The City of Toronto reported more than 1,200 new cases of COVID-19 on Thursday, as Ontario deals with the third and largest wave of the pandemic.
Eileen de Villa, Toronto’s medical officer of health, leads the city’s pandemic response. TVO.org speaks with de Villa about new workplace measures, adjusting to changes in the vaccine rollout, and the post-pandemic city.
TVO.org: In a very bad year, the past two weeks have, I think, likely been especially hard on all of us, including you. How are you doing?
Eileen de Villa: You know, I’m doing okay, I’m going to tell you that I’m probably — more than probably — I am definitely under-slept. It is an incredibly stressful time for all of us in public health and certainly for my colleagues in health care, whom I think about all the time, knowing the burden that they are carrying, taking care of ill patients at unprecedented levels in our city. But I would say that we are also working under unprecedented demands in public health — perhaps not working literally alongside our health-care colleagues, but certainly figuratively.
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My team has been at it for over a year now, and it was certainly challenging in wave one, but it’s that much more challenging now when we still have outbreaks and clusters to investigate — now over a broader range of settings, because we have had schools and child-care centres open when they weren’t at this time last year. On top of that, the largest immunization campaign in the history of the world to manage as well.
So, a new virus and new vaccines, and, as a result, daily learning happening (maybe even hourly, or sub-hourly learning that’s happening). It’s quite a bit. But we’re really passionate about our work, and we care deeply about the health of our communities. So we just find strength to keep going, because we know how important it is, because we’re part of the community. You don’t just work for Toronto Public Health. We live in Toronto. We’re serving people who matter to us.
TVO.org: The big news out of your office this week was new workplace measures that you’ve introduced alongside Peel Region — shutting down businesses with outbreaks. Why was that important, and what kind of impact will it have?
De Villa: We know that the risk of transmission of COVID-19 can be high in workplaces, particularly where workers, by definition of their work, are in close proximity throughout the workday. With the emergence of these variants of concern, which I’m sure you’ve heard about, we know that COVID is now spreading more easily between people. And we’ve seen the impact of that, certainly, on our health-care system. So the idea here is to use whatever tools are available to us to help stop the spread of COVID-19 in workplaces as quickly as possible.
Certainly, having this capacity to act swiftly, and recognizing that investigations take some time, we’re hoping that this will help control the spread within the workplaces where we’re finding cases, create safer work environments, and more quickly allow us to bring those outbreaks under control so that the essential services and goods that are being provided can be restored as quickly as possible.
TVO.org: The powers that were used to introduce the measures, Section 22 of the Health Protection and Promotion Act, have been controversial throughout the pandemic at various times — some people have thought you should use them more liberally. Why did you become more comfortable using them now?
De Villa: Within the practice of public health, the use of powers or authorities to affect necessary action is something that we generally use only when it’s needed, right? It’s a heavy authority to use, and it’s one that’s always used with some degree of caution, and I think that’s appropriate. The general school of thought in public-health practice is: if the use of authorities or the use of powers under legislation isn’t necessary to achieve the objective, then don’t use the powers. It’s a question of using them where they’re warranted. Even in the context of a pandemic, they’re not meant to be used to affect policy or to affect policy changes. The powers under the Health Protection and Promotion Act, in respect to communicable diseases in particular, are meant to be used to control or mitigate communicable-disease risks.
Given where we are now in the pandemic, and given the heightened transmissibility of the variants of concern, we’re still doing workplace-cluster and outbreak investigations, but because the variants spread so much faster, being able to use Section 22 powers allow us to better control the very specific risk that’s presented by variants of concern in order to allow us to conduct the investigation. Because that does take a little bit of time: unfortunately, the variants work faster than an investigation can be completed. It allows us to actually use the powers in a way that helps us to control the risk of communicable-disease transmission within a workplace — you can conduct your investigations to ensure that we’re helping to support as safe a work environment as possible and then get people back to work and businesses back up and running. Especially those that are providing essential goods and services.
TVO.org: With those powers, are there things that Toronto can do to stop the spread in workplaces, in the absence of paid sick leave? Is there another lever you have at your disposal that you can foresee using?
De Villa: Well, so just to be clear, it may seem like a policy lever, but I wouldn’t quite characterize it that way. That’s really meant for governments and politicians. At the local level, that would be through bylaw, and, obviously, at the provincial level, through legislation and regulations. So we’re fairly limited as local public health around what we can do. When there are specific communicable-disease risks — as you know, an outbreak might present within a workplace — we are able to take certain actions. That’s why we’ve actually taken this action here with a Section 22 order.
In respect of workplaces, especially in light of those variants of concern and their transmissibility, we’re constantly looking for, you know, what else? What do the data tell us appears to be a risk? And which of our tools within the public-health toolkit might we be able to use to address that risk?
I do think that, at this point in time, knowing what we know about the variants and knowing that we have some vaccine — albeit in short supply right now, but hopefully not for much longer — it seems to most of us in practice that the key things are: What can we do to support people in their ability to maintain appropriate distance? We do know that COVID-19 spreads from person to person when they’re in close proximity to each other. That’s how the virus effectively moves from one person to the next, through respiratory secretions and droplets — the stuff that comes out of people’s noses and mouths when they breathe or talk or shout.
And we know that distance works. So everything that we can do to support people in terms of their ability to work remotely, to limit mobility, to keep distance from other people outside of those with whom they live. And then when they have to go out, to take appropriate precautionary measures: maintaining distance, wearing a well-fitting mask. All those self-protection and public-health measures are key.
TVO.org: It’s public knowledge now that, when Premier Doug Ford announced new vaccination guidelines, including those about hot-spot zones, public-health units weren’t necessarily given a lot of advance notice. What happens within your team when you get that kind of information? How do you mobilize, and what are the next steps?
