Jordan: So about a month ago, everything looked pretty good. All things considered in Ontario.
News Clip: Doug Ford: Thanks to all of you. Thanks to the heroic efforts of our frontline workers. We’re now in the position to start working towards reopening.
Jordan: Canada’s largest province had done well to flatten the COVID 19 curve, to get the infection reproduction rate down below one, and they were seeing fewer and fewer new cases of COVID 19 every day. And then somehow it all fell apart.
News Clip: We’re going to head back to Ontario now where numbers continue to trend in the wrong direction. Today the province posted its highest number of new COVID 19 cases since early may and for a fifth straight day, Ontario has fallen well short of its testing goal.
Premier Ford fired up Tuesday, not impressed with some regional medical officers of health.
They know who they are. Start picking up your socks and start, start doing testing.
Huge crowds gathered at Trinity Bellwoods park yesterday. Many of the thousands in attendance seemed too close to be safe.
Jordan: Not to put too fine a point on it here as a resident of Ontario, but what happened? Did the province reopen too soon? Did the ministry of health start doing things wrong? Did people in Ontario simply stop following directions? Or was the provinces COVID 19 response always a kind of house of cards just waiting to fall as soon as one thing went slightly wrong. What do we know right now about how the virus is spreading in Ontario or more accurately, what don’t we know? And what are we learning here about our public health officials, about our politicians, and even about ourselves? How does Ontario get back on track? And are we, and I hate to ask this today, but I will. Are we headed back into lockdown just a few weeks after easing up? We will attempt to answer these questions in just a moment, but first, Claire has some truly disturbing news also from Ontario, about what members of Canada’s armed forces saw inside five longterm care facilities. Claire.
Claire: Yeah. Disturbing is the word that everyone is using to describe this report, including prime minister Justin Trudeau. Basically, last month, premier Doug Ford called in military assistance for longterm care homes dealing with COVID 19.
And this report is on five longterm care homes in Ontario. As you said allegations include failure to isolate patients with COVID 19 and allowing them to wander outside of their rooms. At one of the homes, the military said rooms were just filthy. There were cockroach infestations. Residents had not been bathed in weeks, and some of them were crying out for help for over two hours.
The report also says at one home, residents were bed bound for weeks with a significant number of them having pressure ulcers. And because of severe staff shortages, most residents were not receiving three meals a day. These are just some of the allegations in this report. Since the military was called in last month to help at these homes, 14 members have been infected with COVID 19. Premier Ford says he takes full accountability for the system and he says that he will fix it.
Jordan: I’m Jordan Heath Rawlings, and this is The Big Story.
Dr. David Fisman is a professor of epidemiology at the Dalla Lana school of public health at the University of Toronto. He is our favourite guest for explaining what’s going on beneath the surface of the daily COVID 19 numbers. Hi David.
Jordan: Can you explain to me what we’ve seen in Ontario over the past few weeks? It kind of seemed as April turned into May, that we were starting down the other side of this thing, but it’s been relentless bad news the last little while.
David: Yeah, I think we were headed down the other side, not very fast. So we talk about the reproduction number of a communicable disease being the number of new cases created by an old case. And once that number is below one, things subside. And we had a reproduction number below one in Ontario. We’ve actually had it since early April. But it’s never been way below one. And so we’ve been steadily having a decline in the number of new cases. As of about May the 10th, if we backdate cases for their likely transmission date, it seems around may the 10th we had a lot of transmission in Ontario coinciding with mother’s day.
And what we’ve seen since then, is we’ve seen a bit of a surge in cases where we’ve gone from 300 and something a day to 400 something a day. There’s been a slight climb, so the reproduction number has gone above one and has gone as high as 1.2, which doesn’t sound like a big deal, but that’s the reproduction number for Ebola.
Exponential growth with a reproduction number of 1.2 still gets you to high numbers if you let it persist. So it sounds like we have slightly lower case numbers today, which is great news. And we’ll just have to see how that plays out going forward. One of the difficulties of course, is that we have these rising case numbers in the context of the government pushing hard to reopen the economy and folks being pretty sick of distancing. Understandably so. And getting back to business and mingling a bit more, which I think we saw on mother’s day. And I think we’re seeing more and more. So the struggle to make this go away is that much harder. We also, interestingly, are starting to see real pockets of hot activity in the GTA associated with economic disadvantage.
