Health Committee on June 10th, 2020

[The Chair, Liberal, Ron McKinnon]

I call this meeting to order.

I'd like to welcome everyone to meeting number 26 of the House of Commons Standing Committee on Health. Pursuant to the order of reference of May 26, 2020, the committee is resuming its briefing on the Canadian response to the COVID-19 pandemic.

To ensure an orderly meeting, I would like to outline a few rules to follow.

Interpretation in this video conference will work very much like in a regular committee meeting. You have the choice, at the bottom of your screen, of either floor, English or French. As you are speaking, if you plan to alternate from one language to another, you will need to also switch the interpretation channel so it aligns with the language you are speaking. You also may want to allow for a short pause when switching languages. Before speaking, please wait until I recognize you by name or, during questions, by the member asking the question.

When you are ready to speak, you can click on the microphone icon to activate your mike. As a reminder, all comments by members and witnesses should be addressed through the chair. When you're not speaking, your mike should be on mute.

I would like now to welcome our first panel of witnesses.

Appearing as an individual, we have Dr. Joanne Liu, physician and former international president of Doctors Without Borders. With the Canadian Association of Radiologists, we have Dr. Michael Barry, president, and Dr. Gilles Soulez, vice-president. From Southlake Regional Health Centre, we have Arden Krystal, president and chief executive officer.

We will start now with the statements from our witnesses.

Dr. Liu, please go ahead. You have 10 minutes.

[Dr. Joanne Liu, Physician and Former International President of Doctors Without Borders, As an Individual]

Thank you very much, Mr. Chair.

Good afternoon, standing committee members.

My intervention will be limited to my area of expertise, which is, basically, tackling regional epidemic-pandemic responses at the micro and macro levels as a humanitarian aid worker and then through my training as a master in education and health management. We're nearly going to hit the 100-day mark of the pandemic, and very sadly, in Quebec, we have reached 5,000 deaths of patients with COVID-19.

I want to remind everyone that we still don't have a vaccine, that we still don't have a specific treatment, and that we still don't know much about the immunity that we have once we have the infection. Therefore, our best friend and best way of tackling it is mitigating measures for the response, so my speech will be about preventing the preventable.

We have a duty to absolutely learn the lessons to be learned after these 100 days. I think that we have to understand, as well, that there's a cost for response, but that despite the cost, because of the pattern of recurrences of pandemics over the last 15 years—SARS in 2003, swine flu in 2009, MERS in 2012, Ebola in 2014 and 2015, Zika in 2015, and now COVID—whatever we're doing right now is a rehearsal for next time around, and it's an investment. We've learned a lot, and we've managed throughout the pandemic to manage a shortage of inventory. Some variables have been impacted and I think I will not go there because my first statement a few months ago highlighted that. The procurements, the patient beneficiaries, the personnel and the hospital were some of them.

The lesson that we learned over the last few months is about the brutality of the disease and the loneliness of patients dying alone. We learned about the different vulnerable communities: elders, people in prison and homeless people. We learned about how to isolate people in their communities. We learned the hard way how to personalize IPC, infection prevention control, in a meaningful way. We learned as well, hopefully, that we have to protect, mentally and physically, all our staff and front-line workers. We learned that we should manage the mobility of people. We learned that outbreaks happen in hospitals, even university hospitals, more than we want. We learned that communication needs the correct message, otherwise people will get confused. We learned that public health needs the basics to be implemented: tests, contact tracing, isolation and treatment. We learned that internal surge capacity was stretched and that access to care has been an issue for non-COVID patients.

What is the role at the governmental level, at the federal level, now that we have finally passed the peak and flattened the curve to a certain extent? We have breathing space, and we can probably switch from a mode of being reactive to something that is much more anticipatory. What I'm looking for and what I'm begging for are—knowing that the federal level is the only place where we have an overview of the whole country—some sort of norms and guidance for the best practices to be implemented.

I have five points that I'm going to share with you.

The first point is the second peak versus rebounds. There are a lot of people who talk with assertiveness about the possibility of a second peak. The reality is that we don't know what the seasonal behaviour is, if there's going to be a dormant phase for the coronavirus, so we don't know if it's going to become strong in the fall. We need to prepare ourselves for the worst-case scenario. Keeping that in mind, I think we should develop a specific strategy on vaccination for influenza, knowing that influenza is going to be back, because we don't want to overload our hospitals in the fall. We need to do everything to prevent the second wave, if ever it happens.

