Ontario’s current strategy will fail to contain the Covid pandemic because it is not targeted at the dynamic that is driving the increase in “second wave” Covid cases in the province.
The hard truth is that workers in food processing plants, warehouses, manufacturing plants and customer facing workplaces (retail, etc.) are taking the virus home with them to overcrowded, multigenerational households where they are unable to isolate. Because there is no ability to isolate, they then infect other members of the household. This is followed by a spillover into local schools and nursing homes. This spillover is a function, first and foremost, of the provincial government’s under-investment in the staffing needed to properly socially distance in these institutional settings.
It is this dynamic that is resulting in the fact that case rates per capita in much of Brampton and many neighbourhoods in Northwestern Toronto, are as much as ten times that of more affluent parts of the Greater Toronto Area (GTA). Residents of these high rate areas are much more likely to work in low-paying, industrial jobs and live in over-crowded housing than those living in other parts of the GTA.
Recognizing that Ontario residents are not likely to tolerate the massive economic and social collateral damage caused by a severe lockdown such as that implemented in the Spring, politicians and public health authorities are implementing marginal measures such as banning indoor dining and closing movie theatres.
To date, these marginal measures have not stopped the steep rise in Covid infections in Ontario and they will not stop it in the future. What is needed is a massive testing, isolation and contact tracing effort targeted at Ontario’s hardest hit urban neighbourhoods, small towns and rural areas. This must be complemented by immediate measures to contain the spread of the virus in our nursing homes, schools, corrections institutions and shelters.
Why Covid cases are spiking in Ontario
As I write, the number of Covid-19 infections in Ontario is soaring to record-breaking heights, prompting some municipalities to impose new anti-Covid restrictions over and above those imposed by the province.
But while it may look like case counts are rising across the province, the truth is that it is only a small number of areas that are responsible for much of the increased case count. In other words, it is not Ontario that has a serious Covid problem nor is it even the City of Toronto and Peel Region that have serious Covid problems. The Covid problem in Ontario is rooted in specific urban neighbourhoods and specific small towns and rural areas, that have a high proportion of their residents working and living in conditions that facilitate the spread of the virus.
A close look at the Covid clusters in the Greater Toronto Area is instructive.
At the regional level, suburban Peel Region, an area immediately to the west of the City of Toronto, has Ontario’s highest regional per capita case count. This means that Peel Region has a higher case count per capita than even the City of Toronto. However, within Peel, it is the City of Brampton that has the really serious problem – rates in the rest of Peel region pretty much reflect the average for other medium and large urban centres in Ontario. In Brampton, the positive-test rate is now 11 per cent, and its weekly rate of new cases is 170 per 100,000. These are the worst numbers in Ontario and are far worse than the numbers for Peel Region as a whole. Two local hospitals, run by William Osler Health System, were treating 54 confirmed and 37 suspected COVID-19 patients on Sunday. The hospitals had to transfer more than 20 patients to other GTA hospitals to make room.
Almost all experts agree that the biggest source of outbreaks in Brampton is industrial settings such as food processing plants, warehouses and manufacturing plants. These experts also agree that the high proportion of Brampton residents that work in such Covid friendly work settings is compounded by the fact that workers in these settings often bring the virus home to crowded, multigenerational households where there is no place to isolate. Peel Region’s respected Medical Officer of Health, Dr. Lawrence Loh, has confirmed this analysis in many official statements.
Both Dr. Loh and Brampton Mayor Patrick Brown point to increased testing and new isolation centres as the key to solving Brampton’s Covid-19 problem. In other words, the solution to Brampton’s high caseloads is very simple: Test more Brampton residents who work in industrial settings and immediately create a separate isolation centre in Brampton for all those who test positive and have no place to isolate. In fact, in order to accommodate all those who need to isolate outside their homes, more than one isolation centre may be needed in Brampton.
This same “Covid friendly workplace/crowded living quarters” dynamic is playing itself out in Ontario’s other top Covid hot spot, the Northwest area of the City Toronto, which is adjacent to Brampton. It is also playing out in a small corner of York Region (southern Vaughn) adjacent to both areas. In other words, there is a cluster of adjacent neighborhoods with roughly 1.2 million people in three different municipalities that are responsible for a disproportionate part of the Province’s Covid case count. And again, the reasons for the high case count in this cluster of neighbourhoods is the high proportion of workers employed in Covid friendly workplaces such as food processing plants, warehouses, manufacturing plants and customer facing workplaces (retail, etc.), compounded by cramped living conditions where it is next to impossible to isolate.
A similar dynamic is occurring in large parts of Scarborough (the eastern section of the City of Toronto) and in adjacent neighbourhoods in Pickering and Ajax in Durham Region. The numbers aren’t quite as high in these neighbourhoods as in the Northwest region of the Greater Toronto Area (GTA), but they are very close, and are much higher than the GTA average. The population of this cluster of neighbourhoods is roughly 600,000.
