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.
Disclaimer: Just a reminder that, once again, I am not speaking on behalf of the Ontario Medical Association. The opinions expressed in this blog are mine, and mine alone.
Many who read this will wonder why I’m talking about a potential physicians agreement in another province. Some will point to my role at the Ontario Medical Association (OMA) as past-president and suggest that I should stay out of the affairs of another Provincial, Territorial Medical Association (PTMA). Normally I would. But the situation in Alberta has implications for physicians across the country, including Ontario, so I feel compelled to speak out. Besides, considering the then President of the Alberta Medical Association (AMA) commented on our own tentative agreement in 2016 (and he was right by the way), I think it’s ok for me to speak out as well.
I don’t know all the details about the ins and outs of how the AMA works, nor do I know all minutiae about their negotiations process.
But I know when doctors are getting screwed by a government.
Last week, the Alberta Medical Association (AMA), announced a tentative agreement with their government. The agreement allows their volatile, combustible Health Minister Tyler Shandro almost unlimited, and truly unprecedented power over Alberta Physicians:
It reduces their physician pay to 2018 levels
It gives the temperamental Shandro Ultimate authority over how much physicians get paid. Just read this truly scary statement by the AMA:
“The AMA acknowledges that the physician services budget is established by the minister in the minister’s sole discretion,” it states.
“The AMA further acknowledges that nothing in this agreement fetters the minister’s authority or discretion with respect to the physician services budget.”
It places a hard cap on the physicians services budget, meaning that if the demand for care went up above the predicted level, physicians incomes would be clawed back to make up the difference. As an aside, demand will almost certainly exceed the projections. We are coming out of a pandemic and are facing an enormous backlog of care. How eager do you think the volatile Shandro will be to allow an overage of the physicians service budget going forward?
Worse, the AMA is required to discontinue their lawsuit demanding binding arbitration, which all physicians should view as an inherent right.
For me personally, the whole Alberta situation has brought back some particularly bad memories. In 2012 the OMA accepted a 0.5% fee cut in the hopes that appeasement of a bullying government would lead to better things in the future. This of course is not the way to stand up to bullies, and Ontario physicians felt the brunt of this as the now second worst health minister I have ever seen, “Unilateral Eric” Hoskins, sensing weakness, imposed unilateral cuts to physicians in 2015.
After a couple of years of internecine warfare, the OMA and Unilateral Eric came to a tentative agreement in 2016 as well. That agreement:
Reduced physicians pay to levels from a few years back setting a lower base rate for the Physician Service Budget
Allowed for a hard cap on physicians billing
Allowed the Health Minister to claw back physicians billings if usage exceeded projections
Sound familiar? At least the Ontario agreement allowed our own Charter Challenge on Binding Arbitration to continue (which it painfully, slowly does to this day).
We were told by the OMA Board at the time that this agreement was the “best that could be done” and that we were going be faced with even more clawbacks and cuts if we turned it down. As is well known now, the agreement was soundly rejected, the increased clawbacks never materialized and when faced with the prospect of an election, the government of then Premier Kathleen Wynne finally had to recognize that Arbitration was an inherent right for all essential workers, physicians included, and we secured a fair Binding Arbitration Framework.
All of which is my way of encouraging Alberta Physicians to realize that they don’t have to simply roll over and accept the “best we can get”. While there will be some pain in rejecting the agreement, at the end of the day, governments need to go to the polls. That’s when having angry doctors makes them vulnerable. It will not be pleasant to hold out, and say no (it certainly wasn’t in Ontario!) but I submit that it is better to keep your integrity intact and stand up to a patently unfair deal.
But wait, what about these implications for physicians across Canada I referred to? It all has to do with negotiations.
Obviously, I can’t talk in detail about negotiations. BUT, what I can confirm is what many of us have long suspected. Bureaucrats from Provincial Governments talk to each other all the time. They share data. They share information, and they share tactics. They may or may not (depending on their political masters) use a particular tactic/program/scheme etc, but they do share.
