Constant testing, particularly among those at nominal risk, cannot be “the new normal” – Pic by Shehan Gunasekara
A group of Canada’s most eminent doctors, doubtless worried by the histrionic hysterics re COVID and the danger that human history going forward will become a footnote to ‘COVID management’ because of our absurd over-reaction, in terms of actual mortality numbers, have decided to appeal to their leaders for sanity and wisdom.
They issued a statement, which I have unpacked and paraphrased below. It is every bit as applicable here in Sri Lanka as everywhere else on the planet, and I believe our current, more measured approach here will only be heartened, affirmed and reconfirmed by the below.
However, seeing the undue panic in recent days, even from a clearly contained cluster (as reported by our public health specialists), it strikes me, we need to take this guidance to mind and to heart.
Following this, I reproduce the letter sent by the Canadian specialists as is, and list them, so we can have a shared sense of the level of learning and expertise here represented.
The essential points:
- Every death, due to COVID-19 or otherwise is to be lamented, is tragic to some degree, and is to be mourned. However, in overall population terms, the direct impact of COVID-19 on premature mortality is small.
- Those under the age of 60 account for 65% of cases, but only 3% of mortality. With ready access to health services, severe outcomes are avoidable for those without pre-existing conditions.
- The initial unprecedented global public health measures implemented circa March 2020 were precipitated by what we didn’t know, the rapid growth of cases and the potential threat to health systems. Actions were applied to the entire population with that in mind. These actions were intended to buy time to develop a longer-term response. They are not a means for eradicating the disease or a justification for destroying our lives and livelihoods as we know them.
- There are some countries who seem to have suppressed the disease. Sporadic cases and outbreaks though are unavoidable, it is a “virus” after all. Only island nations, through sustained isolation, could “eliminate” the disease, but at what cost, and through what possible cost/benefit justification given the overall low mortality and lethality now established (other than for the elderly or those with comorbidities as they are being called)?
- Canada has retained excess capacity through the crisis. Leaders and public health officials concede that they used highly charged language in terms of potential consequences to get widespread support. They now worry that Canadians have become so fearful of this disease that they fear working, seeking routine and preventative medical care, participating in religious and cultural events, interacting with family and friends, using public transportation, shopping, kindling the economy, in fact engaging in so much that gives life in free societies appeal. Here we run the risk of the cure being then worse than the curse.
- These experts concede that while COVID-19 control remains an important public health priority it is not the exclusive or towering primary challenge to the health of their people. There are clear social determinants of health and they have profound impacts on society. Low income groups in particular bear a disproportionate part of the impact of the over-reaction. There is an equity argument that can’t be ignored if “humanitarian concern” is to be more than a slogan.
- Education, employment, social connection, medical care and dental care, all have to take priority. Children desperately need to interact with their peers (and they are only nominally at risk, and in some societies they are finding they act as a “brake” on the infection given their robust immune systems), be in child care, learn in school, participate in sports, express themselves in social activities. And Adults crucially need to work, to support the cultural and social lives of their community, and family and friends yearn to, and should actively meet.
- Even with gradual relaxation, the social costs of some of these restraints are too high. Missing scheduled or early medical appointments or proactive surgeries, postponing vaccinations, will all lead to other mortality spikes. Early childhood development is one of the strongest predictors of thriving later in life, including economic, social and health outcomes.
- Education is being compromised, domestic violence surges, alcohol and drug intake and food insecurity all become a toxic brew. Unemployment mounts, clearly related to increased deaths in a different way. The mental health toll, regarding which we are so inarticulate and tentative, is only now beginning to be felt.
- Loneliness, isolation, anxiety about jobs and finances, parents unsure about childcare, and just a tsunami of anxiety, depression and stress. And for what? For an illness we objectively don’t even know the death count from (insofar as where it was a “factor” versus a “cause”), or how accurate testing is, or the degree of already present immunity…the known unknowns are staggering, and they don’t point towards justifying more panic, except for the peddlers of it.
- So, the goal has to shift from eradicating this virus, which is not feasible and will lead to the very devastation we have been seeking to fend off.
- New goal: protect life and liberty, and safeguard health, across the entire constellation of health. Protect the vulnerable and allow society overall to function.
- Those at highest risk should be offered effective protection, particularly those in long-term care, but we must do so in a way that respects their autonomy and provides them a reasonable quality of life.
- From what we’ve learned globally, the other biggest superspreader situations have been where people are congregated (homeless shelters, prisons, dormitories for temporary foreign workers, work settings like meat packing plants), and we must develop appropriate protections and supports for those settings.
- The overall maxim should be to empower people to make informed choices about their lives and what they consider acceptable, fact-based risk. Only when on strong, clear evidence, not extrapolation or modelling or “panic-demics”, should universal public health measures be adopted, and then with clear goals, for a limited period of time, and minimising their invasiveness – a duty all governments should owe their citizens.
- n Continue to provide, sane, balanced, practical guidance, and continue to ensure due vigilance, tracking and care. Let schools and businesses operate with benchmarked prudence.
- Develop and share clear mitigation plans, as targeted as possible, for future outbreaks or resurgence that are risk-based and look at the nature of the outbreaks, so universal lockdowns are not mindlessly defaulted to.
- Continue to demand better diagnostics and clearer test outcomes, improve disease surveillance to have an accurate picture so that timely decisions and useful advice can be tendered.
- Constant testing, particularly among those at nominal risk, cannot be “the new normal.” Clear guidance has to be given on appropriate use of viral (“diagnostic” to some extent) and antibody (serology) testing that should have different thresholds for healthcare providers, employers and community organisations.
