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Lessons learned from pandemic in Niagara

Three years ago, we were just beginning to learn of a new virus that would lead to a time of upheaval from which we are still recovering. The first case had been confirmed in Canada
Dr. Mustafa Hirji, Niagara's acting medical officer of health.

Three years ago, we were just beginning to learn of a new virus that would lead to a time of upheaval from which we are still recovering.

The first case had been confirmed in Canada on Jan. 25, 2020, and by March 11 the World Health Organization had declared COVID-19 a global pandemic. Just two days later, in Niagara and across the province, recreational programs and community facilities were closed as we headed into March Break, and didn’t reopen. Schools too remained shuttered to students, with school boards scrambling to offer virtual learning.

By March 20, 2020, Niagara-on-the-Lake had joined the province in declaring a state of emergency. By April 3, Niagara Region and Niagara’s 12 local area municipalities had jointly declared a state of emergency.

What followed has been a swell of COVID waves as the number of cases, deaths and pressure on hospitals rose, peaked and declined — temporarily, as variants emerged, each wave leading to restrictions of different levels on society and businesses, enacted by federal, provincial and municipal governments.

Niagara’s acting medical officer of health, Dr. Mustafa Hirji, has been at the helm of the region’s public health department throughout, and not always in step with provincial regulations, or even Niagara municipalities.

He spoke with The Local recently about his handling of the pandemic, what lessons have been learned and what we might do better in the future.

“I think there’s a whole laundry list of these things, and the list will probably continue to grow,” he says. He’s hoping there will be some kind of commission struck that will have a look at our response and learn from it.

“The last two-and-a-half to three years’ experience certainly have had a huge impact on our society.”

He spoke of the 2003 outbreak of SARS, a severe respiratory syndrome coronavirus, which was often mentioned early on in this pandemic in reference to lessons we should have learned, but didn’t.

It was March 13, 2003, that Health Canada was notified of a cluster of cases in the Toronto area, and following that outbreak, much research was done on how to prevent the spread of the next infectious disease to come along. Reports and recommendations that came after SARS read like a blueprint for preparations to prevent a pandemic such as COVID, but were not all implemented.

One example Hirji pointed out was that masks and personal protective equipment were stockpiled to be ready when needed, but then we stopped paying attention, and the PPE was thrown out when past its due date, never to be replenished.

“We learned a lesson, but didn’t continue to follow it,” says Hirji. “We need to learn this is a cost,” one we won’t have to pay any more if we learn those lessons about how to prepare for infectious diseases of the future.

It’s important we don’t become complacent, and that we remain concerned in the long term, keeping issues ‘top of mind,”’ he says, “but I’m not sure how we deal with that.”

One of the problems has been having funding redirected over time, and funding that should have been spent on preparedness was reduced.

“We need to find a way to fund it. It’s like insurance. It’s expensive, but you have to be prepared for the future.”

Another lesson learned, he says is about the more vulnerable people in our society.

We learned that those most at risk, in addition to those with certain health conditions, were Indigenous people, minority races, and those living on low incomes who, among other problems, might have less access to primary caregivers for early intervention.

Some of those vulnerabilities are systemic, and some that can be changed, he says, but there is no doubt some were more vulnerable than others in terms of suffering the impact of the pandemic.

The vulnerable might be front-line workers, such as those working in grocery stores, people living in crowded housing with poor ventilation, or those who were slower on the uptake of vaccinations.“There is more to it than that, but we do see those vulnerabilities now,” he says.

“We don’t really understand all the dimensions of that, but we saw it clearly in the data around the world.”

He says looking back at the early days of the pandemic, another lesson learned is the need to react quickly, at all levels.

“We weren’t always very quick at absorbing new knowledge,” he says. He recalls the need for scientific data to back up actions, but wonders if there could have been a better balance between waiting for science and the need to move quickly.

The importance of masking is a good example, he says. By the summer of 2020, municipalities were talking about mask mandates, and on July 16, Niagara-on-the-Lake passed its mask bylaw, as other municipalities in Niagara were either considering or approving theirs. Some were waiting for a region-wide policy.

At that time Hirji was promoting the other practices that became routine: physical distancing, frequent hand-
washing, keeping our hands away from our faces, and wearing a mask when physical distancing wasn’t possible.

After a discussion about masking during a mid-July regional council meeting, councillors voted to defer a mandate, on Hirji’s advice. He said then that when issuing an order to deprive someone of an element of their freedom, he needed to have science behind it, and he didn’t think it had reached that threshold. It wasn’t until July 31 that a regional mask bylaw was approved.

“I thought that summer early evidence was showing masking worked and was something we should recommend,” he says now, without what he thought was strong enough evidence to mandate them.

“But maybe that wasn’t the right position. Maybe I should have been quicker to endorse mandatory masking.”

He adds the science was slow in recognizing the virus was airborne. “We largely believed it was spread by droplets.”

That’s where that balance between science and acting quickly is important, “and I don’t know if we always got the balance right.”

It also took some time to realize a two-metre distance was not enough, he added — the scientific community was slow to accept that.

But there was lots that was done right, in Niagara and across the country, he says.

“Canada as a whole took the pandemic serials seriously. We avoided it being politicized the way it was in the U.S. I think we really prioritized to protect people.”

The restrictions in place in Niagara, compared to the U.S., he says, “saved 1,400 lives in Niagara. We occasionally had to accept lockdowns, and we got people vaccinated. If we’d followed the pattern of the U.S. we would have lost many more lives. That's one thing we should be proud of. We made some hard decisions, but we did the best we could.”

