Canada needs a national COVID-19 inquiry now

Abstract

Background

We are now in the fifth year of an ongoing pandemic, and Canada continues to experience significant surges of COVID-19 infections. In addition to the acute impacts of deaths and hospitalizations, there is growing awareness of an accumulation of organ damage and disability which is building a “health debt” that will affect Canadians for decades to come. Calls in 2023 for an inquiry into the handling of the COVID-19 pandemic went unheeded, despite relevant precedent. Canada urgently needs a comprehensive review of its successes and failures to chart a better response in the near- and long-term.

Main body

While Canada fared better than many comparators in the early years of the COVID-19 pandemic, it is clearly still in a public health crisis. Infections are not only affecting Canadians’ daily lives but also eroding healthcare capacity. Post-COVID condition is having accumulating and profound individual, social, and economic consequences.

An inquiry is needed to understand the current evidence underlying policy choices, identify a better course of action on various fronts, and build resilience. More must be done to reduce transmission, including a serious public education campaign to better inform Canadians about COVID and effective mitigations, especially the benefits of respirator masks. We need a national standard for indoor air quality to make indoor public spaces safer, particularly schools. Data collection must be more robust, especially to understand and mitigate the disproportionate impacts on under-served communities and high-risk populations. General confidence in public health must be rebuilt, with a focus on communication and transparency. In particular, the wide variation in provincial policies has sown mistrust: evidence-based policy should be consistent. Finally, Canada’s early success in vaccination has collapsed, and this development needs a careful post-mortem.

Conclusions

A complete investigation of Canada’s response to the pandemic is not yet possible because that response is still ongoing and, while we have learned much, there remain areas of dispute and uncertainty. However, an inquiry is needed to conduct a rapid assessment of the current evidence and policies and provide recommendations on how to improve in 2025 and beyond as well as guidance for future pandemics.

Background

We are now in the fifth year of an ongoing pandemic. Canada urgently needs a national inquiry with the scope and authority to collect documents and hear from witnesses so that we can learn from Canada’s successes and failures. Overall, concerted action and public support in the early years of the pandemic contributed to reduced infections and saved lives. Canada had an enviable rate of vaccination among adults in the first year of COVID vaccine availability. Government financial supports, including grants and paid sick days, and regional efforts (from masking measures to the so-called “Atlantic bubble”) all had positive effects. These are now all gone, but the pandemic continues.

We do not suggest returning to these past measures. Our call for a national inquiry is intended not just to study our failures but also to build on our successes and a growing body of evidence to develop meaningful solutions that will protect the health of everyone in Canada.

Why a national inquiry?

Established in 1993, the Royal Commission of Inquiry on the Blood System in Canada (related to hepatitis B and C in donated blood) offers relevant precedent for an inquiry across different levels of government responsible for healthcare. Canada has a strong tradition of inquiries after healthcare crises, including Ontario’s SARS Commission and the report of the National Advisory Committee on SARS and Public Health, but these had more limited scope and authority than a national inquiry.

Under the Inquiries Act, national inquiries can “issue a subpoena or other request or summons” in calling witnesses and requiring documents and other materials [1, 2]. This supports transparency and accountability as well as comprehensive investigation. The misinformation-fuelled hostility to public officials and healthcare needs to be answered with openness and evidence, including public testimony and media reporting, not reports developed behind closed doors that are vulnerable to interference. Transparency is essential to restoring confidence and trust, including open discussion of why some studies are controversial, conflicts of interest, and the limitations of the available evidence.

Canada’s ability to limit the ongoing and accumulating harms of SARS-CoV-2—and to prepare for future pandemics—requires an inquiry-level assessment of the response. There were productive reports after SARS-CoV-1 but they did not lead to the necessary changes. Ontario’s SARS Commission, for instance, identified the need to follow the precautionary principle and to presume airborne transmission of novel pathogens until proven otherwise. This should have led to routine use of appropriate respiratory protection such as N95 respirators [3] for health care and other workers, as determined by the applicable national standard (CAN/CSA-Z94.4–18, first created in 1982 [4]). The Commission also called attention to the exclusion of critical scientific advice, occupational health and safety expertise, and worker input in decision-making [3]. This advice was not followed at the start of the COVID-19 pandemic, as evidenced by the destruction of provincial and national stockpiles of Personal Protective Equipment (PPE), indicating that critical lessons had not been learned from the past, and what has been learned has not always been applied [5, 6].

