Quebec was a hotbed of COVID-19 transmission—what went wrong?

Key points

1. The Quebec government’s pandemic response was marked by a lack of transparency partially predicated on a need to appear to be in control of the situation.
2. François Legault’s government’s approach to the health crisis favoured a homogeneous vision of collective protection that stigmatized certain segments of the population in public communications.
3. To date, the government has yet to show a willingness to take concrete measures to prevent the spread of COVID-19 in the workplace or other government-run institutions, particularly health care and educational facilities.

What went wrong?

Nearly three years into the COVID-19 pandemic, what lessons have we learned from this once-in-a-century crisis?

Multiple studies have shown that the social, economic and health impacts of the pandemic have perpetuated or even exacerbated pre-existing social, ethno-racial, gender and health inequalities in many countries, and have followed directly from the productivist mentality of late-stage capitalism and fiscal austerity.

For example, most Western governments, reeling from the effects of the economic and financial crisis of 2008, had not made it a priority to update their strategic stockpile of personal protective equipment. This decision went against the advice of scientists and epidemiologists, who saw such measures as essential, particularly in light of SARS-CoV-1 in 2003 and H1N1 in 2009.

Given all of this, it is worth asking how the way different governments have handled COVID-19 might have influenced the course and evolution of the pandemic. In the case of Canada, we must take a close look at the provinces, as health policy is largely a provincial prerogative.

Certain statistical indicators, while not immediately attributable to a single cause, have pointed to Quebec as an outlier in terms of outbreak severity. Quebec has the third highest infection-acquired seroprevalence in Canada, at 76.28 per cent, just behind Manitoba’s 77 per cent and Alberta’s 76.42 per cent. It also has the unfortunate distinction of being the Canadian province with the most COVID-19 deaths, recording a death toll of 17,393 as of January 9, 2023, which accounts for nearly 36 per cent of fatalities nationwide. What has Quebec done differently that brought it to this point?

This article partially answers this question by outlining the three dominant features of the Coalition Avenir Québec (CAQ) government’s approach to the pandemic: a lack of transparency around decision making, a shift to authoritarianism and, last but not least, a refusal to recognize COVID-19 as a an airborne disease that was spreading in workplaces, schools and other institutions—thereby preventing the adoption of effective and necessary preventive measures.

A crisis team without transparency

At the outset of the pandemic, the Legault government declared a public health emergency that lasted from March 13, 2020, until June 1, 2022. This overriding of the democratic rules that normally limit executive power gave Legault carte blanche to govern by decree, without requiring approval from the National Assembly or any other body. While these decrees, which were extended almost weekly, allowed the government to implement public health restrictions, they were also used to impose certain working conditions on public-sector employees and award contracts without soliciting bids. These contracts cost the province more than $6 billion.

Premier François Legault eventually set up an all-male “crisis team” made up of the Minister of Health and Social Services, Christian Dubé; the Director of Public Health, Dr. Horacio Arruda (replaced by Dr. Luc Boileau in early 2022); the Premier’s Chief of Staff, Martin Koskinen; and two Special Advisors, Dr. Eric Litvak and Dr. Richard Massé. Dr. Massé was eventually replaced with his spouse, Dr. Marie-France Raynault.

Representatives from the McKinsey consulting firm were also brought on board between April 2020 and June 2020 for the princely sum of $35,000 a day.

A public working group was never established and para-public institutions like Quebec’s national public health institute, the Institut national de santé publique du Québec (INSPQ), were bound to discretion, meaning that their experts could not challenge government decisions in the media.

In a similar example, the Direction nationale de santé publique [Public health branch] operated as a hierarchy: the regional public health branches under its purview were also prohibited from speaking against provincial government decisions.

Requests from journalists and the public to access the documents (“memos”) being circulated between the crisis team yielded disappointing results: leadership was basically making decisions verbally, without a paper trail.

A repressive approach

To add to the lack of democratic transparency, the Legault government also opted for an approach to risk management that took a homogenous view of collective protection while stigmatizing certain segments of the population via public communications.

A key example of Quebec’s repressive approach: it is the only province in Canada to have imposed a curfew―not only once, but twice. The first was in effect from January 9, 2021, to May 28, 2021, while the second ran from January 1 through 17, 2022.

Even though most COVID-19 outbreaks and hotspots occurred in workplaces, schools, and health care facilities, the government maintained its repressive approach and issued statements in the media blaming the pandemic’s multiple waves on home gatherings, which had already been banned.

In a sworn statement filed with the Quebec Superior Court, special advisor Eric Litvak justified the curfew by how easy it was for law-enforcement to enforce it. In this regard, the Quebec government set a record for the most COVID-related fines issued across the country.

Between March 2020 and April 2021, law enforcement issued $24 million in fines to Quebec residents for violating public health measures. By early 2022, that number had soared to $45 million.

