There is a hierarchy in health care. This pecking order helps both federal and provincial governments allocate funding for services, research and institutions.
Active treatment hospitals are at the top of the pyramid. Along with payments to physicians, hospitals receive the bulk of funding.
As the pandemic has demonstrated all too poignantly, congregate care falls very low on the priorities list. Although some long-term care is provided through Canada’s public health services, much of it is also available through the private sector. To say that the latter, in particular, is inadequate and frequently abysmal, is an understatement, as the pandemic has shown.
Similarly, resources for palliative care, hospice and respite care are frequently relegated to second-tier status. The same is true for home care, many community and home-based services as well as for mental health and addiction services. All of these health care services are considered somehow less important and less prestigious than active treatment and acute care.
Public health, despite dominating the news during the COVID-19 pandemic, is a poorly understood segment of the health-care system. My guess is that pre-pandemic, very few people in Canada could identify the head of the public health organizations in their municipality, province, or even Canada. Nor could the public easily understand the role of these bodies relative to each other or to other scientific or political decision-makers.
From the start, the focus of public health measures has been not to overburden active treatment hospitals. This is a laudable goal. Unprecedented numbers of beds and ICU facilities were required for COVID-19 patients. Few beds were left for non-COVID-19 patients, especially before vaccines were available. Hospital staff at all levels were exhausted by the physical and emotional burden of caring for seemingly unending numbers of COVID-19 patients.
This situation continues to this day, complicated by the virulence of the Omicron variant that is infecting health care workers as it affects the rest of the population.
People requiring other health and hospital-based services were put on hold, as elective surgeries are being delayed and services such as dialysis, scans and chemotherapy are limited. The Canadian Institute for Health Information cites, “From March 2020 to June 2021, approximately 560,000 fewer surgeries were performed, compared with the pre-pandemic period (January to December 2019).”
In the midst of all this, preventive care perhaps suffered the most. We were advised to wash our hands and to socially distance. We moved through bubbles of various sizes and were locked down, told to stay at home, and isolated from public facilities. Then came vaccines and we were jabbed once, twice and then boosted.
Some people in Canada are now in line to be boosted yet again. And yet, with some people not eligible for vaccines, either because they are too young or have medical contraindications, and others refusing vaccines, hospitals are still overflowing and staffing is becoming a real issue.
Recently, in an attempt to reduce hospitalizations, the United States announced that it plans to distribute 400 million free masks to adults over 18. Packets of three will be available at pharmacies. This headline news seems like a positive step. But it is a small one. As of February 1st, 2022 there were some 334 million people in the U.S. Of these, over 259 million were over the age of 18. These eligible people are competing for roughly 133 million packets of masks.
Do the math.
This is not to say that distributing free masks is a bad idea. There are over 37 million people over the age of 18 in Canada as of February 1, 2022. If each of these people were provided free masks for an entire month, Canada would have to purchase and distribute over 111 million masks. At an estimated $1 per mask, that would mean an expenditure of $111 million.
In Canada, the cost of an average hospitalization stay for COVID-19 was $23,000 for the Delta variant. When the patient was in ICU, the average cost increased to $55,000. There is insufficient research to estimate how many hospitalizations could be avoided were all adults in Canada to wear approved masks for a full month. But there is evidence to estimate how quickly COVID-19 spreads in situations with and without masks.
A recent article published in Environmental Science & Technology attempted to estimate “Practical Indicators for Risk of Airborne Transmission in Shared Indoor Environments and Their Application to COVID-19 Outbreaks.” The conclusions of the group of 22 scientists who collaborated on the paper were summarized:
“Go into a crowded movie theater with poor ventilation and a mostly unmasked audience, and there’s a 14% chance of being infected, assuming everyone in the room is silent before, during and after the movie… But if there are people talking throughout… the odds of infection when unmasked jump to 54%. If the crowd is masked, the risk of infection drops to 5.3% without talking and 24% with talking.
Given that COVID-19 spreads primarily though airborne particles, masks, ventilation, the number of people in a room or building and time spent in that space all factor heavily in the equation. Also critical is what’s happening around someone.
Heavy exercise poses the most risk, followed by shouting and singing, then normal speaking. Least worrisome is the ‘silent’ category. Unsurprisingly, being outdoors, masked and surrounded by silence is the best way to avoid coronavirus… And the opposite is true: heavy exercise in a poorly ventilated place packed with maskless people is a nearly surefire way to catch COVID-19 – it’s 99% effective.”
The authors acknowledges: “The percentage isn’t a perfectly accurate estimate.” Still, masks clearly do play a significant role in reducing the incidence of COVID-19 infection. This, in turn, should reduce the number of hospitalizations for the virus.
Canada has some 57,000 acute care beds, including 3,200 ICU beds. At times during the pandemic, occupancy rates have exceeded 100 per cent, with patients accommodated in hallways and temporary structures.
With the Omicron variant, hospitalizations have decreased in length from 10 to 15 days to 6 to7 days. The cost has decreased proportionately to $10,000 to $15,000 per case (excluding cases that still require ICU beds).
If masking could bring down the number of admissions to hospital for COVID-19, what is the break-even in terms of costs? The government expenditure would be $111,000,000. Each avoided admission would save an average of $12,500. To recoup the mask purchases, some 8,800 admissions would have to be avoided. Even if that were possible, these beds would not be empty. People whose care has been delayed during the pandemic would occupy them.
This is the dilemma of health care funding. It is one of the reasons that preventive care is not cost-effective. The math looks primarily at the real cost of public health measures. It does not take into account the soft costs, including the potential to reduce the spread of the virus and decrease hospitalizations.
Yes, we are all tired of being told once again how to behave. N95 and KN95 masks are expensive; a month’s supply for a family of 4, all over the age of 18, could be as high as $250 plus tax. Free availability of proper masks would go a long way to ease the burden of remaining healthy. Consider it new math.
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Nick Seebruch, editor
