Illustration by The Globe and Mail
The discussion about how to begin reopening Canadian society is ramping up, even as the country has yet to pass the peak of the pandemic that has shut it down.
In provinces with relatively low COVID-19 rates, governments have started to publicly express optimism about lifting restrictions – Saskatchewan Premier Scott Moe has said he hopes to release a plan for doing so in the coming week. Prime Minister Justin Trudeau and other federal officials, meanwhile, have emphasized Canadians will need to maintain current physical distancing measures for at least several more weeks, even as they’re increasingly being pressed to communicate a plan and timeline for the resumption of some normal activities.
But based on interviews this week with a wide range of sources – including senior political officials in Ottawa and provincial capitals, and infectious-disease and economic experts both here and abroad – Canadians should be braced for a potentially frustrating and anxiety-inducing second phase of the coronavirus response.
The unwinding of current measures is likely to be gradual, tentative, and occur in fits and starts. And while the earliest stage of fighting the pandemic has featured a high degree of political, regional, intradisciplinary and public consensus about the need for strict lockdown measures, the next one could prove to be more fractious, as governments are confronted with a wider slate of options on how to proceed – not just when to begin reopening the economy, but what sectors and activities to prioritize as the process begins.
“In a way, just closing everything down was probably easy compared to what we have to do now,” says Beate Sander, a specialist in health economics with the University Health Network in Toronto.
Keeping citizens in a perpetual state of lockdown until there’s a vaccine, a highly effective treatment or some other way of eliminating COVID-19 as a deadly threat – and accepting the economic, social and other health consequences that would entail – is recognized by all concerned as not being a viable option.
“From the rational point of view, that should be the approach,” says Elisabeth Puchhammer-Stockl, head of virology at the Medical University of Vienna and part of an expert panel advising the Austrian government, which has been among the first in the Western world to begin rolling back restrictions. “From the practical point of view, you can’t keep people locked up for the year.”
But since there’s still so much we don’t know about the virus’s characteristics and how it can most effectively be contained, Canadian governments are still very uncertain about what they can reopen without allowing a second or multiple waves of the virus to overwhelm the health system.
There’s also a lot of work still to be done to ramp up testing and tracing capacity, which means governments are a long way from having the level and consistency of data that would ideally inform those decisions.
While there’s hope that other countries further ahead on the pandemic curve can help point the way for Canada, officials are struggling to communicate what the coming months will look like here – somewhere between the current societal freeze and anything approaching normalcy.
“Nobody knows what it is – it’s not this, but it’s certainly not what we’re used to,” says Isaac Bogoch, an infectious-disease specialist at Toronto General Hospital who has been providing advice to the federal and Ontario governments.
“There’s no playbook – no one right path.”
COVID-19 case rates across provinces and territories
Seven-day moving average of number of cases per 100,000 population, as of April 17
B.C.
Alta.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
Man.
Sask.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
Ont.
Que.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
N.B.
PEI
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
N.S.
N.L.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
Yukon
NWT
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
Note: There are no cases in Nunavut.
JEREMY AGIUS AND MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE: PROVINCIAL AND TERRITORIAL GOVERNMENTS
COVID-19 case rates across provinces and territories
Seven-day moving average of number of cases per 100,000 population, as of April 17
B.C.
Alta.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
Man.
Sask.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
Ont.
Que.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
N.B.
PEI
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
N.S.
N.L.
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
NWT
Yukon
10
10
8
8
6
6
4
4
2
2
0
0
March
April
March
April
Note: There are no cases in Nunavut.
JEREMY AGIUS AND MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE: PROVINCIAL AND TERRITORIAL GOVERNMENTS
COVID-19 case rates across provinces and territories
Seven-day moving average of number of cases per 100,000 population, as of April 17
Sask.
B.C.
Alta.
10
10
10
8
8
8
6
6
6
4
4
4
2
2
2
0
0
0
March
April
March
April
March
April
Man.
Ont.
Que.
