01 June 2020

The facts of the case #nlpoli


From the start of the pandemic, the provincial government  took decisions for political reasons, not medical ones.  It continues to do so.  It is clear that the provincial government has maintained very tight restrictions on the public far longer than necessary and that far more extensive efforts to control the public since 30 April are not based on evidence and medical necessity.
This is fundamental mismanagement that is harming the province and its people. 
The root of the problem is the political divisions in cabinet. The prospect of a new Premier to replace Dwight Ball brings with it the chance to sort out the problems and get the province ready to deal with COVID-19 for as long as necessary.  
The current situation is unconscionable.
Whatever it takes

The government's own advisors give evidence
that contradicts government's decision.
The Chief Medical Officer disclosed the first case of COVID-19 detected in Newfoundland and Labrador on 14 March.  The woman had recently returned from a cruise in the Caribbean.  Public health officials had tested 114 people half of whom had tested negative for the disease.  They and another eight besides were quarantined at home as a precaution.

The government’s first action attributed to COVID-19 came two days later.  At a news conference, Premier Dwight Ball, health minister John Haggie, education minister Brian Warr, and chief medical officer Dr. Janice Fitzgerald sat literally shoulder to shoulder behind a long desk.

We are “in uncharted waters” Ball told reporters.

Effective immediately, Ball and Warr announced, they had closed the province’s schools and daycares as well as College of the North Atlantic.  The move sent 74,000 children home along with thousands of adults across the province from the post-secondary college.

Haggie told reporters that effective immediately, the province’s health system had stopped all elective, diagnostic and surgical procedures. 

Ball said that public servants were also going to work from home, effective immediately.

“We will do whatever it takes, when necessary, to ensure your safety,” Ball said.

Asked about the impact of public cries to close schools as other provinces had done, Ball said "You always listen to people. We want to do what's best."

Ball and his ministers made the decisions to close schools, hospitals, and the provincial government that Monday morning.  There was a single case of COVID-19 in the province.

None of these measures apparently came at the direction or suggestion of the Chief Medical Officer.  Haggie would take another two days to declare a public health emergency.  He did so, under provincial law, on the advice of the chief medical officer.  The move gave the CMO and regional medical officers of health across the province sweeping powers to contain outbreaks of infectious diseases.

Most likely, Fitzgerald, didn’t advise such a massive shutdown based on a single case.  The three ministers involved seem to have been affected by reports from outside Newfoundland and Labrador rather than what they faced or were likely to face.

Mitigation

We can say it is unlikely that the CMO advised to close schools because there is a large collection of studies that deal with closing schools during public health emergencies. Experience in other places highlight the concerns about the economic impact as well as the impact on the health care system as families struggle to arrange for child-care while maintaining essential services.  Closing schools is something you do at the right time, when children are threatened directly by the disease involved, or when there is a widespread community outbreak. What Dwight Ball and Brian Warr announced that Monday flew in the face of all that expert advice.

A pandemic was not “uncharted waters” at all for the provincial government. Public health officials – plugged into a national network of colleagues - had been aware of COVID-19 since the beginning of the year.  Haggie signed an order in February - almost three weeks before the first case turned up in Newfoundland and Labrador - that amended the infectious disease regulations to include COVID-19.

The government’s pandemic plan dated from 2007.  As with the Canadian plan, which the local plan mirrored, the provincial government would mitigate an outbreak for which there was no cure or vaccine.   Rather than let the disease run wild, overload the health system, and kill potentially thousands in a single maelstrom, health officials would identify and contain infections, applying broader measures as needed to control the impact on health care and on deaths.  The phrase “flatten the curve” describes the idea of holding down the number of infections to a manageable level. That was the strategy.

The strategy is widely known among public health experts globally. A paper by the Imperial College, London, released on 16 March, applied the well-known strategic options to COVID-19. It was clear that the measures taken quickly by a couple of cabinet ministers and the Premier in a quick meeting on Monday morning, a couple of days after finding a single case in the province, was considerably more than an over-reaction. They abandoned the government’s plan.

Even with the public health emergency – declared on 18 March – the government’s response to COVID-19 remained disconnected from evidence.  A hastily-drafted special measure order issued on 20 March effectively cut off food, medical supplies, and fuel to the province and would have shut down the economy.  An amendment the next day exempted enough categories of travellers to keep the province going but preserved the important public health measure that required other travelers to quarantine themselves for 14 days after arrival. 

