What's next?
What have we learned from the COVID-19 pandemic and where do we go from here? Experts weigh in on what comes next for health care in Canada.
By Sharon Oosthoek, HBA’88
The pandemic’s impact on everyday health has been debilitating for some and devastating for others. As we diverted resources to address COVID-19, general health checkups were postponed, bottlenecks for routine lab tests grew and treatment wait times lengthened.
Not only did COVID-19 lay bare the fragility of our public health system, but it also highlighted shameful inequities in social determinants of health and disproportionate impacts on vulnerable people.
So what have we learned and where do we go from here?
Health experts at Schulich Medicine & Dentistry weigh in on how the pandemic has affected non-communicable disease and late-stage diagnosis, the wider public health care system and how we can move forward.
Diagnosing system-wide problems
Even though he restricted his family practice to emergency visits only for just two weeks at the beginning of the pandemic, many of Dr. Daniel Pepe’s, MD’14, patients stayed away and are now coming to him with up to half a dozen ailments. An Adjunct Professor, Family Medicine, Pepe said his ability to deal with the sudden crush is limited by his ability to order timely lab tests.
“There have been so many starts and stops to the acute system that the places we send people for testing don’t have capacity to deal with the backlog,” he said. “Pre-pandemic, someone might come in with hives or a rash and what would have been a wait time of 12 months to see an allergist for skin testing is now 12 to 18 months.”
A surprise finding from a recent study published in the Canadian Medical Association Journal underlines the stakes of delayed routine testing. Respirologist Dr. Mike Nicholson, Resident Alumnus and Adjunct Professor, Medicine, and his colleagues set out to test lung function in patients who had recovered from COVID-19. They also tested 10 ‘healthy’ volunteers so they could compare results.
It turns out that four of the 10 volunteers had significant cardiopulmonary disease, including untreated asthma and seriously high blood pressure. “We were a bit gobsmacked,” said Nicholson. “You could argue it was the impact of the pandemic on regular, normal checkups. The blood pressure and asthma could easily have been identified by a routine GP visit.”
Radiation oncologist and Professor Dr. David Palma, MD’04, agrees that the toll of delayed diagnosis has been high. He points to a recent study showing roughly one million fewer cancer care appointments in Ontario during the first year of the pandemic. Most of those missing services were for cancer screening tests, biopsies, surgical treatments, and new consultations for treatment.
While there is not much Canadian research on patients putting off appointments and subsequently being diagnosed with more advanced stage cancers, some European data show pandemic-related delays in cancer diagnoses and an increase in deaths.
“I’m certainly seeing patients who two years ago might have had a small lung cancer of a couple centimetres that would just need surgery,” said Palma. “Now the tumours are bigger and need surgery, chemo and radiation. This not only means treatment is costlier, but patients have side effects that may last their entire lives,” he said.
The potential of virtual care
There is no easy way to clear this backlog, but the pandemic has shown that judicious use of online and telemedicine can relieve some of the pressure and make routine appointments for remotelylocated patients easier.
“I was probably unaware of the burden on patients coming in from Owen Sound for instance – taking time off work, a three-hour drive, finding parking,” said Palma. Now, if he thinks things are going well, he’ll give patients a choice – phone call or visit?
At London Health Sciences Centre’s Children’s Hospital, doctors have seen 5,600 patients at their virtual urgentcare clinic since its May 2020 launch. Two-thirds of those patients’ parents said they would have gone to an emergency department if the online clinic hadn’t been available, said Dr. Rodrick Lim, Resident Alumnus, Associate Professor and Site-Chief of the Paediatric Emergency Department.
The medical, administrative and technical team behind the clinic had a steep learning curve, but they were motivated to make it work. “We started from scratch and had to learn quickly,” said Lim. “At first, we didn’t completely understand how to integrate the technology into existing systems and which patients were safe to see without an in-person physical exam.”
Lim and his team quickly realized that ‘knowledge-based question’ appointments were best dealt with online. These included what parents might expect at various stages of development and how quickly childhood ailments needed treatment.
“Patients and their families have adapted quickly and have glowing reports of their experience,” said Lim. In fact, the clinic has worked so well that it will remain open even as pandemic restrictions are lifted.
Building more resilient public health
While the paediatric online clinic has proved both effective and sustainable, Shannon Sibbald, PhD, Associate Professor and a health systems researcher with the Schulich Interfaculty Program in Public Health, suggests Canada has something to learn from low- and middle-income countries.
“They have less waste than we do in our health system,” she said. “High-income countries tend to run a high amount of pilot projects, often with the noble aim of innovation, but also quite frequently without an aim of or consideration for sustainability.”
One of the most effective ways to make public health systems more sustainable and resilient is to reduce inequities – social and economic – that make people vulnerable to disease. As Sibbald points out, the World Health Organization urges countries to monitor for inequities in health and access to care so that they have a better chance of weathering public health crises.
That means improving disadvantaged groups’ food quality, education, housing and even the safety of their neighbourhoods, said Gerald McKinley, Assistant Professor, who studies the social determinants of health.
“My hope is that we see now how important this is for public health,” he said. “If we can prevent illness, we’re better off than having to treat it.”