Meanwhile, my biggest fear is repeated rebounds, repeated micro outbreaks away from the epicentre. That's what we've seen with many other outbreaks, with Ebola, with cholera, and then with yellow fever. I know it's different, but nevertheless, I think there is repeat pattern. While we ease the lockdown and we increase mobility of Canadians, especially during the summer vacation period, we might be facing micro outbreaks in different places in rural areas.

Why is it a concern? It is a concern because in many places in rural areas, they haven't been exposed and they haven't had many cases, meaning they don't have much immunity. That's one thing. The other thing is that hospitals in rural areas are often staffed by what we call “depanneur doctors”. From 20% to 80% of the ER shifts are basically covered by locum doctors. How do we frame the visits of those doctors? We probably won't quarantine them for 14 days. Are we going to make sure that they don't become vectors of COVID-19? Are we going to test them, test them before they go, or test them while they're there? That's one thing.

The other thing about rural areas is that I would strongly advise implementing rapid response teams or SWAT teams, as I like to call them, to go in and stabilize when there's a micro outbreak, and make sure that we optimize IPC and we support the response.

My other concern is about interprovincial mobility and what it can bring in terms of having micro outbreaks. The Campbellton case in New Brunswick is a good example of how someone can move from an epicentre to a province to places where there was low transmission, and there we go, we have an outbreak. I would say that at the federal level there must be guidance about how we are going to control interprovincial mobility.

At the international level, my biggest concern is about, yes, the border. I think we have an agreement that it will be closed until June 21, if I'm not mistaken, but how are we going to follow through knowing that, at the federal level, we control the border, but actually the follow through of people is probably going to be at the provincial level by public health? Are we going to follow up on the visitors? Are we going to hand over the information on visitors? Are we going to ask them to self-monitor? Are we going to trace them? Are we going to request that they isolate?

That was my first point on the second wave of micro outbreaks.

My second point is about personnel burnout.

What I've seen in many other outbreaks is that when we pass the first wave, we are facing burnout of personnel, front-line workers. Are we ready to fill the gap when this happens? What is the buffer in terms of staff? Are we going to have a surge capacity knowing that there is also going to be pullout of military from the places where they've been deployed?

I think that in the mid term and long term, we need to start thinking about a civilian reservist workforce that would be trained and could jump in and be functional. For example, the Red Cross has developed some of those models, but we need to think about that and it should probably be at the federal level.

The third point is that we need absolute guidance on best practices for testing and contact tracing in long-term care facilities. The reason for testing is that we have people who have mobility, and we know there are some people who are asymptomatic or people who are presymptomatic, meaning they don't have symptoms but they will develop the disease in one to seven days. These people can be vectors of the disease. We need to have an overarching strategy about testing. We need swabs and serology and we need to make the system happen, and guidance on that would be quite welcome.

On contact tracing, we need to find out if we are going to have the ability and the capacity to do that if we have a second wave. We know in some provinces it's been a real challenge. What is our surge capacity in that respect?

Last, in terms of guidance, I think we need to be clear on long-term care facilities in making sure that we test the people in long-term care facilities, that we protect them and that we staff them properly. We also need to learn from some of the experiences that have been successful.

The fourth point is about access to care for non-COVID patients. In many other places we still have a health care system that is running at low regime. We need to come up with a priority list for our sector to scale up, because non-COVID-19 patients cannot be the collateral damage of the response to COVID-19. I think that guidance would be helpful.

My last point is about the international level. We've realized how much we are interconnected and interdependent, in a complex way, across the world. We know that making all of us safer depends on making each of us safer. To say it another way, making all of us healthier depends on making each of us healthier. We cannot tackle COVID-19 in isolation from the rest of the world.

