Dealing with COVID-19: A balanced response
COVID-19 is a serious public health threat and will remain so until we have a universally available safe and effective vaccine or similar medical treatment. There have been many deaths due to COVID-19 and every single one represents a tragic outcome. However, in overall population health terms COVID-19’s direct impact on premature mortality is small. While those under the age of 60 account for 65 per cent of cases, they represent just three per cent of deaths. With ready access to health services, severe outcomes can be averted in those who do not have pre-existing risk factors.
In March 2020, unprecedented public health measures were implemented in Canada in response to the rapid rate of growth of cases and the potential threat to health system. Because of the potential for exponential growth in cases and the situation in other parts of the world, our governments took these actions that applied to the entire population to protect our healthcare system. These interventions were meant to buy the time necessary to develop a longer-term response. They should not be used as a means of eradicating the disease.
While some countries have been successful in suppressing the disease, most continue to see sporadic cases and outbreaks. Only a few countries, primarily island nations, appear to have eliminated the disease, but it is uncertain how long those countries can completely isolate themselves from the rest of the world.
The public health measures did protect our healthcare system, to the point that Canada had excess capacity. Our leaders and public health authorities had to use strong language to support universal acceptance of these measures. As a result, many Canadians have become fearful of COVID-19 and are worried about the impact of working, seeking routine and preventative medical care, participating in religious and cultural events, interacting with their family and friends, using public transportation, shopping and other normal activities.
COVID-19 control is an important public health priority but it is not the only or the most important challenge to the health of people in Canada. We need to examine the broad social determinants of health and their impact on citizens, particularly with an equity lens, as the consequences of the public health measures have not been shared equally in society. Those in lower income groups, Black and other racialized groups, recent immigrants and Indigenous people are bearing disproportionate burden. The public health efforts must take account of the impacts of both the disease and the consequences of the control measures on all segments of the population.
The fundamental determinants of health – education, employment, social connection and medical and dental care – must take priority. Measures for COVID-19 control need to accommodate these health determinants. Children need to interact with their peers in child care, schools, sports and social activities and summer camps. Adults need to go to work. Family and friends need to meet.
The societal costs of maintaining these public health measures, even with some gradual relaxation, are too high. Canadians are missing scheduled medical appointments and surgeries, which will lead to increased deaths. There are significant challenges for our young with impact on early childhood development, one of the strongest predictors of life-long health and social outcomes. Education is compromised. There are increases in domestic violence, alcohol and drug intake, and food insecurity.
The economic consequences are huge. This leads to increased unemployment, which is related to increased deaths. And the toll on mental health is just beginning to be felt. Personal concerns about the disease, cases and deaths in friends and family, loneliness and isolation, worries about jobs and finances, parents having to juggle childcare and general insecurity are leading to increased levels of anxiety, depression and stress.
We need to shift from a mindset of attempting to eradicate this disease, which is not feasible and will lead to continued devastation of our society, to a new goal.
Our new goal: Minimize the impact of COVID-19 using methods that are practical, effective and compatible with our values and sense of social justice. We need to focus on preventing deaths and serious illness by protecting the vulnerable while allowing society to function.
Elimination of COVID-19 is not a practical objective for Canada until we have a vaccine. We need to accept that there will be cases and outbreaks of COVID-19. We should mitigate the effects of the disease with measures that are equitable, sustainable and acceptable. This includes testing and contact tracing, and ensuring that health services with access to the latest treatments are available for those who contract the disease.
Those at highest risk of severe consequences need to be offered effective protection from COVID-19, particularly those in long-term care institutions, but this protection must be respectful of their autonomy and allow them a reasonable quality of life.
Aside from the outbreaks in long-term care institutions, some of the most significant have been in other congregate living settings (homeless shelters, prisons, dormitories for temporary foreign agriculture workers) and work settings such as meat-packing plants. Appropriate protections and supports are needed in such settings.
COVID-19 control must be balanced with basic human rights. People need to be empowered to make informed choices about their own lives and the level of risk they are prepared to accept. Universal public health measures are appropriate only when they are truly necessary, supported by strong evidence, and when there are no other alternatives.
