Time for the OMA Board to Invoke Arbitration in Stalled Negotiations

While most front line physicians continue to deal with the ongoing Covid-19 pandemic, and the resultant backlog of care, the OMA has continued to perform it’s most important function, that of trying to negotiate a Physician Services Agreement (PSA). A quick summary of what has already been disclosed:

  • The Binding Arbitration Framework (BAF) between the Ontario Government allows for negotiating a Physician Services Agreement (PSA) every four years. The last one was for 2017-2021 . We should already have had an agreement for 2021-2025 but the Covid Pandemic got in the way and delayed negotiations.
  • Negotiations for a PSA are supposed to start the year before expiry of a PSA. There is a framework that allows for a minimum of 60 days for negotiations following which either side can call for mediation. After a minimum of 60 days of mediation, either side (or the mediator) can call for Arbitration.
  • IF Arbitration does occur, the Arbitrator must hand down a ruling within 60 days of the conclusion of the arguments presented at Arbitration. After the ruling is handed down, the work of implementing the Award (or if by some chance an agreement is reached – the PSA) begins, and that in itself can take several months to a year. Those of us who were involved in the last implementation process in any way likely still have nightmares about how complex and fraught with challenges it was – I know I still do.

For the current negotiations, we know the following:

  • Negotiations began in October of 2020. The OMA Board gave the Negotiations Task Force (NTF) a mandate for negotiations. A mandate is essentially a confidential, bare minimum set of asks that the NTF must get from the government before accepting a deal. Considering there is no deal, the NTF clearly has not met that minimum. And no, the members can’t know what that is, it would significantly compromise the negotiations process.
  • Mediation began on April 9, 2021. “A large gap” remained between the OMA’s asks, and the MOH’s offer as of June 2021. As I’m no longer on the OMA Board, I have no idea what the gap is like now. Obviously, if there was no gap, we would have a deal by now.

Why should the OMA Board move to Arbitration now? Why not follow the mediator Mr. Kaplan’s recommendation, and wait till January 25, 2022 to go to Arbitration? Wouldn’t going against his recommendation run the risk of adversely affecting the outcome of a potential award?

Because health care is political in Canada. Being political, the time for governments to attack physicians is always, always, always early in their new mandate. In 1991, the NDP government of Bob Rae imposed a hard cap on the physicians budget (first year in power). In 2015 in the first year of Kathleen Wynne’s government, she also imposed unilteral cuts to physicians and in 2018 the Doug Ford government tried to take away binding arbitration.

The short version of the above is that I’m old, and I’ve been screwed by the government of every political party. It doesn’t matter who wins the provincial election of June 2022, the government that is in power will be sorely tempted to revoke any arbitration award if it seems to meet their short term interests. (Yes I know, the BAF is “evergreen” – meaning the process should continue in perpetuity, but the reality is that governments do stupid things all the time, and if one government has tried to take away a BAF process from physicians to suit their interests, then we can be sure another will as well).

And NO, having Arbitration currently as scheduled for Jan to March 2022 is not good enough. Finishing Arbitration hearings at the end of March gives the Arbitrator until the end of May for a ruling. By that time the election campaign will be in full gear, and Ministry bureaucrats will do absolutely nothing to implement any award as they wait for the outcome of the election.

Obviously, going to Arbitration now entails some risks. The NTF will likely argue that the Arbitrator himself recommended waiting till January, and we should try our best to seem reasonable to him. I have a great deal of respect for the NTF for the job they’ve done for the doctors of Ontario, in particular the negotiation of the BAF. But they are paid a lot of (well deserved) money to let the Arbitrator know of legitimate concerns of the membership.

I’ve met the Arbitrator and I have no doubt he will hand down a fair decision, whether in December or March. But members have every reason based on history to fear politicians of all stripes, and it’s the job of the NTF to let him know that that’s a legitimate concern.

Moving to Arbitration immediately, means the Arbitration hearings end likely by the end of December. An Award is announced (likely) by March. At that point, the government is faced with accepting the award, or revoking it three months before an election, and risking the type of anti-government ads the OMA did so well last time. By the time the election is over, whoever wins, the MOH bureaucrats will be well on the way to implementing the award and any “noise” that the award is too much (there will always be noise) will have gone away.

From the OMA’s Negotiations Page

The OMA’s main responsibility is to negotiate a fair PSA for members. The BAF is the best tool they have for not only keeping the government honest, but for political use to reduce the risk of awards being overturned. (NB- There’s no guarantee of anything, politicians do stupid things all the time. This is simply about risk reduction).

