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Eileen de Villa: “We can’t all live in little bubbles”

A photo of Toronto Medical Officer of Health Eileen de Villa

Public health officials like Eileen de Villa have never been more public than in 2020. At the height of the first wave of COVID-19, all three levels of government held daily press conferences to announce a succession of health and monetary relief measures to combat the pandemic and its economic fallout.

Toronto’s Medical Officer of Health has become the face of the city’s response, ordering closures of parks and playgrounds in the spring when less was known about how COVID-19 transmits. Since Ontario entered a state of emergency, Toronto has gradually emerged from, and then gradually re-entered, lockdown measures.

In the fall, de Villa pushed the province to close indoor dining in restaurants. Premier Doug Ford initially resisted. Initially reluctant to act based on legal advice, she eventually used the powers granted to her under Section 22 of Ontario’s Health Protection and Promotion Act to close restaurants and indoor fitness classes despite a backlash from small businesses.

The way different levels of government are able or not able to react to protect the health of citizens is one of the many pre-existing tensions the pandemic has laid bare. And with legal professionals, housing activists, Toronto city council and the Ontario legislature calling for a reinstatement of the residential eviction moratorium that expired in the spring, many wonder why the city cannot just take action.

On December 29, both Toronto and Ontario reported the highest single-day increase in new infections to date. The testing positivity rate hit a new high and so did province-wide intensive care admissions.

With data showing people are more mobile in the second wave than in the first, the province expanded lockdown restrictions on Boxing Day. But hospitals are still bracing for a forecasted surge in COVID-19 patients that threatens to overwhelm capacity in January.

Before the Christmas break, we spoke with de Villa about COVID fatigue and finger-wagging, suspending evictions, the pandemic’s compounding effect on the opioid crisis and why governments in Canada haven’t taken a more interventionist approach to pandemic measures.

Looking back over the last nine months, what have been moments that stand out as particularly challenging, given all your experience as a public health official?

Unprecedented and challenging are truly words that describe the events of this past year. But there are events that I would say that stand out because you could sense this is the beginning of something different. Things that stand out in my mind are January 25th, when we received our first [COVID-19] case and knew this was the beginning of a significant outbreak. Other moments that stick out in my mind are that time when I had to tell the senior leadership here at the city what the projections were and why we needed to move towards a significant public health measures and restrictions.

How did that news go down?

It was an exercise in trying to convey the gravity of the situation. We were looking at thousands and thousands of cases and, as a result, thousands of deaths in the order of 5,000 to 15,000 in the city of Toronto, never mind the province of Ontario. These were actually really tough things to wrap your head around. We were trying to make determinations as to what actions needed to be taken in the late winter, early spring – and for how long with a virus that we were still learning about. How much did we need to worry about surface transmission versus the standard respiratory breathing transmission? Wiping things down – what did you need to do about groceries, doorknobs and handles? There wasn’t really experience to go on other than theoretical understandings of how viruses transmit in general.

That characterized much of the pandemic: trying to understand what the characteristics of the virus are, and then planning what what were the necessary steps and the best steps to be taken to control its spread when you’re still actually learning about how it spreads. And then to communicate that in a coherent, clear and simple fashion so that it can be digested and acted upon by the public.

Now we have COVID fatigue setting in. We know more about the virus, but people seem to be not listening to the public health advice. Do you have to change the way you communicate to the public? You don’t want to shame people, but the mayor said the other day, “I don’t like to say this but people are dying.”

From a public health practitioner’s perspective, finger wagging generally doesn’t work to change behaviour. But, as you describe, pandemic fatigue has set in. People are tired because actually what’s most challenging about the circumstances is that until we can get tools like vaccines out there and readily available to the majority of the population, the best thing we have, the best tool we have, is to stay away from each other. And I’m not talking about six feet or two metres, we’re actually talking about as much distance as you can get from those with whom you do not live. You have to be reasonable. We can’t all live in little bubbles, but we can stick to our household to the greatest extent possible. The challenge with that is that it goes against our fundamental drives of human nature. It’s kind of like eating and breathing. We are by definition social creatures. So it is really, really difficult to fight against our nature.