This analysis points to serious flaws in Ontario’s new Covid framework released Nov. 3:
1) Under the framework, Covid related thresholds (per capita case counts, positivity rates, etc.) trigger new public health measures at the Public Health Unit level. This simply doesn’t work in Ontario’s largest urban areas because the impact of Covid varies dramatically depending on the neighbourhood. For example, in the Ontario plan, the Toronto thresholds cover three million people living in vastly different City of Toronto neighbourhoods. The truth of the matter is that many neighbourhoods in the City of Toronto have per capita case counts that are well below the provincial average (in fact, some have 15% of the cases per capita of hard-hit city neighbourhoods a 20-minute drive away). Put bluntly, there is no Covid crisis in these better-off Toronto neighbourhoods because the people who live in these neighbourhoods generally don’t have jobs in Covid friendly workplaces. And, in the unlikely event that they do contract the virus, they generally have living quarters that allow them plenty of room to isolate from other members of their household preventing broader infection.
2) Beyond some rather weak screening guidelines, the Ontario framework is pretty much silent on anti-Covid measures in workplaces such as food processing plants, warehouses, manufacturing plants and customer facing workplaces. This is despite the fact that there is overwhelming evidence that it is precisely these workplaces that are driving the soaring infection rates in Ontario’s hardest-hit neighbourhoods and communities. It is clear that some sort of mandatory workplace-based testing regime needs to be developed for workplaces in these sectors.
3) There is nothing in the Ontario framework that triggers specific anti-Covid measures in schools, long-term care residences and corrections facilities. The reason for this omission is obvious – the provincial government doesn’t want its own framework to force it to hire more teachers, Personal Support Workers (the primary caregivers in long-term care residences) and corrections officers to make these provincially funded and regulated institutions safe.
This is not a trivial issue. On November 10, Ontario reported an additional 159 new cases in public schools across the province, bringing the total in the last two weeks to 936 and 2,865 overall since school began. In other words, school related cases are a significant contributor to the current spike in cases but the province of Ontario doesn’t want to spend the money to comply with the school opening guidelines developed by organizations such as the Sick Kids Hospital which recommended that class size be restricted to 15 students. Classes in Ontario are generally in the 20-25 student range violating the guidelines.
The second wave of the pandemic is also slamming into Ontario’s long-term care facilities. This is dealt with below.
Why health authorities favour limits on social interaction as opposed to more effective public health measures
A pattern seems to be emerging in Ontario whereby health care authorities (constrained somewhat by public opinion) favour broad-based limits on social interaction (lockdowns, school closures, inside dining restrictions, etc.). Even with their massive economic and social collateral damage, public health officials favour these practices over more targeted public health measures that are much more effective in fighting Covid such as testing and isolating.
Why is this?
The answer appears to be that the development of new rules that set limits on social interaction in different settings is easy and cheap to develop while targeted testing, isolation, contact tracing and protecting our most vulnerable is hard and expensive. In other words, there are no complex logistical exercises, systems building initiatives, or staffing increases needed to implement new restrictions on social interaction. You just need a few public health authorities dictating the new restrictions to a few government lawyers. Bam, inside dining is banned for three million Torontonians!
In contrast, the measures that need to be taken to truly control the virus require the development of very complex testing, isolation and contact tracing systems, the hiring of a large numbers of trained staff to protect our vulnerable, and the immediate allocation of significant financial resources by the provincial government.
Of course, measures that limit social interaction, if drastic enough, certainly can reduce Covid transmission.
The problem is that measures such as lockdowns of all “non-essential” establishments, closing schools, ordering people to work at home, and other measures that limit social interaction, need to be extremely severe to significantly reduce case counts. As we saw in the Spring, the severity of an effective broad-based lockdown results in enormous economic damage (almost three million Canadians immediately lost their jobs when our governments shut down their employers in the Spring). Perhaps just as importantly, measures that limit social interaction also cause what we might call a “social recession”: a collapse in social contact that is particularly hard on the populations most vulnerable to isolation and loneliness — older adults, children (especially when schools are closed down) and people with disabilities or pre-existing health conditions.
As such, politicians correctly sense that their constituents won’t tolerate another lockdown as severe as the one implemented in the Spring.
A further problem with lockdowns and related government “stay at home” messaging, is that it engenders enormous fear in the population that can radically change behaviour – often in economically and socially destructive ways. Downtown cores empty, enclosed shopping malls are deserted, public transit usage crumbles, and parents keep their kids out of school and enroll them in inferior online learning. Moreover, these destructive, fear induced changes in behaviour will likely continue well after the pandemic threat is over.
To be clear, encouraging inside mask wearing and a respect for social distancing amongst Canadians should be a high priority for our governments. There is also ample evidence that limitations on the size of inside, private gatherings, especially in hard-hit neighbourhoods, is useful.
But creating a fearful population that is afraid to leave their homes is perhaps the greatest harm a government can do.