10
10
10
8
8
8
6
6
6
4
4
4
2
2
2
0
0
0
March
April
March
April
March
April
N.B.
PEI
N.S.
10
10
10
8
8
8
6
6
6
4
4
4
2
2
2
0
0
0
March
April
March
April
March
April
Yukon
NWT
N.L.
10
10
10
8
8
8
6
6
6
4
4
4
2
2
2
0
0
0
March
April
March
April
March
April
Note: There are no cases in Nunavut.
JEREMY AGIUS AND MURAT YÜKSELIR / THE GLOBE AND MAIL, SOURCE: PROVINCIAL AND TERRITORIAL GOVERNMENTS
There are some things we do know – certain metrics that can guide officials on how they can begin reopening Canadian society. Those metrics, according to Dr. Bogoch and other medical experts, include a “sustained reduction in cases,” ample hospital capacity and increased testing and tracing capabilities.
Martin McKee, a leading public health expert at the London School of Hygiene and Tropical Medicine who has been closely studying global responses to COVID-19, says the “fundamental test” for beginning the process should be whether the virus’s reproduction rate is below “R1” – the point at which the average patient is passing the illness on to less than one additional person. (With no measures taken, studies indicate the natural reproduction rate of the virus lies between R2 and R2.5.)
Canada is now sitting somewhere between R1.1 and R1.5, according to an analysis by Jane Heffernan at York University in Toronto and Matt Betti at Mount Allison University in New Brunswick. (Provinces that have been hardest hit, namely Quebec and Ontario, would be higher.) But the reproduction number will start rising again if measures are lifted too hastily.
Disease modellers have emphasized the need to remove restrictions step by step, with at least two weeks between steps, corresponding to the incubation period of the virus – giving health officials time to gauge whether COVID-19 is likely to come roaring back.
That will be much easier if the federal and provincial governments are able to work together to rapidly improve the data and other scientific tools at their disposal.
Those tools have been limited in various ways, including by an incomplete knowledge of the virus. For example, it wasn’t clear until the pandemic was underway that COVID-19 could be spread by infected individuals who show no symptoms of illness.
Unlike with SARS in 2003, identifying single cases together with their immediate contacts wasn’t enough to stop community transmission in Canada. Once that started, and with no reliable way of knowing who was infected, the only strategy available to public health officials was the blunt instrument of population-wide physical isolation to avoid overwhelming the health care system.
This week, deaths in Canada due to COVID-19 topped 1,300 – and that number has been rising steadily. But deaths are a lagging indicator of what the virus is doing. The most recent data suggests the infection curve is beginning to flatten, as officials hoped.
That has spurred discussion about exactly what happens after the lockdown – something that has never been entirely clear.
Near empty streets are pictured in downtown Vancouver in early April.JONATHAN HAYWARD/The Canadian Press
Considering the vast majority of Canadians have yet to be infected and the fact that there’s still uncertainty around whether people who have had the virus are subsequently immune, reopening the economy before a vaccine emerges will likely require a combination of new approaches to protect a highly vulnerable population.
“We’ll really have to have good surveillance systems at the population level,” says Joanne Langley, a professor of pediatrics at Dalhousie University who specializes in infectious disease.
Yet, strong surveillance also implies monitoring for new outbreaks and for people who need to be isolated in a way Canadians – and most other Western populations – aren’t used to.
At the pandemic’s earliest stages, countries such as Israel, Taiwan and Singapore gravitated toward trying to keep tabs on COVID-19 through cellphone alerts that tracked likely carriers of the virus and alerted others who had been near them. In Canada, governments have yet to clarify whether they’re considering going down that road – which has serious implications for privacy – and whether they have the capacity to do so.
Apple and Google have announced a joint project that would enable contact tracing on most of the world’s mobile phones. The tech companies have said the initiative would protect citizens’ privacy, disseminating phone-to-phone warnings without maintaining a running list of infected or potentially infected people. Public health bodies could also build their own apps off the technology – and thus control who is branded as having COVID-19.