People wait in line for a COVID-19 test at the Birchmount COVID-19 Assessment Centre at 3030 Birchmount Road in Scarborough.
Bob Hilscher / Getty Images

At the modelling briefing last week, Dr. Adalsteinn Brown [co-chair of Ontario’s COVID-19 Science Advisory Table] drew comparisons to Australia, and particularly the state of Victoria where they had curfew and military checkpoints, and to France, which has curfews but things are still open. Brown said if we have a hard lockdown for four to six weeks similar to those areas we will get our cases below a thousand a day again or even lower. But it doesn’t feel like the measures that have been implemented by the province currently compare to those jurisdictions completely. What are your expectations of where we’re going to end up? Just below 2,000 cases a day? Or are you hopeful we’ll get back to below a thousand with these measures?

What I encourage people to do is to look at what we were able to do in the spring. And I admit the circumstances were different, people’s motivations were different and fatigue levels, if we can call it that, were certainly different. Fear was much higher, I would say, in in the general population at that time. [Fear] is a pretty powerful motivator and in the sense that it perhaps motivates even against what is our nature, which I just spoke about. But fear can help overcome or can help us fight our nature when it’s warranted, as it did in the spring.

I’m hoping that people can remember that it does work and, with vaccines on the horizon, if we can just push a little bit longer, like to really get that drive and conviction that we had – if we can really just stay apart a little bit longer, we will soon be at a point, with the combination of vaccines and the staying apart, that we’ll be able to bring those levels of disease and a virus spread down to a more manageable level.

I’m concerned about long-term care homes. We know how devastating this virus is for those who are older in our communities. And we know the havoc that it has wreaked in health care, not just because of taking care of COVID-19 patients, but also the delays that have been suffered in the care of all sorts of other medical conditions because of the load of COVID-19 patients. So many people are suffering from pain or disability of other types, or other medical causes because of COVID-19 and the pressures it has placed on our health care. And that’s just the physical health side of things. We haven’t even begun to speak of the mental health challenges that have been exacerbated and worsened because of COVID-19.

What are the conversations like around, as Doug Ford calls them, “draconian” measures like curfews? Because it does feel like there is this impasse between those who think the government should take this heavy-handed approach that other areas have taken – like Taiwan or Australia – and then have seen successful declines in their epidemic curve, versus telling people it’s on you to make the right choices? Why do you feel like the latter approach is effective at this stage?

You asked a little bit about the conversations and what I think might be effective. At the end of the day, we have looked at what others have done. I also have to say that in my position as a medical officer of health for Toronto, I have certain powers and certain authorities for Toronto. But obviously my authorities are not quite as expansive as those that the provincial government has. And the same can be said of the mayor. We know that municipalities have some authority and some powers to effect certain actions to support the health and well-being of our community. But the real power card is actually held at the provincial level. Municipalities are creatures of the province.

When I look at the circumstances in South Korea, Taiwan and in Australia, and as well in Western Europe, you’ll note that none of them relies on any one singular strategy, even when they’ve got optimized versions of those strategies. For example, I think about a place like South Korea or Taiwan where they have incredible testing capacity, really remarkable testing capacity in their system and what I would characterize as augmented case and contact management and tracing capacities. When I say augmented, they’re significantly augmented by the use of all sorts of technologies and some very sweeping powers that they have: access to credit card information, access to specific individualized cellphone mobility data, the use of CCTV. These are pretty heavy duty methods that aren’t really accepted here in Western society. But even with those extremely augmented, and some might say interventionist additions to their more individualized measures, they still deploy significant public health restrictions and measures.

So there isn’t a single simple solution. It is a multi-pronged approach, but it does ultimately come down to behaviour, right? It it always comes down to how much are we able to limit interaction between people so as to limit the opportunities for virus spread.