Which I think means that the agencies charged with controlling this disease are going to need to go the extra mile, not just from a disease control point of view, but from a social support point of view. You have folks who are essential workers, folks who have difficulty with food security at the best of times, now being hit by COVID. If you have to go to a food bank to get your food it becomes very difficult. The food banks aren’t delivering. It becomes difficult to keep yourself fed for 14 days. So we need to figure out ways to support people. A lot of folks now with COVID in more crowded living environments. So there again, we need to figure out ways to support people and actually allow them to isolate and distance safely. If we’re going to try and control this thing.
Jordan: So what went wrong, for lack of a more specific question, between the reproduction number being below one and climbing back up, was it just us not distancing?
David: Well it’s patchy and to be honest, I don’t know what’s going wrong exactly. I think you see that this is something related to economic disadvantage. It may be something related to premature declaration of victory. Clearly there’s a lot of pressure to reopen the economy and get back to business. I don’t know if a combination of those two factors, not rooting it out and then pushing to get back to business a little bit too early. Those in combination may have brought us to a point where we have a growing rather than a shrinking epidemic. Not to belabour this, because other folks have spoken of it. I think we have a problem in terms of leadership and messaging from senior public health officials in Ontario.
I think when you have the premier come out with a clear message, and you have the MOH of Toronto come out with a clear message, and then you have them directly contradicted as he did yesterday by the chief MOH in the province and the associate chief MOH in the province, around whether or not congregating in Trinity Bellwoods, it would be a good idea to go get tested after participating in a mini Woodstock. I think that’s a problem. That confuses people. It’s been confusing all the way along. The premier has been pushing for folks to get tested, and for testing services to expand, which I think is a great idea.
And then you’ve sort of had this fairly dismissive tone taken by the chief medical officer of health, particularly around things like testing people with minimal symptoms or no symptoms, which is important in some settings to protect folks, has been quite dismissive of that. So I think that just creates confusion for a lot of people.
I think even stuff like mother’s day, clearly we had a surge on mother’s day. We’re not insiders, we’re outsiders. The data we have aren’t as good as the data he has. But you can see it quite clearly in those data that this goes back to mother’s day and a lot of mingling. And I think even as recently as a couple of days ago, the chief MOH in a press conference is talking about how ‘well, you know, maybe that was something, but it’s not there in the data’.
Well, I know it’s there in the data. You can see it. So either you’re messaging this in a way that you just sort of want folks to get back to business and not worry too much about it, which is a problem. Or you’re not trying to do that, but you can’t see patterns that are there in your own data. What’s right in front of your face. That’s the problem in my view too. And I think we can go back to the nursing home stuff. We can go back to stuff around community transmission. It’s just been all the way along. When the data have said one thing and the science has said one thing, we’ve had a chief MOH and the associate chief MOH saying another thing. So no wonder folks are a bit befuddled and confused and don’t know what to do and don’t know if we’re winning this fight or not. There’s not clear messaging.
Jordan: We’ve talked to you a few times over the course of this, and I have to say that you sound more frustrated today than you have before.
David: Yeah. I mean at this point, Ontario is sort of the laggard in Canada.
Luckily we have Quebec to somewhat keep us company in the dysfunctional province bin. But yeah we’re lagging. Everywhere else in the country’s figured this out. You can say, ‘Oh, well, you know, the GTA. We have urban issues like poverty and homelessness’. You think they don’t have poverty and homelessness in Edmonton? ‘We’re a big city, we’re a big multicultural city where people speak lots of languages’. Have you been to Vancouver lately? I mean you can pull out whatever hand waving you want in terms of why we can’t get it together and everywhere else in Canada can. To me, the big difference that jumps out, is poor leadership, poor organization, and senior leaders who seem to be at cross purposes on messaging and on how to get this done.
It’s a problem and it needs to change. I realize that folks say, ‘well, you you can’t change horses in midstream. We’re in the middle of a crisis’. Well, you know what? Sometimes you actually have to. Because we have to get out of the crisis. And if we have leadership that can’t get us out, then we really do need to think about new leadership.