That part was important because, as Haggie has noted earlier in the week, the disease was entering the province from outside.  National and international restrictions on movement to deal with far greater outbreaks outside Newfoundland and Labrador limited travel to all but what was essential, anyway.  The requirement to quarantine on entry for 14 effectively contained any likely new disease from entering the province.  Combined with identification of outbreaks, and isolation of those already in the province, public health officials had in place the means they needed to control the disease.

They had also dodged a huge bullet that affected other provinces. March is normally a time for Canadians to flock to the southern United States for a couple of week’s break from winter.  When they flooded back to Ontario, Quebec, and Alberta in the middle of March 2020, they brought with them disease they had acquired on the beaches and in the bars from Florida, along the Gulf coast, all the way to California.

But in Newfoundland and Labrador, spring break 2020 wouldn’t come until April, because schools still tie their calendar to major religious holidays as they did in the days when seven Christian sects controlled them.  As a result, there were far fewer likely sources of disease in Newfoundland and Labrador that came flooding back to the province between the Monday that government closed down and the Friday of the travel quarantine order.  By the end of the week, the flow was a trickle and it stayed a trickle afterward.

Piling on restrictions

Given that COVID-19 takes about a week, on average, to incubate and appear, it’s not surprising that the largest daily number of cases started turning up a week after the travelers started coming back.  On 23 March, public health officials reported 15 new cases.

In the afternoon briefing on 23 March, the CMO announced extensive restrictions on the public.  Fitzgerald closed retail stores, except for a handful deemed essential. She shut gyms, tennis courts, restaurants’ dining rooms, bingo halls, hair salons, and dog grooming shops.  Gatherings of more than 10 people were banned, and funerals and weddings were limited to no more than 10 people.

The next day, the CMO closed health care outside hospitals except for physician or nurse practitioner clinics.

On 25 March, the CMO reported her officials had confirmed 32 new cases.  That was the peak of new cases. A week later, the CMO banned funerals, visitations, and wakes and limited gatherings – including weddings and burials – to a maximum of five people. She also closed campsites and municipal and provincial parks and banned the sale of scratch tickets – but no other such gambling – in corner stores.

What’s remarkable about the week of added restrictions is that they were obviously disconnected from the number of active cases.  Sure, they were accumulating, but the rate at which they grew was already waning.  Analysis by the province’s COVID advisory team subsequently confirmed what the numbers themselves showed as they were being released daily.   

The expert advisors pegged 25 March – just two days after the CMOs sweeping restrictions – as the peak of the infections.  They assessed the rate of transmission after that date as well less than the level public health officials would be worried about.  The disease was under control and on the decline.

There’s no way that the CMO’s restrictions on 23 March halted the growth of infections in two days when the disease takes at least three times that to ripen, on average and make someone sick.  The bulk of the cases that turned up the week of 23 March and the following week came from a single traveler who had attended two wake’s at a local funeral home between 15 and 17 March.   The cluster from that single traveler would eventually account for 70% of the cases identified in the initial wave of COVID-19 in Newfoundland and Labrador. 

Public health officials found them through contract tracing and with a general order, issued on 25 March for people connected to the funeral home outbreak to self-isolate. That’s what worked. Closing parks and dog grooming salons, preventing people from getting scratch tickets or seeing a chiropractor didn’t do anything anyone could detect to affect the trajectory of COVID-19 in Newfoundland and Labrador. Basic public health measures coupled with some good luck did the job.

By early April, it was clear the disease was declining.  The peak number of active cases came on 06 April.  Five days earlier, the number of cases in hospital had peaked at 15 before starting to decline.  

Haggie’s order to shut the health system in the province to all but emergencies – taken when there was only a single case identified – kept half the province’s hospital beds vacant and prevented tens of thousands of people from getting treatment. A system that on some days went well over 100% capacity for necessary care shrank to less than half capacity but it was never in danger of being overwhelmed by COVID-19. 

Regardless of what the numbers say

The Premier and other officials insist their decisions came from evidence and science, but the evidence says otherwise.  The pattern of making decisions without evidence continued at the end of April with the decision to lessen some of the restrictions. 