Will the OMA Board stand up for members and direct the NTF to immediately move to Arbitration, as we are now legally allowed to? I guess we’re going to find out.

OMA Fails Family Practice with Virtual Care Agreement

Recently, the Ontario Medical Association (OMA) approved an agreement to extend virtual fee codes for an additional year. There is much to like about the extending fee codes for virtual care. As the pandemic has taught us, there is a role for appropriately provided virtual care. I have used virtual care with my patients for over three years now, and have found it a useful adjunct to in person visits.

In the current environment however, the extension agreement fails family practice. Since family practice is the bedrock of any high functioning health care system, damaging it will have unforeseen negative consequences.

How will this agreement harm family practice? By allowing negation to occur for care that is provided virtually, without implementing some guidelines on the appropriate provision of virtual care.

About 6,000 of Ontario’s family physicians are on a capitation model (basically a salary plus performance bonuses). One of those performance bonuses is for accessibility. The bonus applies if your practice is available to look after your patients. If, for example, a patient can’t see you, and then goes to see a walk in clinic that you don’t work it, the family physician in question will be deducted the value of the visit to the walk in clinic.

The concept of the access bonus is a good one that I support. We’ve got ample evidence that the absolute best health care outcomes occur when patients see their own family doctor as opposed to seeking out itinerant care from physicians who with whom they don’t have an ongoing relationship.

So what’s the problem then? Why should negation of the access bonus apply only to in person visits, and not to virtual care as well? Because the current landscape for virtual care is so open ended, and so rife with potential for overuse/misuse, that it makes it impossible for family doctors to compete on the availability and ease of access front.

There are lots of private, for profit companies that provide a level of virtual care, but for simplicities sake, let’s look at dot health. A glance at its website reveals that, for the low low price of $69.98 per request, you can get your health care information (including labs/diagnostic tests/clinical notes apparently) from providers, and store it securely on the web where you and only you can access it. The website doesn’t go into the two tier nature of the system – those who can afford to pay for multiple requests can then present their data to a new health care provider they meet and presumably get more appropriate care.

More troubling to me personally is the “free” service offered by some guy (I’m assuming he’s a he based on the icon) named “Dr. M” offering to help you “understand” what your records mean to you.


Patients should be able to understand their own private health information/records. But surely it makes much more sense to ask the doctor that you already have a pre-existing relationship with what the records mean. You know, the one who’s followed you all along, and you’ve seen regularly. Asking essentially a stranger on the internet (no matter how well qualified) seems problematic at best.

I have no idea if “Dr. M” bills OHIP for the phone calls he would provide to patients who request this service. I would simply point out that under the existing virtual care codes, if a patient requests this service, it would be legal for him to bill. This would result in the family doctor for the patient being negated.

Also problematic in my opinion, is there seems to be a consolidation of sorts in private for profit virtual care companies. dot health’s website offers seamless integration with Maple.

Another screen shot from dot health’s website, where they offer connectivity to Maple

Maple is a private, for profit virtual health care provider that allows you, for a fee of course, to chat with a doctor/nurse/nurse practitioner and get care through their patented app. Maple was recently bought by Loblaws/Shoppers Drug Mart for $75 million (!).

And no surprise, their focus appears to be on “convenience”. Here’s the example they use from their own website:

Seriously, diagnosing strep throat, without a throat swab (which can only be done in person)?? And then prescribing antibiotics (I wonder which pharmacy gets the prescription). Have these guys never heard of the issue around over-prescribing of antibiotics and the ramifications? Or the fact that the vast majority of sore throats are viral?

The astute amongst you will also recognize that dot health was founded by Ms. Huda Idris. Who also happens to be a Board Director for Ontario MD, the OMA subsidiary that is supposed to be the “Trusted Advisor for EMRs and Provincial Digital Health Tools” for physicians.

To be clear, I have a great deal of respect for Ms. Idrees as a person. Being from the south Asian community and a Muslim myself, I think it’s incredible that we have role models like her out there given some of the patriarchal attitudes that persist in that community. I congratulate her on her success and wish her more of it.

