Vaccination Street

[Note: this post has been modified in minor ways to clarify points and correct typos.]

Vaccination Street

This was me at St. Joseph’s Health Centre in Toronto on Thursday, having just been vaccinated against Covid-19. I expected it would be a day of celebration: I was the last adult in my household to receive a vaccination, qualifying as an essential caregiver under Phase 2 of the province’s vaccine rollout, and had been watching both the province and country’s vaccination rate tick steadily upward.

I was wrong.

Hours after I received my shot (Pfizer), Unity Health announced it would be shuttering its vaccination clinics at both St. Joe’s and St. Michael’s Hospital due to a shortage of vaccines. This news came a day after three other Toronto-based health networks — Scarborough Health Network (which runs community and hospital clinics in the city’s east end), East Toronto Health Partners (which supports clients in the city’s densely populated Thorncliffe Park community) and University Health Network (whose affiliations include Toronto General, Toronto Western and Princess Margaret Cancer Centre) — closed their vaccination clinics to some or all new registrations and, in some cases, began cancelling previously booked appointments.

On Wednesday, Toronto reported 1322 new cases of Covid-19. On Thursday the number was 1254, and on Friday it rose another 1527 cases. On Friday the Province of Ontario reported 4,812 new cases. These are record numbers for both the City and Province, and represent highs not previously seen at any time during this pandemic.

How did it come to this?

For weeks Ontario Premier Doug Ford and federal representatives (including Federal Procurement Minister Anita Anand and Prime Minister Justin Trudeau) have traded barbs and blame regarding vaccine supply. These accusations reached a fever pitch this past week, while caseloads in Ontario skyrocketed. Ford has blamed the federal government for its failure to provide a steady supply of vaccines, while the federal government has blamed the province for its failure to deploy all the vaccines allocated to it. Unsurprisingly in this ideological age, public perspectives on who deserves the most blame align tightly with political orientation: the left-wing perspective is that Ford has sacrificed the most vulnerable of Ontarians upon the altar of capitalism, while conservative-minded commenters attack Trudeau for failing to secure borders and bowing to the World Health Organization’s compromised authority.

Me, I blame them both.

How the Federal Government Failed Canadians

Canada’s federal government is famously terrible at procurement. Canada’s problems with procurement have persisted and arguably worsened over the last two decades. They are widespread, ranging from failures in procurement for military equipment, infrastructure, even personal protective equipment during the pandemic. Analyses of the federal government’s procurement failures typically point the needle midway between ineptitude and corruption, a classically Canadian equivocation geared to ensuring that little will change.

Some commentators have excused Prime Minister Trudeau on this very basis, pointing out (correctly) that the federal Conservative government under Brian Mulroney began privatizing vaccine manufacturing capacity in the 1980s, adding that for the last two decades what little remains of drug manufacturing capacity in Canada has been controlled by multinational drug companies. Two subsequent pandemics (SARS in 2003 and the H1N1 influenza outbreak in 2009) did not, despite warnings, motivate the federal government to regain domestic control over the country’s drug supply. That the loss of domestic drug manufacturing capacity and attendant drug supply problems have persisted and continued to worsen under Conservative (Mulroney, Harper) as well as Liberal (Chrétien, Martin, Trudeau) leaderships means that while Trudeau’s failure to procure a stable supply of Covid-19 vaccines may have a historical context, it cannot be blamed only on decisions made by another party’s prime minister decades ago. Notably, by the time the pandemic began, Trudeau had been elected to serve a second term as Prime Minister and was in the fifth year of his party’s mandate.

It is my view that the federal government’s failures in Covid-19 pandemic management and oversight are rooted in a combination of inexperience, overconfidence, ineptitude and gutlessness. Inexperience is understandable — it has been a century since the last truly global pandemic — and missteps were inevitable. Shifts in federal messaging as the pandemic has proceeded (regarding border closings, quarantine rules, mask mandates, etc.) are also reasonable and inevitable.

