On the first night of a war games exercise meant to help Canada prepare for a possible global conflict, Russia sent drones into Poland, and NATO forces opened fire for the first time since the beginning of Russia’s war in Ukraine. Not in the game: in real life. On the elevator up to the introductory dinner at the Royal Canadian Military Institute for the sequel to the war game from last year involving Canada’s health-care system, one doctor said, “It’s not so hypothetical anymore, is it?”
One year earlier a group of health-care leaders, Canadian Armed Forces officials, and provincial government representatives completed an almost unprecedented Ontario-focused war games exercise based on a wider war in Europe involving Canadian troops. As trauma expert, NATO blood panel leader, and military surgeon Dr. Andrew Beckett put it, “the last time we did something like this was probably 1939.” To the vast majority of Canadians, and even to those in the room at the time, the idea of a society-wide war was hard to even imagine.
This time, the urgency was palpable. As the Russian war in Ukraine continues, the world is sliding into a more militaristic posture. Eastern European nations along Russia’s border — Lithuania, Poland, Latvia, Estonia — are engaged in various levels of medical wartime planning. Russia’s drone incursion into Poland in early September was followed by suspected drone incursions across Europe, shutting down major airports or seeming to map territory. Norway’s defence minister says Russia has nuclear weapons in the northern Kola Peninsula, pointed at the U.S., the U.K., and Canada, in case of war with NATO.
Meanwhile, Germany is expecting to treat 1,000 wounded patients daily in the case of a wider European conflict, and is discussing the return of mandatory military service; this summer France’s health ministry directed its hospital system to prepare for potential military casualties by March 2026.
Canada is further from Ukraine, and further behind in its preparations — for instance, the plan to use public servants as military reservists, as reported by the Ottawa Citizen, which was hastily reconsidered — which is what this war game was trying to solve. It was called Exercise Canada Paratus, and it was bigger than the first edition. There were federal officials in the room, along with a wider range of expertise: burn surgeons, rehab specialists, a flight surgeon, an airport official, emergency preparation officials, and more. It was conducted under Chatham House rule, meaning nobody’s in-game statements could be directly quoted by name; this reporter played the role of the press, pressing decision-makers with difficult questions.
“We have been extremely blessed as a country to have been exempted, at least on our own fronts, in many ways, from all the tumult that’s going on in the world,” said Major-General Scott Malcolm, the military’s surgeon general and a participant in the exercise. “The broad-based participation shows me there’s a growing sentiment in Canada that the world is growing unstable, that there could be real impacts for them.
”(Canadians) aren’t turning a blind eye to this. They want to be engaged and want to be prepared.”
And as the game unfolded, it became clear that when it comes to health care, Canada at war would be more than just the logistics of hospitals and ambulances and doctors and nurses. It could become something Canada has rarely faced: a true test of national resolve.
“You’re talking about the will to fight,” said one military-associated participant. “And you don’t know how a society will react.”
The war games were a collaboration between the Dalla Lana School of Public Health at the University of Toronto, the CAF, the Canadian Institute for Military and Veteran Health Research, St. Michael’s Hospital, and other military-focused organizations. Last year, the moves to relieve pressure on the hospitals mirrored COVID, because that was the only crisis playbook available, and the exercise was confined to Ontario. This time the field widened, which was appropriate: in a war the federal government would be in charge, and the whole federation would have to work together. Canada hasn’t effectively done that in generations, either.
It was a journey into a different Canada, and world. The instability in the United States was addressed by putting the Americans in a conflict in Asia, while NATO turned to Europe. But what if NATO did not have consistent air superiority over the Atlantic, as wounded soldiers were transported home and personnel and resources were sent over to Europe? Who has a picture of Canada’s national health care capabilities, in a country where provinces run health care and don’t share data? And how would health care capacity — which is already struggling — be managed coast to coast in a nation with 13 health systems, and where almost nine in 10 Canadians live in its four biggest provinces?
Doctors surgery a Ukrainian serviceman during the operation at the military hospital in Kyiv, Ukraine, on Thursday, May 5, 2023. The demands that a large military conflict would make on Canada’s health-care system look to be gigantic.
