The past three months have shown that with major sacrifices, the community transmission of COVID-19 can be slowed down considerably. In Canada, we can rightfully say that we were able to “flatten the curve” to avert a northern Italy, Madrid or New York City scenario. This is something to celebrate.
Now we face the collateral damage of the lockdown: delays in medical care for non-COVID patients, harmful educational impacts on our young people due to a lost school year, a looming pandemic of mental-health issues related to prolonged isolation and a disruption of routines, and massive job losses disproportionately impacting low wage, service workers (a majority of whom are women).
This unintended (but inevitable) damage done by the lockdown strongly suggests that the closure of all non-essential services cannot be sustained until an effective and safe vaccine is widely available – which may not occur for years. And the virus is unlikely to completely disappear from Canada or the world any time soon. Obviously, all provincial governments recognize this and have begun to slowly relax COVID related restrictions in a phased manner so that now, in all areas of the country, there are openings beyond essential businesses.
This Canada Fact Check post assesses the impact of Canada’s particular approach to its lockdown and takes a close look at the winners and losers of the approach taken.
After three, long months of strict lockdown and a steep decline in new cases, many epidemiologists and infectious disease experts believe we may be approaching the point where the cure is worse than the disease.
Are they right?
Did the lockdown work?
Did the lockdown achieve the desired goals in Canada? Yes and no. Success in “flattening” the outbreak curve permitted our hospitals to handle a modest influx of COVID-19 patients (there was no “surge” in any province – even in hard hit Quebec) and to avoid unnecessary COVID deaths. To put it a little differently, our strict lockdown reduced the proportion of Canadians who contracted COVID-19 through community transmission to roughly 25% of all confirmed cases. In many countries, it is higher.
However, for the roughly 56% of confirmed cases that contracted the virus not from community transmission, but from other members of their household (often because of over-crowded living conditions in which at least one household member was deemed an “essential” worker), the lockdown did little to protect them. The same is true for those living or working in institutional settings such as long-term care (LTC) facilities or hospitals (14% of confirmed cases).
In other words, for roughly 70% of Canada’s confirmed cases, the lockdown provided little or no protection.
Ontario and Quebec’s failure in protecting LTC facilities can’t be emphasized enough. The vast majority of COVID-19 deaths to date in Canada have been precisely these LTC residents and workers. Most LTC deaths have been in Quebec and Ontario, although there have been several other hotspots across the country at times. In fact, Canada has the highest reported national proportion of COVID-19 deaths for LTC residents in the world, with 85 per cent of total COVID-19 deaths related to LTC facilities. Other comparable countries report percentages ranging from 29% (Australia) to 35% (U.S.) to 54% (England and Wales).
It gets worse. Globally, the fatality rate for people with COVID-19 is estimated at 3.4 per cent. In Canada, it’s 7 per cent, but the fatality rate of LTC residents in Canada is as high as 29 per cent. LTC residents were not circulating in the community so the lockdown did little to reduce Canada’s overall deaths due to COVID-19.
Nor were we successful in protecting those in corrections institutions, shelters and migrant worker living quarters.
The inadequate pandemic response that led to the above failures is rooted in Canada’s inability to adequately test, isolate and implement effective contact tracing in vulnerable groups. The testing, isolating and contact tracing desperately needed to contain the spread of the coronavirus has been especially inconsistent in Quebec and Ontario, which account for more than 90 per cent of Canada’s infections and deaths.
While things have improved considerably in these provinces in recent weeks, on a countrywide basis, Canada still has mediocre results when it comes to the number of tests performed per confirmed cases of COVID-19.
According to a recent analysis, we are testing 46 people per case. That’s better than the United States, which is doing 21 tests per case. But Germany is doing 123 tests per case, South Korea is doing 309, and Australia is doing 2,481. Those are countries that are out in front of the disease.
Isolating those testing positive has been a particular shortcoming in Canada’s anti-COVID efforts. Toronto public health officials are asking for federal and provincial funding to set up a voluntary centralized quarantine system for low-income people who live in cramped apartments and cannot afford to self-isolate after testing positive for COVID-19.
The proposal is a response to data released last month that shows the neighbourhoods hardest hit by COVID-19 are in the city’s northwest and northeast, where large numbers of recent immigrants live, many of them low-income families living in cramped conditions. Again, 56% of positive cases were contracted from members of a household, not from community transmission which the closure of “non-essential” sectors of the economy were aimed at.
If Canada had ramped up its testing, isolation and contact tracing efforts in early March at a scale comparable to countries such as South Korea, Germany, Australia and other “best practice” countries, Canada could have taken a much more nuanced and targeted approach to its lockdown. Such an approach would have reduced the massive collateral damage inflicted by the lockdown on: 1) those with non-COVID health issues (delayed cancer screenings, cancellation of elective surgery, etc.); 2) the three million (and counting) Canadians who lost their jobs because of government ordered closures of all “non-essential” workplaces; and 3) the set back in the education of our young people due to a loss of much of the school year and the deterioration in their mental health due to extreme social isolation for three solid months.
An early March start to an effective mass testing and isolation effort would also have also prevented the national disgrace of thousands of unnecessary deaths in our provincially regulated nursing homes.
The collateral damage of the Canadian approach to lockdown
In evaluating whether the lockdown achieved the desired results, it is also important to point out that more than 95 per cent of COVID-19 deaths occurred in those over 60, compared with none under age 20.
In Canada, the individual rate of death from COVID-19 for people under 65 years of age is six per million people, or 0.0006 per cent. This is roughly equivalent to the risk of dying from a motor vehicle accident during the same time period.
