On September 24, a news release put out by the Ontario Hospital Association (OHA) on behalf of 38 infectious disease specialists and public health professionals called for the Government of Ontario to:
“immediately place restrictions on non-essential businesses and activities that facilitate social gatherings and increase opportunities for exposure, including dine-in restaurants and bars, nightclubs, gyms, theatres, and places of worship. The province must also ask non-essential businesses to have employees work from home and instruct universities and colleges to offer classes online, wherever possible.”
In a media statement issued Monday, September 28, Anthony Dale, president and CEO of the OHA, wrote that “a return to Ontario Stage 2 — with restrictions placed on bars, indoor dining and other congregate settings or non-essential businesses — is needed to keep schools open and prevent a further acceleration of infections.”
This would be a calamitous mistake. It would also be an admission of failure on the part of our governments and health officials – whether they want to admit it or not. A mistake and an admission of failure because even as we continue to learn about the virus, the truth is that our governments and health care officials know exactly what we need to do to stop Covid —and have known for some time. And it is not large-scale, across-the-board lockdowns.
For months, we’ve known that the essential steps our governments and health care systems have to take to contain the virus are: the testing of all those with symptoms and a 24-hour turnaround time for results; the immediate isolation of all those that test positive; exhaustive contact tracing; mandatory masks when inside; and distancing when in sustained contact with people (again, especially inside).
We’ve also learned that we must protect the truly vulnerable. Almost 70% of Ontario and Quebec’s deaths due to Covid have been in the two provinces’ long-term care residences.
We have long known how to protect long-term care residents and staff. We need better infection control practices, improved workplace safety, and increased access to effective Personal Protective Equipment (PPE) for care workers. When appropriate, there should be more transfer of residents to hospitals which have the capacity as well as the internal infection control practices that most long-term care residences lack. Finally, there has been a deep consensus for decades that the rising complexity and severity of the care needs of long-term care residents requires more care than they are presently given.
And this increased care cannot be left to long-term care operators (many of which are for-profit) to do on their own. Government needs to provide the resources — both financial and human — to support this. In other words, long-term care staffing must be ramped up significantly and there needs to be a significant increase in single occupancy rooms so that infected residents can be quickly isolated.
At least one province has actually done it right in Canada – British Columbia. Residents of long-term care in Ontario were at much greater risk of dying during the first wave of Covid-19 compared to their counterparts in British Columbia. This is because B.C.’s health-care system was much better prepared and responded more effectively than Ontario’s, according to a new study.
The study published Wednesday in the Canadian Medical Association Journal examines both pre-pandemic factors that made a clear difference as well as actions taken by the B.C. and Ontario governments during the pandemic. Researchers found that after adjusting for the difference in population, there were about four times as many deaths in Ontario care homes compared to B.C. As of Sept. 10, Ontario recorded 1,817 deaths in long-term care, while B.C. had 156.
The study notes that prior to the pandemic, B.C.’s care system was in better shape than Ontario’s. There was better co-ordination in B.C. between homes, public health systems and hospitals, allowing for a faster and more effective response.
Provincial governments determine policies, funding and standards at long-term care homes. The study found on average, combined funding per resident per day was higher in B.C. ($222) than in Ontario ($203). Most of that funding is used to pay staff who provide care.
Protecting our most vulnerable also means acknowledging how the pandemic has disproportionately hit people on low incomes and communities of colour, many of whom live in over-crowded housing, rely on crowded public transit and work in places deemed “essential” where they have face-to-face contact with many people.
The reality of the Covid-19 has assailed Canada’s image of itself. How does one reconcile the fact that Covid rates in racialized, low-income, suburban neighbourhoods in Toronto are 10 times higher than in wealthy, predominantly white Toronto neighbourhoods? The most piercing long-term question has come to be whether we live in a just Canada. Inequalities in income, housing, and employment have resulted in non-white Canadians contracting Covid-19 at a much higher rate than whites. The pandemic has especially hurt low-income Canadians, many of whom are now out of work because of Covid related lockdowns and ongoing restrictions.
The collateral damage related to the Spring lockdown
By staying home and flattening the curve this Spring, Canadians did their part and succeeded in buying time for Canada’s health-care systems to adjust and for provincial governments to put the systems in place to ramp up testing, isolation and contact tracing as well as protect our most vulnerable in long-term care residences and in over-crowded housing.