Jordan: When you look at the data you can see, because I know you don’t have access to all of it, and that’s also a problem, but when you look at that, what in your mind do we need? What aren’t we doing that we need to just be doing now, no matter how much it costs?
David: There’s actually stuff we need to be doing, even though it doesn’t cost that much.
When we talk to folks who do frontline public health, one easy win is when doctors are seeing people in hospital or in intensive care units or in emergency rooms. This is actually not that hard a disease to diagnose. It’s got some pretty characteristic features with some unusual stuff with white blood cell counts, unusual stuff with a molecule in your blood called ferritin. Unusual stuff with some of the clotting parameters that doctors can measure in your blood. So it’s a weird pneumonia and it’s pretty easy to diagnose it. When a doctor diagnoses someone as having probable COVID. That should be the moment when the public health disease control machinery kicks into gear.
So at that moment, that is good enough that public health should know about the person. A case file should be created. Their household contacts should be told to isolate themselves and contact tracing should be initiated. What we have right now is a situation where on average, it’s about a week lag from the time someone gets symptoms until they show up as a case file at a public health unit. And that person needs to have symptoms, then they need to go get tested than the test needs to get turned around. Then that test result needs to get reported to a public health unit, and then that public health unit needs to create a case file. That takes about seven days. If you do the math on that, we think that about half of the transmissions from an infectious case happened the day before they get symptoms. So that means about half the people that person’s going to in infect have been infecting other people for four days. By the time you create a case file for that index case for that first case. So if you want to do stuff like contact tracing, what you actually need to do is you need to be doing contact tracing where you are less than one serial interval, less than four or five days out, from the time that that case first experienced symptoms, and we’re nowhere close to that. We’re about twice that. So initiating that process based on clinical diagnosis would help. Getting electronic reporting of lab test results to public health units, which we still don’t have, we still have fax machine based reporting, that would help. Getting fast turnarounds on tests, getting outreach on testing, so that if you have a symptom and you can’t get to a test centre, we’ll come to you. All of those things would help shorten that interval and get us to a point where we’re actually able to control the disease by more than just distancing, which we’re doing right now, pretty much exclusively, and not very well.
Jordan: You mentioned testing, and I wanted to ask you about that because again, when we looked like we were on the right side of this thing, we were seeing testing numbers creep up until 15,000 and sometimes even higher. And now when I look at the daily numbers, that’s shrunk. Which again, to a lay person seems nuts. How do we fix that? What’s gone wrong?
David: Yeah the testing capacity isn’t the problem. I think one of the issues there is sort of the learned helplessness people have now, where many folks who have been trying to get tested for months have been turned away, and you need to teach people that they can actually go get tested and they’ll get a test. I’ve also heard anecdotally that there are folks who are worried that if they go to a test centre, they’ll be crowded together with other people who may have COVID. And that if they don’t have COVID, when they get to the test centre, they’ll have it by the time they leave.
And I think that’s actually a legitimate concern. So we have to figure out ways to do this safely. We can figure out ways to do outreach, be they drive through testing, be they, we come to you kind of testing. These are solvable problems. But I do think that to some extent you’ve set up a dynamic where people don’t expect to get tested, if they present for testing.
I think there’s also kind of the perverse incentive dynamic at play where if health units are being judged based on the number of contacts, the fraction of contacts they trace within 24 hours, they already can’t keep up. So if you ramp up testing, they’re going to have more work to do.
They’re not keeping up with the work they already have because we haven’t found ways to really expand the contact tracing workforce. So it almost seems like a perverse incentive has been set up where if I worked at a public health unit, maybe I wouldn’t be so keen to radically scale up testing because I know it’s going to be impossible to keep up with the cases we find.
Jordan: What you just described sounds to me like a really dysfunctional organization.
David: Do you think?
Jordan: Yeah. We’ve spoken a lot by now, I can tell that you’re mad and that sucks.
David: Yeah, it does suck. I spoke to some seventh graders this morning, was trying to talk about this in kind of seventh grade terms, and I said the other provinces have done their work and what they’re getting is a summer vacation. And Ontario hasn’t really passed the test, and so we’re having to do COVID summer school. And I think that’s one way to look at it, is that this is supposed to be our time to regroup and plan, because we probably are going to get hit by this again in the fall, or harder. And this should be our time to reflect and plan and make changes and build capacity, and we still can’t get it done.