A man holds a phone showing Norway's new mobile app for infection tracking in Oslo on April 17.NTB SCANPIX/Reuters
All that Ottawa will say for now is that the overall technique holds some promise. “Mobile apps can help to encourage physical distancing by empowering Canadians to modify their activities and reduce risky behaviours,” says Geoffrey Legault-Thivierge, a spokesperson for Health Canada. “However, any support from the federal government would be highly contingent on measures taken by developers to protect the privacy and security of users.”
Whatever the approach, a keystone of surveillance is efficient and abundant testing to identify who is infected, which Mr. Trudeau publicly identified this week as a pre-condition for reopening the country.
To date, just over half a million tests have been performed in Canada – nearly 14 per 1,000 people. That’s a higher rate than the United States but well below Hong Kong, which managed to avert a large outbreak, and Germany, which is slightly ahead of Canada in its infection curve and now seeing a decline in new cases.
In order to understand the impact of more relaxed distancing measures, epidemiologists say testing should be conducted frequently across a representative sample of the population – as opposed to just testing people known to be at high risk – with sample sizes in the thousands.
Not surprisingly, Canada has faced supply chain issues, including a scarcity of nasal swabs used for most existing tests, that have prevented it from bringing its testing capacity to the required level. There’s now a push to develop faster, more portable tests. But in addition to questions around the ability to obtain them at scale, their reliability also still needs to be determined.
“When the test is negative, one must feel confident that the person is not infected,” says Dylan Pillai, a University of Calgary researcher who is now working on a rapid, point-of-care test.
The same requirement goes for serological testing, which can reveal if someone has generated antibodies in response to a past COVID-19 infection (in some cases without being aware they had it) and is therefore potentially immune.
While serological testing is useful for a population-wide assessment of exposure – for example, one such study in Santa Clara, Calif., concluded this week that there were 50 to 85 times more cases in the community than reported – immunologists caution it would be a mistake to assume a serological test alone is enough to determine if any one person is safe to return to work. That’s because it’s unclear how long immunity to the virus can last or the degree of immunity conferred by a mild or asymptomatic case, compared to one that generated a more serious bout of illness.
Amid all these remaining unknowns, computer modellers who’ve been busy trying to project the timing and height of the initial wave of the pandemic are now turning their attention to how to move to the next phase. This often means modelling how to divide the larger population into segments and allowing some of those segments to have higher levels of interaction.
These models allow policymakers to explore various scenarios – for instance, what might happen if elementary schools were allowed to reopen ahead of high schools and middle schools, freeing up parents trying to keep their kids occupied at home (which is what Denmark did this week). All models must rely on certain assumptions, however. In this case, those include how much children drive transmission of the virus, the amount of interaction between kids and more vulnerable groups such as grandparents, and how comfortable parents might be with letting their kids leave the house. So social science studies are equally important at this stage to help ground the models with cultural context and other realities.
Similar approaches can look at the impact of loosening restrictions on relatively large or small segments of the labour force.
But while modellers might help determine how much additional contact can be allowed across entire jurisdictions, it will still be left to governments to decide which sectors to prioritize – who returns to work and when. And those decisions could still be highly contentious.
Physically distanced emergency sessions are held at the federal legislature in Ottawa, top, and Manitoba's provincial legislature in Winnipeg, bottom, days apart in April.Justin Tang and John Woods/The Canadian Press
Behind the scenes, planning efforts are kicking into gear. While a few provinces have struck committees to help navigate the economic path forward, the federal government is taking a more informal approach, with some ministers and senior bureaucrats charged with researching various reopening options.
A few of those decisions could be relatively easy. Most experts and insiders agreed that elective surgeries and other medical services made unavailable as health care facilities braced for a coronavirus surge should resume early in the reopening process. Activities that are comparatively inessential and high-risk – such as sporting events and other large public gatherings – will likely return much later.
Many key services fall into a more challenging middle area, where there are conflicting views on how to proceed. At the top of that list are schools and daycares, which are important both for children’s well-being and for adults’ ability to return to work. But they’re also among the hardest places to enforce continued physical distancing measures to prevent the spread of new cases.
