Watchmen on the Tower: LDS church leadership urges masks and vaccination

This post will be a different flavor than most of my previous ones, and addresses a specific audience. I am a practicing member of the Church of Jesus Christ of Latter Day Saints (sometimes called Mormons), and would like to address this post primarily to fellow members of the church.

On August 12, 2021, the global leadership of the church (The First Presidency) released a statement by email to the entire church membership urging members to fight the pandemic by wearing masks or social distancing in public meetings, and to be vaccinated against COVID-19. This statement is in full congruence with previous conference teachings during the pandemic urging compliance with health recommendations, existing church policies on vaccinations (1978 Immunization statement, church handbook section on vaccinations- see 38.7.13), and the example set by church leaders who very publicly received their own COVID vaccinations as soon as they were able. The church voluntarily shut down all regular in-person meetings on March 12 2020, going above and beyond local regulations at the time in many areas. To date, all general conference meetings since the onset of the pandemic have been broadcast remotely, with those in attendance wearing masks. The church is now “following the lead of government and healthcare professionals around the world as it considers a measured return to normal operating procedures.” (reference) While it did not introduce any new doctrine or policy, this most recent statement has been the most direct to date in “urging” members to take these specific steps in response to the ongoing pandemic.

As the pandemic has evolved, many measures to manage it have unfortunately evolved into political issues, fueled by torrents of medical commentary, blatant misinformation, media sensationalism, conspiracy theories, protests, and ideological politicking for popular support. This has caused a great deal of confusion and division within all parts of our world, including within the church. Many church members hold political views (on both sides of the spectrum) that sometimes conflict with the teachings and direction of the church. This is not new, but perhaps for many members, this pandemic and the church’s moderate and medically informed response to it has for the first time generated a significant, and unavoidable collision between deeply held concerns and beliefs. I have witnessed a great deal of consternation by church members convinced their political or personal opinions on the pandemic are steeped in truth, who are now seeing those they revere as modern prophets increasingly contradicting some of those beliefs.

The most natural human instinct in such situations is to minimize the conflict and the resulting internal discomfort it creates: “this is not a commandment,” “they said urge, not must,” “vaccines aren’t required to hold a temple recommend,” “we have our agency to choose about vaccinations, as it says in the church handbook.” This is all true, and I seriously doubt anyone is going to face church discipline for their views on masks or vaccines. However, rather than looking for reasons to discount their strong advice, might this be an opportunity better served by pausing and asking why the First Presidency made this statement? We know church leaders are not infallible, and each is free to hold their own opinions, but when it comes to official statements from the First Presidency or the Quorum of the Twelve Apostles, our doctrine of a church based on revelation from heaven holds such declarations to a much higher standard. Much has been taught on this matter since the restoration of the church. Perhaps one of the most pertinent summaries was given by Ezra Taft Benson at a BYU devotional on Feb 26 1980, full text here. A few excerpts include:

  • The living prophet is more important to us than a dead prophet.
  • The prophet will never lead the Church astray.
  • The prophet is not required to have any particular earthly training or credentials to speak on any subject or act on any matter at any time.
  • The prophet does not have to say “Thus saith the Lord” to give us scripture.
  • The prophet tells us what we need to know, not always what we want to know.
  • The prophet can receive revelation on any matter—temporal or spiritual.
  • “Said President Harold B. Lee: You may not like what comes from the authority of the Church. It may contradict your political views. It may contradict your social views. It may interfere with some of your social life. . . . Your safety and ours depends upon whether or not we follow. . . . Let’s keep our eye on the President of the Church. [In Conference Report, October 1970, p. 152-153]”
  • President Wilford Woodruff stated: “I say to Israel, The Lord will never permit me or any other man who stands as president of the Church to lead you astray. It is not in the program. It is not in the mind of God.” (The Discourses of Wilford Woodruff, selected by G. Homer Durham [Salt Lake City: Bookcraft, 1946], pp. 212-213.)”

While acknowledging that we mortals do not know the mind and will of God, the fact that this statement came as an official communication from the First Presidency (and that it was not the first endorsement of COVID precautions and vaccination they have given), can teach us some important lessons. Consider these words of President Nelson from April 2021 general conference:

“We live in a time prophesied long ago, when “all things shall be in commotion; and surely, men’s hearts shall fail them; for fear shall come upon all people.” That was true before the pandemic, and it will be true after. Commotion in the world will continue to increase. In contrast, the voice of the Lord is not “a voice of a great tumultuous noise, but … it [is] a still voice of perfect mildness, [like] a whisper, and it [pierces] even to the very soul.”

A look at official church communication during the pandemic indeed shows a steady and calming voice delivering a consistent message that can be seen in multiple talks from the past three general conferences: Protect yourself and others by following the recommendations of governments and public health officials, and use the opportunities presented by such unusual times to find ways to continue to progress spiritually and further the work of the Lord. Let’s breakdown what we are taught by the most recent statement. If we acknowledge it as an inspired communication to the entire world in troubled times from a God that loves all his children, and who will specifically not allow His church to be led astray, we can see in what ways it cuts through the “commotion in the world” that currently surrounds us.

“Dear Brothers and Sisters: We find ourselves fighting a war against the ravages of COVID-19 and its variants, an unrelenting pandemic. We want to do all we can to limit the spread of these viruses.”

This simple statement reveals the deception behind the numerous circulating conspiracies that discount COVID-19 as either a hoax, or a harmless everyday virus that has been blown out of proportion. If this was a perpetuated distraction designed to either limit freedom or in some other way distract from other vital spiritual and social matters, it would have been identified as such and resisted or ignored. Instead, the language of war is invoked- a collective struggle in which the cooperation of all is required to defeat a common enemy. COVID-19 is not an us vs them battle between conservatives and liberals, or politicians and free people- it is humanity against the virus. Mainstream and social media are replete with the personal witnesses of countless health care professionals and affected patients and their families warning everyone they can about the dangers of both the virus, and of allowing it to overwhelm health care systems. They are the frontline soldiers in this war, and the First Presidency is not discounting their testimony as “fake news.”

“We know that protection from the diseases they cause can only be achieved by immunizing a very high percentage of the population.”

Again the First Presidency endorses the advances in science and medicine that have blessed us with the relatively healthy society in which we live. We are not a church that eschews god-inspired scientific advancement in favor of faith healing alone. As stated in the church handbook, section 38.7.8: “Seeking competent medical help, exercising faith, and receiving priesthood blessings work together for healing, according to the will of the Lord. Members should not use or promote medical or health practices that are ethically, spiritually, or legally questionable. Those who have health problems should consult with competent medical professionals who are licensed in the areas where they practice.” I imagine the first presidency was very careful in being sure any official worldwide statement on an issue of health was in compliance with these guidelines.

“To limit exposure to these viruses, we urge the use of face masks in public meetings whenever social distancing is not possible. “

Immediately after stating very clearly that COVID-19 is a REAL health threat, and an unrelenting pandemic, the living prophet has just declared two ways to limit exposure to a potentially deadly virus: social distancing, and masking in close proximity. Is that not why we have a living prophet in the Latter Days? To cut through the confusing rhetoric of those who claim you must “do your own research” in order to prove or disprove for yourself the conclusions and recommendations of multiple worldwide experts and scientists? Including in areas in which the experts sometimes disagree? Does the Lord expect everyone to become an infectious disease expert through a year of internet searches in order to learn the truth about PCR testing, viral loads and epidemiological principles? Or to slog through the endless online theories of men to find the real truth? Perhaps amidst such confusion with the world facing a common life and death issue, the Lord might have his prophet make a simple and clear declaration, capable of being followed by “the least among you.” This simple declaration continues:

“To provide personal protection from such severe infections, we urge individuals to be vaccinated. Available vaccines have proven to be both safe and effective.”

Again, this clear statement of truth should cut through the torrent of false claims and deceptions widely circulating about COVID-19 vaccinations. If these vaccinations were a government tracking program, or a form of forced sterility/population control, secretly responsible for thousands of covered up deaths, or likely to be responsible for future large scale death or suffering by those who received them, then the Lord would never allow the prophet of the church to globally “urge” every member of the church to receive them. It would be difficult to believe that, and still believe in a church governed by revelation from a loving Father in Heaven. As with all commandments, exact obedience is never a guarantee of freedom from mortal injury or even death, but it is reliably the pathway to qualify for the most divine protection both in mortality and in eternity. One purpose of a latter-day prophet is to preserve the Lord’s people. Is it possible, that in the midst of a deadly pandemic, with the truth clouded by conflict, controversy and falsehoods, that the Lord might have his prophet make a clear declaration that would help his people make the correct choices to preserve their lives and personal safety?

And the day shall come that the earth shall arest, but before that day the heavens shall be bdarkened, and a cveil of darkness shall cover the earth; and the heavens shall shake, and also the earth; and great tribulations shall be among the children of men, but my people will I dpreserve;” (Pearl of Great Price, Moses 7:61)

This is not the first such statement on the pandemic either. At the time the First Presidency and eligible Apostles publicly received their vaccinations, they released a similar statement:

“Now, COVID-19 vaccines that many have worked, prayed, and fasted for are being developed, and some are being provided. Under the guidelines issued by local health officials, vaccinations were first offered to health care workers, first responders, and other high-priority recipients. Because of their age, Senior Church leaders over 70 now welcome the opportunity to be vaccinated. As appropriate opportunities become available, the Church urges its members, employees and missionaries to be good global citizens and help quell the pandemic by safeguarding themselves and others through immunization. Individuals are responsible to make their own decisions about vaccination. In making that determination, we recommend that, where possible, they counsel with a competent medical professional about their personal circumstances and needs.”

Those resisting vaccination advice point to the last two sentences as justification to decline the strong recommendation of the prophet. There are medically legitimate reasons the vaccine might not be the right choice for some people, and it is also clear that the Lord is going to allow everyone their agency in this matter. But agency has always been a principle of choice linked to consequence. This statement, and the more insistent latest repetition clearly reinforces that being vaccinated is in most situations the right thing to do to serve your community, protect those around you, and also to protect yourself. If you are the exception to that general recommendation, then there must be some very specific and personal reasons that are not generalizable to others around you. Does it need to be a commandment to be good advice? If you or a loved one are going to turn out to be one of the unlucky ones susceptible to a severe case of the delta variant of COVID-19, then not heeding the voice of the prophet in this matter may have significant life-long temporal consequences. The new statement continues:

“We can win this war if everyone will follow the wise and thoughtful recommendations of medical experts and government leaders. Please know of our sincere love and great concern for all of God’s children.”

Again a call for unity on this crisis that affects us all, and clear, understandable instruction on how to end the pandemic and the disruption it has brought upon us. We are a church of agency, and it is not surprising that many members have deep objections to mandates, rules and other government imposed restrictions. Unfortunately, when a nation is loosing a war, sometimes involuntary conscription is turned to as a last resort. It is always better to have the people choose to do what is needed, and that is what we are being invited to do. You can choose to wear a mask and be vaccinated because you trust the advice of medical experts, or the word of the prophet while still objecting to compulsory methods of enforcement. The justification or not for collectively enforced measures to protect the greater community from the action or inaction of others is an entirely different discussion, and does not change the value of the measure.

The closing sentence can be seen as a reflection of the First Presidency’s motivation for making this statement. The church does not lightly speak out on non-doctrinal matters of the world. Instead of seeing this statement as a challenge to their political beliefs, or weak health advice that can be rationalized away as men speaking outside their lane, perhaps those members struggling with it can reframe their questions. Why would the living prophet speak up several times to encourage public health measures and vaccination when he knows it is a divisive issue for many members of the church, and it is not directly linked to church doctrine? If it comes from a place of “sincere love and great concern” from those tasked by the Lord to be the watchmen on the tower during the last days, then perhaps there is an important truth and warning behind these words.

What if the world was in the grip of a deadly pandemic that threatened to get worse, but the loud and false philosophes of men were creating such great clouds of darkness and confusion that many good people both inside and outside of the church were deceived, and refused to partake in the simple and almost miraculously provided protection that was available, because they were unable to discern truth from error? What if there were thousands of preventable deaths looming in our near future, and we could save ourselves or someone around us by a few small and simple things? Would the Lord allow His people to be deceived in large numbers because they lacked the scientific background to recognize the errors of men, resulting in the preventable death and suffering of many? What would the Lord direct His prophet to do in such a situation?

I will finish with another quote from Ezra Taft Benson’s address:

There will be times when you will have to choose between the revelations of God and the reasoning of men—between the prophet and the politician or professor. Said the Prophet Joseph Smith, “Whatever God requires is right, no matter what it is, although we may not see the reason thereof until long after the events transpire”

We will all face challenges to our faith and to our fallible mortal opinions and understanding- that is a part of the test and the growth of mortality. How we choose to respond and reconcile ourselves to God when faced with such a challenge can be a threat to our physical and/or spiritual health, or it can be an opportunity to exercise our faith to trust the Lord when we cannot see the reason, and experience the growth that comes when we look back and understand the wisdom in following the counsel of His inspired prophet. As always, the choice is ours.

Alberta and COVID-19: How protected is our health care system from the 4th wave?

Full disclosure, I am not a statistician, mathematician, nor do I have any special training in statistical modelling, forecasting or epidemiology. However, I have been following the pandemic closely both personally and professionally, and like to look at patterns to see what’s next. As we find ourselves in an early 4th COVID wave in Alberta, driven by the delta variant, our province is set to eliminate all mandatory isolation for positive cases, contact tracing, any provincial mask mandates, and embark on a course of “living with COVID” and carrying on as normal.

I would love to carry on as normal, wouldn’t you? The proposed approach is very reasonable when dealing with an endemic disease to which most of the population carries reasonable immunity, or does not spread too rapidly. By definition, an endemic is a disease that exists at a steady case rate, without significant case increases or outbreaks. See here if you want more nuance. With ongoing spikes and drops in cases, we are clearly still having ongoing outbreaks, which by definition is an epidemic (or a pandemic if it is worldwide).

I wanted to do something simple here- try to get an idea from the numbers how at risk our health care system is from the next wave of COVID-19. Alberta has tracked COVID-19 cases and severe outcomes throughout the pandemic. The gathered data is very reflective of what our experience has been thus far. Our rates of severe outcome by age group have been very consistent with other high income countries around the world. If nothing changes, they can accurately predict future observations. However, things have been changing. We now have a good proportion of Albertan’s immunized against COVID-19. As of writing this, Alberta’s COVID website indicates 56.5% of our population is fully vaccinated with 2 doses (We are at 76.2% of “eligible” population with at least one dose, but ineligible children still count as part of the population, and only having a single dose is not fully protective). Those willing to accept a vaccination have now had ample opportunity, and in general children have much less severe disease and far fewer serious outcomes. Our more vulnerable older populations have the highest rates of vaccination. That, along with the economic cost of continuing to trace and isolate COVID cases, appears to be the primary rational given for no longer carrying on with universal pandemic tracking and mitigation measures. A primary purpose of these measures over the last 16 months has been to prevent overwhelming the acute health care system, as that would greatly increase the risk of substandard care both for pandemic patients, and everyone else needing the health care system. Despite over a year of living very restricted lives, with significant and intrusive public health restrictions to slow the spread, Alberta’s ICU system was still strained, and had to be bumped up above regular capacity to handle the case load. At previous pandemic peaks, COVID cases made up a significant portion of ICU capacity.

