When this pandemic first began, about two years, that feel like ten years ago, every single day we would have Claire Brassard, our producer, run down COVID numbers from provinces across Canada to give you the fullest possible picture of every little detail of how we were doing versus Covid-19. And now two years into this, here’s what you get. You get me saying, “hey, things, really not great”, and you get some evidence about how not great they are.
Canadian hospitals, they are filling up with people who have COVID-19 because the Omicron variant is spreading faster than any other version of the virus. Ontario is the latest province to have more people in hospital with COVID now than at any other time during the pandemic.
The stress on our medical system is so great right now that governments are looking for any way to alleviate some of the pressure. Ontario is credentialing internationally educated nurses hoping to boost staffing levels. And Quebec is proposing a controversial vaccine policy.
François Legault Clip
Those who refuse to receive their first dose in the coming weeks will have to pay a new health contribution.
Is charging people who refuse vaccination ethical? Will it create a slippery slope? Will that even matter if hospitals are full of unvaccinated patients on ventilators? And do we know where we are in the Omicron wave right now? Have cases peaked? With limited testing, how will we know when they do? And critically, when they eventually do decline, what do we do next? There’s been a lot of hopeful talk that Omicron is the last major wave of this pandemic. How do we make sure that’s actually true?
I’m Jordan Heath-Rawlings. This is the big story. Dr. Christopher Labos is a cardiologist with a master’s degree in epidemiology. He has been a regular contributor to many Quebec outlets during this pandemic. He is also the co host of The Body of Evidence: A Health and Medicine Podcast. Hello, Dr. Labos.
Why don’t we start with this? Just because I’m happy to be talking to somebody who’s focused on Quebec during this pandemic. The day after the province announced that it’s tentatively planning at least, to tax those without a medical exemption who decline vaccination. My question is, what do you think of that? And is the situation there in Quebec that dire that this kind of stick needs to be taken out?
Yes, I think it is that dire. The number of hospitalizations is very, very high. There are projections that indicate that if the situation continues a pace as it is now, we will very soon overwhelm the healthcare system and there just won’t be beds available, which would be disastrous for anybody who needs to seek care for either COVID or non-COVID related situations. This is clearly a problem. Clearly, something needs to be done to encourage vaccination as one of the main public health interventions that we need to do to improve outcomes with COVID and to prevent future problems, future waves of COVID.
So I personally have no issues with this tax. Whether you want to call it a tax or a healthcare contribution. We will let the political pundits argue about that one. But whatever you want to call it, I frankly have no issues with it. I’m not exactly sure why people think that it will lead to the erosion of our civil liberties or fundamentally change the nature of Quebec and Canadian society and undermine the Canada Health Act. I don’t think any of that stuff is true.
I also wanted your opinion on this because you’re a doctor, you’re a cardiologist, especially. You are probably used to seeing the results of people who don’t perhaps make the right decisions with their health care, and that leads them into your care. So how do you feel about balancing a person’s right to obviously choose what they take and refuse in terms of healthcare with the repercussions that end up on your table?
It’s a difficult balancing act. I won’t argue with you. I mean, it would be great if we lived in a society where everybody did all the ideal things like not smoke, limit their alcohol, exercise regularly, avoid junk food, eat plenty of fruits and vegetables. It would be great if we did all of those things. But we have to remember that the government has a role to play in encouraging these behaviours. So no government is going to ban fast food. But if you put a tax on sugary beverages, that helps, and there is evidence to show that that helps in getting people to reduce their sugar consumption, which in turn improves health outcomes. If you put a tax on cigarettes, which we have, that helps, that encourages people to not take up smoking because it makes the price of cigarettes more unattractive to people. If you ban smoking in all indoor places, which we have done here in Canada, it makes it more inconvenient for people to smoke, and it makes it less likely that they will take up smoking and it denormalizes smoking, so it makes it less pervasive in society.
The government has a role to play in encouraging healthy behaviours. And so I see this whole discussion about vaccines as a natural extension of that. Fundamentally, they don’t want people to pay more taxes with this policy.
They want them to get vaccinated.
They want to get vaccinated in the same way that parking tickets and speeding tickets are not really supposed to be a way for the government to make money. They are a way to encourage people to follow the rules and park in specific places and not speed on the highway. So we have to remember what the goal of these objectives are and whether you want to do it with a financial penalty or whether you want to do it with a broader vaccine passport system, which, frankly, to me, is the more invasive strategy, even though some people seem to be preferring that to the tax scheme. But whatever you try to do, the fundamental goal remains the same. It is to nudge people towards vaccination by creating a series of consequences to non-vaccination that are practically obvious to people in a way that some future illness isn’t.