Canada has lagged some other countries in beginning to make such difficult calculations. The same goes for decisions around what governments might compel citizens to do – from wearing masks to putting up with potentially intrusive surveillance measures to track new outbreaks – in return for fewer restrictions. But politicians here believe being late on the curve is actually a rare blessing in this fight.
Customers line up at the Costco store in Terrebonne, Que.Ryan Remiorz/The Canadian Press
Every federal and provincial official who spoke to The Globe (most of whom were granted anonymity because they were not authorized to speak on those governments’ behalf) said much of their current preparation for the next phase involves monitoring places that are further along in passing the pandemic’s peak and beginning to loosen restrictions.
That includes looking to European countries that have just started to experiment with gradual reopenings – schools in Denmark, small stores in Austria, recreational facilities in the Czech Republic. Germany, which Canadian policymakers believe is an example of a comparable country that has handled the pandemic well so far, has announced that it will begin phasing in a range of reopenings in the coming weeks.
Experts outside government agree it’s wise to be taking lessons from countries that are testing the impact of reopening society, but warn there are limitations due to variables such as population density and demographics.
“There might be lessons we learn from them, but I think we’d be foolish in thinking that just following another country is going to work,” says Dr. Bogoch.
Ian Culbert, executive director of the Canadian Public Health Association, suggests we might learn more from these other jurisdictions about what’s best avoided – which activities prove to be the most dangerous – rather than assuming any successes would necessarily be replicated here.
Since the bulk of decisions about what to reopen will be made at the provincial level (with a few exceptions, most notably border traffic), a similar dynamic could soon play out here, as provinces experiment with different ways of loosening restrictions and at varying speeds, depending on the severity of their outbreaks. As of now, it appears that Western, and possibly Atlantic, provinces will be able to start sooner than Quebec and Ontario, which have by far the heaviest caseloads.
That presents an opportunity for provincial leaders and public health officials to learn from one another’s experiences. So far, there has been a lot of contact between them, both formally and informally, with some premiers exchanging frequent text messages to compare notes.
One senior provincial official suggested a couple of provinces could start reopening in lockstep to share the political risk of potential negative health consequences – though at present, Saskatchewan seems inclined to get ahead of the rest.
The Prairie province appears to be in a good position to move first. Its active cases are low, while hospital space and reserves of personal protective equipment are robust. Premier Moe didn’t specify this week which businesses would be permitted to reopen, but a senior official says the list would likely include retail stores that could replicate the physical distancing measures already in place at many grocery outlets and pharmacies nationwide. Schools, meanwhile, would probably remain closed until September.
As much as such experimentation may offer lessons for the rest of the country, variation between provinces – and possibly even within provinces, if lower-density areas are opened up before harder-hit cities – could also present challenges. Provinces trying to ramp up economic activities might have a hard time doing so if industries they rely on remain closed. And there could be mounting public impatience in parts of the country where restrictions remain in place if other Canadians are allowed to live more freely again.
“In ... Manitoba, it’s going to be different from what it is in downtown Toronto,” says Dr. McKee, the U.K.-based public health expert. He worries about competitive pressure – which for Canada could also come from across the border, given U.S. President Donald Trump’s desire for a swift end to economic restrictions – causing premature reopenings.
The common view among experts is that governments will need to err on the side of caution, slowly removing one layer of restrictions at a time and carefully measuring the impact on the disease’s spread.
A empty classroom is pictured at Eric Hamber Secondary school in Vancouver, B.C.JONATHAN HAYWARD/The Canadian Press
Some of the most challenging scenarios are those that require intermittently returning to a state of heightened isolation each time the virus surges and case counts begin to rise, whether due to seasonal waves or looser restrictions.
A model developed by researchers at the University of Toronto and published last week in the Canadian Medical Association Journal offers a look at how such a scenario might play out in Ontario. It’s based on linking physical distancing to the availability of hospital resources.