We propose a national inquiry in two phases: an initial stage I, to report within 1 year, that lays out a concrete plan applying expertise from across disciplines to bring the ongoing COVID-19 pandemic under control; and a more comprehensive stage II that follows the usual timeframe of such inquiries (often 3 years or more). The final report would provide recommendations to address structural barriers that interfered with effective intergovernmental coordination, robust and consistent data collection, rigorous application of multi-disciplinary expertise, and input from worker and patient groups. This report would also lay out how its recommendations would be implemented, and what oversight is necessary to ensure that we do not fail again to rectify mistakes identified by inquiries. This point is especially crucial if we want to ensure that Canada is able to address current and future pandemic challenges.

A national inquiry would also help to close the information gap about COVID. With public hearings drawing national media attention, it would help to inform Canadians about the transmission and long-term health risks of COVID, as well as its long-term economic and social consequences. This aspect is particularly important: in the absence of transparency, the information vacuum will be filled by misinformation and disinformation.

The important, unheeded call for a national inquiry in Canada published last year in the BMJ stressed preparation for the next pandemic [5]. However, the ongoing and nearly continuous waves of SARS-CoV-2 infection continue to sicken and kill Canadians. This challenges healthcare, education, and other institutions, almost certainly contributing to the shortage of teachers and family doctors, emergency-room closures, and other signs of strain. There is a paucity of data on all these fronts. An inquiry is urgently needed to help us grasp the full picture, as well as the challenges that lie ahead.

Context for a national inquiry

The best available data, including wastewater surveillance, indicate very high rates of SARS-CoV-2 infection throughout this past winter. Estimates indicate that over 200,000 Canadians per day were infected with COVID-19 in November 2023–January 2024 [7]—about 15% of the population per month. Data from 2022 showed COVID-19 was the third most common cause of death in Canada, and will assuredly be in the top ten for 2023. The true situation is even worse, as organ damage from even a single COVID infection can substantially increase the incidence of a broad range of other conditions where the resulting deaths are unlikely to be recorded as COVID-related [8, 9].

The JN.1 COVID-19 variant contributed to a global surge in infections in early 2024, followed by yet another global surge in mid-2024, underway as we write this. With current estimates of 3.5% of infections in fully vaccinated individuals resulting in post-COVID condition (PCC) [10, 11], acute and chronic effects of SARS-CoV-2 are positioned to be a major detriment to population health, the economy, and healthcare systems for the foreseeable future. As of June 2023, according to a report on PCC from the Public Health Agency of Canada and Statistics Canada, 14.5 million work and school days were lost due to long-term symptoms alone, and “…about 100,000 Canadian adults have been unable to return to work or school because of their symptoms” [12].

Failure to bring the pandemic under control means Canada urgently needs to increase healthcare capacity to manage its effects, just as those same effects are reducing the existing capacity. Acute COVID-19 infections, post-COVID conditions, and increased rates of COVID-caused illnesses such as diabetes [13] and heart disease [14] are not only additional burdens on our healthcare systems, but also affect healthcare workers [15–17], taking them out of the system at least temporarily and, in some cases, permanently. The result will be continued deterioration in access to care despite increases in healthcare spending—which without the clarity of a public inquiry could in turn lead to political instability and endanger support for Canada’s public healthcare system.

It is well-established that airborne transmission is significant for COVID-19 [18, 19], yet there has been no concerted effort to improve indoor air quality, ensure adequate PPE in healthcare and other critical settings, and educate Canadians on how to better protect themselves.

