The Risk of Groupthink in Pandemic Planning and Preparedness
If Big Bureaucracies Can’t Get Important Things Right What’s Their Value?
In the absence of a federal inquiry into the Canadian approach to the COVID-19 pandemic, it’s important to ask questions in the context of the inquiries and reports in other countries, despite the reality that many Canadians would like to move on from hearing anything COVID related.
SARS-CoV-2 continues to evolve with new variants posing potential threats to current vaccines and treatments. We have much to learn from how Canadian health officials responded to the virus in 2020 through 2022. There is no question that Canada can do better and that is why the findings from other countries are of interest – and can be instructive.
Beyond COVID-19 it has been said that it is not a matter of if there will be another pandemic, it’s when. Simply put, Canada needs to be much better prepared.
Instead of signing on to the World Health Organization’s Pandemic Agreement (Pandemic Treaty) through which more than 190 countries agree to accept the WHO’s national influence over pandemic response, Canada should be considering the long-lasting implications of the WHO’s deadly statement early in the pandemic that “COVID is not airborne”. The importance of improved public health understanding of aerosol spread of infectious diseases and an indoor air quality approach to pandemic preparedness cannot be overstated.
Difficult questions surrounding the massive global public health failure to contain SARS-CoV-2 must be asked. Over 25 million people have died around the world in the past five years of the COVID-19 pandemic and millions more have been left with Long Covid also known as Post Covid Condition. Even nosocomial spread continues unabated.
Amongst all the layers of public health and infection prevention and control (IPAC) specialists at thousands of institutions, agencies, tables, and committees across the country, where was the critical thinking about the dominant mechanism of transmission of SARS-CoV-2? Or was it easier to go along with the WHO?
Was the possibility of airborne spread beyond aerosol generating procedures raised but drowned out by the need for consensus? Or by the need to address resources?
Were dissenting voices heard? Or were they peripheralized for convenience?
What were the factors that delayed acknowledging that the focus on contact and droplet transmission was not adequate to control the spread of COVID-19?
What held public health experts and IPAC specialists back from admitting their error for so long? Fear of being wrong? Liabilities?
What help or hindrance was the relationship of the Council of Chief Medical Officers of Health (CCMOH) with the Pan-Canadian Public Health Network’s Special Advisory Committee on COVID-19 (SAC), activated in January 2020 with its multiple advisory committees, the Logistics Advisory Committee (LAC), the Technical Advisory Committee (TAC), and the Public Health Network Communications Group (PHN CG)? Or was this bureaucratic arrangement simply a way for provinces and territories to align with federal thinking and messaging?
Despite a vast network of experts federally and provincially the predominant mode of transmission for SARS-CoV-2 was not accurately identified as airborne/aerosol or communicated publicly for over a year. According to some experts, long-term care homes and other congregate care settings received sub-standard public health guidance despite having the most vulnerable group of people concentrated together.
What does this say about our public health agencies’ ability to practice critical thinking or at least to value it?
To add insult to injury, Canada’s Public Health Agency added to its payroll after the emergency phase of the pandemic was over. Parliamentary Budget Officer Yves Giroux is reported to have said: “Over time we are seeing an increase in the number of public servants, in public expenditures, but year after year, despite the fact departments choose their performance indicators and targets, they don’t seem to be getting significantly better.”
If big bureaucracies can’t get important things right, what is their value?
Can they be depended on to function effectively when their roles are critical to the health of a nation?
Fortunately, the UK COVID-19 Inquiry is helping to answer some of these questions and other countries like Canada can learn from the UK’s years-long efforts to bring some degree of transparency.
The UK Covid-19 Inquiry Transcript of Module 3 Public Hearing on 27 November 2024 is illuminating and deserves a read from anyone wanting to understand how Canada could do better in its response to future pandemics.
Here are some excerpts from pages 25 to 159 (please note that FFP3 refers to N95):
Here is an excerpt from page 25:
“…ageing estates meant that infection control measures could not always be fully implemented. Witnesses described working in unsuitable spaces with large open bays and inability to distance between beds, a lack of side-room capacity to isolate patients and a lack of ventilation. In the words of Michael McBride, there is no doubt that the "fabric" of NHS estates increased the risk of nosocomial infections. Over 9,000 deaths are attributable to nosocomial infection in England alone, and we have heard many moving stories of those whose loved ones were admitted to hospital in circumstances unconnected to Covid-19 only to become infected and tragically die. Regarding the debate about whether the NHS was overwhelmed, the BMA points to the fact that vast swathes of care had to be cancelled and patients who would normally have received treatment did not. Healthcare workers were physically and emotionally overwhelmed and they still bear the scars today. To downplay these impacts, intentionally or not, is a mistake. The BMA accepts that the decision to run the NHS in this way is a political one, however the Inquiry proceedings have laid bare its catastrophic consequences, which are destined to be repeated without fundamental change.”
