After the tearful testimonies about suffering and mass deaths at specific nursing homes, the coroner’s inquest into the impact of COVID-19 on Quebec’s long-term care sector is entering its final phase by widening its scope to look at how provincial policies played a role in the health crisis.
This shift will crucially involve an examination of contentious government directives that health care workers had to follow during the crisis.
Witnesses will include people who shaped the province’s pandemic response, such as National Director of Public Health Horacio Arruda; his strategic medical counsellor, Richard Massé; Health Department assistant deputy ministers Natalie Rosebush, Lucie Opatrny, Luc Desbiens and Daniel Desharnais; and physicians from Quebec’s national public health institute.
It was a government mantra during the pandemic’s first wave that it relied on guidance from experts, including those from the provincial public-health institute, known by the abbreviation INSPQ.
But evidence heard since March by coroner Géhane Kamel during 11 weeks of testimony about deadly events at seven eldercare facilities underscored that many strategies devised in those early days turned out to be ineffective or wrongheaded.
Masks were initially used parsimoniously. Asymptomatic transmission wasn’t considered right away. And the province protected hospitals at the expense of nursing homes.
The inquest heard that those decisions worsened conditions in nursing homes, allowing the novel coronavirus to spread, sickening staff and making it hard for ailing residents to get hospital care.
Nursing-home employees were initially told they couldn’t wear masks unless they were caring for a resident who showed symptoms.
Pascale Dunlop, a nurse at the Yvon-Brunet care home in Montreal, testified that managers wouldn’t even let workers use their own masks because “everyone would then want to wear masks.”
Eventually, as viral transmission increased, it became mandatory to be masked at all times.
Samir Sinha, director of health policy research at the National Institute on Ageing, said in an interview that the initial response to COVID-19 didn’t follow the precautionary principle of applying maximum precautions then easing off as the disease became better understood.
Instead, fearing they would run out of personal protective equipment, officials did the reverse, rationing masks and starting with limited precautions, then adjusting upward – at a cost of human lives.
“What do you do when what you know the science … is not necessarily coinciding with the edicts that you’re getting from the ministry and the public-health agency? That started creating a lot of moral distress,” Dr. Sinha said.
During their testimony at the inquest, several witnesses shared their frustrations at the initial mask directives.
“I wore a mask at the grocery store before I wore one at the [nursing home],” physician Isabelle Julien said.
“We were all waiting for the order to wear masks at all times,” Yvon-Brunet co-ordinator Nathalie Séguin said. When INSPQ changed the directives, on April 3, “it was a day of deliverance,” she added.
In an interview, a licensed practical nurse at a Montreal long-term care home said staff were trained to work without questioning the chain of command. “I have to go by what they say, whether I agree with it or not.”
The Globe is not identifying the nurse because she isn’t authorized to speak with media.
As her elderly charges “started dropping like flies,” becoming ill and dying, it became clear to her that her orders came from people who weren’t at the scene and didn’t grasp the scale of the crisis. “That’s when I basically made the decision to just do what I thought was right.”
Quebec wasn’t alone in issuing misguided directives to front-line workers.
In Britain, a parliamentary report released earlier this month concluded that the National Health Service made the health crisis worse by discharging hospital patients into understaffed, unprepared nursing homes.
“We have a regulator that is not really connected to the reality of lots of care homes,” Martin Green, head of an organization representing care providers, told British parliamentarians. “Instead of issuing guidance for the perfect world, they should recognize that you need guidance for the world we are living in.”
In the pandemic’s early days, Quebec also discharged patients to care homes to free up hospital beds. Officials kept personal protective equipment under lock and key. Dr. Arruda spoke against widespread use of masks, saying it fostered a false sense of security.
The government should have been more candid about the lack of available protective equipment, said Joanne Liu, a former president of Doctors Without Borders who helped manage Ebola disease outbreaks in West Africa.
“In a context of scarcity, my approach … is to be transparent about the difficulties and the shortcomings instead of adapting public-health measures to the circumstances of scarcity,” Dr. Liu said in an interview.
“You have to just say it simply and truthfully – what you know, what you don’t know, and what you would like to know. This is not what many governments here and elsewhere have done.”
Instead, local managers followed the province’s directives to the letter, even yanking masks from staffers’ faces, said Alain Croteau, president of a union local of health care workers in Montreal.
The inquest heard there was one exception that spring during the first wave – the Montreal Chinese Hospital, a long-term care facility where employees took the initiative to use masks at all times, weeks before it became mandatory. None of its residents died of COVID-19. The facility’s co-ordinator, Sandra Lavoie, will be among the witnesses at the final stretch of the inquest.
It was hard for rank-and-file employees to push back because much of that work force is made up of women and part-timers, many of whom are racialized, Dr. Sinha said. “There’s always a huge power imbalance.”
In those circumstances, doctors and professional associations – those with job security and a level of independence – had an obligation to speak up, he said.
Mr. Croteau said workers who didn’t conform to the mask restrictions faced disciplinary measures for insubordination. At several nursing homes, employees filed complaints with the province’s workplace occupational safety board, seeking to be issued N95 respirators, which offer more protection than ordinary masks.
Their complaints were heard together before a labour tribunal which ruled last July in favour of the workers, saying that their employers shouldn’t have limited the use of N95s.
Administrative judge Philippe Bouvier said the INSPQ was wrong to argue that the coronavirus is transmitted via larger exhaled droplets rather than the finer aerosol mist that requires using N95s.
INSPQ’s stand went against the precautionary principle to apply more caution until better scientific evidence could be gathered, he wrote in his decision.
A failure to follow the precautionary principle had also been a factor in previous public-health disasters.
In his investigation into the 1980s tainted-blood scandal, Justice Horace Krever found that the Canadian Red Cross hadn’t properly screened blood donations because it waited for definitive proof that there was a risk of AIDS and hepatitis C. “Action to reduce risk should not await scientific certainty,” he wrote.
His report was cited by Justice Archie Campbell, who investigated Ontario’s handling of the 2003 outbreak of SARS (severe acute respiratory syndrome).
Justice Campbell found that hospitals hadn’t taken enough safeguards initially, then scaled back precautions too early. “It is better to err on the side of caution, especially when dealing with a little-understood new disease,” he said.
In preparing for the onset of COVID-19, Quebec officials did look back at a previous crisis – the 2009 pandemic of H1N1 influenza, which led to a surge in hospital admissions.
Both Dr. Arruda and Danielle McCann, the health minister in March, 2020, cited H1N1 when they explained the decision to off-load patients and liberate hospital beds.
Appearing at the inquest this week, Brigitte Auger, a former administrator for one of Montreal’s local health authorities, testified that its contingency plan for COVID-19 was based on the H1N1 flu experience.
Ms. Kamel remarked that the health authority hadn’t anticipated COVID-19 would be more deadly than the flu. “It was much more virulent. So the H1N1 plan wasn’t able to cope with what was happening,” the coroner noted.
“We went with what we knew,” Ms. Auger replied. “We had plans, but COVID was another beast.”
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