Canada and the United States are, in many respects, similar countries. With the coronavirus outbreak, the two North American nations had comparable risk profiles, sharing (for example) similarly aged populations and similar distance from the earliest hot spots in Europe and East Asia.
Yet the outbreak has been dramatically worse in the United States than its northern neighbor.
Per capita, the United States is currently seeing about twice as many confirmed coronavirus cases as Canada and about 30 percent more deaths. When you look at per capita cases and deaths across the course of the entire outbreak, the comparison looks even worse: the United States has over two times as many confirmed coronavirus cases as Canada and roughly twice as many deaths.
Canadian testing rates have been consistently higher, especially during critical early stages for the two countries: In mid-March, the Canadian testing rate was roughly five times higher than the American one.
To explain this divergence, I spent the last week speaking with Canadian public health experts who had been following the situation in the two countries closely. These experts varied in their take on their own country’s performance during the pandemic, assessments ranging from middle of the pack by global standards to one of the very best in the world.
But they all shared the same view of the difference between the United States and Canada: The Canadian policy response has been orders of magnitude better than the American equivalent.
“We have a federal government that is supporting provinces’ responses,” says David Fisman, an epidemiologist at the University of Toronto. “You have a chief executive who is directly undermining the public health response.”
There are a number of factors that have enabled Canada to perform at a higher level than the United States, including more consistent pre-virus funding for public health agencies and a universal health care system. But one of the most important seems to have been a difference in political leadership.
The American response has become infected by partisan politics and shot through with federal incompetence. Meanwhile, Canada’s policies have been efficiently implemented with support from leaders across the political spectrum. The comparison is a case study in how a dysfunctional political system can quite literally cost lives.
The Canadian approach has not been perfect. Its death rate is currently much higher than best-in-class performers like Germany and South Korea; Canadian officials have fallen down, in particular, when it comes to long-term senior care and the indigenous population. But given the interdependence between these two large neighboring economies, Canadians are not only vulnerable as a result of their own government’s choices but also because of their southern neighbors’ failures.
“The biggest public health threat to Canada right now is importing cases from the United States,” says Steven Hoffman, a political scientist who studies global health at York University.
The key political differences
The easiest way to see the divergence between the two countries is to look at this chart of per capita cases across the epidemic, courtesy of Our World in Data:
You can see in the data that cases began to tick up in the two countries at roughly the same time. But in March, the American caseload spikes significantly higher and faster than the Canadian equivalent, indicating greater Canadian success at “flattening the curve.” Through early May, the Canadian numbers remain consistently and significantly lower.
The most immediately visible reason for this divergence has been the choices made by each country’s political leadership.
Throughout the crisis, Prime Minister Justin Trudeau has taken a consistent stance that the virus is a serious threat that requires a strong federal response. In mid-March, Trudeau’s wife Sophie Grégoire tested positive — causing the prime minister himself to enter strict self-isolation well before mandatory distancing became part of everyday life. He took over parenting duties from his sick wife and conducted socially distanced press briefings from his front lawn. Since his wife’s recovery, Trudeau has been consistently emphasizing the need for Canadians to stay the course and remain distanced — unlike his counterpart in the White House.
Of course, such rhetoric would seem like a performance if not backed up by actual policy. But the Trudeau government has won high marks from experts when it comes to core federal responsibilities. Two clear points of contrast with the US are personal protective equipment (PPE) and testing.
In Canada, the federal government has served as a centralized hub of PPE purchases — buying supplies in bulk and distributing them to the country’s provinces on the basis of need. In the United States, the federal government’s efforts in this area have been haphazard and marked by political favoritism.
Maryland Gov. Larry Hogan is currently hiding thousands of coronavirus tests, purchased from South Korea, in an “undisclosed location” protected by the National Guard. Hogan, a Republican Trump critic, is worried that the federal government might seize them. After the federal government seized 500 ventilators requested by Colorado’s Democratic governor, Trump sent 100 back to the state — crediting them to Sen. Cory Gardner, a Republican up for reelection in 2020.
