'The single biggest crisis in the history of our modern health-care system': Ontario announces new provincewide shutdown

By Jessica Smith Cross, David Hains and Jack Hauen

Ontario is bringing in new public health restrictions to curb the spread of COVID-19 as the virus threatens to overwhelm hospitals’ capacity to care for critically ill patients.

But the new measures do not include a stay-at-home order, a step called for by health-care experts to curb the spread of the virus.

Premier Doug Ford announced the province is applying the "emergency brake" — a term officials use to describe rapidly increasing the state of restrictions in any given area — to the entire province.

“I know pulling the emergency brake will be difficult on many people across the province, but we must try and prevent more people from getting infected and overwhelming our hospitals," said Ford.

Beginning Saturday, the province will enter the “shutdown” zone for 28 days. The new rules are more restrictive than the current grey “lockdown” zone in place in Toronto, Peel, Hamilton and other areas, as they prohibit indoor and outdoor dining.

But they are less restrictive than the provincewide shutdown that began on Boxing Day and included a new state of emergency and a stay-at-home order. This time, non-essential retail stores will be allowed to remain open with capacity limits.

The new measures include:

• Prohibiting indoor organized public events and social gatherings and limiting the capacity for outdoor organized public events or social gatherings to five people, except for gatherings with members of the same household or gatherings of members of one household and one other person from another household who lives alone;
• A 50 per cent capacity limit for supermarkets, grocery stores, convenience stores, indoor farmers’ markets, other stores that primarily sell food and pharmacies, and 25 per cent for all other retail including big box stores, along with other public health and workplace safety measures;
• Prohibiting personal care services;
• Prohibiting indoor and outdoor dining;
• Prohibiting the use of facilities for indoor or outdoor sports and recreational fitness with very limited exceptions;
• Requiring day camps to close;
• Limiting capacity at weddings, funerals, and religious services, rites or ceremonies to 15 per cent occupancy per room indoors, and to the number of individuals that can maintain two metres of physical distance outdoors. This does not include social gatherings associated with these services such as receptions, which are not permitted indoors and are limited to five people outdoors;
• Keeping schools and child care centres open.

Health Minister Christine Elliott said there’s no stay-at-home order this time “because we saw last time that it had tremendous ill effect on both children and adults,” and that the government wants people to be able to enjoy the warm weather responsibly.

Ford said the decision “weighs extremely heavy on me.”

“I know it's difficult, the last year,” he said. “It's painful for everyone. And it's hurt a lot of people. But I am convinced, 100 per cent — not even a question in my mind, that if we don’t do it we’d be in deep, deep trouble. We'd see the ICUs get out of control. We'd see the deaths get out of control."

But the premier said there’s still light at the end of the tunnel: the millions of vaccines needed to get everyone in the province a dose.

"They're weeks away. We know that they’re coming in mass amounts starting soon,” he said. "And that's how we know that things will get better very, very soon."

The modelling

Earlier in the day, co-chair of the province's science advisory table Dr. Adalsteinn (Steini) Brown released modelling showing the number of COVID-19 patients in Ontario's intensive care units is expected to nearly double by the end of April, even if the province implements stringent public health restrictions including a stay-at-home order.

Brown, and other health experts, are warning that ICUs are already stretched near their breaking point, necessitating patient transfers from overcrowded Greater Toronto Areas to hospitals as far away as Kingston.

He said the variants mean younger people are getting critically ill and dying. In some cases, entire families have ended up in ICUs split between hospitals.

"One family ended up spread between three hospitals, one in Simcoe, one in Toronto, and an adult child on a ventilator in a third city," he said. "Another family ended up spread between three cities, three different hospitals, and all of them died."

The modelling Brown presented shows the number of COVID patients in ICUs rising from a record high 430 as of Thursday to just over 800 in late April. That high is reached even in the most optimistic model, which includes the implementation of a 28-day provincewide stay-at-home order. If that action would be taken, the number of ICU patients begins to fall at that point. If they aren't, it continues to rise.

The reason that the high of 800 patients is reached in either case is the delay between implementing new measures and reducing ICU cases, as it takes time to prevent infections and for infected people to become critically ill patients.

'The single biggest crisis in the history of our modern health-care system'

With 800 COVID patients in ICUs, the province’s health-care system will not be able to give patients the standard of care they deserve, experts said.

"Eight hundred is a place where we are not able to provide all the care as well as we would want to people and ... that is a place where clinicians need to make hard decisions we'd never want them to make, where you will see loss of life," said Brown, adding the experience would be comparable to what happened in overwhelmed hospitals in northern Italy, New York City and parts of Europe.

The province has a draft triage protocol that hospital staff have been trained to use. It would require doctors to estimate how likely patients are to survive a year if given critical care so that patients with lower likelihoods of survival are denied care to make room for those with better prospects.

