Public Health Measures During a Pandemic

Steven Hoffman, Professor at York University and Scientific Director of the CIHR’s Institute of Population & Public Health, talks to Vardit Ravitsky about the challenges of creating public policy during the COVID-19 pandemic and how we can better prepare for the next one.





Vardit Ravitsky: So what has the COVID-19 pandemic taught us? And how will we apply the experience when the next pandemic appears. Will we be ready to respond with agility, or will we stumble over unexpected and unpredictable obstacles? Stephen Hoffman, a Professor of Global Health, Law, and Political Science at York University and the Scientific Director of CIHR’s Research’s Institute of Population & Public Health, has been investigating these questions since before this pandemic. 


Steven Hoffman: Well, my research is very much focused on how countries work together to address transnational health threats like pandemics, like antimicrobial resistance. So in some respects, a lot of the research that I've been doing for over a decade now has really been about preparing for that future, inevitable pandemic that would be at some point coming our way and in fact, that we've all been now living through for more than a year. So I have to say, though, it's much more fun to be researching pandemics than to be a researcher living through one. But that's something we can discuss more as we continue. 


Vardit Ravitsky: So I remember a year ago the big ongoing debates of to mask or not to mask. That was the big question when we were getting used to living in these new circumstances. Why did the clear policy regarding masks take so long? What does it tell us about the difficult blend of science and political decisions?


Steven Hoffman: Well, I think the whole mask debates around whether the general public should be wearing nonmedical masks will be one of those enduring situations that we're going to look back on and reflect about the way decisions get made during emergencies. The reason I say that is because, of course, today we have the benefit of hindsight and we're able to look in that rearview mirror and judge whether, for example, should we have been wearing masks from the beginning or not and such. But of course, when making those decisions, public health leaders don't have crystal balls that they can look into and know what the future holds. 


Vardit Ravitsky: Tell us a little bit about the science behind the original hesitancy that governments worldwide had regarding what to tell their citizens 


Steven Hoffman: Well before a February 21, 2020, there was no evidence of pre or asymptomatic transmission of covid-19. And so the key data point or the key bit of evidence that would be needed for a public health leader to recommend the general public to where nonmedical masks would be if there was strong evidence of pre or asymptomatic transmission of the virus. And so there was this worry that if public health leaders just recommended wearing nonmedical masks, that potentially it could have caused more harm than good. In the sense that a mask presents all sorts of opportunities for people to touch that mask, to have the virus go into people's hands, people then touch their faces afterwards. And so there is a risk involved in asking the general public to wear a nonmedical mask. But of course, that risk is trumped if there is asymptomatic or pre symptomatic transmission. Before 21 February 2020, there is no evidence. And on that date, 21 February 2020, there was some initial evidence published in the Journal of the American Medical Association that highlighted for the first time, maybe there is pre or asymptomatic transmission. And it was really only on May 4th 2020 that there is a journal article in Emerging Infectious Diseases that highlights, OK, actually there is now gathering evidence that there could be some pre and asymptomatic transmission. And indeed, it was exactly two weeks later that the Public Health Agency of Canada then made their recommendation on the basis of that very early gathering evidence around pre and asymptomatic transmission. But really, it was only actually a month later, after the public health agency of Canada started recommending the general public wear nonmedical masks that we had a definitive study published in The Lancet medical journal that confirmed that masks are actually effective when worn by general public in specific circumstances. All of that to say, it's clear that evidence evolves and you don't have all the knowledge up front yet. You have to make decisions. And there's always pros and cons to any decision. And we then want to ensure that we're judging our public health leaders to make the best decisions they can based on what evidence and knowledge is available at that time. 


Vardit Ravitsky: So, Stephen, when you do look back, do you think public health officials in Canada made decisions based on evidence in a timely fashion overall? There are so many decisions that had to be made and the science kept evolving, I know it's not fair to look back and judge but overall, would you say that we responded well to the evolving evidence?


