Vincent Lam is the medical director of the Coderix Medical Clinic, an addictions medicine clinic, and a faculty member at the University of Toronto. He is the co-author, with Colin Lee, of The Flu Pandemic and You. He is a past recipient of the Scotiabank Giller Prize for Bloodletting and Miraculous Cures.
Early in the first Star Wars movie, Princess Leia appealed across the galaxy via holographic transmission, pleading: “Help me, Obi-Wan Kenobi. You’re my only hope.” She sent her missive to the Jedi Master on a faraway desert planet, hoping that he could save her home world of Alderaan, light years distant. The “ask” of COVID-19 physical distancing is just like this, minus the starships.
This comparison is not intended to make light of the seriousness of COVID-19, which has taken 21,297 lives at the time of this writing, and will certainly exact a far greater toll in the months and years to come. Without a doubt, a massive human tragedy is unfolding. If we are to mitigate this tragedy, like a reclusive Jedi Master, we must accept the fundamental disconnect between what each of us must do, and our own personal health outcomes. We are likely staying at home to save someone whom we have never met. Most health-related actions have consequences that relate personally to the actor. If I eat well and exercise regularly, my health improves directly and individually. If I smoke cigarettes while riding a motorcycle, the risks accrue primarily to myself. The risks of infectious illnesses, including COVID-19, accrue with less symmetry. Our actions affect others, whether by cough, touch or physical proximity. With a case fatality rate somewhere between 0.2 per cent and 20.2 per cent from COVID-19, depending upon an individual’s age, most of us will survive COVID-19 even if exposed to it. Even though we might prefer not to take our chances with a new zoonotic infection, each of us is still more likely to die of something else. However, what we know with certainty is that if there are more infections among our friends, family and colleagues, and if they strike more rapidly and overwhelm the health-care system, more people around us will die. How well we collectively adhere to physical-distancing measures will determine whether someone else, someone at a distance, someone whom we have never met – but who is not in a galaxy far, far away – will live or die.
It is important to distinguish between hopes and realities. Physical distancing is not our only hope in terms of addressing COVID-19. We hope to find effective treatments with medications, but these are not yet shown to work. We hope to have enough critical care beds to care for every severely ill patient, but this is proving to be a struggle even in wealthy societies. We can hope for a vaccine, which experts believe will take at least 18 months to be developed in the best-case scenario. The reality is that physical distancing, in contrast to these hopes, has been shown to have successfully contained COVID-19 in China for the time being, taking it out of the realm of “hope” and into the realm of imperative direction. The hope is that we all adhere to physical distancing, because it is the most solid strategy that we have to save lives.
It has been said of disruptive public-health interventions, such as closing schools and shuttering businesses, “You’re damned if you don’t, and darned if you do.” One of the ironies of public-health interventions is that with greater success, come less dramatic outcomes. In fact, the successes of some public-health interventions provide the platform for their criticism. Immunizations for childhood illnesses have pushed measles, mumps and rubella out of everyday experience, giving anti-vaxxers a space within which to claim that vaccinations are unnecessary. Pasteurization of milk has eliminated the transmission of listeriosis, typhoid fever, tuberculosis, diphtheria and brucellosis through milk, and without any experience of these illnesses, some people want raw milk cheeses.
Public health is not like a film from the Star Wars franchise where, against all possible odds, the rebels prevail in a dramatic battle in the last few minutes to save the Rebel Alliance. Credits roll. In the best possible scenario, if the next months of physical distancing measures are highly successful at flattening the curve of COVID-19, there will be far fewer deaths in Canada than there would have been. If so, there might be voices that say “darned public health.” They may suggest that public-health officials overreacted, causing unnecessary disruption and economic impact. On the other hand, if not enough is done, deaths will skyrocket and harsher words than “damn” will be used. How much is “just right?" These decisions are made using mathematical models, sophisticated projections and, ultimately, judgment. To see what has happened in Italy, the answer to “how much should we do?” looks like “a lot.” In a letter to the Lancet, published on March 23, doctors from hard-hit Italy have called out to warn the world, “We urge all countries to acknowledge the Italian lesson and to immediately adopt very restrictive measures to limit viral diffusion, ensure appropriate health-system response, and reduce mortality, which appears to be higher than previously estimated.”
Matthew Hancock, the British Health Secretary, put it succinctly and well in addressing the British Parliament on Tuesday, saying that COVID-19 restrictions “are not advice, they are rules.” In order to slow the rate of transmission of COVID-19 and save lives, each of us must stay at home, with four exceptions: 1) buying basic necessities such as food, as infrequently as possible; 2) exercising once daily, alone or with members of the same household; 3) for medical need, or to provide care for a vulnerable person; 4) travelling to or from work, but only when work cannot be done at home. “These four reasons are exceptions to the rule.”
Picture yourself as Obi-Wan, Princess Leia’s last hope. Can you feel the Force? Somewhere out there in the galaxy is someone whose life depends upon what you do. Your mission: read the stack of books on your bedside table. Dust off the neglected exercise equipment. Cook creatively with the neglected cans in the back of your pantry. Make your toilet paper last a little longer before you go back to the store. May the Force be with you.
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