However none of that changes the fact that having the owner of a virtual care company, that has links to another, while OMD is supposed to be taking an impartial look at virtual care solutions going forward creates the impression of a conflict of interest. She likely would recuse herself from discussions around this (she has a reputation for impeccable conduct) but in politics, the reality is that a perception of a conflict of interest, might as well BE a conflict of interest

NB – I should point out that OntarioMD likely had nothing to do with the virtual care extension agreement – that was approved by the OMA Board.

Back to accessibility, I pride myself on being reasonably available to my patients. As with all things, there are some ups and downs, but I have consistently had positive access bonuses for the past 17 years. I have no problem with other clinics trying to set up shop near me (some have tried over the years) because my patients generally know that for the most part either via phone, email, or in person, they can usually get a hold of me in a timely manner.

However it’s not possible for me, or any other family physician, to compete with $75 million operations like Maple or companies like dot health who advertise on Twitter and Facebook, and allow people to simply click on the ads to connect to a physician.

Moreover, this kind of thing is bad for the patients. The example of prescribing antibiotics without a throat swab is just one of many that I could present about inappropriate tests and or prescriptions being given by physicians who may mean well, but don’t know have the insight an ongoing relationship with patients can provide.

This deal will also potentially negatively affect specialists as well. Say you are the best cardiovascular surgeon I know. At some point these private companies will also have other cardiovascular surgeons on staff. Maybe if a patient has a question about their surgery, they will contact, for convenience sake the private company, instead of asking you. Do you think that’s not going to affect consistency and quality of care?

Virtual care is here to stay and I support virtual care. However, when funding virtual care it’s important to ensure that it’s only funded in an appropriate manner. As Drs. Agarwal and Martin wrote in their piece on the virtual care revolution:

“Virtual care should be leveraged to as a tool to interact with your provider – someone who knows you and can see you in person when that’s best.”

Currently, there appear to be no qualifiers on virtual care payments. Maybe there was a sense that the only way to get qualifiers was to approve this first. Maybe the concern was that time was running out on the initial agreement and something had to be done now. I don’t know (I’m not on the OMA Board anymore).

But I do know this, sometimes, you need to walk away from flawed agreements for the sake of the greater good. And this, was a flawed agreement that should not have been approved.

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.

Tone Deaf CFPC Fails Its Members, Embarrasses Itself

Recently, in what seems to these old eyes to be an insulting, vindictive and offensive move, Canadian Family Physician, the “Official Journal of The College of Family Physicians of Canada (CFPC)”, published a hit piece on Family Doctors that only serves to further demoralize and dishearten a beaten down profession. I cannot fathom the amount of, what at best could be described as political naïveté, and at worst a disconnected Ivory Tower mentality that would be required to write such a venomous attack on those who actually pay money to keep their organization going.

Seriously, what was the CFPC thinking when they okayed Roger Ladouceur’s editorial, titled “Family Medicine is not a Business.”?? (I refuse to link to it as I don’t want it to get any more hits).

Truly, it’s not really an editorial, rather a massive litany of complaints against family physicians, while sarcastically suggesting “surely, it’s just gossip!”

What exactly are evil rotten family doctors doing according to Ladouceur? He suggests the CFPC has “heard stories” about family doctors not seeing patients in person and wondering how they can assess complicated patients. He has “heard stories” about doctors only calling patients at more lucrative times and abandoning patients with high medical needs. He has “heard stories” about family doctors “charging excessive fees” for services not covered by health insurance.

He ends off his purulent missive by blithely stating, “Family Practice is not a business.” Marie (“Let them eat cake”) Antoinette would have been proud of such a comment, dismissively heaped on the approximately 40,000 overworked family doctors in Canada.

There’s a lot to unpack in Ladouceur’s diatribe. First and foremost is the fact that despite extolling the virtues of evidence based medicine, the CFPC allowed an editorial to run that had, well, no evidence to back it up. The whole argument was based on “I have heard stories.” There are no numbers to back it up, no names of offending physicians, no statistics on how widespread these alleged problems are. Just gossip and innuendo based on what he has “heard.”

If you want evidence by the way, I can confirm that the OMA Board was told that based on OHIP billing data over 98% of family doctors in Ontario continued to work after the pandemic was declared. It is true that they are using a mix of virtual and in person visits, but given the need to social distance during these times, a mix is clearly the correct way to proceed.

Furthermore, the banal statement that “Family Medicine is not a business” is simply factually incorrect, and reveals a kind of ignorant, Ivory Tower mentality that shows a complete disconnect from the real world.