A photo of people wearing masks in Toronto during the COVID-19 pandemic on November 27, 2020
Samuel Engelking

You mentioned the incorporation of powers between different levels of government. One narrative this year has been your ability to use your powers under Section 22 of the Health Protection and Promotion Act and whether that would result in personal liability for yourself, specifically if you took action to close indoor dining and indoor fitness.

The latest example is the Downtown Legal Services letter, which states that you have the power to suspend the enforcement of evictions. You said at a recent press conference that you were seeking legal advice but you felt that action would be better taken as a regional approach. What is the legal advice that you’ve been given and do you think taking action to suspend enforcement of evictions in Toronto will have a positive public health benefit in the context of the pandemic?

First let’s start off with housing, because eviction prevention is really fundamentally about security of housing. I would suggest to you that what is important here is housing security, but that means it needs to be affordable. And again, depending on the circumstances of the people we’re speaking of, you also want to ensure that it’s got appropriate supports to sustain that independent living and to sustain that housing circumstance that’s safe, affordable and it meets your needs. That kind of housing is absolutely fundamental to health. That is a clear determinant of health.

With respect to the application of Section 22 powers for eviction prevention, I have had the opportunity to review that with legal counsel and I think at best it would be described as a stretch of the powers. When we looked at the circumstances, like I mentioned before, the strongest authorities actually do reside at the provincial level. We are constantly in conversation with our provincial counterparts, certainly seeking appropriate relief for people, whether it is around eviction prevention or whether it is around income supports. Or whatever intervention can be deployed in order to support the ability of people throughout the city, but particularly those who are most disproportionately impacted by COVID-19. What can all levels of government come together to do to support their ability to actually test, to isolate so as to prevent the spread of COVID-19? But at the same time, to do it in a manner that’s consistent with all other aspects of health, putting food on the table, keeping your family housed, keeping them safe. These are the kinds of things that we need to do writ large. And it’s not just about COVID-19.

As I look forward, for people who are in such precarious situations, what can we do on a longer term basis? What can we do on a longer term basis to ensure that you are not as vulnerable to shocks like a COVID-19 diagnosis or a positive COVID-19 test or whatever threat may come. Frankly, the healthier we all are, the more we are able to reduce those inequities and the health equity gap, the healthier the city will be, not only from a medical or clinical perspective, but from an economic and social perspective as well.

You’re not using the Section 22 powers to suspend eviction enforcement?

Yes. You’ll recall that generally Section 22 powers are in respect of specific instances of communicable disease. So if we have an individual and if they’re diagnosed with COVID-19 there’s a period of time for which they need to be isolated. And then communicable disease is no longer a threat. And it’s in the order of about two weeks. There are different periods of time depending on what the unique circumstances are. Then what happens? The communicable disease risk no longer exists and therefore the reason for the order no longer exists. And so what sort of protection have we provided as a result of the exercise of that authority?

You mention the structural factors and the long-term solutions. But we still need short-term action, especially in these 15 high-priority neighbourhoods that the province has identified as part of the $12.5 million plan. We’ve seen that several different measures have not had as great an impact in these neighbourhoods where people don’t have access to suitable housing or job security. What measures will work at this stage?

What I think is really powerful about this plan is it is supported by the city and we have worked hard with provincial partners to ensure that it has the lift that it needs. But what it seeks to do is direct funding and to let agencies that already have trusted relationships in the communities lead the way. It is about this relationship of trust. In order to help people adopt the behaviours that are needed to control the spread of COVID-19, the way that happens most effectively is through the necessary supports – but giving advice and support in a context of an existing trusted relationship. This is the kind of leverage that we need to see more of, not just for COVID, but I would argue if we are to really address existing health inequities in our city, if we are really interested in better addressing the social determinants of health, this is actually a model on which to premise this.

We start to work through and support other agencies and populations themselves to get better access to social determinants of health. But it has to be done again in partnership with those who already have an existing relationship of trust. I think that’s how we can make best use of any investments in these communities to to support better control of COVID-19 spread and, on the longer-term basis, better access to the social determinants of health.

Lack of protective equipment for staff during the COVID-19 crisis has caused some consumption sites to close temporarily.