Hirji points to Canada’s roll-out of vaccinations as one of the best in the western world in terms of the percentage of people who were vaccinated. Although there was some criticism of the time it took to get enough supply of vaccine, “we had the fastest roll-out and one of the highest percentage of people vaccinated in the world.”

The biggest error in Ontario was the initial provincial plan in the roll-out of shots, he says, where the decision was made to prioritize healthcare workers in some communities, rather than the most vulnerable population in all communities. “The group most at risk of dying was in long-term care. We needed to get vaccinations out to those in long-term care first in every community. I think that was the single biggest error. Niagara was not one of the areas selected to get vaccines early on, and sadly we saw a lot of people dying in long-term care homes.”

It was distributed to the areas that saw the highest number of cases, through December 2020 into January and February 2021, “while the virus was spreading quickly in long-term care and we weren’t prioritizing them for vaccinations.”

And although Toronto was considered a hot-spot, with a greater need for vaccinations, “it was just a few days away” from reaching Niagara, he says.

In January 2021, there were 177 deaths from COVID, and 136 of those who died were in long-term care.

“We didn’t get the vaccinations until the fourth week of January. If in mid-December the province had made the decision to send it to every region and prioritize long-term care residents, in Niagara we would have saved lives, and I think that’s true across the province.”

The provincial priority to vaccinate healthcare workers, and only in parts of the province, “was the wrong decision. The death numbers in Niagara speak to that.”

When the region received vaccine in January 2021, the local roll-out “was a real success. We vaccinated all long-term care residents in nine days. We moved quickly to get them vaccinated as soon as possible and to stop the horrible number of deaths we were seeing.”

By March, Niagara was able to offer vaccinations to the public, and was using up vaccines as soon as they were received, says Hirji, prioritizing those with certain health conditions, and some of those considered vulnerable.

Yet another lesson could be doing a better job of educating people about the importance of vaccinations, Hirji added.

As for the future, he hasn’t changed his mind about how to move forward. He continues to promote the importance of booster shots, which have a much lower uptake than the first set of vaccinations. If we don’t think we need to do it for ourselves, we should consider the need to protect the vulnerable in society, especially those in long-term care. And he will encourage people to have annual or six-month shots once we get to that stage. “There is a need to vaccinate for all of us, to protect our fellow citizens who are at higher risk,” he says.

“We could be as high as 95 per cent vaccinated. How do we get from where we are to where we could be?”

With COVID causing only mild symptoms now, especially for those fully vaccinated, there is a sense of complacency, that it’s not such a big danger as it was before, “but people need to understand it still can be serious. It’s still the third leading cause of death,” behind cancer and heart disease.

“Even if you don’t get sick, someone else in your life might.” Or you could be part of a chain of people who will pass it on to someone who will get sick and potentially die, or someone either visiting or working in a long-term care home that will be the cause of another outbreak, he adds.

But despite his desire to see higher vaccination percentages, he says, “we have one of the best uptakes in the world, and it has changed the dynamics of COVID for us. Vaccinations are one of the great success stories for us.”

If vaccinations are our first defence, masking remains the second, says Hirji. “It’s a little bit of a nuisance, but it really does make a difference in the spread of the virus.”

And given that we know it’s airborne, investing in improved ventilation will also stop the spread, not only of COVID, but other respiratory illnesses, such as influenza, and any future viruses that might come along. “There is a huge upside to making that investment” in places where people are going to gather, such as schools, stores and restaurants.

Improved ventilation in new buildings should be a priority, and he hopes to see changes to building codes to make sure that happens. While upgrades to existing buildings can be expensive, “it’s not a lot more to build to a higher standard in new buildings.”

Niagara regional council endorsed a motion earlier this year to recommend the province and federal governments update building codes and make funding available for small  businesses to invest in ventilation, he adds.

As Hirji and the public health department continue to work to keep people safe, after almost three very difficult years, The Local asked how he personally has dealt with those challenges.

“It’s a hard question to answer,” he responds, not surprising from someone who is known for protecting his privacy, and for good reason — during the height of the pandemic, his home was targeted by protesters against vaccinations, especially for children, and who blamed him for the loss of jobs for those who refused to be vaccinated.

Despite some of the challenges, including regional councillors who questioned some of his recommendations — although never as a council voted against him — he says, “it felt a little bit normal.”

He spoke highly of “a really incredible team at Niagara Health. Having that great team means you don’t feel like you’re dealing with it alone. Also there were conversations with colleagues across the province. Feeling like you’re part of a team is one element that helped.”

As someone “oriented in science, like any physician,” he says, “you’re used to dealing with bad news. You focus on the science and know you’re not always going to get it right, but you do your best and make your decisions. That gives me a lot of peace of mind, knowing that I did what I thought was best.”

Criticism is nothing new in the role he plays, he says.

“Some people are upset with rules, some people are against vaccinations, but they’re just voices that are a little louder.”

As for regional councillors who didn’t always agree with him, he says that was another lesson he has taken away from the pandemic. He realized he wasn’t doing a great job of communicating, and that there was a better way to engage with councillors, so they would have a better understanding of what he was proposing and why.

One last question for the region’s acting medical officer of health was not his to answer, he says.

What does he have to do to get rid of the “acting” in his title?

He’s been the acting medical officer of health since Dr. Valerie Jaeger left the position about five years ago, when he moved from assistant medical officer into her job.

The next step “is a decision of regional council,” he says. “I don’t play a role in that. It’s their process, and it’s up to them.”