What lessons has pandemic taught Canada?
What went wrong? What can Canada do to fix it before the next wave hits? This look at how one of Canada’s worst-hit provinces lost control of the coronavirus and its plans to reopen is part of National Post’s Lessons from a Pandemic series.
Imagine you are building a wall to keep an enemy out, but the only pieces of wood and stone and steel you have are weak and cut through with holes. You build an outer layer. And there are gaps, big ones, the enemy can walk through. So you add another layer. And another, and another one. You keep stacking imperfect layers — one beside the other — until each imperfection lines up with a strength.
That’s how you fight a virus without a vaccine, with a wall built from imperfect layers. Put enough of them together, the hope goes, and the barrier will hold. But no matter what you do, the weakness in each will always be a threat to the whole.
Last week, the Ontario government announced the first stage of a gradual reopening of one of the country’s worsthit provinces after almost two months of emergency lockdown. Mass physical distancing did little to prevent more than a thousand lonely deaths in long-term care in the province. It failed to prevent outbreaks among the homeless. It has still not brought the daily count of new COVID-19 cases in Ontario below 300.
But as a first, imperfect, layer, physical distancing worked. It bought the province time: to shore up hospitals, to secure protective equipment, to expand testing and contact tracing.
It gave the province space to prepare for what experts believe will be an 18-24-month fight against the virus in the community. It gave them time to build that imperfect wall.
The question now is whether the government put all that time, and all that sacrifice, by businesses and families, to good effect.
Some experts are skeptical. “What I worry about with Ontario is that we’ll get blindsided. Because I’ve still yet to see any actual plan,” said Dr. David Fisman, an infectious disease specialist at the University of Toronto’s Dalla Lana School of Public Health.
Experts are concerned about a lack of detailed benchmarks for the reopening, about continued weaknesses in the testing and contact-tracing systems, and a seeming absence of plans for supported isolation. They’re worried that as Ontario opens up, new outbreaks will appear and spread faster than they should, forcing everything to shut down again.
Ontario is not Canada. There is no one pandemic across this big land. The outbreaks here have been neither as bad as the ones still devastating Quebec, nor as well managed as they have been in British Columbia and New Brunswick. But the lessons from Ontario, good and bad, will apply across the country. And the outcomes here will be felt from coast to coast to coast.
Ontario’s wall, in other words, is Canada’s wall. And its strength is in those layers. How well will each of them hold?
The broad contours of a successful plan to fight COVID-19 have been in place, around the world, for months. “We’ve seen it work in Australia, we’ve seen it work in South Korea, we’ve seen it work in a number of African countries,” said Dr. Irfan Dhalla, who teaches medicine at the University of Toronto. “There’s no reason why it can’t work in Ontario, Quebec and the United States.”
That plan rests on four pillars: testing, contact tracing, isolation and support. Those are the four imperfect layers of every successful community fight against COVID-19. Done well, from the start, the four-pillar plan could have cut infections and deaths in Ontario dramatically, Dhalla believes. Fail to do it well going forward, and the reopening will likely end in a painful new wave.
Within that four-pillar plan, there are two states: lockdown and release. And broadly speaking, there are two measures to judge whether any jurisdiction is ready to move from one to the next.
The first is blunt enough: is the outbreak under control?
“No. 1 overall we want to see that the epidemic curve — which is looking at number of new cases per day — is actually on a downward trend,” said Todd Coleman, an epidemiologist at Wilfrid Laurier University, “and preferably with, something like this, closer to zero than what we’re actually seeing now.” In Ontario, there were 304 new cases recorded on Sunday.
That decision is going to be different in every province. “If you’re British Columbia or New Brunswick or elsewhere in the Maritimes? Yeah, I think it’s time,” said Isaac Bogoch, an infectious disease specialist at the University of Toronto. “It’s pretty safe to start lifting some of these public health restrictions at this point.” As for Ontario, he isn’t so sure. The province is further along than Quebec. But it still has a long way to go. “I think we need to really scale up these other measures to ensure we just don’t reintroduce COVID-19 into community settings,” he said.
Those “other measures” are the second half of the equation. Even if you have the pandemic under control, to open up effectively, you need to know you can detect and quash any new cluster before they can explode. “One or two cases is inevitable,” said Raywat Deonandan, an epidemiologist at the University of Ottawa. “The goal is to prevent one case from becoming an outbreak and to prevent an outbreak from becoming an epidemic.”
At the beginning of the pandemic, Ontario, like many jurisdictions, was unprepared to conduct the volume of testing required to keep a viral pandemic under control. Part of that, experts believe, was out of the province’s hands. There was a worldwide shortage of the equipment and supplies necessary to conduct tests for COVID-19. But part of it, too, was local. Public health cuts left the provincial lab system, especially, in a poor position to ramp up mass testing and analysis.