Canada was ahead of the North American curve on testing because its federal government once again made the right choices. In mid-March, Canadian federal authorities launched a large-scale testing procurement program aimed at ensuring the country could test early and often. By contrast, Trump put his unqualified son-in-law, Jared Kushner, in charge of the country’s testing ramp-up. Kushner proceeded to hype a Google testing website that didn’t exist and spearhead a drive-through push that, as of early April, had built a grand total of five testing centers across the entire country.
The top-level response isn’t all that matters here. Canada has a similar federal system to America’s, where a lot of the key decision-making on this epidemic — like the power to issue stay-at-home orders — is devolved to provincial authorities. In theory, there could have been a situation like America’s, where Republican governors of large states were either slow to implement distancing measures or refused altogether, largely for ideological reasons.
The premiers (governors) of Canada’s provinces performed at varying levels of quality during the outbreak. But what’s notable is that there was no dissent from local authorities over the basic need for extreme measures to stop the virus’s advance. In late March, Canadian provinces moved en masse toward distancing, with no real difference between provinces governed by Liberals, Conservatives, or any other party.
“We put in factors like physical distancing fairly quickly, and there wasn’t any inconsistency like what you’re getting right now with Trump,” says Anna Bannerji, a physician and expert on respiratory infections at the University of Toronto.
This speaks to the deeper political reasons for Canada’s superior performance, ones that go beyond the personal qualities of Justin Trudeau and Donald Trump.
While Canada’s political divisions are stark, with a sharp urban-rural divide very much reminiscent of America’s, partisan identities are not nearly as fixed or powerful as they are south of the border. In a world where partisanship isn’t so extreme and there’s a greater degree of political consensus between the major parties, it’s much easier for political leaders to come together during a time of national crisis.
“In Canada, polar ends of the political spectrum are completely aligned on how to manage this pandemic. And I gotta tell you, it’s extraordinarily helpful,” says Isaac Bogoch, an infectious disease expert at the University of Toronto. “That’s one of the main drivers of success here.”
A forthcoming paper in the Canadian Journal of Political Science by scholars at Toronto and McGill University, analyzed data on coronavirus attitudes among both members of parliament and the general Canadian public. They found that, unlike in the United States, there was zero evidence of political polarization on the coronavirus — of Liberals taking it more seriously and Conservatives being skeptical.
“Both Canadian elites and the mass public are in a moment of cross-partisan consensus on COVID-19,” they conclude. “Unlike in the United States, response to the coronavirus is not structured by partisanship, at least at the moment.”
Perhaps the most interesting example of this is Doug Ford, the premier of Ontario (Canada’s most populous province). He’s a right-wing populist who won power by contrasting himself with unpopular center-left opponents, rallying rural and suburban voters against the alleged insularity and immorality of the urban elite — though Ford, like Trump, hails from his country’s largest city.
There are certainly places to criticize Ford’s response; an Ontario nursing home made international headlines for being one of Canada’s hardest-hit locations. But he’s held to the national consensus rather than trying to position himself as a leader of a populist uprising. When asked recently about a tiny anti-distancing protest in Toronto, he unequivocally condemned it.
“It’s reckless to do what they’re doing and personally I think it’s selfish,” Ford said, describing the protesters as “a bunch of yahoos.”
In discussing the United States, Ford has taken a decidedly different tone that underscores the disparity between the two nations. Despite being unusually open to immigration by right-wing populist standards, he has been quite concerned about the risks of the much more severe outbreak down south.
“I don’t want them in Ontario,” he recently said of Americans. “We need to keep our borders closed.”
The importance of public health and universal health care
While the nature of politics in the two countries seems to be responsible for the sharpest distinctions between the two countries, it’s also worth noting that there are at least three other notable differences rooted in longer-term approaches to health policy.
First, Canada has more direct experience with novel coronaviruses. In 2002, a coronavirus we now call SARS emerged in Guangdong, China, and eventually spread to about 26 countries. In 2003, there was a significant outbreak in Canada centering on Toronto; 44 Canadians died from the disease (the US had a tiny number of cases and zero deaths).