Alex Babenko/AP
More importantly, the impact on Canadian health care — and therefore Canadian society — would be seismic. As in the first game, 10 per cent of health-care personnel were assumed to be sent overseas, with attrition rates and the need for enforced rest via tours of duty; in past major conflicts, however, that number was closer to 25 per cent. That personnel transfer would be a hammer blow to Canadian health care, and it could just be the start.
“We would be overwhelmed pretty quickly with respect to trying to care for new patients, and doing what we are doing every day, says Dr. Rob Fowler, the chief of Sunnybrook’s trauma program, who was a participant in Paratus.
Fowler has experience with crisis. He’s done front-line work in several Ebola-stricken countries in Africa, and in the past two years was part of a group of Canadian doctors who did reconstructive surgeries for Ukrainian soldiers. They travelled to eastern Poland, just across the border, and did surgeries day and night for 10 days on about 50 Ukrainian soldiers. Fowler notes it was a small operation, but it was an indication that Ukraine requires any help it can get.
“You get a sense of their health-care system sort of being overwhelmed,” says Fowler. “For generations, we’ve been like so lucky that you know that this hasn’t come to our country in the way that you know so many countries in Africa or now Ukraine and others are dealing with this all the time.”
The game presumed an average of 100 casualties per week coming home, with injuries mirroring the data from Ukraine: a huge number of both burns and traumas, a high probability of multi-drug resistant bacteria, significant traumas. There is a shortage of both burn surgeons and skin for grafts in Canada: right now most Canadian skin grafts are sourced from the United States, and as someone noted, skin cannot be donated while you are alive. Later, rehabilitation, physiotherapy, prosthetics and more would be absolutely overwhelmed, in so many ways.
But it’s the societal impact of a stream of those patients, with potentially complex and long-term needs that would impact Canada at a higher level, especially in big cities, with big hospitals. In the game Pearson Airport was knocked offline by a cyberattack, and separately, there was a terrorist attack in Ontario. The wounded had to come home on private planes, reconfigured and under national control — Canada doesn’t have enough military planes to spare. POWs were an added complication: where do you put them?
And to make room, hospitals had be decanted, which in the real world is no easy feat, and it became clear the mechanisms of past crises would also become necessary. In a bad respiratory season, masking and vaccines would ease the burden on already-stressed hospitals — the loud anti-mask, anti-vaccine minority might be louder, this time, and could even become part of an information war — and COVID-era health-care rationing would have be reintroduced: the cancellation of elective surgeries, for instance.
“If we had a horrible respiratory virus season like we did last year, it would be a major problem,” said one government participant with significant health-care responsibilities.
“COVID would be the good old days,” said one health-care-associated participant.
Soldiers would be making the ultimate sacrifice. But a war could once again become a matter of national sacrifice, distributed unevenly, and present-day Canada has almost no societal memory of war beyond the cenotaphs and Legions in almost every town, and the ceremony of Remembrance Day. Still, in a recent Angus Reid poll, nearly half of Canadian respondents expressed a willingness to volunteer for a combat role.
Hospitals and medicine would be a central way most Canadians would experience the war, and would be a key plank in the effort. There would need to be clear communication about how the standard of care will have to drop, where, and why. Access to care would have to be incredibly equal, in a country where that isn’t always the case now: you can’t have people skipping the line because they know someone, or can afford to. (There was an argument that private care would have to be nationalized.)
“The last thing we want is to be seen as not holding up our end of the bargain,” said one doctor.
But it was clear: this would strain the system in ways COVID never did, with no vaccines or public health measures to stem the tide. Ontario’s chief medical officer of health, Dr. Kieran Moore, had clearly done his homework after taking part in last year’s exercise: he had the basics of a provincial plan in place. If CMOHs across the country followed Moore’s example, we might at least have the makings of a province-level national plan for health care in a crisis.
It’s all new. Who would be in charge? How would it work? By the end of the first turn, a command structure was being written out on a whiteboard, which was faster that last year. It was almost like imagining a new version of Canada: one with structures and plans for bad options. The system never totally broke in the game; that was partly because the increased complexity made the details of decisions like decanting hospitals almost too easy. This year, there were fewer giant failures, too: no planeloads of patients left on the tarmac for hours, less confusion at the start.