There are two main reasons to be vaccinated: one is to protect yourself. The second is to protect others by slowing or halting community spread. That’s the same thing we previously did by masking, not gathering and isolating. But with a highly effective vaccine, or effective pre-existing natural immunity, your immune system does that work for you. The SARS COV-2 virus is prone to mutation, which is why we have been dealing with a constant stream of variants. Each one is a subtly new disease. Pre-existing immunity to an earlier strain, either by vaccine or infection can offer partial or full protection against new variants, depending on how recognizable the new variant is to your immune memory. If the immune system is able to quickly identify and kill it, you are unlikely to have much virus replicating in your body, or suffer any symptoms of an infection. If the virus has changed enough that the proteins your immune system is watching for are no longer recognizable, it may behave like a completely new virus, resulting in re-infection needing a new immune response from scratch. This is typical of the seasonal changes of influenza, and the many fast evolving cold viruses. Or the changes may fall somewhere in between – in this case, the virus may be different enough to start an early infection while your immune system adapts to recognize a vaguely familiar foe. Alternately, if the new strain replicates very quickly and your immune system is in stand-by mode, it may be able to infect a lot of cells before your immune memory can be kicked into high gear to start making antibodies to clear it. Either of these scenarios can result in a situation where you can be infected (or re-infected) with the virus, develop symptoms and become contagious. The good news is that in this situation it does not take as long for the immune system to gain the upper hand, and both symptomatic and contagious periods are shorter and less severe.

This is what is happening around the world with the delta strain. A great summary of the latest research on vaccine effectiveness, protection from the delta variant and it’s implications can be found on this blog (by an actual epidemiologist). The short version is that more and more evidence suggests that being fully vaccinated provides good protection against developing symptomatic disease, and excellent protection against severe disease (including hospitalization and death). Below is US data.

The bad news is that data continues to suggest higher rates of breakthrough cases than previously anticipated (meaning vaccinated people may still have low grade infections and spread the virus to others). So, while vaccines still give personal protection, that community benefit (herd immunity) is likely to be significantly weaker with the delta strain than we had hoped. Good details on this can be found on the above linked blog. This is bad news for the at-risk unvaccinated, and bad news for health care systems that still depend on sick COVID patients not showing up all at once.

What might is look like in Alberta?

This brings me to the crux of this post: Given past trends in hospitalizations and ICU admissions, what kind of numbers might our health care system be looking at if most of our unvaccinated population does become infected with COVID-19 in a very short period of time? This is an important question given that:

1- We have never yet allowed COVID to circulate without public health measures to slow or stop it.

2- Despite high immunization rates in our at risk population, protective herd immunity will likely be lower than normally expected at our current vaccination rate. This means the unvaccinated are at high risk of exposure.

3- The delta variant is proving to be significantly more infectious than previous strains of COVID. Viral loads are about 1,000 times higher than other strains, making it more likely to be passed on in close proximity. The CDC now estimates a single case may infect 8-10 other people, making it one of the most easily spread infectious diseases we know about. This, and the breakthrough transmission through the vaccinated, is behind their latest recommendations to reinstitute universal indoor masking for all.

The Exercise:

While this is not a scientifically rigorous modelling method, here’s what I did: I took all my numbers from the COVID statistics pages. I took the numbers off this table to see what our Alberta case rates for hospitalizations, ICU admissions and deaths have been in each age category up to this point:

I then used the data on vaccinations by age group from this table, to calculate how many unvaccinated Albertans there are in each age group.

Using the above data, I created the below table in a spreadsheet. A few caveats – in the pediatric population the vaccine and severe outcome age groups do not fully align with one another. For the 0-11 hospitalization and ICU rates, I used the raw numbers to calculate an average for the group (0.56% hospitalized, 0.15% ICU). The actual rates are slightly higher for neonates, and slightly lower for older kids. 12-19 severe rates are based on the reported 10-19 year old rates. Alberta has reported no direct COVID deaths in the 0-19 age group. In order to find a reasonable estimated death rate in the pediatric group, I used this study, which estimated a worldwide pediatric death rate in high income countries of 0.012%. Applying this case mortality rate to our current total of 0-9 year old COVID cases predicts 1.4 deaths, so not having observed one yet is consistent with that rate. Note this study’s pediatric ICU rate was 0.152%, which is not far off Alberta’s observed ICU admission rate of 0.1%.

rate = events per 100 cases

Next is the simple (ha ha) matter of estimating how many unvaccinated people are going to contract COVID-19 in the coming months, then applying the case hospitalization, ICU admission and death rates to see how much more burden we can anticipate on our system. Now, estimating this properly falls in the domain of professional modelling and statistics, in which I claim no expertise. Yet it seems to me that since we have a disease as transmissible as chicken pox, without mitigation measures, that can spread through some of the vaccinated, with a completely unvaccinated pediatric population that is going to be mingling very heavily in the fall, that a significant percentage of these people are likely to be infected before the end of the year.

Now before moving on, I want to point out some significant limitations to these crude estimates. They come in two categories.

Reasons the numbers might be higher than this estimate:

  • I am not including any severe cases in the vaccinated. Although they are rare, there will likely be some.
  • I am not including the partially vaccinated (one dose only). That totals about 330,000 people. Although they may have some protection from a single does, we know it is poor protection against the delta strain. I do not have data to estimate severe outcomes in this group. Hopefully it represents people on the way to full coverage.
  • I am assuming the same rate of severity for the delta strain as previous strains. We don’t know for sure if that is the case. Online statements by providers from hard hit parts of the US suggest severe outcomes may be more common in both younger, healthier adults, and in children, but I am not aware of reliable data to make an estimate. It’s hard to know if they are seeing a higher rate of severe illness, or simply more severe cases as more people are being infected.

Reasons the numbers might be lower than this estimate:

  • I am not accounting for pre-existing natural immunity. While breakthrough cases in former COVID patients are known to happen (and even more with delta), there will be some protection from natural immunity both from re-infection and severe disease. I don’t have a way to account for that, or for knowing how many of the unvaccinated have previous exposure.
  • We almost certainly have higher levels of natural immunity than we know. Case counts are always under-estimates of the actual number of infections. There are more people protected by previous infections than will be suggested by past case counts.
  • By the same token, the actual case-rates of severe disease are almost certainly lower than those reported, due to the volume of non-reported cases. Applying the reported infection rates onto a full population are going to over-estimate severe outcomes for that reason.
  • Behavior changes. Regardless of official regulations, people will often look to protect themselves and others, changing behaviors when it is clear case counts are high in their community. We’ve all had lots of recent practice at these behaviors. Many businesses and perhaps school boards will also mandate their own protections. These measures will help slow spread where they are used.

With all those caveats in mind (and I’m sure more I’ve missed), here are a few screen shots of the calculated rates of severe outcomes at a few wildly different assumptions about the future infection rate solely amongst unvaccinated Albertans. Each age group is using it’s own historical rate and current unvaccinated count in the calculation. Each table contains the actual pandemic to date counts at the bottom for comparison.

The highest rate I’ve chosen to post is 50%, which one might feel is low in a completely “open for business” world, but I believe my list of caveats in the “numbers may be lower” section will probably have a significant impact on actual future observations. Still, even assuming only 30% of unvaccinated Albertans contract COVID in the coming months, that could almost double our past total COVID ICU admissions. Although kids have low rates of severe outcomes, there are so many that are unvaccinated (all of them), that it is inevitable to see large numbers of hospitalized, severely ill children in completely uncontrolled pandemic spread. We only have 2 hospitals in Alberta with general pediatric intensive care units.

The purpose of this post is not to try and make an accurate future projection, but to point out that even with relatively high vaccination rates (compared to the southern US), we have the potential to still have enough sick, unvaccinated people in a short period of time to cause a significant strain on the health care system. Many US states are now quickly surpassing their peak hospitalization numbers from previous pandemic waves. This is the delta strain that is now dominant in Alberta, as shown in the chart below:

During previous COVID waves, there was a dramatic drop in routine hospital and ER utilization. Cancelled surgeries, people avoiding or delaying coming to hospital for routine issues, and the general full stop to all common respiratory infections cleared space to care for pandemic patients. Hospitals are now very much back to business as usual, and then some. It is an extremely busy summer in most Alberta ERs, and that is with very few serious COVID infections. Hospital capacity in our system is strained at the best of times. This is not the best of times. We are are playing pandemic catch up, providers are burned out, and some places are losing both hospital staff and community providers at an alarming rate. Burn out (the pandemic has been very rough on the health care field), ongoing political confrontation, and the feeling of suddenly having all support for our efforts to keep the pandemic under control swept out from under us is demoralizing for health care providers. On top of all this, there is a real risk that we haven’t yet seen the peak of pandemic demand on the health care system. If many sick COVID patients begin coming in quickly again, we have very little capacity (space and people) to manage it.

It doesn’t have to be that way. The vaccines are providing immense protection (and peace of mind). We don’t need or want to have another lock down. Everyone wants to move on with life, and especially to let our kids be kids. But sticking our heads in the sand won’t make that happen. This is not a call to fear or lock down, but it is a message of concern and caution. Isolating positive cases, testing, tracing and controlling local outbreaks remains essential. They have always been the mainstay for controlling pandemic and epidemic outbreaks. We can’t abandon them now of all times.

Without basic mitigation, we still risk overwhelming the health care system. That means more cancelled surgeries, more delayed cancer diagnoses, longer waits in crowded ERs, and the risk of worse outcomes for any medical condition requiring critical medical care. Too much strain on the system risks making another lockdown the only way to quickly rescue it. Nobody wants that! There are many other small things we can do that may be inconvenient, but still allow us to work, travel, visit and learn in relative safety. We can be cautious a little bit longer until our kids can be vaccinated, protecting them and the greater community. We can live with COVID best by respecting what it is, and acting appropriately. Masks work and remain appropriate in many circumstances. They do not cause harm. If you are not vaccinated, please know that widespread vaccination is the only long term path out of the pandemic. Every time we let infections burn through a community, we increase the chances of yet another variant arising and throwing a monkey wrench in our COVID exit plans. Do it for your community, and perhaps more importantly for yourself. The vaccinations of others are not going to protect you much. A rapidly evolving virus is capable of having different mortality rates each time it comes around, so don’t hang your hat on having been “low risk” one year ago.

The economic and resource cost of pandemic testing and tracing has been put forward as a primary reason to abandon it. I don’t know what a testing center costs, but I do know that an average COVID-19 ICU admission costs $28,000 to our health care system. How many of those can we avoid if we keep up at least the bare minimum of pandemic control measures? How much does it cost to support an infected worker to stay home for a week if it prevents a couple of hospitalizations down the road? When the testing centers are closed at the height of exponential delta spread, how many people will come to the ER for a test when they can’t get one anywhere else? That costs our system several hundred dollars per visit, and I’m sorry to say an over-crowded ER waiting room is not well equipped to keep virus from circulating in the air. As in every part of health care, prevention is always orders of magnitude cheaper than trying to keep people alive when they are seriously ill. Why are we ignoring that fiscal reality?

My colleagues and I are tired of this pandemic, and tired of speaking out. I have heard much more concern privately at Alberta’s new direction than I have publicly, because speaking out into the ocean of pandemic fatigue feels futile. Provincial health policy sounds increasingly like politics and less like science with every new announcement. The constant online environment of medical misinformation takes it toll too. You might not hear from your “medical heroes” of last year as much anymore, but if you look for us, you’ll find us at work, wearing masks, isolating sick patients, washing our hands, and doing most of the same things we have for the past year, while still finding time and space to treat all the other health problems that haven’t gone away. There’s a middle ground between shutting it all down and doing nothing. Can we at least keep up the bare minimum so we don’t have to swing back and forth between those two extremes again?

(Header image source: Aug 10 2021.

A Message from Southern Alberta Doctors

The following is a letter delivered late March 29 2021 to Lethbridge Media outlets on behalf of the undersigned physicians:

We are writing to publicly express our concern about the recent increase in COVID-19 cases in Alberta, and specifically Lethbridge and the surrounding area. As of March 27th, we have 508 active cases in the City of Lethbridge, and the numbers have been generally increasing. At the height of the second wave, we never reached or exceeded 300 active cases. It is important to remember that COVID hospitalizations, ICU admissions and deaths always trail increases in cases by 2-3 weeks. ICU demand can stretch even longer due to the prolonged stays required by the seriously ill. Although not widely made known, the Lethbridge ICU was at capacity during the tail end of the second wave, long after case numbers had been dropping for some time. It is a disease that is stubbornly persistent when it hits hard. Alberta has seen a consistent case fatality rate of 1.4%, and a hospitalization rate of 4.4%. A simplified projection suggests that each day we add 50 cases, we can expect to need another 2-3 hospital beds within the next 2 weeks, occupied for 3-10 days depending on severity. Our ICU also needs to cover severely ill patients in surrounding rural areas. As of last report, the south zone currently has the highest per capita rate of COVID hospitalizations in the province, and 10/14 ICU beds occupied by COVID patients.

We are all tired of the pandemic, the restrictions and the overwhelming impact it has had on our lives. Fortunately, with the vaccine rollout progressing the end is in sight, but we are not there yet. We ask the public and government officials to recognize that individuals and the health care system are both still at risk. Southern Alberta has been fortunate thus far to have escaped much of the damage this virus has inflicted elsewhere around the world, and that is in large part thanks to the collective efforts of so many of our citizens who have made safe and smart choices to protect themselves and others. The unprecedented lifestyle upheavals we have experienced over the past year are the reason we have escaped many of the dire projections of the past.

While we are fortunate that many of our most at risk of death seniors are now vaccinated, it is important to remember that the average age of a COVID ICU patient in Alberta is 58. Those with the most severe baseline health and fragility are often not admitted to the ICU as intensive care can be too invasive and taxing for the body to meaningfully recover from. The ICU is primarily a tool to keep alive those who are young and healthy enough to recover from a severe infection once it has run its course. If the ICU is unable to meet demand, those who could otherwise be kept alive are at greater risk. While evidence suggests the vaccines still prevent severe disease from the ever expanding variants of concern, there is still not enough data to know how well they prevent transmission. For that reason, even vaccinated people are currently still required to quarantine and miss work if exposed. This means we are still at risk of hospital staff shortages due to occupational or community exposure to COVID-19. Furthermore, in Alberta, family physicians and many other community (non-hospital) based health care providers still have not been offered vaccination. They continue to work at risk in a community with rising transmission.

We do not wish to instill fear, but do advise ongoing caution, and wise decisions. We join our voices to those of other physicians encouraging the provincial government to do its part to get Alberta over the finish line without an even larger third wave, vaccinate all front-line health care workers, and prepare for the additional health care resources that may be required in the south zone. Regardless of government action, we ask everyone to continue to do their part to protect themselves and others by taking efforts to limit community transmission. If we continue to look for ways to be safe, rather than for loopholes and exceptions, we can protect lives and livelihoods over the next few months. We know COVID-19 is most likely to spread where people are gathered in close proximity, unmasked, indoors for prolonged periods of time. Making efforts to distance, wear a mask (2 or 3 layers are superior to 1), meet outdoors where possible, and limit time together where any of those is not possible will reduce the risk of transmission. Limiting contact with individuals outside of a small cohort will also break community transmission chains.

Thank-you to all of you who have been doing your part this past year to combat COVID-19 and support the health care community. We know it has not been easy. Please keep up the efforts to prevent our community and hospital from being overrun by this virus. The vaccines are safe and are the best path back to normalcy. Please receive whichever one you are offered as soon as you are able. Eligible health care workers have happily received theirs in large numbers, and those not yet eligible are anxious to as well. The end is in sight, but let’s finish it properly and save lives.

