All Ontarians Should Hope New Health Minister Sylvia Jones Succeeds

New Ontario Health Minister Sylvia Jones

Sylvia Jones is now Ontario’s Minister of Health, the largest, most volatile ministry in government. The Ontario Medical Association’s (OMA) correctly tweeted about this:

My first thought when I saw this was a somewhat flippant “should have sent her condolences instead.” Minister Jones has a whole lot of headaches going forward. To succeed, she pretty well needs to be perfect. A cursory glance at the issues she faces is mind boggling.

Should she support further lifting of Covid-19 restrictions? This will make some doctors mad. Should she instead support re-introducing mask mandates and tightening of Covid-19 policies? This will make other doctors angry. Worse, both sides have credible experts, so the whole “listen to the experts”can’t apply when the experts themselves are saying different things.

There is a Health Human Resources crisis unfolding in Ontario (and Canada). Hospital ERs are being closed due to staffing crises and there does not seem to be a quick solution. As more health care workers plan on retiring or leaving the profession early, finding replacements is going to be exceptionally challenging.

The Long Term Care (LTC) situation is equally dire. Wait times for LTC beds in Ontario are skyrocketing. In 2017 I wrote about how we needed 26,000 hospital beds right away, and another 50,000 by 2023. More beds are being built by the Ford government, which is great, but they will take time to arrive.

A quick solution to ease the burden would be to allow older homes who had ward beds in their facilities, open them up again. Rules were changed under covid to no longer allow 4 residents per room. However, if you do that, people will scream you are committing gerontocide. (This is despite the fact that just about all residents in nursing homes have got four covid shots now).

Need more? (As if that wasn’t enough). Over 20 million medical procedures were delayed due to the pandemic. Many of these procedures are early detection screening tests for cancer (sooner you catch, the sooner you cure and, cold-heartedly, the less cost to the health care system).

How about wait times? Wait times for medically necessary procedures continues to rise. MOH bureaucrats like to refer to these as “elective” procedures. But the reality is that if you are suffering from knee pain every day, and have to wait a year to get a knee replacement, it’s not elective, it’s necessary.

All of which makes me realize just how courageous Minister Jones is to take on the Health Portfolio. Allah/God/Yahweh/(insert deity of your choice) knows I wouldn’t want the job. But if I may, I would suggest the Minister should focus on a few things in the first year, as even improvements in a couple of areas will have benefits across the health system.

A word of caution first. She should take what bureaucrats tell her with a grain of salt. There were a few times when I was on the OMA Board when it became obvious that the MOH Bureaucrats had NOT fully informed then Health Minister Christine Elliot about some issues around physicians that caused needless kerfuffles. The bureaucracy has a certain way of thinking that is rigid, ideological and focussed on self perpetuation as opposed to making meaningful change.

I don’t always agree with columnist Brian Lilley of PostMedia, but he hit the nail on the head when he wrote:

“…Ford and his team shouldn’t rely on the Ministry of Health for solutions. These are the people who got us into this mess and who have been failing upward for years..”

and

“..Ford has a real opportunity to change health-care delivery, to speed up access to services, to do away with wait lists and all without changing the single-payer system that Canadians rely on..”

The last comment lines up nicely with the first part of the OMA’s Prescription for Ontario, where they recommend developing outpatient surgical clinics to move simple operations out of hospitals and free up beds. The bureaucracy will oppose it because they are incapable of new ways of thinking and are beholden to hospitals. But at least the Minister will have the support of Ontario’s doctors to work through some of the blowback (there’s always blowback to anything new).

The other easy win is to develop a digitally connected team of health care providers for each patient (also an OMA recommendation). We have something similar in the Georgian Bay Region for the past 12 years and I cannot stress how much it has improved patient care. If I have a patient in need of increased home care, all I have to do is message the home care co-ordinator directly from their chart and ask for help, and they usually respond within 24 hours among other benefits.

This also ties in with a project I was pushing hard for during my term on the OMA Board that got sidetracked mostly by the pandemic but also with some political issues around OntarioMD. I remain convinced that had that project gone forward there would be people alive today that aren’t because of the improved communication it would have provided. But at least preliminary work on it has been done, and with a nudge from the Health Minister this could potentially be restarted to give patients a digitally connected health care team.

NB- this is another area where the Digital Health Team at the Ministry of Health is going in the wrong direction. Their plans are (in my opinion) needlessly complex and won’t result in the kind of robust digital health infrastructure that is absolutely essential to a high performing health care system.

In short, Minister Jones has a monumental task ahead of her. Someone will will criticize her no matter what choices she makes (it’s no secret that health care is referred to as the third rail of politics). If however, she can set, say, three attainable goals in her first year (my suggestions would be open LTC beds, start building outpatient surgery clinics and get the digital infrastructure done), while keeping the bureaucrats in check, then real progress can be made in improving the health system.

All Ontarians, regardless of political stripe, should hope she succeeds. Our crumbling health system depends on it.