Which means, that IF Alberta docs pass an agreement like this, which chains them to a hard cap and allows even a minister as incendiary as Shandro, free, unfettered reign, then we can expect other governments to attempt this as well. “Your colleagues in Alberta accepted this, why can’t you be as reasonable and co-operative as them?”will be the opening position in negotiations in many provinces after this.
That is why physicians across the country should follow the situation in Alberta with interest. That is why we should support our Alberta colleagues. That is why, for the sake of physicians in Alberta, and everywhere in Canada, this deal needs to be rejected.
If you want more, a colleague has prepared a helpful Q&A about our situation, and you can access it here.
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.
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.
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.
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.
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.
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.
“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
– 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.
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.
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.
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.
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.
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:
The following blog was co-written by Dr. Samantha Hill (current OMA President) and Dr. Adam Kassam (OMA President-Elect). It first appeared in the online version of the Toronto Star on January 11, 2021 and is reproduced here with the permission of the authours.
Images of elated physicians and other health care workers being immunized has been an emotional experience for our community. Our professional stoicism has given way to more fundamental and broadly shared human feelings: joy and optimism.
For close to a year now, we have had to work at the very tip of the spear against the pandemic. This dangerous, exhausting and unpredictable work has taken its toll. That is why the vaccine represents a literal infusion of hope for us, our patients, families and communities.
We are thoroughly delighted for every colleague, long-term care resident and vulnerable person who is now a little bit safer. However, collectively, we are still a long way from defeating this disease. As we encounter record highs of cases, hospitalizations and — sadly — deaths, only a fraction of Ontario’s physicians have received a first dose of the vaccine.
For understandable logistical reasons — which include the need for special cold storage — most of the first vaccines were administered in tertiary hospital centres, which have admirably risen to the immense challenge of organizing the safe and efficient deployment of the vaccines.
Getting everyone vaccinated successfully relies on two key factors: the federal government’s continuous and predictable procurement and delivery of the vaccines to Ontario, and the provincial government’s ability to distribute and administer the vaccine to Ontarians.
To that end, as approvals for other vaccines occur nationally and vaccine supplies ramp up across the country, we will need to move beyond hospitals to build capacity to be provincially successful in rapidly immunizing our population. These centres are already stretched thin, simultaneously treating a growing number of sick COVID-19 patients and the usual hospital health care needs of Ontario.
Which is precisely why, the next leg in this crucial vaccine race requires a co-ordinated community effort to vaccinate front-line health-care workers and the vulnerable patients both within and outside of congregate care settings.
Approximately 60 per cent of physician services occur outside of the hospitals. Many of these community doctors — both primary care and specialists — have direct knowledge of their vulnerable patients. They have developed relationships, credibility and bonds of trust through their continuity of care, all of which are crucial for success of any province-wide vaccination program. Grassroots, community doctors will also be essential to co-ordinating the necessary two-dose schedule.
Community doctors must have clarity on access to vaccines, not only for their own well being, but also for planning purposes for their patients. They have been caring for their communities for years, and these doctors are an invaluable resource with experience, expertise and capacity that must be leveraged. Even now, in this next stage, Ontarians deserve a trusted medical professional — many of whom come from, live and work in diverse communities — upon whom to rely.
This pandemic has challenged every facet of our society. In Ontario, thousands of people have contracted and died from this terrible disease. Our already-precarious health care system has been buckling under this added pressure. Disruption to businesses, communities and families has been widespread.
We all desperately want this devastation to stop. Our path out of this is with these vaccines. Doctors are, unfailingly, at our posts and prepared to help. While this pandemic has been a marathon, we need to now think of the vaccine rollout as a sprint. Because in this race, lives and livelihoods are at stake.
The following blog was written by Dr. Samantha Hill, a Cardiovascular Surgeon, owner of a Masters in Biostatistics and Epidemiology AND another Masters in Health Practioner Teacher Education. In her spare time she is the current President of the Ontario Medical Association, which represents 44,000 physicians, medical students and residents.
