “I think federal governments for decades have been underfunding things like public health preparedness.”
Joanne Langley, an infectious disease specialist at Dalhousie University who worked on the 2006 report, said preparing the document was a crucial exercise after the outbreak of severe acute respiratory syndrome (SARS) in 2003. But its urgency and prominence eventually dissipated.
“Preparing for a novel infection that could cause a lot of morbidity or mortality was as important as any kind of plan you could develop,” Dr. Langley told The Globe and Mail.
“I think there was a real forward stimulus when we had SARS, and that resulted in many improvements,” she said. “Then it fades, and you forget how important it is. And sometimes leaders say, ‘We had no idea something like this could happen.’ But if you were in public health, then you know you have to be in a constant state of readiness.”
The warnings would not have settled debates over whether everyone should wear a mask or not; nor do they provide a schedule for politicians and public-health officials to follow, dogmatically, in a crisis – which demands nimble, evidence-based decision-making at a time when knowledge is constantly evolving.
But the parallels are striking enough that some medical professionals are left wondering why governments didn’t heed the playbook earlier.
In Toronto, Kulvinder Kaur Gill, president of Concerned Ontario Doctors, an advocacy group that represents 10,000 physicians, is blunt in her assessment.
“I am very aware of that  report, and I am very aware of what has not been done,” Dr. Gill said.
On Wednesday, during a daily briefing on the crisis, The Globe attempted to ask Dr. Tam about the differences between what she has said about this pandemic and what her report forecast years earlier. The briefing ended without her or other officials taking The Globe’s questions.
Dr. Tam’s department later sent a statement, which quoted her as saying, in part, “My colleagues across the country and I have been working closely, focusing on the rapid implementation of effective, targeted control measures that are appropriate for the current situation.”
“At the same time, we need to be mindful of the potential side-effects ... including impinging on the rights and freedoms of individuals without good cause and societal disruption in general.”
Late on the night of Dec. 30 last year, an alert flashed across an online network known as ProMED, a monitoring system for emerging diseases used by hospitals around the world. “Urgent notice,” the notification said. “Pneumonia of unknown cause.”
The message relayed details of an unusual outbreak around a market in Wuhan, China, to more than 800,000 members on the ProMED network, which is run by the International Society of Infectious Diseases. Few details were known, but given the ferocity of the virus, it warned medical institutions in the region “to strengthen multidisciplinary professional forces such as respiratory, infectious diseases, and intensive medicine in a targeted manner … and improve emergency plans for medical treatment.”
In other words, brace for impact.
It was the first that many Canadian doctors would hear of what would become known as COVID-19, and the ProMED alert sent ripples through the medical community, because physicians knew what that warning could mean. It was exactly the kind of danger health officials began preparing for in 2006, three years after SARS killed 44 people in Canada, and quarantined thousands.
SARS was seen as a wakeup call. The next outbreak to test Canada’s health-care system could be much worse, so a team of medical experts began drafting a playbook. It was intended to form the basis of the country’s future pandemic preparedness, but it reads like a play-by-play of COVID-19.
“The next pandemic will first emerge outside of Canada,” the 550-page document predicted. The virus “will be present in Canada within 3 months after it emerges in another part of the world, but it could be much sooner because of the volume and speed of global air travel.”
The report assumed that 70 per cent of the population would be infected over the course of the pandemic, but only 15 to 35 per cent of Canadians would exhibit signs of illness, such as coughing and fever. There would be a “relatively high rate” of infection even from patients who displayed no symptoms.
“A pandemic wave will sweep across Canada in 1-2 months affecting multiple locations simultaneously. This is based on analysis of the spread of past pandemics,” the report said, including the 1918 Spanish flu, which raced across Canada as soldiers travelling by train returned from the First World War.
“The first peak of illness could occur within 2 to 4 months after the virus arrives in Canada. The first peak in mortality is expected to be approximately 1 month after the peak in illness,” the report said, projecting there would likely be two or more waves of the pandemic, each lasting 6 to 8 weeks.