With concern,

Dr Tavish Barnes MD FRCPC (Critical Care)- Lethbridge

Dr Parveen Boora MD FRCSC (General Surgery)- Lethbridge

Dr Richard Buck MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Susan Byers MD CCFP (Family Medicine)- Lethbridge

Dr Rhona Capisonda MD FRCPC (Pediatrics)- Chinook Pediatric Clinic

Dr Tara Daley MD FRCSC (Obstetrics and Gynecology)- Lethbridge

Dr Ehi Eyayi MD CCFP(EM) (Emergency Medicine)

Dr Kevin Foster MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Tony Gomes MD FRCSC (General Surgery)- Lethbridge

Dr Charlotte Haig MD CCFP (Family Medicine)- Lethbridge

Dr Nic Hamilton MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Andrea Hargrove MD CCFP (Rural Family Medicine)- Taber

Dr John Holland MD FRCPC (Pediatrics)- Chinook Pediatric Clinic

Dr Cathy Horsman MD CCFP (Family Medicine)- Medicine Hat

Dr Rozemin Kizuk MD CCFP (Family Medicine)- Lethbridge

Dr Peter Kwan MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Jay Malach MD FRCSC (Obstetrics and Gynecology)- Lethbridge

Dr Bilal Mir MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Victor Onyebukwa MD CCFP (Family Medicine)- Lethbridge

Dr Lee Oviatt MD FRCPC (Respiratory Medicine)- Lethbridge

Dr Paul Parks MD CCFP(EM) (Emergency Medicine)- Medicine Hat

Dr Kristy Penner MD CCFP (Rural Family Medicine)- Crowsnest Pass

Dr Karen Robertson MD CCFP (Family Medicine)- Lethbridge

Dr Vanessa Rogers MD CCFP (Rural Family Medicine)- Crowsnest Pass

Dr Hollis Roth MD CCFP(PC) (Palliative Care)- Lethbridge

Dr Sharon Rowan MD CCFP (Family Medicine)- Lethbridge

Dr Ghazala Saif MD CCFP (Family Medicine)- Lethbridge

Dr Melissa Setiawan MD FRCPC (Anesthesia)- Lethbridge

Dr Parisa Shamsi Shahrabadi MD CCFP (Rural Family Medicine)- Crowsnest Pass

Dr Gregory Smith MD CCFP (Rural Family Medicine)- Raymond

Dr Julie Smith MD CCFP(EM) FCFP (Family Medicine)- Lethbridge

Dr Sean Spence MD FRCPC (Critical Care)- Lethbridge

Dr Adrienne Stedford MD CCFP (EM-PGY3)

Dr Michelle Thibodeau MD CCFP (Family and Hospital Medicine)- Lethbridge

Dr Jessica van der Sloot MD CCFP (Family Medicine)- Lethbridge

Dr Iffat Waheed MD CCFP (Family Medicine)- Lethbridge

Dr Nicoelle Wanner MD CCFP (Family Medicine)- Medicine Hat

Dr Dionne Walsh MD CCFP(PC) (Palliative Care)- Lethbridge

Dr Adam Wiebe MD CCFP (Family and Hospital Medicine)- Lethbridge

Dr Sean Wilde MD CCFP(EM) (Emergency Medicine)- Lethbridge

This Pandemic Sucks and So Does Fighting it. No Conspiracy Necessary.

Here we are about a year into the COVID-19 pandemic, and amidst the deluge of statistics, warnings, changing guidelines, protests, conspiracy theories and the continued disruption of our lives, I don’t think everyone feels like they are “in the same boat” anymore. And why would we? The pandemic experience has been different for everybody, and pleasant for nobody. We have all experienced it through the unique lens of our personal experience, personal belief systems, media preferences, and view of the consequences from wherever we are personally standing. With that in mind, I would like to acknowledge the common ground we still share. Whatever your opinion on lockdowns, masks, protests, freedom, public health, economic policy, vaccinations, government competence and overreach, let’s take a moment to agree that this whole experience sucks, and no one likes it.

Think of all the things you miss from late 2019- the changes that make you sad or angry, the things you can’t do and are missing, the people you can’t see because of safety, restrictions, or because they are gone. The losses of income, opportunity and experience are real. Kids are missing out on milestones in their lives, and friends and families are isolated from one another like never before in most of our lifetimes. I feel confident in saying that the person on the other side of the political aisle, the confrontation at the grocery store, or the stranger in the online debate is almost certainly missing the exact same things. Human beings do not thrive in isolation, families cannot succeed in continual economic turmoil, and communities cannot experience normalcy when an invisible deadly threat can strike us or a loved one from a friend or stranger without warning. I think we deserve to give ourselves and those around us a healthy helping of empathy and understanding.

This does not mean we need to accept misinformation, or irresponsible and selfish behavior. It also does not demand a blind and unquestioning acceptance of every decree of government or health authorities. It does ask us to start our questions and our discussions from a place of mutual understanding and respect for the experience and perspective of another. If you do not own a small business that is failing and are at risk of losing your house, then recognize you may not be as intimately aware of the crushing economic consequences of shutdowns as someone who is. If you have not lost one or more loved ones to a sudden and unexpected death with little chance to say goodbye, consider that you might not be able to appreciate the danger and personal anguish of the pandemic as much as someone who has. If you do not work in a hospital or care facility where you see and care for some of the many people suffering and dying from severe Covid-19 infections, your internet-informed musings questioning the reality of the pandemic probably make your entire opinion irrelevant to someone who does. If you have the financial security to enable you to self isolate when sick or exposed without risking loosing your job or the ability to feed your family, then you might not appreciate the terrible choice facing those who risk the possibility of loosing everything when filling out a “fit for work” form when they might not be.

We like our world to be good versus evil, obvious wrong versus obvious right; Luke Skywalker vs the Empire. But real world scenarios are seldom that straightforward, and this pandemic is a perfect example. We (as individuals and as a society) often do not have complete information when making decisions. Especially when it comes to rapidly developing and implementing policies to combat a new and fast spreading infectious disease. Even the experts do not have perfect information, and have been learning as they go. You have heard changing and sometimes conflicting recommendations from health experts through the course of the pandemic. This is because scientific recommendations evolve as new and better information becomes available. When we start off knowing little and learn quickly, what looks to be the best approach is going to change often and quickly. When it comes to scientific advancement, this is in fact “The Way.” And it works. As one example, continuous study and changes in medical practice based on new data in several areas of care have increased the odds of survival in hospitalized COVID-19 patients since the early days of the pandemic. The modern world is awash in information, and no one can be an expert in everything; but as in all complex fields of work and study, the experts still know a lot more than the rest of us do, and we need that expertise. Did you know that the genetic sequence of the COVID-19 causing virus was entirely decoded as early as January 2020? Or that the first prototype mRNA vaccine was developed in a single week-end in that same month? We owe the unprecedented pace of development of current vaccines in part to the experts who were already trying to solve the end game of this pandemic before most people in the world had even heard the word “coronavirus.”

But of course, eventually everyone did hear about the coronavirus, and soon enough could hear about little else. And it goes on. Everyone’s life in one way or another has been turned upside down by something invisible that can only be studied by biological and statistical methods that most people know nothing about, or have only heard about on an episode of CSI. People do not like to lose control of their own lives, especially without understanding why. If the answers were complicated and slow to be found for the experts, is it any wonder people have reached for simple explanations that are easy to understand? There has been an explosion in online commentary on the nuances of PCR cycle counts, infection case definitions, antibody testing, false positives, comorbid diseases, R-values, aerosolization, and a host of other biological and medical terminology that many of these commentators are unlikely to have ever discussed or even hear of before 2020. A few months of online curiosity cannot replace the years of academic background needed to appropriately synthesize and use this information to make and evaluate complex decisions. However, it is often enough to provide a semblance of understanding that feels sturdy enough to support a scaffold of suppositions and inferences that allow someone to explain to themselves what might “really” be happening. In this way one can regain some of that lost sense of control by feeling they can see through the apparent chaos around them, and anchor to an explanation that fits the paradigm of their core belief systems. Often these paradigms cannot fully explain the current reality without the addition of outside interference by someone who is secretly in control, perhaps with sinister motivations that can explain the apparently irrational or overblown responses to the problem. Such ideas often lead to significant suspicion of political or scientific authority figures, or even full blown conspiracy theories.

I do not intend to directly address or challenge every doubt or conspiracy theory, but rather to provide some simple descriptions of some of the unique features of the virus behind the COIVD-19 pandemic. By understanding what makes this virus different than other ones we routinely face, it is much easier to understand why different health organizations and governments around the world have been pushed towards the similar policies and restrictions that have defined our 2020 and early 2021 experience. They are a direct reaction to the nature of this pandemic, and do not require the addition of sinister or conspiratorial motivations to understand how we got here. My intent is not to defend or critique the details of what governments and public health authorities have or have not done, because it has been far from perfect, and is of course colored by political motivations. In fact, I echo the sentiments in this very long article suggesting that if governments were less paternalistic (or conversely dismissive) about COVID restrictions, and more openly communicative about the specific challenges we face and our options to respond, we may have achieved greater cooperative action, and less of the confusion and chaos that has been a breeding ground for suspicion and protest. Understanding the reality of this viruses behavior can better equip us to have the necessary discussion about how to best continue to live with it in the coming months. It is perfectly acceptable and important to discuss the unfortunate trade-offs between public safety, individual freedom and economic security we continue to be faced with, and where it is best to draw the lines. However, this conversation cannot possibly bear fruit unless we understand and accept the same facts, and do not allow them to be overshadowed by fanciful or fearful imaginings of the ulterior motivations we falsely ascribe to others, or wishful thinking about the reality of the virus itself. To use a related medical analogy, you can’t have an open and trusting conversation with your surgeon about treating your life threatening illness if you secretly worry he or she stands to personally benefit from your death and is trying to trick you into making the wrong decision.

As a disclaimer, I am not a virologist or an epidemiologist. I am an emergency department physician with a decent background scientific education and certainly an above average “hobby” interest in immunology and virology, but without credentials in those fields. I have paid close attention to the pandemic, including learning from many better educated in the field. I have treated patients who have suffered and died from COVID-19, and I have also sat around in an empty ER that people were afraid to come to when in retrospect there was little to no COVID-19 circulating in my community. I have tried to pay attention to how the pandemic and it’s societal disruptions have affected those around me, and have thought a lot about why people have come to some vastly different but equally passionate opinions about it and how we have either done too much, or too little to respond. I have become convinced that although opinions will always differ, appreciating the harsh reality of the virus, and acknowledging both the harms of infection and the efforts to limit its spread can open much more productive discussion and solutions.


SARS-CoV-2 (the official name of the virus causing COVID-19 infection) is somewhat of a perfect storm to disrupt modern life. There are a couple of simple reasons for that.

1- It is significantly more deadly than our usually circulating and easily spread viruses. Yes, it absolutely has a higher mortality than the seasonal flu and similar respiratory viruses. I’m not here to convince you of that if you don’t believe it, but there are many good sources to do so with facts instead of media hype (see below for a small sampling). When it enters a particularly vulnerable population, it can cause very high mortality in that group.

2- Infections are mild in most people (about 80%), and completely asymptomatic in some (probably 15-20%). The fact that it is so mild in so many people is what makes it so insidious and has brought us where we are. It is absolutely true that most people who contract COVID will be just fine. This can still be true even with a higher overall mortality. If airplanes had a flawed design by which 1 or 2 out of every 100 passengers died of altitude sickness, most air travelers might still be fine, but the risk of death when flying would still be dramatically higher than it is otherwise.

3- COVID-19 is more transmissible than similar respiratory viruses. This means that with normal human day to day behavior, a single infected individual will infect more people than they would with a simple cold or influenza virus. On average, one case of influenza in the general public will infect 1.3 new people. A SARS-CoV-2 case probably leads to 2- 3.5 additional cases (in the absence of infection control measures). This infections per case rate is loosely what is meant when you hear reference to an R-value, although the term and its variations have not always been properly applied in public usage. If you have a hard time visualizing that, draw it out on paper. One person infects 2. Then they each infect 2. Draw that happening 4 times. Then do it again if each person infects 3 others and see how those totals compare after 4 cycles. At each step that gap grows greater and greater. This is exponential spread. On a population scale, this is why fractional increases in seemingly low infection attack rates (R values of 1.5 vs 1.9 for example) can translate into such enormous population effects, and why personal behavior patterns and public health measures that can reduce the current R value can have such a significant effect.

4- COVID-19 has a long incubation period and significant period of asymptomatic infectivity. It is a stealth virus. It commonly takes 5-10, and even up to 14 days to develop symptoms after being infected. And there is a period of time (probably 2 days) before you feel sick (if you ever do) when you can spread it unknowingly to others. In the absence of very intentional and careful surveillance, this allows it to silently spread very extensively in a community for 2-4 weeks (or perhaps longer) before we start to see a significant number of people actually becoming very unwell. Once it is detected in the form of a rise in very sick people coming to hospital and action is taken to stop the spread, it takes 2 weeks just to see how bad it was when you started, and 2 more weeks to see the results of your attempts to slow it. That can be a long time to have no room in the ICU.

5- Those who do get unwell with COVID-19 tend to be sick for a long time. There are two manifestations of this. First is the long ICU stays and long time requiring a ventilator. Time needing mechanical ventilation for this infection is notoriously longer than in other respiratory illnesses, with a median of 2 weeks on a ventilator in several studies. This makes the virus a disproportionately heavy burden on health care systems. That means compared to another disease with a similar hospitalization rate, COIVD puts more pressure on the system because those coming into hospital need to stay there longer. Secondly is the COVID “long hauler” syndrome. Still little understood, this describes the significant number of survivors who are left with some level of functional disability lasting for a prolonged period of time, with some still suffering indefinitely since their infection. We still don’t know how long these symptoms might last. About 10% of those infected experience some form of prolonged illness. It occurs in people of all ages, and even in those who only had mild symptoms during their initial infection. Due to a propensity to increase the risk of blood clots, COVID infections also cause a disproportionate rise in life or ability threatening strokes, heart attacks, pulmonary emboli and other viral inflammatory complications. Lives can be ruined even in survivors.


That’s it really. It’s those 5 features of the virus introduced into a naïve population (meaning one without any pre-existing immunity), combined with modern global travel patterns and the structure of our health care systems that can explain almost all the unique challenges of this pandemic. In the absence of testing and interventions to control it’s spread, it has followed the same pattern in many places. It enters a population silently, and begins rapidly spreading through asymptomatic or mildly unwell individuals. That 1 – 2 week cycle between infection and illness can be repeated several times without much notice, as most people are not getting very sick, and those who are going to eventually be very sick do not become so right away. By the time the trend of increasing illness gets onto the public health radar, there is already a high level of community spread, and many more people who are on the cusp of severe illness. This was the hallmark of early pandemic experiences at hospitals in places like China, Italy, Spain and New York that raised the alarm for health care workers around the world. And it was health care workers speaking out first. Days to weeks before COVID-19 began to dominate headlines, it was filling my med-Twitter feed with posts by concerned caregivers throughout the world. The warning was stark: first you don’t see it at all, then you see a trickle of mildly ill people, then you are crushed by a wave of the severely ill that keeps on coming. At this point, even if you implement strict public health measures, it takes another 4 weeks before your actions today will start to lessen that crush of sick people that is just starting to come in. This is how health systems have become overwhelmed. The crush is reliably followed a few weeks later by overwhelming demand for morgue space, and other body transportation and storage services.

