Montreal stands out as a hub for business and commodities, but it is also a crossroads for the encounter of viruses and bacteria. Diseases from all corners of the world regularly make stopovers there before deciding to settle or continue their journey. Indeed, since the past centuries, several health issues have been documented in the city before spreading to other regions of Quebec and other provinces in Canada. In 1832, a cholera epidemic from Europe finally contaminated the St. Lawrence River, spreading to Montreal and the surrounding region [1]. Much later, in 1885, Montreal received the smallpox from Chicago; starting from a single case, the disease eventually reached nearly 20,000 individuals  [2] . In the case of Spanish flu in 1918, while Montreal was not the starting point for Canadian transmission, it later became a major transit point[3]. With regard to HIV/AIDS, retrospective diagnoses indicate that the first case in Canada was recorded in Montreal in 1979  [4]. Although multiple routes of dispersion of the disease subsequently emerged, Montreal remained a focal point of cases, accounting for 75% of the total prevalence in Quebec at the end of the 1980s [5]. The COVID-19 pandemic is no exception; it struck Quebec harder than any other province [6] and Montreal was its primary target. Similar to the case of AIDS, it was also in Montreal that the first case of simian smallpox in Canada was recorded [7]; ​today, with 525 cases, Quebec is, on an proportional account, ahead of all the other provinces in the country. The spatiotemporal dynamics of epidemics show that the city has often been the starting point for some of the major health problems in Quebec and Canada. However, the fact that the city is often caught up in epidemics is not in itself a peculiarity. Rather, it is the approach to management that needs to be questioned.

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Considering the metropolis's exposure, shouldn't another control system be considered? The task is immense because in such a situation, in addition to the surveillance (passive and active) and the immunisation of the population, there is also surveillance of other vectors, i.e. animals, birds and other carriers, as part of the One Health approach [8]. The efforts should match control measures comparable to those established for Highly Pathogenic Avian Influenza surveillance [9]. Even though there is no doubt that a certain effort is being made in this regard, what was observed at the beginning of the COVID-19 pandemic does not seem to be an indicator of anticipation and hope. Indeed, while anxiety was prevalent among populations around the world, travelers departing from or arriving at Montreal's P.E. Trudeau Airport seemed to find themselves in a desert of prevention and precaution[10]. No one was tasked with welcoming and guiding them on the measures to be taken and the behavior to adopt to avoid contracting or transmitting the disease. This situation is reminiscent of the C. difficile crisis in 2004. During that crisis, the bacterium was also transmitted through direct hand-to-hand contact, among patients, or with healthcare personnel. Strangely, neither the authorities nor the hospitals had informed the public that a health crisis was underway [11]. Like a century-old habit, the authorities during the Spanish flu had also almost maintained a veil of silence over the diagnosis, merely referring to it as an ordinary cold (McGinnis, 1977). The management of smallpox in 1885 appears to be the benchmark for failure that Montreal has carried throughout the century. After failing to promote the smallpox vaccine, which was already well-known, the Montreal Health Bureau discharged from the smallpox-invaded hospital (Hôtel-Dieu) all patients who didn't appear to be afflicted. This mistake propagated smallpox in the city [12].

 

As for the measures to be taken at the airport against Covid-19, Montreal's public health officials certainly had their own ideas. Did they only have their own power? Certainly not. This situation recalls the context of the birth and evolution in the 1870s of the public health unit in Montreal, which for a long time had received scant consideration from the authorities [13]. Changes are necessary to improve the situation, and specifically the decision-making process for future health crises. The distinction of competencies and division of powers between municipal, provincial, and federal governments cannot be accepted as an excuse for all preventive failures. The expected collaboration between these levels in these circumstances should be more scientific than political, and a science-based decision would dictate a uniform solution.

 

[1]Rutty & Sullivan (2010). This is public health: A Canadian history. CPHA100, Celebrating a century of public health leadership.

[2] INSPQ, (2022). Ligne du temps des maladies infectieuses. https://www.inspq.qc.ca/sites/default/files/documents/lspq/ligne-du-temps-maladies-infectieuses.pdf

[3] McGinnis J. P. D. (1977). The Impact of Epidemic Influenza: Canada, 1918-1919. Historical Papers / Communications historiques, 12(1), 120–140. https://doi.org/10.7202/030824ar

[4] Société Canadienne du Sida (2022). History of Canadian AIDS Society. https://www.cdnaids.ca/about-us/history/.

[5] Remis R. & Roy E. (1991). Sida : le suivi de l’épidémie au Québec

[6] Alami H, Lehoux P, Fleet R, Fortin J-P, Liu J, Attieh R, Cadeddu SBM, Abdoulaye Samri M, Savoldelli M and Ag Ahmed MA (2021) How Can Health Systems Better Prepare for the Next Pandemic? Lessons Learned From the Management of COVID-19 in Quebec (Canada). Front. Public Health 9:671833. doi: 10.3389/fpubh.2021.671833

[7] Sharon S. Sukhdeo MD, Khuloud Aldhaheri MD, Philip W. Lam Un cas de variole simienne chez l’humain au Canada CMAJ 2022 August 2; 194:E1031-5. doi : 10.1503/cmaj.220886-f 

[8] Aenishaenslin C., Hongoh V., Cissé H. D., Hoen A. G., Samoura K., Michel P. et al. (2013). Multi-criteria decision analysis as an innovative approach to managing zoonoses: results from a study on Lyme disease in Canada. BMC Public Health, 2013, 13:897.

[9] Inspection Canada, (2022). Aperçu des méthodes de prévention, de préparation et d'intervention en matière d'influenza aviaire. https://inspection.canada.ca/sante-des-animaux/animaux-terrestres/maladies/declaration-obligatoire/influenza-aviaire/prevention-de-preparation-et-d-intervention/fra/1375982718329/1375982719875

[10] Gosselin J. (2020). Aéroport Montréal-Trudeau: des voyageurs calmes malgré l’épidémie de coronavirus. La prersse, https://www.lapresse.ca/actualites/2020-03-01/aeroport-montreal-trudeau-des-voyageurs-calmes-malgre-l-epidemie-de-coronavirus.

[11] Eggertson L. & Sibbald B. (2004). Hospitals battling outbreaks of C. difficile. CMAJ  171 (1) 19-21; DOI: https://doi.org/10.1503/cmaj.1040979.

[12] Marsh J. H.  (2021). L'épidémie de variole de Montréal en 1885. L’Encyclopédie Canadienne. https://www.thecanadianencyclopedia.ca/fr/article/un-fleau-frappe-montreal. 

[13] Gagnon E. (1937). Notes on the early History and evolution of the Department of Health of Montreal. Abstract of a paper presented before the Section of Vital Statistics and Epidemiology at the twenty-sixth annual meeting of the Canadian Public Health Association Ottawa June 1937.