Covid is Not Over – and It Won’t EVER Be

As provinces across Canada begin to lift restrictions from the Covid pandemic, there is a plethora of opinions raging about this. Some physicians feel the restrictions are being lifted too slowly. Others feel that it is just right. In Ontario at least, the most outspoken group are the physicians who demand ongoing restrictions. They have taken to using #Covidisnotover on Twitter.

Obviously, when dealing with a once in a century pandemic that has truly decimated patients and health care workers alike, there are still going to be unknowns going forward. But personally speaking, I think we have to realize a couple of things. First, Covid is not over. Second, and most importantly, it never will be.

Is the flu over? Is HIV over? Heck, are measles and RSV over? The answer to all of those is no. The viruses are still around, they are still infecting people and are mutating all the time (that’s why we need an annual flu shot).

There are always a certain amount of these viruses in the ecosystem. Why would Covid be any different? We are not going to completely eradicate Covid.

Given this – the question becomes, what do we do as a society?

One option, and certainly one that is promoted by the #covidisnotover types, is to continue ongoing restrictions, for much longer. Be it mask mandates, enforced vaccine passports, or continued limits on indoor capacity, the message from them seems to be to keep imposing restrictions for……well, I couldn’t really find consensus on an end date.

The most common argument for continuing restrictions (in Ontario anyway) is the continued positive case load. There are more positive cases than ever before, so why should we stop restrictions now?

Well, the short version is that while it is absolutely true that our case load is higher now than in, say October of 2020, many other factors have changed. In October of 2020, there were no vaccines. There were no oral medications that could help treat those who were infected. Guidance on the fact that Covid is airborne was still (shockingly) lacking.

In comparison, in March of 2022 over 90% of the adult population of Ontario has two covid vaccines, and are well on the way to their third. Evidence is clear that the vaccines are remarkably effective at preventing serious complications of Covid. There is now a strong emphasis on good ventilation as a way to reduce the Covid burden. The government is providing funding for Hepa filters in schools and child care settings. A protocol for rolling out the new oral medications exists, and, like all things, supply of the medications will increase with time.

So to compare just case numbers from October 2020 to March 2022, quite frankly is just comparing apples to oranges. We need to take all these other factors into account.

The other common argument is essentially “Look at Denmark!“. Pro restriction types point to the fact that Denmark lifted all Covid restrictions on February 1st, 2022, and now seems to have an exploding number of cases and mortality. Graphs like the one below are designed to shock people into thinking there is a catastrophe in Denmark:

But the graph doesn’t tell the whole story, and in fact a much more nuanced approach requiring a deep dive into the data is needed. I was going to try but I can’t do a better job of it than Michael Petersen did in his twitter thread:

The short version is that because so many people have Covid now, we need to do a better job of determining who died because of a covid infection (usually a covid pneumonia) vs who died of other causes, but incidentally happened to have Covid at the same time. A better graph showing the Denmark situation (taken from Petersen’s thread) taking this into account is here:

Before people start jumping all over this, let me also point out that I am acutely aware that there is a significant spike in deaths in Denmark recently, even if not specifically caused by Covid. We clearly need to do a deeper dive into why there were excess deaths. But part of that deeper dive must include whether deaths were caused by the restrictions themselves (delayed care, depression and mental health issues leading to people just giving up etc). In essence, is the cure (restrictions) causing more harm than the disease (Covid)?

Look, lockdowns and restrictions were initially necessary. There is good evidence that they helped to blunt the course of Covid. But there is also evidence that they have harmed society as well. The economic impacts with record government deficits that will tax our great grand children are well known. However, there are also other health care impacts.

In Ontario, we have a back log of 20 million health care services, leaving many patients feeling forgotten. There are consequences to delayed care and I have seen that in my own practice, and expect to see much more in the coming year. Yes, those consequences sadly will include deaths.

All of this is before we even consider the collateral damage done to mental health especially in our pediatric population. As Dr. Jetelina points out in her excellent sub stack, there has been a world wide increase in paediatric mental health issues. A 24-31% rise in children presenting with mental health issues and a shocking 69-133% (depending on age group) increase in children presenting with suicidal thoughts to Emergency Departments.

What does all this mean?

My personal feeling is that while we cannot ignore Covid (it’s a bad disease) and we need to continue to encourage vaccinations (they work), we need to start looking at the health care system as a whole. Should we mask in high risk areas? Sure. But should we continue to isolate people socially and restrict interactions in a lower risk population, when that clearly causes other harms? I would argue no.

We have been making decisions for a long time based on Covid numbers alone. There are other illnesses and disease that are out there, many of which have been worsened by the restrictions Covid has forced on us. We need to start basing our health care decisions on what’s best for overall population health, not just Covid.

Governments Should Listen to the Experts and Ease Covid Restrictions

It’s time.

For the past two years, the majority of Canadians have done their part to help combat the greatest health care crisis in a generation. We’ve dutifully worn masks, social distanced, gotten vaccinated and done our part to help protect others.

When the pandemic began (has it been two years already?), very little was known about Covid19 and still less was known about how to treat it. Public Health leaders did their best to provide guidance in an ever changing environment. They got some stuff wrong (remember how we were all initially told not to wear masks ?). But they got more stuff right (the lockdowns did help slow the spread of Covid19).

