What the NWT’s chief public health officer learned from the pandemic

Dr Kami Kandola says she is proud of the leadership role she played at a “critical time in the NWT’s history,” and is now working on how things could improve.

Interviewed following the publication of a report on lessons the territory could learn from Covid-19, Dr Kandola said important changes can be made to better protect vulnerable people and society as a whole.

In all, the GNWT’s report into its own handling of the pandemic sets out 23 recommendations.

The report recommends re-examining the legislation used by the NWT in emergencies “to ensure that there is the appropriate level of public accountability for decisions that are made during a pandemic,” and queries whether a state of emergency should be able to last indefinitely.

Kandola said she agreed that sharing accountability among more branches of the territorial government would be a better outcome, “so that we don’t have a scenario where the perception is that it’s just the Office of the Chief Public Health Officer being fully responsible for pandemic response.”

Below, read our full interview with Chief Public Health Officer Dr Kami Kandola. You can also read our interview with Premier Caroline Cochrane and our full report on the GNWT’s recommendations for change.

This interview was recorded on April 14, 2023. The transcript has been lightly edited for clarity.

Ollie Williams: Do you remember the point at which you realized that you were going to be the figurehead, in the NWT, for this? Were you aware of that almost immediately, or did that only become apparent over time?

Dr Kami Kandola: I was the chief medical health officer – that was the term – back during H1N1, so I was the spokesperson for that specific pandemic. So when we were looking at what was happening in China and in Italy, in Iran at that point, I was meeting with other chief medical health officers across Canada. The point where I took over control was in mid-March when I declared a state of public health emergency in the Northwest Territories. And so naturally, the role as figurehead and spokesperson was made publicly known at that point.

Were you always comfortable in that role?

That is the role I signed up for. If you look at the Public Health Act and look at my mandate, in October 2018 I assumed the role as chief public health officer. That’s a role that is assigned to you by the Minister of Health and Social Services, it’s an appointed role. And that role has a responsibility of protecting public health and the safety of the NWT residents. So when it comes to pandemic threat, that’s my role. That’s my job.

If you go back to the earliest days of the pandemic, what do you like about the NWT’s response and what would you change with the benefit of hindsight?

In the beginning, there was not much known about the virus Sars-CoV-2. It was information we were learning. What we did know was that there were severe outcomes, there were people dying from severe pneumonia. When we look at the NWT and I look at past infectious diseases – how they are imported and how they spread – our best option at that point, because we already were seeing this happening in other countries, was to restrict the introduction of Sars-CoV-2 in the Northwest Territories while we waited on an effective vaccine or effective antiviral. None of that was available at the beginning. But what I did know was our best chance to avoid the deaths and the hospitalizations that we were seeing across Canada was to slow, as much as possible, the introduction of the virus in the NWT. So that led to declaring a state of public health emergency before we had cases, but it also led to the travel restrictions.

And when I look at that, I would say it was effective, because we avoided wave one, we avoided wave two, we avoided wave three and, by the time we actually had community transmission, that was in August of 2021. And that was starting with the Sahtu. But at that time, we also had rolled out the vaccines, and so we had a better chance at that point of dealing with community spread and transmission than in the beginning, because people already had immunity to it and we understood a lot more about this virus.

As time went on, the Sars-CoV-2 virus changed. In the beginning, there were a lot more lower respiratory tract infections. When Omicron came in December, it was like a blessing in disguise because it mainly targeted upper respiratory tract infections, and what we noticed was a dramatic drop in severe outcomes. And at that point, it wasn’t about zero Covid – it ended up being slowing down Covid just so we didn’t overwhelm the healthcare system. Because of the lower severe outcomes, we at that point felt more and more comfortable loosening our public health measures.

The one situation, looking back – what I know now and wish I’d known then – was the rate of severe outcomes was so low among our children, among our youth. We had scenarios where we had schools closed just to slow down the transmission, but once we knew that the rate of severe outcomes was so low in that population, it became a priority to keep the schools open come January, once we started to see that Omicron was the dominant virus.

So looking back now, you feel as though we could have been a little easier on school closures a little earlier?

What helped was having an Omicron variant that, overall, had low severe outcomes in general. When that variant arrived in the NWT, I felt a lot more comfortable keeping schools open even though we had high rates of Covid transmission during that time. When it was the Delta, Alpha, I was not as comfortable because those particular variants impacted younger people, and so we had younger people being hospitalized – and we hadn’t rolled out the vaccine for the adolescent age group until May of 2021. So I feel there was no way I could have eased up on school restrictions before we had the Omicron variant. At that point I felt more comfortable.

The report sets out a perspective, informed by feedback, that you were very much in charge for much of the pandemic. When you were making decisions, what were your considerations? Did you see it as your job solely to protect the public using the evidence at hand, or did you also see it as your job to think about societal disruption, or the challenges of implementing the instructions that made the most sense from a public health perspective?

For a public health emergency response that had this level of societal and economic disruption, I saw it as a whole-of-government approach. My focus was on the data and evidence around Sars-CoV-2 and how it was evolving. But managing the entire impact? Just as a chief public health officer that would not be feasible, but the focus on the public health measures, watching the data, decreasing importation and then mitigating the community spread, that I saw as my role. Where I would look to the GNWT as a whole is around the community supports, the impact on society, providing these other supports.

If this were to occur again, do you think there is a way to secure similar public health outcomes – or better ones – and minimize societal disruption?

