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"Yet COVID-19 is about to reveal just how fragile the system is. A system that constrains costs by limiting the supply of essential services is a system that cannot cope with a pandemic."

This was by far the most scary part of the blog post. It does make me wonder if we can do things like field hospitals (tactics used by the Americans now) to try and limit the damage?

I also like the idea of more dedicated federal funds. Bravo on a very timely piece.

Thanks for your kind words! I think if this thing gets bad a field hospitals type approach is exactly what we'll have to do - just assume a modest infection rate (1% of population infected at any one time) and a modest hospitalization rate (10% of those infected require hospitalization) and you've got 1/1000 people needing a hospital bed. That's more than half the beds in our system - and that's counting in things like obstetric beds. And it's not like the people who are currently occupying those beds right now aren't acutely ill!

I think that this question should also be asked about the people who are being asked to do this work. My wife is an ER doc, and they have been under stress for some time with hallway medicine, increasing complexity, and pay that has been frozen and has actually declined for well over 10 years. They are stepping up for this crisis, but are deeply disillusioned with what has and continues to be asked of them.

The frontline Dr.s in this crisis are not the radiologists, cardiologists and other Dr.s who have benefitted over the last few years from faster procedures, but the ones who have had more and more complex patients in stressed systems that were already at the breaking point.

Whitmore, thanks for those points. This post was partly inspired by a doctor I was speaking to who is in a similar position to your wife (hospital specialist, but not radiologist or cardiologist etc). I was talking to them about the hospital where they work and asking about the impact of coronavirus. The conversation went like this "...and we have to cancel surgeries, and ... and....it's a sh*tshow" "since the coronavirus hit?" "no, since 2018".

The one difficulty I see with the solution I propose in the article is that simply transferring more funds to the provinces won't change the dynamics that cause resources to be misallocated in the health care sector or at the provincial level more generally. My suggestion is along the lines of "where could the money come from" rather than institutional change. One can only do so much in 1000 words!

When I go past the local firehouse, l see most of the crews and trucks « doing nothing ». That’s infrastructure is for, waiting for the surge. MBA courses call that « idle capital «  that must be « returned to shareholders. » Exactly what DJT learned at Wharton and said concerning CDC pandemic team. « I am a businessman and I don’t like having people doing nothing. »
The 1990’s austerity closed our health system. We’ll die but a few years we produced nice returns to shareholders and lower taxes.

Jacques René - absolutely. I'm trying to get my head around this idea - the ability of all of our various systems, health care, of course, but others, to respond to random shocks. Nothing coherent enough to blog about yet, but perhaps soon.

In the meantime, the one upside for all of us for socially inept people like me is that now saying hi from a distance and standing there awkwardly waiting for the conversation to begin is now *the* best, coolest, most awesome way of greeting someone!

'In the meantime, the one upside for all of us for socially inept people like me is that now saying hi from a distance and standing there awkwardly waiting for the conversation to begin is now *the* best, coolest, most awesome way of greeting someone!'


Have to wonder why some cultures use the greetings they do and what the history is behind it. Brain food.

I guess, for context, isn't there a strong relationship between the number of hospital beds and ICUs per capita and the average age of countries? It's not a coincidence that some of the countries with the most beds per capita are Japan, Germany and France -- all of who are among the oldest countries in the OECD (measured by elderly as share of population).

Luan - yes, you're absolutely right. Population growth and population age are inversely correlated, so the trends in the data are certainly consistent with the notion that higher bed/population ratios in countries with lower levels of population growth has as completely rational and sensible explanation: countries or provinces with older populations deliberately choose to keep beds open in response to greater care needs. I think when you see my next post, however, I might be able to convince you that funding inertia - i.e. provincial governments being slow to change the allocation of funds in response to population growth - is a good part of the story as well.

Excellent post Frances. Unfortunately there is no social norm for heavy spending on pandemic preparedness, in the sense of an accepted institution. Few people question the billions spent on the military for wars that may happen, or firefighters for increasingly rare house fires. Yet a standby force of people and materiel doing nothing but rehearsing mass vaccination, and maintaining their ventilators and the Strategic Isopropyl Alcohol Reserve isn't something we have internalized.

Because the world is (sort of) normal 99.9% of the time, thousands of marginal resource adjustments happen daily or monthly within the HC system that collectively keep it always financially taxed: a somewhat costlier EKG here, a pay hike for surgeons there, another 0.5% benefits in the nurses' collective agreement there, facilities aging year by year, and so on. To assume a system like that will be prepared for an extreme event is unrealistic. It's sort of like asking the police to respond to war, when they're mostly absorbed in managing everyday crime. So what you really need is the healthcare equivalent of an army, the cost of which is politically acceptable.

If you told me today I had a 10% chance of stubbing my toe, I wouldn't care, but if it was a 10% risk of a car accident I'd change my behavior. Our institutions don't support that kind of thinking. Stay well.

Shangwen, great to hear your perspective on this! That is fascinating question: why do few people question the billions spent on the military but not emergency/pandemic preparedness? You make an excellent point about which threats have been internalized and which ones haven't been. I think economists have been culpable in this, too, by teaching everyone that military spending is a "public good" (but that health care is something that will be overconsumed unless limits are placed on consumption.

Your police responding to war example is spot on.

We learned today that Québec stock of masks and other equipment bought for H1N1 and Ebola were used without replacement because it was excess to normal operation. That is to save money (remove idle capital).

Jacques René - Jeez. Not good. Hang in there, and stay well!

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