But the severe, stay-at-home lockdown that was put in place for approximately six weeks from late March to early May, could not be maintained indefinitely. In just six weeks, it devastated the economy and caused enormous collateral health damage. Three million Canadians were immediately thrown out of work and tens of thousands of Canadians had their medical care postponed or cancelled, or have chosen to avoid health care altogether for fear of contracting the virus. Many have already died because of this and many more will die in the future.
The health collateral damage of massively diverting finite health resources into the Covid fight can be seen in the increase in opioid deaths. Deaths in British Columbia hit new highs over the spring, including a monthly record of 181 illicit drug toxicity deaths in June, and Alberta on Wednesday revealed that opioid poisoning killed 301 people in the spring – also a record. In both provinces this year, overdoses have taken far more lives than COVID-19.
Since 2016, more than 3,100 Albertans have died from opioid overdoses; in B.C., the number is more than 6,000 people.
There has also been massive collateral damage in education. The blow to our young people’s education and mental health due to the three-month school closure in the Spring is incalculable.
And the sad fact is that, as of the end of September, many of our provincial governments had largely squandered the opportunity Canadians gave them to put in place the systems and practices needed to control the spread of the virus and to protect the vulnerable. The capacity to identify those infected with the virus, immediately isolate them, and then aggressively track down their contacts, was never put in place.
Instead, many of our governments have resorted to hectoring Canadians about supposedly irresponsible personal behaviour and have encouraged a general atmosphere of public shaming that does little to actually contain the virus.
Meanwhile, Ontario, and Quebec in particular, still lack the comprehensive systems of testing, isolation, and follow-up contact tracing that would enable rapid identification, treatment and quarantine of infected people, and those who have had contact with them. Nor have these two provinces implemented the measures (described above) needed to protect long-term care residents.
The truth of the matter is that it is because these provincial governments simply haven’t done their job that case counts are rising. To take Ontario as an example, on October 2, Ontario reported an additional 732 new cases of COVID-19, the most new cases on a single day since the outbreak began in late January. The figure far surpasses the previous high of 640 from Spring peak. It is simply inexcusable that the provincial government was unable to put in place an effective testing, isolating and contact tracing system that would contain the virus in the six months since Covid first hit Ontario.
Germany, Japan, South Korea and Iceland are among the jurisdictions that long ago perfected such comprehensive systems. Lagging behind those countries, as much of Canada still does, is unacceptable.
The need to micro-target Covid related restrictions
Infectious disease specialists and public health professionals are correct that transmission of communicable diseases such as Covid-19 is very much a function of how much – and what kind of – contact we have with each other. And governments have at their disposal many policy levers that they can use to reduce the effective numbers of contacts between people and the nature of those contacts.
What the Ontario Hospital Association (the lobby group for hospitals in Ontario) and many public health officials don’t seem to appreciate, however, is that there are massive costs associated with the use of some of these broad-stroke policy levers to reduce social contact. For example, we could have kept K-12 schools shut down until Christmas (on top of the three months they were shut down in the Spring), and this would have been justified if all we were concerned about was minimizing social contact and reducing the number of Canadians that test positive for Covid. But most Canadians have other things they value in life – they feel that the damage to our children’s education and mental health that would have resulted from another four months of school closures was simply unacceptable. In other words, provincial governments (with the support of a substantial majority of parents) chose to open K-12 schools fully aware that school re-openings would result in a modest increase in Covid cases. They simply felt that a return to school was a risk worth taking in order to further the education and mental health of five million young Canadians.
The evaluation of the trade-offs involved in the relaxation of any Covid related restriction should be similar to the evaluation of trade-offs taken by provincial governments in deciding to send K-12 students back to school. The fundamental question that needs to be asked of all Covid related restrictions is this: Is the likely increase in Covid cases that would flow from the relaxation of a particular restriction justified by the social, health, and economic benefits of lifting the restriction? If a restriction is judged to be doing more harm than good, then it should be loosened in an evidence-based manner.
The 14-day federal quarantine on Canadian residents on return from foreign travel that is crippling the airline industry and tourism more generally, is a case in point. The international airline industry has proposed a testing regime that would, in effect, replace the 14-day quarantine. To date, the federal government has rejected this proposal leading to criticism of the federal government by the International Air Transport Association (IATA), the association representing the world’s airlines. The European Union has also criticized Canada’s 14-day quarantine. The question is this: would replacing the 14-day quarantine with a testing regime be justified by the increased economic activity related to lifting the quarantine? Of course, it is possible that dropping the quarantine in favour of the testing regime would result in a modest increase in Canadian Covid cases. But even if that is the case (and it may not be), it is also possible that the increase in jobs and business activity justifies the modest increase in those testing positive.
