Why is COVID-19 hitting Quebec harder than the rest of Canada? Dr. Horacio Arruda, the province’s public health director, has suggested it could be because Quebec’s strain of the novel coronavirus is especially virulent. A far-fetched hypothesis, it was quickly disproved by scientists. But Dr. Arruda is no stranger to this kind of nonsense.
Several days earlier, Arruda said that airborne transmission of COVID-19 is negligible — wrong again. Which reminds me that, at the beginning of the pandemic, he claimed that wearing a mask is dangerous. He has never apologized for this misinformation. He also said that as of mid-March, it was unknown that the coronavirus could be transmitted asymptomatically. But this was a well-known fact, and had been for several weeks. This collection of blunders raises the question: is Dr. Arruda qualified to occupy the crucial position of director of public health when Quebec has one of the highest rates of infection in the world?
Let’s examine his statements one by one.
The allegedly ‘more aggressive’ strain
On Sept. 25, a journalist asked the following question at the press conference featuring Minister of Health Christian Dubé and Dr. Arruda: “It’s fall, and Quebec is still the epicentre of the pandemic in Canada. Why?” Here is Dr. Arruda’s full answer (You can hear it at the 37-minute mark here):
“There are several hypotheses, one of which, I’ll tell you, although I don’t want to go into the technical details, there was a study that was done of the virus that entered Quebec, which is different than the virus that was in China, that came much more from Europe, which had a higher mortality and morbidity rate, so there was that strain, it’s not me who says this, it’s experts who did analyses of the strain’s genotype, that, that could have been a factor. After that, there’s all kinds of factors of how a society is organized, I mean. … The behaviour of individuals, maybe now that we’re not all together, it’s hard to say exactly what the thing is, it’ll become clearer in time, but there’s already some hypotheses linked to the fact that there are some strains that are more aggressive, more deadly, more easily transmitted than others. The Asian strain that arrived in British Columbia isn’t the same as the one we had here.”
Dr. Arruda didn’t specify which study he was talking about. All we know is that just four days earlier, the Institut national de santé publique du Québec (INSPQ) and the McGill University Genome Centre announced the preliminary results of an analysis of the genetic sequence of the SARS-CoV-2 virus responsible for the first cases of COVID-19 in Quebec. Dr. Jesse Shapiro of the McGill Genome Centre explained that the most common strain in Quebec is 614G. On Twitter, he added, “No, we can’t attribute the severity of the epidemic [in Quebec] to genetic causes.”
Fatima Tokhmafshan, a geneticist at the Research Institute of the McGill University Health Centre, was more scathing. Several hours after Dr. Arruda’s statement, she wrote on Twitter that it is “IRRESPONSIBLE to blame how the pandemic is unfolding on a [viral] variant as opposed to bad policy.” “Scientific evidence shows that this variant [614G] is NOT more dangerous.”
Strain 614G is a mutation of strain 614D, which emerged in China. Dr. Shapiro and Tokhmafshan cited a study that showed 614G is more easily transmitted, but isn’t correlated with higher mortality or morbidity … contrary to Dr. Arruda’s claims. Other studies point to the same conclusion. Aaron Derfel, one of the best journalists at The Gazette whom Premier François Legault has shockingly personally attacked on three separate occasions for reporting on concerns about the government’s handling of the pandemic, relayed their comments. “Communication by authorities is critical during a pandemic,” he concluded in one of his Twitter threads. “At the very least, Dr. Arruda should elaborate on [his] assertions ... and make public the study to which he alluded” that shows that Quebec’s viral strain is more aggressive.
Tokhmafshan emphasized that strain 614G is also spreading through the rest of Canada. Research indicates that it has become the dominant strain in the country, and, in fact, throughout most of the world — America, Europe, Africa, the Middle East, Oceania, the Indian subcontinent. China is almost the only country in which the original strain, 614D, is still dominant. A pre-publication study (not yet peer-reviewed) shows that strain 614G has been dominant in Washington state since April. It would be extremely surprising if the same development did not occur in British Columbia, which is directly north of Washington.
Airborne transmission of the coronavirus
There is no doubt that SARS-CoV-2 can be transmitted by air. Far from being negligible, this kind of transmission explains several super spreader events, very likely including the outbreak that followed a night of karaoke in Quebec City, which resulted in at least 90 infections, as well as the outbreaks at Chaleur Bay, which stemmed largely from a bingo night.
Aware of mounting evidence of the importance of airborne transmission, the INSPQ released a document in July inviting public building managers to keep their premises well ventilated. “These recommendations are based in particular on the complementary but consistent findings of a growing number of studies on the dynamics of infectious aerosols in indoor environments. These show the relevance of applying optimized ventilation to densely occupied spaces as an additional measure to mitigate the risk of infection associated with exposure to SARS-CoV-2. The results of recent quantitative analyses ... all emphasize the importance of ensuring proper ventilation in this type of environment in order to minimize the risk of COVID-19 transmission.”