Given the threat of multiple waves, the document called for the Canadian government to stockpile everything from ventilators to N95 respirator masks, gowns, gloves and face shields. “There will be shortages of the materials and supplies needed during the pandemic period,” the officials concluded. Therefore “a consistent 16-week supply (i.e. two pandemic waves)” was the minimum needed.
It added: “The government does not have control over when this will occur.”
As hospital workers have learned in recent weeks, those key warnings were never heeded. As SARS faded into history, so too did the anxiety over a deadly outbreak.
But the dire shortages at hospitals during this pandemic – ranging from basic items such as masks to testing equipment and ventilators – has shaken the medical system. Dr. Gill, who practices in Brampton and Milton, said hospitals there are straining to the breaking point in normal times. She said her colleagues are now scared, and many don’t believe the government’s figures on the number of people infected, partly because the ability of COVID-19 to be transmitted without symptoms has been so underestimated, contrary to what the 2006 report warned against.
“They are only testing symptomatic people – and it’s asymptomatic people who can be the vectors. The health-care professionals could be those people, in any health-care setting,” Dr. Gill said.
She attributed the lack of widespread, uniform testing and shortages of protective equipment to a failure by Ottawa to act quickly and decisively when it first learned of the virus.
“There should have been a cohesive response,” Dr. Gill said, speaking on behalf of doctors in her organization who are disappointed in how the virus was handled early on. “We had many, many weeks that the government squandered.”
Created in the 1950s, the National Emergency Strategic Stockpile (NESS) exists to warehouse everything from ventilators and stretchers, to X-ray machines and protective equipment such as masks, gloves and gowns, along with medicines including antibiotics, antivirals and anesthetics.
After the 2009 outbreak of H1N1 swine flu, the federal government conducted an audit on the NESS and the results were troubling. According to the 2010 Audit of Emergency Preparedness and Response report, public-health officials across the country weren’t certain what exactly the stockpile contained.
“There could be better communication about the supplies that are available in the stockpile,” the audit said. “Representatives from the provinces and territories stated that, in some jurisdictions, little information was available to them regarding processes and products. Some were not aware of which supplies are available to them.”
The audit flagged a particular problem with shoddy record-keeping, saying it was unclear how much of the stockpile was up to date, and how much of the goods had expired.
“NESS does not have reliable useful life information for the majority of its supplies stored at the main warehouse, the regional warehouses, or at the pre-positioned sites,” the audit warned. The creation of an electronic database might solve the problem, it said.
The audit also questioned whether the emergency stockpile contained enough of the right supplies for an emergency like a pandemic.
“NESS acquisitions in the recent past have also been driven by established budgets and available funds, as opposed to being based on more comprehensive needs analyses,” the audit said. “The rationale supporting the size, content, and acquisition strategy of the current inventory is questionable.”
It concluded: “There are increased risks that assets may not be deployed in a timely and effective manner.”
However, despite years of planning to address weaknesses with the stockpile, it was still on the agenda to be fixed before the COVID-19 outbreak hit.
Jim Kellner, an expert in infectious diseases and epidemiology at the University of Calgary, said it upsets him that the federal stockpile system has come up short, leaving Canada at the mercy of international competition.
“Not to have enough masks on hand – that probably bothers me the most,” Dr. Kellner said. He, too, was involved in crafting the 2006 pandemic preparedness plan.
“We had to know something was going to happen … and we are going to find out how bad and how critical our lack of stockpiling is,” he said.
“I don’t want to see health care workers die.”
Warnings about potentially deadly shortages of medical equipment were numerous.
In 2018, the Public Health Agency of Canada issued a report that looked at the lessons learned from the 2009 H1N1 swine flu pandemic. That outbreak sent 8,678 people to hospital, put 1,473 in intensive care and killed 428. In the report, the agency flagged “a high demand” for critical care, in addition to “ventilators for affected children and adults.”
Yet, despite seeing that surge in demand as a lesson learned, the federal government has only just launched a massive procurement blitz to source tens of thousands of ventilators in Canada. They have leaned on auto-parts makers, tech companies and a host of other manufacturers to shift production to ventilators, in an effort likened to wartime.