Brown said it is a “definite possibility” that the triage protocol will be required.

Anthony Dale, CEO of the Ontario Hospital Association, told QP Briefing that the current level of overcrowding has already required some level of triaging and sacrifices from patients.

Hospitals have had to ask patients to delay life-saving care, including cardiac care, cancer care and organ transplantation, and that is triaging, he said.

“So the question becomes, what are the choices that our physicians will be asked to make in the weeks ahead, if and when conditions become so serious that they have to make choices that no physician should ever have to make?” he said.

Dale said hospitals currently have just over 1,800 open critical care beds with 430 COVID-19 patients, the balance being people with other health-care needs. Hospitals are funded for up to 2,300 beds and were recently instructed to increase that by 15 per cent, or another 350 beds.

“It will be impossible to staff that number of critical care beds at one time with the normal staffing that would otherwise be provided to someone in critical care,” he said. “And hospitals will move heaven and earth to try to care for patients under those conditions. But without question, it comes at a cost to quality of care. A very heavy cost, I would say.”

The only way to staff the beds is to reassign staff from other parts of the hospital, which likely means a very significant shutdown of elective or scheduled surgical procedures and diagnostic procedures, he said. That is on top of the transfer of patients from overcrowded ICUs those with remaining capacity and the ongoing redeployment of health-care resources.

“This is the single biggest crisis in the history of our modern health-care system,” he said. “And it will be the challenge of a lifetime to try to provide equitable access to critical care services for both COVID and non-COVID patients under those circumstances.”

Hospitals and their ICUs weren't designed to run at 100 per cent occupancy for an entire year, nor to deal with a mass causality situation that lasts for weeks, he said.

“This is the big one that we feared would come and it's going to be quite a challenge.”

On Thursday morning, 150 critical care physicians released a joint letter expressing stark alarm and urging immediate and substantial action to curb transmission.

"We are being led down a very dangerous path by using ICU capacity as a benchmark of tolerance for COVID-19 spread," the letter, addressed to Ford, Elliott and Chief Medical Officer of Health Dr. David Williams warned.

"Trying to adjust our public health response to ICU capacity will not break the chains of transmission," the letter continued. "Countries attempting this approach faced massive numbers of deaths and had pushed hospital capacity beyond its limits.”

It said it is unethical to let the variants of concern spread unchecked, even with unlimited ICU capacity, noting that about four in 10 COVID ICU patients die and more than half requiring mechanical ventilation die.

"As ICU doctors, we are the last line of defence, and we are ringing the alarm bell. Please hear it. We implore you to act now."

Health experts raise fears

Health experts expressed grave concern for what the data modelling indicated, with Dr. Michael Warner, the medical director at Michael Garron Hospital in Toronto, calling it "shocking."

"It's foreseeable that we could run out of [ICU] beds, which is our worst nightmare," he said of what the projections indicated.

If the forecast of 700 to 800 COVID-19-related patients by the end of April comes to fruition — which is projected even with a stay-at-home order in place — Warner said there are two potential outcomes: either some patients are denied care or the care patients receive is sub-optimal.

He also expressed significant frustration that the chief medical officer of health did not acknowledge responsibility for the third wave, which was widely predicted by health experts, or accept that it represented a policy failure.

"I was floored, I couldn't believe it," he said of the province's top doctor rejecting the premise of the question he’d been asked the morning’s press conference. "If this is where he expected us to be because he thinks he did everything right then the future is bleak."

Warner called for the government to issue a stay-at-home order, which it stopped short of doing, noting that case numbers didn't fall in the second wave until those measures were implemented. "The colour-coded framework has failed to protect Ontarians," he said.

Warner also urged the government to use the next 28 days to target vaccinations strategically. While he said that the velocity of vaccinations will not outstrip the variants of concern, he argued that the government should "take the hose to where the fire is" and speed up the vaccination of front-line workers like those who work in factories and teachers.

Doris Grinspun, the CEO of the Registered Nurses' Association of Ontario, did not have confidence in the government's plan.

"It's too little, too late," said Grinspun, who has consistently called for stronger measures in order to protect the health system and avoid going in and out of the measures. "They should be basically doing a complete lockdown except for absolutely essential services," adding that this should include shutting down religious services and warehouses that are not producing essential goods.

She theorized that the half measures the government is taking are also about appeasing dissenting voices within the PC party who do not want to see that course of action. "This is about his base," she charged.

"This is politics over science, but it is costing people's lives," she added.

Warner and Grinspun are both among the advocates who have been calling for a provincial paid sick leave plan to protect essential workers.

Brown, speaking before the premier announced the new public health measures, said it’s important that people be able to follow them — including making it easy for people to stay home when they’re sick or have been exposed to COVID-19.

