hen a novel coronavirus outbreak in China first came to the world’s attention on New Year’s Eve in 2019, Canada had a long-established global health surveillance and pandemic early warning system in place. The government pandemic strategy identified surveillance as “the key to effective action.” Faced with a new and unprecedented coronavirus threat, the surveillance and warning system failed, resulting in costly delayed responses. An understanding of the causes of its failure will be critical to building a better Canadian system for the future. Canada, of course, was not alone in failing to appreciate early enough the true dimension of the threat posed by what came to be called COVID-19. This fact does not ameliorate the Canadian failure, but the elements of what went wrong, and recommendations for change, may have relevance for other counterpart states.
The Canadian health security system that was deployed to meet COVID-19 had roots that reached back to the experience of the severe acute respiratory syndrome (SARS) outbreak in 2003. Although SARS imposed far less a toll than COVID-19 has done, it was a wake-up call. In its aftermath, a serious effort was made to learn lessons and to make fixes to Canadian public health. One sweeping change, recommended by a National Advisory Committee that reported in October 2003, was to the federal governance structure. This led to the creation of a new federal department of health (Health Canada), a new federal agency (the Public Health Agency of Canada [PHAC]) and the position of chief public health officer of Canada.
Ontario, the province hardest hit by SARS, conducted its own inquiry, led by Justice Archie Campbell, which found major failings in provincial health care. One of the most important recommendations made by Justice Campbell was for the adoption of what he called the “precautionary principle” as a guide to all preparedness and response activities. The precautionary principle, in the words of the Ontario commission report, “states that action to reduce risk need not await scientific certainty.” In essence, Justice Campbell was arguing for the adoption of a “reasonable worst case” approach to threats posed by health outbreaks, which would be a standard later adopted by Public Health England.
A third component of changes made in the aftermath of SARS was to be found in Securing an Open Society: Canada’s National Security Policy, issued a year later in 2004. The national security policy, itself unprecedented in Canadian history, was notable for three things: its adoption, despite the ongoing climate created by the September 11 terrorist attacks, of a broader all-hazards approach to national security; its discussion of the role of intelligence as the nation’s “first line” of defence; and its efforts to ensure that health security was better integrated into national security going forward.
Experience has taught us that in a post-pandemic (or “interpandemic”) period, the urgency of change diminishes over time and some core lessons can be forgotten or unrealized. In the Canadian context, organizational changes at the federal government level did become entrenched. But neither Justice Campbell’s precautionary principle, nor the new approach to national security outlined in the 2004 policy, gained traction.
Canada’s post-SARS approach was cemented in The Canadian Pandemic Influenza Plan for the Health Sector, first issued in 2006. The plan emphasized the importance of health surveillance to “drive” the pandemic response and to determine the various phases of a pandemic outbreak. In the critical “pandemic alert period,” defined by the detection outside Canada of a new type of human infection, the Canadian approach would be to work closely with the World Health Organization (WHO), and with international partners, to establish current risk assessments. The key collection sources would consist of official information from the WHO and other governments’ influenza surveillance programs, alongside what was described as “unconfirmed reports” from media scanning systems such as the Canada-based Global Public Health Intelligence Network (GPHIN) and the US private sector-run ProMED, an internet-based warning network. No mention was made of any reliance on national intelligence systems, either Canadian or allied, for any early warning information or assessments. No guidance was provided in the plan’s detailed annex on health surveillance (including later iterations) on how to conduct health security risk assessments.
The pandemic readiness system eventually settled into a bureaucratic routine, perhaps even complacency. No large-scale exercises or simulations were carried out to test the system. There were scares, including the swine flu (H1N1) outbreak in 2009; the emergence of Middle East respiratory syndrome (MERS-CoV) in September 2012; a new strain of avian influenza (H7N9) first revealed in China in March 2013; and the Ebola outbreak in West Africa that began in 2014. Of these, only H1N1, which originated in Mexico in March 2009 and quickly spread to Canada, posed a direct threat to Canadians.
