The Anguish and the Agony

The spread of COVID-19 ramps up. (Ben Nelms/CBC)

"In the next two weeks, that's when we're really going to start feeling that [burnt-out] in our hospitals. We are very worried. We're terrified."

"It 's inevitable it's going to happen and we just need to brace ourselves for it [a COVID 'third wave']."

"Let's say the ICU is full. That's a real risk right now. How do you make the choice about which person deserves a ventilator or an ICU bed more [than another patient]?"

Dr.Shazma Mithani, emergency room doctor, Edmonton, Alberta 

"We're all really, really scared about what the next -- not even just the next couple weeks, it's the next few days -- we know that ICU numbers can increase by leaps and bounds in a matter of hours."

"We don't know if we're going to be able to keep up tomorrow or the next day, forget the next couple of weeks."

"Everyone is just extra tense, extra nervous."

"[With workers off sick or caring for family, or resulting from virus exposure, the] pool of nurses is getting smaller and smaller."

Edmonton emergency room nurse, name withheld

"It's so busy. this is the forgotten part of the pandemic."

"When we talk about burnout, it's because we are really being called to go above and beyond what we would naturally do in our general family practice."

"I'm really tired, I'm really, really tired ... we're just at the early stages of this wave."

Dr.Christine Gibson, Calgary family doctor

Quebec Orderlies train on the job   CTV News

Canada has seen the number of COVID-19 cases sweep past 344,000 with deaths linked to the coronavirus over 11,600 in number leaving medical workers fearful of the health system breaking down. They also worry that while treating patients with COVID they are exposed to the virus; will they become ill, will they bring the virus back home with them? Who will look after their family if they're ill? For that matter, who will be left to look after patients' needs, if health workers continue to succumb to the virus? 

Even now, staff shortages bedevil the system resulting in part from nurses and orderlies becoming ill. Burnout and illness continue to sideline medical workers right across Canada. This second wave that has inundated the country has taken its toll, and even while it has not yet reached an anticipated crescendo, fears of a third wave haunt the health community. Health care workers are doing double duty given the growing shortage of workers and they're exhausted.

Doctors like Shazma Mithani feel Alberta's government has failed to bring in sufficiently stern legislation, leaving people free to gather indoors at places of worship, in bars, casinos and restaurants. Contact tracing has broken down while up to 80 percent of cases are without data to show where they were contracted. COVID-related hospital occupancy and ICUs across the country both on the rise in an already difficult situation where most hospitals have reached their capacity.

 

‘This is the most scared I’ve seen people in my 27 years as a nurse.’ BC’s health care workers are doing their best to find relief. Photo by Joshua Berson

 

Two days ago Ontario had 523 people in hospital, 159 of those in ICU, while in British Columbia 284 people were in hospital, 61 in ICU. "It becomes a daily struggle to find the right place to care for people and the right tools to apply your knowledge well", remarked Dr.Kevin Smith, president and CEO, University Health Network, Toronto. Hospital staff fear longer wait times in crowded hospitals will result in worsening health outcomes for their patients.

The first wave in the spring presented a problem of shortage of protective gear and medical supplies, along with hospital beds, whereas this second wave threatens outcomes through a shortage of trained medical personnel. Demands of the pandemic has led to 'moral distress' for health workers. "When you can't provide the quality of care that you have in the past, it becomes that much harder to tell yourself you're doing a good job", explained Lonee Rousseau, a registered nurse, and vice-president of the union local at Royal Alexandra Hospital in Edmonton.

In Steinbach, Manitoba, nurses point out that patients are now forced to wait in their cars as a result of insufficient hospital space, calling out for more staff in a province that has recently seen its case load explode. Over 3,200 health-care workers in Alberta alone have been infected by COVID-19. According to data published by the Ontario government, over 8,400 health-care workers ranging from dentistry to first-responders, to respiratory therapists, to personal care workers, have contracted COVID-19 since spring.

 

Care workers are ‘constantly on edge waiting for the next step and reflecting on the last step,’ says Dr. Ed Marquis of Prince George. Photo by Joshua Berson

"The fear right now is that this is only getting worse and so there's an anticipation, a dread anticipation, going on within our system."

"We really need to see people when they're sick. There was this mortality bump [in May and June] ... basically due to people putting off hospital visits for illnesses when they should've [come in]."