Canada has been investing in R and D for a vaccine. There has been a massive investment locally in Canada of $150 million in R and D for a vaccine. We're not sure yet what the scale-up capacity would be for manufacturing it, if it were successful, and we don't know how affordable and accessible it would be. More recently there's been a pledge of more than $600 million for Gavi in the global polio response. I think if we are planning to invest that much in R and D for a vaccine, we absolutely need to get a seat at the table to influence the outcome—the outcome of the public good from the vaccine that comes from the R and D. It's important, because Canada needs to influence how we'll distribute whatever discovery happens. If we don't have a seat at the table, it would probably be really hard to influence the process.

Meanwhile, I really urge that we develop a strategy on how we would vaccinate Canadians if we were to have a vaccine available by the end of 2020 or early 2021. We should do that now, when we have a bit of a lull time. We need to find out who we're going to vaccinate as a priority, such as front-line workers or vulnerable subsets of the population. We shouldn't improvise that at the last minute. We need to think that through.

To summarize, I think it is really, really important that we do everything to do the mitigating measures. We still don't have a treatment. We still don't have a vaccine. We don't know about the immunity. We have to prevent the preventable. It's about preventing people from getting infected, and about preventing people from getting sick, but it's about lives.

Thank you very much.

[The Chair, Liberal, Ron McKinnon]

Thank you, Dr. Liu.

We go now to the Canadian Association of Radiologists.

Dr. Barry or Dr. Soulez, please go ahead for 10 minutes, please.

[Dr. Michael Barry, President, Canadian Association of Radiologists]

Mr. Chair, I thank you and the committee for having us today. Gilles and I will be sharing the presentation. I'll tell you a little bit about who we are.

The Canadian Association of Radiologists represents about 2,800 radiologists from coast to coast who are dedicated to medical imaging excellence around the country. Today we're going to talk somewhat about the lessons learned through the COVID-19 crisis, where we were going in, where we are coming out, the lessons learned, and our recommendations/asks, at the end. I may have met some of you before, through some of our days on the Hill, within the last few years. Some of this information we're sharing on lessons learned comes from the Conference Board of Canada's report, reported a year or so ago, that many of you have received through our national organization.

For those of you who are unfamiliar with radiology, we're the physicians who are trained for about 15 years post-secondary and who diagnose and perform CAT scans, MRIs and ultrasounds. We do interventional procedures, more recently stroke events, treatment for acute stroke presentation, cancer treatment of ablating tumours, and a number of complex procedures that occur in hospitals, community and radiology alike. We also do other things: broken bones in emergency rooms, lower back pain with an MRI, and things like that. Many of you have probably used a radiologist or had interaction with a radiologist.

That's who we are. Gilles will now talk a little bit about our experience so far, and I will come back at the end.

Gilles, it's yours from here.

[Dr. Gilles Soulez, Vice-President, Canadian Association of Radiologists]

Thank you, Mike.

My name is Gilles Soulez. I'm an interventional radiologist at CHUM hospital. I'm a professor of radiology at the Université de Montréal. I am also vice-president of the Canadian Association of Radiologists. Thank you for listening to us on this very important topic on the health of Canadians.

As you probably know, radiology and imaging are gateways to our health system. In other words, almost all patients having medical or surgical treatment will require diagnostic imaging and an imaging follow-up to monitor the efficacy of the—

[The Chair, Liberal, Ron McKinnon]

Pardon me, Dr. Soulez, could you please hold your mike.

[Dr. Gilles Soulez]

Okay, sorry about that.

As you know, measures related to COVID-19 postponed diagnostic imaging for hundreds of thousands of Canadians, resulting in a 50% reduction in medical imaging services across the country. On top of that, non-urgent cancer screening was suspended. This has created a real sense of urgency, causing an overwhelming backlog in diagnostic imaging services.

As you know, before the crisis we already had extensive wait-lists across the country, compared to other countries. Prior to the pandemic, patients were waiting an average of 50 to 82 days for a CT scan, and up to 89 days for an MRI, magnetic resonance imaging. Those wait times are 20 to 52 days longer than recommended. This wait-list for essential services is now putting the health of Canadians in dire straits for much longer. This is especially concerning for cancer patients who are awaiting life-saving treatment that is dependent on medical imaging.

The throughput in a radiology department, with the COVID crisis, is currently estimated to be at 70% of pre-COVID activities, mainly because of the disinfection and social distancing protocols. This reality will stay with us for a long period of time due to the eventuality of a second wave of the virus.