On June 16, Canada had only 360 new daily confirmed cases compared to 20,722 new cases in the US. If the US had the same rate of new cases per 100,000 residents as Canada, it would have only 3,800 new daily cases rather than over 20,000.
What this all adds up to is that the threat of COVID infection for the general population in Canada is far less than in the US at the present time. This is particularly true of those under 65 which the lockdown is designed to protect (the vast majority of those over 65 are not in the workforce). Yet, if anything, the US is unwinding their lockdown at a faster pace than Canada – albeit in at least a few states, probably unwisely.
Given the greatly reduced threat of infection in Canada in mid-June relative to the peak in mid-April, it is important to ask if the broad stroke lockdown measures are now doing more harm than good. Remember, the original approach of “flattening the curve” was to relax restrictions if the hospital system was not overwhelmed. That is still the appropriate approach. Hospitalizations are dropping quickly and it is unrealistic that zero infections can be achieved for COVID-19, which fundamentally spreads like influenza or the common cold, including from those without symptoms. The virus causes disease so mild in many people that it can circulate without detection, until it is introduced into a vulnerable population.
As such, the focus should now be on massively ramping up testing, isolation and contact tracing in institutional settings such as long-term care facilities, shelters, corrections facilities, migrant worker living quarters and specific neighbourhoods where there are high concentrations of vulnerable people due to overcrowded living conditions. Other enclosed spaces where social distancing is difficult (e.g. work settings such as meat packing plants), should also be a priority for testing.
According to experts, it is entirely possible that in two years we will still not have a vaccine for COVID-19, and very probable that a vaccine will not eliminate the virus entirely. The fundamental point is that while redoubling our efforts to protect our most vulnerable, Canada is at a point in the pandemic where we need to come to terms with the fact that we cannot eliminate this virus and therefore we have to learn to live with it in the same sense that we live with the presence of other infectious diseases (the common cold, various strains of the flu, etc.) and other threats to our health (cancer, heart disease, automobile accidents, etc.).
What criteria should be used to loosen or re-impose restrictions?
As we embark on this new stage of increased testing and tracing of contacts of COVID cases, we will find that the better our testing capacity, the more cases we will find, making it appear that the disease is worsening when it isn’t.
This is particularly problematic as restrictions are being lifted. Should a provincial government automatically reinstate restrictions if the number of daily new cases reported increases a bit? That would be a serious mistake. Instead, we should use local hospital capacity as the guiding principle, ensuring that all patients who need hospital or ICU care can get it.
Going forward, we need a tailored regional approach in the highly unlikely case that a local hospital system gets strained. Germany, for example, chose a local threshold of 50 new cases per 100,000 population per week before re-institution of lockdown measures must be considered based on local hospital capacity. The Ontario equivalent using the same threshold would be 7,300 new cases per week, or 1,043 per day.
In contrast, Ontario has recommended a much lower province-wide threshold of 200 new cases per day as a threshold for loosening restrictions. This is bad policy even though Ontario is now meeting this overly high bar and regularly reporting under 200 new cases daily. The number of confirmed cases should not be the metric of choice for relaxing restrictions as it is not a reflection of the more critical measure, whether those with serious COVID symptoms can get the hospital care they need.
What governments need to do immediately
Canada’s hospitals never came close to exceeding their intensive care (ICU) capacity. In the absence of hospital strain, provincial governments should immediately quicken the pace of ending broad stroke lockdown measures. This means the immediate opening of elementary schools on an optional basis (as in B.C.), child care, stores, restaurants, summer camps, pools and beaches, playgrounds, community centres, workplaces, and small, live music venues that can provide appropriate social distancing.
However, while quickening the pace of re-openings, governments must double down and enforce basic physical distancing rules and hygienic practices in all re-opened settings (including the re-configuration of workplaces). For the time being, governments should also continue the ban on large private and public social gatherings (large concerts, professional sports events, etc.). For both public and private gatherings, the size limit on gatherings should be higher for outside events where effective social distancing protocols can be implemented.
And again, testing, isolation and contact tracing must be ramped-up amongst vulnerable populations where the impacts of the disease are the highest.
Finally, masks must become mandatory on all mass transit systems and other locations where social distancing is not possible.
If we continue the present lockdown, the real crisis could be that our attempts to control the virus will have caused severe and lasting damage to the country’s economy, the overall health of the population, and the education of our young people. Moreover, the damage done could have harmful repercussions for decades.
Continuing the lockdown also undermines social justice objectives as the burden of the lockdown has fallen disproportionately on children, young families, low paid service workers (a majority of whom are women), and racialized communities. With daily new cases in mid-June under 350 nationally (again, a fraction of the rate in the US), the more we focus on COVID to the exclusion of other health objectives (including the mental health of our children), the greater the danger to our overall public health.
Most Canadians who are “spooked” by COVID-19 are “spooked” not because they personally know someone who got seriously ill from the virus, but because for three months they have been bombarded daily by broadcasts and government advertising of the dangers of COVID in the absence of any context.
So here is the context.
Almost 300,000 Canadians will die every year from cancer, heart disease, stroke, motor vehicle crashes, suicide and a myriad of other causes. Since mid-March, for every Canadian outside long-term care who has died of the virus, 50 have died of something else. Because finite health care resources have been massively diverted to the fight against COVID-19, more Canadians will die of cancer, heart disease and other causes than would other wise have been the case.
Three million Canadians have lost their jobs because their employers were deemed “non-essential” by their provincial government and were shut down.
Finally, our children have lost much of their school year and are beginning to suffer incalculable damage from the prolonged social isolation of the lockdown.
It is mid-June, 2020 and Canadians understand the importance of common sense social distancing and of wearing masks where that is not possible. But the broad stroke lockdowns are now doing more harm than good and it is time to end them and let our children play.