Ultimately, this punitive approach to trying to contain the spread of COVID-19 disproportionately impacted young people, homeless people, drug users, racialized communities, women victims of domestic abuse and other marginalized subgroups. Dr. Marie-France Raynault’s justification for the curfew involved stigmatizing young people’s behaviours.

The government finally lifted the curfew in January 2022, following pressure from journalists and the general public to prove that the measure was epidemiologically effective despite statistical evidence of the contrary. The Legault government, recognizing the effectiveness of the vaccine to contain the spread of the virus, used many of the same authoritarian tactics, which further stigmatized vulnerable communities when it introduced a vaccine passport in September 1, 2021,—a controversial move that only increased Quebec’s vaccine coverage by 0.9 per cent.

Denial of the impact of airborne transmission

Given that it is estimated that more than 15 per cent of those infected by the virus will develop long COVID, we predict that this high prevalence will have harmful effects on the workforce and is likely to aggravate the labour shortage and increase disability claims.

In the United Kingdom, the Public and Commercial Services Union has been campaigning since last year to ensure that long COVID is recognized as an industrial disease when the infection occurs in the workplace.

The Legault government, however, has yet to acknowledge the scope of the problem or make any attempt to use the means at their disposal to control infections in the workplace or other government-run institutions.

In keeping with the lack of transparency mentioned above, the INSPQ had stopped publishing its detailed report on workplace outbreaks as of January 1, 2022. Given that measures such as systematic case tracking and publicly available PCR testing have been dropped since January 1, 2021, outbreak data for various settings (workplaces, schools, living and care facilities, recreational areas, and other settings) were no longer methodologically sound and are, therefore, no longer used.

It is worth noting that, up until December 20, 2021, public health reports showed that workplaces alone accounted for 35.2 per cent of active outbreaks. A breakdown by industry showed a higher proportion of infected workers in the restaurant, retail and manufacturing sectors.

Yet, to this day, the COVID-19 protocols published by the Commission des normes, de l’équité, de la santé et de la sécurité au travail [Labour standards, pay equity, health and safety board] have continued to ignore aerosol transmission across variable distances, focusing instead on surface disinfection and cleaning. Scientists estimate that only one in a thousand COVID-19 infections is due to surface contamination; the rest of the time, the virus is transmitted by air, often from several metres away.

Similarly, while people often contract COVID-19 while staying in Quebec health care institutions, the INSPQ’s protocol for preventing this kind of infection has no specific guidelines for COVID-19.

Lastly, even with evidence showing that elementary schools and high schools are major vectors of transmission and have poor indoor air quality scores, the government continues to refuse to install HEPA filters, the most effective filters for cleaning airborne particles, in its schools. This despite the fact that air purifiers could lead to three to four times fewer cases in classrooms.

A pandemic response based on solidarity?

The Legault government also landed a position as the Canadian leader in another category: it had the highest COVID-19 ad spending ratio per capita for 2020-21. Quebec spent over $15.75 per capita on ads, nearly 15 times more than British Columbia, which has only had 4,760 COVID-19-related deaths throughout the pandemic. British Columbia’s COVID-19-related mortality rate per 1,000 inhabitants was 0.94 compared to Quebec’s 2.5.

Quebec’s poor epidemiological situation points to an ineffective pandemic response by the CAQ government from a health standpoint. The science denialism and anti-democratic tendencies exhibited by the Legault government throughout this unprecedented event have only confirmed its tendency toward a style of public management that is incompatible with ensuring people’s well-being.

This administration’s emphasis on individual blame for COVID spread, while simultaneously repressing individual freedoms in favour of a homogeneous approach, allowed the government to wash its hands of its duty to prevent airborne infections, all while avoiding the need to negotiate stricter rules with private-sector employers. It is time to leave this typically neoliberal panic/neglect cycle behind and move toward a concrete approach that is focused on long-term prevention and public education.

It goes without saying that a pandemic response based on solidarity and science could have yielded different results. It is important to mention that two main approaches should have guided the government from the start: the precautionary principle and the principle of harm reduction.

As mentioned above, the Legault government was reluctant to admit that the virus is first and foremost airborne, although data supporting this had started emerging in February 2020. Therefore, the use of masks, improved ventilation in enclosed areas, the use of HEPA filter modules, and the implementation of protocols adapted to aerosol exposure in health institutions could have been applied before reaching a global consensus on how the virus is transmitted.

Secondly, if the government was guided by the principle of harm reduction, it could have encouraged outdoor gatherings instead of prohibiting them. The HIV/AIDS experience has shown that repression and abstinence are counter-productive in containing community transmission and that it is best to rely on education about modes of transmission and safe practices to adopt in different contexts.

In terms of governance, the centralist approach of the CAQ government and the Direction nationale de la santé publique [Public health branch] prevented regional health departments and other local actors from making decisions well suited to the reality on the ground.

The government needs to adopt a more democratic and transparent approach to managing its health and social services, particularly when it comes to pandemic readiness, if it wants to effectively weather other pandemics in the future.