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Wednesday, June 3, 2020
By Ian Becking and Jordan Miller


labThe ongoing response to the COVID-19 crisis has shown unprecedented cooperation and collaboration between different orders of government (including health, finance, public safety and emergency management), the private sector, and the voluntary sector. The collaboration we are seeing is effectively a ‘whole-of-society’ response not envisaged since the Second World War or even the Cold War. When this crisis has stabilized, a detailed re-examination of our assumptions, systems, and supporting structures should be conducted to capture lessons learned and formalize the good work done in response to COVID-19. 

The end of the Cold War in late 1991 signalled a massive reduction in the threat of nuclear war. Throughout the Cold War, East and West faced the prospect of mutually assured destruction through the exchange of nuclear weapons if things turned ‘hot’. Civilian and industrial centres would be targeted, and Canada as a NATO member would not have been exempt from Soviet action. This was all known at the time, with robust civil defence measures implemented. Though a Civil Defence Coordinator was appointed in 1948, it took until 1959 for an Emergency Measures Organization (EMO) to be formalized at the federal level to protect the population and ensure continuity of government.

The measures taken were extensive. Hardened government communications centres were built across the country to ensure communications in the case of a nuclear attack. The Diefenbunker in Carp, Ontario just outside of Ottawa, is a notable example. This also included stockpiles of material to allow people to carry on and underground hospitals located across the country. The  National Emergency Stockpile System (NESS) consisted of 11 central warehouses and over 1300 smaller warehouses across the country. Activation of the NESS and other civil defence measures could have been accompanied with the activation of the War Measures Act. As the Cold War was ending, this was replaced with the Emergencies Act in 1988, showing a perceived thaw in relations with the Soviet Union.

The end of the Cold War and the post 9/11 period changed the threat model upon which the NESS was based. The nuclear war we had previously prepared for seemed less likely. A new range of threats emerged including terrorism, pandemic, natural disasters, and the potential for threats to major events.  A 2011 report from the Public Health Agency of Canada [1] acknowledged these new threats:  bio-chemical terrorism, another pandemic like SARS, the need for mass pharmaceuticals for events like the 2010 Olympics, and natural disaster response requiring a different mix of capabilities than originally envisioned by NESS.   Unfortunately, there was little action on the report. As we heard recently from the Minister of Health, Patty Hajdu, the NESS has faced under-investment for decades, and has not been a central tool in addressing the COVID-19. 

Stethoscope CanadaThe response we have seen to COVID-19 has been significant and has included all of society. All levels of government are cooperating on response and doing their best in coordinating response measures; the private sector is sustaining supply chain needs and government has removed as many barriers as possible to sustain this; companies are re-tooling manufacturing to meet medical equipment needs, and; government, voluntary and civil society groups are mobilizing to surge support capacity for vulnerable people.   

Daily press conferences have kept the public informed on the situations, new risks, and communicated new measures to support people and organizations. In terms of legislation, we have not seen major limitations. The Health Minister invoked the Quarantine Act to enforce self-isolation for Canadians returning from abroad. The Emergency Measures Act has not been implemented, though there has been public debate over whether or not it should be. Some provincial governments have activated their equivalents in order to implement extraordinary measures like closing businesses, public spaces and issuing fines and sanctions to those who do not comply.

Organizations have been collaborating to meet clear needs based on existing best practices. They are utilizing existing response plans and business continuity plans to identify key functions and work through potential challenges to keep people safe and keep society operating. Speed and effectiveness appear to be the key metrics – getting measures in place to protect people and ensuring the sustainability of the supply chain and critical services. Government and public health officials are providing updates as quickly as they can, typically daily, with clarifications provided as required.  
There have been challenges, however. A shortage of respirators and safety equipment prompted re-tool and surge manufacturing from some Canadian companies. Personal protective equipment (PPE) shortages are being managed through the global supply chain as best possible. Quebec is seeking hotel space for non-COVID-19 hospital patients to open more capacity in actual hospitals for an anticipated surge in COVID-19 patients and temporary field hospitals construction is being planned. These measures were not part of existing plans. They were the result of the innovation and ingenuity of government and dedication of  industry leaders to find immediate solutions. 

