Fusion-medical animation (Upsplash)

November 4, 2021

We have monoclonal antibodies to treat early COVID in high risk patients, so why is Nova Scotia still not using them in routine care?

By Linda Pannozzo

The Nova Scotia government continues to be reluctant to make use of a federally authorized COVID-19 treatment that could potentially be saving lives now and into the future. Health Canada has recently given emergency use authorization to three monoclonal antibody treatments found to be effective against the DELTA variant. The antibody treatment works by neutralizing the virus that causes COVID-19 by binding to the spike protein, blocking its attachment and entry into human cells, thereby reducing the severity of symptoms.

Health Canada purchased 10,000 doses of sotrovimab (GlaxoSmithKlein), “with an option to purchase additional doses in 2022, based on emerging needs.” It also purchased 9,000 doses of REGEN-COV—which is a combination of casirivimab and imdevimab —with 6,000 doses already being delivered by the manufacturer, Hoffmann-La Roche, for use in provincial and territorial healthcare systems.

When the Nova Scotia Health Authority was asked about whether the province would be making use of any of these new monoclonal treatments during the fourth wave, Carla Adams got back to me with this reply:

“Nova Scotia received a very limited supply of casirivimab and imdevimab… We are working with partners to see if they can help identify high-risk patients who may be eligible in the community.”

But as it turns out, the new monoclonals on offer now—much like the monoclonals on offer a year ago—are only being recommended in the “context of pragmatic research,” and not in routine care.

But to understand the implications of this current recommendation, we have to revisit what happened with bamlanivimab, the very first monoclonal antibody treatment to be authorized  by the feds for emergency use.

Bamlanivimab

In late 2020, Health Canada purchased 26,000 doses of bamlanivimab at a cost of US $1,250 per dose and shipped 17,000 of them directly to the provinces and territories, and to the Public Health of Canada’s National Emergency Stockpile. The remainder was available for shipping upon request.

As was previously reported, the treatment is administered intravenously and was recommended for adults and adolescents 12 years of age and older (at least 40 kg) with mild or moderate COVID-19 who are not yet hospitalized but are at high risk of progressing to that stage. Patients considered high risk include those 65 years or older, with a BMI of 35 or higher, with chronic kidney disease, diabetes, immunosuppressive disease or receiving treatment, or 55 years and older with cardiovascular disease, hypertension, or chronic respiratory disease.

Even though it was authorized and purchased by Health Canada, the use of the treatment falls under the practice of medicine—which is a territorial and provincial jurisdiction. So the decision to use the drug has been at the discretion of these jurisdictions.

Documents obtained through Freedom of Information indicate that the Nova Scotia COVID-19 Therapeutics and Prophylactics Advisory Group appeared enthusiastic about using bamlanivimab early on and decided in February of this year to enhance the province’s supply of the treatment from 50 to 150 doses. But even so—for reasons that are still not fully clear—the treatment not only continued not to be recommended for routine use, but apart from administering one dose during the third wave—it was never rolled out in the “context of pragmatic research” for which it was recommended.*

The Advisory Group was initially established to provide recommendations to the health system regarding the clinical use of antiviral and immunomodulatory agents for treatment of COVID-19 based on evolving evidence and research. In the meeting minutes obtained, the Advisory Group cited the drug’s potential to reduce transmission of the virus and described how it could be used in Long Term Care Facilities (LTCF).

Dr. Lisa Barrett, an infectious diseases expert and assistant professor at Dalhousie University, co-chairs the Advisory Group along with Clinical Infectious Diseases Pharmacist Dr. Tasha Ramsey. Both are also members of the COVID Network.**

As was reported in The Halifax Examiner back in May, Barrett said she was initially a “huge advocate” of the treatment. “Figure it out, people. I don’t care if there’s an infusion clinic problem. Figure it out. We may need it.”

But she also said that as a result of both complex issues related to timing and logistics, bamlanivimab was not offered routinely as an early treatment to high risk patients in the province.  She explained that one of the main drawbacks of the therapy was that it’s administered by IV outside the hospital.

“If you were to do this at a mass level, it requires mass infusion clinics which are not only really difficult to set up, but you’re putting people into groups to bring them in to do infusions for people who potentially have been exposed and are incubating. And we don’t want to do that routinely either.”

Indeed, even Dr. Anthony Fauci is a proponent of the treatment, saying here that COVID-19 sufferers can reduce their risk of hospitalization and death by up to 85 percent if they receive monoclonal antibody treatments in the early stages of their illness. He also stated in an interview with the Centre for Strategic International Studies back in August 2021 that monoclonals are “really very good if you give them early enough.” But he says the treatment’s “major stumbling block” is “the logistics of getting somebody into a situation where you can hook them up to an IV and observe them as they’re getting an infusion.”

But in addition to the infusion clinic challenges, Barrett also told the Examiner that there was a timing issue and that in the third wave, when the UK/ ALPHA variant was dominant in the province, bamlanivimab would not have been effective.

“There’s a difference between the early UK variant and the late UK variants, and the late UK variants are the February/ March ones and those are the ones that we seem to have in Nova Scotia,” she said.

However, documents obtained through FOI seem to contradict Barrett’s statements. As well, correspondence with Eli Lilly, the drug’s manufacturer—which took place after The Halifax Examiner article was published—raises additional questions about the existence of a “late UK” variant in Nova Scotia at the time of the third wave—a subject we’ll return to.

‘150 patients that could be treated’

Early on, there were discussions about how bamlanivimab could be administered province-wide. On December 3, 2020, not long after Health Canada authorized it for use, Ramsey emailed Angela Tracey, the administrative assistant to Cindy MacQuarrie, who co-chairs the COVID Network, and wrote:

“I would like to ask the network for their thoughts on the implementation of these agents. Several that have just come out (or are about to come out) require infusion. Some will require infusion on an outpatient basis (in non-severe patients). We may have to put some thought into the creation of something along the lines of a NS Health affiliated infusion clinic specifically for COVID patients… it looks like NS Health is going to be provided with bamlanivimab for free from the federal government. We have to determine how to get it to non-severe patients.”

The next day, Richard Gabrielle, a pharmacist consultant with the Department of Health and Wellness and a voting member of the Advisory Group wrote an email to some of his colleagues with the subject line: “possible solution to bamlanivimab administration location issue.”