New problems have also emerged. Large reserves of unused PPE have been reported, as have questions about the rigor and integrity of pandemic-related procurement and approval processes [20]. This suggests that Canada will need an inquiry that will “consider and make recommendations regarding the procurement and distribution to end-users... of key healthcare related equipment and supplies” [21]. While recent news suggests that Canada may need to look at procurement in general [22], the ongoing pandemic means healthcare-related procurement, stockpiling, and distribution need to be improved expeditiously.

Comparisons could be made to outcomes in countries with different policy approaches, such as the US, the UK, Sweden, Australia, NZ, Singapore, South Korea, and Taiwan.

Key topics for a national inquiry

We identify here six areas for the first phase of an inquiry to assess and improve decision-making in the response to the ongoing COVID-19 pandemic and ensure that Canada is better prepared for future threats.

First and foremost, more must be done to reduce infections. Infections not only disrupt lives during acute illness and lead to hospitalizations and deaths but, in a significant percentage of cases, also lead to a wide range of poorly understood sequelae, with those identified to date generally grouped under the umbrella terms long COVID or PCC [9, 11, 23]. Most Canadians had been infected at least once by the end of 2022 [24], and without serious effort to mitigate transmission Canada will see repeated infection across the population. PCC is not yet well understood, but cumulative PCC risk is higher with repeat infections [12]. Reducing infections remains the only way of reducing PCC cases. An inquiry is required to chart a more effective course and investigate why Canada still lacks a robust public education effort around the harms of PCC. While we may hope that there will be significant recoveries and effective treatments for PCC, the precautionary principle should drive us to act to reduce cases now.

Secondly, making schools safer for children is morally imperative as well as practical. Children are among those affected in both the short- and long-term, and transmission in schools appears to be a primary component of community spread [23, 25, 26]. Some provinces have attempted to address indoor air quality in schools, consistent with evidence it will protect children’s health [27, 28], yet no national standard is being implemented. An inquiry needs to investigate and then deliver evidence-based recommendations on school safety and other measures that might protect children's health. The same applies to other indoor public spaces such as universities, colleges, arenas, theatres, restaurants, and other public buildings, including hospitals, long-term care homes and clinics.

Thirdly, while the precautionary principle compels us to act to protect the health of Canadians and healthcare workers in advance of scientific certainty, scientific certainty is being stalled by weakening data collection, including the recent cancelation of Ontario’s wastewater program. In particular, Canada cannot effectively monitor or respond to disproportionate impacts on under-served communities and populations. The critical importance of this data was clearly evident early in the pandemic [29–32]. There is well-documented racial inequity in COVID-19 impacts [32], as well as clear evidence of disability-related increases in risk [33]. Statistics Canada demonstrated that Black and poor Canadians had a risk of COVID-19 death that was 400% higher than non-racialized, non-poor Canadians [32]. An inquiry should map out what data collection is required to understand and mitigate inequities as well as adequately assess other trends.

Fourthly, confidence in public health requires accountability and clear, credible communication. While there are notable exceptions, most public health officials are still not accurately advising Canadians about the basic facts of COVID-19 transmission and how to mitigate it. The messaging should be consistent and clear: COVID-19 is airborne, transmitted primarily via infectious aerosols that move through the air like smoke and remain suspended in the air for long durations in poorly ventilated spaces [18]. Advice to stay home when ill is sound, but Canadians are not being reminded of the substantial risks of asymptomatic COVID-19 transmission [26]. To restore trust and better advise the public, communications must be vastly improved and transparently linked to comprehensive and trustworthy interdisciplinary information that is accessible to all [34]. Credibility also demands that assessment and communication of the inevitable successes and failures of pandemic decision-making must not be left to the discretion of those who made those decisions. An inquiry would provide much-needed transparency and guide more effective, consistent communications.

Fifthly, a national inquiry could develop guidelines for a more coordinated and consistent evidence-based approach. The proper roles of elected officials and of medical, scientific, and other experts involved in decision-making must be clarified, as well as how lay public and patient groups can be engaged to enable confidence that their interests are protected and their perspectives are considered. Provincial differences in public health practices and messaging are striking, contributing to regional inequities, raising questions in the media, and confusing the public [35]. Major inconsistencies in pharmaceutical interventions, such as criteria for access to nirmatrelvir/ritonavir (Paxlovid) and spacing between vaccine doses, do not rest on robust scientific foundations. We need a whole-of-nation approach. Here an inquiry can be aspirational: how do we want to ensure that going forward, our responses are consistent, scientific, and evidence based?

