Describing the province’s efforts to battle COVID-19 as piecemeal and ineffective, one of Ontario’s 34 regional medical officers of health is urging his colleagues to band together and use more powerful measures to contain the pandemic than provincial leaders have yet endorsed.

In an email obtained by the Star, Dr. Shanker Nesathurai wrote Thursday that Ontario’s response has undermined the province’s attempt to contain the outbreak, as businesses remain open and travellers ignore advice to self-isolate. He writes that “many” other medical officers of health, who are leading the regional response to the pandemic, believe Ontario needs to take a more assertive response.

Nesathurai called on his colleagues to use their legal authority to require businesses to close and people to stay home.“We do not have the luxury of time,” wrote Dr. Nesathurai, the medical officer of health for Haldimand Norfolk Health Unit.

As the coronavirus pandemic continues to sweep the globe, there is hope that Canada is better positioned to confront this crisis than many other Western nations. In a new Lancet article published Friday, David Naylor — one of the country’s leading pandemic response experts — said changes implemented after the 2002-03 SARS crisis have vastly improved Canada’s ability to confront outbreaks like COVID-19.

But the email is one of several signs that cracks are appearing in Ontario’s response to the COVID-19 pandemic. The email was sent to Nesathurai’s three dozen regional counterparts and copied to Drs. David Williams and Barbara Yaffe, Ontario’s chief and associate chief medical officers of health.

Frontline health-care workers are working furiously to prepare for the coming onslaught. The wave became visible Friday: at least 22 of Ontario’s 318 reported COVID-19 cases are hospitalized, and Toronto announced new cases in a paramedic, a resident of a long-term care home, and a person who uses the city’s shelter system.

Many argue that Ontario should be prepared for this. The province had a glimpse 17 years ago at how a new infectious disease could rapidly sink its health-care system, when it battled SARS.

The pandemic is an unprecedented situation for everyone involved and Yaffe stressed that she and everyone else is “learning every day.”

“We’re all in this together,” she said. “We’re all trying our very best.”

Here is a look at three critical areas of Ontario’ pandemic response: clear communication, rapid detection and hospital preparedness.

COMMUNICATIONS

At a news conference on Monday, Toronto’s medical officer of health Dr. Eileen de Villa put it bluntly: there is evidence in Toronto of community transmission.

That means the novel coronavirus is now spreading from person to person locally, rather than just being imported by travellers and passed only to their close contacts. De Villa told reporters two days ago that Toronto was investigating 11 cases of community transmission.

The same afternoon, the province’s top public health officials were holding their own news conference. And when questioned about the same issue, the response was much more muddied.

“To be conservative, we’re saying we cannot rule it out at this point,” said Yaffe. “There are some that do not seem to have a travel history or a contact case at this stage,” Williams, chief medical officer, added. Neither Yaffe nor Williams have offered a firm number on community spread.

Health-care workers question why the province won’t just declare there is community spread, which many already consider to be a reality on the ground. Yaffe believes people are applying different definitions to what constitutes “community spread” and “can’t understand why people are so caught up with that term.” But she agreed there are “a small number of cases where it’s unclear where they got it” and the situation is worrisome. “We’re trying very hard to be transparent with all the information we know and don’t know.”

Critics say such inconsistent messaging has confused Ontarians, a problem in fighting an outbreak like COVID-19. People have to understand the threat facing them if they are being asked to undertake strict social distancing, which carries a heavy personal and financial toll.

For Dr. Michael Warner, medical director of critical care at Michael Garron Hospital, the statements from the province’s top health officials have been frustrating to watch. “There is community spread in Ontario and they just need to say it,” he said. “If people know that, they might take things more seriously.”

Ontario’s incremental response — adding new voluntary measures piece by piece — has been ineffective, Nesathurai suggested in the email circulated to the province’s medical officers of health. Businesses big and small remain open; unnecessary social contacts continue.

The medical officers of health should “act together” and use their legal authority to require closures. “It would be better for the province to make this determination,” he wrote. But decisions from the province and its “complex governance structure” are too slow. These stricter measures are necessary to stifle the outbreak, he says, citing modelling data that suggests hospitals and their critical care units will be overwhelmed by the increase in cases.

Asked for comment on his email, a spokesperson for the Haldimand Norfolk Health Unit said Nesathurai “is in constant dialogue with the province’s other medical officers, who as a group are regularly discussing a wide range of items related to COVID-19 containment. The private email that you viewed is just a part of that larger, ongoing discussion, in which there are many active participants.