Why targeted testing and isolation in hard-hit neighbourhoods should be the number one priority in the fight against Covid
In contrast to “stay at home” measures such as lockdowns and government communications campaigns that engender fear resulting in enormous economic and social harm, Ontario needs to massively improve its testing, isolation and contact tracing systems – especially in hard-hit neighbourhoods and communities. These measures have the advantage of causing no economic and socially destructive collateral damage. This was the strategy that was followed by all jurisdictions that have successfully contained Covid-19 such as Japan, South Korea, Australia, Taiwan, and New Zealand.
Yet Ontario is having enormous difficulties in developing effective testing and isolation systems – especially in the hard-hit areas where it would do the most good. In fact, the number of tests performed daily is significantly down in Ontario – just when it is needed most.
Whatever the challenges, the truth of the matter is that it is absolutely essential that our politicians and health authorities develop effective, targeted testing, isolation and contact tracing systems that can control the spread of the virus. There is simply no other way to stop Covid that doesn’t result in massive economic and social harm.
There are many ways to do this. We can engage in careful contact tracing to find out how people were infected and reconstruct the paths of viral transmission. We can examine genetic identification from the virus in infected people to try and figure out what makes some of them more infectious than others. And we can monitor wastewater for viral remnants to give a more accurate picture of its spread.
Most importantly, we can invest far more in less expensive but faster antigen tests. Slovakia, a country of 5.4 million, announced on the weekend that it intends to test every citizen over the age of 10. The effort will be difficult, and the method used may not achieve its goals – but it at least shows the kind of imagination and ambition that Ontario has been lacking.
One study published in late October said Canada should aim to control virus spread in part by testing 500,000 people a day (up from around 75,000 now), with greater emphasis on less expensive but faster antigen tests. Although not as accurate as the diagnostic PCR test presently used in Canada, antigen tests in high-risk areas could help to limit infections and save lives, even while allowing more of the economy to remain open.
But even conventional testing can be much more effective. In fact, after eight months of living with COVID-19 in this country, only now are we starting to focus real attention on the notion of superspreading events and what it means to controlling the pandemic.
Controlling the spread of the virus in institutional settings
Nursing homes were devastated in the pandemic’s first wave. By mid-summer, long-term-care residents represented two-thirds of Ontario’s total COVID deaths.
The second wave is now crashing into our nursing homes with potentially disastrous results.
In September, eight Toronto long-term-care homes declared an active outbreak, according to ministry data. In October, 26 did. Perhaps most worrying, another seven have declared outbreaks in November, almost as many as the whole month of September though only ten days have elapsed.
In September, two Toronto LTCs had outbreaks that infected over 40 residents. In October, five had outbreaks that large. It’s difficult to calculate exactly how many deaths resulted, because the ministry does not report exact numbers for any totals lower than five. But at least 50 residents died across both months combined.
In response to the Spring tragedy, the Ford government appointed a long-term care task force to examine what went wrong in these homes. Two weeks ago, the task force rushed out some of those answers for him in an interim report.
The commission’s recommendations include increasing hours of care for residents to four hours a day, hiring more full-time staff and more qualified staff to handle the increasingly complex health care needs of residents, and faster COVID-19 testing.
Those are all good suggestions and there’s nothing particularly surprising about any of them. Indeed, they’ve all been called for multiple times before. And in July, when Ford appointed the commissioners, he vowed to “take up” any of their recommendations.
Days before the Ontario budget was unveiled last Thursday, Ford appeared to agree with the recommendations and pledged to hire thousands of nurses and personal support workers to ensure four hours of hands-on care for residents up from two hours and 45 minutes.
But that promise, which is estimated to cost $1.6 billion a year, was not specifically spelled out in Thursday’s Ontario budget, which added $7.5 billion in new funding to fight the pandemic that has killed some 3,200 Ontarians since March – again two-thirds of them in nursing homes.
The biggest critique of the long-term care measures detailed in the budget, is that the government isn’t guaranteeing four hours of care until 2024-25 and is not even beginning to move on the staffing recommendations until yet another long-term care staffing report is completed in December.
The truth of the matter is that there is no excuse for postponing the urgently needed staffing increase in the province’s nursing homes. The Ontario government’s slow timetable to act on this promise will only lead to more preventable deaths in our long-term care facilities. The government’s refusal to act quickly demonstrates an appalling lack of urgency on the part of this government and is completely unacceptable given the carnage we witnessed just last Spring.
The vulnerable seniors in these homes were forgotten in the first wave of the pandemic – the interim report makes that clear – and given the Ford government’s go-slow response to these recommendations it seems there’s a good chance they will be once again.
Ontario is battling a second wave of the virus that is far from being brought under control. This past weekend saw record high case numbers, the seven-day average is up and positivity rates are up.
And what comes as a surprise to absolutely no one is that this rise in cases and community spread is a deadly threat to people in long-term care. Outbreaks in homes have quadrupled over the past month. There are now 83 outbreaks in long-term-care homes.
More than 2,000 people have already died in Ontario’s long-term-care homes from COVID-19. There’s no time to waste before taking measures to better protect both residents and staff.