Overconfidence in the federal government’s response is more of a problem, as overpromising and then under-delivering on vaccine supply promises has simultaneously worsened conditions on the ground and eroded public trust. In December of 2020, Bloomberg Media reported that “Canada has reserved more vaccine doses per person than anywhere,” adding that the country had raised eyebrows internationally by reserving enough does to fully inoculate 154 million people, or four times Canada’s total population. Noted in passing was Canada’s “lack of local manufacturing capacity,” a problem that has since become the punchline in the subsequent months of vaccine shortages. By February, Canada’s vaccine shortages had become international news. In the same month, the Canadian government drew international criticism for being the only G7 nation to draw vaccines from COVAX, an agency set up to fund vaccines for poorer countries. Unsurprisingly, vaccine shortages have hampered the provinces’ efforts to plan and deploy vaccine rollout. Also unsurprisingly, they have eroded public trust. Public opinion polls have found public confidence in the federal government’s handling of the pandemic to have slipped greatly a year into the pandemic, linked mainly to perceptions of delay and ineptitude in federal response.

Why has Canada experienced so many vaccine shortages? Because — oops — while its procurement teams managed to negotiate boastfully large quantities of vaccines, the contracts do not appear to have included strong benchmarks for their actual delivery. This is an amateur error, at best, and its consequences have been embarrassing and costly. When vaccine manufacturers have run into production issues, they appear reliably to have prioritized other commitments to other countries. Canada has been punted unceremoniously down the line.

Ineptitude at the beginning of in an unprecedented crisis is connected to inexperience. But more than a year into the pandemic, ineptitude is no longer so forgivable. Fourteen months into the pandemic, Canada’s border with the US remains more-or-less closed, but international flights continue to leave and enter Canada every day, bringing devastating variants into a country poorly equipped to withstand them. The federal government has received sharp criticism for its failure to screen residents adequately upon arrival and to ensure people quarantine after arrival as required, and has been slow to implement new measures (which, like Covid quarantine hotels, were then criticised, perhaps perversely, for being heavy-handed).

As for gutlessness, well. Perhaps ‘gutless’ is too strong a word. And to be fair to the Canadian government, global relations, even at their best, involve a delicate dance of diplomacy and consequence. And Canada has, for better or for worse, taken its lead from the W*rld H**lth Organization, which has its own delicate dance of diplomacy and consequence to choreograph. But from the beginning, even when evidence was pouring in that the Ch*n*s* government had concealed the spread of Covid-19 within its own borders, threatening and disciplining even its own medical experts who raised the alarm and resulting in the virus’s spread to other countries, Canada downplayed criticism of the country, refused to close borders or test passengers, and shipped PPE to Ch*n*a — the world’s largest manufacturer of PPE — weeks before our own country faced a critical shortage of this urgently needed equipment.

The W/H/O has, to its credit, sought to encourage Ch*n* to contribute to global efforts to fight Covid-19, and has worked with Ch*n* to uncover the virus’s epidemiological origins. This is not a simple task, particularly in an environment of epochal tensions among global powers and superpowers, and the W/H/O has undoubtedly been hamstrung by its fully understandable wish not to destabilize any of the existing im/balances. The W/H/O’s mandate is to improve global health and wellbeing and respond to health emergencies, and it has tried, admirably under the circumstances, to do so. But countries like Canada could have done a far better job of supporting the W/H/O’s efforts by, say, holding the Ch*n*s* government at least somewhat accountable.

Canada’s own position is made difficult, of course, by the imprisonment of two Canadians in Ch*n*, currently on trial under circumstances reflecting a power struggle between Ch*n* and the US. It is also complicated by a surge of Anti-Asian racism and violence during the pandemic. But it seems to me that the federal government could have done a better job of juggling these considerations in ways that would have better protected the public or at least reduced Canadians’ exposure to Covid-19 and its variants. Other countries, including New Zealand, Australia and Japan, have managed this juggling act without, for the most part, inflaming international tensions.