As an example, from Quebec City, a 20-year-old male patient presented with abdominal pain. His physician filled a hospital requisition for a CT scan at the CHUL in Quebec City. Because of the backlog of the waiting list, he finally had his CT scan after two months. The pain was debilitating. A large, 20 centimetre retroperitoneal lymphoma was found. Consequently, acute therapy was initiated with significant delay, thus hampering his prognosis.

At Quebec City, the MRI wait-list is very worrisome. There are currently 12,000 patients on the wait-list for an MRI at the CHUL. As discussed before, the throughput is currently estimated at 70% compared to pre-COVID. They are working on eliminating less relevant examinations on the wait-list. Even if they can eliminate 20% of those requisitions, the wait-list will still rise to 17,000 patients in one year, just to give you an example.

In Alberta, they calculated that with the suspension of breast screening by mammography during the last two months, they've already missed 250 cases of cancer that should be treated now.

We understand that postponing non-urgent medical imaging services was necessary during the height of the pandemic. Now that the first wave has passed and the spread of the virus has been contained, we stand to resume diagnostic imaging at its fullest capacity, but in a safe way.

The health and safety of Canadians is our number one priority. We also respect the emotional well-being of patients and staff. The resumption of diagnostic imaging needs to happen in a planned, efficient and safe manner so as not to overwhelm the health care system and our health care workers.

Our task force group on the resumption of radiology services recently provided guidelines to help radiology departments to resume medical imaging safely. It is a national emergency, given the already exhaustive wait times for these procedures, and incorporating the further delay that the pandemic has created, which caused patients to wait even longer.

Prior to the pandemic it was estimated that in 2017 the economy lost $3.5 billion in GDP due to people being unable to work while waiting for medical imaging procedures. This will be substantially increased due to the COVID-19 crisis. For example, a 25% drop in patients being seen will result in an additional $1 billion of lost GDP, so close to $5 billion.

Mike, our ask.

[Dr. Michael Barry]

Thank you, Gilles, for going through some of those examples.

As the committee can see, with the delays in some of this imaging, people are still frightened to come back to the emergency room or the hospital to get their tests done. It's a really unnerving thing for people to come into the hospitals now. Almost everybody is wearing a mask.

We have two firm asks we are going to put to the committee. One you're familiar with. We asked it about a year or two ago, but a larger light has been shone on it. That is the $1.5-billion investment in medical imaging over three years to bring us up to speed with our G7 partners. We're about ninth in the world for advanced imaging with CT, MRI and some of the other high-tech procedures. We're well behind other jurisdictions. COVID-19 has exacerbated that. The $1.5-billion investment won't fix the whole wait-list, but it will be a strong start to get us in the right direction.

On the lessons learned, we found that our infrastructure is quite dated nationally. There are not enough wait rooms, consultation rooms or spacing in the hospital. There are even things as simple as engineering, like our air ventilation is from the 1970s without windows. With COVID-19 and future pandemics, that's a real concern, so CAR asks the committee to consider a large task force to look at not only new equipment with the influx of patients, but also waiting room spacing, additional cleaning and mechanisms to keep people safe during the pandemic.

As for lessons learned, in conclusion, our health care system was not ready to deal with the demand. In the large urban centres, in particular, Toronto, Montreal and, to a lesser extent, Vancouver and Calgary, we didn't have the medical equipment or the staff to handle extended wait times or deal with the acute onslaught of very sick patients. We also learned that our spacing was not strong and that our PPE was not strong. We had a lot of deficits, but we've learned, and we'll learn from that going forward.

We're asking the federal government, through your committee, to support the resumption of imaging by making an investment through the federal transfers to look at new medical imaging equipment and infrastructure, hire additional radiologists, medical radiation technologists and stenographers in particular to improve our quality of care for our patients.

That's our presentation. I believe there will be questions later.

Thanks again very much to the Chair and the committee for hearing us today.

[The Chair, Liberal, Ron McKinnon]

Doctors, thank you.

We'll go now to the Southlake Regional Health Centre.

Ms. Krystal, go ahead for 10 minutes, please.

[Arden Krystal, President and Chief Executive Officer, Southlake Regional Health Centre]

Thank you very much.