On page 30:
“Further, if the efficacy of FFP3 is seriously in doubt, why are they recommended for intensive care and aerosol-generating procedures? Attempts to justify the failure to recommend FFP3 based on considerations of comfort are equally surprising. PPE can be uncomfortable but this is nothing balanced against the need to protect against a deadly disease transmitted by everyday actions such as coughing, sneezing, talking and breathing. These arguments are simply a continuation of the stubborn refusal to acknowledge the risks of aerosol transmission, to recognise they'd got it wrong and to take remedial action. In the words of a doctor in Scotland: [As read] "The PPE guidance was based not on safety but rather the lack of preparedness. False platitudes of staff safety were peddled out when in fact staff were left at higher risk." Staff confidence in the IPC guidance is essential for safety, and the widespread loss of confidence is a very serious concern. It is a matter of regret that the opportunity has not been taken to restore confidence by properly explaining the risks faced by staff and the extent to which supply shortages were a factor.”
On pages 141 and 142:
“For too long, officials have tried to prop up the house of cards on incorrect assumptions about modes of transmission. The Inquiry has heard plenty of evidence about explanations, groupthink, entrenchment, confirmation bias, deference to the IPC Cell. But whatever the reason, the reality is that this led to a failure to adopt a sufficiently precautionary approach. I don't propose to dwell on the reasons; instead, now that the house of cards has come tumbling down, in fact has been blown down, and the significant role played by airborne transmission is beyond doubt, CVF urges focus on the next steps. Adequate ventilation has been something of an afterthought by IPC professionals, as Professor Beggs said. Now, everyone seems to agree on its importance, from Beggs, to Hopkins, to Ritchie, and many in between, including the Inquiry's own expert Dr Shin, who picked this as his headline recommendation. He said: "It would be really important to review and improve the NHS estate, particularly in ventilation and isolation capacity. The reason why this is important is because, in facing any epidemic or future pandemic, if the legacy inadequacies of our NHS estate across the country, which in some places is very old, if that is not improved, we will face the next emergency with the same difficulties that we encountered this Covid pandemic." Sir Chris Whitty: "... we should [take] indoor ventilation ... a lot more seriously and ... more vigorously than we [did] previously ..." No one has seriously challenged Professor Beggs' robust conclusion that the HTM guidelines are not fit for purpose and in urgent need of reform. And no one disputes that modernising the NHS estate, and so improving mechanical ventilation makes a remarkable difference to the rates of nosocomial infection for Covid-19 and other pathogens. My Lady, we hope that you don't shy away from making a strong recommendation on this despite the cost. The cost of doing nothing will be much higher, especially when -- when, and not if -- there is another pandemic with a pathogen which spreads through the air. In the meantime, HEPA filters are low-hanging fruit, as one expert said. No one has disagreed they need to be more widely deployed now, and that urgent research is required on how they can be deployed more effectively.”
On pages 154 and 155:
“We now know that the UK IPC Cell was de facto the central government body evaluating and determining issues of transmission, appropriate RPE and healthcare worker infection prevention and controls. Although it received inputs from other organisations such as SAGE and the EMG or NERVTAG, it discussed and determined its response to those inputs. So, the fact the entire edifice appears to be the work of four individuals working for ARHAI carrying out rapid reviews with no clear methodology is a real concern, particularly when that work became the institutional position for one of the four constituent public health agencies. You may think that when that work was being discussed in the UK IPC Cell meetings, there was an unacceptably restrictive base of expertise. Vital additional expertise from disciplines like engineering or physics were excluded. Key sectors such as the ambulance sector were inadequately represented. This had real world consequences, as explained by Tracy Nicholls, or John's evidence in the first impact video, one of the most effecting pieces of evidence in the Inquiry. Even within the cell, a few handful of people became the true decision-takers; what they called “consensus" was really just what some key people, including Lisa Ritchie, and the ARHAI personnel, thought should happen. Sustained and consistent dissent from December 2020 onwards from Public Health England and belatedly the UKHSA, concerning airborne transmission and the wider use of FFP3 masks, was brushed aside. This consensus view is also fundamentally dangerous. Essentially, consensus is a popularity test for an agreement rather than seeking the right answer based on facts. Those problems were compounded by there being insufficient safeguards in relation to what was produced by the UK IPC Cell. Public health bodies did not re-review the guidance before publishing it. The witnesses from Public Health Wales and Public Health Agency in Northern Ireland said that in their oral evidence. The CNOs and CMOs did not review the guidance despite having oversight responsibility. Those involved in the IPC Cell have demonstrated, even in their evidence at this Inquiry, they would rather maintain wrong thinking than admit those failures. “
On page 157:
“In this topic also, the production and dogmatic insistence on the AGP list, you may conclude, was either about rationing or, worse, seeking to provide false reassurance to healthcare workers. Ultimately, this AGP list and the debate around it was pointless because the rationale was flawed. The fact that the list itself became the subject of arguments distracted from the futility of the list itself. Obviously, many ill people will generate aerosols from a cough. A symptom of Covid is coughing. Professor Banfield agreed, a cough is a cough, whether naturally produced or stimulated by a procedure. The cough and the aerosols generated by do not change. RPE was obviously required well beyond intensive care.”