Of course, there is still a need for targeted closures and related distancing restrictions. There is also a need for mandatory mask wearing inside. However, rather than across-the-board lockdowns and restrictions, a far better approach would be to identify the exact source of an outbreak and order the closure of a specific workplace or venue for a period of time or have additional public health measures or restrictions applied. If the outbreak was a particular event (wedding, inside house party, etc.), then aggressive contact tracing should take place. Finally, a certain type of higher-risk business (strip clubs, large live music venues, large sports stadiums/arenas, etc.) in a particular area might be kept closed until trends in Covid case counts improve in the region.
Why daily case counts mean something different in the Fall than they did in the Spring
It is also crucial to understand that Covid case counts in the Fall mean a different thing than they did in the Spring. This is because the average person testing positive in the Fall simply isn’t as sick as the average person testing positive in the Spring.
There are a number of reasons for this.
First, while there is still a need for a significant increase in testing, it is also a fact that far more people are being tested now than in the Spring. More people being tested inevitably means higher numbers testing positive. We are simply identifying a higher proportion of all those who have the virus in the Fall of 2020 than we did in the Spring of 2020.
Second, there has been a significant shift in the demographics of Canada’s coronavirus epidemic. More young people, particularly those under 40, are testing positive. In fact, over 65% of those testing positives are under 40. While younger individuals can certainly experience lingering health effects from the disease – even if they aren’t hospitalized – they are much less likely to get seriously sick and very few under 40’s are likely to die.
Third, hospitals have vastly improved their Covid treatment procedures since the Spring, and those that need to be hospitalized are staying for shorter periods of time. For example, hospitals now have a better idea of how much PPE they need and staff are now much more comfortable using it.
Doctors are also regularly using a steroid — dexamethasone — which has been used before to treat patients with acute respiratory distress syndrome. The steroid acts as an anti-inflammatory, and lung inflammation is one of the problems with COVID-19.
Hospitals have also dramatically changed the treatment for patients who need oxygen. Early in the pandemic, patients were being put on ventilators because medical staff were told not to use high-flow nasal cannula, which deliver oxygen through the nose at a high flow rate, but were thought to be too risky. Now they are using the nasal cannula which is much less invasive.
In the second week of May, the number of Canadians in hospital with COVID-19 peaked at just over 3,000. By the end of September, with Canada-wide daily new case counts at their Spring peak, that number was at about 350.
Over 1000 Ontarians were hospitalized with Covid in late April. And as of Oct. 2, 167 COVID-19 patients are hospitalized in Ontario. Of those, 38 are in intensive care, with 21 on ventilators.
This post argues that:
- In order to contain Covid-19, governments must: test all those with symptoms with a 24 hour turnaround time for results; ensure that those that test positive actually have a place to isolate and do so; implement a program of exhaustive contact tracing; make masks mandatory when inside; and enforce distancing when in sustained contact with people (again, especially inside);
- Some Canadian provincial governments (especially Quebec and Ontario) have failed to implement and enforce the above program in an effective manner and this is the main reason Canadian case counts rose so dramatically in September;
- Public health officials and infectious control experts often fail to factor in the massive collateral damage of broad-based lockdowns and restrictions on health, education, and the economy. Therefore, in the face of rising case counts, Canada should not reimpose stricter broad-based lockdowns and restrictions but rather, should continue to slowly relax existing restrictions that hard evidence shows are doing more harm than good.
- Along with an effective testing, isolation and contact tracing system, targeted closures of specific locations associated with outbreaks (specific workplaces, nightclubs, etc.) should be pursued. Large music venues, arenas and stadiums should also remain closed until case counts are significantly reduced.
- Case counts in the Fall mean a different thing than they did in the Spring. This is because the average person testing positive in the Fall simply isn’t as sick as the average person testing positive in the Spring. Even with current case counts at almost the peak Spring levels, hospital admissions due to Covid are roughly ten percent of hospital admissions at the Spring peak.
By giving up much that brings joy, happiness and meaning to life, Canadians did their part in the fight against the spread of Covid-19 during the Spring lockdown.
It is long past time for our provincial governments to do their part and put in place the testing, isolating and contact tracing systems needed to truly contain Covid-19. It is also absolutely crucial for provincial governments to implement all necessary measures to protect long-term care residents and other vulnerable Canadians.
Finally, re-imposing broad-based restrictions is a bad idea if only because it penalizes those who have sacrificed much to further the health of their fellow citizens and lets Canada’s governments off the hook for failing to do their part.