Social Policy in Ontario

Belatedly, and with great reluctance, governments across Canada have recently released their projections of how far and how fast the COVID-19 pandemic will spread among their populations. Their hesitation was understandable, though not for the reasons given: that forecasts of this kind are inherently uncertain, or that they did not want to incite panic.

Rather, it seems plausible to think their chief concern was that the numbers were too good – that the projections would induce not panic, but complacency, undermining public support for the stringent regime of physical-distancing measures now in place. This may explain why the projections seemed so obviously inflated, offering “best-case” scenarios for infections and deaths that were considerably higher than current growth trajectories would suggest.

Indeed, there is mounting evidence the epidemic is losing steam. Only a few weeks ago the number of cases was growing by more than 30 per cent a day; of late, the pace has been more like 5 per cent, on its way to the 2 per cent or less rates now seen in much of Europe, where the virus struck earlier. The numbers of those who have recovered from the disease, meanwhile, are accelerating; some day soon, the number of new recoveries will exceed the number of new cases, at which point the number of active cases – and hospitalizations, and intensive care admissions, and eventually deaths – will begin to fall.

CANADA’S COVID-19 CURVE: OTTAWA’S THREE SCENARIOS

And yet it is not possible to remove the restrictions at one go – as if some day an all-clear would sound and we could all return to our normal lives. That’s an unfortunate consequence of the policy’s success: With so few Canadians having been infected (the number of reported cases stands at roughly 80 per 100,000, but even if it were 10 times that figure it would still exclude more than 99 per cent of the population), few have acquired natural immunity. The rest are all but defenceless. Left unchecked, the virus would infect hundreds of thousands, kill tens of thousands, swamping the hospital system and leaving thousands more to die, untreated, from other ailments – the worst-case scenario of which we were warned.

COVID-19 CASES PER 100,000 PEOPLE, BY PROVINCE AND TERRITORY

Are those the only two choices, then: economic collapse, or mass death? Happily, no.

Experts advise it is possible to gradually phase out the current system of controls, once the immediate crisis has passed, replacing it with an equally strict but less confining regimen of screening, testing, and other safeguards. Even this will take time. It will be weeks before we can even begin to transition out of lockdown – not only to ensure the number of new cases has been beaten down to a manageable level, or that hospitals have built up enough spare capacity to survive another surge, but to get its replacement up to speed – and months more before the last restrictions are lifted. Indeed, there can be no real return to normalcy until the vaccine arrives.

Nevertheless, the outlines of an exit strategy have emerged in a number of expert proposals, synthesized here. In broad terms, restrictions might be removed in the reverse order they were introduced, starting with the most draconian, such as park closings and regulations on pedestrian movements, ending with the bans on large gatherings and international travel. Provinces where the epidemic has subsided the furthest, might move faster than others – though this will need at least to be co-ordinated with the other provinces, if not federally supervised, given the potential spillovers.

Demographic groups less vulnerable to the disease might likewise be allowed out of isolation before others: the younger and healthier first, the old and infirm last. (The idea of giving similar preference to those with acquired immunity, much discussed in other countries, seems of limited utility here: there just aren’t that many of them, relative to the population, and in any case the logistical difficulties, and practical limitations, of issuing “immunity passports” hardly seem worth the risk.)

Businesses, finally, might be allowed to reopen in stages, depending on their size and degree of public interaction: small shops before large, factories and construction sites before restaurants and gyms. Even within each classification, there is room for gradualism. Restaurants might at first be limited to 50-per-cent capacity, for example, to ensure continued distancing between customers; office workers might still be encouraged to work from home, even if it is no longer legally required. Boarding a plane, even for domestic flights, will doubtless require submitting to a temperature check, as now we submit to being scanned for weapons. And of course the current heightened concern for hygiene – hand-washing, disinfecting common surfaces, limiting physical contact – is unlikely to be relaxed any time soon.

A graduated, multispeed approach seems preferable to the alternative strategy, known as “intermittent distancing”: relaxing and imposing restrictions, according as the number of new infections falls or rises. The point of this is not merely to give people periodic relief from life under lockdown, but (less advertised) to allow some spread of the disease, the better to build “herd immunity” – the point at which a sufficient portion of the population (50 per cent to 80 per cent) has been infected so that the virus has nowhere to go.

This seems extremely hard to manage: We are nowhere near herd immunity at present, and even if we could time the unlocking and relocking just right to get us there in a controlled fashion, at whatever cost to the economy and to public morale, scientists are not yet certain, so new is this disease, whether survivors are even immune. Reimposing restrictions, once removed, should be a last resort, to be used only in an emergency.