The pandemic has compounded the opioid overdose epidemic issue. The city has decided to put overdose prevention services in shelters but, at the same time, we’re seeing an increase in people overdosing alone in private residences, according to data Public Health Ontario put out this year. Why did it take two years since the Chapman inquest to get the overdose prevention in the shelters? And how do you proceed in a situation where there are people at home that support workers can’t reach?

There is a mindset, I would say, in our society and a tendency to characterize some drugs as good and others as bad. We need a whole paradigm shift. And these things take time to effect. But that doesn’t stop us from continuing to try. I think it is very good that we are moving forward with with overdose prevention services within the context of the shelters. I hope to see that they’re able to contribute to the health of those who are shelter clients within the services that the city provides. The other areas that we’ve been working on are ensuring that we have more viable pathways for people between the various harm reduction services that are currently available. I am a firm believer in looking at the resources that are already in use in the community and how we better connect them so that we’re maximizing their potential and their value to all.

The Board of Health has supported decriminalization as part and parcel of a true harm reduction approach to drugs. Yes, we need naloxone and yes we need treatment and withdrawal management services. But it is the entire context that needs to be changed. This is evidence informed. So we’ve seen interesting developments in other jurisdictions all over the world, most recently in Vancouver. I do think that this is a conversation that needs to continue here in Toronto. It hasn’t stopped. I still do seek to advance the conversation on what I would characterize as a more health-based approach to drugs and drug use in our community, rather than one that is premised on the justice system and what I would call a corrections-based approach, and a punitive approach to drugs and drug use.

COVID-19 has highlighted all kinds of inequities and this is one of those inequities that has really had that light shine on it. Not that people didn’t recognize it, but there was something about COVID-19 that has just put things in a very, very bright spotlight. My intention is to capitalize on the increased awareness that people have on health inequities and on health-based approaches to drugs and drug use and how much more productive I think they would be. And frankly, how much healthier we would all be as a community if we were to adopt these kinds of approaches.

Are you able to direct the city services to prescribe safe supply? Because we’re seeing clinics, I guess you could say going rogue, and just prescribing it regardless of what the law says.

There are responsibilities at different levels of government, the vast majority of which ride both at the federal and the provincial level when it comes to drugs and what is allowed in terms of medical practice. Like, what can you prescribe to do what things, what’s on formulary? When it comes to the legalities, that falls under federal legislation. There is ongoing conversation. At Toronto Drug Strategy, the secretariat is constantly working with local partners, with provincial partners and with federal partners to figure out how best can we bring an evidence-informed approach to what’s happening on the ground.

Is safe supply something that we need urgently?

Yeah, I think it’s something we need urgently. It is part and parcel of what I call a comprehensive approach to drugs and drug use, one that really is about focusing on health: health at the individual level and certainly health at the community level. You need the full spectrum of interventions in order to have the desired impact.

You’ve had a lot of criticism directed at you from business leaders, housing activists, anti-maskers and people from different sectors of society who are watching everything that you say and do very intensely. What has that been like?

The position is quite public so of course we’re used to media and having a bit of a public persona, but certainly not to this extent. This is, for lack of a better word, unprecedented. Are there criticisms and harsh words that are directed my way? Yes. And are those easy to hear? No, but it is important, as I described earlier. You can’t just be the medical officer of health for some Torontonians or only for the Torontonians who agree with you. The job is to be the medical officer of health for all.

It’s important to hear the dissenting voices. I think the strength of democracy is to listen to them, to assess whether there’s merit or is this really without basis or evidence? One should always be, as a medical professional, assessing, reassessing and then reassessing again to ask are we doing the right thing? If we can look at what we’re doing and assure ourselves that, yes we have considered other people’s perspectives and we’ve asked for others to offer sage and thoughtful critique, then at least we can go to bed at night peacefully saying did we do our best. Did we practise the best public health on behalf of the residents of Toronto, our patients? That, I think, is all that we can ask for.

This interview has been edited for length and clarity.

@KevinRitchie

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