HOW TO REOPEN SAFELY: THE BALANCE BETWEEN PUBLIC HEALTH AND ECONOMICS

Guest Post by David Vardy

Are We Ready?

The pandemic has become the biggest public policy issue which we face. It poses a threat to our public health and to our economic and fiscal sustainability. Yet government has hesitated to engage in a systematic consultation process as had been recommended or to establish advisory councils to seek guidance from concerned citizens on governing in the age of coronavirus.

How far should we go in locking down our economy? Should we protect only the vulnerable and the elderly or lock down the full economy? GNL is being pressed to reopen the economy, particularly by the tourism industry and various business people who recently wrote to the Premier. Are we now ready to reopen fully and to invite tourists to the province? The letter to the Premier asked for “an immediate end to the State of Medical Emergency and a return of the governance of the province to our elected officials.

“Choosing a path forward that carefully measures the value of our health and our economy is essential and urgently required. We are calling on your government to prepare the people to live with the virus in a manner that balances all costs to society. That is why Level 2 should be eliminated and the Province should move directly to Level 1 on July 6th.

The general public appears to support the government’s tight control and its cautious approach to reopening. Is there wisdom in the crowd, given the fact we face such great uncertainties? The key issue for our province is control over infections imported by arriving passengers. My post of April 27 highlighted weaknesses in these controls. While changes have been made in the regulations we need to be vigilant in their enforcement and in auditing compliance with the new rules.

Related:

Travel Controls - Can  Concerned Citizens Make a Difference?  by David Vardy

One of the provisions contained in the May 15 Special Measures Order (Travel) requires:  “All individuals arriving in Newfoundland and Labrador from outside the province must provide specifics of their plan for complying with the requirement to self-isolate for 14 days following their arrival in the province.” How is this being implemented? Can arriving passengers still take a taxi to their homes and infect the driver?

Just after New Zealand declared itself covid-free the government discovered that two people from the UK had just been diagnosed with the virus. This ended a 24 day period without infections. Prime Minister Jacinda Ardern (pictured) said: "This case represents an unacceptable failure of the system. It should never have happened and it cannot be repeated", emphasising that people returning to New Zealand need to be in controlled government quarantine "The risk to our collective efforts to eliminate COVID are simply too great. I cannot allow the gains we have all made to be squandered by processes not being upheld," said the New Zealand Prime Minister. 

Prime Minister Ardern said this case proved the need of a rigorous system at the border and appointed a military leader to oversee quarantine and manage isolation facilities.

New Zealand's health ministry has identified 320 potential contacts of the two women. All of them will be contacted by public health officials and encouraged to get a test.

In future those who are being quarantined after arriving in New Zealand from overseas will also be tested twice: on day three and on day 12 of the 14-day isolation.

Should we consider such an approach, adding the requirement for not one test but two, in addition to quarantine? In our province only one infected person remains. Yet our streak of zero infections can quickly end if we relax our controls over arriving travellers or our oversight over nursing homes.

Gwyn Morgan: Lift Lockdown on working-age population

The National Post on June 16 carried an article by Gwyn Morgan which favours a more focused approach, citing the Swedish model. Morgan believes that Canada should give priority to the elderly and immune-compromised and lift the lockdown on the working-age population.

Sweden aimed to achieve “herd immunity”. Tomas Pueyo shows that Sweden is a long way from achieving herd immunity. An official model had predicted that the infection rate would go from 2.5% on April 3 to 26.0% a month later. Instead, by May 20 the infection rate had reached only 5.4%. Pueyo tells us that the “death toll would have to multiply by up to 10 before getting to Herd Immunity.”

Pueyo also describes the severity of the virus, as compared with influenza:

“When countries make the decision of whether to pursue Herd Immunity or control the virus, they should also look into collateral damage, side effects, and chronic conditions that the coronavirus might cause. We now know it affects the lungs, the kidneys, the intestines, the immune system, the blood, the heart, the brain…”

He advances the same question posed by Gwyn Morgan in the National Post article: “a very sensible strategy comes to mind: Can we free young people, let them catch the coronavirus, seclude older people during that process, and once all the young people are infected and there’s Herd Immunity, let older people free too?”

The Swedish Model: Did it succeed?

Pueyo concludes that Sweden was not successful in protecting the elderly. Sweden had one of the highest death rates in nursing homes. “This is among the highest in the world, in a country that had special protections for them. Only Belgium has a higher share of care home deaths…” Pueyo cites other countries that have had more success in protecting the elderly but, on balance, “The idea of protecting those at risk sounded good in theory, but in practice it hasn’t worked so far anywhere in the world. There have been outbreaks in nursing homes all over the world. In the US, around 60% of the top ~1,000 outbreaks have been in nursing homes.”

“In the future, we might get better at protecting them, but if we take the time to learn, there might not be many guests in care homes left to protect. Unfortunately, seniors are not the only ones affected.”