Steven Hoffman: Well, I think that no response to a pandemic is perfect. And certainly, when you look across countries around the world, and I've done that, there is no country that has responded perfectly to this pandemic. Every country can do better. Should have done better if they were better prepared. I think the reality is, if you consider what we had done before this pandemic and how we've prepared or not prepared, I think at the federal level, the response has been overall pretty good in the sense that as evidence evolved, and so did the public health guidance. I think where the Canadian response has really broken down is at the provincial level. I mean, there are several provinces that have cut their funding to public health budgets over the last few years. And indeed, in the case of Ontario, it was literally the day before this pandemic was alerted to the World Health Organization, a massive budget cut to Ontario's system for public health came into effect. So you literally have a public health agency and public health units in Ontario that have just fired a whole lot of their staff. And the people who are left over are now suddenly asked to mount a heroic response with far fewer resources after having just said goodbye to a lot of their colleagues. And yet we then, in our society, we are making criticisms of them for not being ready. I mean, the time when you decide how well a jurisdiction is going to be ready to respond to a pandemic is not during a pandemic. It is the time when the legislatures make decisions on budgets. I mean, and that would be the number one predictor of how well we are prepared for a pandemic. It would very much be around what we invest in our public health system. The massive budget cuts, I think everyone would agree that came before this pandemic were clearly a mistake. Again, though, with the benefit of hindsight, we can say that. we know that investing in public health is one of the very best investments a government can possibly make. And cuts then to public health not only don't allow us to reap the rewards, but it also means where we're less ready to react to these kind of emergencies like COVID-19 that we know we're going to be increasingly frequent in the future.


Vardit Ravitsky: To follow up on what you just said, and it's it's really difficult to digest now, as you say, in hindsight, with the information that you're sharing with us about budget cuts to the public health system. But I hear public health experts say that this is probably not the last pandemic we will see in our lifetime. None of us wants to think about this right now. We have pandemic fatigue where we we suffered tragic losses and all we want is to move on. But we may be facing another crisis such as this in maybe the near future. What is your recommendation to the Canadian government, the federal, provincial and to governments around the world in terms of pandemic preparedness and the future?


Steven Hoffman: Well, what is clear is that there's no society around the world that invested in a way that investments needed to be made in advance of a pandemic. No society around the world was ready for covid-19. But that was a choice because it's not like we didn't know it was coming. Indeed, I remember just a couple of years before covid, we were celebrating the 100-year anniversary of the Spanish influenza pandemic and of course, celebration. I put it in air quotes because that was an event that resulted in massive loss of life and radical consequences for everyone around the world on a scale that's similar to what we're now seeing with covid-19. And so we knew something like that was going to happen again. And because of the way that we are traveling more and trading more around the world, we are more globally interconnected. We know we are going to see those events happening more frequently. I think the tragedy of it is that it was just only a few years before covid when we saw a little bit about the dramatic consequence of a pandemic. And by that, I'm referring to the Ebola outbreak in West Africa. 


Vardit Ravitsky: Yes.


Steven Hoffman: That was an event that should have been the clarion call to get ready, because that event, while it was mostly contained within West Africa, it caused such devastation to the countries affected. And it gave us a window into what might happen if the virus of that next pandemic was slightly different, more transmissible, potentially airborne transmissible, such that it gave us a sense of how bad it would be in real time. And I remember after that outbreak, I wrote a commentary in a journal and the title was “How many people must die before we start treating pandemics seriously?” And then the conclusion of that editorial was that, well, fifteen thousand deaths from Ebola in West Africa? Not enough to activate the world's preparation for that next pandemic. And my only hope is that the millions who have died in COVID-19 proves to be enough to activate the world. And because that, I think, would be the best sort of solemn monuments and recognition of all that death, which was totally avoidable if only we were prepared. The best way to honor those who have been affected and those who have died in this pandemic is to make sure we're better prepared for the next one. And that is a choice that we have to make. 


Vardit Ravitsky: That is such a heart wrenching way of presenting the past few years and in a way also infuriating until we remember that every decision to fund means resources allocated in one direction and taken from another.


Steven Hoffman: I think one of the challenges from a political perspective is that you don't actually know if these investments are going to reap the rewards within the political time frame. And I think essentially what we see is that, at least in democracies, every democratically elected leader is just praying that that pandemic doesn't happen on their watch, that it happens when the next person is in office. And so as a result, there's a massive underinvestment in managing this risk.


Vardit Ravitsky: Absolutely. I also work in a school of public health. And we always say that success in our domain is when nothing happens and then politically we have nothing to show for. Good public health preparedness means that no life was lost and the pandemic maybe was beat before it even started. That is a huge challenge for our field, isn't it?