We all paid a terrible price to fight Covid. Job losses. Economic uncertainty. Decreased social interaction. Mental health impacts on ourselves and most troublingly our children. Delayed medical procedures. The list could go on forever.

Through it all however, was the hope that at some point the pandemic would either end, or change to a more manageable form and we could start to live more normal, if not completely normal lives. I submit that time has come.

In Ontario, we have almost 90% of residents over age 12 who have had two covid vaccines. This would be the number we were told was necessary to achieve herd immunity. I understand that most people need three shots. But the reality is that with Covid being a seasonal virus that seems to mutate regularly, we may need annual booster shots. Surely we won’t keep restrictions forever because we will likely need vaccines forever.

Additionally, we now have new promising medications to treat covid infections. An oral medication that is 90% effective in reducing hospitalizations has been approved by Health Canada, and early distribution to those at highest risk has already begun. I appreciate we need to ramp up production of the medication, and have more of it in stock, but at least we have viable treatment options.

It’s not just this old country doctor saying we need to ease restrictions more. Last week, Ontario’s Chief Medical officer of health himself stated that we needed to re-assess the proof of vaccination process. Canada’s Chief Public Health Officer, Dr. Theresa Tam admitted that we needed to get back to some normalcy. Despite the fact that British Columbia had some of the highest Covid related death tolls with the Omicron wave, even their provincial Health Officer, the excellent Dr. Bonnie Henry, signalled that restrictions would be easing.

I would note that throughout the pandemic, there have been calls for all of us to “listen to the experts” and follow their guidance. Well, they are all signalling that it’s time to change the approach and that it’s time to start lifting restrictions.

To be clear, the restrictions should not be lifted all at once. There should be a stepwise approach to lifting them, but that stepwise approach should be relatively rapid now.

The first thing to go should be the Vaccine Passports/Mandates. Before I go further let me be abundantly clear – I strongly urge everyone to get vaccinated (unless you are one of the one in 100,000 people who has a legitimate medical reason not to). The covid vaccines were incredibly effective against the alpha to delta variants of Covid. They are “just” really good against Omicron. However, with even Dr. Moore admitting that the vaccines will not stop transmission of the Omicron variant (but will drastically reduce your risk of getting critically ill from it) the passports/mandates make no sense anymore.

As an aside, my loyal readers (both of them) will remember that I wrote on July 30, 2021 that vaccine mandates were a bad idea and would “embolden hesitancy and create more fear and mistrust.” Look what’s happened. We now have our nation’s capital essentially under siege from a convoy of people who have been further emboldened by these coercive measures. Think there is enough trust there to come to an amicable solution? Particularly in light of Dr. Moore’s comments that transmissibility will not change if vaccinated?

This is in no way meant to support whatever the Ottawa convoy/protest/blockade is calling itself right now. They have frankly lost the moral high ground by not calling out the fringe few among them who are anti-semites, racists and just plain loons. They need to leave Ottawa and go home.

None of that, however, changes the fact that since you can get Omicron from a vaccinated person as well as from an unvaccinated person – there is no point to a vaccine passport. Get rid of it now.

Once that’s done, the next step should be to ensure our health care system goes back to full regular work and then some. We are already severely backlogged, and there is a whole lot of overtime needed to catch up on the delayed medical procedures.

Next (and in short order) capacity needs to be increased at restaurants/arenas/other indoor gatherings. We need to allow many of the businesses who have suffered terribly to start getting back on their feet.

The last step should be to remove mask mandates. Covid is airborne, and as such, masks provide a significant amount of protection. It will likely be a bit longer yet before we can say that Covid 19 is endemic (always circulating in the community at a stable level without fluctuating) as opposed to pandemic (essentially prevalent at a higher level with significant impacts on the health care system). So mask rules should be the last to go.

But make no mistake, the harms of all the other restrictive measures, whether on significantly delayed health care procedures, or enormous effects on government budgets and the economy now clearly outweigh the effects of continued restrictions.

It’s time to start lifting.

For those of you interested in such things I briefly spoke about Covid19 on CTV News and the link is below where I did mention vaccine passports had to go.

Vaccine Certificates/Mandatory Immunizations are a Bad Idea

First things first, if you’ve read the title of this blog, and are hoping to find ammunition to promote a vaccine hesitant agenda, you won’t find it here. Go watch Fox News or Newsmax or any other QAnon affiliated vaccine disinformation service.

The COVID vaccines are safe and they are incredibly effective. Something like 99.5% of all patients in hospital ICUs with COVID are people who have not been fully immunized. Many of them beg to get immunized after getting sick, but by then it’s too late.

Frankly, I think an argument could be made that the mRNA COVID vaccines are the most effective vaccines science has ever developed. If you remember nothing else from this blog – remember this – I encourage you to all voluntarily get vaccinated for COVID, especially now that we seem to have adequate supplies.

Making vaccines mandatory/vaccine certificates however, introduce a whole new set of concerns that I don’t think have been well thought out.