I'll give you a bit of an introduction to Southlake and our role in Ontario, and then I want to talk about our experience with COVID-19.

We have over 525 beds. This is one of the largest hospitals in Ontario. We're located in Newmarket, which is 30 minutes north of Toronto. We provide community hospital services to a large catchment in York and southern Simcoe, as well as regional tertiary programs such as cancer care and cardiac care. We have the third-largest cardiac program in Ontario.

We've had quite an experience with COVID-19. We have seen quite an impact in our GTA hospitals. That impact has taught us many lessons. I'd like to talk a bit about those lessons and also about what some of the bright sides of this have been.

Just to give you an example of where we've been, we initiated an incident management team and an emergency operations centre in late January. This was earlier than most, and that was very helpful to us, because we started to anticipate the kinds of things that we would have to get up and running.

We had a daily emergency operation centre meeting. We staffed that for many hours a day, and we had many managers, administrators, physician leaders and others working many hours. We held daily town halls with staff and sent out a lot of information to our staff. There's no question that transparency in communication at both the local level and the provincial level, and also at a federal level, has made a big difference through this pandemic response.

One of the things we did is that we were very transparent in posting our volumes, what kinds of personal protective equipment inventory we had and our projections. We developed a logistic regression model to project demand for intensive care unit beds and also modelled the local epidemiological reproduction rate in our catchment areas to support our response.

We had our first patient in the ICU on March 16, which was five days after the pandemic was declared by the WHO. As of today, we've had 88 patients with COVID-19 admitted to our ICU and our wards, and we unfortunately have had 22 deaths.

Starting in mid-March, we developed a drive-through assessment centre. We've tested literally thousands of patients, both at that centre and as outreach to our long-term care and retirement homes in congregate settings within our catchment. We most recently have become one of the first two hospitals in Ontario that were ordered by the Ministry of Long-Term Care, under a mandatory management order, to take over the management of a long-term care home in outbreak.

With that as the background, I want to talk about a few things that were our biggest challenges and where we believe the federal government can have some role.

The first one is in procurement supply chains and PPE. There is no question that one of the most stressful aspects of COVID-19 and our response has been PPE availability. It's clear that our current just-in-time procurement and delivery approach in Ontario—and I know that it is pretty common throughout the provinces, as I've also spent a lot of my career in B.C.—needs to be fundamentally reviewed.

The pandemic stockpiles that were present federally and in some provinces, including Ontario, and that were in place for SARS were allowed to expire. That not only resulted in a lot of expensive stock not being able to be used, but it also created a scenario where we were critically short when we should have been prepared. One of the recommendations we have around this is that the federal government and the provinces work together to rotate pandemic stock with the regular supply chain to prevent expiry, so that we will be ready the next time something like this happens.

Those shortages not only created sleepless nights but also created a lot of challenges around the time and effort to manage, count, order and go back and forth with central supply chains and numerous vendors directly to reconcile and model our PPE supply. This was a massive, massive amount of labour and time, and the churn of changes in terms of strategy and approach to PPE left significant levels of stress in morale. We have to study what we've done with that and make some changes for the future.

Long-term care is the other area where I have some advice and counsel. We have known for many years that the long-term care model we have in Ontario, but also across other jurisdictions in other provinces, has significant flaws. Those were clearly illuminated during COVID-19.

A lack of sufficient oversight, inspection and integration with the rest of the system have created substantial issues for many homes. Many of these homes are very outdated, very old and very crowded. It is almost impossible to prevent outbreaks in these situations.

There is lack of training for staff, a lack of staff in some cases and a lack of management capacity in many cases. One of the things that would be of help is to have national standards for long-term care, very similar to what we have in other hospital jurisdictions.

We also need some very fast capital investments. Many of these homes simply cannot operate the way they need to operate during an outbreak because of their size and the problems they have with infection control.

I want to talk about hospital capacity. There's no doubt that hospitals across Canada, and it doesn't matter which province you're in, have been operating at over 100% capacity even well before COVID-19. Further to the comments by my radiologist colleagues, one of the challenges with working over capacity is the only way you can recoup capacity to deal with a pandemic like this is to cancel elective procedures.