An internal lessons-learned exercise on the H1N1 experience concluded that the response of the PHAC and Health Canada had been effective. Canada functioned as a leader in the international response to H1N1 and had been the first country to identify the H1N1 genome. The health surveillance system had worked well in identifying and monitoring the outbreak, according to the study. Some tweaks were recommended, including to mechanisms to ensure good cooperation across federal, provincial and territorial jurisdictions; to continue work on readiness; and to develop better approaches to the communication of scientific evidence. The change agenda focused exclusively on improvements to the domestic capacity for information collection, sharing and epidemiological modelling.
Confidence in the Canadian health security system was subsequently bolstered by two external evaluations. A visiting WHO team, drawing on data and self-assessments provided by the PHAC, completed a study in 2018. Canada gained exceptional scores. The WHO mission report noted the important role played by the GPHIN, commenting that “signals” from the GPHIN and other informal sources are “rapidly acted upon as they trigger a cascade of actions, across jurisdictions and government sectors, ranging from assessment and monitoring to discrete or large-scale responses.”
Another major pat on the back was provided by an independent study, the Global Health Security Index, of the 195 member countries of the WHO, published in October 2019. Canada scored fifth overall in the world for its health security capabilities (behind the United States, the United Kingdom, the Netherlands and Australia). In the category of “Early Detection and Reporting Epidemics of Potential International Concern,” Canada ranked fourth in the world, with a very high score of 96.4 out of 100.
High confidence in the Canadian system was the theme of a presentation to the WHO by a senior Canadian PHAC epidemiologist in November 2019. The WHO audience was told that Canada was fully ready to provide early warning of a global health outbreak, thanks to the recent modernization of the technological capacities of the GPHIN and improvements made to the PHAC’s situational awareness reports.
One month later, a novel coronavirus outbreak began in the city of Wuhan, China. On December 31, 2019, according to a PHAC vice-president, Canadian officials received their first “ping” about the outbreak.
Two weeks later, the PHAC began to circulate a daily situation report (sitrep), summarizing the latest developments with the outbreak and conveying the Canadian risk assessment. Thirty-seven of these sitreps were made available to a parliamentary committee and form the basis for the analysis of the Canadian record of early warning that follows.
The first sitrep of January 15 utilized existing data from the Wuhan Municipal Health Commission in China (which we now know to have been unreliable), cast doubt on the possibility of human-to-human transmission of the virus and assessed the public health risk to Canada as “low.” This risk level was benchmarked against a US Centers for Disease Control and Prevention (CDC) preliminary risk assessment on January 13, which also considered the risk to be low in the United States.
While daily sitreps continued to be released, the underlying PHAC risk assessment was not updated until 10 days later, on January 24. The new PHAC risk assessment was reported with the January 26 sitrep. By this stage, Canada had experienced its first confirmed case of COVID-19 (a traveller from Wuhan to Toronto). The sitrep noted that “identification of an imported case of 2019-nCoV in Canada was not unexpected, and the assessment of the public health risk of spread within Canada remains low.” On the global stage, the PHAC noted that China had reported 1,975 cases of the novel coronavirus in 30 provinces and had taken “exceptional measures to reduce further spread of the virus.” These measures were publicly announced by the Beijing authorities on January 23. Forty-six cases of the novel coronavirus had been reported outside mainland China in 14 countries; the United States reported three of these cases.
The WHO’s risk assessment matrix, meanwhile, was shifting. The WHO now rated the risk of 2019-nCoV (as it was then denoted) as “very high” in China, “high” at the regional level and “moderate” at the global level. The CDC, our other main benchmark, used a confusing mix of language in its assessment, but sustained its “low” risk outlook: “While CDC considers this a serious public health threat, based on current information, the immediate health risk from 2019-nCoV to the general American public is considered low at this time.”
A third update to the PHAC risk assessment took another six days to produce and was incorporated in the January 30 PHAC sitrep. The virus continued to spread massively in China, with 7,711 reported cases and 170 deaths. Globally, the virus’s advance also continued, with 105 cases reported in 21 countries. Canada’s case count now stood at three. The January 30 report stated that only three countries outside China had confirmed locally acquired novel coronavirus cases: Germany, Japan and Taiwan. This was factually incorrect. The WHO had reported the first human-to-human transmission outside of China in Vietnam on January 24. By January 30, the CDC had also confirmed human-to-human transmission in the United States.