"And that [seeing two COVID-19 deaths recently] may seem like, whatever, you're an emerg.doc, you see death."

"But this is different. And so fast. And we just know that it's going to get worse."

Dr.Joe Vipond, emergency room doctor, Calgary

COVID Panic over Cushy Tushy Paper

"Found some toilet paper in the wild! Driving it home now."
"This is as close as I'll ever come to knowing what it feels like driving one of those armoured money trucks."
A bit of Twitter fun from @TransForYang

Rolling, rolling, rolling: A Procter & Gamble manufacturing facility. David Salpeter

Things have been so tense in North America with wild panic setting in over the possibility of consumers unable to access toilet paper that the Twitterer might even have experienced how nasty it can be when an armoured truck is held up, its driver held at attention with the barrel of a revolver held to his head while a voice emanating from a face mask snaps at  him, report this to the authorities and I'll neutralize you, while making off with his cushy tushy paper.

Supermarkets in North America and no doubt elsewhere sported shelves empty of cleaning products, refrigerated units void of meat, shortages of eggs, but it was the sight of empty shelves where shoppers knew toilet paper should be stacked that really set civilization aflame. Consumers of toilet paper had a mission: find out where the toilet paper is being shipped to, get there first, and grab it -- all of it -- before anyone else can get their greasy hands on it!

Hmm, toilet paper. Those big double, soft, three-ply, embossed stacked rolls take up a whole lot of room. So supermarkets, unwilling to take up precious stock room with it, order and shelve only what is estimated to sell during a certain period of time. How would they know there'd be a run on toilet paper? It's as though people had become so irritably nervous over the very thought of the threat hanging over the world at a time of SARS-CoV-2, their bowels continually ran.

Meticulously cleaning up the ensuring - er - mess, takes lots, scads of toilet paper. Evidently. Consumer products data tracker NCSolutions issued updates on the pathetic lack of toilet paper and data for re-stocking shelves. 73 percent of U.S.grocery stores came up perilously slack on re-stocking sending consumers into a blizzard of failing confidence in the market. One mightn't think that a 27 percent increase in demand over the same period a year earlier would produce such terror.

Consisting on average of 2.6 people, U.S. households use roughly 409 rolls annually. This, according to the producer of Angel Soft and Quilted Northern, Georgia Pacific. Remaining home 24/7 under lockdown would boost that average usage by 40 percent -- imagine! Increasing the need to purchase said rolls to the rate of 9 doubles in about two weeks.

Toilet paper was in the exalted company of other shortage items such as pasta, soap, flour, yeast and canned goods, all of which swiftly vacated store shelves and became unavailable to other citizens equally entitled to share the riches of civilized living but hadn't had the speedy wit to begin stockpiling as their more savvy-selfish neighbours had.

It's a clear bet that Procter & Gamble, Kimberly-Clark and Georgia Pacific never in their wildest industrial dreams imagined that they might ever represent the pot of gold at the end of the rainbow in popular appeal during a global pandemic.

A shelf at a Kroger-owned Ralphs store is stocked with toilet paper in Los Angeles, California, U.S., April 25, 2020. Picture taken April 25, 2020. REUTERS/Lisa Baertlein

Adapting to COVID Food Preparation Options ... and After

"Whenever there are times of trouble there's innovation or ways of getting better from it. A lot of the discussion has been, 'How do we improve the food system?' ... but there are businesses doing well out of this and I think in the future things could get better."
"We've had a massive increase of unemployment in Canada. People have lost wages and obviously can only eat what they can afford."
"I think frugality will change once the economy opens up -- once people can get back to their jobs, once they've got money, once they've got the ability to spend it."
"The convenience angle -- 'I'm busy. I have to work long hours. I don't have time to cook for the kids' -- that will come back."
"Meal kits maximize time and are convenient, and the product offering is reasonably well-priced. [But they're] not the cheapest way of feeding a family of two, three, four people. So you're paying for that convenience."
"When we move to a time period where people can get out and work like they did before, they'll start becoming more time-poor. Because of that, they'll need that convenience aspect more than they have during COVID. And that's when we'll see restaurants becoming more prevalent again, and meal kits fit nicely in there as well."
"When people start getting time-poor, they have less time to cook for themselves."
Simon Somogyi, Arrell Chair, Business of Food, University of Guelph

One-third of people have been baking more than usual during the pandemic, and 20 per cent expect to keep it up. Getty Images

Consumers now know what food scarcity looks like. They saw its image in bare shelves within supermarkets, and long lines of would-be food shoppers awaiting entrance to a grocery store that would admit new shoppers only when the current ones departed to ensure sufficient distancing space could be respected. When they did have the opportunity to enter, they looked for shelf staples with long stable lives, since who knew how long scarcity would go on for, much less the new state of existence in the universal lockdown. So tins of fish and dried beans were high on their list -- if they could find them.

