Earlier this week, I unloaded some pent-up frustrations about our health-care system, and how we talk about our health-care system, in a column published here. It felt good! But it also left me wondering how system participants are currently feeling about it. I have my anecdotes, and I shared a few, but what about the people on the front line? During the pandemic, I often turned to Dr. Zain Chagla for guidance and information. Chagla is an associate professor at McMaster University and an infectious-disease physician practising at St. Joseph’s Healthcare in Hamilton. He spoke with TVO Today by phone on Thursday.
Matt Gurney: So we spoke many times during the pandemic, and I remember us joking once — maybe we were just hoping — that, one day, it would all be over. Things would be normal again. COVID began almost four years ago. I wrote my first column about it almost four years to the day, in fact. Yet I’ve been hearing anecdotally of real problems in the health-care system. That was the theme of my most recent TVO column, which was that it’s never been good in my lifetime. But there seems to be a lot of alarm about respiratory viruses overwhelming our emergency rooms. So we’ll start with a very basic question: What’s happening out there? What’s the situation?
Zain Chagla: The health-care system is challenged during respiratory season; it’s something we’ve dealt with and talked about for decades. It’s a big challenge, and we deal with it alongside all the other issues that present in an emergency room — injuries, medical emergencies, psychiatric issues, and all the rest.
So, yeah, it absolutely adds an additional pressure. The health-care system is staffed by some incredible folks, but there are challenges in terms of dealing with older demographics and the system’s overall capacity. We unfortunately see this pressure in the emergency room the most because that’s the entryway into acute-care hospitals. We get a lot more people coming in for care — some respiratory, some not, but they all come to the same place. Some of these people do require hospitalization to deal with their respiratory illnesses.
But it’s more complicated than many might realize. People think people come to the ER with a respiratory illness because they are having trouble breathing. Sometimes they are. But, for example, in older populations, frailer populations, the patients may also be presenting with issues like dehydration or gastrointestinal illness, both of which can be a manifestation of respiratory illness. Some populations in the community can compensate and manage these issues; others can’t and may require hospitalization or even a transfer to long-term care. And we know there are associations with influenza and heart attacks.
So we see a rise in this stuff as post-infectious complications afterwards. We recognize that people who have even a mild flu or case of COVID-19 might be tipped over the edge into other medical issues. That also represents some of the health-care utilization that we have to deal with. It’s not a ward of patients needing ventilators like we saw in the pandemic’s darkest times. It’s multifactorial, the whole system is impacted by these respiratory illnesses, and it adds real stress onto the system, which is already dealing with all of its normal challenges. And this all presents in the emergency room.
Gurney: Let’s talk about the mix of respiratory illnesses that you guys are seeing. One of the things that you and I talked about during the worst of the pandemic was that we were probably stuck with COVID — it was going to be just part of the mix from now on. Eventually, it would no longer be a pandemic threat, but it would be part of the seasonal brew. What has been the overall effect of taking an entirely new potentially serious respiratory illness and adding it into the mix of stuff we already were dealing with up until, say, December 2019?
Chagla: It makes it trickier, obviously. Unfortunately, we still see a good number of people who are experiencing COVID hospitalization — not just pneumonia, but all those other complications I mentioned. So that adds pressure on the system.
But there are other factors, too. As patients are coming into the health-care system, where these respiratory infections are part of the milieu, we test for the illnesses because we want to make sure that we know what their condition is as we admit them into the hospital. For infection-control purposes, we may have to isolate patients. That’s not instantaneous. That’s another challenge. It might take 12 hours or whatever, and a hospital only has so much isolation space.
So that creates bottleneck challenges for moving patients from emergency to acute care. We know enough about COVID to know that it is a disease that can spread, and we have to respond accordingly in the hospital. That really creates some logistical challenges with getting testing done on those folks, isolating those folks, even if the diagnosis isn’t a respiratory infection, and sometimes that takes 12 hours or 24 hours to deal with. All of that logistical stuff creates bottlenecks, which also, unfortunately, influence emergency capacity.
Gurney: I don’t know if what I’m about to ask you really matters in terms of outcomes. I’m just curious. Are the challenges we’re facing today a result of a higher-population-level incidence of illness? Or is it a reduced health-care system capacity due to COVID-related burnout? Or is it both at the same time — burning the health-care candle at both ends, so to speak?
Dr. Zain Chagla is an infectious-disease physician practising at St. Joseph’s Healthcare in Hamilton. (St. Joseph's Healthcare and Foundation/Facebook)
Chagla: It’s both. It’s multifactorial, for sure. Over the last year, and even into this year to a point, we have a population that hasn’t seen a respiratory infection for a long time, and they’re experiencing them again as we get back to mixing socially. These illnesses spread. So we’re seeing burdens of disease, and it’s still not fully predictable. We’re getting to a point where our seasonal predictions are almost back to as good as they were before COVID-19, but we are still seeing some surprises, both from COVID-19 and how all these burdens overlap.
But there are definitely post-pandemic challenges across the health-care system itself. There is burnout. There are staffing and human-resource challenges — not just in health care, I know, but certainly in it. That really affects our ability to scale up in times of stress. In the long-term-care system, we’re trying to implement some lessons learned in terms of isolation and infection control, but that can overall mean fewer long-term-care beds in the system, and then that, in turn, puts pressure on the hospitals and other parts of the health-care system. We are seeing a kind of culmination of a lot of these things.
And we have to remember, four years have passed since this began. We’re older! Our entire population has aged. The baby boomers were four years younger when the pandemic started. They are requiring more care and more complex care as they age, as expected. So there are a lot of overlapping burdens. Some of them may not have anything to do with the respiratory viruses or COVID. But we’re trying to evolve to keep up with it all.