“Dr. Nesathurai recognizes the social disadvantage of enhanced self-distancing strategies, however in the context of this public health emergency, he believes that enhanced, assertive policies are necessary to control this pandemic.”

TESTING

Last year, the Ford government proposed a $13-million cut to Public Health Ontario. The agency hosts the province’s public health laboratory, where millions of tests for infectious diseases and other pathogens are processed every year.

The agency had already experienced several years of flatlined funding, and had warned the province that this was impacting the lab’s ability to process high volumes of tests.

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“Laboratory testing volumes at PHO continue to increase and the need for quality and timeliness of testing remains paramount,” the agency wrote in its 2017-20 business plan. Fiscal challenges are “resulting in increased operational pressures at PHO’s testing sites.”

The Ford government’s budget brought the agency to its lowest funding level since 2010-11. Public Health Ontario (PHO) currently has a head count of 895; in the 2015-16 fiscal year, it was 998.

The $13-million cut was restored for one time this fiscal year. The government just announced $50 million in funding for COVID-19 testing and screening through public health. Dr. Brian Schwartz, vice-president of PHO, says the province has not provided further details on the funding, “so we don’t have any further information on this.”

Asked about reports of days-long delays in COVID-19 test turnaround, Schwartz said on Friday the earliest samples in the lab were from Tuesday, and that along with unprecedented test volumes, global shortages of chemicals needed to process the tests was part of what is hindering the turnaround time.

“At present, we do have enough PCR machines to conduct the tests. That said, we also recognize that the demand for testing will likely increase and we are adding more equipment.”

The SARS commission, a panel of experts convened by the province to probe how the novel infectious respiratory disease swamped the province’s health care system, wrote about how difficult it is to add capacity in the middle of an outbreak.

“Laboratory capacity is much like the rest of public health: its importance is not appreciated, nor the impact of its inadequacies felt, until there is an outbreak and then it is too late.”

SARS “illustrated dramatically the urgent need for sustained resources [for the public health laboratory system], without which Ontario will continue to be unprepared for the next outbreak of infectious disease.”

On March 5, Stan Grossman, a 72-year-old Toronto lawyer, had two long meetings with a friend who had just returned from Washington, D.C. The following day, the friend attended a bris (a Jewish circumcision ceremony) along with some 50 other people. Grossman had dinner with his extended family, making sure to get extra snuggling time with his three-week-old grandson.

By the end of the weekend, Grossman had also visited his synagogue and two long-term care homes when he got the phone call from Patient 31. “They just told me I tested positive for the coronavirus.”

When Grossman developed a cough and other flu-like symptoms five days later, Toronto Public Health directed him to the nearest COVID-19 assessment centre, where he waited nearly five hours along with “hordes” of people “hacking and sneezing.” He was told his test results would return in 48 hours; one week later, he is still waiting.

“I am frustrated with this province and their inability to do their job,” Grossman said. “It does not give me faith in the government’s ability to confront this.”

HOSPITAL PREPAREDNESS

As he watched the coronavirus sweep across China and Italy and finally North America, Dr. Michael Warner believed that “absolute Armageddon” was headed for his critical care unit at Michael Garron Hospital. But Warner never imagined that mere days before an anticipated surge of cases across the province, he would find himself spending hours on the phone with veterinarians, cosmetic surgeons and construction companies.

He was begging them for their ventilators, anesthetic machines, and any N95 masks they could spare. All crucial equipment that he feared would quickly run out as the virus’ spread begins to pick up speed.

“We will run out of beds, we will run out of ventilators, we will run out of doctors, we will run out of nurses,” he said. “The level of anxiety is high and I think people are scared.”

Warner believes that leadership has been lacking in the province, because “you need people who make decisions anticipating what’s going to happen, not waiting until it’s so obvious (you’re forced) to make a decision.” He wants to know: Where are the stockpiles of personal protective equipment, like face masks? Where is the mass training of health workers who can take over for doctors and nurses who fall ill? And who will take care of them when that inevitably happens?

His concerns reflect a broader sentiment amongst health-care workers, many of whom are increasingly speaking out as the outbreak worsens across the country. On Friday, a petition co-signed by 62 physicians called on all levels of government to implement a “warlike effort” to scale up production of protective gear, collecting more than 60,000 signatures.

“Our front-line health care workers are already running out of personal protective equipment,” states the petition, which was started by Dr. Melissa Yuan-Innes, an emergency physician at the Glengarry Memorial Hospital north of Cornwall. “This is unacceptably dangerous for health care workers and, in turn, the public.”

The Ministry of Health did not respond to questions about the email, funding levels for the public health lab and doctor’s concerns about protective equipment.