When the COVID-19 crisis has passed, a detailed review should take place. This is not supposed to be a ‘blame game’ situation, nor should it be.  As far as the global response goes, Canada took actions in line Dining in Isolationwith many other similar countries . The purpose of the lessons learned process is to identify where we can improve threat modelling, long-term planning, improve collaboration, systems and approaches, integrate technology, re-visit legislation if required to build a truly ‘whole-of-society’ approach. We should also identify the implications for all-hazard planning, in addition to pandemic planning. No one is suggesting we rebuild Cold War plans. The threats are different, the context has changed, and technology has changed so much that doing so would be impractical. Nor should we rebuild only for the next COVID-19-type pandemic (although this should be part of the process). 

The lessons learned from COVID-19 can form the baseline for the new ‘whole of society’ approach to events, and then be extrapolated for other threats. Future public health crises are likely, in some form or another. However, other threats should also be revisited. Things like infrastructure failures such as the 2003 blackout, weather-based natural hazards like fires, floods, and ice storms, and a range of others should be considered. We need to look at all of the best practices learned from dealing with all hazards that require a whole of society effort. 

The COVID-19 crisis and how this has been handled globally will provide an opportunity to ask the tough questions about how we can do better as a society, and which opportunities we take advantage of to limit the impact of future epidemics and other hazards. The costs of prevention are always cheaper than the costs of response. This is an opportunity Canada should not overlook once the crisis has passed.

[1] Evaluation of the National Emergency Stockpile System (NESS), Public Health Agency of Canada. April 2011

Ian Becking


Ian Becking is Director, Business Delivery, Calian Emergency Management Solutions

Jordan Miller is Program Manager, Strategic Initiatives, for Calian. 

 

 

 

 


Friday, May 1, 2020
By Jordan Miller


Health SafetyIn the last two installments we discussed the “all-hands-on-deck” approach and the importance of all elements of society working together to address COVID-19, and the need to re-think how we can re-organize our response systems to better absorb these shocks in the future. It is clear that this is an unprecedented crisis and response, with the Government of Canada and Provincial Governments exercising more influence over the private sector since the Second World War. 

The clear priority during the COVID-19 crisis is treating the infected, protecting those individuals who are not infected but are still at risk of contracting the virus furthering the spread, and observing public health warnings. Assigning blame and pointing out limitations at this stage is not useful. Where necessary, improved methods should be implemented in order to maximize effectiveness in real-time. However, as we transition back to normal life (or whatever the new normal will look like in the days to come) a detailed lessons learned process should be undertaken across all organizations and at all levels.

The lessons learned process is not just a polite version of the ‘blame game’. Lessons learned is not about comparing one organization’s response to another. Lessons learned is about identifying not only things that didn’t work as well as planned, but also about finding opportunities to improve upon things. This is important to ensure that organizations stop doing things that are not helpful, and also improving on areas that could be more helpful. This is an important point, as we have seen with the medical response and the supply chain. Doing one thing really well has not been the challenge with COVID-19: it has been doing a particular thing tens of thousands of times, and the challenges this presents for capacity.

BrainstormingThe scale and scope of the lessons learned process will need to get buy in from governments, the private sector, and the voluntary sector in order to be comprehensive. This doesn’t mean having thousands of participants in one place, though a wide-angle analysis will be needed to see how all the parts worked together. It does mean having sector-by-sector lessons learned sessions to identify areas for improvement in each sector. These lessons should eventually be aggregated to provide a system-level, whole-of-society perspective for priority areas. This process will provide the basis for cross-organizational improvements and focus areas for where technology and IT systems can be implemented to streamline collaboration and response. This might include developing a new national standing capability to coordinate more whole-of-society information integrating organizations at the Federal level, corresponding organizations in the Provinces, large private sector firms and the voluntary sector. It might mean legislating some elements of information sharing on essential supply stockpiles, manufacturing capacity regulations, and designing public buildings for multiple purposes in the case of emergency. Legislation may be needed, but this is not a challenge that can be overcome through legislation alone. Addressing challenges at a systems level is essential to being better prepared for future threats. 