Gabrielle writes: “NSHA [Nova Scotia Health Authority] did set up ILI [influenza-like-illness] clinic locations that are INTENTIONALLY off-site from the hospitals… So for example, in Truro, it is located at the Senior’s Clinic/ PCU offices in the building across the road from CEHHC. And it is staffed with hospital staff waiting for patients with ILI to come in… there are multiple sites provincially that are not on hospital grounds. I was thinking this might be a good place for the administration of bamlanivimab around the province.”

By December 8^th, at the COVID Network’s weekly update meeting, the Advisory Group provided this “therapeutics update.” From the minutes:

“Bamlanivimab may be used in the context of pragmatic research. Several monoclonal antibodies have just come out (or are about to come out) that require infusion… This is typically done in infusion centres. However, infusion clinics in Nova Scotia are usually booked well in advance and often to capacity with patients that are immunocompromised. Use of these agents will depend on the level of disease (non-severe vs. severe) and those with non-severe disease will require infusion on an outpatient basis. Administration logistics for the wave of monoclonal antibodies that are about to come out will require careful consideration.”

On December 18^th, the Advisory Group meeting minutes indicate a discussion around access to the drug in the context of pragmatic research and indicated “all Regional Health Unit patients regardless of site should qualify for inclusion in pragmatic research.” It was also noted that there was a need “to be practical about the decision.”

At the December 22^nd COVID Network meeting, the Advisory group reported that studies were showing that use of bamlanivimab early in non-hospitalized patients with high risk factors for serious disease was resulting in “numerically reduced hospital admissions” and a “signal of increased benefit in those 65 and older with a BMI greater than 35.” It also showed no signal of serious harm. “Individuals 65 years of age and up are at highest risk for progression to severe disease and death and [have] less of an immune response.”

Despite these stated benefits—including a reduction in hospitalizations—the Advisory group said it could not endorse its use in routine care based on the published evidence to date. Mention was made of there not being Phase 3 clinical trial results yet.

The Group recommended it only be used in “pragmatic research,” such as the COVID Victory Study, “in patients with non-severe COVID-19, 65 years of age and older in NS Health affiliated Regional Care Units.”

But from what I can gather, the treatment was never used in this context either.

The COVID Victory Study (CO-VIC), launched in June 2020 by the Nova Scotia Health Authority, with Barrett as its principal investigator, was to take place over 18 months with the stated goal of enrolling 798 hospitalized patients, to test potential therapies and monitor their impact on COVID-19 symptoms. According to the study’s only news release–the main goal was to gather information about the immune response during and after treatment and infection “to make smarter choices for the next round of vaccines.”

According to the CO-VIC Web site, bamlanivimab does not appear to be included in the roster of drugs being tested. Those listed are lopinavir (an HIV medication), hydroxycholoroquine (an anti-malarial medication), and baricitinib (an anti-inflammatory). But according to the May interview with Barrett, remdesivir and tocilizumab were added to the list, and were provided to hospitalized COVID patients enrolled in her study. No mention was made of bamlanivimab being part of the existing protocol.

By late January, more data was emerging on Elli Lilly’s clinical trials (BLAZE) showing effectiveness of bamlanivimab as outpatient treatment, as well as its usefulness as prophylaxis (prevention). For instance, it had been found (in combination with etesevimab, another monoclonal) to reduce the risk of infection by up to 80% in nursing home residents.

In the minutes Ramsey writes, “The BLAZE-2 press release is exciting in terms of its role in prophylaxis, but it strikes me as something hugely resource intensive and not aligned with the federal pandemic supply we received.”

Despite the legitimate questions around the challenges of administrating it, by February the group was considering ordering more doses.

In an email to Barrett, Ramsey writes: “If you are considering using bamlanivimab to reduce transmission, should we request more of the free federal supply now? If so, how much?”

As previously stated, at the time the province was in possession of 50 doses of the treatment, but none had yet been used in the province. Barrett replied: “I think we should (esp if others are not using) consider adding more doses (i.e. 150 doses on hand) which would cover most people in most LTCF.”

According to the emails, 100 additional vials were ordered and it was confirmed that the necessary storage required was available. By the March 23^rd COVID Network meeting, it was noted in the minutes that the province now had 150 vials available:

“150 patients that could be treated,” it stated.

The arrival of variants of concern

By April an article that appeared in Nature—which was circulated among the members of the Advisory group—pointed to some good news for Canada. While bamlanivimab alone or in combination with etesevimab was “no longer able to neutralize” B.1.351 (BETA or South Africa variant), it maintained activity against B.1.1.7 (ALPHA or UK variant). According to the federal government’s Health Infobase data (for April 5^th) on variants of concern (VOC)—which was also circulated among the group members— the B.1.1.7 variant was the most prevalent variant of concern (VOC) in Canada, comprising more than 92% of all VOCs publically reported.

In Nova Scotia, around the time the Advisory group was assessing the effectiveness of the monoclonals in light of the new variants of concern, the province was reporting a total of 23 cases of ALPHA and 10 of BETA.

Eli Lilly was also reporting at the time that while the variants of concern (VOC) in the US had changed—rendering bamlanivimab alone ineffectual, it stated that in Canada this was not the case.

By April 22, while the provincial vaccination campaign was well underway, the “epidemiology” had taken a turn for the worse. In what was being called a “circuit breaker,” former premier Iain Rankin imposed restrictions once again. Thirty-eight new cases were reported in the province on that day, with three people in the hospital. By this point, 79 of all the cases reported in the province were identified as VOCs – 66 (or 84%) of which were the ALPHA/ UK variant.

On the same day, the Advisory Group decided to expand its recommendation for bamlanivimab to include offering it to those 18 years and older, hospitalized for other reasons and at high risk for “clinical deterioration,” but still only within a clinical trial, and not for routine use.

By mid-May, with the province still under severe restrictions, Chief Medical Officer of Health, Dr. Robert Strang—who is also a member of the Advisory Group—was quoted saying, “With almost 100 people in hospital, we all have a responsibility to our fellow Nova Scotians to keep them safe and stop that number from getting higher.”

Given the desire and necessity of keeping people out of the hospital, why wasn’t an effective, safe, and federally authorized treatment rolled out during the third wave?

As previously stated (and reported), in addition to the logistical challenges posed by setting up infusion clinics, Barrett explained that in the third wave, bamlanivimab was not used here in Nova Scotia because it would not have been as effective due to the presence of the “late UK variant”—something that did not appear to be mentioned anywhere in the un-redacted sections of the minutes of either the Advisory Group or the COVID Network.