It’s nearly June now and we’re struggling.
Jordan: Let’s put the public health response, such as it is, aside for a second, and talk about messaging, which you also kind of touched on. How do we get through to people like the folks who crowded into Trinity Bellwoods this past weekend? Because obviously that’s a flashpoint and it wouldn’t shock me to see cases go up because of that. Those people are clearly at the end of their rope. What can you say to them?
David: I think what you say to them is this is not about you. And you may not be vulnerable. You may not think that this is an issue for 30 something year olds or 20 something year olds. It’s very unlikely that you’re going to get sick and die from this. Even if you get it.
What you are going to do, is spur the transmission of this in the community. That’s going to infect your parents and that’s going to infect your grandparents. And we see this rippling out. If you look by case age in Ontario since March, what happens which is interesting, is from emergence in early March until the beginning of April, the average age of cases on a given day climbs and climbs. And that goes along with the increasing traffic into the ICUs. And you see that with a lot of communicable diseases, is that young people tend to be better at spreading, and old people do most of the getting really sick and dying. So I think basically recreating Woodstock in Trinity Bellwoods, it may not hit you and it may not hit your parents and grandparents for another week or two. But it is going to hit the community and it is going to harm people. And I think it’s reasonable to ask people not to be selfish. And if people want to be selfish and do stupid things, then I think that’s where city bylaw officers and law enforcement should come in and help remind people that they have to do the right thing because we’re not allowed to intentionally harm people in our society. It doesn’t work that way. And this I think falls into the category of either by intent, or by neglect, harming others. And I think that’s very unfair.
Jordan: I’ll only keep you for a few more questions because I know you’re really busy right now, but you did touch on, just now about what we’re learning about how the age of infection changes. What else, on a happier note, what else have you guys been learning about this disease and how it spreads as this goes on?
David: I think what we’ve learned from other places this past week, which has been really interesting, is we’re finally starting to really hone in on what the true infection fatality rate is.
So there’s a the case fatality rate, which is the fraction of cases that die, and that’s up around seven and a half percent in Canada right now. We know the true infection fatality rate is much lower. Because we know we miss a lot of infections. What fraction of infections we miss is subject to some debate. It’s probably somewhere between 90% and 95% of infections don’t get diagnosed. So you can scale down that case fatality accordingly to estimate the infection fatality and say it’s probably about something like half a percent, something like that. What was interesting last week was in Spain, they actually did a national seroprevalence study and it’s a really good study. And nationally, what they find is that 5% of the people in Spain, which is a very similar sized country to Canada, it’s about 40 million people. 5% of people have been infected across the country, about 11% in Madrid. And comparing the number of infections to the number of deaths, what they’re able to come up with is an infection fatality rate of about 1%.
Which again puts this on a par with what we think happened with H1N1 influenza in 1918, and sort of underscores what a dangerous infectious disease this is. And so that’s one really important insight that’s come up over the past week. Probably the strangest and most inconvenient, and I’ve already received emails scolding me for saying this out loud, the smokers die less. And I don’t know what that is. And the smokers are also more likely to be asymptomatic in the data that we have access to. And you know, I think my response, I am absolutely not advocating that anyone light up, smoking has killed a lot of people that I’ve loved in my life. It’s an absolute scourge on humanity.
But it also, part of being an epidemiologist and working with data is that you actually listen to what the data is telling you. You don’t take it on faith these are causal relationships. Smoking’s correlated with a lot of other things, and I’m not saying it’s causal. But I’m also not gonna pretend that I didn’t see a relationship in the data when I saw it. It’s interesting. It’s been seen in other places and it warrants further study and further thought. Being a smoker does seem to be a marker of decreased risk for getting severely ill with this. So if that’s terrible messaging and I shouldn’t tell the truth because there’s some greater good argument, then I guess I’m in the wrong job. I think you start off by telling the truth and then you figure out what the implications of that truth are. That’s my approach to epidemiology. I think there’s enough going on right now in North America with people starting with their version of what they think the story should be, and then trying to fit the truth to that predetermined version of how this disease looks or how these events are playing out. I think it’s important to go the other way. You follow the data where they lead, even if it’s inconvenient, and even if it’s confusing.
