Sharmistha Mishra, associate professor of infectious disease epidemiology, Department of Medicine, University of Toronto, Li Ka Shing Knowledge Institute, St. Michael’s Hospital-Unity Health Toronto
Tania Bubela, dean of health sciences, Faculty of Health Sciences, Simon Fraser University
Sharon E. Straus, director of knowledge translation programme, Li Ka Shing Knowledge Institute, St. Michael’s Hospital-Unity Health Toronto
Scientific reviews detail “what” happened and “why”. What worked and what didn’t; how can we repeat successes and avoid, or at least mitigate, failures?
In reviewing the ‘what’ and the ‘why’ of the COVID-19 pandemic response, researchers use rigorous methods to tease apart the policies and intervention strategies that worked, how they worked, and for whom. The approach is analogous to understanding a medication. What’s the right dose and formulation? What populations does it work in? What are the potential side effects? When should it be replaced by a new, better medication?
We need to ask the same questions about how the epidemic was managed and how we did or did not use evidence in making decisions. What type of evidence informed decisions about policies, programs, and the allocation of resources? Why did it take so long to do research to collect evidence on health inequities and the social determinants of health? We know that the burden of the pandemic was not equally felt across communities. Why, then, was that evidence not used to provide science advice and inform policies, and services?
We argue that part of the problem was the types of research and insights that were privileged over others, and the voices that were excluded from advisory or decision-making tables. Saying that equity was at the core of an advisory group, report, or recommendations did not make it so. In reality, the tables and the evidence considered mirrored existing structural inequities in science, scholarship and decision-making. Questioning why means looking deeper than a word search for “equity” or “diversity”.
Asking the hard questions about the COVID-19 response will require us to reflect on our own and systemic biases. Such tough reflection will require an inquiry that is independent, without conflicts of interest, courageous, and exercised with humility. We don’t know all the answers, and some of the answers will make us uncomfortable. This is the spirit of discovery, innovation, and science. Not asking the questions guarantees failure and maintenance of the status quo.
The Hon. Monique Bégin said Canada was a nation of perpetual pilot projects. And to this, we might add a nation of inquiries, reviews and reports. So, why do we need an independent, public inquiry into the COVID-19 response if there is little chance for reforms to be implemented? How can we facilitate its success?
First, make a COVID-19 inquiry transformative by linking recommendations to an action plan with teeth. This means specifying not only the what and the why, but most importantly who is accountable for the action. Federal funding should be linked to evidence-based outcomes for which provinces and territories are accountable.
Second, create an action plan that is bold. Go beyond reshaping and integrating data systems across Canada to make data systems accountable to the communities they serve. Ground the changes in structural reform so these data are used to dismantle longstanding health inequities.
Third, ensure a national inquiry fills critical gaps in recommendations left from previous pandemic inquiries – such as preparing for public health threats shaped by structural and social inequities. Such an approach would merge previous thoughtful reports and recommendations from across sectors with the clear lessons from COVID-19 on health inequities and social justice.
Fourth, create an inquiry process that is inclusive, engaging and working with communities who experienced disproportionate risks - especially older adults and their caregivers, patients with other health conditions, and communities experiencing social and economic marginalisation - including essential workers.
Fifth, an independent, inclusive inquiry, conducted with rigor, transparency, and scientific humility, could help rebuild public trust. It could validate concerns while also challenging perspectives, and prevent information vacuums filled with polarizing biases.
A national inquiry means asking hard questions and deriving nuanced answers for transformative change. It means linking those answers to actionable strategies with clear accountabilities for implementation. Can we see transformative change without an inquiry? Only if we have the hubris to believe we already have all the answers to “why” and aligned solutions.
Conducted with humility, a national inquiry need not devolve into a finger-pointing, blame-game with twenty-twenty hindsight. Instead, with meaningful inclusion of diverse voices, we can hold researchers, public health, and decision-makers accountable to community needs in the face of future threats.