In fact, an April 29 email by Ramsey, further confuses the matter. Ramsey makes no mention of a “late UK variant” but instead says that bamblanivimab “maintains activity against the B.1.1.7 [UK] variant and that is our predominant variant at the moment.”

Furthermore, Barrett’s assertion that the “late UK variant” was here in the province at that time was also called into question by the drug’s manufacturer, Eli Lilly, who, in an email sent after the May article was published, wrote:

“There are reports of some pockets, in some parts of the world, where additional mutations (such as the E484K mutation) which have the potential to alter their neutralization-sensitivity profile, have been seen in the UK variants. However, these reports are very rare, and there is no strong evidence of a significant presence of these “new UK variants” in North America. Based on data publicly available on Canadian and provincial databases, there are no reports of such variants in circulation here at this time.”

Numerous attempts were made to reach out to Barrett, to provide her with the opportunity to respond to Eli Lilly’s statement, and help shed light on how she or the Advisory Group came to the conclusion that a “new” or “late” variant was present in Nova Scotia, rendering bamlanivimab useless. But a response was never received.

Could bamlanivimab have saved lives in the COVID-19 outbreak in the QEII Halifax Infirmary?

In May of this year, 21 patients at the Halifax Infirmary tested positive for COVID-19. As reported earlier this month, three patients were said to have died because of the virus, and three more patients died with the virus, but other health factors were responsible for their deaths. According to an investigation led by Dr. Ian Davis, and reported in this official update, all of the infirmary cases involved the ALPHA (UK) variant of the virus.

Davis’s report focused on improving COVID-screening for incoming patients, reducing or eliminating the use of shared rooms, and better control of patients with dementia who sometimes wander between rooms, unwittingly carrying the virus with them. All good advice, but there is one strategy not in Davis’s report: using drugs authorized by Health Canada for emergency use as an early treatment for high risk COVID patients. This is an odd omission, given that just before the Halifax Infirmary outbreak, the province declined to take part in a study that was using the treatment on people in exactly the way it might have benefited those at the QEII: in people already hospitalized for other illnesses but who became infected with the virus while there.

While it’s impossible to say whether participating in the study would have lessened the impact on the QEII patients or saved any lives, the patients certainly seemed to be good candidates for bamlanivimab: “Most of the patients on the unit were unvaccinated at the time of the outbreak and had at least one co-morbidity that made them vulnerable to infection and severe illness from infection,” reads the update.

In the minutes of April 8, just a few weeks before the outbreak, the Advisory Group reviewed its recommendations for bamlanivimab, and referred to a “pragmatic” study that was underway in which the Nova Scotia supply of the treatment “could be used.” The CATCO-NOS trial was focusing in on nosocomial COVID-19, which is where COVID-19 is acquired in a hospital setting.

The first reference to the CATCO-NOS trial in the Group’s meeting minutes was February 4, 2021.

“Nosocomial acquisition… is a frequent concern across hospital settings in Canada and is associated with substantial morbidity and mortality,” as high as 25-30%, according to the study.

According to the Group’s minutes, patients were still being enrolled in Calgary and Ontario, and British Columbia also recently received ethics approval. “We have been asked to move forward with [our] ethics submission.”

Did NS Health move forward on its ethics submission to join the clinical trial as a way to finally use some its supply of potentially life-saving doses?

Apparently not.

According to Tasha Ramsey:

“Writing a protocol for a new pragmatic trial that could include non-severe, hospitalized patients takes time and must be approved by the research ethics board before it can be used. The decision was made to not pursue enrolment in CATCO-NOS in April, as their population was COVID-19 infection which was acquired in hospital. This was not in line with our COVID-19 therapeutics and prophylactics advisory group recommendation for bamlanivimab.”

Ramsey also pointed to Barrett’s CO-VIC trial as another potential avenue that could have allowed for the use of the antibody treatment in a hospital setting, but she said the “existing protocol” for the CO-VIC study was for remdesivir, tocilizumab and baricitinib, indicating that because bamlanivimab was not already included, it couldn’t be added during the QEII outbreak.

Ramsey also says something I hadn’t been made aware of until now: “Bamlanivimab was used for one inpatient in wave 3.” According to Ramsey the patient was in Central Zone, but she was unable to comment on the circumstances or whether the treatment was effective.

‘What’s missing in Canada is a COVID-19 Therapeutic Strategy’   

When thirteen western lowland gorillas tested positive for COVID-19 at the Atlanta Zoo, veterinary staff responded with a combination of treatment and prevention. According to an article that appeared in The Guardian, Ozzie, the 60-year old male considered most at risk for serious outcomes was treated with monoclonal antibodies. Those that were not infected were vaccinated and closely monitored.

This wasn’t the first time during the pandemic that monoclonals were used on gorillas. Back in February, Winston, an elderly 49-year old silverback mountain gorilla at the San Diego Zoo Safari Park was reported treated with monoclonal antibodies due to concerns over his age and underlying medical conditions, namely pneumonia and heart disease. Winston made a full recovery. It’s also interesting to note that despite being infected, the veterinary team decided that Winston wouldn’t be isolated, but instead quarantined him for 6 weeks with his social group because of the undue stress the separation would have caused him. When it came time to provide the gorillas with vaccines, only those that were not previously infected with COVID received the injections because the others had already developed natural immunity.

In humans, monoclonals are used widely in the US at infusion centres including this one, and in June the European Union purchased 55,000 doses of a monoclonal cocktail. Monoclonals can be deployed, along with the vaccines, to help keep people out of the hospitals.

According to Dr. Zain Chagla, the currently available data suggest monoclonals could result in a 70% reduction in hospitalization, which translates to a 70% reduction in ICU stays and a marked reduction in death. Chagla is an infectious disease physician at St. Joseph’s Health Care and an associate professor in the Department of Medicine at McMaster University in Hamilton. He recently launched a pilot project in Hamilton to treat patients in a targeted way with antibodies.

In an interview that aired on October 20 on CBC’s The Current, Chagla said the Hamilton pilot will be targeting people at the highest risk of hospitalization rather than the people that would likely have a reasonable outcome.

According to Chagla, the treatment would be administered about seven days after symptom onset, “to get in early before the virus starts wreaking its damage, so that inflammation gets under control and give the body a chance to actually get that jump start to clear the virus out. So we need people to get tested early in order to be eligible for these therapies.”