Reporters started asking about the possibility of easing restrictions the week before Easter.  They did so partly because other provinces had started talking of similar moves and partly because a fairly simple assessment of trends in the province pointed to a steady decline in new cases. By the end of April, as SRBP noted on 13 April, the government would likely face a situation of having virtually no new cases every day. That’s what happened.

The three officials in the daily briefing dismissed such talk out of hand.  They used phrases like “a few days of low numbers” to insist that the province needed to stay under restrictions that were more in line with the number of cases, the outbreaks in long-term care facilities, and with pressure on health care in Ontario and Quebec.

CBC’s Peter Cowan asked on 13 April about the constant talk of a surge in cases even though local cases were declining.  Haggie in particular justified current high levels of restriction on the need to avoid a surge.  ‘The facts of the case” Haggie replied, using one of his pet phrases even though what he frequently stated wasn’t factual. 

Continued restrictions kept the virus from spreading, Haggie said, because it was in the community.  Regardless of what the numbers show,” Haggie said, “we cannot relax physical distancing. The only question in my mind is whether we need to be even more strict or even more restrictive.”

The average number of new cases reported each day that week would be less than two. Over the next month, the daily briefing reported more days with zero cases than not.  From the first week of May onward, Haggie’s own advisors would assess the rate of transmission at zero.

Looser and tighter at the same time

Another two weeks of constant questioning pushed Ball and Haggie to have Fitzgerald draft a plan to lower restrictions.  She announced on 30 April that restrictions would change on 11 May, followed by further changes 28 days later.  Fitzgerald’s plan assumed the restrictions in place on 30 April were the highest level.  While she insisted the entire scheme was based on evidence, Fitzgerald could not and still has not been able to explain the reason for using fixed dates for making changes or what triggers would cause an increase or decrease in the so-called alert level.  She has also rejected any changes to the timing in the plan, although there is no explanation for why given the disease simply doesn’t exist in the province any longer.

The trigger dates are bureaucratic, selected to give time for government officials to put in place a bewildering level of added restrictions on residents. The first date was Monday, 11 May, two weeks after Fitzgerald unveiled the plan.  The next was a Monday 28 days later. Officially, the 28 days was two incubation periods but the facts of the case – easily discerned by the lack of evidence in favour of the dates – suggest that someone chose the date arbitrarily because it was a Monday.  Four working weeks gave officials plenty of time to sort out restrictions on everything from hair salons and spas to tennis.

The mitigation strategy described by the Imperial College and others isn’t tied to dates but to rates of hospitalization, impact on the health system, and number of deaths.  Specific points on the calendar are no marker. That shouldn’t be very hard to figure out. Experts in the United Kingdom are warning that the country’s plan to lower COVID restrictions ignores the risk of the disease, which is still widely active.  Use the indicators about the spread of the disease and risk, they say, and lower the restrictions when the risk is lower.

The UK government’s official  Scientific Advisory Group for Emergencies (SAGE) said in early May that the government should lower restrictions when the number of new cases had dropped, instead of setting a fixed date. The political origin of the plan in Newfoundland and Labrador should be plain in comparison.

There are other examples that decisions are not guided by evidence. The day before she unveiled her scheme, Fitzgerald closed the province to non-residents, except for essential workers.  The order came after a day of unfounded claims from one part of the province that tourists were in the province.  There was no evidence the tourists existed or that they had violated any of Fitzgerald’s public health orders.  Rumour and speculation, which Haggie readily accepted, was apparently more important than evidence.

The provincial government also passed an amendment to the public health law that allowed the minister of justice to send police to detain anyone accused of breaking one of Fitzgerald’s special measures orders.  There has never been an explanation of why government needed the power of arbitrary detention given that there were enforcement measures already in the public health protection law.

As with the other government COVID-19 decisions, Fitzgerald’s travel ban was also subject to amendment based on something other than evidence. She amended the order in a deal with opposition leader Ches Crosbie who, according to Crosbie’s account, agreed to support the unconstitutional detention powers as part of the bargain.

That wasn’t the last of it. The amended list of exemptions to the travel ban included returning to care for elderly parents.  Two people were denied entry to attend the funeral of a parent who had died. That option wasn’t on the list.  In both cases, publicity of the two rejections prompted Fitzgerald to grant hasty approval to both women to attend separate funerals.