“Sometimes we talk about public health measures and the economy or public health measures and mental health as a trade-off,” said Brown. “This is a false debate. The faster we get the pandemic under control, the faster we return to normal. Partial measures, halfhearted adherence and denial prolong the pandemic and make life harder for everyone.”

Meanwhile, Dale, despite his deep concern for the health-care system, said he recognizes the extraordinary sacrifice the private sector and workers are being asked to make for sake of patients.

“I'm also deeply worried about our social cohesion in this province,” he said.

“At the end of the day, we either accept as a province and as a society that aggressive, comprehensive measures are necessary, or we don't. And then the consequences will follow.”

He said the hospital sector was more focused on what it needs to do to “minimize human harm and the unnecessary loss of life” than on debating what steps the province should have taken before now.

That said, the OHA found the stay-at-home order was effective at curbing community spread and has questioned the province’s decision to lift it and return to the colour-coded framework, he added.

Inefficient vaccinating

Another part of the morning modelling update focused on the vaccine rollout. Brown presented data showing that vaccination rates so far are highest in neighbourhoods with lower incidence of COVID-19 and lowest in the neighbourhoods with more infections.

That doesn’t only raise concerns about equity but also delays the impact of vaccinations and an effective strategy for curbing transmission. However, he acknowledged that it is difficult to quickly target only the people who could benefit from vaccination the most.

Brown said that while the vaccinations aren’t coming quickly enough to break the third wave they are they are the key to the long-term control of the virus.

Political reaction

Ford partially blamed increasing cases on the fact that “a lot of people let their guards down,” noting that “the patios were packed” since his government reopened outdoor dining in some regions.

"It's just my personal opinion, driving around, you know, a lot of people were gathering in larger groups," he said.

"I just ask the young people, please, you aren’t invincible.”

NDP Leader Andrea Horwath said she was “shocked” to hear the premier blame Ontarians.

“Meanwhile, experts warned him very clearly that this is exactly where we were headed. He ignored them, and walked us straight into danger," she said.

“I really want to say to people: keep doing your best. It’s not your fault.”

Ford distanced his government from its decision to reopen some services despite warnings from infectious disease experts that the third wave could quickly spiral if allowed to, saying that mayors and local medical officers of health wanted to reopen, too.

Ford said Ontario has the “toughest restrictions in North America,” but opposition leaders said the new plan amounts to half measures.

Horwath said it was “basically more of the same,” and “too little, too late.”

Horwath, as well as Liberal Leader Steven Del Duca and Green Leader Mike Schreiner, called for a provincial paid sick leave program.

Horwath and Del Duca called for front-line workers to move up the priority list for vaccinations, as a major source of spread is essential workplaces.

Schreiner wanted personal protective equipment mandated in vulnerable workplaces, and more inspections.

Del Duca also said the government should move teachers up the vaccine queue.

All three also called for more funding for small business support grants, and expanded eligibility.

“I think it’s clear Doug Ford's in over his head, and I believe the people of Ontario deserve far better,” Del Duca said.

Schreiner also said the government should increase funding to mental health services, saying they were underfunded before the pandemic.

Ford sidestepped a question about whether reopening patios and telling people they would be able to get haircuts on April 12 sent the wrong message, pivoting to talk about how Toronto, Peel and York represent about 60 per cent of all cases in Ontario.

The premier said he was “kind of shocked” to see how many seniors haven’t signed up for vaccine appointments. The province is increasing “door-knocking” to try to get those numbers up.

He also implored front-line health-care workers to get their vaccines if they’re eligible, saying there hasn’t been enough takeup. The province has estimated that under three-quarters of long-term care workers have received a dose of the vaccine.

“So that’s very, very concerning,” Ford said.

Horwath said the government needs to come up with a plan to combat vaccine hesitancy, and noted that the NDP has been calling for postal-code-based vaccines for a while now.

Schreiner told Ford to “stop blaming the federal government for your own challenges. Get doses out of freezers and into arms, and make sure we start prioritizing those most vulnerable places, especially vulnerable workplaces,"

Ford made sure to point out that it’s not just Ontario that’s experiencing a third wave.

"We're seeing provinces across the country, and also many states, face the same challenges," he said.

Ford said he felt pressure from people who don’t want to lock down at all.

"I know there's a lot of people that just want to go out there and open up, and oh, they don't believe those variants can be passed — I'm sorry. I’m a business person. I want to open up patios. But we just can’t,” he said.

The premier said there was a lot of debate about the measure at the cabinet meeting last night, which lasted for “eight or nine hours,” he said.

"There’s debate. Really, a lot of debate. But I told them if we want to see the summer and be able to get out there [before] we receive the millions of vaccines that we expect, then we have to do this. We have to crunch down one more time, for four weeks," he said.