“The paradigm has been get tested and isolate, and if you get sick, go to hospital. It is hard to start breaking that paradigm and saying, actually, there’s a step in between here where if we intervene for a lot of people—yes, we have to reconfigure our health care systems to deal with that—there is a big reward here. Hospital beds are a commodity. They’re incredibly difficult to come by, especially going into the winter. Preservation is going to be incredibly important and it’s a lot of work, but a huge amount of downstream reward if they’re implemented correctly.”

According to Chagla, when you factor in the operating costs of an infusion clinic as opposed to hospitalization, there are clear fiscal reasons for administering the treatments too.

“There are operating costs of a clinic, of paying nurses, a pharmacy cost. The drug has been procured by the federal government, so for now, it’s not costing hospitals anything. But eventually [the treatment] will likely have to be bought by health care facilities. But again, you know, the average infusion likely runs, with people’s time, maybe $500 to $1,000 a day to run a clinic. A single hospitalization prevented is $23,000, and if that person goes to ICU, it costs over $50,000.”

As mentioned, Health Canada has recently given emergency use authorization to three more monoclonals found to be effective against the DELTA variant, which is dominating much of Canada.

As well, Eli Lilly’s bamlanivimab and etesevimab together, currently under review by Health Canada, has also been found to be effective in neutralizing the DELTA variant.

According to Eli Lilly, “What’s missing from Canada’s approach to managing this pandemic is a strategy for reducing the number of people who progress from infection to hospitalization, and who progress from primary care to the ICU.”

In an interview, Eli Lilly contends that the biggest road block to using the treatments is that, “health authorities, hospitals and ultimately provinces are not willing to implement outpatient infusion. Even when ER physicians and infectious disease physicians see the benefit in administering these antibodies, the roadblocks are in the hospital protocols and hospital administration preventing the set-up of infusion for outpatients.”

It’s worth bringing Chagla back in here. In the CBC interview, he tells Matt Galloway that back in the third wave when bamlanivimab was available and effective against the variants that dominated in Canada at that time, “no one had an implementation plan and health care was stretched to the limit… so it was kind of put on the back burner, even though the data was starting to suggest that it did save people from ending up in hospital.”

Now, he says, the new monoclonals are on the market, approved by the World Health Organization, and approved by the Ontario Science Table.

“People know this drug exists and again, we have to give them a fair shot at accessing it.”

Near the end of the interview, Galloway asks Chagla about how he squares promoting a treatment that could be “co-opted by people who might be vaccine hesitant or anti-vaccination.”

Chagla replies:

“I think we have a duty to use what we can for patients. And again, we do this in other forms in infectious disease. You know, we have lots of preventative therapies for HIV, but it doesn’t mean we stop caring about HIV patients who contract the disease. And you know that similar paradigm has to just be put into place here. We have tools that are evidence based. We have access to them regardless of the patient population. We need to treat patients first and foremost, and that’s what health care providers do.”

Back in May when I interviewed Barrett, she said that with most people vaccinated, the “role” of the monoclonals coming on board would change and could be used in what she called “very niche circumstances.”

“I do think there’s capacity to do this when it’s going to be needed… there does need to be health system change to identify mild people and that’s still the best place to offer monoclonal antibodies given the data at the moment,” she said.

Since there will always people who are not vaccinated for any number of reasons, and since the current available evidence, which is limited, indicates there is lower vaccine effectiveness against COVID-19 illness among immunocompromised people, and since there are questions being raised about whether the increasing number of symptomatic infections among fully vaccinated people is evidence of waning immunity, it’s seems really obvious to me at least, that it’s in all our interest to have an effective, early treatment that can be targeted and available to anyone at high risk if they end up needing it.

The Nova Scotia Health Authority recommendation for monoclonal antibodies should be for routine use. Figure it out, people.

 

Endnotes:

* According to Dr. Nicole Boutilier, VP Medicine with the Nova Scotia Health Authority, the COVID-19 Therapeutics and Prophylactics Advisory Group was established to provide recommendations to the health system regarding clinical use of antiviral and immunomodulatory agents for treatment of COVID-19 based on evolving evidence and research. “The advisory group is closely tracking antiviral and immunomodulatory therapeutics pursued by the federal government for COVID-19, medications with Health Canada approval for COVID-19, and medications with phase 3 clinical trial data and makes recommendations to the COVID-19 Network who then makes recommendations to Nova Scotia Health’s Clinical Operations Committee and leadership team. The COVID-19 Therapeutics and Prophylactics Advisory Group is co-chaired by Dr. Lisa Barrett and Tasha Ramsey, and includes 8 other voting members (Glenn Cox, Kathleen Coleman, Gabrielle Richard, Lisa Grandy-Allen, Emma Reid, Ken Rockwood, and Kathy Slayter), as well as ten non-voting members including Dr. Robert Strang and Dr. Shelly McNeil. McNeil is listed twice as a member, once as co-chair of the COVID-19 Network and second as a “NS COVID vaccine expert.” Other non-voting members include: Barbara Goodall, Karina Top, and Amanda Porter. The Advisory group makes recommendations to the aforementioned COVID-19 Network, which are considered for approval. According to its Terms of Reference, the COVID Network is “a group of clinical, operations, and research and innovation experts that has a provincial scope and mandate to design and recommend strategy and improvement plans that will allow for evidence based, safe, and sustainable infection prevention and management practices within NSH during the COVID-19 pandemic.” The COVID Network makes recommendations to Nova Scotia Health’s Clinical Operations Committee and executive leadership team, which in turn determines what happens to patients presenting with COVID. As of August 9, 2021, the COVID-19 Network had 76 members with some overlap with the Advisory Group (McNeil, Barrett, Ramsey). It is chaired by Dr. Shelly McNeil, Cindy MacQuarrie, and Alyson Lamb. In addition to being the COVID Network co-chair, McNeil is listed as having “NS COVID vaccine expertise” and is also co-chair of the Vaccine Expert Panel, and a member of the “C-19 COVID vaccine workstream.” She is also a member of the Vaccine Surveillance Reference Group. The COVID Network makes recommendations to the Clinical Operations Committee and executive leadership team (ELT). According to Nova Scotia Health, the Clinical Operations Council consists of ELT members and Zone Executive Medical Directors. While ELT includes CEO Karen Oldfield, she does not join the Clinical Operations Council. The members are: Colin Stevenson, Nicole Boutilier, Gail Tomblin Murphy, Krista Grant, Derek Spinney, Bethany McCormick, Tanya Nixon, Madonna MacDonald, Vickie Sullivan, Dr. Aaron Smith, Dr. Cheryl Pugh, Dr. Don Brien, and Dr. Todd Howlett.