The January 30 PHAC assessment of public health risk within Canada remained at “low” and continued to diverge from the WHO benchmark, which had been revised to rate the risk from the virus as “very high” in China, “high” at the regional level and now “high” at the global level. After an initial deadlock among WHO executive committee delegates, the WHO director-general had declared the outbreak in China to be a “public health emergency of international concern” on January 30. This was a major step in identifying the global threat posed by this novel coronavirus, but it did not produce any change in the official Canadian risk assessment.
Astonishingly, the PHAC risk assessment machinery ground to a halt, for unknown reasons, in February. Only one new risk assessment report was produced, on February 2. The next PHAC daily sitrep on February 3 indicated the Chinese case count had leapt to 17,205, with 361 deaths. Globally, there were 181 cases of the novel coronavirus from 26 countries outside China. Canada had four confirmed cases. The sitrep noted that “only” six countries outside mainland China had identified locally acquired (human-to-human) cases. This was double the number from the previous (and incorrect) risk assessment of only a few days earlier. Despite the mounting toll in China and the continued pace of global spread, the PHAC risk assessment continued to identify the public health risk within Canada as “low.”
The final PHAC daily sitrep in the package released to Parliament is dated February 26. It relied on the three-week-old (February 2) risk assessment, despite the fast-moving pace of COVID-19, and continued to specify a “low” public health risk for Canada. By February 26, there were 78,064 confirmed cases in mainland China, with 2,715 deaths reported. There were 3,178 cases outside China, with 53 deaths reported. The health crisis in Italy was well under way, with 374 cases reported in that country. The Canadian case count had risen to 12, with one case confirmed involving travel from Iran (another newly emerging global hotspot for the disease). The United States had not yet begun to experience its precipitous surge in cases, but its official count had risen to 53 confirmed.
Canadian government statements and briefings from public health officials reveal that the risk assessment for Canada remained at “low” into the first weeks of March. It was not until March 15 that Canada’s chief public health officer, Dr. Theresa Tam, stated that COVID-19 was now to be considered a “serious” health risk to Canada and to Canadians. A whole cascade of government responses followed, including the closure of Canada’s borders starting on March 18, and an appeal for Canadians abroad to return home, where they would face self-isolation (not official quarantine) for 14 days.
Failure to budge from an initial “low-risk” assessment in the two-month period from mid-January 2020 to mid-March 2020, despite the mounting toll and global spread of COVID-19, is the starkest illustration available of the Canadian failure of assessment and early warning. Risk assessment degenerated into daily reporting and failed to find a predictive voice. The consequences of a failure to warn were that preparations and measures for dealing with the crisis, such as border closures, ramping up of critical health-care supply stockpiles and societal lockdowns, were introduced late and in incremental and often confusing fashion.
There were missed opportunities. The Canadian health surveillance system could have started “blinking red” in the aftermath of any of these developments: after the January 23 announcement by the Chinese government of exceptional measures taken to combat the COVID-19 outbreak in Wuhan; following the WHO determination on January 30 of a “public health emergency of international concern”; or after witnessing the fearsome scale of the outbreak in northern Italy in the third week of February. None of these opportunities were seized.
Preparing for future pandemics requires a “back to the future” moment. Some of what was learned and lost post-SARS needs to be reimagined. There is a need for a new national security strategy that will articulate for Canada, in an all-hazards framework, the nature of major threats, including pandemics, and the response capabilities required to meet these threats. There is a need for better integration of health security and national security capabilities, specifically in global health surveillance, early warning and risk assessment. There is a need to understand that singular reliance on open-source collection and channels of reporting through the WHO will not suffice in every global health outbreak. The special collection capabilities and assessment expertise of the national security system will have to be ready to be called upon. Important governance changes introduced after SARS need to be further extended to ensure that there is a senior coordinating authority for health surveillance and early warning that can operate in a whole-of-government system. Models are emerging for study in our Five Eyes (Australia, New Zealand, the United Kingdom and the United States) allies. The recent British creation of a Joint Biosecurity Centre offers one such model. The new powers of the Office of National Intelligence in Australia might offer another.
We need, in short, a new blueprint for health security intelligence and early warning. A future pandemic may be right around the corner; it may be lurking in the middle distance or it may, if we are lucky, be farther off. When it comes, Canada must be ready to have the blinking lights go red.