This recent experience with a respiratory disease outbreak is something Canada has in common with some of the best international performers during the coronavirus crisis, most notably South Korea and Taiwan. All of these countries, Canada included, studied these past experiences and used them to guide their policy during the current outbreak.
“Obviously there were lessons learned from SARS,” Bogoch says. “How the municipal, provincial, and federal public health agencies coordinate with each other — many of those lessons [came from] SARS.”
Second, the public health budget in Canada has increased in recent years. In the US, by contrast, authorities have been relatively starved of resources: CDC funding has fallen by 10 percent over the last decade in inflation-adjusted dollars.
“Public health has faced chronic underinvestment in the United States for quite some time. Over the last couple of years, there have been further cuts,” says Hoffman, the York professor. “Countries get to choose how prepared they are for pandemics. And the United States made strategic budgeting choices that do not position it well.”
Third, and finally, every expert I spoke emphasized the value of Canada’s single-payer health care system at this crucial moment, especially when compared to America’s extremely expensive and low-capacity system.
The reasons varied. Some pointed out that, in a single-payer system, the universality of care meant that everyone would go to a doctor if they needed a test or treatment. If care is affordable, poor and marginalized communities — like, say, undocumented migrants — are less likely to become hot spots than they are in the American system, where out-of-pocket costs can be prohibitive.
Others argued that a single-payer system gives Canadian authorities coordinating powers that their American counterparts lack.
When the government controls the system of payment for health care services, rather than leaving decisions up to hospitals and insurance companies, they have a huge amount of power to commandeer the health system for national goods. If a Canadian hospital is having a spike in cases and needs an emergency shipment of PPE, the government can work to get it shipped over from a less-needy hospital. If an American hospital is having the same problem, they’re going to have a tough time getting it from a competitor (absent a level of aggressive police intervention we haven’t seen here).
It’s a little tricky to say how much of the difference between these countries can be explained by the specific nature of Canada’s health care system. If you look across the world, there are countries with single-payer systems that have had severe outbreaks (like Italy) and countries with more privatized systems that have done well (like Australia).
What’s clearer, rather, is the difference between the United States and everywhere else: Every other developed country has some kind of universal coverage system, while the United States does not. It’s not the sole reason why the United States has done worse than Canada, but it appears to be a factor.
Canada’s not perfect. But America is clearly worse.
One problem that a lot of Canadians have with American reporting on their country is a tendency to romanticize its northern neighbor: making a country with real and significant problems seem like a cold, polite paradise.
That’s as true on the coronavirus as it is on anything else. The Canadian experts I spoke to had no shortage of complaints about their country’s response.
The most striking such failure has to do with senior care facilities. As of mid-April, roughly half of all Canadians who had died were residents of such buildings, raising questions about the standard of professional attention and medical care at dedicated homes for the elderly. “It is profoundly troubling and deeply disturbing to me how broken this part of our health care system is,” Susan Bartlett, a professor of medicine at McGill University, told the New York Times’s Dan Bilefsky.
Canada’s indigenous population is another important problem area. These communities, some of which are so isolated that they can only typically be reached by aircraft, are chronically under-resourced and underprivileged. While the death toll has yet to reach astronomical heights in those areas, they remain acutely unprepared for an outbreak.
These are serious failings, ones that shouldn’t be glossed over or excused. Canadians can and should hold their government accountable for its mistakes.
But no country’s response to this outbreak has been perfect. Even early success stories have faced problems down the line — second waves in Hong Kong and Singapore, for example. Canada could see a turn for the worse and end up with an experience closer to America’s.
But at this point in the crisis, the worst you can say about the Canadian response is that it has been basically competent — what you would expect from a country with a functioning political and health care system. The United States, by contrast, hasn’t cleared this lowest of bars. Our lack of attention to public health, poorly designed national health care system, and deep political dysfunction have contributed to the greatest public health crisis of our lifetimes.
The United States could have been in a similar situation as Canada. We have the world’s largest economy and its finest academic institutions; the Canadians show us that, had our political leadership marshaled these resources in the right ways and at the right times, some significant numbers of American lives would likely have been saved.
That’s not what happened. We now have every reason to believe that our broken political system is quite literally deadly.