Steven Hoffman: Exactly. No, I think that is right. And one of the things that gets me is there is a lot of rhetoric at the provincial level around sort of cutting the red tape or cutting the back-office function and putting all the investment into the front lines, into the hospitals and such. And of course, our hospitals need investments according to what their needs are. But, you know, I think people don't realize those back-office functions, it's things like epidemiologists, it's things like contact tracers, it's things like ensuring we have good plans in place for when that next pandemic happens. And so there has been over the last couple of decades these systematic efforts to cut and cut those budgets and functions. And as you said, if success is not hearing about it, then politically, based on the systems we've created, it then becomes very difficult to continue to justify those investments. And that's a problem.


Vardit Ravitsky: That's our job, yours and mine, to keep it alive, to sensitize the public and politicians to the implications of such funding decisions. Let's move on to the solution, the vaccines. We're in the midst of rolling them out as an epidemiologist, as someone working on the global scale, would love to hear your thoughts about how the vaccine campaign and how the rollout is happening here in Canada and how do you compare that to other countries?


Steven Hoffman: I mean, obviously, the vaccine rollout in Canada has not gone as fast as citizens would like. I think that the problems that we're seeing today with the lack of manufacturing capacity around the world, these were noted by people who research pandemics like me. And the situation of vaccine nationalism that we're seeing around the world where each country is doing their own thing and doing what they perceived to be best for themselves. This was written in the textbooks. Like this, of course, is what would happen, because politically it becomes so difficult to take a global approach when actually we elect our leaders on a national basis. And why would a country allow vaccines that are manufactured in that country to leave that country, unless its whole population has already been vaccinated? These were predicted and we knew this was going to be a problem. That being said, just because you know it's a problem doesn't mean you have a solution. And, you know, the really sad part of this whole thing is  what's actually best for all of us is to take a global approach, noting especially that new variants of concern are emerging. So this virus is changing and there is a real risk that this virus will continue to change and that it might actually escape immune capture. And by that, what I mean is the vaccines and diagnostics and other technologies that we're counting on to beat this virus might actually, over time, no longer start to work. I mean, already we're seeing that the new variants that were first identified in the UK and South Africa, that the vaccine, existing vaccines are not as effective against those variants as the original virus. And so that's a real challenge. What it means, though, is we need a global approach and the fact that most rich countries in the world are suggesting that they need to vaccinate their entire populations even before poor people in poorer countries are able to vaccinate their health care workers or those who are at greatest risk of death from getting covid such as the elderly, that highlights not only a broken system, and broken global governance in this space. But actually, it's not in any of our interests because all that means is that this virus will continue to circulate. It's going to continue to mutate and change, and we're increasing the risk that it will escape immune capture. That's not good for anyone, including everyone who's in richer countries. 


Vardit Ravitsky: Stephen, I heard a testimonial at the U.N. that really touched my heart. And it said that history will judge us, that generations to come will look back at this moment in history and how we responded globally and whether or not we have abandoned the more vulnerable societies and those who had less resources or whether we stood together and supported each other with solidarity, and that our children and grandchildren will judge us ethically on this decision. What do you think about that?


Steven Hoffman: I think there's many aspects to our response to this pandemic that we will be judged for very harshly in the future. But it's on vaccines where we're going to be judged so harshly. And that's around the way we then did not ensure that amazing technology was accessible in an equitable way because it's so not equitable. And this is actually going to only exacerbate problems. And I think when it then comes to on one hand about the development of the vaccine, I get excited and I'm excited that, OK, through science we can solve the range of global challenges we face climate change, weapons, managing outer space, plastics in the oceans. We can solve these big, tough issues and science is a leading way of getting through them. But then when we watch about the access to vaccine, it's really depressing. Is this the kind of world that we're creating for ourselves and our future? Because if so, we are not going to be able to solve any of these other very big challenges that we also face. I think the one bit of silver lining is that it is actually not too late to remove ourselves from this very dangerous path of vaccine nationalism before even thinking about what's in the best interest of everyone. And instead, there is still opportunities to shift towards a path of solidarity, of equity, of fairness around the world. And my only hope is that we shift off the dangerous path and move to that path. That's not only better, but it's actually safer for all of us and benefits all of us.


Vardit Ravitsky: Thank you for this optimistic and hopeful message. It's nice to end with a positive tone and a hope that we can get on the right track. Thank you so much, Steven. It was a great pleasure talking to you today. 


Steven Hoffman: Thanks so much Vardit.