How much longer?
That’s the visceral plea from Canadians who have been stuck at home for more than a month, many trapped in private purgatory.
Some are stranded with abusive family members, others are watching their family businesses deteriorate. There are people grappling with mental illness, chronic disease, addiction and loneliness.
It’s an entire nation with noses pressed up against the window, staring out at the blossoming spring just out of reach.
So there might well have been collective discouragement when Prime Minister Justin Trudeau announced on Tuesday that our isolation must continue for “weeks.”
Will it really take weeks to start easing the social restrictions?
Or is there a way back that can begin sooner — slowly, intelligently, creatively building on the success Canadians have demonstrated in a collective effort to flatten the curve and protect the health care system?
It’s a debate that is just beginning, with some pushing for faster easing and others — especially those on the front lines in hospitals — begging for more time.
“We would want to relax measures in a very controlled manner and looking at where the biggest benefit would be,” said Dr. Matthew Muller, the medical director of infection prevention and control at St Michael’s Hospital in downtown Toronto.
“So if the hospitals are not overwhelmed — and I think it’s a little too early to say because we’re still rising and I’d like to see things to be stable for a bit longer — it might be possible to restore more normal health care for a larger number of people.”
It’s working. Canada is flattening the curve
It’s now clear that Canadians deserve to be congratulated for the gift they’ve bestowed upon their public health officials and political leaders.
By putting their lives on pause, Canadians have created precious time to repair broken supply chains, to increase capacity on the already overloaded hospital system.
And after five weeks, there are signs the sacrifices are paying off.
Hospital intensive care units are still seeing a steady stream of COVID-19 patients, but so far they are not overwhelmed. Because many non-COVID patients were transferred out of hospitals several weeks ago, there are still empty beds.
Although It’s still too soon to declare victory, some are allowing themselves to admit they’re seeing the first rays of light at the end of the tunnel.
“I believe we’re at the peak but not through the peak,” said Dr. MIchael Gardam, an infectious disease specialist and veteran of the SARS epidemic and H1N1 influenza pandemic. He has been bracing for the COVID-19 surge for months as chief of staff at Humber River Hospital in Toronto.
“I thought it would be much worse. I was thinking about battlefield triage and who would get ventilators,” he said, adding he’s not expecting Canada to face the nightmare scenarios of New York City and northern Italy “as long as we keep being intelligent and keeping a lid on things.”
“A lot of the deaths that were happening in Wuhan, Italy and New York were because people couldn’t even get basic care like oxygen,” said Gardam.
But with cancer screening on hold, routine health care interrupted and increasing evidence that people are hesitating to go to hospital for genuine emergencies, the non-COVID collateral damage could be accumulating.
“We’ve delayed a lot of pretty urgent surgeries, for example, people who know they have cancer but haven’t been able to have their surgery yet,” said Gardam.
That’s why he suggests it could be reasonable to start easing up in a specific area — perhaps resuming elective surgeries — and watching the COVID-19 case numbers closely.
“I think you start gingerly opening up. You start with your semi-urgent and urgent cases in the hospitals.”
Testing, PPE still needed
Opening up health care depends on a steady supply of protective equipment. So far, Muller, on the hospital front line, is not confident that support is in place.
“We’ve already depleted a lot of our supplies that have not been replenished yet, so there’s a number of pieces to the puzzle,” he said.
Another important tool in the back-to-new-normal tool kit is wider diagnostic testing — a critical part of the pandemic response that has been plagued by shortages and delays.
This week, Health Canada approved a portable DNA analyzer that will add testing capacity outside the major health care centres. Ontario has cleared its laboratory testing backlog and is now testing more than 8,000 patient samples a day. Ottawa announced a New Brunswick company will supply critical testing chemicals.
But testing capacity will need to increase to the point that front line hospital workers will be able to quickly determine if a patient is infected and use proper personal protective equipment.
“If we had better testing infrastructure in place and better testing capacity, it would make it more feasible to start relaxing more physical distancing,” said Muller.
Critical COVID-19 data gap
One of the biggest challenges of COVID-19 has been the lack of evidence for key indicators, including the true rate of infection, the actual death rate and the impact of social distancing policies.
Stanford University epidemiologist John Ioannidis is renowned for his evidence-based assessments of drug treatments and other health interventions. He’s researching the prevalence of COVID-19 and analyzing the emerging data. He believes there will be fewer COVID-19 deaths than the models forecast, in part because the disease has already infected more people than the case counts suggest.
“This means the infection fatality rate is much lower than the ones that were built into the mathematical models that make astronomical predictions,” he said.
A higher number of infections is important for two reasons. First, it will help establish the true fatality rate. So far, the death rates are based on the number of diagnosed cases. But If there are more cases than we know about, the fatality rate will end up being much lower.
Second, the more people who have been infected and recovered, the slower the virus will spread in the community, because those people will have at least some short-term immunity to the disease.
That includes those who were asymptomatic, which may be a surprising number of cases, with some estimates as high as 80 per cent.
What’s called seroprevalence research — using blood tests to check for antibodies in a random group of people — will help answer that question. Those studies are not yet underway in Canada.
‘It has to be done gradually’
Ioannidis supports a gradual easing of social restrictions while protecting the most vulnerable populations.
“I don’t think you can open up immediately. People are shell-shocked. It has to be done gradually,” he said. “Start taking these steps and measure what happens. If you see a resurgence, you can go back to more restrictive measures.”
When can that social easing begin? Not yet, said Muller.
“I think my medical colleagues who are working seven days a week, 24 hours a day, and grappling with COVID patients are strongly in support of ongoing physical distancing despite the impacts it might have on their own personal lives and families, because we see the harm of COVID,” he said.
“On the other hand, I do think they’re starting to think about and advocate for providing care to patients who don’t have COVID. So that’s the balance.”
Physical distancing was only intended to slow the spread
The bottom line is that physical distancing was never intended to prevent people from catching COVID-19. The goal was to keep everybody from getting sick at once.
“We want the epidemic to simmer, not to boil. The cases are going to happen, but if they happen at a simmer, we’ll be able to handle them,” said Gardam, adding that discussions of how to begin easing up have already started.
“I’m on calls today to start talking about what’s next. So we’re doing it, we’re getting there. And we’re going to have to be very selective.”
Dare we imagine at least some form of street life this summer?
“Can you go to restaurants again in the summer? Probably smaller restaurants, maybe removing a third of the tables and keeping them further apart,” Gardam said, admitting that he might be going out on a limb a bit.
“Until the cases start to go down, I”m jumping out a little bit ahead by saying this. But I feel comfortable saying this.”