ROUTE BACK TO NORMAL LIFE
NORMALCY WILL COME IN SMALL STEPS, BUT A DROP IN CASES MIGHT ALSO FEED COMPLACENCY
Four potential milestones
Ontario Premier Doug Ford likely spoke for the nation when he said this week that people are “getting squirrelly staying inside the house” as the country obeys stay-athome orders to fight the COVID-19 pandemic.
And although some politicians and public health officials have started talking about “cautious optimism” and “light at the end of the tunnel,” Prime Minister Justin Trudeau reiterated Wednesday that it will be weeks before the stayat-home guidance is relaxed and the economy can gradually start to reopen.
That means we’re in for the long haul and the deadlines remain frustratingly vague.
But with reports from health organizations and think tanks, we can start to put some markers in the road — for a hint of when people will be able to visit friends and extended family and go back to restaurants.
A report by the American Enterprise Institute, a right-leaning think tank in the United States, set out four phases to expect in the course of the global pandemic and, crucially, the triggers that tell us when we can move on to the next one.
Along with a report from the progressive think tank Center for American Progress, guidelines from the World Health Organization and interviews with medical experts, we’ve set some rough triggers that could herald a return to something approaching normalcy.
PHASE 1: SLOWING THE SPREAD
Canadians are already intimately familiar with phase one. We are living it.
Phase one involves physical distancing, only making essential trips to the store and huddling at home with direct family or roommates. While Canadians try to keep their distance from each other, the government is furiously building testing capacity and ramping up health care infrastructure, including increasing the supply of personal protective equipment for front-line health care workers.
We are also building the country’s capacity to conduct contact tracing and offering voluntary isolation and quarantine to people who are possibly infected. The government has embarked on a recruitment campaign for volunteers to track COVID-19 cases.
If there’s one thing to pay attention to during phase one, though, it’s testing.
The Center for American Progress recommended a stay-at-home policy of at least 45 days, and ramping up testing capacity to the point where everyone with a fever is tested, along with everyone in that person’s household.
Trudeau said on Wednesday that the most important task for the country right now is to establish “massive rapid testing on a very widescale basis.” The quickest way to stop transmission is to quarantine people who are infected — but right now we don’t know for sure who is infected, so the whole country is effectively in quarantine. A massive increase in testing allows us to be more precise about who needs to isolate.
Economist Paul Romer has called for 20 to 30 million tests every single day in the United States before the country contemplates lifting lockdown measures. Adjusted for Canada’s population, that would be more than three million tests every day.
The more you accomplish with other factors, though, the less you have to rely on testing, said Maura Calsyn, the managing director of health policy at the Center for American Progress.
Calsyn said a concerted effort on instantaneous contact tracing using a custom-built app could allow countries to have much lower levels of daily testing.
WHEN WILL PHASE ONE END?
According to the American Enterprise Institute’s plan, a province can shift to phase 2 when it has sustained a reduction in cases for at least 14 consecutive days; hospitals are no longer in “crisis mode”; we are able to test all people with COVID-19 symptoms; and we can actively monitor confirmed cases and their contacts.
The key measure, though, is how many people are infected and whether that number is growing or declining. Some experts say that the barrier should be two weeks of absolutely zero transmission before Canada considers opening up parts of the economy.
“What we would be looking for is no new cases and there’s a bit of a time lag between when it actually happens and when we can confidently say that. So whether that’s two weeks or a month with no new cases, it’ll be hard to know exactly when that happens,” said Alison Thompson, a public health professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto. “Once we’re pretty sure that the transmission activity has stopped, that would be when we would look to reopen things. Obviously that’s going to be done on a local basis because all of Canada isn’t going to open up at the same time.”
Whatever the measure Ottawa decides to use, Canadians can track the progress each day with the numbers announced by public health officials.
Some provinces will get there before others, so pay close attention to how provinces like British Columbia and Saskatchewan perform in the next week or two.
PHASE 2: REOPEN, PROVINCE BY PROVINCE
Phase two involves gradual reopening but, crucially, provinces should be ready to go back to Phase 1 at any time if cases jump and the country suffers a second wave of infections.
