Vivek Goel is a professor at the Dalla Lana School of Public Health and vice-president of research, innovation and strategic initiatives at the University of Toronto.
We are all starting to wonder when physical-distancing measures may ease and we can go out to a restaurant, movie, basketball game or the hair salon. Perhaps some bored children are even wondering when they can return to school.
There is evidence of the flattening of the curve across Canada. Unfortunately, there are also still clusters of cases in settings such as long-term care facilities and meat-packing plants. But in the rest of the community, across Canada, the outbreak is coming under control. The focus is now shifting to how we can re-start society and the economy.
The long-term care facility outbreaks highlight the need for continuing to focus on our high risk and most vulnerable populations. The outbreaks in essential work settings foreshadow what we will face as we return to work.
A phased approach will be followed to open up society and allow businesses, schools and social and entertainment venues to re-open. Physical-distancing requirements, use of personal protective equipment and strict hygiene and cleaning protocols will be the norm. Increased capacity for identification of cases (diagnostic testing), and contact tracing of confirmed cases is essential. Plans need to ensure that a sudden increase in cases would not again threaten to overwhelm our hospitals and endanger high-risk populations.
The search for vaccines and antiviral drugs will continue. As blood, or serological tests, become available to test for past disease, we will gather evidence on the degree to which immunity is conferred and how long that may last. But all of this research will take time. Until we establish whether immunity in the population exists, or we have vaccines and antivirals available, the only tool we have to counter COVID-19 is public-health measures.
The current strategy prioritizes averting all cases and deaths from COVID-19. It was an appropriate initial strategy in the face of an unknown and rapidly spreading pathogen. The lockdown bought us time to prepare our health system for an unexpected surge and avoided the scenarios that played out in Italy and New York. But this approach has come at a tremendous health, social and economic cost.
We have not yet had a comprehensive discussion about all of these other impacts. From a health perspective, there are many direct ones – most significantly, all of the postponed medical visits and surgeries. Individuals waiting for hip and knee surgery are enduring weeks of extra pain, and cancer patients face agonizing waits and potentially worse outcomes, including death.
There are potentially more severe long-term health outcomes. We know that early childhood factors correlate to lifelong health and social outcomes. What is the prolonged impact on our children? There are also social impacts, such as increased domestic violence and child abuse. Isolation and loneliness increase mental-health concerns. While some are busy baking sourdough bread and gourmet meals, others are struggling with food security. We are less active, another strong predictor of chronic disease. Finally, we know that income is the strongest social determinant of health status, and experience from past economic downturns show increased mortality. We have not yet forecast what the cumulative health consequences of all this will be.
Our response to date has been largely guided by the medical model. This focuses on preventing individual cases and supporting our health care system. We need to shift to a population health model, where we consider a broader set of outcomes. This means balancing averting individual cases with the health and wellbeing of the entire population.
The reality is we have to be prepared for COVID-19 to be in our communities for some time to come. Vaccines and antivirals hold promise, but the road to their development and approval will be long. Even when a vaccine becomes available, it will take years to roll out an immunization program that will cover the world’s population.
We must be prepared for there to be cases of COVID-19 as we open up society. Our mindset has to shift from averting all cases to minimizing cases and adverse consequences, while maximizing overall population health. We need to take precautions in the workplace and social settings but be willing to accept that there will be cases in the community. We need to ensure there is adequate testing, contact tracing and immediate access to health services for the infected. And we must avoid looking for blame when there are cases and not stigmatize groups that become infected; inevitably there will be clusters in identifiable communities.
I am not calling for us to move naively and recklessly, like some jurisdictions south of the border. We need a more considered and nuanced approach, such as that suggested by Premier François Legault in Quebec. Otherwise we face months of restricted measures, with devastating consequences to our society.
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