Still, no matter how gradual and careful the unlocking, it would not take many new infections to trigger a new epidemiological spiral. Mere gradualism, then, will not suffice. Rather, a suite of supporting measures will be needed to contain any fresh outbreak – the sorts of safeguards we might have put in place at the start, had the sheer size of the epidemic not surprised and overwhelmed us.

These start with a vastly expanded capacity to test for the disease. Testing in Canada has soared since the outbreak began, from 24,000 in mid-March to nearly 500,000 today, but lags behind many other countries in proportion to our population.

As the number of tests has increased, so has the number of confirmed cases, but the real dimensions of the outbreak can still only be guessed at, particularly as a large proportion of those infected, perhaps as much as 80 per cent, are symptom-free. That’s a problem, because even the asymptomatic can spread the disease. If people are allowed back into close contact, even in smaller settings, the risk is that an outbreak may once again pick up speed, undetected. Any relaxation of physical distancing will require the capacity to do two types of tests, at a scale orders of magnitude greater than at present: one, to test individuals at the first sign of infection, isolating those testing positive and tracking down and testing all those with whom they have been in recent contact; and two, testing random samples of the population, to learn not only how many people might have the virus now, and where they are concentrated, but how many have recovered from the disease and may now be immune.

Each type of testing, diagnostic and surveillance, will depend on technological advances to succeed. Isolation and contact tracing can only be effective if test results are returned quickly – not in days or hours, as at present, but in minutes, a capacity that is only now being developed. Testing for past as well as present cases will require going beyond the current practice of analyzing nasal swabs for the presence of viral material, to testing blood samples for the antibodies with which the body combats the virus. This, too, is still in development.

Contact tracing presents its own challenges. Traditionally this has required teams of workers to identify, locate and call up all recent contacts. Not only is this highly labour-intensive, but with a disease that is as infectious, and as lethal, as COVID-19, not nearly fast enough.

So attention has turned to the use of smartphones, with their near-ubiquity and interconnectedness, as tracing devices. Apps have already been developed that can track and contact all those who were near the same cellphone tower at the same time as the infected person. Apple and Google have recently announced they will embed a similar technology in the next operating system of their phones.

This raises obvious privacy concerns. The potential for abuse is frightening. But is it disqualifying? Few in Canada would want to go as far as China or South Korea, where apps are used not merely to alert those who have been in contact with an infected person, but to warn others who might be about to come near them – or even to advise the authorities of their movements. But a voluntary system, such as Apple-Google’s, in which the data were kept out of the state’s hands and deleted every few weeks, just might be tolerable, in view of the circumstances.

So, too, might another measure we would ordinarily find unacceptable: widespread, even mandatory, wearing of masks in public – a kind of soft social distancing. Public health authorities in this country and elsewhere were initially dismissive of this strategy. Ordinary cloth masks, they feared, might give their wearers a false sense of security, while the more impermeable surgical masks and respirators were needed for health care workers.

Since then a new consensus has emerged: While cloth masks may not provide much protection against infection, they do seem to be of some use in preventing those already sick from infecting others.

Whether it makes much sense to wear them on the street may be doubted – why not just stay six feet away from people? – but in enclosed, high-traffic spaces masks may be of some use. Might we soon see them being handed out in public-transit stations and store entrances, to be deposited at the exits?

It is a horrifying vision in many ways: mass testing, cellphones snitching on their owners, much of the population in masks. It is also hard to see how it can be done. It has been difficult enough to get testing up to the 500,000 mark, with the necessary ingredients in short supply worldwide – could we really organize ourselves to test millions of people, in the space of a few weeks? Would enough people consent to have their phones used in this way, and if they wouldn’t, could we impose it on them? Would the complexity of a staged withdrawal of restrictions confuse people? Would its slow pace exhaust them?

And it is hugely risky. Rather than allowing the disease to spread, and build up herd immunity, it would mean attempting to protect substantially all of the population from infection, for a year at least, maybe two, with no guarantee that a vaccine will be available even then – or ever. Six months from now we might find ourselves, for all our efforts to prevent it, in a second wave of infections, much the same as the first.

It’s only conceivable when you remember what the alternatives are: economic collapse, or mass death. There is no easy option. This is not just a bad dream from which we will all soon wake up. We can tough it out at home, or we can tough it out at work. We can live a little less free, or a lot. We can lose thousands of lives, or tens of thousands; endure slow growth, or a depression. Those are the real choices before us.

Either way, it will take months, at least, before we can declare victory. But one day we will dance in the streets.

https://www.theglobeandmail.com/opinion/article-we-can-see-the-way-out-of-the-coronavirus-pandemic-but-the-steps-to/