In any case, by any measure, the situation has improved dramatically over the past eight weeks. Last week, Ontario Health Minister Christine Elliott announced that, for the first time, anyone showing symptoms of the disease will be able to get a test. But public health experts and epidemiologists are still concerned. “We’re not testing as high as we should be, especially when we’re reopening,” said Coleman.
They aren’t just worried about the volume of tests, though. They’re worried about the testing strategy, too. “We need to know where the cases are in the community and that requires surveillance,” Deonandan said.
Right now, testing in Ontario is focused on people showing signs of the disease and people living or working in vulnerable, congregate settings, like hospitals and long-term care homes. But as rules around social distancing ease, many experts believe the province will need to adopt a system that goes out and actively looks for the virus in the community. “We need (to) hunt this virus down,” said Deonandan. “That means doing random testing across the entire community continuously.”
But tests are just the beginning. Just as important is the next layer in the wall: what happens after the test results come in. If the province does have a plan for surveillance testing, they aren’t sharing it yet.
There is no element of Ontario’s plan to contain the COVID pandemic that remains as mysterious to experts as contact tracing. “I have no idea what’s going on with contact tracing,” said Dr. Lesley Barron, a general surgeon who has been working in a COVID testing centre in rural Ontario. “Do we have robust contact tracing in Ontario? I don’t think we do.”
When it comes to measuring and containing community spread, contact tracing is just as vital as testing. In a nutshell, the process works like this. When someone tests positive for the virus, an official from their local public health unit will contact them and let them know. A trained contact tracer will then follow up and try to get a list of everyone they’ve had close contact with since they started shedding the virus (usually a few days before symptoms occur). The contact tracer then reaches out to all those people to tell them they’ve been exposed, ask them to self-isolate and warn them to be on the lookout for symptoms.
The province has a stated goal that 90 per cent of all relevant contacts of a confirmed case should be reached by a public health unit within 24 hours of a positive test. Public officials this week said that “most” local units are now reaching that goal and that many that aren’t are getting close. But none of the Ministry of Health, Public Health Ontario or any local public health unit contacted by the National Post over the past two weeks would provide detailed statistics.
To Dalla Lana’s Fisman, that’s all incredibly frustrating. “If you’re setting benchmarks that say 90 per cent of contacts need to be identified within 24 hours, that’s nice. Where’s your data?”
Dr. Barbara Yaffe, Ontario’s associate chief medical officer of health, said information on contact follow-ups is not being entered into the central provincial database. “But we’re very confident that the contact follow-up is being done. It’s priority.”
Dr. David Williams, Ontario’s chief medical officer of health, said last week that 28 out of the 34 public units were hitting the 90/24 target. “The challenge comes in with some of the health units that have the biggest caseload,” he said, citing Toronto, Peel Region, Durham and Ottawa.
Even if the testing is broad and contact tracing is fast and thorough, the wall can still break down in the next layer: isolation. In Ontario, self-isolation, which is crucial to preventing spread, still relies on the honour system and some magical thinking about how most of the people in this province live. That’s why some experts believe the province should be doing more to make sure everyone has the tools to isolate safely.
Public health units across the province are telling people with confirmed or suspected cases of COVID-19 to isolate at home, away from their families, unless they need medical care. But many homes in Ontario don’t have enough bedrooms, bathrooms and space to make that work.
That’s a problem. “I had friends of mine who are physicians say to me, if one of us got sick, I wouldn’t really know how to isolate in my own home,” said Dhalla. “But if you work at a grocery store or if you’re a taxi driver and you live in a relatively small home with several other individuals … are we some really supporting (these) people well enough to isolate?”
The risk isn’t just that they’ll infect the rest of their family. It’s that without the right supports, people won’t stay safely isolated. They’ll go out into the community because there’s no one else to do it for them.
Right now, in Toronto, when it comes to supportive isolation, the focus is on people who have nowhere to live. Everyone who has a home is effectively on their own. Some experts believe that should change. “If you’re asking people to self isolate and they have small space, can we provide them with an alternative place to isolate?” said Tuitte.” If we’re asking people to self isolate and they’re not able to get out for groceries or for other needs, do we have systems in place to support that?”
The answer, in the end, as it so often has been in this pandemic, comes down to trust. The premier of Ontario and his top health officials speak publicly and take questions almost every weekday. But many details of the province’s plan to reopen are still hazy or hidden. They are asking Ontarians to trust them, to trust that the layers they are lining up will make a decent wall.
Not everyone is confident that they will.
“No one seems to be aware of anything, which positions us very nicely to get knocked over when this resurges, whether that’s in the middle of the summer, whether that’s in the fall,” said Fisman.
Ontario, and Canada, are reopening, one way or the other. How long we stay open depends on each pitted layer of that imperfect wall.