Let’s look more closely at what we mean by an overwhelmed health care system- or more correctly, an overwhelmed critical care system. It might be surprising to know how few extra very sick patients it takes in a given hospital to overwhelm its resources. Many are running on the edge (or just over) capacity in any given normal influenza season. Intensive care is exactly that- intense; it requires a lot of people and resources. It’s much more than just a bed and a ventilator- it’s all the doctors, nurses, respiratory therapists and other health care team members needed to care for the patient. There is a good deal of specialized training required to know how to do this. You can’t just throw any doctor or nurse in the ICU and expect they are going to be able to provide the best care. Overflow can be dealt with to some extent, but only for so long. Staff become burned out, or exposed and infected themselves. The COVID-19 death toll among health care workers is sobering. People have often been brought in from elsewhere- which can only happen when there are places with people to spare of course. COVID patients may begin to overflow into other units and critically ill people may stay in the ER longer than they should. All these resources turned towards pandemic patients need to come from somewhere. This blocks critical care beds and staff from the usual, routine needs that are still there: trauma, heart attacks, strokes, sepsis, overdoses, recovery from critical surgery, and all other forms of critical care are affected in an overwhelmed system. It can become impossible to provide the normal standard of care for a host of medical problems. Not to mention the difficulties presented by all the PPE staff must wear and work in. If you think it’s hard to order coffee through a mask and plexiglass shield, try working a multidisciplinary cardiac arrest wearing a mask, face-shield, a gown made out of a rubber shower curtain and still maintain good communication with people inside and outside a sealed room. All these factors increase the risk of substandard care and can inflate both the COVID death rate, and the rates of death or lasting harm from every other medical need requiring critical care.

This is the situation that health care providers, public health officials and concerned governments around the world have been trying hard to avoid for the past year. Success has varied from place to place, and time to time, but it has been widely agreed that it is unacceptable to allow health care systems to become so vastly overwhelmed that the death rate from otherwise survivable COVID soars, and that anyone needing hospital care for any reason becomes at risk of not being able to get it. This is the rallying cry to “flatten the curve;” it is to smooth out how many people become infected in a given amount of time so the system can cope. If it seems like it’s taking a long time and repeated interventions to flatten, that’s rather the point. If it seems like you are making a lot of sacrifices for an overall death toll in your area that is sad but not terrifying, that is also the point. The alternatives are to try to completely eliminate it (with the most extreme public health measures, as has been largely achieved in places such as New Zealand and several Asian countries), or to let it “flame out” as quickly as possible, permitting the system to be overwhelmed for a time in the hope of achieving early herd immunity. Both these approaches take a view of getting over the pain more quickly; one the pain of a lockdown, the other the pain of the virus. The hope in each case is to limit the overall damage, albeit with a vastly different perspective on what is more important to protect. Jurisdictions that have opted for the fast flame method have generally reversed course after finding the cost and difficulty to be too high (Great Britain, Sweden), and seeing that it really hasn’t ended the problem any quicker. There is a lot of experiential evidence suggesting countries that pursued the elimination strategy successfully have suffered the fewest infections, least economic damage and shortest disruption to normal life. They are currently living with the lowest levels of pandemic restriction in day to day life.

This is a good time to point out that when we talk about interventions to protect the health care system, we are really only talking about a subset of infected people who are the problem: those who are sick enough to need the hospital, but strong enough that they have a chance to recover with medical care. This does not include the group with the highest risk of death- the elderly and the very infirm. Keeping someone alive through a devastating illness is not a trivial matter. It means taking over a number of the body’s failing organ systems, sustaining life and providing the body with time and resources to help it overcome an infection and heal enough to resume it’s own life sustaining functions. If the body is unable to recover despite this care, there is little further we can do for it. This is why the very elderly and those with very poor baseline health are often not even offered life support/ICU care. In some people this care is futile, as the body is not going to be able to recover from a severe illness, regardless of the care we provide. That’s when medical care becomes focused on end of life comfort. Everyone has seen the statistics showing those 80 and over are at highest risk of death from COVID. Yet in this US study (as one example) the median age of COVID ICU patients was 64, with only 22% of them aged 75 or older. This means a very large percentage of covid deaths are among those who were never treated in an ICU because such care would have been futile, or against their desires for a focus on comfort and dignity near the end of life. Covid ICU patients are for the most part those who are somewhere between middle age and recently retired; people who may have a comorbidity (most commonly diabetes, hypertension and obesity), but were otherwise living normal, functional lives. These are the “salvageable” potential COVID deaths that require an intact medical system to save.

Faced with this specter in the early stages of the pandemic, with incomplete information on how the virus spread, how high its true mortality rate was, and a limited ability to test for it, the best course of action was an abrupt and complete as possible shut down of much of society. Initially this was to buy time to develop tests, study the best treatments, ramp up production of PPE and medical supplies, implement pandemic capacity plans, and figure out how far the virus had already spread. When you have a pathogen that can spread so insidiously, with carriers unaware and a long incubation period, the only way to fight it initially is to change people’s behavior to deny it the opportunity to spread. In fact, until vaccination is widely achieved, this still remains the best way, which is why it has been so difficult to find a way to move beyond that heavy handed approach. Hence the cycles of quarantine/lockdown- both terms used rather nebulously over the past year to refer by most to the various rules, restrictions and recommendations designed to (or at least intended to) limit the amount of person to person contact through which the virus spreads. People are prone to argue whether or not lockdowns “work,” by which presumably they mean work in limiting the spread of COVID. How effective any single intervention is, and its trade off cost is a very valid discussion. However, the underlying intention behind such interventions is a sound principle that does work; anything that reduces how many, how often and how long people are gathered in close enough contact to share a respiratory virus with people outside their household IS going to slow, and could ultimately stop the spread of the virus. Further data over the course of the pandemic has confirmed that the highest risk “super-spreader” scenarios are large groups of people, indoors, unmasked and in close physical proximity for extended periods of time, as is reflected in the current CDC prevention guidelines. To the extent we limit or stop that from happening, we will slow the spread of COVID.

In fact, we have seen astounding evidence at how effective this is in other circulating diseases. You have no doubt heard the incredulous reports that there is little to no influenza (the flu) circulating this year. (And yes, we’re still testing for it. No the flu won’t make a COVID swab positive, any more than having tuberculosis would give you a positive syphilis test). It’s not the only thing that is AWOL this year. Pediatric bronchiolitis, croup, even asthma exacerbations are all staples in the ER every winter, triggered by respiratory infections. Where I work, they are almost non-existent this winter and I have seen similar observations by physicians in many places. How many colds have you had in the past year? Contrary to conspiracy claims, this is not because we are arbitrarily relabeling everything as COVID. It is because these conditions are all caused by infectious respiratory viruses, and we are in the midst of a worldwide campaign to stop an even more infectious respiratory virus. Reduced travel within and between countries, limited social gatherings, compulsive hand sanitizing and mask wearing are all having the exact effect one would predict- stopping the spread of respiratory infections. In the case of influenza, it may well have been largely stopped in the Asian and southern hemisphere nations where we usually get our new annual strains from- areas that are generally doing a better job than North America at COVID control. In fact, in my opinion seeing how well COVID has still spread as much as it has in the face of current measures that have nearly eliminated the flu and other respiratory infections is an even greater indication of just how contagious it is. If we had done nothing, it would surely have hit us so much harder.

Accepting that reducing personal contact does reduce transmission, we can then rationally discuss what measures work better than others to achieve this, what the costs of such measures are in dollars, freedom and mental health, and who pays the price for either decision. Certainly the hodgepodge of variable rules, restrictions and exemptions experienced in any of a number of jurisdictions during the pandemic highlight that there is not always a lot of evidence based decision making going on, but rather a lot of best guesses, influenced heavily by individual opinions, financial limitations, and local political persuasions or lobbying. While the rationale behind the lockdown approach is valid, the devil is most certainly in the details. Any intervention is also only as good as the public’s compliance to it, which has certainly waned as the pandemic stretches on, leading to further discussions on the merits and ethics of education, enforcement, and the diminishing returns of repeated “shut-downs,” where a possibly less effective result is being paid for by a potentially diminishing pool of voluntarily compliant individuals. There is a cost to moving in either direction, and it is often paid by different people in each case. This is a classic demonstration of how interconnected we are. No man (or woman) is an island, and our choices in these matters always affect others around us.

The costs of pandemic control measures to individuals, businesses and society continue to be abundantly clear. Limits on personal mobility, isolation from friends and family, loss of opportunity in education, sports and recreation, mental stress, loss of jobs, collapse of small businesses, bankruptcy, domestic violence, delays in routine health care and elective surgeries, delayed cancer diagnoses- the fallout from these and more will be with us for years. The longer the pandemic drags on, the more it is going to “suck” because of all these things. Much of this is unavoidable. Even if we assumed that no mandated public health restrictions were imposed, much of the economic and isolation consequences of the pandemic would still be with us. When people are aware of an existential threat to their own health, and that of loved ones, they change their behavior to limit risk. When a community is in outbreak, many people will chose to stay home, and businesses that rely on mobility and mingling will suffer. These are self preservation and economic choices; both immediate income and future earning potential can be decimated by serious disease in a home- to say nothing of medical costs where insurance is inadequate. It is a false dichotomy to assume that in setting a pandemic policy we chose either health OR the economy. Likewise, a full focus on protecting everyone from infection will still have inadvertent health consequences as surgeries are delayed and medical appointments put off. There is no policy of pure health or pure economic protection- only compromises and priorities. There is evidence to support that the harsher short term economic and public restrictions of a viral elimination strategy actually do the least overall economic damage. If viral spread is successfully stopped and nearly eliminated early on, life can return to normal much sooner- albeit with significant surveillance effort to prevent a re-entry. The alternative, which most of the world is living with, is repeated cycles of opening and closing as cases and hospitalizations cycle, with no return to normalcy in between. Whether these closures are driven by government policy, or people’s natural behavior in the face of local flare-ups, the effect is often similar. And given the long incubation period, each part of the cycle drags on for weeks. Off and on half measures to live with this “slow burn” of cases leads naturally to the longest period of societal disruption and living with an ever present small to moderate risk of infection. Whether there is more suffering from prolonged restrictions, or more suffering from viral infections and deaths varies from place to place and is perhaps a matter of personal perspective.


A prevailing theory in understanding the anti-vaccination movement is that vaccines are a victim of their own success. In a world where very few people have personally seen the effects of polio, tetanus, or even measles encephalitis, it becomes increasingly more difficult to remind people that these diseases exist, and that they are terrible. People become complacent, and question the need for vaccination. I suspect we are seeing a similar effect from the tenuous control we have achieved in much of the world over COVID. While the overall death toll still remains distressingly high, the fact that we have prevented the near simultaneous overwhelming of most of the world’s medical facilities that was feared in the early months means that most people’s entire experience of the pandemic has been the disruption of their lives from the policies and restrictions put in place to control it. They may see low local death tolls- a consequence of successful transmission suppression- and wonder what’s so bad about this virus. Combine that with how well we have isolated the sick, and the very common experience of having “mild COVID,” and it is not surprising to see doubt creep up about how necessary this all is. Certainly millions of families worldwide have personally experienced the tragedy of an early death of a love one, but maybe the very isolation that keeps us safe also prevent us from sharing with one another more intimately the reality of death from COVID. If you have not had someone close to you be very sick, or if you do not work in a facility that cares for them, then you will have little first hand knowledge of what is so bad about COVID. We live in a world where there are many voices trying to convince us someone is fooling us about any given issue. When it is so hard to see the damage for yourself, many people may find such claims about the pandemic to be a seductive path back to normalcy.

A part of this perception is certainly the striking regional variability that has been seen with “spikes” of covid. Parts of a country or even city can have much higher case loads than another, and the strain on the local health system can come at different times. This is likely a result of decreased movement between regions, but with the propensity for COVID to spread rapidly within a susceptible, localized population. If the virus gains a foothold in a care facility, a close knit neighborhood with poor distancing practices, or a homeless shelter with a large transient population, there can be a significant local spike in cases and hospitalizations. Super spreader events like weddings, funerals or house parties can make a noticeable difference to local health facility needs a few weeks down the road. Governmental restrictions or recommendations tend to be much broader than these local outbreaks, meaning you may be living under restrictions tailored for communities nowhere near yours. It’s also important to remember that an overwhelmed ICU can still exist in an otherwise underutilized hospital and primary care system. When critical care is overwhelmed, elective surgeries get cancelled, visitors are restricted and anyone who doesn’t need to be in the hospital is kept out. People self restrict their movements, so medical clinics may be empty, and ERs avoided except in the most extreme need. Remember not everyone in health care can provide critical care- those that do can be over-run with sick patients while the rest of us find we have much less to do than normal. If you are not in the ICU, the hospital can seem a surprisingly empty place at such times. It’s not going to look like a scene from an outbreak movie, or from Lombardy Italy in early 2020 unless things are seriously out of control. That’s the scenario we are trying to avoid.

The average person is not going to see the side of the pandemic that critical care providers, or nursing home staff are going to see. And that’s on purpose- the fewer people exposed to the environment of heavy COVID viral loads, the better. Likewise it is fair to say those in health care and political decision making are sheltered from the most severe economic impacts compared to those who are losing their jobs or businesses. I will mention that is not universally the case- as surgeries are put off, clinic visits reduced, and even routine ER visits tumble, there is probably an overall loss of income that has been experienced by most of the health care community this year, at least where I am from. Yet, that is not the same as businesses that can no longer open, or employees who’s service based skills are no longer in demand. There is also the important consideration of those working low income labor jobs who do not have the economic luxury of staying home, even when sick. Working conditions often come with their added risks too. There is a reason there have been so many large outbreaks linked to meat packing plants. No plan for the sick or exposed to take a mandatory leave of absence is going to work if the financial support to make that possible is not provided. It is important for all of us to consider the perspective of those experiencing a very different pandemic than we are.


That’s what everyone wants to know, and I don’t have the knowledge or qualifications to give the answer. There are a lot of popular and attractive ideas out there. Some give simple, painless sounding (or at least less painful) solutions that they insist are better. As in all complex problems, I fear many simple solutions are too simple, and gloss over some of the realities of this pandemic. We can look at them too through the lens of understanding the unique properties of SARS-CoV-2.

One popular approach advocated in the Great Barrington Declaration and similar proposals is to simply protect the vulnerable, get on with our lives, and wait for herd immunity to take hold, presumably after everyone young and healthy has been infected and recovered. It’s a nice idea, but if you try to develop a specific policy based on that, while keeping in mind the insidious and stealthy nature of the virus, it loses its simplicity. Who are the vulnerable? The elderly for one- do we simply lock them away with no outside contact? No visitors, no leaving home? Are we not already essentially doing almost that and still seeing regular stories of terrible outbreaks and death in senior facilities? And this is while we still have all these other rules and restrictions on for the general public. Where do they go for medical care? Who takes care of them in their facility? Do we also make caregivers live in the facility with no outside contact? What about their families? How often do we test everyone? The tests are imperfect, and false negatives are the most common error. What do we do when a case slips through? What about those not in a senior facility already? Do we build massive complexes to house them in? Are they allowed to stay at home or with their families? If they do, are their families allowed to work or leave? Maybe you don’t want to impose rules, so everyone “voluntarily” decides how they are going to protect their relatives. How can they do that when anyone they meet could potentially pass on the virus without warning, and they themselves could be unknowingly infectious for the next week or two? It’s a false choice- there is no real action they can take to protect their loved ones without completely isolating themselves from society. Who else is on the at risk list? There’s the immunocompromised (including cancer patients and those on immunosuppressive drugs for many different chronic diseases). People with high blood pressure, diabetes, obesity. Pre-existing respiratory conditions. There is no firm line between high risk and low risk- there is a spectrum and it is very hazy at points. What policy do you make that is going to realistically allow those at high risk to stay safe while letting everyone else carry on with life as normal? There isn’t one- you can’t do it. Even the blanket shut-downs many of us have been living under (which are entirely un-necessary according to the Barrington philosophy) are not enough to adequately do this.