 

**The COVID Network membership (on December 8, 2020):

 

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March 14, 2021

What the Pandemic Revealed

A conversation with veteran journalist and radio documentarian, David Cayley about the past year and why we should be reflecting on it

By Linda Pannozzo

About a month after the World Health Organization made the assessment that COVID-19 could be “characterized as a pandemic,” writer and former CBC broadcaster David Cayley wrote an essay called Questions About the Pandemic from the Point view of Ivan Illich. Illich was a profound thinker and intellectual, most famous for his critique of modern institutions, in which he argued against monopolies and said there were thresholds at which point institutions become counter-productive and cause more harm than good.

For Cayley, channeling Illich during the pandemic came naturally. He describes Illich as his teacher and friend. “I don’t know if everybody is guided in this way, but for me, he was the man who most shaped my way of life and my thought.”

Cayley is known for documenting the philosophies of prominent thinkers and intellectuals including Illich, George Grant and Northrup Frye. In his provocative and prescient 1997 book, Expanding Prison: The Crisis in Crime and Punishment, Cayley argued that burgeoning prisons reflected an increasingly polarized society and that alternative forms of justice should be explored. His  24-part radio series, “How to Think About Science” for the CBC Ideas program in 2007-2008, explored how the institution of science “knows what it knows.” When Cayley left the CBC in 2012, he devoted himself to writing about Illich’s life—an effort that culminated in the 2021 publication of Ivan Illich: An Intellectual Journey.

Cayley tells me he began writing about the pandemic to “clarify my own mind and to share my thoughts with a few like-minded friends.” But his writing “went viral” and has since been translated into every major Western European language. “I’ve been getting mail from all around the world. That’s when I realized that it was time to enter into this discussion and to keep it going, to keep trying to say more about it.”

Cayley published two pieces: “Pandemic Revelations” which appeared in The Journal of Ivan Illich Studies and “The Prognosis: Looking consequences in the eye”, published in the Literary Review of Canada. The pieces are long and thought-provoking and Cayley does not hesitate to raise difficult questions about the pandemic in his attempt to understand and try to find meaning in how the world responded.

In his essays he explores how the policy of total quarantine and lockdown gained wide acceptance, despite their harmful effects on livelihoods as well as social morale and public health. He argues that “societies like Canada had, for a long time, been ‘practicing’ – we’d already turned the concepts on which our pandemic policies have been founded into common sense.” Cayley points to a set of what he called “pre-conditions” – ways of thinking about risk, safety, pro-active management, science, and ultimately life – that set the stage for the global mobilization against the virus.

“Gradual naturalization of these concepts has made the policy that has been followed seem so rational, so inevitable, and so entirely without alternative that it has been possible to freely vilify its opponents and largely exclude them from media which might have made their voices politically influential,” he writes.

I reached David Cayley by telephone at his home in Toronto.

[This interview has been edited for length and clarity]

Linda Pannozzo (LP): What prompted you to write these essays about the pandemic?

David Cayley (DC): Well, I just needed to wrestle with this. I was astonished by the instant consensus that seemed to take shape in March, as if everyone already knew what this was, as if really it didn’t need to be studied or thought about or discussed because we already knew it was a grave global emergency that should be followed by turning our societies upside down. So I was amazed by that and I realized I couldn’t think about it without going back to what Ivan Illich had written, since he was the author of a book called Medical Nemesis, published in the middle 1970s, which really challenged the hegemony of medical thinking in society.

LP: Given you’ve had a very long career working at the CBC, I wanted to ask you about freedom of the press. I wondered about how press freedoms have fared during the pandemic and came across a report by the International Press Institute, that was posted on Global Affairs Canada, that reported there was a “concerted effort by governments [in both democracies and authoritarian regimes] to limit independent information” and that governments all over the world were “misusing the crisis to restrict press freedom and freedom of expression.” In one of your essays you described how in the early weeks of the pandemic there was an “emerging consensus” and that this narrative had “developed such momentum, and such an impressive gravity, that marginal voices had little effect.” You also said that critics were excluded from the media, “which might have made their voices politically influential.” What do you think this has revealed in the Canadian context?

DC: Well, I’m a student of Noam Chomsky, and I think Chomsky and his associates have shown a long time ago that a free press can operate more or less as a propaganda system. So I’m not saying this is a new thing, but I think the permissible opinion has definitely narrowed during the pandemic, and I think an effective censorship has been exercised.

Probably the most singular instance for me is a statement that was released in the summer calling for what they named “a balanced response” to the pandemic, which was signed by three former chief provincial medical officers of health, a number of former deputy ministers of health, a number of deans of medicine. This was a star-studded cast in the public health field and they were saying, let’s be cautious here. Let’s remember the well-established principles of public health, which is that you consider the public health as a whole, you don’t stake everything on the control of one illness, particularly when you don’t yet know how severe the illness is and where your testing instruments may be fairly blunt and where co-morbidities may be seriously hiding from you how many are actually dying of this disease. And as I said, this was a star-studded cast of public health luminaries, and I didn’t see it reported. So don’t you find that pretty astonishing, that people of this eminence in their field and retired, so less likely to be partisan, are not heeded at all? I have found this note of incredulity again and again. I mean, the three epidemiologists who signed the so-called Great Barrington Declaration all have expressed this astonishment that what they took to be established public health principles—not controversial—are suddenly seen as a disposition to see millions die.

So what I call “scientific dissensus”—that there are varying opinions and that there are many highly qualified, cautious, thoughtful people who don’t agree with the way this has been managed is, I think, unknown to the great majority of our fellow citizens and the reason it’s unknown to them is because it has not appeared in the sources of information they consult. That seems to me to constitute a fairly effective censorship or policing of the boundaries of opinion and the justification is essentially that this is war. From the very beginning a state of war was declared. The National Post, the day that the World Health Organization declared a pandemic, ran a headline that took about a third of the page in black print saying, “PANIC.” Nobody was panicking at the time so I read it as an instruction rather than a piece of reporting. They were declaring that it was time to panic and people consented to panic.