And finally, on page 159:
“So we say that healthcare workers can no longer have confidence in the current IPC leadership. The evidence that you've heard from the IPC witnesses is unhelpful and, going forward, healthcare workers are not going to be able to have their trust restored in that. The NHS and other public health bodies have a leadership issue. It speaks to wider cultural issues with healthcare which have already been laid bare by other investigations. The contribution to this Inquiry of those in leadership positions has the potential for far-reaching consequences on the confidence of the healthcare worker professions and also the ability of the system to respond to major healthcare crises in the future. Deflection and covering up will not do. The worry, my Lady, is that in future pandemics that loss of trust causes issues with whether healthcare workers are going to be wanting to refuse to treat people if they know that their own lives are not protected in that way.”
The ill-fated statement by the World Health Organization on March 28, 2020, that “FACT: Covid is NOT airborne” misinformed a public health COVID-19 response that was entirely inadequate.
Trust in public health has been seriously eroded and may take decades to recover with all the repercussions. The WHO perpetuated this false information for many months and national public health agencies accepted it without full transparency. Now the WHO wants to have even greater power over pandemic management with the signing of a Pandemic Treaty. Countries around the world, Canada included, should say “No”.
In mid November, Co-chairs of the Word Health Organization’s Intergovernmental Negotiating Body announced that the Pandemic Agreement will not be adopted at a special World Health Assembly (WHA) this December. The explanation is that some countries have not yet concluded complex talks. WHO officials are now worried that a new treaty will not be signed in 2025. If this is the case, there is still time to avoid another global health failure from top-down public health politics.
Canadian health officials need to learn from their missteps in this country’s response to COVID-19. Again, in the absence of a public inquiry into Canada’s 2020 pandemic response, Canadians should be taking note of the UK COVID-19 Inquiry testimony and findings to learn what can be done better.
View related short video:
Dr. Merrilee Fullerton’s book “A Physician in the Political Arena” can be read here.
References:
“Expert reaction to report from module 1 of the Covid inquiry”, UK, Science Media Centre, July 18, 2024
https://www.sciencemediacentre.org/expert-reaction-to-report-from-module-1-of-the-covid-inquiry/
“Transcript of Module 3 Public Hearing on 27 November 2024 - UK Covid-19 Inquiry”, November 27, 2024
“Increased Hiring After Covid”, Blacklock’s Reporter, November 22, 2024
https://www.blacklocks.ca/increased-hiring-after-covid/
“Systematically omitting indoor air quality: sub-standard guidance for shelters, group homes and long-term care in Ontario during the COVID-19 pandemic”, Critical Public Health Volume 33, 2023, Issue 5, received October 25, 2022, Published online October 13, 2023
https://www.tandfonline.com/doi/full/10.1080/09581596.2023.2262736
“Pan-Canadian Public Health Network, COVID-19 Response, Special Advisory Committee on COVID-19”
https://www.phn-rsp.ca/en/about/covid-19-response.html
“Statement from the Council of Chief Medical Officers of Health: Working with Canadians on the ongoing management of COVID-19 in the months ahead”, Public Health Agency of Canada, modified November 1, 2020
“Ontario Implementing Enhanced Measures to Safeguard Public from COVID-19, Although Risk in Ontario Remains Low, New Structure will Ensure Health System Readiness”, Government of Ontario Newsroom, March 2, 2020
“Ventilation data clears up air quality questions in Ottawa’s city-run LTC homes”, CBC News, March 19, 2022
https://www.cbc.ca/news/canada/ottawa/ottawa-long-term-care-ventilation-1.6387319