The entire question of whether or not herd immunity can be achieved through natural infection is another issue. I won’t delve into it, but there is mounting evidence that natural infections may not provide the complete long term immunity that would be needed for this to work, at least not for enough people. We also know this virus mutates easily. Every new host is another opportunity for mutation, and any new mutation could be the unlucky one that raises mortality, increases infectivity, and evades the old immune response. There’s a very good chance if you let if “burn through” the population that the virus that comes out on the other side will be different enough to start the whole infection cycle over again. This is the same phenomenon by which we have new flu variants every year. Furthermore, with uncontrolled community spread (even somehow sparing the elderly and infirm) there would also not likely be a way to prevent prolonged overburdening of the health care system, which as described above will increase all cause mortality. Remember, the ICU system is there to support mostly the middle age to retirement age group who are the infection deaths potentially preventable through good medical care. There would be a large sacrifice in this age group too with this approach (and certainly some even younger too). Alberta Health Services put out a very fair and comprehensive discussion of some of the limitations of the Great Barrington Declaration.

So what about elimination? It has been done very well in several nations where people are living a mostly normal life today. Can other countries, states or provinces go for COVID zero? Perhaps. I don’t think there is any theoretical reason it could not be done, and the evidence certainly suggests that it is the least painful and quickest path out. There is an argument to advocate for it in Canada, in light of the new variants beginning to spread more widely. If you are not an island there are certainly more travel complexities to address, but I think the biggest barrier is public buy in. It won’t happen if most of the public is not entirely on board with the true, real and significant lockdown that would be required to get there. Even with the promise of “normalcy” afterwards. Even if a western government was willing to impose such a program against the will of a part of the populous, it would not be enforceable. Maybe at the beginning of the pandemic there would have been more appetite for it. If we knew how long it would drag on, I think there might have been in many places. But here in the west we have generally been given political messages of overly-optimistic reassurance with too early reductions in restrictions, and inadequate travel rules to keep new cases out, and existing ones from spreading. A more realistic comparison to the multi-year phases experienced in all prior pandemics may have made the prospect more attractive. I would support the attempt, but I don’t see it happening now, especially with vaccinations beginning (even though that too will take a long time to significant herd immunity).


Clearly there is no quick and easy path out of the pandemic. Whether we double down in squeezing it out, or give up and let it run rampant, there is pain in either direction. There is hope in the excellent clinical data and evolving real world experience with all the major current vaccines undergoing distribution. Mass vaccination is I think the best way out, but it will take time and public buy in. If you are frustrated by wearing masks, not seeing family, and an inability to work or travel, this is certainly the fastest way back to normal. Get vaccinated when you are able to. It is safe and effective. Most frontline healthcare workers where I live have already gladly received it. The longest, and most painful path is to deny the virus is a threat and help keep it burning right on the edge of overwhelming the critical care system by refusing to follow the basic health guidelines that have been given. They only work if they are followed, and if they don’t then we either enforce more painful restrictions until they do, or give up and surrender to the virus. There is at least now an endpoint on the horizon.

As I’ve said before, there is a valid discussion to have about what interventions, rules and public health measures are most useful, and which have a greater cost (economic, personal or otherwise) than they are worth. If we are to continue on the path of the slow burn until herd immunity by vaccination, then we must continue to be diligent and cooperative, and accept that things will not return to normal until that point. If we acknowledge both the reality and the risk of the virus, as well as the cost of the measures we take to control it, we are better able to make wise decisions. There continue to be challenges ahead, particularly with new, more infectious variants staring us in the face. We will also continue to learn more about the virus, and the success (or not) of different containment measures. We should be willing to alter our course based on new information, and that information- as well as its limitations- should be freely shared with the public.

The COVID-19 pandemic is a major challenge to our society- no secret plots or conspiracies necessary- it’s the nature of the virus. It’s not the first such challenge to humanity, and not the last. I’m not going to claim there are not people who are using this as an opportunity to further their own political agenda, or to profit economically from the suffering of others- these things have always been with us, and in the increasingly hyper-partisan political world of the west, will continue. The media loves sensationalism and will focus on what catches the most attention, as they too always have. But there is still plenty of good and objective reporting behind the hype of headlines and sound bites, and there are plenty of civic and medical leaders trying to find a path forward where there is no clear best answer. Hopefully a little more understanding will motivate people to spend less time looking for hidden agendas, and more time discussing the legitimate and difficult questions of how to live with this reality. How do we balance saving lives with restricting personal liberty? How do we protect health care systems from becoming overwhelmed without causing irreparable economic harm? How can we make it more financially possible for people to isolate when they should? How do we make these decisions when we still have incomplete information about the spread of viral variants and the best ways to contain them? These are not simple questions and are worthy of tough discussion. But when we are distracted by false information, unyielding conspiracy theories, and the need to constantly defend the utility of scientific expertise, then we cannot even have these discussions. Let’s acknowledge that this is hard on everybody, and we are all doing our best. Opinions can and should differ, but we can still do our best to make sure we are using real information to make really important decisions.

Alberta Doctors are off to Battle. Who has our Backs?

The COVID-19 pandemic is undeniably here. Most of Alberta is currently in the calm before the storm. We are doing the right things to prepare our hospitals, our medical staff and our province. Social distancing started early compared to elsewhere. If it is adequately embraced, we will hopefully be spared the worst effects other parts of the world are already experiencing. It is a stressful time for everyone, and we in healthcare are feeling it all day every day.

Yet while we prepare to be part of the front line against the coming storm, our stress is amplified by the persistent need to look over our shoulders. As we’ve been looking to the fight to come, we have little trust or confidence in our political generals, and are still bleeding from wounds they inflicted, and unsure how to deal with the bigger ones still to come. The Alberta government has not relented in their attack on physicians, despite the bluster of unity in political press conferences. You may have read otherwise in the media, and yes, as of this writing, after months of physician outcry, they have relented on one proposed change; delaying the reduction of complex modifiers (despite still claiming they should not be a problem). See this previous post for an understanding of why this will be so bad for primary care. A step in the right direction, but this is only one of many ill conceived changes that are still scheduled to come into effect on April 1, leaving many physicians unclear on how they will manage their businesses beyond that date. This coincides almost exactly with the period when we expect to see our health system beginning to strain under the load of Covid-19 pandemic patients. Physicians are far from the only ones facing significant economic uncertainty right now, but we are the ones being asked to put our own safety on the line for Albertans. Health care workers around the world have a higher infection rate than the general population due to our risk of multiple exposures (see here and here).

I’m busy with plans for how our local ER is going to cope, so I do not have time for details, but in brief these pending changes still include:

  • The loss of clinical stipends to support palliative care, trauma and other critical programs (note AHS has announced it will delay until August some of these cancellations given the pandemic. I suspect this was an AHS rather than direct government initiative and it does not include all stipend losses).
  • Daily “encounter caps” still mean many after hours walk-in clinics will need to close
  • Still undisclosed cuts to in hospital consultation fees that may make hospital work unsustainable for some specialists and rural physicians

More specific concerns as addressed in recent communications to government can be read here.

Even in the midst of pandemic planning, further stress has been put on Alberta physicians through the following developments:

On March 13, the Minister of health gave 1 year notice of termination of the contract with provincial radiologists, with the apparent intention of putting out a tender to have the province’s medical scans in the future read by the lowest bidder. This is a contract that was recently renewed in binding arbitration with a 12% fee cut. The full implications of this are not entirely clear, but one possibility is that the reading of diagnostic tests in Alberta could soon be filled by a cheaper overseas radiology “call center” of sorts. Would you rather have your MRIs, mammograms and CT scans read by Canadian trained and regulated radiologists, or the lowest worldwide bidder? As an ER doctor who relies on those reports to care for you, I know who I would rather have reading them, and who my lawyer would.

Social distancing is beginning to be achieved in health care throughout the country by the roll-out of “virtual care” fee codes. These allow your doctor to be paid when communicating with you through email, phone or video call to minimize face to face contact, and avoid clinic visits for at risk patients during the pandemic. It has been recognized throughout Canada as a key pandemic response. The fees need to be high enough to allow the doctor’s office to use them, and still pay overhead. Premier Kenney is fond of comparing Alberta physician billing to the rest of the country, so let’s do that here:

  • BC: $31 -$35 per visit
  • Manitoba: $38 – $44
  • New Brunswick: $45
  • Quebec: $49
  • Yukon: $51
  • Saskatchewan: $35
  • Ontario: $37 (> 10min), $68 per half hour of counseling

Health minister Shandro proudly re-introduced the old H1N1 pandemic virtual medicine fee, at the same old fashioned rate of $20, regardless of time spent. That’s 30-70% lower than anywhere else in the country. We have a few other pre-existing telephone fees that also pay about $20, but are limited to 14 uses per week. There are many Alberta family doctors on social media who are trying to protect their vulnerable patients during a pandemic by keeping them at home, and are right now operating at a loss to do so. Remember this money is used to pay clinic rent, utilities, staff and equipment.

This is completely unsustainable, especially in a pandemic. There are already clinics in Alberta that have announced or are planning a closure. We (speaking from the soon to be overwhelmed hospital front) need our community physicians to be able to stay in business and keep caring for Albertans! All your chronic diseases and usual day to day health problems are not going to be put on pause as easily as a Florida vacation. If family doctors, palliative care doctors and other specialists cannot provide good, comprehensive primary care – from their patient’s own homes when needed – we will further burden the acute health care system at the worst possible time in our provincial history.

[Update March 23: Today the Alberta government announced some additional temporary virtual medicine codes that are similar to regular office visits fees for both family physicians and specialists. There are a few significant restrictions including that the patient, not the physician must initiate the call, no time modifiers will be paid for longer visits, visits must last a certain minimum number of minutes to be paid, and there is no remuneration for additional administrative time including chart review, charting, prescription or consult letter preparation. They will not be subject to daily caps. This represents a definite improvement, and time will tell how clinics will adapt to survive a potentially prolonged period of “socially-distant” medicine with newly restructured rules governing their income.]

This is an unprecedented time. Everyone is suddenly either out of work or overworked, depending on what they do. Financial times are suddenly stark for many, and are going to get even harder – but is this the time to carry on with draconian and frankly completely uninformed tinkering of the health care system? By politicians who have shown no interest in listening to the experts about how that system works? Nurses have been told their layoffs will be delayed until after the pandemic. I’m sure they are grateful for the message that while they are needed to shield the province from harm they are at least temporarily of more value.

The Alberta government wants to renovate the house of health care. Instead of working with the architects who built that house, and the people who maintain it, they have come in and started unilaterally demolishing the foundation – primary care. We have spoken up loudly about it, insisting we can fix the house together, but that they are going about it the wrong way. They have persisted, and now a hurricane is coming – we are rushing to hold up the walls, leak proof the roof and make room to shelter more people. Meanwhile the government continues to dismantle the structure behind us.

It’s becoming clear that the UCP does not want this pandemic to delay their plan to reshape health care into an as yet unknown image. Have you seen the ads suddenly popping up in your social media feeds for virtual online health care in Alberta? Is that where the health care budget is going now – to these private companies? As I am writing this, Premier Kenney happily announced (on twitter) new partnerships with online health delivery companies to take care of your health needs over the phone or an app. Don’t be fooled – they are paying discount doctors a cheaper rate to do incomplete electronic medicals while a private company is pocketing the difference. Do you think that service will be an adequate replacement for your family doctor? What kind of health care relationship will you develop with this app while your GP who knows your health history and can actually physically examine you is being undercut and going out of business? This is one more thing that looks like it will save money in the short term, but will cost much more in the mid and long term because it destroys the patient’s medical home- the most health and cost effective tool in Alberta’s public health system. This government has proven itself incapable of understanding the basic principles of health care and health economics. They are dangerous.

We no longer have time to continue this asinine fight, but perhaps you are finding yourself with more time than you used to have. Perhaps you can take up the battle to defend our backs while we face the storm.

If you can,

Contact your MLA. There is growing feedback coming to physicians from some back-bench UCP MLAs that they are not happy with their own government’s approach to health care, especially once they understand the facts – that the system is going to suffer and health care is going to cost more. This is not ideological, it is math and basic health economics. We have been encouraged by some to continue our advocacy to THEIR bosses – the Minister of Health, Premier Kenney and whatever small room of yes men is setting provincial policy. Don’t accept willful ignorance or cowardice from your elected MLAs. It is their government, and its power rests in their votes. Their future jobs rest in ours. The UCP recently passed a bill limiting their own member’s ability to debate or comment on some legislation- the Premier does not want his own MLAs to speak up. Demand that they do.

Find your member of the Legislature and their contact information here.

Contact the Premier and the Minister of Health. Tell them you see through the propaganda, and insist that they acknowledge the problems that have been identified by so many physicians. Their response is always the same: “We are holding the line on health care funding.” “Alberta doctors are paid more than anyone else.” These are deflecting answers that ignore the problems in the details of their actions. Do you care what the total budget for your new house will be if the builder refuses to properly pay for the pouring of the foundation? It doesn’t matter how much you spend on the roof tiles, the house is going to collapse.

Premier Jason Kenny contact information

Minister Tyler Shandro contact information

Demand at the least that these changes be put on hold until after the worst of the pandemic is past. Invite them to then take that opportunity to collaborate with doctors and other healthcare providers who can help find the inefficiency and waste in the system, and who will continue to offer sustainable cuts  to  their own income in hard economic times – later, when there is time.

Demand our province raise virtual medicine fees to a level commensurate with other provinces, so clinics can stay open and avoid further layoffs while caring for patients in isolation.

Consider signing this petition, asking the government to see sense and delay the changes.

While you’re at it, please sign this petition, asking provincial and federal governments to please immediately implement a national plan to ramp up production of protective medical equipment. We will need it badly and the entire world is headed into an immediate severe shortage. What a great way to create some jobs in a crisis! Please consider speaking out about this.

If you want to get out of the house, please consider donating blood. It will be sorely needed for many, and is safe to go and do.

Please continue to follow the excellent advice and leadership of Dr. Deena Hinshaw, our chief medical officer of health. Thanks to her, and thanks to the blessedly wise decision of our Premier to follow her advice, Alberta has a chance to be more prepared, further in advance than much of the world. We hope it is enough, and we hope you will have our backs, while we do our best to protect the health of every Albertan.


Alberta South Zone Physicians Speak Out

Below is the text of 2 letters put out by Alberta physicians in the south zone in response to upcoming health funding changes implemented by the Alberta government:


An open letter from Alberta South Zone emergency physicians

March 3, 2020

Premier Jason Kenney
Health Minister Tyler Shandro
Mr. Nathan Neudorf
Ms. Michaela Glasgo
Mr. Drew Barnes

c.c. Ms. Shannon Phillips

We write to you today as a united voice of southern Alberta Emergency physicians in the cities of Lethbridge and Medicine Hat to add our voices to those of physicians across Alberta in response to the imminent changes coming to our healthcare system. We are deeply concerned that as early as April 2020 our emergency departments will begin to be overwhelmed due to reductions in local primary and specialist care. We also warn that any decision that degrades access to community based primary care medicine will inevitably result in increasing, unsustainable health care expenditures that will rapidly reverse any budget savings anticipated by these measures.