Recommendations
1-Carefully reopen schools, businesses and health care. Allow gatherings of friends and family. Provide practical guidance that allows citizens and institutions to operate safely and effectively. Restore public confidence that it is safe to go out, that appropriate precautions are in place and conditions will be closely monitored.
2- Develop clear control plans for future outbreaks or resurgence of disease that are risk-based and focused so further universal lockdowns are not necessary.
3- Improve our disease surveillance so that we have an accurate picture of disease activity to make timely decisions and provide useful advice to Canadians. Ensure that public health has the resources to conduct timely and effective testing and contract tracing.
4- Provide clear guidance on appropriate use of viral (diagnostic) and antibody (serology) testing for healthcare providers, employers and community organizations. While testing is a critical element for control of COVID-19, it has to be done in a smart way. Indiscriminate testing, for example daily testing of all employees in an office setting, is less effective than testing of those with greater exposure to the general public.
5- Assess community risk in applying infection control approaches in different settings. Procedures that are appropriate for a hospital, with high risk of exposure, are not necessary across all of society. Control measures need to be evidence-based and address the level of risk in a particular setting and community. Measures should take account of costs and benefits at the individual and community level using a social-determinants-of-health model and applying an equity lens.
6- Assess the appropriateness of recommendations for physical distancing from a risk benefit perspective. Where risk of community transmission is very low, the absolute benefits of physical separation are negligible, particularly if good hygiene is practiced and individuals with symptoms stay home.
7- Reassess quarantine and isolation periods based on current evidence. Strategies that use testing to further reduce this period should be examined. Review the restrictions on nonessential travel to all parts of the world. Travel should be restarted to countries where there is little community transmission.
8- Be clear on when the use of medical and non-medical masks is recommended. When advice varies based on local epidemiology, provide clear evidence-based criteria for decision-making. Any requirements for mandatory masks must be based on strong evidence with clear specification of where they are most appropriate (close quarters, congregate living settings, etc).
9- Improve infection prevention and control in long-term care as deaths have come mainly from a break down in these practices within some facilities.
10- Canadians must be better informed about their true level of risk from COVID-19. An accurate accessible risk assessment tool is a priority. This will help empower people to make informed decisions about how they choose to lead their lives. Help people understand and manage their fear and anxiety.
11- Provide support for vulnerable people living in the community who choose to isolate when the disease is active. Some individuals, even though at risk for severe disease, may wish to make informed decisions to carry on with normal life. Such choices should be respected and supported.
12- Ensure there are adequate supports for those individuals that have been adversely affected by COVID-19, or the consequences of the public health measures. In particular, support for mental health and addictions is essential as the potential toll on the population is massive.
The comments section is closed.
The resources wasted on turning COVID-19 into COVID-1984 would have been better spent on real health care.
In 2017 Canada had 2.9 hospital beds per 1000 people, ranking Canada 36th in the world . Japan had 13.4 beds per 1000 (WHO, Wikipedia). Every flu year for at least the past decade was an escalating crisis especially in large urban centres. As the population aged and became more vulnerable to respiratory illness, real healthcare did not keep pace.
Over a year and into the 2nd wave of COVID-19, and health care is still ‘overwhelmed’.
Many deaths and a whole lot of suffering could have been avoided had COVID moral panic not quashed discussion of real and practical medical care options and administrative accountability.
The official narrative of lockdowns and vaccines is an ongoing fail of virtue signalling and done little to meaningfully protect lives and heal the sick.
well put now if only the gov’t would listen and quit ruining our lives
Well thought out and affective approach to a respiratory virus. Still as relevant today as it was when sent to politicians.
Well thought out and affective approach to a respiratory virus. Still as relevant today as it was when sent to politicians.
https://docs4opendebate.be/en/open-letter/
Thanks, Tom, for this excellent information. See above for an English translation.