The rationale for introducing Vaccine Passports/Certificates appears to be to protect society. By requiring documentation that you have been vaccinated prior to allowing you to go to a restaurant/travel in Canada/attend sporting events etc, the thinking is that you will prevent the spread of COVID.

The argument for making COVID vaccinations mandatory for health care workers is that patients should feel safe when accessing health care, and be assured they won’t get COVID19 from someone who is treating them. The point has also been made that health care workers are often required to show proof of immunity to things like Hepatitis B and Tuberculosis. So why not add COVID to the list? (Interestingly, those who espouse this view conveniently forget that health care workers are not required to immunize yearly for the flu, and the flu kills far more people every year than either TB or Hep B).

But.

One thing this pandemic has taught us, is that there is a small group of people out there who are extremely mistrustful of authority. They won’t trust doctors/public health officials/nurses etc. They prefer to do their own “research”. Their “research” is frankly guided by confirmation bias (looking only at information that supports your agenda, as opposed to looking at all the facts, whether supportive or not). These people then (sadly very successfully) use social media to spread their half truths (and in the case of noted health experts Donald Trump and Tucker Carlson – outright lies).

The damage caused by these people is in calculable. COVID appears to be resurgent in the United States and is being (rightfully) called a pandemic of the unvaccinated. Third world countries are struggling with another wave, and are desperately trying to keep their health systems afloat, while they get the needed vaccines. International travel remains in limbo, and the economic damage caused worsens by the day.

So why then are vaccine certificates or mandatory vaccinations for health care workers a bad idea?

Because no matter what I or other health officials think of the idea, the simple reality is that the vaccine hesitant crowd will spin this as co-ercion.

Celebrated Infectious Disease Specialist Marjorie Taylor Greene discusses the pros of Covid Vaccination (sarcasm fully intended by writer)

And that, in a nutshell, is why I oppose the idea of vaccine certificates, and mandatory vaccinations. We have the weight of evidence on our side that vaccines work. We have been able to debunk many of the stories about the COVID vaccines (remember when the Pfizer vaccine was going to cause an outbreak of Bell’s Palsy and we were all going to walk around with half droopy faces?). With each passing day seeing only unvaccinated people being admitted to hospital with severe COVID we keep building our case. We should be pro-actively promoting all of this in order to let the vaccine hesitant know that their concerns are unfounded.

One thing that has been badly done during this pandemic is the dissemination of information. In any crisis, the first thing to do, should be to have clear, consistent, factually accurate communication. This has been sorely lacking in the past 16 months with health authorities disagreeing with each other.

Yet now, we are again running the risk of doing the same thing. On the one hand, we’ve got experts (quite correctly) proclaiming the vaccines are the best way to prevent COVID.

And now health authorities are turning around and essentially saying ” yah, but we’re going to make you have a special passport to go anywhere so you are protected.”

What exactly do you think those that are already suspicious of authority are going to think? They are simply going to double down on their belief that we have to be “forced” into getting a vaccine, because it’s really not as good as we say it is. We’re going to lose any chance of trying to build bridges with the vaccine hesitant crowd, and win them over with the force of reason and facts (which is overwhelmingly on the side of those who believe in vaccinations).

The whole point of taking the incredibly effective COVID vaccines, is so you can go places and NOT WORRY if the other person is unvaccinated. Even if you are exposed to COVID, it will be the unfortunate misguided unvaccinated individual who will get sick, not you.

Building trust with the vaccine hesitant crowd is hard. It takes time, effort, repetition of facts and a calm approach. But if we go down the road of creating the impression of co-ercion, we’re going to embolden hesitancy and create more fear and mistrust. Vaccine hesitancy will only rise as a result and mistrust of health authorities will increase. Who knows what the long term implications of that are? I worry those implications will last beyond the pandemic, and will cause ongoing problems for health care in the future.

We have facts/reason/data to support the COVID vaccines. Let’s keep promoting that, and not give those who mistrust health authorities, more ammunition.

Let’s Discuss the Astra Zeneca Covid Vaccine

The following blog is written by Dr. Anne-Marie Zajdlik, MD, CCFP. She is the founder of ARCH Clinic Guelph and Waterloo, Founding Director of Bracelet of Hope and Founder of the Hope Health Centre

Let’s discuss the AstraZeneca vaccine.  I am just going to give you some facts.  You can make your own decision about the AstraZeneca vaccine.

On March 29th,  Canada’s National Advisory Committee on Immunization (NACI) recommended provinces pause on the use of the AstraZeneca-Oxford COVID-19 vaccine on those under the age of 55 because of safety concerns. NACI’s priority is vaccine safety.   Their decision came after the European Medicines Agency ( EMA), Europe’s Health Canada equivalent, investigated 25 cases of very rare blood clots out of about 20 million AstraZeneca vaccines given.  On March 18th the EMA concluded that the benefits of the AstraZeneca vaccine far outweigh this risk if there is a true increased risk of the blood clots.

Most of these rare blood clots occurred in women under the age of 55 ( 18 out of 25).  Thus, NACI’s recommendation to halt the use of the AZ vaccine in this age group pending further review of the ongoing real-time research.