- We need a “social determinants of health” model, which includes an equity lens, and this should be leveraged, along with evidence-based measures that clearly address the level of risk in a particular setting and community. Again, a trade-off between “costs” and “benefits” is inescapable, and without that, there is no leadership or responsible stewardship.
- Physical distancing norms need to be filtered through the same lens, particularly where good hygiene is practiced, and individuals with symptoms stay home and are actively encouraged to do so. Then, if risk of community transmission is relatively low, physical “separation” can be less draconian.
- Quarantine guidelines need to be reviewed, ditto isolation periods, based on best current evidence, not prior “theology” or initial “panic orthodoxy.” Using smart testing to reduce this period needs to increasingly become the norm. Travel should be restarted to parts of the world where there is little community transmission, this is hardly the only “risk” out there, otherwise we are continuing to jointly undermine the global economy.
- Clarity is needed on medical and non-medical masks. Stress their use in close quarters, congregated living settings, etc. Don’t harass people for not wearing masks in parks or public thoroughfares where this is “voodoo” medicine and not public health. Local epidemiology is not uniform on this, err on the side of caution perhaps, but again not extremity, as these masks have issues re hygiene, breathing and more.
- Infection prevention and control in long-term care has to be an overwhelming global priority.
- A true COVID “risk assessment model” should be a compelling global imperative, ideally aligned upon by best medical practice, sharply evidence based and unromantically experience biased.
- Those who are vulnerable and choose to isolate should have the support needed to do so. Those who may be at risk, but value quality of life, or the dignity of the years they feel they have left, should also be respected and supported.
- Ensure we are ready to deal with the emotional fall-out, psychological impact and addictions that may flow in the wake of this for some time to come.
And with this magnificent, magisterial summary of resounding sense from these “sainted” Canadian high priests of medical wisdom duly paraphrased and summarised, I indicate the date the letter they issued to their government leaders came out for anyone interested in reading or referencing the primary source and list the eminent contributors to this thinking.
Date: July 6, 2020
Dealing with COVID-19: A Balanced Response
www.balancedresponse.ca
Robert Bell, MDCM, MSc, FRCSC, FACS
Former Deputy Minister of Health, Province of Ontario
Former President and CEO, University Health Network, Toronto
David Butler-Jones, MD, MHSc LLD(hc), DSc(hc), FRCPC, FACPM, FCFP, CCFP
Canada’s first Chief Public Health Officer and former Deputy Minister for the Public Health Agency of Canada
Jean Clinton, BMus, MD, FRCPC
Clinical Professor, Psychiatry and Behavioural Neurosciences, McMaster University
Tom Closson, BASc, MBA, FCAE, PEng
Former President and CEO, University Health Network, Toronto
Former President and CEO, Capital Health Region, British Columbia
Janet Davidson, OC, BScN, MHSA, LLD(Hon)
Former Deputy Minister, Alberta Health
Former CEO, Trillium Health Centre
Martha Fulford, MA, MD, FRCPC
Infectious Diseases Specialist
Associate Professor, McMaster University
Vivek Goel, MDCM, MSc, SM, FRCPC, FCAHS
Professor, Dalla Lana School of Public Health, University of Toronto
Former President, Public Health Ontario
Joel Kettner, MD, MSc, FRCSC, FRCPC
Former Chief Public Health Officer, Province of Manitoba
Onye Nnorom, MDCM, CCFP, MPH, FRCPC
President, Black Physicians’ Association of Ontario
Associate Program Director, Public Health and Preventive Medicine Residency Program
Dalla Lana School of Public Health, University of Toronto
Brian Postl, MD, FRCPC
Dean, Rady Faculty of Health Sciences and Vice- Provost, Health Sciences, University of Manitoba
Former President, Winnipeg Regional Health Authority
Neil Rau, MD, FCPC
Infectious Disease Specialist and Medical Microbiologist
Assistant Professor, University of Toronto
Richard Reznick, MD, FRCSC, FACS, FRCSEd (hon), FRCSI (hon), FRCS (hon)
Professor of Surgery and Dean Emeritus, Faculty of Health Sciences, Queen’s University
Susan Richardson, MDCM, FCRPC
Professor Emerita, University of Toronto
Richard Schabas, MD, MHSC, FRCPC
Former Chief Medical Officer of Health, Province of Ontario
Former Chief of Medical Staff, York Central Hospital
Gregory Taylor, MD, FRCPC
Former Chief Public Health Officer of Canada
David Walker, MD, FRCPC
Former Dean of Health Sciences, Queens University
Chair, Ontario’s Expert Panel on SARS, 2003
Catharine Whiteside, CM, MD, PhD, FRCPS(C), FCAHS
Executive Director, Diabetes Action Canada - CIHR SPOR Network
Emerita Professor and Former Dean of Medicine, University of Toronto
Trevor Young, MD, PhD, FRCPC, FCAHS
Professor of Psychiatry
Dean, Faculty of Medicine and Vice Provost, Relations with Health Care Institutions
University of Toronto
Additional signatories who have agreed to be listed after the posting date
July 11, 2020
John H Dirks CM,MD, FRCPS, FRSC
Emeritus President and Scientific Director, Gairdner Foundation
Emeritus Professor of Medicine, University of Toronto
Erica Frank, MD, MPH, FACPM
Professor and Canada Research Chair in Preventive Medicine and Population Health, University of British Columbia
Founder/Inventor, www.NextGenU.org