Finally, an inquiry could address the decline in vaccine uptake. COVID-19 vaccination rates have dropped sharply since the 2021 COVID-19 vaccination campaign. While over 83% of Canadians have received at least one dose of COVID-19 vaccine, uptake of updated COVID-19 vaccines in autumn 2023 was approximately 15% [36, 37]. Well-funded, well-organized vaccine misinformation and disinformation campaigns are part of the problem [38], but better, regularly updated information could also have been distributed by Canadian public health institutions. Canada needs a national strategy to support existing vaccination programs and the infrastructure to scale up if vaccines with more durable immune protection become available. Recently published data demonstrate that updated vaccines continue to prevent severe infection [39]; mitigate post-COVID increases in risk of events such as heart attacks, strokes, and venous thromboembolism [40]; and reduce forward transmission to other individuals [41]. Lukewarm efforts to support ongoing SARS-CoV-2 vaccination programs and inform the public of the benefits of high levels of vaccination represent a missed opportunity and warrant investigation.

Our understanding of SARS-CoV-2 continues to evolve and academic debates will continue as well. An inquiry may add other items to this list, or change our perspective on some of the fundamental issues. But Canada cannot wait for perfect clarity with so many becoming sick—the precautionary principle means that “action to reduce risk should not await scientific certainty” [3]. Canada needs a frank, open, and public discussion of the evidence and its limitations, across disciplines and perspectives. Part of the contribution of an inquiry to healing rifts and restoring trust will be documenting and transparently addressing the concerns of all Canadians.

Conclusions

A complete analysis of Canada’s response to the pandemic is not yet possible because the event is still ongoing. What is possible is the launch of a two-phase inquiry to conduct a rapid assessment of the current evidence and response in order to develop recommendations on how to improve in 2025 and beyond. A high-quality national inquiry would help re-establish much-needed trust in public institutions, identify ways to mitigate health inequity, and better protect everyone in Canada from the harms of repeated acute infections and long-term illnesses. To borrow a sports metaphor from a hockey-obsessed nation, Canada is going into pandemic overtime. The game is not yet won, so we must work to improve our chances. But we need a national inquiry to put us on a firmer path to success.

Abbreviations

PCC

Post-COVID condition (long COVID)

PPE

Personal Protective Equipment

Authors’ contributions

JW wrote the first draft and edited subsequent drafts. All authors reviewed drafts, submitted comments and edits, and approved the final version. Authors are listed alphabetically.

Funding

No authors received any funds in relation to this article.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

N/A.

Consent for publication

N/A.

Competing interests

Dr. David Fisman has served on advisory boards related to influenza and SARS-CoV-2 vaccines for Seqirus, Pfizer, Astrazeneca and Sanofi-Pasteur Vaccines, and has served as a legal expert on issues related to COVID-19 epidemiology for the Elementary Teachers Federation of Ontario and the Registered Nurses Association of Ontario. He is a member of the Canadian COVID Society. Dr. Jillian Horton has received speaking fees from AstraZeneca for delivering talks related to healthcare worker burnout. Dr. Mark Ungrin is the co-chair of the Legal Committee of the non-profit Canadian Covid Society. He receives no remuneration for this work. Dr. Joe Vipond is the co-chair of the non-profit Canadian Covid Society. He receives no remuneration for this work. Dr. Julia M. Wright served on the Royal Society of Canada’s Task Force on COVID-19 and now serves on the Board for the Canadian Lung Association. She receives no remuneration for this work. Dr. Dick Zoutman has served as an expert in legal proceedings and class actions concerning COVID-19. He is also a board member of the Canadian Covid Society for which he receives no renumeration. No other author has competing interestss COI to declare.