So, 25 cases out of 20 million vaccinations is a risk of about 1 in a million.  That means that if there actually is an increased risk, the risk is 1 case of the rare blood clots out of 1 million vaccines given. One in a million.

Let’s shed some light on that: The risk of blood clots developing among new users of oral contraceptive pills ( birth control pills) is 8 out of 10,000. Thirty four out of 10,000 women who use  hormone replacement therapy ( HRT ) will develop a blood clot at some point.  And, the risk of developing a blood clot in women in general  is is 16/100,000. 

The Canadian maternal mortality rate ( the rate of death in women during childbirth) is 8.3 deaths per 100,000.

No medical intervention is without risks.  The question is, should we take that risk?  That is what NACI will try to figure out in the coming weeks. Let’s balance that risk of 1 in a million with the risk of COVID-19. 

A new briefing note from a panel of science experts advising the Ontario government on COVID-19 shows a province at a tipping point. Variants that are more deadly are circulating widely, new daily infections have reached the same number at the height of the second wave, and the number of people hospitalized is now more than 20 per cent higher than at the start of the last province-wide lockdown.

These variants are more dangerous and more easily transmitted.  They cause 2.5 to 4.1 deaths per 1000 detected cases.  That’s deaths.  The risk of serious complications with the variants is double the risk of the original COVID-19 virus:  20 out of 100.

Here’s a quote that scared me.  “Right now in Ontario, the pandemic is completely out of control,” Dr. Peter Juni, the scientific director and a professor of medicine and epidemiology with the University of Toronto and member of Ontario’s COVID-19 science advisory table.

The AstraZeneca vaccine is over 70% effective up front and almost 100% effective at preventing deaths and hospitalizations from COVID-19. Breathe.  It is not time to throw out the baby with the bath water.  No blood clots have occurred in people over 60.  We should continue using the AstraZeneca vaccine in this age group which is most at risk of serious complications and death from COVID-19.

Open Letter to the Emergency Operations Centre

I wrote this email on March 23, 2021 to the Emergency Operations Centre of the Ministry of Health in regards to Directive #3 which places significant restrictions on the residents of Long Term Care homes during the pandemic. The email has gone unanswered and so I making it public today.

Hi there,

I’m currently the medical director for Bay Haven Long Term Care in Collingwood Ontario.  I had sent the email below asking for some easing of restrictions for our LTC as we now have all but two residents (new admits) who were fully immunized for COVID-19.  Our medical officer of health, Dr. Colin Lee expressed that while he was sympathetic, he could not overturn Directive #3, and asked that forward you with my original email.  I would ask that you please consider the overall well being of the residents in LTC centres like mine, where we have almost full immunization.


Begin original letter:


Hi Xxxx, 

I understand you are the contact person at Public Health for Bay Haven.  I’m hoping that you can help me advocate for the residents of the nursing home.  As you are aware, most nursing home residents throughout the province are suffering from “confinement syndrome”.  The year long isolation caused by the COVID pandemic has had a devastating effect on their emotional health and the residents are really struggling as a result.  

As the Medical Director, I see these issues when I visit, and it pains me to see how much the mood of the residents has gone down in the past year.  Don’t get me wrong, I do understand the rational behind some of the restrictions that have been put in place, and I have supported those restrictions.  They were important to protect the health and safety of Bay Haven, and we have been fortunate to not have a COVID outbreak in our facility. 

But we also now are in a situation where all but two of the residents (new admits) are immunized for COVID and a good number of staff are immunized as well.  With that, I need to focus on the other aspects of care for the residents.  

The blunt reality however, is that Bay Haven will not go against Public Health directives, no matter what I personally think of them.  So I need your (or somebody in public health’s) support to change some of the directives. 

I want to point out that the most recent data shows that the COVID vaccines DO, in fact, reduce transmission (https://www.nbcnews.com/health/health-news/pfizer-covid-vaccine-cuts-transmission-coronavirus-new-real-world-study-n1260542).  This is unsurprising as every other successful vaccine also reduces transmission, but we now have proof of this.  In fact, transmission of COVID is reduced after just ONE dose of the vaccine (https://www.huffpost.com/entry/pfizer-covid-19-vaccine-reduces-transmission-after-1-dose-study-finds_n_6038e92ec5b6b745c4b655ba). 

With that, I would like to implement the following changes (and need Public Health to support): 

1) We continue to have less than 100% of our staff immunized.  To encourage more of them to be immunized, I would like to stop screening with np swabs, those that have been immunized (two weeks after their second shot).  Nobody likes getting an NP swab.  If the un-immunized staff see that they will not be subjected to this test, it might encourage them to get their own shots.  And we get to save our swabs for those who really need it.  (Addendum – Since this letter is public, what I was not aware of when I wrote the original is that Bay Haven actually has one of the highest percentages of nursing home staff who’ve been immunized in the province – almost 80%! Having said that, nothing wrong with going for the other 20%)

2) All the residents who have been immunized need to be allowed to go back to congregating as usual.  This includes all their group activities and sessions. 