Let me be clear about this, I consider myself one of the lucky ones. My family has food on the table. We have a roof over our head. There is no danger of my car being re-possessed. I’m fortunate compared to the average Canadian and am extremely grateful to be in that position.

But while I genuinely enjoy seeing my patients (they’re a great bunch of people), I still have to pay my staff, order supplies, pay rent and utilities, ensure my computers are working properly, get payroll taxes paid, comply with labour legislation etc etc. In short, while we all hate to think about this side of things, Family Medicine has been, and will continue to be a business of some sort. That the CFPC would allow such an obtuse comment by Ladouceur to run, shows a wanton disregard, and, dare I say it, contempt for the many day to day issues that its members face.

Look, no physician likes seeing one of their organizations scold them (and certainly I will always push back when I see this kind of stuff happening), but I really have to wonder just how completely out of touch the CFPC must be to allow this type of berating in the middle of the biggest physician burn out crisis I have ever seen. Prior to the pandemic, 26 % of physicians were clinically burnt out, 34% were suffering from a degree of depression and over 50% reported some symptoms of the burn out. Exactly what do you think has happened to those numbers after the pandemic? Especially with physicians recognizing that even though we seem to be coming out of the pandemic, there is an overwhelming backlog of delayed care to address?

Yet amongst this backdrop, here comes the CFPC, not to try to find ways to support physicians or provide tools to help them be healthy so they can look after their patients better, but to berate, admonish and vilify them as a group. This is supposed to make things better??

The type of evidence free invective Ladouceur ran should never have been given any platform, much less a platform on an organization who’s mission statement includes advocacy on the part of the specialty of Family Medicine. Frankly, I’m embarrassed to be a member of the CFPC, though given the regulatory requirements to maintain my continuing medical education, I can’t resign from it.

If the CFPC really wants to help, they will pull Ladouceur’s screed from their magazine, and apologize to all 40,000 Family Physicians in Canada. Anything less will suggest complicity and sympathy with his views, and will contribute to Family Physicians losing confidence in the CFPC.

Conscience Rights are HUMAN Rights

Last year, I wrote a blog about Conscience Rights.  The motivation for the blog was the concerning move by the Ontario courts to “infringe on doctors’ religious freedoms.

I know, I know, the case dealt with whether physicians (and other health care providers) had the ability to refuse to provide a referral for situations where they conscientiously objected. Currently, the hot topic for this scenario is Medical Assistance in Dying (MAiD). And yes, the headlines simply said the request for an appeal of a lower court decision on granting physicians conscience rights was denied. I also know there was a lot of talk about the right of the patient to determine their own health care (which is of course must be respected).

But in the text of the initial ruling, the courts clearly and unequivocally admitted that they were infringing on doctors’ rights.

I made a Star Trek reference in my last blog on this issue. Hence, one would be appropriate here. It would seem the Ontario Courts were using the logic first uttered by Mr. Spock in Star Trek 2 – The Wrath of Khan:

“Logic clearly dictates that the needs of the many outweigh the needs of the few.”

But is that really the case here? Will patients be unable to access legal health care services, simply because physicians are able to keep their fundamental human rights? The short answer is no.

In Ontario, for a service such as MAiD, all a patient really has to do is call the MAiD co-ordination service, and they are guaranteed an assessment. A physician who gets a request for this service simply has to give a patient the 1-800 number to call. Heck, patients can even look the number up online and call themselves without asking their own physician.

In short, the service is readily available to those who want it. The needs of the many are not, in any way, shape or form compromised by Conscience Rights legislation. The Ontario Courts have therefore willingly infringed on the rights of a minority, on the basis of a false premise.

Let me also mention the reaction to my last blog on this issue. I had mentioned that in the near future, we would be facing many ethical dilemmas as a society. Not the least of these include new genetic treatments and therapies. Most physicians were supportive of my blog but some expressed concern that brining up genetic advancements was too extreme. One commentator even used the analogy that seemingly all twitter arguments degrade to – “…can’t compare asking for MAID to asking to revisit the Nazi eugenics movement

And yet.

Look what’s happening in the world.

In China, a group of scientists have inserted human brain DNA into monkeys. They state the reason for this is to study conditions like Autism. Jeez, have these people never seen Planet of the Apes????

As Elon Musk dreams of colonizing Mars, scientists are now actively looking at “tweaking” the DNA of people who wish to colonize Mars as a way to protect them from harmful radiation and microgravity. There is even thought being given to merging our DNA with tardigrades (weird microscopic creatures that can seemingly survive anything).