Pre-existing conditions

People with cardiovascular disease, those with diabetes or cancer, all are placed in great risk by Covid-19. “How common are these risk factors? Sweden is a healthy country. People have fewer pre-existing conditions that worsen their outcomes. In the UK, adding people with pre-existing conditions, old people, and their shielders, we get to 40% of the population that needs to be protected.

“In the US, it’s even worse. 45% of the population has pre-existing conditions that increase their risk of death. That doesn’t even include old people. More than half the population is at serious risk.

It’s not sufficient to protect these people. All their contacts would need to be extremely careful not to catch the virus and pass it to their vulnerable loved ones. As a result, substantially more than half of the US population would need to be extremely careful for years. How are we going to keep more than half of the population safe from the rest?”

“…If we decide to protect old people, people with pre-existing conditions, and their shielders, we would need to seclude a huge chunk of the population from the rest.

“Are we sure it’s doable to protect all these people from catching the virus for so long?

“Are we sure this is better than the alternative of completely controlling the virus?”

Pueyo questions whether the Swedish economy will rebound quickly but the evidence he cites suggests that Sweden is in no better position than other Nordic countries, which imposed a full lockdown.

Is command and control the path to success?

Pueyo believes that Sweden has to make major course corrections but that all is not lost. There is a path to success but it is questionable if herd immunity by itself offers a panacea.

His approach is constructive rather than critical and he is prescriptive, rather than agnostic. He believes that there are solutions in sight, without relying upon a miraculous vaccine.

 “But now we know what to do. We can keep the economy open and reduce the caseload, the way South Korea, Taiwan, Vietnam or Hong Kong have been able to.

“Many measures can be taken to stop the coronavirus, including testing, contact tracing, isolations, quarantines, universal masks, hygiene, physical distancing, public education, sewage testing, travel restrictions and crowd restrictions. All countries should apply these measures, since they’re mostly proven, much cheaper, and can dramatically reduce the epidemic.

“Whoever tells you it can’t be done hasn’t done their homework. Not taking these measures and letting the coronavirus run amok will only cause more sickness, more death, and a worse economy.”

Few countries have yet found the path to success

AndrewPotter is sceptical about our ability to manage the pandemic with the necessary testing, contact tracing, quarantines, travel restrictions and crowd restrictions. A small group of countries have been successful in his opinion.

“And so if you look at the list of countries that have done test, trace, and isolate properly, is anyone really surprised that it includes the South Koreans and the Germans and the Australians? These are countries that have retained a high capacity to do command and control at the civilian level -- you only have to visit them even as a casual tourist to see that they are countries that take getting things done seriously.

“By the same token, is anyone really surprised that the United States and Canada have manifestly failed in this regard? Just look at our airports or our public infrastructure. The problems facing the United States are legion and well-discussed and not worth getting into here, but Canadians like to flatter themselves that they have their act together in a way that the US does not. But the COVID-19 pandemic has exposed Canada as little more than a big federalized public insurance scheme.

“But you also need an organisation with the capacity to coordinate and run the programme.  And if you know anything about Canada, the problem becomes immediately obvious: what institution could conceivably do this? What agency or organisation in our society has anything close to the top-down, command and control expertise and the strategic wherewithal to do something like this at anything close to the scale required?”

Imported Infections

Many US States are pursuing a herd immunity strategy and are now reopening their economy. This places all States and perhaps Canadian provinces as well, at risk, and heightens the need to control imported infections.

“If some states are going to continue in this Herd Immunity path, the only alternative for other states that want to save their citizens and are trying to Dance is to restrict travel from other states. Otherwise, they will carry all the costs of heavy lockdowns and dancing measures, and few of the benefit in the reduction of cases.”(Pueyo)

This suggests the need for great care in lifting restrictions on arriving passengers to our province. In this context should we not consider the need for all arrivals to be both tested and quarantined?

Gwyn Morgan’s proposed solution in the National Post needs to be approached with caution. Similarly our provincial government should continue to pursue caution in reopening the economy and particularly in lifting controls over arrivals to the province, both residents and non-residents.

Conclusion

The province must continue to be vigilant and pro-active in managing the pandemic. They need to learn from international experiences and to consult with citizens in seeking the best answers.

National and international experience highlights two major challenges: imported infections and spread of the virus into nursing homes for seniors. There should be an external audit of our controls over travellers arriving in the province to ensure the policies are fully effective and faithfully administered. In the meantime we should consider testing arriving travellers as is being done in New Zealand and elsewhere, in tandem with the 14 day quarantine now in effect. Also, following New Zealand, should we consider two tests, one on day three and another on day twelve of the 14 day isolation period?

There should also be an audit of the safety of our senior citizens homes to minimize the risk to our vulnerable citizens so we can avoid the tragedy that is taking place across our country.

Yes we must move on to the next level, in a cautious and prudent manner, but we must be transparent in so doing and provide the public with confidence that we can cope with a second wave of the pandemic, which appears more likely when many US States and many national governments are reopening despite surging infections and the failure to meet defined thresholds for reopening.

David Vardy