3) We should allow an increased number of visitors to the facility.  I would agree the visitors should have proof of either immunization, a recent negative COVID swab, or be willing to have a rapid swab done in our facility.  I think each resident can assign 4 people who can come and visit, and we can work on putting a limit on the number of visitors at any one time.  

4) If a resident has been immunized, they should be able to leave the facility for social gatherings, not just medical appointments.  Whoever drives them would need to have proof of immunization, a recent swab or have an NP swab in our facility since they presumably enter the building.  But the immunized resident cannot (as per the articles above) bring back and transmit the infection themselves. 

If Public Health could support this, it would go a long way to improving the mental health of the residents and improve their quality of life.  It’s the least we can do after all they have done for society over their years.   

Sohail Gandhi, MD, CCFP

Medical Director, Bay Haven Seniors

The REAL Reason NACI Recommends 16 Weeks Between COVID Vaccine Shots

Recently, the National Advisory Council on Immunizations, or NACI, announced that it was reasonable to wait up to sixteen weeks between your Covid-19 vaccination shots. This applies to the three, Health Canada approved, two shot vaccines (Pfizer/BioNtech, Moderna, and AstraZeneca). Canada is the only country in the world to stretch out the interval between shots to four months. The manufacturers of the vaccines continue to suggest three weeks between shots.

This decision was not without controversy. No less than Canada’s chief scientist, Dr. Mona Nemer, called this a “population level experiment.” Multiple other physicians have tweeted concerns about this. Pfizer/BioNtech won’t sign off on this, and I’m not aware of Moderna or AstraZeneca agreeing to this extended interval either.

But NACI is made up of some really smart people as well. They’ve been providing independent and unbiased advice on all vaccines to the Federal government since 1964. No doubt NACI looked at data from countries around the world, and found that in countries like the UK and Israel, the incidence of COVID19 fell dramatically in the general population after just one dose. This was particularly of note in the UK because they had delayed their second shot (to 12 weeks) despite being called reckless by other countries.

So, we have one group of extremely bright and knowledgeable people saying delaying the second shot up to 16 weeks is ok. Another group of extremely bright and knowledgeable people is saying that this is a problem.

Look, I’m just an old country doctor, not a virologist or immunologist or population health specialist or so on. There is no way I could get into an educated discussion about whether going to 16 weeks between shots will be safe and effective or not because my brain is just not big enough to understand all the minutiae around rising and falling antibody levels.

But I’ve been around long enough to have read multiple statements and press releases from bodies like this, and I’ve learned to read between the lines. Here’s what’s really going on, that nobody (including the press) is talking about.

It’s the fourth bullet point in the summary section of NACI’s recommendation:

  • NACI recommends that in the context of limited COVID-19 vaccine supply, jurisdictions should maximize the number of individuals benefiting from the first dose of vaccine by extending the interval for the second dose of vaccine up to four months

“The context of limited COVID-19 vaccine supply.” See the reason that NACI felt obliged to have Canada be the only country in the world that extends the interval to 16 weeks, is because Justin Trudeau and the Liberal government have botched the procurement of COVID-19 vaccines. If we had more COVID-19 vaccines, NACI would never have been put in a position of having to explore a population level experiment.

Trudeau has been saying for weeks now that more vaccines are coming. Heck back on Feb 19 he promised a “big lift” of vaccines. But despite all the hyperbole, the simple fact remains that as I write this blog, Canada is 62nd in the world when it comes to delivering COVID-19 vaccines to our population. We’re behind such illustrious world powers like Dominica, Serbia, Estonia and Aguilla to name a few. For a G-7 country, that’s just embarrassing.

Table courtesy of Our World in Data. Shows Canada has immunized only 8 people per 100 as of March 14, 2021)

This source for all the above information is Our World in Data and you can link to the relevant page here. It is updated daily so my comments are based on what I saw as of March 14, 2021.

Is it any wonder that there’s actually a #TrudeauVaccineFailure on Twitter?

Look, I, like you, am acutely aware that the Trudeau government has signed lots of deals with vaccine manufactures to get Canadians the vaccine. But it’s also extremely telling that Trudeau has refused to release the vaccine contracts. These contracts undoubtedly have a delivery schedule in them, so the fact Trudeau won’t let us see them really incriminates his government. It does nothing to dispel the concerns around the competence of how his government handled the vaccine procurement process.

Th main role of a national government is to protect the welfare of its citizens. If Canada had been in the top ten in vaccines procured per capita (surely not unreasonable for a G-7 country), NACI would not have needed to explore a 16 week vaccination interval. And we likely wouldn’t be looking at a third wave in Ontario.

By not procuring COVID-19 vaccines in a more timely manner, the Trudeau Liberals have failed the people of Canada.

Which COVID Vaccine Should You Get?

Me getting the first dose of my Covid-19 Vaccine.

Canada now has 4 different vaccines to help us fight COVID-19, BioNtech/Pfizer, Moderna, AstraZeneca and Johnson and Johnson. While that’s a (very) good thing, this has led to some inevitable questions about which vaccine is “better” and whether people should wait for one or the other. An email from a friend who questioned the AstraZeneca vaccine inspired me to write this.