Few of those ventilators will be ready for the first wave of patients who need intubation for COVID-19, should hospitals run out – as they have in jurisdictions the world over.
Doctors and medical experts point out two problems that have existed in plain sight for years. The first is Canada’s unique patchwork of provincial health jurisdictions that don’t often work in lockstep together or communicate effectively. Ultimately, it is the provinces’ responsibility to source and maintain adequate equipment, not Ottawa’s, though the emergency stockpile – to be tapped during a pandemic – is under federal purview.
The second problem is a lack of manufacturing capacity in Canada, leaving the country reliant on buying key medical supplies elsewhere, which becomes extremely difficult in a global pandemic, when countries end up bidding against each other for supplies.
“In such an interconnected world, we are so dependent on other countries to supply us with materials,” Dr. Kellner said.
Paul-Émile Cloutier, CEO of Ottawa-based HealthCareCAN, which represents 54 hospitals and health authorities across the country, said there is no excuse for the shortages faced by health-care workers.
“It is extremely regrettable that we may have expected to have that stockpile [but] it is not sufficient to respond to the surge,” said Mr. Cloutier. “There needs to be more leadership by the federal government. Ottawa has to play a stronger role in the sustainability of our system,” he said. “This will not be our only crisis.”
The lack of manufacturing capability in Canada could hurt the country’s pandemic preparedness well beyond the immediate need for ventilators and masks. Scientists estimate it will take at least a year to find and create a vaccine for COVID-19. But even if that vaccine is discovered by Canadian scientists, some experts warn, the country lacks the ability to mass produce the doses. When a solution is found, the government will have to depend on international suppliers to produce it.
“Canada, at the moment at least, has a real shortage of [vaccine] manufacturing capacity,” said Dr. Volker Gerdts, head of the VIDO-InterVac lab at the University of Saskatchewan. The facility is one of the country’s largest and most important vaccine research labs, and is taking part in a WHO-led effort to find a coronavirus solution.
During the 2009 H1N1 pandemic, the United States locked up roughly two-thirds of the world’s vaccine production for that outbreak, which made it difficult for other countries to secure enough for themselves, he said.
“It really comes down to Canada depending on other countries to manufacture vaccines for them. If you think about the current U.S. administration, clearly they already have said ‘Americans first,’” Dr. Gerdts cautioned. “It’s important for a country like ours to make sure that we have enough manufacturing capacity in the country when these things happen.”
On March 23, Ottawa announced emergency funding for vaccine research and production, including an injection of $12-million for Dr. Gerdts’s facility to build a manufacturing plant. But the new building will take at least a year, possibly longer, to be finished and certified. The emergency funding may have come too late for the COVID-19 outbreak.
“It’s very positive that the government recognizes this and has found a mechanism to quickly release that funding,” Dr. Gerdts said of the announcement. But the money wasn’t available until last month.
“We’ve been talking about this facility for years now,” he said.
Though the project is moving as swiftly as it can, the new manufacturing facility likely won’t be ready until the tail end of the outbreak.
“The next emerging disease is just around the corner,” Dr. Gerdts said. “Hopefully the next time we’ll be better prepared than what we are at the moment.”
Three months before COVID-19 emerged in China, a report co-written by the World Bank and the World Health Organization warned that governments around the globe were not prepared for a pandemic.
“For too long, we have allowed a cycle of panic and neglect when it comes to pandemics: we ramp up efforts when there is a serious threat, then quickly forget about them when the threat subsides,” the report said.
“It is well past time to act.”
That was in September. A month later, a report by the Global Health Security Index, a study led by scientists at Johns Hopkins University that rates the ability of national health-care systems to handle an outbreak, determined all 195 countries it evaluated, including Canada, were insufficiently prepared to handle a pandemic.
Though Canadian doctors were alerted to the outbreak in late December after the ProMED notification began raising alarms, it wasn’t until mid-January that the federal government addressed the COVID-19 outbreak publicly.