Jordan: In light of that, is there anything in the data from other provinces, like you mentioned, [about] how many of them across Canada are doing so much better than Ontario? Is there anything concrete we can take that they’re doing that Ontario is just not?
David: I’ve said this before, that I think one of the advantages British Columbia has over us is they have an excellent provincial public health agency at BCCDC. They have an outstanding provincial medical officer in Dr. Henry. She is able to explain things to people. She spent her career explaining things to people. She’s written this marvellous book, I think it’s called soap and water, and common sense is basically how to protect yourself from infectious diseases.
And she published that a few years ago, and this is what she does. She explains to people in plain language how not to get sick. So this is a situation that she’s abundantly prepared for and it makes a difference. It actually saves lives. I think you can look at a place like Alberta and seen that they had a tremendously strong testing game.
The Prairies have done well. Manitoba’s quiet, no one talks about Manitoba. That’s cause there’s nothing going on in Manitoba. They’ve got a reproduction number of one, just like we do in Ontario. The difference is Manitoba has about five cases a day and we have 400 so a reproduction number of one has very different implications depending on what you’ve got your prevalence to. And again, the Atlantic has outperformed the country as a whole, and nobody talks about PEI because PEI is cold stone quiet. Newfoundland has been amazing. Nova Scotia, New Brunswick. All of those are places that, as I say, are kind of starting to think about next steps in terms of reopening their economies because they’ve actually been able to shut this down.
So I think there’s a lot to be proud of here in Canada and hopefully Ontario and Quebec will join that club eventually, but it’s not looking super great at the moment.
Jordan: My last question then is one I’ve kind of been tiptoeing around this whole time. I asked it in the intro, and should I be stocking up given that I live in Ontario? Are we looking at another potential hard lockdown?
David: I don’t know. I think politically that’s going to be extraordinarily difficult to do, and I wouldn’t anticipate that unless we start to see the ICUs filling up and threatening to overflow, which we’re a long way from that yet, we have more ICU beds than we did in March, and they’re less occupied than they were in March.
So we have some wiggle room and we have some time to get this right. I don’t think another lockdown is imminent. And I hope that we start to see some regionalization of Ontario, where some places that have done much better can reopen more than places that are still struggling. Cause this is overwhelmingly, if you look at Ontario, the hotspots are overwhelmingly GTA and places that face the state of Michigan. So Lambton, Windsor and Chatham. And that’s just very tough. As dysfunctional as we have been in Ontario, we have a Southern border with the country that has the largest COVID case count and the most deaths in the world.
And that’s not changing anytime soon. So we do have a lot of ongoing challenges, but outside of those regions, most places have been pretty quiet. I think it’s very important for the provincial public health leadership to not undermine local medical officers of health. We’re doing the right thing.
I think, for example, MOHs in Ontario use the health protection promotion act to keep people away from their cottages and then apparently been undermined by the chief MOH who said, ‘no, you can’t use it for that’. And I think that’s really a problem. I think places that have achieved success need to be allowed to prosper and need to be allowed to enjoy that success.
And we also need the province to think about possibly restricting movement from regions in Ontario with a lot of disease to regions that have managed to get rid of disease. Because I don’t think that’s fair to let people re-introduce infection into places that have managed to control it.
Jordan: Well thank you for all of this and I hope we talk next time when some of your advice has been taken and we’re once again headed down the other side.
David: Thanks so much.
Jordan: Dr. David Fisman of the Dalla Lana school of public health. That was The Big Story. If you would like more big stories, including David’s previous guest appearances when he was slightly more optimistic, you can find them at thebigstorypodcast.ca. You can also talk to us @thebigstoryFPN or you can email us. The address is firstname.lastname@example.org.
And as always, find us wherever you get your podcasts, in your favourite podcast player, or find us and all the other podcasts on Frequency at frequencypodcastnetwork.com. We have a new one that drops next Monday. It’s called a Heaven Bent. I won’t even spoil the surprise for you, but go and take a listen to the trailer.
Thanks for listening to us. I’m Jordan Heath-Rawlings and we’ll talk tomorrow.
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