First, to re-iterate once again, while is true that all of these vaccines were developed at a rapid pace, the reality is that they all have been thoroughly tested. The shortcuts that were made were made in the bureaucracy, not the human trials. You can read my thoughts on that here, or see my colleague Dr. Greg Rose explain it better here.

There will likely never, ever be a vaccine (of any kind) that is 100 per cent safe (ever), but overall these vaccines are extremely safe for the general population.

The difficult part in sorting out information about the COVID vaccines is two fold. First, there is a whole lot of information that comes out, almost on a daily basis. It’s hard for not just physicians to keep track of it all, but also members of the general public. Second, some of the information that is released is extremely premature, without a full analysis being done. First impressions being lasting impressions, this often times creates an incorrect perception of a vaccine, that is hard to refute later on.

For example, the BioNtech/Pfizer vaccine was initially plagued by concerns that it caused Bell’s palsy (based on a report that 4 people got it after taking the vaccine) and that death was a side effect (based on report in Norway of 33 people over the age of 80 dying after taking the vaccine). It wasn’t until later that a through review showed that the Bell’s palsy issue was actually the same or less than the background rate. Essentially, you would expect about 12 people a year in the vaccine group to get Bell’s palsy anyway, regardless of whether they got the vaccine or not, so the fact that 4 got it didn’t mean it was linked to the vaccine, just that they were going to get it anyway. As for the 33 deaths, turns out that was in keeping with Norways normal death rate for their population of over 80 year olds, so again, not related to the vaccine.

Think of it this way. The most common time to get a heart attack is actually three hours after you wake up. Does this mean eating breakfast causes a heart attack? Of course not. Just because those two things happen close together, doesn’t mean that one caused the other. In statistics this is referred to as “correlation does not imply causation.” Sadly, there is rather a lot of correlation that is brought up about all of these vaccines, and the assumption is made that they are causing problems.

It was initially claimed the Moderna vaccine had more side effects than the BioNtech/Pfizer one. But it was only after studying it more that people realized that these aren’t really side effects, but proof that the vaccine is working. Your second shot of the Moderna vaccine made your immune system mount a response to what it viewed as a foreign body. Thus the muscle aches, fever and headaches that went along with it.

Now most recently there is some sub-optimal information circulating around the AstraZeneca vaccine. First, there was concern that they would not work against certain strains of COVID19, particularly the South African strain. Second is concern about blood clots.

The South African strain issue was particularly overblown. “Only 10% effective” screamed out some headlines. South Africa even stopped using this vaccine as a result. The full story is somewhat different.

Turns out the study that suggested AstraZeneca wouldn’t work against the SouthAfrica variant was very small (2,000 people), and not well done. Further more, what really matters, is preventing deaths, hospitalizations and severe disease and AstraZeneca works for this with the South African strain. Perhaps you may get a mild case of COVID19 (cough, fever, mild muscle aches for a couple of days). But the point of the vaccine is prevention of severe cases and deaths.

Similarly, the blood clot issue again appears to be one of correlation, not causation. The background rate of blood clots in the population would explain the ones found in Europe. Health Canada and Thrombosis Canada is not worried, and you shouldn’t worry either.

So back to the question at hand. Which vaccine should you get? My personal feeling is the J&J one would be the best simply because, logistically it’s much easier. Get one shot and it’s done. The problem with that one is that we have an effete Prime Minister who’s totally botched vaccine procurement for Canadians. There’s a reason #trudeauvaccinefailure is on twitter. Last I checked we are 61st in the world for procurement of vaccines (and for a G-7 country, that’s just embarrassing).

While happily announcing the approval of the J&J vaccine, Trudeau and the Liberals neglected to emphasize the fine print. Namely that the vaccine would likely not start to arrive until the end of April or early May, and that would only be in small amounts. The bulk of this vaccine won’t be in Canada until September.

Of course, right on queue, a few days after boasting about J&J, it was announced there would be production delays. Why the media isn’t talking about the outright incompetence of Trudeau and his government in protecting Canadian lives is beyond me.

Therefore, the best thing you can do is get the first vaccine that you are offered. When you get notified to get your shot, don’t ask which one, just get it. For what matters the most (keeping you out of hospital or dying from COVID19), they all work roughly the same.

I urge you all to do your part, protect yourself, protect others, and let’s get ourselves out of this pandemic, and back to a normal life.

A Great Cause.

As an addendum I would like to encourage all of my readers to consider buying some merchandise from Conquer Covid 19. This all volunteer group did yeoman’s work providing PPE to physicians, health care workers and others in need. Last year they raised $2.4 million and donated around 3 million (!) pieces of PPE.

This year they are selling their extremely boring merchandise (check Ryan Reynolds take on it here) and proceeds will go to LTCfrontline foods, providing hot meals to those workers who are struggling in long term care homes and Call Auntie, an organization that helps Indigenous people navigate issues around COVID19.

Please click here and donate what you can.