How the Federal Government Saved Canadians

Having criticised the federal government for failures that will inevitably, alongside others, come up in the public inquiry that will also inevitably (Canadians having an endless appetite for inquiries and commissions whose earnest, evidenced, balanced and usually excellent recommendations are quickly forgotten) follow the pandemic, I think it is also fair to praise it for an action responsible for as many as 2.3 million vaccinations (and counting), including up to 900,000 in Ontario to date: its unpanicked response to reports of rare blood clots in people who have received the AstraZeneca vaccine.

When some other countries paused or completely halted distribution of the AstraZeneca vaccine following reports of a link between AastraZeneca and blood clots, Canada’s health agency reviewed the data and adjusted its recommendations (currently, Canadians aged 55 and older remain eligible to receive AstraZeneca, and other vaccines are recommended for younger people), but did not pause its approval of AstraZeneca. This is because the risk of developing blood clots after receiving the AstraZeneca vaccine are exceedingly low (about 1 in 250,000 to 1 in 500,000), significantly lower than the rate of blood clots among the general population and vastly lower than the blood clot rate among people diagnosed with Covid-19 (1 in 100 among people diagnosed, and 1 in 20 among people hospitalized with Covid-19).

This move, which seems balanced and responsible in light of what is currently known about Covid-19 and its risks, has undoubtedly saved Canadian lives. It is precisely the kind of leadership we should be seeing from the federal government. Canadians are owed a lot more of it.

A ‘Folks’-Filled Diatribe of Deflection: How the Ontario Government Blew Vaccine Rollout

At this point it is hard to know even where to begin with Ontario’s provincial government. And I will begin by saying that for months I thought Premier Doug Ford was not doing an abysmal job. At the very least, for some months I did not think a different leadership under a different party would have been likely to do better.

Now I think it would be difficult for any premier to have done worse. And the worst thing that can be said is that Premier Ford genuinely seems to have been trying his best. But a pandemic is not just something you can wing, and I think Ford is genuinely out of his depth.

The carnage in long-term care facilities was predictable and inexcusable. That the Ontario government’s management of long-term care homes has been a disaster at least since the 1980s (under a succession of Liberal, NDP and Conservative governments) does not change the reality that things have gotten steadily worse, and that conditions reached genocidal levels during the first and second waves of the Covid-19 pandemic. Privatization, profiteering, relentless cost-cutting, limited inspections, poor working conditions (low pay, inadequate training, part-time-only positions lacking benefits) for staff leading to high turnover, warehousing of care recipients (including many crowded four to a room) and culpable indifference to suffering have resulted in 3,766 deaths in long term care homes (almost all among residents but 11 among staff) and almost 22,000 cases in total. Notably, long term care homes run by private corporations had more breakouts and higher death rates than in municipally-run facilities.

Despite claims by the provincial government that it was implementing protocols and investing in staff and equipment to protect long term care residents and staff, it became clear in the second wave of the pandemic that little had changed from the first. Long term care residents continued to get sick and die in disturbing numbers until late February of 2021, by which time — in what is arguably the province’s single success in its vaccine deployment — most residents and the majority of staff had been vaccinated. It also became clear that long term care residents, quarantined, isolated from family, restricted to their rooms and sometimes even their beds, denied access to amenities, resources and even routine medical care, were suffering the effects of a year of neglect. This is a travesty for which public authorities and long term care operators must be held accountable.

The much ballyhooed rollout of vaccines in Ontario has been a bust in important and costly ways. When retired General Rick Hillier was brought on board in November of 2020 to oversee the Province’s vaccine task force, like many Ontarians I was delighted. Hillier had a reputation for military excellence as Canada’s Chief of Defence Staff, and military leaders are by definition expert at deployment. But during Hillier’s tenure the Province never developed a detailed implementation plan, and not long into the new year (a few weeks after Hillier apologised for pausing vaccine rollout over the Christmas holiday, calling the interruption “a mistake”) the task force seemed increasingly rudderless. Hillier left the task force in March, amid fanfare from the Premier, but was quietly replaced a few weeks later by ORNGE CEO (and former fellow soldier) Dr. Homer Tien.