It’s time for some serious advice from your doctors to ensure that everyone has the safest and happiest holiday season.
The recently announced lockdown is effective Boxing Day, but Ontarians do not have to wait. All of us can, and should, take action now, including cancelling plans to visit family and friends on Christmas.
COVID-19 is serious. The numbers of Ontarians confirmed positive for COVID, hospitalized, admitted to the ICU, and ventilated continue to rise dramatically. Hospitals are again reducing non-emergent care and preparing for surge capacity. LTCs are overwhelmed and calling out for help, as their patients, our elderly, suffer.
Clearly, we need to do better.
This spring, we demonstrated severe lockdowns save lives from COVID. But, we failed our most vulnerable, saw high health costs (late presentations of other illnesses, marked increase in mental health challenges, and a staggering pandemic deficit of health) and severe economic consequences.
In September, we moved indoors again. Despite most people following public health guidelines, labs and contact tracers are again overwhelmed. Lockdowns are present and imminent.
Let me be clear, that means we are failing.
Lockdowns are a last resort, imposed when we fail to live safely within tenuous new normals and escalating precautions are not enough to protect us. There is no space for blame. We are all in this together, and we all have a role to play.
I find myself needing to remind you, that during lockdowns, essential workers still go to work: your doctors, all front-line health-care providers, teachers, but also “invisible” essential workers who stock grocery store aisles, work the cash register, service the TTC, support LTCs and hospitals, etc. Many ride the TTC to do so.
Doctors know that being deemed essential does not equate with being safe from COVID-19. A grocery store is no safer than a clothing store. Lunch in the work breakroom is no safer than lunch with others anywhere else. An hour on public transit is no safer than a one-hour flight. Over the past nine months, we have seen outbreaks, illness and deaths stemming from essential services. These services stay open because we need them.
Essential workers are exposed to increased risks for the well-being of others. We decided we can’t live without them. So we have an obligation to protect them, not just bang pots. Their lives, literally, depend on our choices.
So how do we keep people safe? You already know: Mask up, wash your hands, maintain social distancing. Always choose the safer activity, skip the social event or stay home. When we get it right, we decrease the spread of COVID in our communities, avoid lockdowns, protect our most vulnerable, our essential workers and everyone else, without sacrificing everything else.
A COVID vaccine is on the way for all of us – we can finally see the light at the end of the tunnel. But we are still squarely in the tunnel, and will be until the majority of Ontarians have been vaccinated (and the timeline for this is the end of 2021). Worse though, one-third of Ontarians are planning to ignore the public health recommendations to not socialize over the holidays. Worst-case modelling projections predict nearly 10,000 cases daily by January. Our choices today determine that.
So, this doctor’s advice?
Assess the risk and benefit of each action, job, trip or interaction, particularly during the holidays. Is it worth the risk not just to you, but to all of Ontario? For those scanning: ALMOST EVERYONE SHOULD STAY HOME FOR THE HOLIDAYS.
When worth the risk,
wear your mask and distance yourself from those who will not
wash or sanitize your hands frequently
stay two metres apart
minimize the time you spend in close quarters with others, the number of people involved, how often you interact with others.
Don’t grow complacent. Small actions matter: start a line when a store is full; redirect friends to gather outdoors or skip eating; keep your kid with a runny nose home; no one can tell if it’s just a cold.
Keep getting tested for COVID-19. We need to know where it is to eradicate it.
2020 has been a long, dark, year but the vaccines are arriving, bringing renewed hope. Let’s all do our part and ensure that as many of us as possible make it into the daylight 2021 promises.
The following blog was co-written with me by Dr. Leonie Herx, Division Chair and Associate Professor of Medicine at Queen’s University and Past- President of the Canadian Society of Palliative Care Physicians and Dr. Ramona Coelho, a family physician who provides care to a large number of marginalized patients. A version of this opinion piece initially ran in the London Free Press on Saturday December 5, 2020.