Gurney: I honestly don’t have a ton more questions for you, but I want to grab onto something you just said. You talked about almost being back to a position where we could predict seasonal challenges as well as we could before COVID-19 began. So … what does that look like? What do you guys predict? I won’t hold you to it! I know things are unpredictable. But as you get back to a sense of confidence in your forecasting, well, what are you forecasting?
Chagla: I think for COVID-19, it’s still unclear — we are still learning a lot about a relatively new virus. But some things are clear already, right? On a year-over-year basis, and every wave, the effect of COVID-19 on our acute-care system is going down. There is some emerging stability there. We have a highly vaccinated population, many people have had prior infections, and therapeutics are available. A lot fewer people need ICU care, and illnesses are resulting in fewer deaths. And this goes back to 2021, really. Hopefully that trend toward stability will continue.
We have to stay vigilant for new variants. For now, though, we can say, in a general sense, that we will continue to experience a winter “COVID season.” I think for diseases like RSV and influenza, last year was very atypical. We saw an explosion of diseases in late fall, early winter that disappeared by this point in the year. That’s not what we typically see; we typically see the rise happening in November, getting worse in December, and starting to peter out in January. We aren’t back to that yet, but this year was closer — more like what we’d have expected. More “normal.” But with COVID-19, for now, all we can really say is we expect winter waves, next year and for following years, and we’ll face increased system burden because of it — but we hope the burden goes down. Hopefully, we see that trend continue: less hospitalization, fewer deaths.
Gurney: You’re talking mostly about the impact this is having in hospitals and emergency rooms. I want to ask you another question. And I honestly don’t know how much visibility into this you’ll have or how much information you’ll have or what is even tracked. But something I have anecdotally noted is that people are sick. None of them is showing up in the hospital, but it just seems to be that, even in my own family and social circle, there is a lot of mild illness. Enough to ruin an evening plan and send someone to bed, but not enough to send them to hospital. Conversations I’m having with people reflect similar observations. My gut sense is that we are sicker, as a population, than five years ago. As you said, we’re all older, and God knows that includes me. But on a broader level, do we have a sense of the illness burden on the population that is not showing up at hospitals? They’re just staying home and doing what I do, which is have some soup, have some tea, and rest?
Chagla: We have a few networks that look at what we call syndromic surveillance: why people are presenting to health-care providers. The one in Canada is called FluWatchers, for example. And they really just look at people who have a flu-like illness. The data from FluWatchers isn’t particularly alarming, but there was a small increase linked to COVID-19. So there is activity we’re picking up, with people reporting coughs and fevers, but nothing that was too alarming. These systems aren’t perfect, but they’d catch something super-alarming, and we don’t see that.
But there are other factors, too. The pandemic really highlighted that people come to work sick. The social responsibility of staying home when ill was not being respected as much prior to the pandemic but really is being respected much more afterwards, and that may be at play there. And, again, a lot of people did not have respiratory infections over the last few years due to the lockdowns, masking, a lack of travel. They are getting them again, and there’s a bit of amnesia about what being sick is actually like!
But, yes, a lot of people also got COVID recently, and that would mean an additional number of coughs and colds on top of the general baseline population level of coughs and colds. So I think there probably has been an increase compared to five years ago, and that makes sense: we have a new virus. But we’re also a bit more cognizant of being ill in public, and people are better at recognizing that and staying home. That’s a piece of this, too.
Gurney: All right: second-to-last question. Years ago, during the worst of it, every few days, I’d hear through a phone call or on a group chat that someone “had it.” Jim has COVID! Susan has COVID! Everyone was testing all the time; every sniffle was feared. Today, people get a cough and a runny nose and just shrug. I have a wife who teaches in an elementary school and two kids who go to an elementary school, so I basically live in a leaky bioweapons lab. I get sick all the time. But I haven’t been seriously sick in years. I’ll get a bit of a fever, a cough, some chills. Like I said above, nothing that some soup and tea can’t handle. Maybe a nap. I stay home and spare others. I don’t know what I had. I don’t know if I had COVID or RSV or some old-school cold or even a touch of the flu. I don’t know. Should I? Does it matter?
Chagla: I think that’s it, right? So, to be clear, there are some individuals where we really should be making the diagnosis of COVID-19, because due to the huge progress of the last few years, we actually have therapeutic options for this disease that actually don’t exist in other infections. In immunocompromised patients or older patients, our oral and intravenous interventions have really shown that they can improve outcomes and reduce the burden of disease. But for the general population, who are low risk, staying home until you feel better is good advice. Also, masking. Masking when you feel unwell, masking in high-risk environments or avoiding them. Don’t go visit your elderly relatives in the hospital if you have a mild respiratory illness, even if it’s not COVID!
The bottom line for us is that we know not everyone gets tested, so testing isn’t our best measure for surveillance. Things like wastewater are a whole lot easier to follow in terms of burden of disease in a population, as well as our hospitalization metrics. For the average person, who’s just lived through a pandemic, we know more about respiratory illnesses and hygiene. Follow good practices. Workplaces have to learn, too, and factor some absenteeism into their forecasts and planning, especially after the social mixing around the holidays. Consider masking when feeling unwell or recovering from illness, and avoid vulnerable people while sick.
Gurney: Doc, that’s all the main questions I had. Any last thoughts?
Chagla: We have vaccines! They work! We have COVID vaccines and now RSV vaccines and flu vaccines. Get them. And as for the health-care system, I don’t want it all to be doom and gloom. We are doing our best to innovate and improve and learn, because we do recognize that there are going to be real challenges in the system for the foreseeable future. But sick people will get care. There are big challenges in this country and around the world, but there are also health-care professionals ready to care for people.
This interview has been condensed and edited for length and clarity.
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