The Globe and Mail, take another example, made a sort of formal declaration of war, stated boldly at the beginning of an editorial, “Canada is at war.” Well, you know, if you’re at war, then dissent is sedition. When Roman Baber, who’s a provincial member of parliament here in Ontario, spoke against the lockdown and was kicked out of the caucus by [premier Doug Ford], the statements that both our premier and our health minister, Christine Elliott, made at the time basically accused him of sedition: that he was spreading disaffection among the people and you can’t do that in a time of war. This is not an ordinary time. This is a special emergency time, in which different rules apply, and so I think that’s an important part of the censorship and the policing of opinion.

David Cayley (photo submitted)

LP: The countries that the International Press Institute listed—where they found there were violations— included both democratic and authoritarian regimes, but all the violations involved the government controlling or limiting what journalists could say, in some cases arresting them for questioning the mainstream narrative. But in a place like Canada—which was not among the countries listed—the message has also been controlled, as you have pointed out. Who do you think has been doing the controlling here?

DC: I think it’s a group production myself. I don’t think you can say this has been engineered by this political class or business class or any other class. I think there was a disposition seemingly to panic. So the National Post tapped into that disposition. They didn’t create it. Why? This is a huge issue in crowd psychology right now, and it has to do for me with what I’ve called “preconditions,” where you’re practicing styles of thought.

So take risk as an example. Risk consciousness has spread through our society in an amazing way over the last, let’s say almost arbitrarily, 30 years. Much more of medicine than formerly is focused on risk and risk is a kind of mathematical construct, it’s not a pragmatic assessment of danger. It’s learning to think of myself as, in effect, somebody else: the risk group that I belong to. It’s learning to think of myself as this statistical doppelganger who has a certain calculable risk, who is not me, but someone like me, someone who has the same weight as me or the same ethnicity, or the same eye colour, or whatever it is. So the habit of thinking in terms of risk develops and then suddenly the moment occurs. And the same can be said for the sanctification of safety and the glorification of management. Politicians have been constantly spanked through this crisis in all the Western countries that I know about for not managing well—or the lucky ones who seem to have managed well, like in New Zealand—but often by people who couldn’t tell you how they could possibly have managed it or whether it is possible to manage the way a virus reproduces in a population.

So there’s the sanctification of safety. Safety has increased its profile in everyday talk, amazingly, over the last 20 to 30 years. As an example, when I started at the CBC, you could walk in and out of the building. How is that possible? What about security? Surely you have to control access to every space. You can’t just have people coming in and out, right? And yet we did. We never thought about it.

So you have all these preconditions, habits of thought, that would suddenly converge on this moment including a lot of pent up apocalyptic anxiety and fear relating to climate change and other issues.

So the paradigm for me has always been the beginning of the First World War just because I’ve read about it and because I was very impressed years ago by Karl Polanyi, who was an economic historian and an officer in the First World War, who said that Europe sleepwalked into that war. That became a kind of model for me—that trancelike behavior. So the whole catastrophe of the 20th century—if you include the Second World War as an implication of the First World War, which I think is quite defensible—is entered into in a kind of trance state. It seems to me, and I say this tentatively, we seem to have entered on what may turn out to be a kind of health-security state, we seem to be entering it in a similar kind of trance without any discussion about if we want it or if there might be a better way to live.

LP: I want you to speak a bit more about the “litany of preconditions”—which is how you referred to them in your writing. You wrote that they led to “the total mobilization against the virus” and converged in a “perfect storm.” You’ve mentioned apocalyptic fear, the sanctification of safety, heightened risk awareness, and the glorification of management. Are you arguing that because we already tended to think this way as a society, when the pandemic was announced by the World Health Organization, the reaction to it was almost predictable?

DC: Well, I can’t explain it otherwise. How could it happen that a word like lockdown that came out of prisons and then some time ago began to be used in schools, could now spread to the whole society without much resistance? That everyone would start using this expression without horror but with a “Well, OK” seems to me to speak for that idea that somehow one has practiced or is accustomed to this already. Total quarantine doesn’t seem like an astonishing idea, except on the libertarian right, where they have been practicing resistance to it because they’ve believed that this kind of collectivization has been going on all along. But I don’t think the left knows what’s hit it yet.

LP: In what way?

DC: Well, I think it will be able to be shown that those who paid the price for the lockdown policy were the weakest. The most vulnerable people suffered the most and the most well established people suffered the least because they could work from home, and all they had to put up with was the irritation of too much of each other’s company. And yet the left, which thinks of itself as speaking for the weakest, is very much on board and seems to be infatuated with a zero COVID strategy, which is a total control strategy. I don’t know if that’s viable in a society where the virus is already endemic, but that’s how people are thinking.

LP: In his 2020 book Democracy without journalism? Confronting the Misinformation Society, Victor Pickard argues that for roughly a century the mainstream media has functioned to help generate profits for media owners through advertising and that now, with the advent of social media, instead of “if it bleeds it leads,” the adage has become “if it’s outrageous, it’s contagious.” This might help explain why fear mongering headlines and sensational and often misleading stories overwhelmed the media during the pandemic. Do you think the suppression of press freedoms is really anything new?

DC: The short answer is ‘no.’ But I do think that can be nuanced. I mean, in a real war, let’s take the Second World War, there was an enforced consensus. There is always more or less a consensus and there’s always a boundary to what one can say. Chomsky’s example—because I said Chomsky shaped my thinking on this—was that you could always have a discussion. There could be hawks and doves, which would be more, or less in favor of the Vietnam War, but you could never say that the United States invaded South Vietnam. They didn’t invade, they defended freedom there. The United States can’t invade other countries because its hegemony is assumed. Its hegemony is not to be brought into question or put on the table. So there’s always a boundary of opinion but I think the boundaries have shrunk a little during the pandemic in a way that worries me.

LP: After I posted one of your essays on Facebook recently, a friend of mine commented that your article had been “embraced by the pro-Randy camp,” referring to Ontario MPP Randy Hillier, who has been very outspoken in his criticisms of the measures taken, particularly regarding the mandatory requirement to wear masks. My friend wanted me to ask you what you make of the fact that your essay is resonating with people who have been labelled by some as “right-wing libertarians? But I also wanted to ask, what you make of people who might otherwise be swayed by your arguments, but seem more concerned about which “camp” this might identify them with?

