Ontario's independent commission into long-term care interviewed the province's chief medical officer this week, raising concerns that the top doctor didn't draw conclusions and act quickly enough to save lives in the fast-moving pandemic, and instead waited for evidence he didn't always see.
Dr. David Williams spoke to the commission for several hours on Monday and a 266-page transcript of the interview was made public Thursday morning. Many passages consist of tense dialogue between the top doctor, the commission and, at times, a lawyer for the Ontario government.
In some exchanges, a lawyer questioning Williams on behalf of the commission appeared frustrated with trying to get answers from the doctor.
"I'm just trying to get a straight answer from that question," remarked John Callaghan, after repeatedly trying to get Williams to speak about what efforts he made to ensure long-term care homes got their test results faster, in order to prevent the rapid spread of the virus among vulnerable residents.
Williams initially said the long-term care homes should not depend only on testing — they must employ good infection prevention and control practices (IPAC), even though he also acknowledged that the state of IPAC awareness was very poor in the sector.
Callaghan recapped evidence the commission had been given about how homes had followed a key direction on IPAC Williams had given, to cohort — or separate — the sick long-term care residents from the well, and how it could backfire. Because the home examined in a case study didn't have test results on which residents were infected, they unknowingly placed asymptomatic, or presymptomatic but infectious residents with uninfected residents, further spreading the virus.
In response to that, Williams said the home should have waited for test results.
Williams ultimately said that he wanted rapid results but did nothing to address one of the barriers to them — the fact that some homes had to wait to get their results by mail because they were lacking the technology used by the rest of the health-care system.
"No," he said, when asked if he ever raised that issue with anyone, "because in the middle of it we were dealing with the outbreaks, not with the technology."
Whether or not COVID spreads asymptomatically was a key part of the interview. Williams told the commission he didn't accept that to be the case until "later in the summer."
When those comments became public, some experts immediately noted that that became clear in the early spring.
I'm stunned by Dr. Williams' admission that it wasn't until "later in the summer" that he accepted there was asymptomatic spread of #COVID19 in #LTC homes: https://t.co/XQP2IS29BW
The @CDCgov published convincing data on this in @CDCMMWR on Mar 27, 2020: https://t.co/ZxJzn4QCD3 https://t.co/iFikCULO5e
— Nathan Stall (@NathanStall) February 25, 2021
Williams seemed to remain resistant to the idea, saying repeatedly that when many people say they're asymptomatic, they actually had mild symptoms.
There were other issues where Williams appeared slow to act.
For instance, he told the commission the province didn't have concerns about the availability of personal protective equipment (PPE) until well after the pandemic was declared, in the second or third week of February.
However, concerns about the supply chain were reported in the media prior to that. For instance, QP Briefing reported that hospitals were concerned that the supply chain for masks on Jan. 31, 2020. Asked to comment for that story on that day, Williams replied that if hospitals are experiencing gaps he'd like to know and that the hospitals should manage their stocks judiciously.
Williams attributed his delay in realizing there was a PPE shortage to not understanding how the supply chain was linked to hard-hit areas of Asia — to that the commission lawyer pointed to years-old pandemic-prepared documents that anticipated supply chain challenges in the event of a pandemic, citing Asian supply chains specifically.
Instances where Williams appeared slow to act prompted an exchange with the commission lawyer about what is meant by the "precautionary principle" established by the SARS commission led by Justice Archie Campbell.
Callaghan described it as, when "evidence isn't possible due to the lack of data and uncertainty of an evolving event, you take the most precautionary road."
He suggested that meant Williams should have acted to prevent asymptomatic spread as evidence mounted, even if the debate was not fully settled.
Williams pushed back on his interpretation. "No, his aspect was that if you are waiting for the case-control studies and all the science to get formulated, that is too late. You need to take some steps before that. But it doesn't say throw science out the door and just wing it. He didn't mean that either."
Williams stressed the importance of listening to the various advisory tables, at both federal and provincial levels, for advice before acting.
The commission also delved into specific decisions about controlling the spread of COVID-19 in long-term care. The commission recommended in both of its interim reports that the province take steps to "decant" long-term care homes, by moving out residents who are positive or exposed to allow for better infection prevention and control. Williams said that was considered and while the province could have secured the facilities to do so, it did not have adequate staff.
He also elaborated on a provincial emergency order that was made prohibiting staff from working at more than one long-term care or retirement home — Williams said it came from cabinet, not from him. He'd issued advice to homes to limit staff movement while possible but did not make a mandatory order, fearing it would lead to staffing shortages and he raised concerns that limiting staff employment outside of long-term care would violate their civil rights, particularly as many only had part-time hours.
He also maintained that there has never been any evidence of LTC-to-LTC transmission of COVID through staff in Ontario, although he acknowledged it occurred in British Columbia. Again, an outside expert — geriatric Dr. Nathan Stall — pointed out that it was established by the U.S. Centres for Disease Control last March.
Another decision of cabinet was to open up testing to any Ontarian who wanted it, which was against the advice of the province's testing advisors, and Williams, due to fears — that materialized — that the testing system would be overwhelmed, causing an unacceptable delay in receiving results.
"It was a desire by the premier and cabinet that anyone who wanted to get tested could go to an assessment centre and ask for a test, whether they had symptoms or not," said Williams.
"So that is just the process," said Callaghan.
"Correct," said Williams.
The commission concluded the interview with questions about public health restrictions. In a series of questions about the colour-coded framework that was implemented in the fall, and under which the second wave grew, Callaghan asserted high prevalence in the community imperils the lives of LTC residents, a finding well established by research.
"You don't think as a chief medical officer of health that you ought to go and speak publicly that they were going to risk lives?" he asked.
Williams disagreed.
"There was no sense that that itself was risking lives," he said. "The protection of residents in place has to deal with proper assessment of staff, screening and proper IPAC and principles in that."
The province's staged restrictions were not only geared at long-term care, he said. "That was not the main intent."
The interview began on a tense note. Callaghan told Williams, and the phalanx of lawyers sitting in on the interview, that the delays in the production of government documents to the commission would hinder the interview. They had received 217,000 documents in the week prior and were given notice only on the Friday before the Monday interview that Williams' documents from July to January had been produced. They received 2,000 pages of his handwritten notes two days before the interview and had to go to arbitration to get them unredacted.
A government lawyer jumped in at that point — and despite Chief Commissioner Frank Marrocco telling him he didn't want to hear from him at length — he asserted that Williams should not speak to the issue because it was covered by solicitor-client privilege.
The subject was dropped.
The opposition seized on that, calling it "stonewalling."
"If the government and the premier really wanted to get the answers for Ontarians — if they really respected them — why does this look like a stinking coverup?" NDP Leader Andrea Horwath asked in question period on Thursday.
Speaker Ted Arnott asked her to withdraw her unparliamentary language, which she did.
Health Minister Christine Elliott defended the commission's independence, saying there were concerns that some of Williams' documents contained records of cabinet decisions. Later, in a media scrum, Elliott also said she and the government remain confident in the advice Williams is giving.
Horwath said the transcript raised concerns for her overall about how Williams was slow to act and whether the government actually followed his advice.
Elliott was interviewed by the commission on Wednesday and Long-Term Care Minister Merrillee Fullerton is set to be interviewed Friday.
With files from Jack Hauen
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