For designing future IT systems, collecting data will be important. Process flow architectures can help identify procedural or communications exchange limits. The Japanese manufacturing sector pioneered the use of the Kaizen concept, viewing improvements to process by their impact on the overall operational efficiency. Factors analysis can also provide rich data sets for modellers to identify priorities areas. 
Most importantly for whatever comes out of the lessons learned process is that lessons be implemented. Lessons learned are sometimes derisively referred to as ‘lessons observed’ because the organization does not take the necessary steps to drive change. If we simply observe the lessons from COVID-19 the next time there is a large crisis we will be no better prepared. 

Open for Business SignFinally, whatever the way forward ends up looking like, the social bonds between disparate organizations need to be fostered and solidified. This means 1) conferences and workshops to better understand how others operate, 2) joint exercises where plans are put to the test, 3) cross-training to build knowledge across organizations, 4) shared technology platforms where appropriate for real-time information sharing, and 5) above all normalizing the idea that government, industry and the voluntary sector will be collaborating for emergency response.  

Formalizing the good collaboration we are seeing now during COVID-19 is essential to retaining the lessons learned from this crisis, building national resilience across all sectors, and to better protect the nation for future threats and crises. 

 

Jordan Miller is Program Manager, Strategic Initiatives, for Calian. 

 


Monday, April 27, 2020
By Jordan Miller


Puzzle pieces connectingThe response to COVID-19 has taken an “all-hands-on-deck” approach. All orders of government, the health sector, the armed forces, the private sector and the voluntary sector are all contributing to help effectively manage the response. This has required a re-think on roles and responsibilities for the national response. Government is not typically involved in the supply chain for safety equipment; the military is not typically involved in planning domestic logistics; the Government of Canada is not typically having daily calls with the Premiers. And yet, all of this is happening during COVID-19, leveraging the digital means necessary to keep lines of communication and collaborative efforts moving forward. 

This raises some questions for the future, once the COVID-19 crisis has passed. It would be a mistake to re-orient all emergency management design for something of this scope and scale. Equally, it would be a mistake to revert back to previous concepts that focus only on first responders and evacuation. The full range of potential threats, from localized industrial accidents up to national level response should be evaluated from a capability perspective to see if we have the right mix and the ability to surge. Not everything will be another COVID-19. In fact, it almost certainly will not be the same; but there will undoubtedly be future crisis.

So where to start? How to organize reconsidering roles and responsibilities? A useful model for re-visiting emergency needs is to group the types of crises we may face, using the size of the crisis, and whether or not it will be predictable or unforeseen.  

MatrixThis matrix (at right) is a useful tool to considering where the lessons of COVID-19 will apply most. Small, geographically defined crises are the kind of things that first responders at the municipal level respond to regularly. They still require multi-agency response, depending on the nature of the crisis. Medical teams may need to surge to treat casualties, the voluntary sector may engage in outreach to ensure vulnerable people are safe, and some public facilities may be temporarily closed. Generally, these are over quickly, so not much reconsideration is necessary.  

Larger, geographically defined crises have the benefit of being able to do geographically-bound risk modelling. This is in no way meant to minimize the impact on families and communities of massive flooding like we saw on the Ottawa river in the past few years, or the wildfire that engulfed most of Fort McMurray. These events are devastating to communities, some of which will never be the same. However, risk models show these events are made possible based on terrain, weather and other factors. In that sense, they were not totally unforeseen. The lessons learned from those events have highlighted the need for more regular planning for annual impacts, and the need to iterate based on new risk information. These crises are large, which means evacuation of communities may be required. Evacuation means getting people safely out of the area and then sustaining them in a new space. This means food, shelter, medical support, family support, considerations for children, the elderly and vulnerable populations. Evacuations may require military assistance and the activation of voluntary sector organizations. There is value in reconsidering the planning and response for this kind of event.