Here’s a self-explanatory open letter from Doctors in Belgium, complete with footnotes indicating sources. I trust you have some Google translate or similar app as it’s written in German. (15 min. read) http://healthydebate.ca/opinions/an-open-letter-to-pm-covid19
And if that’s a bit too clinical, here’s an impassioned plea for sanity. (13 min. video)
https://youtu.be/R3mg33HpVQM
Oops; sorry; wrong link to the Belgian Doctor’s open letter in my previous comment.
Too bad there’s no edit feature.
Here you go! https://docs4opendebate.be/open-brief/
Thank you for sharing your reasoned and ethical approach to the COVID 19 pandemic response in Canada. Prior to this pandemic, Canada had a pandemic guideline, the CPIP, which is a risk assessment/risk management approach similar to your approach. (I suspect some of you were involved in the development and/or updating of the CPIP)
The CPIP has an ethical framework that is lacking in Canada’s current pandemic response. According to the CPIP, public health measures during a pandemic must be flexible, evidence based and proportionate to the risk of viral infection to all members of the population. Restrictions must be imposed only to the extent necessary to prevent foreseeable harm. Public health planning must consider both the benefits and harms of public health measures to all members of society.
When the COVID-19 pandemic was declared by the WHO, Canada abandoned the CPIP. Our current pandemic response guidelines ( See: Government of Canada: Guidance for a strategic approach to lifting restrictive public health measures) do not take into account the harms of lockdowns to society and the economy. Its time for Canada to return to the CPIP.
Several New Zealand public health experts have formed a group called COVID 19 Plan B – covidplanb.co.nz. On their website they post Covid 19 news, pertinent data and science on COVID 19, and webinars from international experts in public health and infectious disease. Any chance you could start something similar in Canada? We desperately need to hear more from you and other experts like you.
Thank you for speaking up for the people. We love this country because of our freedoms to critically think, speak and choose. It has felt like communist tyranny this past six months with no science to even back it. We will never irradicate viruses…our focus should be on how to support our own amazing immune systems which includes living life, human connection, healthy lifestyles, etc. Let’s not surrender our freedoms to fear. Support the vulnerable and allow the rest to live and choose. Thank you!
As we continue to move forward, I am asking for even a stronger stance to come against fear based shutdown/lockdown. Never in my life have I battled such depression and loss of hope. I was so lonely during the lockdowns and am so afraid of going into it again. I am 62 and am responsible for my own health. I would prefer to live the life I have than hide away. I feel like I am wearing a burda when I where a mask – such a loss of identity as well as the inability to use my senses to judge others wearing a mask. I am so worried about our economy and all the people out of work! So much collateral damage with this stance the government has taken. I am also afraid of a rushed vaccine that could have long term side effects. Please do more. Write the Provinces and the Federal Government – I want my life back.
Truthful not politicized measures would be very appreciated
I agree. Let our children return to school, work place’s should open but we need to follow all protocols put forward through Public Health.
Finally some accredited professionals who have it right.
I’ve forwarded your letter to the EOHU who has recently mandated the wearing of masks in all public places when the incidences of COVID-19 in our region doesn’t warrant it.
Hopefully they’ll head your advice as my opinion doesn’t matter.
Thank you for this clear, easy to understand, very well written article and the good suggestions on managing Covid 19.
Excellent perspective. Total agreement.
Finally, some cool minds speaking out. Why so late? Whole public health textbook interventions were ignored, panic prevailed.
The Government’s approach to Saving Lives in Long Term Care Homes is doing the opposite.
Isolation is causing more harm.
Thousands of attempts to get this acknowledged.
Orders 95/20 and 77/20 will go on forever with Bill 195
Seniors have not had a hug for 119 days and their average lifespan in LTC is 500 days… 119 with the impact of isolation is more like 240 day… they are dying from giving up their will to live and it’s being reported as old age.
Next phase that will come out is by appt only 30 mins per week to hug… 1 week after the end of State of Emerg
We *know* there are issues with Long Term Care…by banning Family then none of it will get reported and there will be No inspections.
Seniors in LTCH’s Need Help!