The emergency department has often been called the “canary in the coal mine” for problems in any healthcare system. When patients are unable to obtain or visit a family doctor, they come to the ER for routine care. When referral visits to specialists or for elective surgeries are delayed, patients come to the ER in crisis. When community long term care beds and accessible home care is unavailable, patients who no longer need hospital care have nowhere to go and languish in expensive hospital beds. When hospital beds are full, new patients requiring admission cannot be accommodated and remain in the emergency department. Elective surgeries are cancelled because there is no postoperative recovery space available.

All these factors combine to grind the efficiency of the emergency department to a halt, impairing its ability to accept and treat new patients. Wait times soar, ambulances pile up and become unavailable to respond to new emergencies. These causes of emergency department crowding are well documented and understood by health care professionals. There is abundant evidence that emergency department crowding increases costs to the health care system and has a cost in patient lives. There is also abundant evidence and consensus from health care experts here and around the world that investing in primary care, long term care and home care is the most effective and affordable way to reduce the burden of expensive hospital-based care.

We recognize and applaud this government’s stated intention to increase the availability of community long-term care and await details as to how this will be implemented. Nonetheless, we are concerned that the current government either does not fully understand the above relationship, or does not understand how the unilaterally imposed changes that were vehemently resisted by the Alberta Medical Association will rapidly decrease access to quality community health care, resulting in poorer health for Albertans, and a rapid increase in the utilization of expensive emergency and hospital based care.

Southern Alberta currently enjoys some of the best emergency department wait time indicators in the country. The average wait to see a physician in a south zone regional hospital is about 55 minutes. Our zone has been identified in the past as one of the most cost efficient in the province. This is in large part due to an excellent primary care system that is accessible to patients, and a network of specialists available to provide timely consultation, admission and follow-up for emergency department patients.

Currently, a simple visit to the family doctor costs Alberta Health $38-$56, from which clinics pay their operating expenses and employ their support staff. An equivalent simple visit to the emergency department costs $359 in hospital overhead + $29 in doctor fees. If additional time, complexity, consultation or testing is required, that expense rises significantly. There is a similar disparity in cost to the system between community and hospital care in other areas of medicine. The ER is generally busiest on weekends, holidays and Mondays – all related to times when community care is less readily available. As community care decreases and more people become reliant on the ER for their care, it is easy to see how health costs rapidly rise.


The following are specific ways in which we anticipate our emergency departments will be immediately affected by these changes beginning April 1:

  • The reduction and loss of complex care modifiers will make it difficult for family medicine and specialist clinics to remain financially viable unless visit lengths are significantly reduced. Less time translates into poorer care, making it more likely complex patients will experience a health crisis requiring a trip to the ER and/or hospital admission.


  • Daily visit caps on community physicians will shorten or eliminate evening walk-in clinics. These patients will come to the ER instead.


  • Daily visit caps will disproportionately affect high volume orthopedic, surgery and cast follow-up clinics, meaning more patients will come to the ER as they cannot see their surgeon.


  • Yet to be clarified changes to specialist in-hospital visits and the loss of on-call stipends have our consulting specialist colleagues already notifying us of decreased future availability to rapidly see and admit patients in the ER, as they will need to book additional time in clinics to continue covering their overhead expenses. This will dramatically increase the amount of time patients will be held in the ER before moving into the hospital or receiving an urgent procedure.


  • Of particular concern is the potential loss of the stipend supporting the Acute Trauma on-call service, which provides general surgeon coverage in hospital to respond to trauma team activations. This 7-year program has decreased adult and pediatric trauma death in Lethbridge by 65%. In 2018 there were 107 major trauma patients treated in Lethbridge, and 63 in Medicine Hat. Time is critical in these instances, and an increase in preventable traumatic deaths is highly likely should it be lost. The status of this program is unclear due to governments’ lack of response to requests for clarification and is expected to be lost on April 1.


  • Palliative care is losing the stipend needed to cover the travel cost of home visits to vulnerable and dying patients. Home visits may no longer be possible requiring more palliative patients to be admitted to hospital and preventing us from discharging them back home into palliative care.


  • We provide emergency referral care to all community hospitals in southern Alberta. Rural physicians across the province have been speaking up loudly about their impending inability to provide the same level of care under the new framework. We anticipate unplanned intermittent rural ER closures due to a shortage of physician coverage, similar to those experienced elsewhere in Canada. This will mean more visits from rural communities by patients seeking emergency care.


  • The elimination of “good faith billing” means that disadvantaged patients with addictions, mental illness or homelessness are likely to face significant barriers to obtaining care in the community, as many of them are unable to produce proof of provincial health insurance.


  • Already we are hearing established community physicians and soon to be graduating medical residents making plans to work outside Alberta due to the instability and acrimony of the relationship between physicians and government. The government’s plan to dictate where future doctors will be allowed to practice will drive many graduates from Albertan medical schools to other provinces. There is abundant work elsewhere. This will mean fewer community providers, and higher reliance on the ER.



Alberta has developed its current model of “the medical home” in primary care over two decades of thoughtfully structured changes to all levels of health care funding. World leaders in health economics and comprehensive patient care have helped build a primary care system that is the best in Canada. It is currently used as an example by other provinces to improve their health services and recruit physicians into similar models providing the best value per dollar in health care. To be frank, the currently planned changes on April 1 risk rapidly destroying 20 years of health delivery progress in this province.

We recognize that the fiscal reality of Alberta means savings must be found in all areas of the budget. Physicians have been willing partners, voting to accept decreases in fees in our last round of negotiations, and had again proposed global cuts to their own fees in the recent negotiations terminated by your government. The Alberta Medical Association has repeatedly expressed its willingness to return to the negotiating table to find sustainable decreases in health spending that will not have draconian and devastating effects on the foundation of Albertan’s medical care. If the AMA was “not willing to consider” your proposals this is why; they will immediately harm patients, and they will not save money.

It is not too late to put a hold on these changes and return to the negotiating table to repair this government’s relationship with physicians and find actual savings in health care. We urge a similar cooperative rather than adversarial approach to ongoing negotiations with other public sectors. The experts in each field are the best positioned to identify potential cost savings and avoid the unintended consequences of indiscriminate cuts. Use their knowledge and experience. A financially secure Alberta is in everyone’s best interest.

The elephant in the room right now is the inevitability that health care workers in Alberta may soon be overwhelmed by the response to a coming pandemic. As always, we will rise to the occasion and provide the best care we are able. Please Premier Kenney, Minister Shandro – can we deal with one freight train crashing into our health care system at a time?



Chinook Regional Hospital (Lethbridge) Emergency Physicians:

Dr Stephanie Brass

Dr Richard Buck

Dr Nathan Coxford

Dr Ryan Derman

Dr Chrisjan deWaal

Dr Sharon Fehr

Dr Kevin Foster

Dr Nic Hamilton

Dr Mervyn Hiebert

Dr Ehi Iyayi

Dr Matthew Kriese

Dr Peter Kwan

Dr Magdalena Lisztwan

Dr Duncan Mackey

Dr Kevin Martin

Dr Nicholas McPhail

Dr Adrian Millman

Dr Bilal Mir

Dr Wes Orr

Dr Braden Teitge

Dr Alan Wilde

Dr Sean Wilde


Medicine Hat Regional Hospital Emergency Physicians:

Dr Ryan Currah

Dr Hendri Faul

Dr Chris Ghazal

Dr Dan Girgis

Dr Geoffrey Harris

Dr Joe Hawkwood

Dr Ash Jaffer

Dr Jan Joubert

Dr Michael Lee

Dr Tyler van Mulligen

Dr Edwin Orellanna-Jordan

Dr Paul Parks

Dr David Sameshima

Dr Chris Stewart



From Dr Tony Gomes, Chinook Regional Hospital Department of Surgery

Dear Residents of Southern Alberta: When you are brought to the Chinook ER after a serious accident or an with an urgent surgical problem, we Trauma and GI Surgeons would love to assure you that we will be there waiting to take care of you, but the Alberta Government does not value this (hopefully you do). Her is our letter to our local MLA’s-please take a moment to read it.

Dear Local MLA’s:
I am attaching a letter sent to Alberta Health Services administration last month. We still have not received a reply from AHS, and assume our Acute Surgery/Trauma service will terminate at Chinook regional Hospital as of March 31, as all such programs are being defunded by the current government.

In a nutshell, in 2013 our group of 6 General/Trauma Surgeons saw gaps in Hospital and Trauma care and proposed an in house surgeon to provide better onsite care, improve trauma mortality and move patients through the hospital system more efficiently, avoiding or shortening hospitalizations and completing as much care as possible during the daytime to (avoid nighttime overtime for our support services such as Nursing, and saving money).

This program has been very successful, decreasing the number of patients dying of trauma by over 65%. We have succeeded in saving money , shortening hospital stays and delivering more efficient care. In addition, our rural patients transferred in for surgical opinions and specialized procedures received them within a few hours and were often transferred back to their local rural hospital on the same day.

Unfortunately, all such stipend arrangements end March 31, and combined with other fee changes (the clawback of any physician fees related to hospital visits), will make it impossible for us to keep a surgeon in the hospital during the daytime for emergent issues or rapid trauma care.

We also want you to be aware of the consequences of not having this program after March 31- longer hospitalizations, longer waits in ER for the surgeon who will be working in their office and cannot attend til 5 PM, more night time emergency cases, which all lead to more overtime, more hospital overcrowding and higher costs. In addition, based on our statistics, there will also likely be a higher trauma death rate.

Please support programs like this by supporting your local physicians and contacting your MLA to ask why important and vital programs are being deleted by our present UCP government.

We want to be there waiting for you!

Please Give Me a Reason To Stay

This is a follow-up piece to my last post Incompetence and Consequence: Alberta’s New Framework for Health Care, in which I describe why physicians are so upset over the Alberta Government’s cancellation of their contract with doctors, and why the government’s sudden cuts targeting primary care medicine are so damaging and will actually increase cost to the health system in a very short period of time.

An excellent 3 minute visual summary of the problem can also be viewed here.

Most of this post is not my words but those representing a sample of the hundreds, if not thousands of family physicians, rural physicians and specialists across Alberta who have spent the last 6 days trying to understand the magnitude of the change just thrust upon them, planning and sometimes weeping while they struggle to decide how they can continue practicing medicine in Alberta, and realizing it will be impossible to provide the same quality of care they have previously provided to you, their patients. Despite the government’s mainstream and social media advertising campaign patting themselves on the back for not cutting overall health spending, they continue to stubbornly ignore the devastating impact they are about to have on primary care due to cuts already made and fee changes scheduled to come into effect April 1 2020. This despite numerous warning from physicians of all specialties since their proposals were first released last November. In a complex health care system it is less important how much money you spend, and more important how you spend it. They have chosen to ignore the input from the many experts in health care in this province and to make these decisions on their own. Here are the fruits of this incompetence, after less than one week.

Meet Dr. Tannis Spencer, a doctor running a family practice in Edmonton, and doing extra work during her evenings and weekends in the form of home care visits to palliative patients, and sorely needed detox treatment for addictions. She recently made the difficult decision to start closing her palliative care practice, as it is becoming too financially difficult to maintain all components of her work. This tough decision inspired her to share the following words with fellow physicians, who encouraged her to pass her story on to others. She has invited me to share her words on my blog. Following her story, you will see screen captures I have collected over the last few days of Alberta doctors on social media, publicly sharing their frustrations with their patients and with the Government of Alberta. You can find these and more discussions on twitter at #ABdocsforpatients


“I found a random assignment from grade 5 while cleaning out my basement a couple weekends ago. On the bottom it said, “Future Plans: To see Egypt, become a writer and a doctor.” I can’t believe I wanted to be a doctor as far back as grade 5.
But wait, I also wanted to be a writer. I paused for a long time looking at those words. No one really knows I loved to write novels and short stories, because I never pursued writing after high school. I went straight for medicine, full speed ahead.

Now I barely have time to read a book unless I’m on vacation.

This weekend, I asked myself “Why am I doing this?”

It’s a question that has sadly come up much more often than I care to admit. As I approach the official “5 year post-graduate” mark from Family Medicine residency, it feels like 2020 will be the worst for Alberta doctors.

Maybe I should have been a writer instead.

I am so very tired everyone, and I think I speak for all Family Doctors when I say those words. I think anyone can understand that being on overnight call is exhausting. People might get that working from 9am to 9:30pm with only 30 minutes for lunch and no break for dinner is pretty tiring too. I’ve been working long hours, charting on days off, burning my eyes out on a computer until I needed glasses and then being unable to stop for at least 14 days at a time before I take a day off – it’s physically demanding.

Emotionally, I am drained too. People don’t go to the doctor to say “Hey doc, everything is fine, just wanted to check my blood pressure”. They come in with “Doctor, I felt a lump in my breast” or “Doctor, I am only 17 and I think I’m pregnant”, or “Doctor, I was gang raped over a decade ago and I am finally telling someone now”. I never truly have ‘easy’ days. I understand that part of my job is to take on that emotional burden of the sorrows of humankind, and then file it away on the drive home so that I can be emotionally present for my husband, my friends and myself. I can do it. I’m learning how to do it. But it is exhausting.

I accomplished the goal of being a doctor, starting from the dream of a little girl in grade 5. The dream to help people. To be a doctor.

Last week, that dream was soured by the sweeping policy changes made by Tyler Shandro, Jason Kenney and the UCP. This is really not about money. This is about Tyler Shandro telling the little grade 5 girl that still lives inside me that doctors are ‘bad’ and then watching her heart break. After all these years of school, sweat, tears and misery, the government thinks doctors are simply expendable. We aren’t worth even the respect of proper negotiation. We aren’t worth honouring a contract. We are worthless to the UCP government.

We must bend a knee before our government and their wishes. We belong to them.

When I go into clinic on April 1st, start the time clock and turn to that woman who just lost her husband to cancer, and tell her “You have 10 minutes”, who do you think will be blamed?

Shandro? Kenney? The UCP?

No, not in this province.

The overwhelming majority voted UCP. When Kenney arrived, he came on a cloud with the voices of angels singing his praise, as he floated gently into the Alberta Legislature with money flowing from the deep oil wells in his pockets. He can do no wrong. He is as blue as the pure sky.

No, instead they will blame me for the decline in patient care. They will blame doctors. They call us greedy, money-grabbing, and irresponsible health care spenders.

I don’t want to work here anymore, Alberta.

I don’t want to be hated by you.

I am so tired of being surrounded by people who voted for men in suits who are using slimy propaganda and fake news to make me look like a greedy doctor who only did this for money.

I just want to live out the dream of that little girl in grade 5. To help people. To be a doctor.

But I am already so very tired. We all are – the Family Doctors of Alberta have been burned and we are just so tired. How long are we going to fight for you until we decide it isn’t worth our health and sanity anymore?

One of my palliative patients said to me before he died, “Dr Spencer. can you please take care of my wife when I die?”

I said to him, “I promise. I’ve got her.”

Please don’t make me break that promise Alberta.

Please give me a reason to stay.”

Dr. Tannis Spencer.