De Villa: First and foremost, there’s an announcement, but the devil is always in the details. So it’s, okay, that’s the announcement — what do we understand that means? What we’ll do is make sure that we actually have the details, that we understand specifically what was said and what is the intent. There’s often a communication of some kind or a written piece to say “this is what that means.” Once we actually have a sense as to what the policy direction is, we start to think through, okay, so what does that mean for us, if anything? Who needs to be engaged? What are the steps that we need to take in order to affect that policy direction? Who do we need to communicate with, and what are we communicating specifically?
It sets off a chain of activities, and we are organized, as I suspect most other local public-health organizations are, in what they call an incident-management structure. It’s a very widely used method for organizing one’s team in emergency response. The interesting thing, of course, is that very, very few emergencies last this long, so I think that’s the really challenging part here.
TVO.org: The result in this case is that there are these mobile clinics in the hot-spot neighborhoods. I visited the one at Driftwood and, you know, people are going to it — there’s no question about that. For people who might not be online much or involved with a community group, how do you make sure that people know that there’s one coming to their neighbourhood?
De Villa: The interesting thing about those mobile or pop-up clinics is they’re actually organized by our health-care partners and community partners. They’re the ones that are doing the heavy lifting on the organizing and the promotion of the of those clinics. For example, let’s take the Driftwood one. The lead community agency was Black Creek Community Health Centre. They are a local agency that knows the population well.
As the health-care vaccination partners here in Toronto, we use data and agree that there were hot-spot neighbourhoods that the province delineated — a number of hot-spot postal codes — and we further focus down, because you can’t do all of them. There are 53 postal codes, and if you want to focus resources, particularly when they’re tight, spreading them out among 53 different areas is the opposite of focus, right? We knew that, especially because supply is limited right now, in order to have impact, you actually had to focus on a particular subset of those areas. Using data, we, along with our health-care partners, determined that there were certain forward-sortation areas of the city — that’s the first three digits of the postal code — that had high incidence rates in particular and low vaccine uptake.
One of those areas was M3N, and that’s why the Driftwood clinic came to be. Recognizing that the M3N forward-sortation area was an area of focus, the local community agency partner, Black Creek Community Health Centre, was the one that helped to determine: okay, if we’re trying to serve this area, where is the place that we need to go to? What’s the best site to establish a clinic, where we’re actually going to get people who live in this area who would otherwise not use a mass-immunization clinic or would have difficulty accessing one of the other vaccination channels? And then the other health-care partners came along with the equipment — including the information-technology equipment, the vaccine, the supplies, and the vaccinators — and work together with local partners. And, lo and behold, you have a local clinic serving a population that otherwise was not able to access or wasn’t accessing other existing vaccination channels.
TVO.org: The vaccine rollout in this city and province has taken a lot of heat. One thing I think might get lost, at times, is that this city is actually vaccinating a lot of people every day, which is obviously great. How would you assess the state of Toronto’s vaccination rollout, and what comes next?
De Villa: There’s lots to be proud of. Over a million doses of vaccine have been administered at the various vaccination channels throughout Toronto, and the larger-scale component of the vaccination campaign only began in early or mid-March. So that’s an incredible number of doses to have been administered in a relatively short period of time. I think there’s a lot to celebrate in that. But, as with everything, there are always opportunities for improvement, and we wouldn’t be good professionals if we weren’t constantly seeking ways to do what we do better. That’s part of our job. So are we content? No. But I think we have to acknowledge we’re not going to be content until everybody who wants to be vaccinated is fully vaccinated. We’re certainly not going to be content until the pandemic is in the rearview mirror.
But there have been massive, massive efforts. It has been a very big lift on the part of many people, not just in public health. We’ve relied on our city partners, our health-care partners, and our community partners — and they have all worked really, really hard. So I think there’s something worthy of celebrating and worthy of acknowledging. There have never been this many vaccines given in this short period of time, not in this city.
TVO.org: This feels almost inappropriate to ask, given the ongoing tragedies in the health-care system. But in the not-too-distant future, this wave will end. Looking forward to the next month, two months, three months: What does the future hold for the city?
De Villa: It’s interesting that you asked that. I agree — we’re often very caught up in the present, in the here and now. But in public health, you have to always keep one eye out to the future. Public health is about prevention, and prevention is about the now, but it’s also about doing what we can now to make for a brighter future. So there’s always a forward-looking component to public health.
Of course we are thinking about the near-term future — as you said, one month, two months, three months from now. Obviously, controlling the transmission or controlling the spread of COVID-19 around the city is key for now, as well as delivering on the vaccine campaign as efficiently and as effectively as we can.
But when I think about the future of the city, while COVID-19 has been a very heavy burden for many people, if not everyone in the city, the fundamentals of what makes Toronto a great city are still there, right? I think we have a lot of strength to build upon. And, you know, if there is something I can say that’s positive and forward-looking about the pandemic, it’s that it has opened the eyes of many people around the city to the inequities that existed in our city for a very long time.
And this is actually the fundamentals of what public health does. The goals and objectives of public health are about improving health status, but doing so in a way that actually reduces inequities in health status. Having a greater proportion of the city attuned to the extent to which inequities exist in the city — and interested and motivated to do something about it — just opens up a whole world of opportunity, I think, for me and for other public-health practitioners.
So while we are very much focused on addressing COVID-19 and helping the entire city get to the other side of this pandemic, we’re also keeping an eye on the future: let’s make sure that we really capitalize on the lessons learned and commit ourselves to making the necessary changes to reduce inequity so we can all enjoy better health, not just with reduced COVID-19 and other communicable diseases, but thinking about health in the broadest of ways. That’s really where we want to go.
This interview has been condensed and edited for length and clarity.