Last week, again in apparent response to public criticism of the delay in lowering restrictions again, Fitzgerald unexpectedly announced a change to her guidance on social distancing.  As with the initial announcement of the restrictions scheme, Fitzgerald said the public could expand the size of their personal “bubble” in advance of the official start of the next phase.  The bubble concept is nonsense, anyway but even in the provincial government’s decision-based evidence-making scheme, there’s no rationale for deviating from the scheme by expanding “bubbles” before the fixed date.  No rationale, of course, except for a response to political pressure made with the full knowledge it won’t cause any problems.

After all, there is no active disease in the province except for two cases both of which are isolated and under control.

Headless Bureaucracy

On Friday, the provincial government’s advisor on COVID-19 told reporters that the provincial government’s response to COVID-19 had worked.  Dr. Proton Rahman specifically singled out contact tracing and social distancing as key measures that had worked very effectively.  The available evidence supports his observation.

But that isn’t the whole story of what has happened since the middle of March.  A more detailed assessment of the kind presented here - something that Rahman’s team was not mandated to do – tells a different story.

There are problems in government’s management of the emergency.  In particular, there is strong evidence that the provincial government implemented measures for political reasons and continues to do so. It is especially clear that the provincial government has maintained very tight restrictions far longer than necessary and that far more extensive efforts to control the public since 30 April are not based on evidence and medical necessity.

While there may well be specific issues like shorts of hospital protective equipment that may be driving decisions to some extent, there are unmistakable signs of problems in the management of the crisis at the highest levels.

Major emergencies like a pandemic or severe weather event affect so many aspects of life in the province that they require the provincial government to manage its response using time-tested approaches.  In particular, emergency management during a pandemic makes it imperative that government actions be coordinated from the highest level.  In making its decisions, cabinet or a committee of senior cabinet ministers must consider many aspects of a single initiative before taking a decision.

The provincial government’s response to COVID-19 does not use that “whole-of-government” approach to a whole-of-government problem.  The Public Health Protection Act allows the minister of health alone to declare an emergency.  Under the old Communicable Disease Act, cabinet declared the emergency. That was consistent with its other emergencies legislation that out cabinet at the apex of the decision-making.

Dwight Ball could have used a cabinet level committee to manage the emergency, but he did not.  The most likely reason for this is his ongoing political problems within cabinet and his own caucus. Instead of group decisions, Ball seems to be juggling things himself with the help of his office staff and ministers with whom he deals one by one.  Andrew Parsons’s refusal to speak about the detention orders suggests this is the case.

The result is that Haggie has far more control over government’s response to COVID than would have been the case before or need be the case now.  He also has an extraordinary influence over the Chief Medical Officer, who must persuade him and no one else of the need to maintain the emergency order. 

Collective decisions – the way cabinet normally works – prevent one person from gaining too much sway.  It can serve as a check on rash or misguided decisions.  But with Dwight Ball alienated from his cabinet and running the province more or less alone, the provincial government simply doesn’t have that important governor on action at the top-most levels during COVID-19.  As a result, it has obviously been easy for a strong-willed minister to get his way regardless of the costs across society.

Another result of the imbalanced decision-making process is that health officials such as the Chief Medical Officer are making decisions that affect things beyond health care.  Neither the CMO nor her staff are equipped to decide about the provincial economy or government finance.  There’s no indication that cabinet or the House of Assembly wanted this when they approved the current public health law in 2018. And yet, today, the Chief Medical Officer is adjudicating everything from tee-off times at a golf course to social distancing rules on fishing boats.

The result of all this has been:
  • a lockdown that has gone on longer than necessary,
  • a lockdown that is being replaced by far more restrictive measures than are warranted by the evidence,
  • severe constraints on the provincial economy,
  • two unconstitutional measures (the travel ban and the detention powers), and  
  • a health system that continues to operate far below capacity, and health consequences for tens of thousands of Newfoundlanders and Labradors that have not been assessed publicly. 

It is likely that one woman who carried a dead fetus for eight weeks is just the tip of a very large iceberg of health care problems that have resulted solely from ongoing strategic mismanagement of the provincial response to COVID-19. 

Whatever the cause of the current mismanagement, the prospect of a new Premier to replace Ball brings with it the chance to sort out the problems and get the province ready to deal with COVID-19 for as long as necessary.  The current situation is unconscionable.

-srbp-