01-Care and crying02-Crying onions03-lost sleep04-Childcare05-Retire Rural06-Imaging delays07-PhysFamilySupport08-Suicide note09-Respect10-leaving AB11-Leaving12-lost graduate13-In training

Palliative- Lethbridge14-MH grad leaving15-Warren-116-Warren-2

Today I cried
(Dr. Charlene Dinakaran, Family physician, Edmonton Zone)



Lest you think Doctors have not tried to educate the minister through his new preferred communication platform of twitter, or have not agreed to take fee reductions both under past governments and currently please see the below:


01-AMA-102-AMA-203-AMA-304-Against evidence05-Costs rise06-economic sense07-evidence-risk08-attack09-Negotiations failure10-Previous concessions11-Lies called out


Please add your voice to those of Alberta doctors to stop the drain of physicians out of the province, keep good family practice financially viable, and return to the negotiating table to find actual, sustainable savings in the health care budget. We are trying to sound the alarm before it is too late.

Dr. Sean Wilde, MD, CCFP-EM


[EDIT: Please see this letter to the minister of health signed by 85 concerned Calgary emergency physicians. ER doctors have always advocated for more investment in primary care and home care as this is what reduces cost and crowding in emergency departments]


[EDIT: Please sign and share this petition asking the Minister of Health to return to the negotiating table with doctors to find sustainable health care savings that won’t decimate Alberta’s health care system.]


Minister of Health: Tyler Shandro
423 Legislature Building
10800 – 97 Avenue NW
Edmonton, AB
Canada T5K 2B6

Phone: 780-427-3665
Fax: 780-415-0961
Twitter: @shandro


Premier Jason Kenney
307 Legislature Building
10800 – 97 Avenue
Edmonton, AB
T5K 2B

Phone: 780-427-2251
Fax: 780-427-1349
Twitter: @jkenney


Incompetence and Consequence: Alberta’s New Framework for Health Care

[Edit Feb 26/20: For a visual overview that summarizes the urgent crisis facing Alberta family medicine as described in this article, please watch and share this short 3 minute video.]


To anyone paying attention, it’s clear that Alberta doctors are very upset about the provincial government’s recent announcement over changes in physician compensation. It can be a little confusing to see through all the political spin and bureaucratic jargon to know what exactly is going on. The details are not that complicated, and it is important for Albertans to understand this is not simply a case of highly paid professionals upset about earning a little less money; when inadequately executed, changes in health care funding can have dramatic effects on the day to day healthcare provided to you. There are a few important things to understand.

How are doctors paid and where does the money go?

Click here to read my more detailed explanation about how doctors are paid (including fee for service vs ARPs) and where the money goes. In summary:

  • When the government “pays” doctors for care, the money is pre-expense and pre-tax business income, not a salary.
  • Physicians working in a clinic tend to spend 30-40% of this payment on overhead to pay for rent, staff, equipment and other office expenses.
  • Additionally, practicing as a physician requires multiple annual dues to various regulatory bodies to be allowed to practice medicine, maintain your certifications, keep up on mandatory continuing medical education, and holding expensive malpractice insurance. Annual totals can vary widely between specialties, but somewhere around $12,000 – $57,000 dollars per year is a reasonable estimate for most Alberta doctors.
  • Medical education is an investment of at least 10 years of time and for some upwards of $300,000 in borrowings that needs to be repaid.
  • Physicians receive no work benefits or pension, and need to budget for their own insurance, health expenses, time off, vacation time, and retirement savings.
  • Physicians have a high demand, low supply skill set that commands a high market value. These skills are in demand everywhere, so if under-compensated, there are many options for work elsewhere.
  • Physicians can and do earn a good living after a significant time and money investment, but are usually motivated by reasons other than money, as this career is not by any means a quick and easy path to wealth. It is worked hard for over a lifetime.

The information above is to help understand why when you hear that the average family doctor “earns $298,000” per year, it is not accurate to directly compare that to a generic salary in another field. When the government says they pay X amount to doctors, remember that this total includes (among other things) the salary and benefits of every single nurse, secretary and office assistant that works in any (non-AHS) physician clinic in the province. That includes almost all family medicine, walk-in and specialist clinics. These are all publicly funded private clinics, and that public funding comes under the umbrella of “doctor fees.”


Why does Alberta pay doctors more than in other provinces?

Part of the reason should be obvious when you understand the previous section. Clinic rents and employee salaries are on average higher in Alberta than elsewhere. To a run a business in Alberta costs a doctor more than in other provinces.

Another reason is that due to historically greater financial resources, Alberta could afford to pay more than other provinces, and intentionally did so to solve its physician shortage. These shortages stem from the Ralph Klein years of deep cuts to health care, which have taken the province almost a generation to recover from. Financial incentives to recruit and retain physicians have been central to the health care plan of Alberta governments for the last two decades. And it worked. The current government has cherry picked certain health indicators (like elective surgery wait times) to claim the province does not receive good value for its health expenditures (while ignoring the variable costs of doing business). However, in one of my last posts, you can see a long list of examples of terrible systemic health care problems faced by the rest of the country that have not been nearly as bad in Alberta. Does Alberta pay too much for health care or do other provinces not pay enough? The government frequently compares our spending to that of British Columbia. I’ve seen a lot of patients who left BC specifically because they could not get adequate and timely health care. If you know someone who lives there, ask them about it. Recent fee change discussions in BC have actually been using much of Alberta’s system as a model of a successful system to emulate in their future.  Health care is expensive no matter how you pay for it, and each society needs to decide what it wants – shorter wait times for hip replacements, or adequate doctors to provide preventative primary care and enough space in the hospital for everyone who needs it.


What is the big deal with the government’s new compensation plan?

First, trust.

Negotiating physician compensation has always been a complicated back and forth of asks and concessions from both sides: the government needs to control its budget, and doctors need to make enough to have a viable practice, fund their education and future, and feel they are receiving enough value for their skills to stay in this province. Friction is inevitable. Despite this, agreements have always been made and honored before returning to the negotiation table when it was time for another. Budget restraints have been a reality for a few years, and the AMA has made concessions, and found millions of dollars of savings already by cutting and adjusting the fees paid to doctors. You can argue it has been too little and too slow for the current reality, and yes, it is a challenge to get 10,000 people to agree on who is going to take what pay cut, but there has been a collaborative process. Until now.

Late last year the UCP offered “proposals” to physicians outside of the AMA negotiations to cut a number of fees. The response was both an explanation from doctors as to why these ideas would not work, and an insistence that they be put in with the rest of the renewed negotiations. Meanwhile the Minister of Health, and several government health agencies began a social media campaign disparaging the value the province receives from physicians, including the usual misleading information about how much doctors “get paid” (gross billings). Eventually the government agreed to take negotiations into mediation (Jan 31), and declared it a failure on February 15, despite the AMA offering concessions to save over $150 million, and informing them they were working on others. On February 20th the government announced they were using the new powers they legislated to themselves last year to rip up the current agreement with doctors, and give themselves authority to unilaterally dictate physician compensation. They simultaneously rolled out their original proposals to go into effect on April 1. It is hard to believe they were ever negotiating in good faith, and the entire process appears to have been a sham with the intention to find an excuse to take over full control of physician payment.

Incredibly, at the same time they have offered (but only on Twitter) to give doctors the option to quickly sign up for a 3 year ARP (basically a complex fixed income arrangement – discussed here). The Minister tweeted a document that he claimed was sent to doctors the week prior (no physicians I know have received it), that included an out of service phone number to get more information. Those physicians who have tried to get more information have found little more than an answering machine (eventually) and some form letters implying that the details will be worked out later. No information has been passed on to the AMA’s ARP negotiation group that has helped establish all former ARPs. Who would sign an incomplete agreement with a government who just used its new power to break any legal contracts it is in and has been tweeting about how over paid you are? At the best of times ARPs result in doctors handing a great deal of control over their practice and income to the government, trusting them to honor the agreement with little recourse if they don’t. They are complex and require mutual respect and trust between both sides. It is unlikely this government will be successful at convincing many or even any physicians to give them that trust. The UCP’s negotiation efforts seem to have been all smoke and mirrors propaganda; used against a group who regularly hold frank life and death discussions with the people of Alberta.


Second, competence.

In addition to fair pay, physicians have a vested interest that the health system works for our patients. We see them everyday, we care for them. We try to get them urgent care when they need it in a system that often makes it difficult. There’s a reason that health reform is a slow process. Politicians need to spend less and get more, managers have the pulse of day to day big picture business, and front line providers have the inside knowledge of how things really work, where the waste is, and what would work better. Collaborative efforts between these groups take time, but have always been the best way to reduce cost, increase efficiency, and improve health outcomes for patients. There are countless examples of this working well in Alberta and elsewhere.

The UCP government has never shown an interest in being collaborative. They have been adversarial from the start. It’s the government against doctors, against nurses, against all public employees. Patients are stuck in the middle. Anyone paid by taxpayers is a mooch on the system, and is the enemy of the current government. In an organization as large and complex as Alberta Health Services, and an expanded community health system that is even larger, how is that approach going to do anything but cause damage? Can the top down dictation by a handful of career lawyers and politicians make better decisions on healthcare than consultations with the experts? No one who works in the health care system wants it to fail or be financially unsustainable. But instead of inviting doctors, nurses and outside consultants to work with them to save the system, Premier Kenney and health minister Shandro have said we will tell you what to cut and what to change. We are not interested in your opinion. Does this approach make any business more successful? Or does it just drive people deep into their own silos, protecting their own livelihood, knowing they have no ability to improve or protect the whole? I would not buy stock in that company. It’s a recipe to destroy public health care, and maybe it is no accident.

The UCP’s new framework is an example of the incompetence this approach breeds, which I will explain next.


Third, this will immediately affect your health care.

While a number of fee cuts and physician benefit program reductions were just announced, the biggest, most short-sighted mistake is the decimation of family medicine time modifiers. When these codes were first introduced they were instrumental in giving Alberta one of the best “medical home” models of primary care in the world. It might be best explained in an allegory.


Imagine you are tasked with the upkeep of a large companies’ fleet of cars. Each requires regular maintenance to keep it out of the repair shop. You have a handful of mechanics who do this, and you pay them each $38 for a regular check up: change the oil, filters, top up fluids. Each mechanic takes about 10 minutes to do the basic work. It mostly works well, but as cars get older, some get more complicated and break down. When a car breaks down, it needs to be taken to the repair shop for urgent work. This costs $1000. If you’re lucky, it can be patched up and sent back to work. If not, it needs to stay in the shop for a week, usually costing about $8,000 for a full overhaul.

So you go to your mechanics and say “Hey, let’s keep cars out of the repair shop, it’s too expensive. I heard if you do a little extra work on them you can stop them from breaking down so often.”

Mechanic A says, “I tried to do that, but then I can only get 3-4 cars done an hour, I’d only make $1,216 a day at most, and it’s barely enough to cover expenses. Mechanic B over there only works on the easy newer cars, and whips through 6 an hour. He makes $1,824 and doesn’t help keep anything out of the shop. That’s not fair- I’d like to do quality work, but I can’t afford to.”

So you add in some money to encourage your mechanics to take a little extra time on those cars that need it. If they work on a car longer than 14 minutes, you pay them an extra $18 for every further 10 minutes they spend. Mechanic A is now happy to keep those older models running, and is making $1,648 a day, dealing with 1 simple and 3 complex cars every hour, as an extra 4-5 minutes is enough to deal with many of the extra problems. Mechanic B is still in it mostly for the money, hasn’t changed, and still makes about $1,824 on simple stuff. Others do a mix of both and make something in between. The mechanics willing to work on complex cars can now afford to do it, and you are saving a lot of money by sending fewer cars to the shop.


This is an exact allegory of primary care as it currently stands (or stood). Doctors are the mechanics and patients are the cars. A trip to the shop is an emergency department visit, and a prolonged stay is a hospital admission. The numbers are actual billing numbers, and estimates of the cost of average ER and hospital stays. Wise past negotiations have made it possible for good doctors who need and want to spend a little more time with their patients to do so, and run a financially viable practice. This revolutionized primary care in Alberta, making it possible to offer good care, and break out of the “10 minute medicine” paradigm that no one wants. Experts in medicine will tell you that every dollar spent on primary care saves many times its value in reduced ER hospital costs. We have an excellent primary care system due almost entirely to the existence of these fees.

To return to our allegory, what the UCP has just done is say: “You now don’t get paid that $18 extra unless you spend at least 25 minutes working on a car.” So if mechanic A keeps doing what he is doing, he will go back to being paid $1,216 a day. Maybe he will try to spend even more time on the needy cars, and see 2 each hour + 1 quick one, but that is only $1,200 a day. His only choice is to take a substantial pay cut, or return to mechanic B’s plan, and just do the bare minimum. He won’t be able to do the extra work needed to keep cars out of the shop very often, but can at least stay in business.


This is the sudden reality facing many Alberta doctors on April 1 who have built a practice on being able to spend 15-20 minutes with complex patients. Their average hourly business income will drop from $224 to $152 –  a 30% decrease. Perhaps the government is encouraging them to spend even more time with complicated patients to get the bonus. Nope – doing that works out to $134 per hour when averaged over a day. This loss either comes out of their take home income, or their overhead – firing clinic staff. For most clinics there are only 2 viable solutions – return to 10 minute appointments (which will cost the government MORE per hour than they are currently paying) or close up shop. In musings on worried physician discussion groups on social media, I have seen doctors already making plans for both.

It’s not hard to see the insanity of this “solution.” The change is a clear incentive to spend less time with patients- to return to a model that provides inferior primary care, will result in sicker people making more visits to the ER, needing more hospital admissions and will ironically increase physician expense in both primary care and the much more expensive hospital care. This is only one example of the unintended (presumably) consequences that will stem out of one ill conceived change. Other initiatives announced at the same time will almost certainly impact front line care. The loss of stipends (bonuses) for being on call means specialists will need to book clinics or surgery at the same time they are on call. This will delay specialist consults in emergency departments and hospital units by hours, further compounding the problem of hospital and ER overcrowding. Wait times will rise. The loss of stipends in rural areas may lead to complete loss of emergency and/or hospital coverage in some communities. Deep cuts to AMA liability support programs risk making some obstetrics practices unsustainable because of the enormous insurance cost, especially for rural physicians. None of these payments were initially established without a good reason, and ignorantly eliminating them will dramatically affect front line care. This is why politicians should not vote themselves the power to make uninformed health care decisions all by themselves.


What can I do about it?

Please contact your MLA, Premier Kenney, and the Minister of Health. Insist they return to the bargaining table with doctors to negotiate a stable and fair deal. There is still money to save, but they are proving themselves not experienced or competent enough to do it without making short sighted decisions that will cause irrevocable damage to the health care system, and increase the very costs they are trying to cut. Consult with health care workers and they will show you more ways money can be saved – if they feel they can trust you. Do it genuinely, not with meaningless AHS “surveys”  incapable of collecting information useful for anything beyond propagating a pre-determined agenda. Work with doctors and nurses instead of against them. If there is no acceptable way to lower costs enough to balance the budget, stop ignoring government revenue as a factor in the equation. Canadians are proud of their equitable health care system, and Alberta probably has the best one in the country. Don’t go down in history as the government that destroyed it.


[EDIT Feb 27/20: Please see this followup post for a brief snapshot of the impact of these changes on Alberta physicians just one week later as they struggle to find a way to continue practicing good medicine under a fast approaching deadline.]


[EDIT: Please sign and share this petition asking the Minister of Health to return to the negotiating table with doctors to find sustainable health care savings that won’t decimate Alberta’s health care system.]


Minister of Health: Tyler Shandro
423 Legislature Building
10800 – 97 Avenue NW
Edmonton, AB
Canada T5K 2B6

Phone: 780-427-3665
Fax: 780-415-0961
Twitter: @shandro


Premier Jason Kenney
307 Legislature Building
10800 – 97 Avenue
Edmonton, AB
T5K 2B

Phone: 780-427-2251
Fax: 780-427-1349
Twitter: @jkenney

How Doctors Are Paid and Where the Money Goes

This information is provided in conjunction with this post about the February 2020 UCP termination of its contract with Alberta doctors.

