A new normal, or new abnormal? Change in direction needed on COVID-19 response
The prevention must not be worse than the disease, cautions former Manitoba chief public health officer
As we enter the next phase of the pandemic response, there are still unanswered questions about the lockdowns from which we are emerging.
Were they necessary? Has the prevention been worse than the disease?
The societal impacts are increasingly apparent, but it is too soon to know the extent to which these extreme measures have prevented premature deaths or saved potential years of life.
Today's decisions, however, may be more consequential.
How we reopen society could set precedents for the future. How quickly to go is one question; which direction to go is another.
The 'new normal' we want?
What kind of "new normal" do we want?
Our children attending virtual and part-time school with forced physical distancing? Getting health care remotely — or in person, wearing masks that muffle speech and conceal facial expressions? Discouraging human interaction and mandating the covering of smiles?
Do we want the continuation of restrictions of commerce, travel, recreation, and social gatherings? Should we just accept unremitting unemployment and economic hardship — especially for those most disadvantaged (e.g. single mothers, casual and non-unionized workers), small organizations, and small enterprises?
Should we just tolerate the growing government debts and shrinking expenditures on health care, education, and social services?
These conditions cannot be good for us.
Is it desirable to live in so much fear of one disease that every aspect of our lives is disrupted and other threats to our health are increased?
It is appropriate to be concerned about serious respiratory illness, to stay home when sick, and to cover our coughs or sneezes. But excessive concern and anxiety can make us ill and weaken our immune systems. It can lead to irrational decisions and behaviours, including those by our leaders.
Some fear at the beginning of an outbreak is understandable. But why are we still subjected to relentless daily reports of cases and deaths?
Numbers need perspective
These numbers can be misleading without the context of denominators and simply calculated rates. Media reports of crises in other countries — often without critical analysis of their relevance for Canada — can exacerbate fears and may have overly influenced policy decisions.
If we tested for influenza every winter as we have done for coronavirus, we would have similar daily reports of cases and deaths, nursing home outbreaks, and stretched capacity of hospitals. Unlike for COVID-19, there would be several reports of influenza deaths in children.
Has a precedent now been set for lockdowns every flu season?
The reported COVID-19 population-based mortality rate in Canada is roughly one per 4,000 persons (about 8,800 deaths among 38 million people).
Based on Statistics Canada data, it can be estimated that for every COVID-19 death, there have been 10 deaths from other causes. We should not lose sight of other more common causes of premature death and their pressure on the health system, including heart disease, cancer, chronic lung diseases, and injuries. We should not forget about other preventable causes, such as alcohol and tobacco.
In Canada, more than 95 per cent of COVID-19 deaths have occurred in people over 60, most of whom had chronic health conditions.
Eighty per cent have occurred in residents of long-term care facilities. To date, there have been no deaths reported in children and youth. In other words, less than five per cent of all deaths have occurred in people under the age of 60.
Many of these deaths were associated with chronic health conditions.
Based on provincial reported case-fatality rates and research estimates of undiagnosed infections, the probability of dying from an infection for a person under the age of 60 can be estimated at less than one per 2,500 — and even lower in the absence of risk factors.
It is debatable how much higher the COVID-19 mortality would be without lockdowns and other restrictions. Doubtless it would have been higher — at least in the short term — but how much higher and over what time period is not yet known.
Whether for COVID-19 or influenza, it is important to minimize premature deaths, maintain hospital capacity, and prepare for future outbreaks. But a strategy to prevent all cases or deaths is not reasonable or feasible.
It could also divert us from other preventable causes of illness and deaths, many of them now increased by adverse social and economic circumstances and less access to health care and social services.
We need approaches with a better balance of benefits and harms. A more risk-based strategy should be achievable.
Rather than generalized restrictions for all people in all settings, most people at low risk should be allowed now to go to work, school, and other settings. They should not be required, as a general rule, to socially distance or wear a mask.
It can be expected that more than 99.9% of infections in people under 60 years would have mild or no symptoms. Most would be expected to get some immunity and contribute to the protection of others at higher risk.
In the absence of effective vaccines or treatments, population immunity may be the most effective and least harmful way to achieve short- and long-term control.
We need policies that are more balanced, practical, tolerable, and fair. Within reasonable limits, people should be allowed to make informed decisions.- Dr. Joel Kettner
Would it be feasible to allow the natural spread of infection amongst those at low risk and also protect adequately those at highest risk? This is an important question.
More focused strategies would be needed to safeguard people who are older or have a chronic health condition. Current policies could be modified to ensure more targeted distancing, strategic testing, quarantine, and isolation.
It would be important to ensure better social and economic support for those that should not work or need special services. Long-term care settings should have sufficient resources for more optimal care, better infection control, and considerate visiting. Details of these strategies should be worked out in consultation with those most affected.
A healthier new normal
Manitoba's Public Health Act and the Canadian Charter of Rights and Freedoms specify that severe societal restrictions must be justified by the severity of the threat and the necessity of the interventions. These are difficult judgments to make.
The projections of psychological, social, educational, and economic harms have not been described clearly in public health reports or models. Measuring and assessing social and economic consequences of public health interventions are not within the usual expertise of epidemiologists, infectious disease modellers and clinicians, or public health practitioners.
Public health officials do have expertise to advise governments about the severity and preventability of diseases and to communicate that to the public.
But the responsibility for the big policy decisions rests — appropriately and legally — with elected leaders. Their decisions should be made transparently in consultation with the public, community leaders, affected groups, experts, and other stakeholders.
We need policies that are more balanced, practical, tolerable, and fair. Within reasonable limits, people should be allowed to make informed decisions.
Manitoba's reopening plans state that most individuals and businesses may use their judgment based on their own comfort level of risk, while those at higher risk should continue to avoid close contact and limit other activities.
The situation is complex. There are many unknowns. We need to be humble, think critically, and be open-minded to different points of view.
As policies and directives evolve, we need clear descriptions and explanations of their short- and long-term goals, their rationale, and indicators — not only case counts — to monitor progress and guide decisions.
Yesterday's interventions and tomorrow's decisions have significant consequences for everyone. We need to change direction away from a new abnormal and to turn instead toward a healthier new normal.