There was a sea change in how people ate, with restaurants closed and no longer could they plan to spend 40 percent of their food budget eating out and slipping into convenience stores to pick up extras. They experienced a frightening shortage of eggs, flour, meat, dairy products, even yeast as everyone, from seasoned to novice class, began to panic and bake their own bread. People became socially isolated by dictate and all their meals thenceforth were taken at home. Prepared by themselves. How novel.

The global pandemic disrupted lives in many ways, none more fundamental than in the way we eat. Home cooking -- food preparation at the very least -- became a necessity. A new respect arose for farmers, delivery systems, food warehousing, service workers. And ordering meal deliveries took the place of eating out. Restaurateurs went out of business or acquiesced to take-out and deliveries. Suddenly the home kitchen became the focal point as it was meant to be; not merely decorative but functional.

According to an AMC Global survey, 60 percent of people have experienced what it's like to dedicate time and labour in elemental cooking with food staples, more often than they ever envisaged they might under normal circumstances. Under these anything-but-normal circumstances everything has changed; people who stockpiled the bare essentials began to understand that they'd have to learn how to use them to advantage.

And suddenly waste became a sin and frugality automatic. Pandemic cooking meant nothing would be allowed to go to waste; no one could know if, when or whether shortages could become more acute and widespread. More prepared meals such as canned soup, frozen pizza, boxed macaroni and cheese have been eaten by 28 percent of the people responding to the AMC Global survey, since the start of the pandemic. People became concerned with making fewer shopping trips.

And a new shopping variation arrived with online food delivery and the sale of food kits. Relatively new in Canada, meal kit providers like Goodfood and HelloFresh have begun to expand their services and their offerings in recognition of their new market niche, not about to evaporate any time soon. Bets are that those who have given food kits a try will stick with them as attractive options once social distancing has been relaxed, they're returned to a normal workday and available time contracts.

Photo by David Ciccon

Worldwide Phenomenon of Prescription Drug Shortages

"[When regulators find a problem and a company has to curb or shut down production to fix it, the impact] cascades in a domino effect throughout the global supply chain, affecting many countries and many end users."
"If you can draw a direct line between the opioid crisis and OxyContin, you can draw a direct line between heparin and drug shortages."
Canadian multi-stakeholder group

"In many cases, there are one or two plants that produce the world supply for a single drug. When you only have one or maybe two manufacturing sources, they are much more vulnerable to disruptions."
Barry Power, Canadian Pharmacists Association

"People have forgotten that it wasn't always there [a now-major issue of drug shortages]."
"It wasn't like this ten years ago. We didn't have these problems. Why do we have them now?"
"[The] vast majority [of shortages relate to medicines with expired patents, enabling generic makers to compete in the pharmaceutical marketplace and roughly 70 percent of shortages relate to generic companies.]"
Dr.Jakalyn Duffin, hematologist, professor emerita, Queen's University

"We carried products that were losing money for a long time. Companies leave the market because they can't afford to make products at a loss."
"[The shortage began when the largest, Apotex, decided to change its manufacturing and formulation process at an Ontario-based plant]."
Jordan Berman, spokesman, Apotex, Canadian generic giant

There has been of late an alarming scarcity of the drug tamoxifen -- prescribed for post-breast-cancer patients to avoid recurrences -- among other scarcities where a shortage of almost two thousand drugs are currently listed on Health Canada's site as being in short supply -- also affecting children with leukemia, Parkinson's patients, and depression patients. Scarcity is nearing chronic status in Canada, as it is in various other parts of the world, causing no little amount of consternation and fear on the part of patients reliant on the drugs to extend and give quality to their lives.

In an effort to lay blame and avoid any themselves, governments and industry point the finger at a litany of production glitches such as factory shutdowns, regulatory interventions and a lack of raw ingredients. Despite that drug shortages only began to evidence as an issue in 2010, affecting the worldwide community. One explanation that mirrors reality is that there has been a dramatic consolidation within the pharmaceutical industry and globalization of the medicine supply chain.