The one area that was difficult is slowing the introduction of the virus. Travel restrictions went really well, we were able to pass the first three waves and roll out the vaccine. But once we had community introduction, the one difficulty which I didn’t see in the report, but which led to a difficulty to control the pandemic, is when you have hard-to-house populations and vulnerable populations that needed wraparound support and safe isolation. That was the biggest difficulty I experienced throughout the pandemic.

In future pandemics, we as the GNWT, working with communities and Indigenous governments, need to be able to rapidly respond if people have a virus that’s contagious, to be able to safely isolate them and provide those supports so they’re not interfacing with society and having continuous spread. The hardest part to control was the spread within these hard-to-house and vulnerable populations. We didn’t have the supports there to prevent further introduction to other populations. That’s an issue we need to work on for future pandemics.

A quote from the report: “People cannot govern their actions if they are unclear about what they are supposed to do.” How much did you wrestle with that dilemma, finding the balance between actions that were necessary and the clarity that was necessary?

There are always ways to improve coordination and communication, and this was a dynamic and changing situation. I do agree that clear roles and responsibilities and pathways for communications could have helped reduce the confusion. Some of the recommendations of the report are not a surprise, but the purpose of the report is looking at this very unusual situation, looking forward and saying, “OK, what can we learn and what can we do differently?”

These recommendations on providing clear direction, so the public can understand and front-line providers can understand? That is important and something that, definitely, we need to work on for the next pandemic. Definitely.

You say some of the recommendations weren’t a surprise. Were there any recommendations that were a surprise?

There are 23 recommendations – four specifically refer to the Office of the Chief Public Health Officer and three refer to legislation. Some of the recommendations I’m working on right now.

Once the pandemic was over, there were some very practical recommendations. One was the role of 8-1-1. 8-1-1 was not what 8-1-1 is in other jurisdictions, it was enforcing my public health measures but it wasn’t a line where people could get 24/7 nursing advice while they were experiencing the pandemic. That was something that I did recognize, I wish we had that during the pandemic. This is something that we worked on and actually rolled out in November 2022. We would have loved to have the public having 24/7 access to timely advice while experiencing Covid.

We’re also working on a public health information system as we speak, putting funds into that, because we felt that would have reduced the turnaround time getting information, and the turnaround time providing information to the public. The information system wasn’t there. That would have helped a lot to speed up that communication process.

The one struggle is around communication accountability within the Public Health Act. In the experience I have had dealing with outbreaks – it’s not like I was new at this, I’ve had 20-plus years of experience in public health, I’ve dealt with H1N1 and dealt with flu outbreaks – I know how quickly these outbreaks can occur. I know, once it has settled into a community, how fast it can transmit. Some of the measures were based on where the virus is, the data, the evidence we had at that time. And so those decisions were made, the public health measures were made, and then the communication was provided after.

The difficulty is, in making those rapid public health decisions to protect public safety, if we had to go through reviews – like, if we took one week or two weeks to go through giving feedback on the public health measures – we would have missed some opportunities to contain the outbreak. That is an awkward balance, the speed with which we need to initiate public health actions and communicating about that ahead of time.

Another quote reads: “Most interview participants expressed concern about the level of OCPHO authority over GNWT operations and the public for prolonged periods of time, and felt that this level of authority should be limited in the future,” How do you feel about that sentence of the report?

Even though this was a pandemic, because of the level of societal disruption, this was not only one office. This did require an all-of-GNWT approach. We did have the Covid Secretariat but if we’d had emergency support – so the accountability is not just in one office, but different components are spread across the government – that would have been helpful, and I could have just focused on the pandemic response and not the whole wraparound and services.

We need to be working on a different structure – now, because we don’t know what’s around the corner – so that we don’t have a scenario where the perception is that it’s just the Office of the Chief Public Health Officer being fully responsible for pandemic response. I do believe the weight will be redistributed, even if it is a pandemic, so that I can just focus on the pandemic components but not on mitigating societal disruption.

Do you wish that there had been more political shouldering of the burden from the territory’s politicians?

When I look across Canada at all the other chief medical health officers leading the pandemic response in their jurisdictions, I honestly I feel like a lot of people envied the Northwest Territories because of the level of support I got from my premier. I’m very fortunate.

The reason why we were able to avoid so many casualties, so many hospitalizations and deaths, was that I had the immediate support of the premier to allow something that’s never really been done, I believe – the travel restrictions to prevent the importation of a pandemic virus – which bought us time to vaccinate. Who knows how many people are walking around right now, that would not be walking around, because we missed the first three most deadly waves of the pandemic. In that, for sure, I had the support and backing of the premier. But that wasn’t the case across Canada.

Have you recovered from the pandemic in terms of your own mental health, and your own reflection on what that took as chief public health officer?

There’s a song that whatever doesn’t kill you makes you stronger. I actually feel I’m stronger. I feel like I have a level of resilience.

The strange thing is over the past year – when we lifted the state of public health emergency – to watch the severe outcomes drop, to watch Covid become endemic, to see the rates go down among the 80-plus, to hardly see any hospitalizations… that gives me a level of satisfaction. I am really happy with where the NWT is. At the same time, I’ve had time, a year, to reflect and go: what did I need then that could make it better for the next time? And that’s what I want to work on.

The thing with the NWT – and I’ve been here 20-plus years – is it’s a very unusual jurisdiction, in that you network. I know a lot of people in communities and I’ve had people come up from all different communities, all different backgrounds, thanking me for taking that leadership role when I did. So to me, I’m actually happy. I’m honoured that during a critical time in the NWT’s history, I could take a strong leadership role. I showed up when people needed me and I didn’t hightail it out of the NWT. That’s all I can say.