As critical-care beds began to fill up, distancing measures go into effect; once the hospital burden eases, so does physical distancing. The result is a cyclical pattern in which infections peak every three to five months or so, triggering increased distancing measures to tamp down the demand for ICU beds.
Ashleigh Tuite, an epidemiologist and lead author of the study, says the group didn’t originally set out to model such a scenario, but as the tradeoffs between health resources and economic hardship became more apparent, it began to look more plausible.
“When we first showed it to people, we were told that’s not what policymakers would do,” Dr. Tuite says. “But I think it’s much closer to what we are probably going to end up experiencing.”
Cycles of Infection
When physical distancing measures in Ontario are
linked to demand for ICU beds, case numbers of
COVID-19 rise and fall in cycles lasting a few months
without exceeding maximum capacity. Higher
demand triggers a return to stronger distancing
measures until lower demand allows more
relaxed measures.
No public health
measures
Prevalent cases requiring
intensive care
Enhanced
case detection
Per 1,000 population
Intermittent
physical distancing
4
Combined physical
distancing and
enhanced case
detection
3
2
1
0
0
.
4
0
DETAIL VIEW
0
.
3
0
0
.
2
0
ICU max. capacity
0
.
1
0
ICU current capacity
0
1
3
2
7
7
1
2
2
1
8
1
2
4
0
2
9
9
3
5
8
4
1
7
4
7
6
5
3
5
5
9
4
6
5
3
TIME (DAYS)
ivan semeniuk and JOHN SOPINSKI/THE GLOBE
AND MAIL, SOURCE: Ashleigh Tuite, Canadian
Medical Association Journal
Cycles of Infection
When physical distancing measures in Ontario are linked to
demand for ICU beds, case numbers of COVID-19 rise and
fall in cycles lasting a few months without exceeding maxi-
mum capacity. Higher demand triggers a return to stronger
distancing measures until lower demand allows more
relaxed measures.
Prevalent cases requiring
intensive care
No public health
measures
Per 1,000 population
Enhanced
case detection
Intermittent
physical distancing
4
3
Combined physical
distancing and
enhanced case
detection
2
1
0
0
.
4
0
DETAIL VIEW
0
.
3
0
0
.
2
0
ICU max. capacity
0
.
1
0
ICU current capacity
0
1
3
2
7
7
1
2
2
1
8
1
2
4
0
2
9
9
3
5
8
4
1
7
4
7
6
5
3
5
5
9
4
6
5
3
TIME (DAYS)
ivan semeniuk and JOHN SOPINSKI/THE GLOBE AND MAIL
SOURCE: Ashleigh Tuite, Canadian Medical
Association Journal
Cycles of Infection
When physical distancing measures in Ontario are linked to demand for ICU beds, case
numbers of COVID-19 rise and fall in cycles lasting a few months without exceeding maxi-
mum capacity. Higher demand triggers a return to stronger distancing measures until lower
demand allows more relaxed measures.
No public health
measures
Prevalent cases requiring intensive care
Per 1,000 population
Enhanced
case detection
4
Intermittent
physical distancing
3
Combined physical
distancing and
enhanced case
detection
2
1
0
0
.
4
0
DETAIL VIEW
0
.
3
0
0
.
2
0
ICU max. capacity
0
.
1
0
ICU current capacity
0
1
3
2
7
7
1
2
2
1
8
1
2
4
0
2
9
9
3
5
8
4
1
7
4
7
6
5
3
5
5
9
4
6
5
3
TIME (DAYS)
ivan semeniuk and JOHN SOPINSKI/THE GLOBE AND MAIL
SOURCE: Ashleigh Tuite, Canadian Medical Association Journal
Indeed, health imperatives could be more difficult to square with political and economic ones during the second phase of the pandemic response than during the initial lockdown, when they were largely aligned.
While some stretches of relative normalcy might be preferable to none, a senior provincial minister expressed concern about repeated loosening and tightening of restrictions, saying that could damage governments’ credibility among a weary public. That sort of inconsistency, however scientifically necessary, could also push beleaguered businesses past their breaking point.