The fear of covid is real, but its greater that there’s no one, especially in the political section of the Ontario government, who are interested or capable of actually following the recommendations given. I worry that a letter such as this will be the excuse used to further the needs of business at the expense of the vulnerable. The last word on reopening measures should not be in the hands of regressive agenda driven politicians.
My wish is to see the government take a position on overall health. To each people how to use nutrition to keep our bodies strong. No Dietitians but Nutritionist advice and teachings would be so great to see. many prevenative oils, herb,s and so many substances that are available in health Food stores really do help to keep us safe. WE need more grass roots information – not just vaccines and drugs.
While the recommendations are very generic they might well form the framework for further work to add detail and specificity. What I like most is the concept that we must move away from shutting down everything to prevent transmission and begin a new paradigm of (i) targeting support to vulnerable populations and (ii) focusing efforts on strategic testing and contact tracing to prevent spread following the inevitable flare-ups, while recognizing that life goes on.
First, I would like to address the statement that, “…many Canadians have become fearful of COVID-19 …”. This is very true, however, our southern neighbours seem to be less concerned thanks to their president! Look where this has got them! There is nothing wrong with healthy fear of a highly contagious deadly virus! We do not yet know the long term impact of this virus for people who contract it. Examples of other virus long term effects are polio and post polio syndrome and chicken pox and shingles.
As much as there is, “recovery”, many people are left with long term damage of the kidneys, brain, lungs and nervous system.
Yes there is an impact of this pandemic on the mental health of people, but let’s be real: how could there not be? It is a pandemic. Let’s give people tools to cope rather than a Pollyanna approach where we inform Canadians, “… about their true level of risk from COVID-19.”
As I said before, a healthy fear is a good thing. It’s akin to walking across a mine field. Does one run or does one pick their way carefully?
What is interesting to me is that this article is written by a lot of people that held positions and not present holders of public health and experts in their field. To have a real conversation about this pandemic and the impacts on people, let’s get some others who are actually practicing as well as a diverse group of practitioners in many fields such as child and youth counsellors, social workers, addiction counsellors, teachers, psychologists,
as well as personal support workers and nurses.
Sincerely Louise King
This letter fails to address the significant number of Canadians who, because of the pandemic, have not been able to be seen for serious health problems other than Covid-19 . Many family doctors are still not seeing these patients. ER visits, when they occur, are aimed at quick fixes that don’t really address what is going on. People are punted back to their homes, anxious and without diagnoses. Many Canadians, especially Ontarians, are understandably worried about health matters unrelated to Covid-19.
Calling needed cancer and cardiac surgeries “elective” sure hasn’t helped matters. What is the government planning to do about these significant backlogs?
Finally! A more targeted perspective which focuses on the vulnerable and high risk circumstances and communities. However, the economic consequences above are portrayed solely as employee based. The real economic consequence is the effect that “broad brush” strategies have on the economic engine of the country; small and big business. Strategies must not retard the ability to keep the economy flowing. Coping strategies need to favour employers by enabling business to institute practical measures which permit the economy to function as close to 100% as possible, reducing all other social economic consequences. Finally, health care needs to be able to more quickly scale to meet spikes, surges and unforeseen circumstances, and employ proven and available short term treatments in parallel with vaccine development. Waiting for the perfect solution, or overlaying heavy-handed and restrictive “one-size-fits-all” measures are not realistic or viable, and generally result in unintended (usually negative) consequences.
Thank you, thank you, thank you for putting this in writing and articulating that we still have choice in our own risk tolerance and the importance of the broad social determinants of health! We must restore common sense. The toll on family economics, physical and mental health has been staggering. I agree that there could have been more direct, practical suggestions in the letter, that the government could implement, such as a statement example that could be made public about true risk, public health statements that would support people’s right to live normally in social contact, and statements about the concrete steps that health agencies will take to protect the vulnerable. The administration of medical assessment, diagnosis and health care by phone call or virtual visit only, has to stop now!
I find the points in this letter too generic to be of use.
Surprise given the caliber of the authors.
I wish there were more concrete and practical recommendations.
Amen!
Thank you for thoughtful, common sense approaches to moving our society forward. The next wave is common sense balanced with scientific evidence.