I do not know what went on inside the Province’s vaccine task force during Hillier’s tenure, and I do not know why he left. But contrary to claims by both Hillier and Premier Ford, the job of overseeing the task force was far from complete, and it was a very strange time to exit a contract. Hillier’s terse statements in announcing his departure (and his cagey refusal of requests that he remain on board) seemed strikingly at odds with his usual plain-spoken demeanor. If it made sense, as the Premier suggested, to bring on new staff for Phase 2 (which at the time of Hillier’s departure was a back-of-the-envelope shambles), then it would have made equal sense to also replace the Province’s Chief Medical Officer of Health Dr. David Williams, whose rambling, unfocused statements on the pandemic during daily pressers have hardly inspired confidence in his presumably prodigious abilities. I have a feeling much more will eventually come to light about task force functionality and Hillier’s reasons for leaving, and will be very interested to see what is revealed (because of course there will be a public inquiry into Ontario’s pandemic response).

Two weeks before vaccine rollout was anticipated to move on to populations beyond residents and staff in long term care facilities and front line health care workers — and after having promised for months that a single provincial portal would open, through which Ontarians could confirm their eligibility and register for vaccine appointments — the Province dropped this burden in regional health units’ laps. In mid-March a provincial portal did become operational, but even a month after opening for registration, the provincial portal has no way to register most categories of people eligible for vaccines.

In response to complaints that obtaining a vaccine appointment was confusing and difficult, at a press conference on 13 April 2021, Premier Ford said, “I have to tell you that 2.8 million people didn’t find it confusing,” adding, “It’s very, very simple.” At this same presser, Ford announced — surprise — that people aged 18 to 49 in ‘hot spot’ areas would be eligible to receive vaccines, and invited them to register via the Provincial system, although as of today it remains impossible to do so (and in any event, most of the mass vaccination clinics where these populations could have been vaccinated have closed due to a lack of supply). The Province has now added a note to the portal instructing people in this demographic to wait for “community partners and public health units” to advertise “mobile and pop-up clinics,” and instructed, “Do not book through the provincial booking system.”

This seems pretty confusing to me.

For most supposedly eligible conditions, the provincial portal returns the response “You might be able to book COVID-19 vaccine appointments through the City of Toronto Health Unit general phone line.” For other categories of eligibility, the provincial portal directs the visitor, helpfully, to the VaccineTO website — which then directs the visitor, equally helpfully, back to the provincial portal. For educators, whom Ford announced would be eligible for vaccination starting Monday 12 April 2021, the portal states “You can book COVID-19 vaccine appointments through City of Toronto Health Unit if you directly support students with complex special education needs in an elementary or secondary school in Ontario.” Toronto, for its part, directs eligible educators back to the provincial vaccine information line. A visitor to the provincial portal clicking “other groups” (a catch-all for an increasingly wide variety of eligible groups) is told “This booking tool does not currently offer online booking for some priority groups who are eligible for a vaccination. ”

It’s not just confusing: it’s like a Magic 8 Ball.

[The future is murky.]

On Thursday, just hours after I had gotten my own vaccination there, when St. Joe’s announced it was shutting down its clinic due to a shortage of vaccines, the provincial cabinet met to discuss further public restrictions the government could enact to slow the accelerating spread of Covid-19. The new restrictions, announced Friday, include an extension of the existing stay-at-home order until May, and the closure of outdoor playgrounds and basketball courts (although no cases of Covid appear, ever, to have been linked to parks or playgrounds), and give police the power to stop and question anybody outside their home. [Update: while I was writing this post, the Province reversed its closure of public playgrounds, meaning, hopefully, that no little children will be fined $750 for using a slide.]