An aerosol is a liquid or solid particle suspended in a gaseous medium, such as a small droplet in the air. We emit thousands not just when we cough or sneeze but also while simply speaking or breathing. We can see this very clearly in winter, in cold and dry weather, when our warm and humid breath forms a little cloud. In a closed and unventilated environment, a 10-micron particle can stay in suspension for up to eight minutes. These aerosols are found in high concentrations around the transmitter — hence the importance of keeping a distance of two metres and wearing a mask — but they can also travel and accumulate in an unventilated room, and then infect one or more other people located more than two metres away.
On Sept. 8, a journalist asked Dr. Arruda about the changes in knowledge around airborne transmission. He responded as follows: “As far as airborne transmission is concerned, very quickly, we know that airborne transmission can happen, but it’s not the ‘driver,’ it’s not the main engine of the disease. That doesn’t mean it’s bad to aerate the house, or ventilate the house, I think that’s just a good practice, even just to remove toxic substances after cooking, etc. But it’s not the ‘driver’ ... of the disease.”
If we don’t understand the importance of airborne transmission, we can’t understand the importance of ventilation. On the other hand, if we understand the importance of ventilation, we understand the importance of airborne transmission.
Ventilation dilutes and expels infectious aerosols. It doesn’t affect the ballistic trajectory of larger droplets measuring 100 microns or more, which, dragged down by gravity, fall within a metre or two — either on the ground or, if they’re unlucky, on the face of a nearby person. More and more scientists estimate that aerosol transmission is much more significant than droplet transmission.
It is worth comparing Dr. Arruda’s statement with that of German Chancellor Angela Merkel (who was a doctor before becoming head of state). Merkel declared that, although it might seem primitive at first glance, ventilation is “probably the least expensive and most effective way” to control the spread of the virus. The German government has added room ventilation to its list of recommendations to protect against COVID-19, alongside physical distancing and wearing a mask. “Regular ventilation of private and public rooms can considerably reduce the risk of infection,” it argues. It’s widely accepted that 90 per cent of patients contract SARS-CoV-2 indoors, not outdoors.
The Quebec health administration and its director’s poor understanding of the relative importance of different modes of transmission has very real consequences. The best example can be found in the back-to-school plan, which is silent on the importance of properly ventilated classrooms. Experts say the air should be changed at least five times per hour.
A group of 28 physicians, epidemiologists, and scientists expressed concern about this serious oversight in a letter published by La Presse on Sept. 30. “The risk of infection with the new coronavirus is at its highest in an enclosed room containing several unmasked people in prolonged contact,” they explained. “That’s exactly the situation that characterizes the tens of thousands of classrooms in Quebec.” (Since the publication of this letter, the Ministry of Education has changed course somewhat, requiring that high school students in red zones wear masks in the classroom.)
Silent on ventilation, the back-to-school plan instead recommends the following: “Special attention should be paid to surfaces that students touch frequently, including microwaves and vending machines; water fountains should be disinfected regularly, and it is recommended that they be used only to fill personal water bottles.”
This is undoubtedly helpful, but is it really the top priority? In its report on COVID-19 in indoor environments, the INSPQ emphasizes twice that there have been no documented cases of infection from contact with a contaminated surface.
For comparison, the back-to-school plan in Vermont — the U.S. state with the lowest rate of infection — dedicates an entire page to the importance of well-ventilated classrooms. (Dr. Anthony Fauci, the foremost expert on infectious diseases in the United States, states that Vermont should serve as a model in the fight against COVID-19.)
Banter, ignorance, and nonchalance
On Jan. 30, alarmed by the spread of the new coronavirus from China, the World Health Organization declared a Public Health Emergency of International Concern. As of February, the entire world mobilized to fight the wave. In British Columbia, Provincial Health Officer Bonnie Henry was working tirelessly to implement successful measures to combat the pandemic.
As for Dr. Arruda? He was catching a flight to Morocco, where he was met with — in his own words — a “royal” welcome. He had been invited on this all-expenses-paid trip to participate in a symposium. Speaking before a group of pharmacists, he proceeded to banter and joke about the dangers of the pandemic. “I told my people to wait until I come back to have our first case of coronavirus in Quebec. Well, they didn’t wait for me. So, when I get back, the evaluations for my assistant directors will be very bad,” he added, to laugher from the audience. He lamented the fact that the media are giving “a lot of space” to the new virus rather than other issues, according to the Journal de Montréal, which got its hands on a video of his presentation.