Getty Images

This, while government agencies and private-sector health groups have been working to drive down the price of generic medications; a situation offering relief from increasing health budgets, but which also has the effect of curbing any incentive for suppliers to produce drugs. The number of suppliers is being reduced not only through consolidation but because some generic makers decide to drop certain drugs when it no longer seems feasible to profit, with driven-down prices.

The world has gone from a situation of numerous drug-manufacturing competitors copying any off-patent drug or its raw constituents, to add to the current situation of endemic shortages. There were no fewer than 800 mergers and acquisitions in the drug manufacturing industry in 2008, inclusive of 15 "megadeals", resulting in "fewer options for end customers" according to Canada's "multi-stakeholder" drug-shortage committee.

A recall of various brands of heart medicine last year by Health Canada, the FDA and other regulators containing a tainted version of valsartan where the raw ingredients were issued from a single producer in China, a case in point. Increasingly manufacturing all manner of consumer goods has been relegated to low-cost-production locales. Currently, an estimated 80 percent of raw ingredients for the world's drug production come out of China and India, two countries whose industries are well known for a tendency toward a casual attitude in critical production issues.

A recent U.S. Food and Drug Administration report noted the drug supply chain is "longer, more complex and fragmented" so that it is more difficult to respond to a production disruption. In 2008 the United States experienced the heart drug heparin being imported with tainted versions traced to a factory used by Baxter International Inc. in China. As a result, over 80 patients died, prompting the FDA to increase inspections of foreign drug suppliers.

According to the Patented Medicine Price Review Board in Ottawa, Canadian provinces have been mandating or negotiating prices as low as ten percent of the brand product, resulting in the cost of generics falling by 60 percent from 2007 to 2018. In the U.S. a handful of private-sector "group purchasing organizations" have used leverage to price down generics with a "race to the bottom" providing little incentive for producing companies to turn out low-profit medicines representing "root cause 1" for drug shortages the FDA report concluded.

So what is the solution?

"We cannot talk about the drug-shortage problem until we know what it is and how it changes over time."
"It blows me away that in a country like Canada with intellectual capital and human resources, we don't just start making them [through government auspices]."
"When there are only a few makers, the margin in the system is narrow. Any manufacturing problem will result in shortage."
"We as a society accept the notion that drug marketing and drug development belongs in the private sector. These private companies are not charities; if they are losing money, they stop making the drug so that they can keep paying their employees and their stakeholders."
Jacalyn Duffin, professor emerita, Queen's University 

Breast cancer treatment Tamoxifen is in short supply.JB Reed/Bloomberg

Yet, according to Health Canada:
"Many shortages can be resolved through supply management measures without their effect ever being felt by patients. Health Canada works closely with the Canadian companies that supply drugs, the provinces and territories, and health stakeholders across the supply chain to identify and facilitate mitigation measures, as needed."
What shortages? Well, remember the Health Canada note to consumers on their website, listing close to 2,000 medications in short supply? They don't seem to recall that.

"There are different situations leading to out of stock of medicines. Some of them can be solved without causing obstacles to health care provision or in the availability of the best therapeutic option, whereas others may require additional efforts and ways to overcome affected health conditions. There have been several important efforts to document countries’ experiences and potential ways forward to address concerns with medicine shortages. The study of ISAGS UNASUR published in 2017 characterized and analyzed the situation among eight South American countries: Bolivia, Chile, Colombia, Ecuador, Paraguay, Peru, Venezuela, and Uruguay (ISAGS, 2017). In 2018, Bochenek et al. (2018) systematically characterized, compared, and evaluated current measures, as well as legislative and organizational frameworks, to address medicines shortages among a wide range of European and Western Asian countries. These included 20 countries of the European Union (EU) and the European Free Trade Association (EFTA)—Austria, Belgium, Croatia, the Czech Republic, Estonia, France, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Malta, Norway, Poland, Portugal, Slovakia, Slovenia, Spain, and Switzerland. In addition, eight non-EU/EFTA countries: Albania, Azerbaijan, Israel, Kosovo, Montenegro, Republic of Srpska (Bosnia and Herzegovina), Serbia, and Turkey."
Research article: Frontiers in Pharmacology, July 19, 2019