Large, non-geographically defined are more challenging.  The idea that a pandemic could happen was not unimaginable and not unforeseen. We saw SARS, MERS and Ebola. We know what the overall threat is (illness), but we are not always certain about how and when the crisis materializes. We can only identify the geographic vectors after the fact – before hand, any port of entry is theoretically a vector. The central feature is the long duration of the crisis and the permanence of the impact while they unfold. There is no work-around to a global pandemic or a systems-level failure. As we are seeing with COVID-19, all activity that does directly support response becomes a secondary consideration at the societal level. The basic system is not the problem; it’s the capacity and endurance that requires a ‘whole-of-society’ approach. In fact, short of nationalizing the private sector, there is no other way.  

Woman looking out windowWe are seeing real concerns about personal protective equipment (PPE) shortages, concerns about enough medical professionals, enough medical facilities, and having the manufacturing and human capital. The Minister of Health underlined this point in stating that investment in preparation for an emergency response has been lagging for decades since the end of the Cold War. The idea is not to simply rebuild Cold War plans. Too much has changed since then. Digital and wireless technology enables tracking and information management that would have been unthinking during the Cold War. 

Internet-of-Things enabled supply chain tracking offers the promise of greater visibility systems wide, providing near-real-time business intelligence on supplies and stock, and where they are in transit to facilities that needs then.  Additive printing – or 3D printing – means that some things can be produced close to the point of use. There is potential to rely less on traditional supply chains for some challenges, allowing facilities to produce some material on-site or near-site to meet changing needs. Robotics and autonomous vehicles provide the promise of some human-based tasks being enhanced or made more efficient, allowing humans to do more testing, move more material, or whatever else is required.  The use of robotic and autonomous vehicles can greater reduce the risk profile by removing some physical human elements from the response space.

Another challenge for integrating 21st century technology into a whole-of-society approach is that doing so mid-crisis risks creating more confusion and creating gaps in delivery. We should aim to limit experimentation during a crisis. Gaps in delivery are not something we can afford when the stakes are this high. Once the crisis has passed, a bigger discussion about how we can mobilize all of society more efficiently for a range of possible scenarios is necessary. Design efforts will need to see beyond just orders of government. Integrating supply chains – from raw materials, through to production, and delivery – into response is showing itself vital for the endurance of the response. The voluntary sector serves an important role, especially for the most vulnerable in society who are disproportionately impacted by any emergency.  

Game of ChessThis isn’t about rethinking everything about emergency management: this is about re-focusing on how all elements of society can work better together before an emergency occurs to create more resilient systems.

 

Jordan Miller is Program Manager, Strategic Initiatives, for Calian. 


Thursday, April 23, 2020
By Jordan Miller


Office Team CollaboratingThe response to the COVID-19 crisis has mobilized all orders of government, health response, the private sector to sustain the supply chain, and the voluntary sector. Government announcements on physical distancing measures are supported by medical and public health professionals and apply broadly to prevent community transmission. Elected leaders have consistently warned against hoarding food and supplies, reminding people that the supply chain is still delivering and that there is no anticipated shortage. The most notable thing we are seeing during this response is that “all-hands-on-deck” means organizations that don’t normally interact are engaging with each other directly. This is happening at the political level across all orders of government, with the private sector to ensure the supply chain is resilient, and ensuring the voluntary sector is being leveraged accordingly. This collaboration is happening on-the-fly in the sense that organizations are not normally part of each other’s planning, training and delivery; especially not to this extent. What this really means is taking a whole-of-society approach.

Federal and provincial emergency operations centres are staffed for 24/7 operations to manage this escalating crisis. The health component is central to this effort. The federal government’s daily update briefings are typically comprised of the Chief and Deputy Public Health Officers, Dr. Theresa Tam and Dr. Howard Njoo respectively, providing detailed science-based answer to questions from the public and the press. Travel restrictions, distancing requirements and shutting down federal offices were all driven by health assessments. Ontario, Nova Scotia, Saskatchewan, British Columbia, Quebec and others regularly have their Chief Medical Officers speaking about the risks and the measures being taken. Elected leaders regularly defer to the public health authorities and remind the public that policy decisions are being made based on the science and the evidence. This applies to shutting down any non-essential businesses, recreational facilities, schools and childcare facilities. Generally, in emergency management we do not associate business hours with the response; either businesses stay open or they don’t, based on whether they are able. Mandated shutdowns are rare. Mandated closures are unprecedented on this scale in recent memory.