This s all in addition to work that is being done by companies like Neuralink (another Elon Musk organization) to develop brain implants.

Indeed, as Davis Masci pointed out last September:

“But thanks to recent scientific developments in areas such as biotechnology, information technology and nanotechnology, humanity may be on the cusp of an enhancement revolution. In the next two or three decades, people may have the option to change themselves and their children in ways that, up to now, have existed largely in the minds of science fiction writers and creators of comic book superheroes”

These aren’t some weird tabloid, National Enquirer type stories. There are real scientists actively doing this kind of work. The point being that protecting Conscience Rights is not just about MAiD, it’s about ensuring that on a go forward basis, peoples fundamental freedoms are not impugned in what promises to be the most ethically challenging time for science in human history. It’s about ensuring that people do not have to work on or accept for themselves, things that they find morally objectionable.

As a free society, we have always recognized certain inalienable human rights. It’s not just the right to free speech, assembly or vote. The Canadian Charter of Rights and Freedoms specifically mentions freedom of conscience and religion (see section 2). This was due in large part to a recognition that a diverse society is a stronger society and in order to protect that diversity, we must protect fundamental freedoms.

That’s where the judges erred last year. By infringing on the rights of a few, stating that by doing so they were protecting the right of many (which as I’ve shown above, isn’t even the case), the judges have damaged our society as whole, and made it easier to take away more rights from more people. They failed to realize that you cannot make a society stronger, or more free, by taking away the rights of a minority. You only increase the possibility of taking away more rights in the future.

As a society, we must be ever watchful for these infringements on our freedoms. To use another Star Trek quote, this time from Captain Jean-Luc Picard (nerd alert – TNG episode “The Drumhead”):

Vigilance. That is the price we continually have to pay.

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

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.

COVID19 Has Exposed Flaws In Our Public Health System

“Be hard on the problem, not on the people.” – unnamed OMA Executive

When I was President of the Ontario Medical Association (OMA), I had the privilege of touring the province. The tour was during flu shot season, so I took the opportunity to meet many Public Health physicians and staff. They are all good, hard working people who are dedicated to their communities and doing their best to advocate for the health care needs of the population.

Unfortunately, the Public Health system in Ontario (and Canada) is fragmented and disjointed. This really impeded the ability of Public Health to act in a unified manor prior to the pandemic. But because Public Health wasn’t as “visible” at the time, the flaws in the system remained hidden.

To understand just how this fragmentation affected our health, one only looks at the situation around trans fats. I wrote about this previously, but in short:

– We’ve known since 1993 that trans fats are linked to increased heart disease

– We’ve known since 1995 that Canadians are one of the highest consumers of trans fats in the world

– Denmark, led by their strong public health system, essentially banned trans fats in 2004 and within 2 years had 4% less deaths from heart disease. There was also a reduction in childhood and adolescent obesity.

– The results were so good that many other European countries followed suit.

If we apply the Denmark results to Canada, we could prevent 600 heart attacks a year. Banning trans fats would seem to be a no-brainer, and clearly the type of thing Public Health should effectively advocate for.

But here in Ontario, outside of the City of Toronto trying to ban trans fats in restaurants in 2007 not much has been done about this. Part of this is because Ontario has 35 different Public Health units, who all function independently. They may not even have the same software when collecting data, and some still use paper charts. Because they all function independently, just because Toronto Public Health wants a ban, doesn’t mean all the other units would even know about it, much less share information on it, or advocate for it. And of course, every Province and Territory has their own autonomous Public Health System.

So essentially, the Public Health Units were unable to co-ordinate around this issue, and outside of trying to ban Trans Fats in school cafeterias, and a failed voluntary guideline by Health Canada, not much has happened.

It wasn’t even until 2017 that Health Canada got around to proposing a ban on trans fats, and 4 years later this still hasn’t happened. It’s worthwhile noting that over 10,000 heart attacks could have been prevented if we had acted at the same time as Denmark.

If in “normal”, non-pandemic times, the Public Health system was so fragmented, and disjointed, that something this straightforward couldn’t be accomplished, how would they perform in a once in century pandemic?

The answer, sadly, is not very well.

Just as the various Public Health Units couldn’t co-ordinate on the same message for Trans Fats, it appears the various units can’t co-ordinate on the same messaging around COVID. Case in point, on Nov 4, 2020, Health Canada finally (!) announced that yes, indeed, the coronavirus has airborne spread, and all facilities should take airborne precautions.