As the COVID-19 pandemic dominates the political agenda and strains the country’s health-care systems, the federal Liberals are intent on passing Bill C-7, which proposes to expand medical assistance in dying (MAiD) to those who are not dying. Proponents of the bill state that it allows choice and dignity for those with chronic illness. However, the bill fails to provide them with the dignity and humanity of requiring them to have good care or access to supports.
As physicians, we witness the struggles that confront our patients and their loved ones every day. Those living on the margins and with disabilities face significant barriers to care though systemic discrimination (ableism) that can make it harder to live a healthy, fulfilling life in community. As doctors we should be instilling hope, supporting resilience and using our expertise to find creative solutions to address health and wellbeing. Instead, we now will be required to suggest assisted suicide as an option.
Spring Hawes, a lady who has a spinal cord injury for 15 years publicly stated,
“As disabled people, we are conditioned to view ourselves as burdensome. We are taught to apologize for our existence, and to be grateful for the tolerance of those around us. We are often shown that our lives are worth less than nondisabled lives. Our lives and our survival depend on our agreeableness.”
A choice to die isn’t a free choice when life depends on good behaviours and compliance to societal norms. Sadly, the medical community can be complicit in this messaging.
Gabrielle Peters, a brilliant writer, who has struggled with poverty since her disability, has shared that a healthcare professional sat at her bedside and urged her to consider death. This was just after Gabrielle’s partner announced he was leaving her because she was too much of a burden and she no longer fit into the life he wanted.
Doctors can pressure someone to die as in Gabrielle’s situation but also more subtly can confirm a patient’s fears that her life is not worth living and MAiD would indeed be a good medical choice.
Day after day, we participate in a healthcare system and a social support system that does not come close to meeting the basic needs of our most vulnerable patients. However, our role as physicians should always be to first advocate that our patients access all reasonable supports for a meaningful life with no suffering. But alas, Canada does not seem to prioritize health care and supports for all, and soon, that lack of support will be pitted against an option to access death in 90 days.
Patients entrust doctors to make ethical decisions every day regarding their care and to make recommendations that are always aimed at promoting health and healing. The core role of medicine is to be restorative, not destructive. Advocating for our patient’s health and wellbeing, is a solemn oath we took.
As physicians we help our patients do many things in the context of a trusting, shared, decision making process. Doctors encourage healthy habits. We refuse to prescribe antibiotics when patients have a viral infection, or opioids on demand. We pull a driver’s license when we have concerns for patient safety and the public good. We refuse to write mask exemptions without good reason. We serve both patient and the common good.
All of this requires courage to not betray the trust society and the patient has bestowed on our profession. Society’s belief in the inherent virtue and ethics of the profession has been the necessary basis of the physician-patient trust. Would you trust your doctor if you thought they didn’t care about your safety and well-being?
While we recognize patients have the right to ask for MAiD, physicians must not be forced to suggest or forced to facilitate this, when reasonable options for living with dignity exist. We must continue to offer our patients what is good and practice medicine with integrity.
As Dr. Thomas Fung, Physician Lead for Siksika Nation stated,
“Assisted death should be an option of last resort, and not the path of least resistance for the vulnerable and disadvantaged. Conscience protection is needed in this bill, as no one should be forced to participate in the intentional death of another person against their good will.”
One of the most important foundations of our Canadian identity is that we are a caring, compassionate country. We are proud of our universal healthcare mandate, and we place a high premium on being inclusive and tolerant while working hard toward the accommodation and integration of marginalized and vulnerable members of our community. And yet, if Bill C7 is allowed to stand without amendments, we will be in serious danger of losing this fundamental element of our Canadian identity.
For many of us 2020 was arguably the worst year we will (hopefully) ever see. The annus horribulus of our lifetimes. But for the Ontario Medical Association (OMA), arguably its worst year was 2016. Reeling from repeated attacks from then Health Minister “Unilateral” Eric Hoskins, the OMA as an organization made a decision to try to play nice by agreeing to a tentative Physicians Services Agreement (tPSA) in an effort to end the war Hoskins started. Unfortunately the deal was substandard, and like everything Hoskins did, was bound to hurt patient care.