Our hospital went down to 30% of our normal volume. We've modelled that for hip and knee replacements alone it could take us seven years to recoup the number of surgeries we would need to do if we don't work evenings, weekends and everything else. Of course, the problem with that is human resources. As one of my other colleagues mentioned, they are pretty burned out. To try to get them to work those extra hours, even if we were funded for it, would be very difficult. Once again, we need to rethink our hospital sector.

I'll mention bright spots very quickly. Virtual care has been a really bright spot. After years of painfully slow uptake in Ontario and other provinces, this pandemic triggered widespread adoption of virtual care. We realize now we don't need to go back to exactly the way we were doing things. We will be able to convert a substantial number of visits, particularly ambulatory visits, to virtual care.

We've also noticed the good collaboration we have had between the hospital sector and some of the other sectors has helped us, but that is not widespread. There needs to be a move toward better integration across all provinces and certainly within all sectors. That amount of integration, something we had here in Ontario through Ontario Health Teams, was very helpful.

Last, I want to extend a very big thank you to our communities. Throughout this pandemic, our staff and physicians have been continually bolstered by an unprecedented outpouring of support from the communities we serve. For people who are very tired and overwhelmed, and in some cases experiencing some level of PTSD, that amount of support was incredibly helpful, and we were incredibly grateful for it.

I will leave it at that and wait for questions.

[The Chair, Liberal, Ron McKinnon]

Thank you.

We will start our questioning now. We'll do two rounds of questions. We will start the first round with Mr. Jeneroux.

Mr. Jeneroux, you have six minutes.

[Matt Jeneroux, Conservative, Edmonton Riverbend, AB]

Thank you, Mr. Chair.

Thank you everybody for all the work you're doing in your work lives, but also for joining us at committee today. It's obviously very important to see where we want to go in any potential waves or any other potential pandemics.

Dr. Liu, you made some comments about the vaccine. Would you agree that the Government of Canada is doing all it can right now to be at the table for a vaccine?

[Dr. Joanne Liu]

Mr. Chair, on the question of a vaccine and whether Canada is doing all it can to be there, I would say there's massive investment right now. I think the issue is the concern about the diversity of the investment. That's one thing.

The other concern is making sure that we are following through on the money when we have invested such a massive amount. On Gavi, the reality is that it's about regular vaccinations, but it still gives a better voice. We need to make sure we have a strategy and a recommendation about R and D and how it will be used.

Right now, I'm not totally convinced that the follow-through is done. There's no.... Maybe it's done and it's not yet public, but I think this is something that needs to be followed through.

[Matt Jeneroux, Conservative, Edmonton Riverbend, AB]

Thank you, Dr. Liu. I would agree. Certainly, on the transparency front, we're not seeing whether or not it's available right now.

Because I have a limited amount of time, I want to move on to Dr. Soulez and Dr. Barry.

We heard of the delay in the number of screenings. I think you said it's 20 to 52 days later than recommended, Dr. Soulez.

One of the Conference Board recommendations was to spend money to replace the aging machines and buy new ones. You mentioned that as one of your asks. How much would that help? Do you have the data available in terms of helping that backlog and getting caught up? You referenced the 250 cases in Alberta. Are there others out there that we could be helping with these machines?

[Dr. Gilles Soulez]

Yes, it's very important, in the sense that in the heat of the COVID-19 crisis, our capacity to operate our unit as before was decreased. For one unit, let's say, we were able to do 80 patients a day. Now we are doing 60 patients a day. We are not sure it will change in the short term, because of the issue raised by Dr. Liu that we may have a second hit coming. Also, other infections can change. I believe that, for all high-throughput procedures, we need to change the way we are doing them.

We have two ways to increase our capacity. The first is to further capital investment, as raised by Dr. Barry, to increase the number of units, because we cannot do the same amount as before. In Canada, we have the most productive radiologists for one unit, compared to the U.S. There's a really big difference. The second is to extend the operation time. It means that we need more personnel, more resources. Third, in all the waiting rooms we need to install...to be sure we are safe. We have some really important measures to do.

Mike, perhaps you want to comment on that.

[Dr. Michael Barry]

It's really difficult to know how long it would take to catch up, because we're still in it. As Gilles said, we could have a second wave and a third wave. It's been mentioned on the call by others as well. We are running at about 70% capacity. We might get to 80% within a year. We might slip back to 60% for a while. I don't think we'll go back to 30% because of lessons learned.