Parents have reportedly already ripped caution tape from swings and teeter-totters, and police forces across the province have lined up to indicate that they will not stop people for being outside. There is little public support for the new restrictions, and a growing sense of what might as well be called what it is — fury — at the province’s failure to manage the pandemic before caseloads got out of control and hospitals so overwhelmed they may need to implement triage protocols.

Throughout the pandemic, outbreaks in congregate residential environments (like long term care homes), workplaces and high-density residential neighbourhoods have driven caseloads in Ontario. Cases have been diagnosed disproportionately in racialized and poor communities because front-line and essential workers — in shipping, delivery services, retail, personal support work and manufacturing — come disproportionately from these communities. The province’s response to calls to prioritize vaccines to these groups has been almost staggeringly slow. Despite outbreaks at construction sites, the province was slow to shutter non-essential construction, and even with the additional 17 April 2021 restrictions, it is not clear which construction sites, if any, are affected. Despite having had the technological capacity to do so since early in the second wave, the Province has implemented almost no asymptomatic testing at higher-risk work sites. Despite well-evidenced requests, the province has implemented no paid sick leave program which would have enabled ill people to stay home from work rather than hide symptoms in order to avoid going unpaid.

In short, the province has failed to anticipate the predictable surge in cases associated with the (inevitable) third wave, and, beyond its successful vaccination program in long term care settings, has directed few resources to other locations and populations disproportionately affected by outbreaks. It appears to have learned little from the first two waves. The province’s responses and implementation of its own policies have been reactive and often frankly inept. Despite claims it listens to advice from medical experts, the province appears not to have grasped the enormity of the situation until it was too late to stop an overwhelming surge in caseloads.

And then we come to the vaccine gap, and here is where the story gets circular. Progressives have blamed Ford for what they claim is a growing ‘vaccine gap in Ontario, claiming that hundreds of thousands, even millions of doses are “sitting in freezers.” The federal government has taken up this charge, offering yesterday, in a tactical gesture of political theatre, to deploy the Canadian Red Cross help to assist with vaccination in Ontario. The provincial government’s position, in response, is that all the vaccines delivered to Ontario have already been allocated.

Who has a more convincing story? On this one I’m with Ford, at least right now. I’ve been watching this Covid-19 Vaccine Tracker website since it first began keeping track of vaccine deployment data in Canada. Over many weeks, I’ve watched the doses of vaccines given (shots into arms) ramp steadily upward, while doses delivered from the federal government have varied depending on available supply. In other words, Ontario’s capacity to deploy vaccines has increased steadily, while federal supply has remained somewhat inconsistent. On any given day, between 70 and 80% of vaccines delivered have been injected into people’s arms. It is not physically possible to have deployed 100% of vaccines delivered at any time, unless the supply has stopped entirely (which it has done on a number of occasions), and given that vaccine appointments are made days or sometimes week(s) ahead, doses need to be available for those appointments. Accordingly, given the information currently available, I am more inclined to believe that my local hospital, St. Joe’s, has been forced to close its excellent and busy vaccination clinic to new registrations not because the Province is hoarding doses of Pfizer in the basement of Queen’s Park but because the federal government isn’t able to supply enough to keep the clinic going.

This is a shitty situation, especially at a time when it should be possible to celebrate the pace of vaccination. Despite culpable screw-ups from both the federal and provincial government, 23% of Canadians have received at least one vaccine dose, and the pace of vaccinations is increasing steadily. The successful pace of vaccinations is owed not to the federal or provincial government, however, but rather to regional health authorities, Local Health Integration Networks, hospitals, community health agencies, municipalities, community centers, faith communities, and pharmacies which have stood and delivered doses, and also to Ontarians who have braved the complicated, changing, and sometimes contradictory registration systems long enough to obtain appointments for themselves, their families, and neighbours.