Amongst much controversy (which I won’t restate) the tPSA was rejected by physicians. This led to a realization that the OMA needed to change. The organizational structure was archaic, pondering and built on the concept of “politicking” at a large Council meeting of almost 250 people, and passing motions as opposed to developing solutions. A revolutionary change was needed, which required a “disruptor” as leader.
Out of nowhere, in a seemingly vertical career trajectory, came my friend and colleague Dr. Nadia Alam, who wound up becoming the OMA president based on a promise to transform the organization. Her greatest strength was her ability to inspire people that they could be better. Becoming the face of a change agenda, she helped all of us believe that the impossible was possible, and that with hope, and a leap of faith, a better organization could be there for us.
The first step was to revamp the operational side of the organization. Led by CEO Allan O’Dette, the staff became more organized in cross functional teams, and had a clear purpose delivered to them.
These changes were unquestionably helpful, as seen by the strong response to the COVID19 pandemic. I’ve never heard so many members actually say nice things about the OMA staff as I did over that response. All the staff deserve a great deal of credit for how they came together around this issue, which would not have been possible without the operational re-alignment.
But the governance of the OMA was still antiquated. The bylaws said OMA Council governed the OMA (even though this was a direct contravention of the corporations act). Council has 250 well meaning physicians who give up their own personal time to serve the profession. Unfortunately, trying to secure blocks of votes to pass motions, is simply not a modern way to deal with issues.
The OMA Board had 25 physicians, also well intentioned, who gave up much more personal time and tried to represent the profession as a whole, while mindful of the constituencies that elected them. Twenty-five is just too big for an organization that needs to be nimble, and as dedicated as Board members are, it was apparent that some professional Board Directors were needed to guide the Board so that it could do the best for the profession.
Over the past 18 months, the Governance Transformation Task Force 2020 (GT20) worked overtime to make the OMA a much more modern organization. There were a lot of people involved in GT20, from OMA staff, other physicians, and the consultants. They all are extremely deserving of the thanks of the profession, but to name all of them would use up the word allotment of my blog.
However, I need to make a special mention of the GT20 Co-Chairs, Drs. Paul Hacker and Dr. Lisa Salamon. I have had the opportunity to provide a bit of support to Dr. Salamon, and somewhat more to Dr. Hacker (P.S. Yes, General Manager of OHIP all those K005 claims are legitimate). If not for their dedication and focus, this process could have gone off the rails at multiple occasions.
Change is hard. It’s one thing to want change, it’s another to look at proposed changes and realize just how significant they are. Human nature being what it is, many people suddenly had second thoughts or concerns about the transformation at multiple points throughout the consultations and reviews.
But Drs. Hacker and Salamon (and the rest of GT20), stayed the course. They focused on what physicians in Ontario deserve – a leaner, more nimble and strategic organization. An organization where elected leaders come together in a manner that enables them to create positive solutions instead of politicking for votes on motions at a large meeting. An organizational structure that allows for rapid responses when crises inevitably arise.
This past weekend, after many many ups and downs in the process, OMA Council reviewed the proposed changes. As expected, there were lots of well thought out questions about the changes.
However, at the end of the day, one unassailable fact remained. All of the issues that had previously plagued the organization (contracts that paid sub-inflationary increases, not enough progress on relativity, concerns about representation, gender pay gap and much more), would still be around. Yet these were the very things the Council structure had failed to fix.
So the choice for Council was to stick with the old model, or to build a new one. In the end, they followed the advice of someone much smarter than me:
What does this mean for physicians? It means that come May the OMA Board will go from 25 physician members to 8 (plus three non-physician Board members to provide professional guidance). Council has been sunset. In its place, a new model with a Priority and Leadership group (max 125 docs) will exist. The bulk of the policy work and recommendations will be done by Working Groups dedicated to a specific task and which will allow expert members from throughout the profession.