It used to take 10 minutes to do a CAT scan. Now it takes 30. It used to take half an hour to do an ultrasound. Now it takes 60 minutes. The turnover takes time with cleaning. I think we're going to be in this for a long time, as we redefine how we're going to improve our productivity. In the meantime, we'll try to slow the wait-list.

I don't think we're going to catch up to our OECD countries in a hurry without a significant investment of capital and, as Gilles says, HR resources. I think it has also been mentioned on the call by others, too. There's a real challenge ahead of us—

[Matt Jeneroux, Conservative, Edmonton Riverbend, AB]

I think I have about 15 seconds. I'm sorry.

Are you familiar with the Synaptive 0.5T MRI at the QEII health centre? They're beginning to study COVID-19 patients' brains and hope to learn more about the virus. Could you perhaps quickly comment on the potential of that study?

[Dr. Michael Barry]

I am familiar with the scanner, but unfamiliar with the study. It's interesting work, and we will keep an eye on it. We can find out more for you, if you'd like, through the office, through Nick Neuheimer, our CEO in Ottawa.

[Matt Jeneroux, Conservative, Edmonton Riverbend, AB]

That would be helpful.

Thanks, Chair.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Jeneroux.

We go now to Dr. Powlowski.

Dr. Powlowski, go ahead, please, for six minutes.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Thank you.

My questions are primarily for Dr. Liu, and I guess a little bit also for Ms. Krystal.

Doctor, correct me if I'm wrong, but you kind of have two hats. You work for Médecins Sans Frontières, and you've done work on epidemics and public health, but you are also currently an emergency room doctor in Montreal. Am I correct about that?

[Dr. Joanne Liu]

Yes, I'm an ER doctor now in Montreal. I'm not with MSF anymore, but I still have communication with them.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Given your two hats, I think you're a good person to answer this question. It would seem to me that in Canada we're becoming two countries in terms of COVID-19. There are places like Thunder Bay, and I would suggest vast areas of Canada, most of Canada, where we have a really limited number of cases, the incidence is low and our testing capacity is getting pretty good, basically, and we're managing, whereas metropolitan Toronto and metropolitan Montreal are a different story; there still seem to be large numbers of cases, and they don't really seem to have it under control. I want to ask why there is a difference. Why are Montreal and Toronto not getting this under control?

The second part of the question will hopefully allow both of you to get a response in there. As long as it continues to circulate in Montreal and Toronto as we start to open up, if we allow people to travel from Montreal and Toronto, there's going to be a threat throughout Canada, including, as I think you know, Dr. Liu, in northern indigenous communities. Should it get into those communities, given their socioeconomic problems, their lack of health care is going to be a real problem.

What can Montreal and Toronto do to do better at getting it under control? Should there be some mandatory use of masks, particularly in mass transit? What can we in the rest of Canada do to help Montreal and Toronto get this under control?

Maybe I can start with Dr. Liu and then Ms. Krystal. Thanks.

[Dr. Joanne Liu]

Mr. Chair, with respect to the two countries, I think this is not an unusual scenario. In many places, when you have an epidemic, you have an epicentre, and then other spots where it's not as severe in terms of the number of cases. Why the difference? I wish I could answer this question, Mr. Chair, for the committee.

I think most of the time, it's a multifactorial environment, and at this stage, I think we're going to need to take a step back to figure it out. What we've seen is that in some places—especially in the long-term care facilities, which became a centre of amplification—having a health care worker working in more than one place adds to the contamination and community transmission, so there is at least some of that.

Then there is this thing about the timing and the influx of people who came in straight from the beginning. These are all assumptions. When people came back from the break week, there was no big follow-through on people who were coming in. I know that; I came back mid-March, and nobody asked my name. I just walked in, they gave me a pamphlet, and I went home. It was up to me to do my quarantine.

This is going to need much more investigation than me just saying my opinion, but I think it's going to be multifactorial, and it's the addition of all those little things that makes it a recipe for disaster, plus the density of the population in Toronto and Montreal.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

What can we do in order to try to get it under control? How about mandatory masks, for example, in mass transit?