How did I manage to get all three adults in my household vaccinated? Let me tell you. In March a family friend passed on the rumour that people living in the community aged 80 or more would soon be eligible to book a vaccine appointment. After confirming that this was indeed the case, I spent about 20 exhausting and frustrating hours trying to book an appointment for our vulnerable elder. This culminated in a night spent sitting at the dining table with multiple browsers open on both my laptop and phone, clicking and waiting and refreshing and clicking, and closing tabs when the registration system simply froze me out, and waiting and clicking and waiting some more. And then, when the system let me in, clicking on telephone poles and bridges and tires to prove to a captcha that I was not a robot, and then, rapid fire, entering personal information only to have multiple appointment spots disappear while I was typing. I secured an appointment only after what felt like inordinate and unreasonable effort that depended on expert familiarity with institutional websites and their quirks.

When the province extended vaccine rollout to Ontarians aged 55 to 79, making this cohort eligible to receive the AstraZeneca vaccine at participating pharmacies, I spent an evening finding out which pharmacies were indeed participating (at the time there was not a centralized list, although one did appear later) and navigating their widely varying systems. Some had pre-registration forms, while others would only accept phone calls. I registered my husband at as many local and local-ish pharmacies as I could, and waited. Some pharmacies never responded (a pharmacy assistant at our local Shoppers later told me their system had gone down entirely), but Rexall did (Rexall’s Covid vaccination system, at least in my experience, seems excellent, and if you are eligible to receive a vaccine through the pharmacy roll-out, I recommend it highly), and about a week later my husband (who does essential work and has health risks) was vaccinated. Phew!

The vaccine rollout at pharmacies has probably been the most streamlined part of the whole deployment in Ontario. Some of my friends may not wish to hear this, but it seems to me this is a case of the private sector being more nimble than government. I do not always think this is the case (see the discussion about the carnage in privatized long term care homes, above), but it is instructive here. Local pharmacies also have the advantage of being, well, local, and most pharmacists are known or at least familiar to their customers.

Depressingly, however, some of Ontario’s ‘vaccine gap’ may reflect doses of AstraZeneca sitting in pharmacy fridges, unused because some eligible-but-entitled people think they are too good for a budget vaccine whose efficacy rate at preventing symptomatic illness is lower than ‘high end’ Pfizer (at about 95%) and Moderna (over 90%). When I’ve talked to people or overheard casual conversations about vaccines, too many people have said they are holding out for one of the ‘good’ vaccines. This is the case even though AZ is about 100% efficacious in preventing serious illness and death — the principal purpose of the vaccines — and in this sense is as ‘good’ as Pfizer and Moderna, and may be more effective against variants than Moderna (findings on efficacy against variants are very preliminary at the moment, and in all likelihood most vaccines will end up being tweaked). It is also my impressionistic prediction that AZ may end up being the sleeper hero in vaccine deployment, because it is inexpensive to produce, requires no special storage beyond ordinary refrigeration, and works. Its efficacy is also reported to increase with a longer wait (12 weeks) between the first and second doses, which seems to make it a perfect fit for Canada’s get-at-least-a-first-dose-in-as-many-arms-as-possible approach to vaccinations.]

When I booked my own vaccine appointment at St. Joe’s, I had no idea this was going to end up being the day the clinic would close to new bookings. I assumed my vaccine was going to be part of the ongoing chain of successful vaccinations that will beat down this pandemic.

On the morning of my appointment I biked down to St. Joe’s in the chilly April air, locked up beside the vaccination clinic, donned my mask, and went in. Five minutes later a needle was in my arm. Everyone at the clinic was friendly and helpful, and the feeling in the air was the same as at a polling station on voting day: a sense that everyone present was there to do something that will serve not only personal interest but also the civic good.

Let more civic good be done.

Leave a Comment

Your email address will not be published. Required fields are marked *