Warehouse TeamThe political level of collaboration has also accelerated to a degree not seen in recent history. The Government of Canada has struck a cabinet committee specifically for collaboration with their provincial counterparts to manage the response. Cabinet meetings are typically for considering strategic issues and re-evaluating policy options, not for day-to-day management.  While the federal government regularly works with the provinces in areas of mutual interest through the Council of the Federation, daily collaboration is something that is almost unheard of in contemporary history. 

The supply chain question has become very prominent during the COVID-19 response. The Government of Canada has allowed an exemption for cross-border movement of trucks to sustain the supply chain. Provincial prohibitions on regional travel have not applied to the supply chain, underlining its importance. The Government of Canada has also consulted with the manufacturing and defence industry to determine how much additional production capacity is available for producing medical equipment, safety devices and clothing. The Government of British Columbia passed measures to get up-to-date information about grocery stocks and warehouse levels from grocery chains, the right to take over private spaces to support the supply chain, and the power to commandeer commercial transport. These measures are extraordinary. The Government is not typically in the business of business, beyond broad regulatory frameworks for product safety standard to protect the public.

The military is including sustaining supply chains for remote communities as part of their planning for COVID-19 and for upcoming seasonal hazards. The Chief of Defence Staff (CDS)  discussed the challenge of planning for the response to spring floods and wildfires in the context of the current COVID-19 environment.  The military is including medical, engineering, transport, infrastructure repair, and logistics support as part of its response planning. The military has a dedicated logistics function to sustain its own operations. Providing fuel, food, ammunition and replacement equipment is essential for sustaining military operations. However, being a key provider of those functions for civilians is something typically associated with things like the Disaster Assistance Response Team (DART) that response to crises abroad. The military is the ‘force of last resort’, and in the context of COVID-19 this is likely to include more than disaster relief only (sandbagging, medical evacuation, etc.). It will likely include sustaining the supply chain to allow communities to shelter in place due to the COVID-19 risk. 

The voluntary sector is providing support to those affect as best they can while still observing physical distancing requirements. The Canadian Red Cross’s support includes meals for those in quarantine at Trenton and Cornwall, offering mental health services and offering financial assistance through their national and regional networks.  The Salvation Army is supporting food relief to limit food insecurity impacts on the most vulnerable members of the communities during this time. This support cannot be provided in a relief centre as supply warehousewe often see during disasters; it needs to be provided while observing distancing, especially with those diagnosed with COVID-19.  This is an entirely new model for the voluntary sector too.

This nature of COVID-19 and its response are unprecedented in modern history. The public, private and voluntary sectors are all doing what they can in the moment to respond to this crisis. This has been a significant effort that demands a lot from the people involved.  The ‘whole-of-society’ approach is showing the closest thing to maximum societal engagement we have seen since the days of the Second World War. 

In our next installment we will talk about what happens after the crisis, and how we can think differently about designing organizations to meet challenges big and small, predictable and unforeseen. 

 

Jordan Miller is Program Manager, Strategic Initiatives, for Calian. 


Friday, April 17, 2020
By Mathew Fetzner and Jordan Miller

 

Hand WashingThe daily COVID-19 figures show new cases every day. Guidance is clear: emphasize safety and distancing measures to reduce the risk of spread and flatten the curve. Those who are diagnosed with COVID-19, and whose symptoms are manageable, are either sent home to self-quarantine or admitted to hospital if required. Health care workers are providing care to those with the virus or to presumptive cases in hospitals, and are doing so at surge capacity during this time. Long-term care facilities are facing challenges with the vulnerability of their patients and the speed with which the virus has spread, with high death tolls in some cases. Concerns about personal protective equipment (PPE) shortages underline the significance of how hard health care teams are working to provide care. 

