Dr. Gutkin’s talk provided us with a view of what has happened to our health care system in Ontario over the past 3 decades or so, and the impact of those changes on our ability to respond to the COVID pandemic.

He began with describing and event from the 1980’s, the sale of Connaught Laboratories to Sanofi of France.  Connaught had a storied history as a key element in the development of insulin by Banting and Best, as well as one of the sites heavily involved in the Salk polio vaccine.  Why the sale of this asset is important in the COVID environment is that countries that have been hosting and supporting R&D and vaccine production in their countries had favoured access to COVID vaccine production.  Recently, it has been announced that the Federal Government has struck a deal with Sanofi to build an R&D and production operation in the Toronto area.

In the 1990’s, there was the Ontario Healthcare Restructuring Commission, chaired by Duncan Sinclair.  It was challenged with looking at the whole health care delivery system, including hospitals, long-term care, primary care and home care, with a view to recommending changes to improve delivery.  Recommendations included hospital consolidation along with moving more care into the community.  As it happened, hospital restructuring did occur, including a loss of beds overall, but investments in the other aspects of restructuring did not occur.  As Dr. Gutkin described it, cherry-picking was the order of the day with the result being that there was a decrease in acute-care hospital beds, and so an already tight situation became that much tighter.  These changes continue to affect us to this day.  When a surge such as a normal flu season brings, hospitals are bursting at the seams.  Canada has a very low ranking in terms of hospital beds per capita.

Long-term care has been very poorly resourced.  During the onset of the COVID pandemic, they were the site of the greatest surge of infections; the result was that 80% of deaths occurred among residents and staff of LTCs during the first two waves.

Also in the early ‘90’s, there was a national commission resulting in what is known as the Barer-Stoddart report.  It’s conclusion was that Canada has too many physicians, and so recommended that we reduce the number of places in medical schools by 15%.  Not surprisingly, this led to a significant doctor shortage.  About 50% of physicians are family doctors, and we went through the period where it was almost impossible to find a family doctor.  And because of increased workloads and the inability to do a good job, many doctors retired.  By 2004, it was finally agreed to reverse direction and train more doctors.  But it takes a long time to recover from this type of shortage, and the effects linger.  There really were no resources available to handle the COVID crisis, but it had to be done anyway.  We are still paying the price for the decision in the early ‘90’s.

Meanwhile research has shown that there are better medical outcomes to be had when there is a strong family physician – patient relationship.  It is recognized that we need new models of practice, because a small practice cannot do it all.  Teams of family doctors supported by nurses, nurse practitioners, mental health workers, occupational therapists, physical therapists and clinical pharmacists, all linked together working in one facility on behalf of the practice’s patients will be more efficient and work better for both the providers and the patients.  The College of Family Physicians introduced a concept called “Patient’s Medical Home” which provides integrated and coordinated care.  Surveys showed that 85% of potential patients surveyed responded positively to the concept.  It was accepted at the Federal level in 2010; versions have sprung up in several provinces.  Dr. Gutkin is a board member of one called Carepoint Health in Mississauga, which is a 30,000 square foot facility with the elements described above, along with some specialists also having office hours in the same facility.  Meanwhile, Ontario’s Local Health Integration Networks (LHINs) have been replaced with Ontario Health Teams, so there may be some recognition that this model is the way forward.

Back to COVID – one issue is the relatively slow rate of vaccination.  Dr. Gutkin speculated that this may be because the public is much more informed than they would have been 100 years ago, but since the science is evolving, it is leading to confusion in the messaging.  Another issue is the abysmal failure to test and contact trace.  If you can do that, you can isolate infected people and suppress the spread.  It is difficult to do, but apparently most jurisdictions had no plans as to how to do it, and many, including many states and Alberta have given up trying.  This is concerning given the rapidity with which mutations can arise.

As hospital beds have filled up with COVID patients, other services have had to be curtailed, clearly detrimental to the health of non-COVID patients.  ICUs have been expanded into other wards to meet the demand.  Along with this are conspiracy theories circulating that the whole thing is a hoax, and moreover, that the vaccines are dangerous.  Dr. Gutkin made the point that no vaccine will be 100% effective, but that the COVID vaccines are excellent.  COVID is becoming a disease of the unvaccinated.  THEY are THE risk to the rest of us because they will be the breeding grounds for new mutations, which current vaccines may not be as effective against.  And vaccinated people may be asymptomatic but able to infect others.  We will probably need masks and social-distancing measures for quite some time.  However, the good news is that vaccinated people will likely have a much smaller viral load even if they are infected, so less likely to pass it along to others, such as unvaccinated children.  It is likely that we will need a booster, perhaps something that is formulated to be more effective against variants.  However, there is not yet a policy covering if and when a booster is required.

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