DC: I have believed for most of my adult life that the left–right map of political opinion is hopelessly out of date and hopelessly inept. It is essentially an antique measure going back to the 18th century, which tells you the proportions of state and market in its deployment, but nothing about what it does, how big it is, how harmful it is. So I don’t accept that framework, but I do think it’s striking that all the resistance seems to have come from the so-called right. But what has preoccupied me—since this is a huge subject and we can’t discuss all of it—is what I would call the production of conspiracy theories or forcing people farther to the right, if we can continue to use that language.

If Premier Ford calls you a “yahoo,” or Hilary Clinton puts you in her famous “basket of deplorables,” one way of dealing with the scorn and the denial of the legitimacy of your position is to adopt the character that has already been imputed to you. I’m not denying that stupidity, malice and willfulness exist, just saying we should try to minimize them rather than amplifying them. Right wing populism is partly a result of the denial of any other ground on which to stand.

So let’s take masks, for instance. There is no good science saying definitely that masks are going to help prevent the spread of this. By good science I mean randomized trials with proper controls. The only randomized trial done that I know of during the pandemic was done in Denmark, a fairly large study, and it found no statistical difference between the two groups.[1] I didn’t see that reported in any newspapers in Canada that I know of. The other thing is that a proper study would have to take account of the possible harms from mask wearing, and who knows what they are? And in fact, our own chief medical officer of health, and it was the same in the United States, did not recommend masks initially. The change in the recommendation was not caused by a new scientific finding, it was caused by the critical need for a ritualization of this crisis.

So you have no solid science in favour of masks and yet it’s possible to say, as I read in the National Post last week, Chris Selly, speaking about the “anti-mask-wacko-sphere”—that’s the expression he used—crazy people are against masks. So this is an astonishing bit of cognitive dissonance. How can it be that there is no solid science, no gold-plated science—maybe you can find some suggestive, observational studies in favour of masks—I’m not saying you can’t—but you cannot prove it and at the same time, you can vilify those who oppose masks.

The group that began appearing outside the Ontario legislature probably in May with their first demonstrations—these demonstrations have now gone on ever since, some of them quite large, involving several thousands of people. They are never reported. The [Ontario] premier calls his fellow citizens “yahoos” for manifesting an opinion, for showing up outside the legislature. I find this an astonishment. So my view is that I have to say what I think is the case even if Donald Trump says the same thing or Randy Hillier says the same thing, for example. Trump said the cure mustn’t be worse than the disease. Well, so did Hippocrates! You know, it’s not really a controversial opinion, right, but if you said it after Trump said it, then uh, oh.

Do you remember Abbie Hoffman in the 1960s? That’s before your time. He said, “ideology is a brain disease.” This is a kind of brain disease where you only think what your enemy doesn’t think, or you let enmity form your views. This is not a good way to think. This is not thinking in fact. This is group and identity formation.

United Nations Covid 19 response (Upslash)

LP: Earlier you said the recommendations around masks was caused by the critical need for a ritualization of the crisis. What did you mean by that?

DC: I think it was because of the fear. I had trouble initially believing that, but I’ve become convinced that people were really frightened and remain really frightened. The people who don’t look at me on the street, the people who walk out into the street rather than pass me on the sidewalk, I think must be really afraid. So if you’re that afraid and you’ve had this lock down and now you’re going to come a little bit out of it, you need some way of ritualizing that fear, some way of feeling safe.

LP: What about the view that we should wear masks as a precaution, even if we don’t yet have the definitive science.

DC: I do it out of courtesy and to not embarrass others and so on. But you’d think you’d want some evidence.

LP: You’ve said that we need to “renovate our political discourse” and “make space for uncommitted thought.” What did you mean by that?

DC: Well, I think “renovate” partly means establish a new term so that we’re not in these left–right boxes quite so much. There’s really nothing in the left–right spectrum that can tell you that we need to learn to think about science critically, not because science is bad, but because we need to know what science is, what it can do, what it can’t do, what its own interests are, and so on. What I mean by “making space for uncommitted thought” is that I think thinking depends on that. You’re not thinking if you’re committed in advance, you’re just rationalizing a position that you hold in some way. That is not what I would call thinking. Thinking is either going a level down to try and understand what you think it’s built on or being able to experiment in thinking differently or just generally freely asking questions without fear or favor. But you don’t have to end in a certain place.

So my prescription for the CBC is that we desperately need a place to think as a country. I mean, that’s probably a crazy thing to say, but I’m an old man and that’s what I believe. A CBC, let’s say, or any other journalistic institution that functions as a cheerleader, however admirable the opinions for which it’s cheerleading, is not much use to us because I think that basic assumptions need to be rethought and for that there has to be such a space of uncommitted thinking.

LP: Can you give an example of a basic assumption that needs to be rethought?

DC: How about progress, or economic growth or take climate change, that would be a pretty good example. There are probably more than two, but let’s just say there are two ways out of the climate crisis. One is by a fundamental pulling back from the brink, which is a much different kind of society, which people like me have been dreaming of since the 1960s. The other is by control, by actually trying to regulate your way out of it. So that you regulate every gesture more and more minutely. How the pandemic will show itself to have been related to the ecological crisis generally is, I think, a really interesting subject and would probably take a whole other interview to discuss, but is very much about the idea of control.

LP: In terms of climate change, in one of your essays you touched on how, when the pandemic was announced, everyone appeared to know right away what it meant. For instance, some environmentalists referred to it as “nature’s wake-up call to a complacent civilization,” or a “dry-run” for a world with a changed climate, when nothing will be “normal.”

DC: Yes, my model of that is 9/11. Let’s put aside the conspiracy theories and assume this was really a small cabal who brought off this coup d’état—they brought down these immense buildings and they did a lot of damage. So is it a slam dunk that the thing we should do next is set the Middle East on fire? Well, yes, it was, in fact, because everybody knew the next morning what had happened: that the world had changed forever. One columnist proclaimed the end of the age of irony. I could only think that everyone had been in some unconscious way waiting for this. They had their answers ready. Certainly, George Bush and his friends had their answers ready, as we saw, with unimaginably catastrophic consequences if you include the destruction of Syria in the eventual implications of that invasion of Iraq and the destabilization of the whole region. That all followed as a consequence, and everybody knew what it meant. There was no pause to ask, “could this mean something else?”