A few weeks later, Dr. Tam spoke to MPs at a committee hearing, saying the risk of an outbreak in Canada, and of asymptomatic spreading, was low. “For the general public who have not been to China, the risk is low in Canada,” Dr. Tam told the committee.
The government said it was putting information on screens at airports, asking passengers to self-identify if they had travelled to Wuhan, but more concrete actions, such as travel restrictions, quarantines and banning public gatherings, were not discussed.
In an interview with The Globe last week, Jonathan Vance, Chief of the Defence Staff, said the situation became evident in early January. It was a new coronavirus, he said, “so there wasn’t much known about the disease, how it would translate.”
Lobbying records suggest that as the COVID-19 virus was spreading in Canada, top federal health officials were still busy with routine files. Between Jan. 23 and March 10, officials held talks with roughly a dozen different organizations, mostly about the federal budget.
Ideally, Dr. Kellner said, the move to ban crowds and urge Canadians to stay home should have come more decisively, at a national level, as soon as Ottawa knew how the virus can spread. “Once we had a sense of how transmissible it was, there was no reason not to take more extreme measures right away,” he said. “That is a lesson learned.”
In Canada's patchwork of jurisdictions, Ottawa began talking to provinces and municipalities about using their local powers to restrict public gatherings and commerce. But the federal Emergency Act, Prime Minister Justin Trudeau said, would be a measure of last resort.
Sumon Chakrabarti, an infectious-disease physician in Toronto, said Ottawa should have taken over the reins early on, to give consistent direction to community labs and hospitals, when people urgently needed leadership. “If you had a federal directive that every lab had to do this – ‘We are going to recruit all of you’ – then we would have had less issue with the backlog and the delays in testing,” Dr. Chakrabarti said.
The uncertainty over personal protective gear just added more unnecessary stress, he said. “If we were marching for one coach [at the federal level], we could have gotten to the point we would have had good data and then we would have gotten to the point where we are all on the same page at the same time.”
“Rather than thinking, ‘We have a surge coming and we can accommodate it,’ it’s more: ‘We have a surge coming and we don’t know how we are going to cope with it.’ ”
The warnings contained in the 2006 pandemic preparedness report, particularly the foretold shortages of medical supplies, now haunt the COVID-19 outbreak.
“The  preparedness process identified all those things,” said Dr. Langley, of Dalhousie University. She believes the alarms were sounded early enough, but Canada’s fragmented health system – with 13 different provincial and territorial systems – likely slowed down the response.
The lack of a unified plan, and the inability to heed warnings from years ago, has left governments scrambling to supply hospitals with basic protective gear, venturing onto the precarious – and protectionist – global market to buy supplies that aren’t readily available.
“We are working, I would say, 24 hours around the clock trying to procure equipment in a global situation where equipment is extremely tight,” Ms. Hajdu said last week.
She acknowledged that the outbreak has exposed the need to invest in better pandemic preparation. “I would say this is an opportunity for all governments to consider reinvesting in public-health preparedness and I look forward to those conversations on the other end of this,” the Health Minister said.
Canada, of course, is not unique in its urgent quest to secure supplies. “I think we’re seeing right now that the entire world was unprepared,” Mr. Trudeau said this week.
Just as the urgency over the 2006 report was lost soon after SARS, the feeling of a system under duress is back again. But whether that lesson will stick this time remains to be seen.
After neglecting for years, and over successive governments, to address several key problems with pandemic preparedness, including the weaknesses of the emergency medical stockpile, government documents show Canada was looking at confronting some of those issues.
When the Public Health Agency of Canada issued its 2019-20 departmental plan last year, one of its stated priorities was pandemic preparedness “to strengthen its ability to prepare for, and respond to, public health events and emergencies.”
The goal was to have the national emergency stockpile better aligned with “current needs and the operating environment,” and to improve how the agency “collects, analyzes and uses public-health intelligence to facilitate early detection, identification, and monitoring of emerging global health events.”
That meant ensuring that if a pandemic occurred, Canada would be better prepared.
According to federal documents, the department set itself a goal for when it wanted to reach that target. The goal, which was never realized, would have been this month.
With a report from Robert Fife
The tally so far
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