In general, there is increased risk for health care workers to be diagnosed with a mental health condition after an epidemic. This can include feeling helpless, demoralized, or a sense of mourning over losing the person they were before the crisis [1]. Lessons from specific crises in the past provide more detail. The lessons from SARS showed there are significant mental health and substance abuse risks for health care personnel in the time after the crisis has passed. Hospital workers in China were more likely to suffer PTSD and misuse alcohol as a means of coping after the SARS crisis [2]. A similar study on SARS health care workers from Singapore found that 20 percent of doctors and nurses were diagnosed with PTSD as a result of caring for the sick [3]. The H1N1 outbreak in 2009 showed that health care workers were concerned about treating a new disease they didn’t know much about. In Australia, their concerns were for the safety of their patients, fear of transmitting the disease across patients or to other members of the health team, and the overall capacity to deliver care [4]. The COVID-19 pandemic has many of the same characteristics as the H1N1 crisis: a disease that is new, not as well understood as other diseases, with health care workers putting in long hours and expressing concerns over long-term safety from the potential of PPE shortages. 

The mental health challenges for health care workers may not follow on immediately from the COVID-19 pandemic stabilization. It may take time for symptoms to materialize, giving the false impression in the immediate term that health care workers were unaffected by their experience. A Canadian study showed that, during SARS in 2003, health care workers were no more likely to experience mental health challenges than non-health care workers. However, in 2004, one year later, health care workers showed significantly higher depression, anxiety, and post-traumatic stress symptoms [5]. This underlines the potential for a future crisis of mental health needs for mental health workers after the crisis passes.

StethoscopeWith the prevalence of digital technologies for people to stay connected while self-isolating and physical distancing, there is potential for digital tools to be developed to provide more options for mental health service delivery. Virtual care appointments, allowing patients to speak with mental health professionals, means those needing service can access it more conveniently. Digital chat services based on text can be expanded for crisis service, where needed. Providing patients with instructional and education material using digital and interactive means can be developed to allow for improved self-awareness and self-care outside of other options. Although face-to-face contact continues to be the prevailing delivery method for psychotherapy (e.g., cognitive-behavioural therapy [CBT]) and psychopharmacotherapy (e.g., selective serotonin reuptake inhibitors [SSRIs]), some evidence suggests that, for many mental health conditions, remote therapy and medication consults can be provided – or integrated with in-person services – with similar effects [6]. This could be especially useful to address a potential surge in mental health needs, especially from health care workers who were involved in the COVID-19 response.

The benefits of integrating new tools into mental health treatment options could have broader societal benefits. Reducing barriers to access and  improving access on a societal level could be significant in improving broader access for other vulnerable or marginalized populations. The COVID-19 crisis will eventually pass. Solutions to help us, as a society, manage the consequences of the crisis likely have wider societal applications. These should be harnessed wherever possible.  

Dr. Mathew Fetzner is a Calian Clinical Psychologist and Acting Program Manager at CFB Petawawa for Canadian Forces Health Services. Jordan Miller is Program Manager, Strategic Initiatives, for Calian. 

Notes
[1] Damir Huremović, ‘Mental Health Care for Survivors and Healthcare Workers in the Aftermath of an Outbreak,’ Psychiatry of Pandemics. 2019 May 16 : 127–141.

[2] Ping Wu;  Xinhua Liu;  Yunyun Fang; Bin Fan; Cordelia J. Fuller; Zhiqiang Guan; Zhongling Yao; Junhui Kong; Jin Lu; Iva J. Litvak. ‘Alcohol Abuse/Dependence Symptoms Among Hospital Employees Exposed to a SARS Outbreak,’ Alcohol and Alcoholism. 008 Nov-Dec; 43(6): 706–712.

[3] Angelina O. M. Chan; Chan Yiong Huak.  ‘Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore,’ Occupational Medicine. 2004 May; 54(3): 190–196.

[4] Amanda Corley; Naomi E. Hammond; John F. Fraser. ‘The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: A phenomenological study,’ International Journal of Nursing Studies. 2010 May; 47(5): 577–585.

[5] Lee AM; Wong JG; McAlonan GM; Cheung V; Cheung C; Sham PC; Chu CM, Wong PC; Tsang KW; Chua SE. ‘Stress and psychological distress among SARS survivors 1 year after the outbreak,’ Canadian Journal of Psychiatry. 2007 Apr; 52(4):233-40.

[6] Carlbring P; Andersson G; Cuijpers P; Riper H; Hedman-Lagerlof E. ‘Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cognitive Behavior Therapy. 2018 47(1): 1-18.


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