A roadmap out of lockdown
Over the past few weeks, Ontario has seen a significant rise in the number of new COVID- 19 cases and hospitalizations, particularly in Toronto, Peel and Ottawa. As a result, the provincial government moved these regions back to a modified Stage 2 of its reopening plan. This situation was completely predictable and preventable, and unless the province comes up with a clear plan to get out of Stage 2, we may be left with the same recurrent issues for the foreseeable future.
The Venn diagram published with this column illustrates the pressures on the Ontario government’s response. Our hardest- hit areas are affected most by the intersection point of all three bubbles — ineffective contact tracing, increasing community contacts and high community burdens.
As we talk about potentially entering a period of increasing restrictions, it is important to review the entire landscape that contributes to the latest developments, rather than simply focusing on the high- risk businesses that were reopened during Stage 3. And if we want to formulate a path out of the current restrictions, it is important to come up with a plan that incorporates all the factors that created our current predicament.
Our greatest asset in keeping our communities safe has always been the public health official at the local level, who work on contact tracing, community education, enforcement and many other critical areas. However, pressures on co- ordinating effective school and workplace safety, contact tracing and worsening turnaround times for testing, paired with limited human resources and funding, have led to limitations, despite the herculean effort of many municipalities and health regions.
Tracing is becoming significantly impaired in many places due to resource demands and increasing networks of contacts, and has almost completely ground to a halt in Toronto. Without a large investment in training, hiring and empowering our local public health units to deal with escalating demands, the scaffolding that holds our community responses together will fail repeatedly.
Testing has also become a significant issue. Despite the fact that Ontario conducts the largest number of tests in Canada, it remains a finite resource. Paradoxically, while our numbers improved over the summer, the province pushed ahead with increased low- yield asymptomatic testing, despite repeated warnings from public health professionals that this was a waste of resources.
We started respiratory virus season with a backlog from the low- yield asymptomatic testing that was being conducted, and are now unable to cope with the need to test all those who have symptoms. The slow turnaround times are disrupting peoples lives and hampering our response. Assessment centres have done incredible work to cope with the volume, but the circulation of seasonal rhinovirus, combined with the reopening of schools, has led to an ever- increasing number of individuals meeting the testing criteria.
Instead of wasting resources on low-yield testing, that money should have been invested in increasing laboratory capacity and expanding assessment centres. We now need significant investments in testing capacity, and integrating new rapid- testing devices, otherwise we may never be able to completely achieve a sustainable test-and- trace approach in the winter months.
Furthermore, we need to have a transparent discussion about our testing criteria, and critically re- evaluate our asymptomatic testing criteria regularly, with a transparent discussion on costs, resources and benefits. If our testing strategy isn’t evidence- based and doesn’t adhere to some modicum of fiscal responsibility, we will essentially be flying into a storm without a navigation system in place.
At the very least, making top- down changes to our public health system and testing strategy can be done fairly easily. The hardest piece of the puzzle to control is society at large. We have tried to regain some semblance of normality, despite the changes made to our daily lives. We yearn for social interaction, a meal at our favourite restaurant and the comforts of our daily lives.
An incredibly co- ordinated effort by citizens to remain in lockdown over the spring successfully flattened the curve during the first wave, and the doomsday scenarios of early models never materialized. However, with ongoing public pressure even with low case numbers, we are left with the new challenges of COVID and alarm fatigue when the public is needed the most.
Messaging has become confusing, as we have been asked to restrict our household contacts, but are still able to engage in meals with 100 people indoors without a mask. Imposing restrictions on high- risk environments may reduce some transmission, but without an acknowledgment that a lot of transmission occurs in private settings, this may not achieve its intended goal.
Any new restrictions and advice requires people to understand the rationale, otherwise, fatigue and resistance may emerge. Public education needs to promote individual risk mitigation, the ability to have some of our interactions in a safe way and teach people how to protect themselves against transmission in personal spaces.
Our health- care system is also a key player, given the need to preserve capacity for COVID-19 care, but also clear the backlog of procedures that built up during the lockdown. A well positioned health- care system would not be strained by the current number of hospitalized COVID-19 patients, but our health-care system has been running above capacity for years. The need for funding for surge capacity, co- ordinated care models in hospitals and ambulatory care, along with technologies to improve patient care, are paramount, and should be a priority.
The restrictions introduced over the weekend only address a small facet of our underlying vulnerability to another wave. They may offer a temporary solution, but they are not sustainable. While long- term planning may seem costly and resource intensive, the consequences of lockdowns are costlier. Without a roadmap back to normalcy that addresses the multidisciplinary needs highlighted in our Venn diagram, with constant and transparent re- evaluation of its effectiveness, we will be chasing our own tail in perpetuity.