  • As a rule physicians are usually not salaried employees – they provide medical service either inside government health facilities or private clinics, and then “bill” Alberta Health and wellness (AH) for the work they do. This is called “fee for service.”
  • The fee paid for each service is set in the “Schedule of Medical Benefits” (SOMB). The rates and any changes are negotiated periodically between the government and the Alberta Medical Association (AMA) which represents doctors for collective negotiations.
  • With the money received through billing, doctors must first pay their operating expenses. For doctors working outside a hospital, this includes rent for the clinic, salaries and benefits of all the staff working at the clinic, and all the medical supplies, office supplies and utilities and services needed to run the clinic – normal business operating costs. Most clinic doctors report these costs represent about 30-40% of their billings. This is called overhead.
  • All doctors must also regularly pay substantial fees for the ability to continue practicing medicine. Currently in Alberta these include:
    • Annual license with the College of Physician’s and Surgeons: $2,360 (legally required)
    • College of Family physicians (required to maintain status as a registered family physician): $1,113
      • Specialists will pay a similar (or higher) fee to their own regulatory body
    • Optional but important membership dues in organizations like the AMA, or a sub-specialty focused association. My costs for these are typical and run about $2,760 a year.
    • There is a regular continuing medical education requirement (to keep up to date with changes in the field of medicine). This can include medical journals, conferences and online subscriptions. Obviously cost varies, but they usually cost me in the neighbourhood of $2,000-$4,000 per year.
    • Liability insurance to protect physicians and payout successful lawsuits to patients. This is also mandatory and varies by specialty – higher risk practices like surgery or obstetrics pay more. This currently varies from about $2,050 to $47,350 per year.
  • After all this, is your gross take home pay (what most people see on their paycheck before deductions). Then like everyone else you pay taxes, and then you deal with your personal budget.
  • Keep in mind that unless they came from a wealthy family, most new physicians end their education with at least $100,000 to $200,000 in educational debt to pay off. Canadian banks currently will offer up to about $320,000 in credit to doctors and doctors in training to manage their expenses over time. This is in addition to government student loans. In Alberta the lifetime cap for medical education is currently $175,000. Individuals like me who were married with young children during our medical education tend to use a lot of that credit. I’m still paying loans off 8 years into practice with a son graduating from high school himself in 2 years.
  • Physicians also have no paid benefits: no health plan, no pension, no sick leave, so need to plan for their own unexpected expenses and retirement out of what is left.
  • Physicians have a skill set that is in high demand for good reason, and should be compensated accordingly. Personally, if I need to miss a shift at work for any reason, there are only about 15 other people in my whole community of 90,000 people that are qualified to “cover for me,” 6 of whom are already working a different shift that day. If a few others are out of town or busy with other commitments, there are very few coverage options, and you can’t just not have a doctor working in a busy emergency department. I have to be very sick before I avoid a day of work. Family doctors who miss work often cannot be replaced, and need to cancel entire clinics.


What about ARPs?

ARPs (Alternative Relationship Plans) are an alternative to fee for service billing that is used in some places. Each plan is unique and the rules can be complicated. The general idea is that a hospital physician is paid a fixed rate for a specific number of hours of work. If you work less, you don’t get the full amount, but if you work extra you do not get paid anything extra for it. In a rural or clinic setting, an ARP physician group is paid a fixed amount every year for each patient on their roster, and sees them as often as necessary. If your patient is seen by an outside clinic, there is usually a penalty deducted from your payment as incentive to make sure you are available for timely appointments. There are also blended models that use some of each to account for the many physicians with complicated work schedules who work in multiple different capacities. Just as in a fee system, this money is all paid before expenses, and there are no benefits provided.


ARPs are attractive to governments as they make payments to doctors a more predictable expense than fee for service. They also decrease the unfortunate revenue generating “pill-mill” practice some walk-in clinics are accused of where good patient care is sacrificed for high volume billings. They can and do work well in many different places, but as they should not create either unfair work hours or payments when compared to fee billing, they tend to be complicated to setup and monitor. Most are tailor made agreements between doctors and government in certain practices or communities that take a long period of study and consultation to develop.


One potential downside to ARPs can be the volume of patient care provided. Imagine you are working in a busy clinic with a waiting room full of people waiting to see you. There is always an incentive to help as many people as possible, but when you are being paid for each person you see, it is human nature to be more willing to skip taking a break, miss lunch, or stay late to fit a few more people in, because at least you are being paid to do the extra work. However, if you get paid the same amount of money to take work at a more reasonable pace, there is little incentive to run yourself into the ground, or work unpaid overtime, especially day after day, year after year. While ARPs make budgets more predictable, implemented inappropriately they can result in lower output per physician and longer waits for patients. Physicians within ARPs tend to lose some autonomy to alter their practice, and become very dependent on the government holding up and not unilaterally altering the deal. This is one reason they tend to be complex to establish, and require a high level of trust between both parties.

“Bringing Down” Health Care in Alberta

Recently, Alberta Health Services employees and physicians received an email from the new UCP Health Minister, Tyler Shandro. Mr. Shandro echoed Premiere Jason Kenny’s prior commitment to “maintain or increase health spending, and strengthen our publicly funded health system.” In the next paragraph among a list of the usual platitudes of improving this and that, was the goal of “bringing down Alberta’s health spending to national norms by 2022-23.” Here is the UCP pre-election health platform.


There’s no question that Alberta has been fortunate in the past due to the revenue provided by the successful monetization of our natural resources. Whether this excess was squandered or not is perhaps a matter of opinion, but Alberta has historically benefited from the ability to spend more on health care than other provinces. The UCP would have you believe that this extra spending is a frivolous excess that provides no real benefit, as alluded to in their above election platform- an assertion that seems mostly based on wait times for hip surgery. Perhaps patients and health care providers in other provinces who have lived with those smaller budgets would see it differently. Every system has its challenges; health care is expensive, and there’s always something that you could do better with more money. More hospital beds and more long term care beds means better care and lower waits times. So does hiring more nurses. Paying doctors a bit more than they can get elsewhere encourages them to work in your province and eases community and physician shortages. It also enables them to hire the essential clinic support staff to provide better care and jobs in the community. Did you know that your family doctor’s billing “income” is used to pay for clinic rent, supplies, administrative staff, nurses, nutritionists, psychologists, and anyone else who works out of the same clinic, before they get their own take home pay? The government does not directly pay for any of that.


Now that the oil gravy train appears to be on an extended, or maybe even permanent hiatus, there are tough decisions to make. Everyone gets that. Health care providers of all stripes have accepted little to no pay increases for several years in Alberta, despite living with the same rising costs as everyone else, and dealing with an aging population with increased health care needs. Physicians have helped identify antiquated fee codes that could reasonably be reduced or eliminated in a modern health system. We have all participated in multiple “streamlining” exercises over the last several years that have identified inefficiencies and cut down many AHS expenses. In this recent letter, the current president of the Alberta Medical Association section of family practice outlines some of the initiatives to cut costs and improve patient care that physicians have recently collaborated on, and expresses the professions interest in working collaboratively with the current government to further streamline care.


However, the actions of the UCP in the days and weeks before and after this mail out have me seriously questioning their actual commitment to the publicly funded health system. In addition to targeting education, post secondary students, and many other public sector workers, the government has used recent omnibus bills to give itself the power to withdraw from all previous or future contract agreements with doctors and nurses, and given itself the power to dictate where newly licensed doctors are allowed to practice in the province. Since then, there has been loud signalling towards doctors to expect deep unilateral fee cuts, and notice of hundreds of expected front line nurse layoffs. There is no way eliminating front line nurses is going to improve or speed up any aspect of patient care in an already struggling system. You can argue political ideology all you want about who should pay for what in health care, but when you directly remove front-line health staff, and provide dis-incentives for doctor’s to work in the province, there is no way that the public health system is not going to be severely weakened. Patients (you and your families) will suffer for it. Other provinces have tried to “force doctors where to practice,” and have abandoned it when they started running out of doctors. Who wants to work in a socialist dystopia where the government gets to tell you where to work, and unilaterally cut your income with little to no notice without negotiation or consultation? Just two months ago New Brunswick announced it was abandoning this approach, the health minister saying: “It is flawed because it restricts the number of physicians practising, restricts the mobility of physicians and impedes recruitment.”


How is it possible the Kenny government doesn’t know this? It’s very hard not to conclude that they are trying to decrease the number of doctors in this province, because that’s what these policies are designed to do. It will certainly lower costs if there are not as many doctors to pay- for a while at least. It will also cause a lot of other problems. Perhaps it will weaken the public system enough that the UCP will have a good excuse to “give private health care a try.” That’s a supposition on my part, but if that was my goal, this is exactly how I would start.

There’s a lot more I could say about this, but I have a different purpose in this post. The Kenny government wants to “bring down Alberta’s health spending to national norms.” As a member of the Canadian Association of Emergency Physicians, I receive a monthly email that contains multiple articles of interest on the current state of emergency medicine across Canada. Each one usually contains a handful of stories about challenges faced by various emergency departments across the country. I reviewed the last several months of those letters, and pulled out all the articles that describe a system challenge that results in poor or dangerous patient care because of a lack of resources- things that are going wrong because there is inadequate staff, beds or other resources. None of them were about Alberta. Not because we don’t have challenges- we face all the same challenges to some extent in parts of the province- but because ours are generally not as bad. Why? Because we have been able to allocate the resources necessary to prevent or minimize many of these problems. So I present to you below some of the  “national norms” for emergency department care. All articles are from this year. This is just from the perspective of the emergency department, but the ER has always been the canary in the coalmine of health care- when it becomes overwhelmed and non-functional, it is almost always a symptom of unmet problems at other levels. Is balancing the budget a good enough reason to accept moving further in this direction? Is a modest provincial sales tax perhaps worth the pain to keep the good thing we have in Alberta going? Isn’t it easier and cheaper to maintain what we have rather than to try and rebuild it in some hopefully more prosperous future? Those are the questions Albertan’s should be asking themselves.


CIHI Data: Emergency department wait times on the rise in Canada

“Canadians are waiting longer to receive emergency medical care, according to new figures from the Canadian Institute for Health Information (CIHI), with patients in Quebec and Manitoba enduring the longest emergency room visits in the country. …Alberta and Ontario had the second and third lowest emergency wait times, respectively, with B.C. in fourth place.”


N.B. hospital diverting ambulances due to overcrowding, staff shortages

“Hospital closures have been a problem across Atlantic Canada. In Nova Scotia, 11 of the province’s 37 emergency rooms were forced to close in August due to the unavailability of doctors. One doctor said that she’d seen people who’d suffered cardiac arrests in the waiting room and triage area.”



One-fourth of Moncton Hospital beds occupied by people waiting for nursing homes

“We need a much more efficient process for moving them from the hospital to the nursing home,” says Dr. Ken Gillespie. “Right now, the average length of time that patients are in hospital is about seven months. But we’ve seen that go longer. In some cases, even two or three years that patients are in hospital waiting for a placement.”


Action needed to address Nova Scotia emergency room closures: reader

“Emergency room closures in Cape Breton, Richmond County, along with all other Nova Scotia county hospitals need to be addressed as a crisis throughout the health-care system.”


As Clinton ER to close overnight, other rural hospitals face similar issues


“A shortage of qualified nurses is to blame….She says there are other hospitals in rural Ontario that are “one retirement” away from facing a similar nursing shortage.”


Offload delays, no downtime and other problems are stressing out metro St. John’s paramedics

“ST. JOHN’S, N.L. — Offload delays in which paramedics are left waiting in hospital corridors to hand over their patients to staff have ballooned from minutes to hours in just a few years at overcrowded St. John’s emergency rooms.”


‘People are dying’: Life and death at level zero: Paramedics, doctors and patients sound the alarm about lack of ambulances in Ottawa


“The problem isn’t unique to Ottawa: hospitals across the country deal with similar overcrowding issues in their emergency departments, said Dr. Howard Ovens, an emergency physician and chief medical strategy officer at Sinai Health System in Toronto.

“It’s just soul-destroying. It goes against every reason you’ve come to work that day,” Ovens said.

Paramedics are feeling the strain, too.

“Paramedics go into work and they feel despair. And we feel it for our patients,” Wilton said.”


Hamilton’s hospitals overflowing heading into flu season

“In June, when overcrowding should normally be easing off, HHS had an average occupancy rate of 107 per cent — meaning it had more patients than beds funded by the Ministry of Health. Known as hallway medicine, hospitals are forced to open up beds on their own tab, sometimes in unconventional spaces like sun rooms, hallways and family rooms.

The problem is now so severe that HHS hasn’t been below 100 per cent occupancy since August 2016.

It’s tough for Hamilton hospitals to afford the extra beds at a time when they’re also cost-cutting $42 million by March 31.”


‘That’s a crisis’: P.E.I. senior spends 9 nights in ER waiting for long-term care bed: More than 200 Islanders are waiting for long-term care services


“According to the province, as of the start of October, there were 201 Islanders waiting for long-term care services, and as of Oct. 10, 46 people were in hospital beds waiting for access to a long-term care bed. Nine of those people, like Gallant, were waiting for dementia care in Prince County.”


More than 100 Toronto emergency room professionals urge province to reverse public health cuts


“In Toronto emergency departments today, many patients have to be ill, first of all, in a chair — so there are no stretchers available for many patients and many patients ask me directly: ‘Can I please lie down,’ and when they can’t lie down, they lie on the floor. They lie on the floor in the waiting room, they lie on the floor in treatment areas,” Venugopal said.


Hospital employee unions call for end of “hallway medicine”


“patients are being treated on stretchers outside of emergency wards      without access to bathrooms, privacy, or the ability to have a confidential discussion about their medical condition.

Hurley notes people have even died in these environments, and others have had to stay in broom closets and other inadequate accommodations.

“As recently as July 12, 2019 [Premier Doug Ford] said his government would     eliminate hallway medicine within a 12-month period,” says Hurley. “It’s a great promise, but we’re very concerned because that’s not born out by the budget that was passed in the spring.”

Hurley explains Ontario has closed more than 20,000 acute care beds over the last 20 years.

“This leaves us with the lowest capacity in terms of beds to population, and staff to population, of any hospital system in Canada, or, in fact, of any country with a developed economy…,” he says.

This includes countries such as Turkey, Mexico, and the United States.”


New numbers show rise in wait times at Winnipeg ERs, urgent care centres

“Newly released numbers show wait times this July were worse at all but two of Winnipeg’s emergency rooms and urgent care centres when compared to the same time last year.”


A doctor’s warning: Safety is at risk in Ontario’s ERs


“Do the math. A 30-per-cent reduction in acute care bed capacity and a further 20-per-cent reduction due to patients with nowhere else to go. The healthcare dividend never materialized and now hospitals and more specifically emergency departments are crowded and dangerous.”


Report finds Montreal emergency rooms over capacity

“On the Island of Montreal, 14 of the 21 emergency rooms have more patients than beds to accommodate them, according to an Index Santé report. This is also the case for the Cité de la Santé Hospital in Laval, three of the six hospitals in the Laurentians and eight of the 10 hospitals in the Monteregie.”



NSHA, Doctors Nova Scotia clash over emergency department closures

“10 of 37 emergency departments across the province will be closed at certain points this week. The ED at Musquodoboit Valley Memorial Hospital will be closed for a total of five days reopening its doors Saturday.”