Dr. Theresa Tam, Chief Public Health Office of Canada announcing COVID19 was, indeed spread by aerosols

Yet a look at the website for my Public Health unit (Simcoe Muskoka) on Jan 10, 2021 (2.5 months later!) still shows the same guidelines that’s before the announcement. Namely, that the virus is spread through droplets and so cleaning surfaces is more important.

From Simcoe Muskoka Public Health, Jan 10, 2021.

So here we have two different messages coming from public health authorities.

By comparison, take a look at Japan. Japan decided back in February 2020 that the virus was aerosolized. They too have many regional public health offices, however, the regional branches send the information to the national office, and the national office makes decisions. Those decisions are clearly communicated to the public, so the same message goes through the country.

They very quickly focused on things such as air purifiers with HEPA filters in rooms, improving ventilation by leaving windows open (even in the crowded community trains) mask wearing, and improved HVAC systems.

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

As a result, on a per capita basis, Japan has only 1/8th the number of infections, and 1/14th the number of deaths from COVID19 as we’ve had in Canada so far.

But it’s not just messaging that’s the problem. Public Health Units are hampered by their archaic systems from adequately preforming the test/trace/isolate process so important to controlling the spread of COVID19.

My practice is close to the border of the Simcoe Muskoka District Health and the Grey Bruce Health Unit. If one of my patients comes down with a reportable illness, I have to figure out which health unit to report to. But they use separate forms. Additionally because they use separate data systems, they can’t share information between the two.

Supposing one of my patients were test to positive for COVID-19. What if they live in Grey Bruce, but work in Simcoe Muskoka. Who should I report this to? And more importantly who is responsible for the contact tracing considering they work in one area and live in another? Especially since they can’t share data.

The result? Effective test/trace/isolate does not occur in Canada.

Compare this to South Korea. South Korea has multiple regional offices for public health, but they’re integrated by the Korean Ministry of Health and Welfare (KMHW). They share software, and so can share data and information.

By having all of Public Health integrated, South Korea was able to have one source for information. So not only did they have a consistent message (the KMHW gave two press conferences a day), but they were able to effectively test/trace/isolate.

On a per capita basis, South Korea has only had 1/13th the number of COVID cases as Canada, and 1/20th the number of deaths.

Canada’s response to the COVID pandemic is among the worst in the world. Only the fact that we are next door to a country that has had arguably the worst response in the world seems to prevent Canadians from recognizing this fact. If there is one learning that me must take forward from this, it is that lack of an integrated, seamless and co-ordinated Public Health system has cost us many lives.

As a country, we need to support the people working in Public Health by improving the systems they have, so they can protect us in the future.

Note: This blog is based on the first part of a presentation I gave to the Public Health Youth Association of Canada (my thanks to them for asking me to speak). If you are suffering from insomnia, or if you are generally good person and want to support young people who are keen to improve the world, feel free to watch the presentation here:

Facts and Myths About the COVID Vaccine

Disclaimer: As always, the information I present here is meant to be an overall summary of what we know, and not specific medical advice for one person. If you have questions, please talk to your doctor.

As I write this blog, almost 52 million doses of the new COVID vaccines have been delivered to people around the world. Our knowledge about COVID (and the vaccines) continues to increase almost exponentially, and while we don’t know everything yet, here’s what we’ve learned so far.

Time to put the whole “Guinea Pig” argument to rest.

Many people have told me they don’t want to be a human “guinea pig” to test the vaccine on. The clinical trials on the vaccines (while quick) were thorough. More people have gotten their first dose of the vaccine than the entire population of Canada. If you get it now, you won’t be first. In fact you’ll be after this guy:

What if I have an allergic reaction?

After Britain warned against giving the Pfizer vaccine to people with a history of severe allergies, some people were concerned. However, now that we have given so many of these vaccines, we know that the rate of a severe allergic reaction (anaphylaxis) with the Pfizer vaccine is one in 90,090. Your odds of being struck by lightning in your lifetime are 1 in 15,030. Remember, all the vaccine sites have Epipen.

The Moderna Vaccine is Better/Has Less Side Effects

Some people are waiting for the Moderna vaccine. However, both the Pfizer and Moderna vaccines are equally effective. I had suggested that if your allergies were so bad that you needed an epipen, you might want to wait for the Moderna vaccine. But Canada’s federal government has done a poor job of ordering the vaccines. With Canada having deferred purchase of more of the Moderna vaccine (!), you probably should just get the first one you are offered.