Clemens Fuest, executive director of Germany’s Ifo Institute for Economic Research, recently produced a multidisciplinary report proposing various processes for managing a gradual reopening. Initially, he says, he thought a trial-and-error process would be fine. But he became skeptical after hearing warnings from larger companies that shutting down industrial operations is so incredibly costly that “you can only do it once.”
Erin Strumpf, a health economist at McGill University, is similarly concerned about the industrial impact. She compares the prospect of sudden and repeated closures to the sort of regulatory uncertainty that can make it impossible to do business. It could easily apply to smaller businesses, too – many of which have less financial leeway and are already facing potential doom from the initial lockdown.
“Even though I think we should expect there to be some back and forth, we want to minimize that as much as possible,” says Ms. Strumpf, arguing that helps make the case for proceeding “slowly and incrementally” in the initial reopening stage.
A Garrison Brewing Company employee prepares orders of the brewery's blonde ale "Stay The Blazes Home" in Halifax. The name of the beer refers to a comment made by Nova Scotia premier Stephen McNeil that went viral following one of the premier's public updates in early April.Darren Calabrese/The Globe and Mail
A recurring theme in The Globe’s interviews this week was that Canadians deserve a strong explanation of why they’re being asked to do what they’re doing and how it fits into longer-term plans. That will be essential for governments to retain public confidence and co-operation through the months ahead.
Dr. McKee notes that past research has shown people who are more optimistic about their futures at the end of a period of quarantine or other restrictions are more likely to comply during it.
Citizens will also need to feel confident in governments’ advice that it’s safe to return to work or public activities. Among the biggest unknowns of the post-lockdown period will be the behavioural impacts of the experience to date – whether people conditioned to live in fear of other people will be comfortable returning to more regular interactions as long as the virus remains a potential threat. If not, it could impede any efforts to reinvigorate the economy.
All of that could require clearer communication than governments have managed to date on matters ranging from best-estimate timelines to the relative safety of various activities to how much protection masks offer.
That won’t be easy for government leaders, who are at once being advised to signal a clear path forward while avoiding an appearance of overconfidence and being ready to admit what they don’t know – which at this point is still a great deal. It’s not going to get any easier, because governments are likely to get more conflicting advice in the second phase than they did in the first.
Mr. Fuest acknowledges that when producing his institute’s report on next steps – relatively broad recommendations around matters such as prioritizing which sectors open first, and ensuring adequate medical supplies and capacity – it was challenging to arrive at a common text. That wasn’t just because the effort pulled together advice from economists, medical experts and other professionals. More of the disagreements were within the disciplines, he says, reflecting the range of potential options around each priority.
“I think all the politicians can do is listen to different people within disciplines – never listen to one or two,” says Mr. Fuest, “and then go with who they trust.”
Some of the directional challenge – the burden of sorting through conflicting views and pressure from different experts, industries and provinces – will fall on Mr. Trudeau, despite his government’s limited role in actually deciding what opens. Nobody else is as well positioned to provide a sense of common purpose, to offer Canadians a high-level sense of what lies ahead, and to avoid a breakdown of national consensus.
To date, the Prime Minister’s approach has been to eschew public discussion of what the second phase might look like. Presumably that’s to avoid giving Canadians a dangerous false impression that the country has already entered that next stage of the pandemic and can start relaxing physical distancing measure and to avoid setting medium-term expectations that can’t be met.
Mr. Trudeau’s officials, along with some provincial ones, have been comforted by opinion polls that suggest the public remains supportive of current measures. In a recent Leger survey of roughly 1,500 Canadians, for instance, half the respondents said they only wanted restrictions lifted after at least two consecutive weeks with no new cases. Only 25 per cent said it should happen before new cases become “sporadic.”
But every government knows such patience won’t last forever. They’ll spend the coming weeks struggling to come up with some answers for when they can no longer escape questions about the new normal.
With files from Patrick White, Colin Freeze, Daniel Leblanc and Gary Mason
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Adam Radwanski
Ivan Semeniuk