After the symposium ended, Dr. Arruda extended his stay in Morocco for a vacation until March 8. In the meantime, thankfully, other government officials had taken the WHO’s alert seriously. Quebec in turn declared its own public health emergency on March 13. At that time, Dr. Arruda was unaware that asymptomatic carriers of the coronavirus could be contagious. Invited on popular talk show Tout le monde en parle two months later, he admitted his own ignorance about this “damn virus that we didn’t know spreads before people have symptoms.”
So, mired in its ignorance, the Direction de la santé publique (DSP) did not alert doctors of the risks of asymptomatic transmission. Even Dr. Karl Weiss, president of the Association des médecins microbiologistes infectiologues du Québec, was unaware. However, several studies and statements from official health authorities had already sounded the alarm. It’s understandable that a doctor on the front lines like Dr. Weiss doesn’t have time to keep up with all the latest research. But doesn’t the DPS have a responsibility to be well informed? If not, what is it for?
As of Jan. 31, six weeks earlier, Dr. Anthony Fauci had already cited a study by German researchers that showed that people could transmit the coronavirus before showing symptoms. “There's no doubt after reading this paper that asymptomatic transmission is occurring,” he told CNN.
The consequences of the DSP’s ignorance have been catastrophic. Public health did not know that, if they did not have symptoms, members of healthcare staff — attendants, nurses, technicians, etc. — could transmit the virus to elderly residents of long-term care homes, who, because of their age and their already fragile state of health, were very at risk. Therefore, very few precautions were taken to prevent asymptomatic transmission.
Foolishness about masks
Then, on March 18 — five days after the start of lockdown — Dr. Arruda urged Quebecers not to rely on masks as protection against COVID-19. Gesticulating to underline his point, he argued that masks provide a false sense of security, and could even increase the risk of infection. This claim was entirely unfounded. No serious scientific journal would have published such nonsense. There was already overwhelming evidence to the contrary. A meta-analysis of 172 studies published in the Lancet in June shows that masks have long been known to significantly reduce transmission of the virus.
One month later, the Canadian Public Health Agency and the U.S. Centers for Disease Control recommended mask-wearing to the general public, and Dr. Arruda quickly changed his tune. But he never explicitly corrected his previous claims. And the damage had been done. The March 18 video in which he gesticulated wildly to demonstrate the uselessness of masks has continued to circulate on social media, especially on conspiracy sites (Facebook eventually shut down several of these sites, including that of prominent conspiracy theorist Alexis Cossette-Trudel).
On June 16, Dr. Arruda confessed that he was unaware of the shortage of personnel in the healthcare system when the epidemic first struck Quebec. “What I didn’t know was the state of staffing shortages in the CHSLDs [long-term care homes], the number of people who were moving from one facility to another. I didn’t have that information. It’s not my area anyway, but still, I think we were taken by surprise.”
“It’s jaw-dropping,” responded columnist Josée Legault in the Journal de Montreal. “The labour shortage in CHSLDs has been documented and decried for years. It has been denounced in every outlet. Including in several reports, as public as they are scathing, from the Auditor General of Quebec and the Ombudsman.”
Josée Legault isn’t the only columnist to ask themselves these questions. “Horacio Arruda has been of political service to a government whose priority in a public health crisis, it appears, is no longer public health,” wrote Don Macpherson in The Montreal Gazette this summer, following the government’s decision to renew Arruda’s contract for three years, with a starting salary of $305,000, making him one of the highest paid civil servants in Quebec. Is Deputy Minister Arruda worth this all-star salary? Macpherson asked, “That depends: Worth it to whom, and for what?”
Unlike Dr. Arruda, Ontario’s chief medical officer, Dr. David Williams, keeps his distance from Premier Doug Ford. In May, he publicly opposed Ford’s reopening plan. In Quebec, Dr. Arruda has his office in the same building as the premier.
Elsewhere in the world, experts in similar positions are scrambling to provide thorough and in-depth educational programs. In the United States, Dr. Fauci is an example. He’s not the only one. In Germany, virologist Christian Drosten, special counsel to Angela Merkel, launched a podcast in February to communicate the most relevant information to the public. Up to five times a week, he spends an hour responding to questions about science, the latest research on COVID, and how societies can navigate this crisis. His podcast, titled Das Coronavirus-Update, has grown more popular than programs focusing on sex, crime, and even soccer.
In terms of navigation, the little ship Quebec is now facing rough seas. François Legault was elected premier: he is and will remain the captain. But no one elected Dr. Arruda as helmsman. Perhaps it is time to acknowledge that he has demonstrated that he lacks the qualifications to steer us through this storm. Adding to a long list of blunders, his recent statements don’t show that Quebec has a problem with a “more aggressive” strain of the coronavirus: they prove instead that Quebec has a problem with its public health director.