I’m Worried About a Sore Arm and Other Symptoms After

Sore arm, fever, and muscle aches are all symptoms people can get after any vaccine. However, what’s important to note is that these are not side effects. A vaccine works by stimulating your immune system. If you get a cold, your immune system activates to fight the virus, and as part of that, will often give you a fever, and muscle aches. You may feel crummy, but your immune system is doing its job.

If this happens to you after a vaccine, it may be miserable to experience but at least you can take it as a sign your immune system is working, and you are getting a response to the vaccine.

It’s off label but I ensured that all of the resident of Bay Haven Nursing home got 1,000 mg of Acetaminophen three times a day the day before, the day of and the day after the vaccine. We have had no reports of flu like illnesses after the vaccine. I intend to take this myself before my second shot, and you may want to consider this as well.

I Am Pregnant or Trying to Get Pregnant

There were women of child bearing age in both the Moderna and Pfizer studies (although no pregnant women). The vaccine did not appear to cause issues. We routinely give other vaccines (like the flu shot) to pregnant women and it is felt to be safe.

When I study the science around it, there is no reason that the COVID vaccine should affect pregnancy. The Society of Obstetricians and Gynecologists of Canada has stated that: “Women who are pregnant or breastfeeding should be offered vaccination at anytime if they are eligible and no contraindications exist”. Please talk to your doctor about this.

But I Still Have to Wear a Mask/Get Swabbed/Get Screened!

Alas, yes you do. I share the frustration on this one. Health Canada only approves what it knows. The evidence from the studies on the vaccines was very strong that they would reduce your chance of getting COVID. However, to study whether the vaccine will reduce the risk of transmission is much more complicated. It requires a high level contact tracing which we don’t have in Canada.

However, every other successful vaccine in the past has reduced the ability to transmit whatever disease we were protecting against. That’s why we no longer have small pox, and until the rise of the renowned neurobiologist/brain surgeon Jenny McCarthy, had almost eliminated measles. I’m hoping that Health Canada will lift the requirement to wear masks for people vaccinated in the near future.

This should at least show you how much confidence they have in the Covid vaccines. I mean if an organization that historically takes it’s time to approve things moved so quickly when they saw the evidence for the Covid vaccines.

Are You Sure These Vaccines Were Tested Properly? They Were Approved Awfully Fast.

There was good reason to be approved quickly. As I mentioned in a previous blog, there was a significant reduction in bureaucracy. Everybody (drug companies/regulatory bodies/politicians) agreed we needed a vaccine as soon as possible, so the five years (!) of red tape was cut.

The second thing to keep in mind is that to test a vaccine, you have to expose people who had the vaccine to the illness. For a condition like shingles, you often times have to wait for years to see if the virus is effective, because as painful and awful as it is, Shingles is still relatively rare. It takes a LOT of time to accumulate the data needed to see if enough people benefited.

For COVID, one perverse benefit of the fact that the United States has one of, if not the worst responses to the pandemic in the world is that the virus is, well everywhere. That means the over 70,000 people in the studies could be exposed to the virus very quickly, and we could see very quickly if the vaccine worked.

Moreover, it’s a myth that all the drug companies who developed a vaccine were approved. There are 14 vaccines for COVID that were being developed. But if flawed, the trials were halted (like CSL in Australia or Sanofi-Glen‘s vaccine).

The Vaccine Is Genetic and Will Affect My DNA

Simply not true. The mRNA used in the vaccine will not affect your DNA. DNA is the stuff that makes you, well you. I can’t explain it any better than Dr. Abdurrahman:

I Don’t Trust Big Pharma/Bill Gates is Injecting Nanochips Into My Body/It’s an Illuminati Conspiracy

………. I got nothing. If you really believe this there’s nothing I can do to convince you otherwise.

Should I Get The Vaccine (Whichever one) When It’s My Turn?

YES! The lockdowns and economic harm caused by this pandemic are having a terrible toll on us. The social isolation, job loss, economic harm, mental illness and much, much more is devastating society.

If we want to visit our friends, if we want to go to a restaurant, if we want to go to Church/Mosque/Synagogue/Temple, if we want to travel, if we want to……..simply live a normal life again, we need to get everyone possible immunized. Without this, the pain we all suffer from this pandemic will continue.