How well will this work? Well it will depend on how much thought members give to the election process. They need to focus on who can represent them best at the various levels. But the reality is that a newer model of representation that is more nimble, strategic and rapidly responsive is finally here for physicians of Ontario. And we all owe a huge vote of thanks to Dr. Alam for starting the change and Drs. Hacker and Salamon for seeing it through.
Several years ago, one of my colleagues was having a disagreement with an external health care agency. She’s a very bright young family physician, and is extremely passionate about one part of comprehensive family medicine care. She really felt the external agency was failing in providing a reasonable level of service for one group of marginalized patients. In particular, she felt the agency’s process for accepting referrals was deeply flawed.
After months of advocacy by her, the agency finally reviewed their intake process. They then pronounced that everything was ok, because 90% of the referrals were processed accordingly.
In response, my tenacious colleague sent an email to all the family docs in the area, asking them for feedback on the referral process. She the proceeded to blast said agency for the 90% processing rate. “If a server at McDonald’s got the order wrong 10% of the time, would he still have a job?” was the line in her email that really got everyone’s attention. As a result, my colleagues sent feedback, the external agency’s response was proven inadequate, and changes were made. In her own way, my colleague was following the wisdom of Ruth Bader Ginsburg:
It also shows, in one neat example why physician autonomy is so important to patient care. Because without that autonomy, and independence, we can’t speak out. We can’t advocate for our patients even if it makes bureaucrats uncomfortable. We can’t expose those situations where patient care has been compromised.
This is, of course, exactly what those who want to take autonomy away from us want. For the most part this includes two types of people. First are health care bureaucrats, who feel that because they control the purse strings, everything should be done their way, and no pesky front line physicians should dare question their judgement or expose their flaws. The second group consists of a small number of physicians, who, while well intentioned, feel that physicians autonomy impedes whatever fancy new health program they want to implement.
Suppose you are an employee in the IT department of a corporation. You make a statement like say, “If our legal department worked at McDonald’s they would get fired because they get orders wrong 10% of the time.” What happens then? Human Resources gets involved, you get called out for making derogatory comments, the CEO might even get involved, you get disciplined and basically told to shut up. Even (especially?) if you are right in the first place.
This is exactly what those who oppose physician autonomy want.
The anti-autonomy crowd feels that physicians resist change. Therefore, the thinking goes, physicians will use their autonomy and independence to impede whatever new program/model/team is being promoted. Hence, autonomy must be curtailed so physicians can do what they are told, and accept whatever the powers that be tell them is good for them.
However, this couldn’t be further from the truth. The vast majority of physicians are open to new ways of doing things. If they truly believe a new process will help their patients, and help their lives, they will adapt. This is why we use new medications, new treatment protocols and yes, newer models of health care delivery than we used in the past. Medicine would not have changed so much in the past 25 years, if it wasn’t for the willingness of physicians to explore newer and different methods of delivering health care.
But as my friend’s example shows (and there are many like hers), what is essential to the provision of good patient care, is for physicians to retain their ability to speak out. My friend saw an area where a health care agency was failing a group of patients. Because she didn’t have to fear retribution in the form of being hauled up in front of Human Resources, she was able to effectively advocate for patients (who in this case happened to be too frail to advocate for themselves). Eventually, due to her persistence, the agency recognized their errors and fixed their flawed process.
In much the same way as we explore transforming the health system again (in Ontario these are to be done with the Ontario Health Teams or OHTs), it is fundamentally important to ensure that physician autonomy is protected in these models. This will allow physicians to speak up if the implementation plans are not going the way they should, or if programs promoted by the leaders are not really going to help patients. While painful for those in charge to hear criticisms, it results in better outcomes in the long run because the new programs will be better, stronger and more effective.
Let’s hope that as the new OHTs are developed (full disclosure, I support the concept) the message of the essential nature of physician autonomy is not lost. Physician autonomy has allowed us to be the best possible advocates for patient care in the past. If we can no longer, as Ginsburg urged, fight for the things we care about, it will be the patients who suffer.