Without a vaccine or herd immunity, all the public health measures are like holding down the brake on a car rolling down a hill with no ability to put it in park, said Timothy Sly, a professor emeritus at Ryerson University’s school of occupational and public health.
When a province lets up on the brake, the car could start rolling again, like in China where positive cases have started to accumulate after declining almost to zero last month.
Politicians and public health officials are likely to be very cautious about taking their foot off the brake pedal because it will be traumatic if Canadians have to be slammed back into lockdown.
“Now, you imagine psychologically how difficult that’s going to be for people to say, ‘Oh my goodness, I thought it was over’,” said Sly. “I mean, it’s going to be even more difficult.”
As we gradually reopen, daycares and schools will restart and some Canadians will return to work, although people who can work from home will be encouraged to do so. The most draconian physical distancing measures will begin to relax in phase two, while special care is provided for vulnerable people.
Large gatherings will still be banned and restaurants may have to adapt to new rules that limit the number of people at a table. Stores will have to continue to count customers coming in and be vigilant about employees who are symptomatic.
People who are immune will be identified with antibody tests and could be encouraged (perhaps with government wage top-ups) to tackle high-risk roles in the health care system or help vulnerable people.
“Those people who are positive now become almost fireproof. They’re extremely valuable, they’re untouchable, they’ve got kryptonite,” said Sly. “They could work in a hospital, a nursing home. They can’t be infected again, as far as we know.”
How immunity works with COVID-19 will need to be studied so we can be sure of how long it lasts, said Sly.
The Center for American Progress recommends that people be instructed to wear masks until herd immunity is achieved. Public health bodies should offer instruction on how to make and wear cloth masks, “given the low cost of homemade cloth masks and that two studies have demonstrated” that they do provide some protection.
WHEN WILL PHASE 2 END?
Phase 2 ends and something resembling normal life begins once a vaccine has been developed and has been approved by Health Canada or we can deploy anti-viral medications on a massive scale. It could also be possible to use antibodies from people who are immune but, for now, a lot of this is speculation.
Thompson said we can’t really know what the world will look like for the next few years. “I’m not sure that we’ve ever been here before,” she said.
PHASE 3: ESTABLISH PROTECTION, THEN LIFT RESTRICTIONS
The best case scenario may still take 12-24 months, but a vaccine will be a gamechanger.
At first, if supply is limited the vaccine will be reserved for front-line health workers and vulnerable Canadians. When production ramps up, there will be a mass vaccination program and then a huge effort to ensure population immunity.
Governments should be looking at other options, because vaccines require extensive testing and there are some historical horror stories about poorly tested vaccines.
“We can roll out a vaccine really quickly if we want to. But the problem is that we don’t know, unless we take the time, what the safety and effectiveness profile of that vaccine will be. And you really can’t rush that,” said Thompson. “There’s some real cautionary tales there about rushing these things just because it’s an emergency and you can do more harm that way.”
Sly noted that the drug thalidomide caused thousands of babies to be born with defects in the 1960s due to improper testing.
“What would happen if you put five and a half trillion dollars into a vaccine and people all over the world ramp it up and as a result, we begin to see 4,000 cases of some horrible, horrible condition caused by the vaccine?” said Sly. “Can you imagine how angry people are going to be with the World Health Organization after that? So we’ve got to tread as carefully as possible.”
PHASE 4: GET READY FOR THE NEXT PANDEMIC
Either globally, or on a country by country basis, there will be a huge effort to make sure vaccines for novel viruses can be made in a matter of months, not years. Lessons learned in the health care world, including about protective equipment will be applied.
“We need to have some prescience here. There will be another pandemic. There’s usually two or three in a century,” said Sly. For example, Canada could be more diligent about replacing expired masks and other protective equipment, he said.
A national, or international, infectious disease forecasting centre can be established to make sure that warnings are heeded in the early days about a worrisome virus.
One of the biggest issues Canada faces is standardizing and centralizing the data that is so important during a health crisis, said Amir Attaran, professor of law and medicine at the University of Ottawa with a doctorate in immunology and infectious disease. Right now, the provinces collect and release data with varying levels of transparency and diligence.
“Statistics Canada can tell you very accurately in a given neighbourhood how many bathrooms there are in the house, right? We have better federal data on toilets in Canada than on a disease that threatens to kill us,” said Attaran.