But it was still a brutal exercise. Hospitals struggled. The magnitude of the impact was society-wide, and immense.
Still, there was real progress. On Day 1, the officials in the room overwhelmingly said Canada is unprepared for this kind of war. By the end of the exercise, the split was even. As one organizer put it, “Last year, we crawled, and this year, we walked. And our goal is to run next year.”
The society-wide sacrifices during COVID were, in the broadest sense, about preserving our hospitals, which came closer to breaking than the public might remember. Hospitals are where people need the most serious kind of help, but more, the resilience of a society’s health-care system is a strong proxy for societal cohesion.
One attendee at Canada Paratus was Margaret Bourdeaux, the director of the Program in Global Public Policy and Social Change at Harvard, who has done extensive research on how warfare — in Haiti, Kosovo, Afghanistan and Libya — affected health systems, and how in turn that impacted societies. She gave a speech to the group.
“(Since World War II, the Russians have pursued) the strategy of (finding) ways to sever, to cleave the population from the leadership of the health system as a way to undermine democratic governance and democracies,” said Bourdeaux, who cited Ukrainian experience in this area. “There are three goals: make it so militaries are hard to sustain, undermine civilian support and material support for war, but really, trying to undermine governance of health systems that will cripple societies economically and socially for decades after the cessation of the war, regardless of if you win the war.
“The challenge in front of us is that this is different than other crises that health systems are going to have to face. This is different because there is an adversary who is intent on destruction. That’s a very different kind of mass casualty planning exercise. It’s very different than the pandemic. It’s very different to actually have to go up against another nation that is intent on destroying democratic institutions, and particularly destroying civilian health systems. So what do we do?”
She looked out to the assembled faces in the war games crowd: from government, the military, health care, and more.
“Exactly what you’re doing.”
The report offered recommendations on command structures, medical system integration, triage protocols, emergency health-care staffing solutions, procurement challenges, communications strategies, and more: it amounts to a road map towards getting ready. Governments, of course, have a long history of leaving urgent reports on the shelf. But there is much to do.
More and more, the world feels like a pond filled with black swans, some of which might come ashore. The word polycrisis came up in the exercise; someone noted that Canada has a mobilization plan, but it’s 23 years old. (“Someone blew the dust off last year,” they said.)
This exercise was about war. It could have been about anything.
Military pallbearers carry the caskets of Master Cpl. Kristal Giesebrecht and Pte. Andrew Miller — killed by an improvised explosive device in Afghanistan — during a ramp ceremony in at Kandahar Airfield in 2010.
Sgt Daren Kraus/The Canadian Press file photo
“This particular tabletop takes an all-hazards view, rather than just any one singular point,” said Malcolm. “You always hope for the best and plan for the worst, but as we say in the military, hope is not a course of action. I wear that conflicted space where I am. I’m in the military. I support military operations, but I’m also a physician in the military whose job it is to cure and heal and save lives. And so obviously, I don’t want to see scenarios in this world where what we tested in the tabletop come out to be reality.
“But what I would say to you is, even if everything goes swimmingly well, and we see no more conflict in the world, no more fires or floods or pandemics, the work that we’ve done in this tabletop exercise to further stress test the system, allows us to identify areas where for the benefit of Canadians today, we can still get better … if you assume that we’re good and there’s nothing to improve, that’s the moment where you start to decline.”
Canada, it should be said, has always operated on the basic idea that nothing too bad would ever happen to us.
“In a very different way, I have seen in different places, whether it’s COVID or it’s SARS or with outbreaks in different parts of the world, when all of a sudden you’re in it, well, people dig in,” says Fowler. “And what is sort of unimaginable on one day becomes sort of a reality very quickly the next day. And so while it’s hard to imagine right now, when you’re faced with something, people will react. They’ll dig in, and you’ll do what you need to do.
“But on a peacetime day like today, it’s hard to imagine.”
How would the country react if Canada actually returned to war? How would we react? How ready would we be? All we have is history, hope, and the beginnings of a plan.