LP: In your essays you also raise the point that policies around COVID excluded any recognition of the real health related harms associated with the measures themselves, such as illness and death from diseases that have gone undiagnosed or untreated, unemployment, mental health related harm, suicides, family violence and lost education. You said that whether these harms outweigh the benefits of flattening the curve is a moral question, not a scientific one. What do you mean by that? And why do you think so few have been willing publicly to take a moral stance on that?

DC: Well, I think everyone’s worried that we are abandoning science or that there is an anti- science faction or that we have to have trust in science—you hear that very commonly. But I think this is often said without any recognition of where the limits to knowledge are and that we cannot settle scientifically how to live. There are many questions that either can’t be submitted to science or that we don’t want to submit to science, and that’s what I call moral. I don’t think you could ever settle those questions. You would have a billion ways of counting up those harms. Everyone counting them differently, assessing them differently. In the end, you make a decision about how you’re going to live.

What will be the downstream consequences of this level of debt? Does anybody know the answer to that question? I don’t think so.

LP: Recently there was a CBC piece that described how the loss of jobs, routines, personal connections and life milestones for so many Canadians has resulted in a “collective grief.” And yet, the reporter stopped short of questioning the measures/ restrictions that contributed to this grief. Do you think the reason for this has to do with the “litany of preconditions” you discussed earlier or is there some other explanation?

DC: Yes, I think it ultimately has to do with the creation of the sacred or a religious ground. This is another question and this is one of these questions that I think demands thought. I think a new religion is present and its central object is life. We don’t accept death really any longer. I saw something astonishing, I think it was in The Spectator, that the average age of people dying was 82, which is above the average life expectancy, and yet it’s treated as completely unacceptable. You could turn society upside down to prevent that death. Well, what’s going on with that? I think you really have to look at the religious ground and what has been made undiscussable, untouchable, and can’t be considered. Saving lives is a desideratum that is not to be questioned.

That, I think, then allows you to become sentimental about the harms without ever touching what you’re not allowed to touch, which is, “Was shutting down the whole society a good idea in the first place?” This question has become untouchable. This increases as we go along. So now it’s become much more possible to discuss harms and even to wax very sentimental about the harms without ever bringing the policy that caused the harms into question because there can be no question about that policy because it was the right thing to do.

LP:  You’ve interviewed so many people. Is there anyone in particular who’s influenced your own thinking on the pandemic as well as your personal reaction to the mobilization against it?

DC: Well, [Ivan] Illich was my teacher. Yeah, and later he was my friend. I don’t know if everybody is guided in this way, but for me, he was the man who most shaped my way of life and my thought. In 1973 he wrote a book called Tools for Conviviality, and in it he gave three essential preconditions for what he called recovery, which ecologists call re-inhabitation, which is a viable, limited human society that doesn’t constantly push the edge of the biosphere, that can actually inhabit the earth with other species. The three Illich gave were the recovery of language, which is becoming able to speak for yourself, the recovery of law—that would be like not allowing big pharmaceutical companies to collectivize the risk of their vaccines, let’s say—and the third was to get over the delusion about science and what he meant by the delusion about science is this idea that it’s not a fallible human operation.

LP: I also wanted to talk a bit about how the dying have been treated during the pandemic, which is something you also raised in your essay. My mother is 90 years old and when I was speaking to her on the phone one day, she said to me, “It’s not that I’m afraid of dying, it’s that I’m afraid of dying alone.” That really shocked me. It’s almost inconceivable that as a society, we’ve come to accept that our loved ones will die alone, which some have justified, as you say, as “an unfortunate temporary trade off.” I wonder if you could just talk a little bit about this. What’s happened here?

DC: Well, I mean, I’m reluctant to say that I know what’s happened, but I’ve been shocked. I think the accompaniment and the comforting of the dying is just something that we must do and we haven’t done it. A lot of people have died alone. So it seems to be a fundamental divide. Are you willing to say the health of all is more important than this individual? It’s dangerous to be with this individual. I might get sick. I might make somebody else sick, therefore I won’t do it. I mean, obviously St. Francis was taking quite a chance with the lepers. Christianity has put quite a strong emphasis on visiting the sick and comforting the dying. We have a new God which is life and according to that new God, this is too dangerous to do. I think it divides cultures and I don’t know what’s going to happen in the future but I can’t believe that I will ever accept this. I don’t see how I could become convinced of it because it’s how I see the world. Death has become a kind of obscenity or something that should be fully under our control.

LP: I know you don’t have a crystal ball here, but do you think that we will emerge from the pandemic with our rights and freedoms and humanity intact? Or do you worry that this protracted period of restrictions and public fear will result in an erosion that’s more permanent?

DC: Yes, I do. I think that whatever is going on at the moment, we all tend to think it will go on forever. But maybe by September I’ll be at a baseball game with my grandson. Who knows? I don’t think the health–security state—if I can call it that—which has taken charge here is going to easily relax its grip without a lot of hard critical work to establish different grounds, because I think these grounds have been widely accepted and people have been on the whole, very, very obedient and willing to [negatively] characterize those who have been disobedient.

The United States found out what it means to consign that many of your neighbours to an enemy class when they elected Donald Trump. That was quite a vengeance they wreaked. I don’t think Canada is nearly that polarized but I do think we’re recklessly consigning people to categories that we should be very careful about. So yes, I’m worried. That’s why I’ve written so much about it. No one ever knows what’s going to happen next but this has been a surprise.

LP: I wanted to end on more of a personal note. I often wake up feeling quite overwhelmed with a deep sense of uncertainty and foreboding about the future. You’ve been wrestling with a lot of questions yourself and I’m wondering if you’re able to maintain a positive outlook and if so, how?

DC: Well, I’m pretty old, so I’m not going to be around as long as you and I think that if an old man isn’t a philosopher, it’s all the worse for him. But the world is beautiful, and for some reason a poem of Robert Frost’s comes to mind, a very short little lyric in which he says: The way a crow/Shook down on me/ The dust of snow/ From a hemlock tree/ Has given my heart/ A change of mood/ And saved some part/ Of a day I had rued.

So there’s the beauty of the world. And the last thing I’d say is that I think I’ve always had a crazy belief that I’m just about to convince everyone that I’m right, which is probably why I chose the profession I did. And you could probably detect that note in the interview we’ve done, that I’m hopeful that we can re-understand things, that this can be analyzed, that it can be discussed. That’s ultimately a faith because it’s not really that I have solid empirical grounds for believing it. It’s that I hope that will be the case.

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