HEPA Filters, Focus on Ventilation Can Help Open Economy

This week, much of Ontario moves out of a complete lockdown (I finally get a hair cut!). The move itself has not been without controversy, with some critics saying the government is opening too fast, and others saying they’re opening too slowly.

There is no doubt in my mind that if we can re-open the economy safely, we should. COVID19 has done terrible damage over the past year. Lives lost. Families unable to say goodbye to their loved ones. On going health issues in those who survived COVID19 infections and much, much more. But there is also an increase in the number of people suffering from mental illness, a rise in domestic abuse, and very real economic hardships faced by millions of Canadians.

It has been noted that there were were more deaths than expected in Canada last year, and not all of these “excess deaths” were directly caused by COVID19. We are starting to realize that some of deaths are “indirect”. That’s to say, the social isolation, the lack of emotional, financial and other support, the delayed medical procedures and more, have caused these deaths.

This situation is particularly bad in British Columbia and Alberta, where there were 270 and 360 more deaths than expected between March 15 and April 25 alone, and these were not directly attributed to COVID19.

To be clear, the lockdowns were necessary. And if we open the economy in an un-safe manner, COVID cases will rise again, there will be more death and perhaps even a dreaded third wave. We’ve seen from Sweden what happens when a country doesn’t shut down in the face of COVID. Even their king has admitted Sweden’s approach was a total failure.

It’s just that we cannot ignore the pain and suffering that occurs by a lockdown as well.

That’s why to my mind the focus needs to be on how to re-open safely. We have one of the worst pandemic responses in the world, so we must do better. Is there something we can do, that hasn’t been done in Canada yet?

Turns out, there just might be.

For far too long, Health Canada did not focus on airborne spread of COVID19. They stressed the “droplet” method of transmission, where fluid particles are expelled from your mouth, land on a surface and are then when you touch them, wind up on your fingers, and then into your body when you touch your eyes, nose or mouth. Full disclosure, if you search hard enough, you can find a video of me somewhere on the net saying exactly that, and telling people not to wear masks. It is clearly outdated now, and should be ignored.

Japan, by contrast, focused on airborne spread as far back as February of 2020. Their whole focus was to ensure proper ventilation and using air purifiers with HEPA (High Efficiency Particulate Air) filters in rooms. Everybody was asked to wear a mask early last year. Granted it is culturally more accepted to wear masks in Japan. But the focus was on airborne spread right from the start.

A diagram showing Japan’s process for dealing with COVID19, part of their submission to “Environment International” – September 2020 edition

How well did Japan do? Japan has a population of 125 million people in a country about 3/4 the size of Baffin Island. As I write this, data from their COVID tracking system shows that 417,116 people have been infected (0.33% of the population) and 7,038 have died (.0056% of the population).

These numbers are all the more remarkable considering that Japan did just about everything else wrong. They did not test enough (at least at the beginning), the lockdown measures were half hearted and voluntary, many pachinko parlours (a mix of gambling and alcohol) stayed open, and traffic on their notoriously crowded commuter trains to work was only down 18%.

Health Canada did not even acknowledge airborne spread of COVID19 until November 2020 (9 months after Japan and 4 months after the World Health Organization). Our Covid19 tracker shows terrible results. We have a population of 38 million. Yet as I write this, we have had 826,528 cases (2.17 % of the population or 6.6 x as many as Japan on a pro-rated basis) and 21,309 deaths (.056% of the population or almost exactly 10 x as many deaths as Japan on a pro-rated basis).

It does make one wonder, if we had approached COVID19 as having airborne spread right from the start, could we have saved a number of lives, and limited the lockdowns we endured? And now that the evidence is strong that COVID19 is airborne, should we not have businesses focus on safe ventilation as a condition for opening?

What’s required for optimal ventilation? Well ideally, you should have an HVAC system that exchanges the air in a given room 6 times an hour with an HEPA filter. HEPA filters can remove the vast majority of droplets that the COVID19 virus (and other viruses!) live in. But the reality is that this would be ultra costly and take far too long to replace every HVAC in most commercial buildings. (Should definitely be a requirement for new commercial properties and especially the new nursing homes Ontario is building).


What can other businesses do instead? One of my patients is a manager at a Tim Hortons. They have 14 tables at the Tim’s. What if the restaurant put a portable air purifier with a HEPA filter on each table? There are many brands that cost $80-$100 each for a small size one. But with one on each table (where people would be talking and eating without masks, thus expelling the virus), you could reduce viral spread.

Granted at that price, the air purifiers would only last about six months, but by that time hopefully we will all be vaccinated anyway.

Similarly, we could mandate appropriate air purifiers in other businesses as requirement for opening. To be clear, people should still wear masks, wash hands regularly and physically distance as much as possible. Those are important and necessary precautions for re-opening. But the HEPA filter purifiers would simply provide that extra level of protection. It’s why I asked my nursing home to install them in their facility (and thank you to the owners of Bay Haven for doing that).

Canadians have suffered terribly over the past year. For the sake of our physical and mental health we need to re-open the economy, but do it in away that will not increase COVID19 infections, and not have us yo-yo between lockdowns and re-opening. Focusing on ventilation and HEPA filters can help us do this safely.