The problem with most people is that when you try to explain to them why vaccination decreases the risk that they will get sick and end up in hospital in the ICU, it’s a very abstract concept in some way. And especially when you talk about younger people, as most people know when you’re young, you are in fact indestructible. And so it’s very hard to explain to young people or to make them appreciate the dangers and the risks because they say things like, Well, I’m young and healthy. I’ll get over this. And they are probably right. They probably will. But it creates a great stress on the system as a whole if people are unvaccinated because some of them do get sick and then they end up spreading the virus to others.
So it’s a very abstract benefit. And if you can give them a concrete benefit, like if you don’t get vaccinated, you can go to the liquor store, to the outlets to buy marijuana, then that is something that shows them like, oh, okay, I need to get vaccinated in order to do XYZ, and that’s enough to at least shift the position of people who are not, frankly, anti-vaccine but who don’t see the benefit and wouldn’t do it otherwise.
That was a great answer. And I will leave the discussion there for the medical ethicists. And I’ll ask you about the stuff that we really asked you on this show to discuss, which is, we’ve talked about the Omicron variant on the show a few times, and every time we have so far it’s been in the capacity of how much we still don’t know what we’re waiting to find out. Now, we are seeing the worst, hopefully the worst of this wave in Canada. How has that changed? How well do we understand this variant now compared to, say, mid December, late December?
I think we know a little bit more about the Omicron variant, and there still is a lot of uncertainty. And frankly, the problem is that it’s very hard to answer these questions in a way that is satisfying for most people. Some answers are very clear. If we’re going to ask, is this variant more infectious? I think the answer is undeniably yes. I think we’ve proven that to ourselves. We are seeing case numbers surging. At least in Quebec, we’ve been breaking records on a daily basis up until the point when the testing capacity system became overwhelmed and the numbers essentially became chronic underestimates that are essentially unreliable.
That’s happening here in Ontario as well.
Yeah, it’s frankly, across the country. So clearly it’s more infectious. The question is, is it more severe? It’s a very hard question to answer because you then have to say, well, what do you mean by more severe? Do you mean, what is the probability that you, as an individual are more likely to get hospitalized because of the virus? Are you talking about society as a whole? What’s the parameter you want to look at? Because even if this virus is less dangerous, even if the rate of hospitalization is low, is lower than, say, the Delta variant. Let’s say the hospitalization rate is half what it was with the Delta variant, for example. But if it’s twice as infectious, the same number of people are going to end up in hospital, and that’s what really impacts the healthcare system. It’s the number of people that are there.
So it really depends on how you want to define seriousness or dangerousness or severity of this virus. And frankly, if you’re going to look at the healthcare system as a whole, this is clearly more severe because it is stressing the health care system in a way that we didn’t see in previous waves, just by virtue of the fact that it spreads more easily and infects more people.
As we try to figure out what we can expect over the next few weeks here, when this variant began to show up in Canada, I think a lot of people looked to some of the places it had hit early, South Africa, Denmark, a few other places in Europe, and tried to maybe extrapolate what Canada could expect from that. And so now that we’re sort of a month down that road have those examples held up? Has Canada’s experience kind of tracked to what other nations saw earlier, or is it different here?
Well, it’s clearly different here because we’re a different country. There are different variables at play. And so it’s very hard to take comparisons from one country and bring them to another country for a few reasons. The big one, of course, is we have different vaccination rates to other countries. We have different patient demographics, so younger, older populations. That makes a big difference.
But I think one of the big things, especially if you want to try to compare Canada to South Africa, is also we need to keep in mind something very basic that I think a lot of people have overlooked. It’s winter in Canada now, it’s summer in South Africa. We’re in different hemispheres. So that’s going to make a big difference in how easily a virus spreads, because when it’s winter time, people spend more time indoors, viruses spread more easily. It’s not an accident that we call this cold and flu season. It’s because this is when respiratory infectious viruses spread.
So we can get general lessons from other countries. We can look to see what new variants are emerging, see if they spread more quickly and sort of it gives us a warning sign if you will, as to what’s going to happen. But we need to be a little bit careful about overinterpreting the data. Especially early on, there were a lot of people who were saying like, oh, this is a mild virus. We should just let it spread through the community and we’ll be fine. And that was, I think, a little premature because you don’t really know what’s going to happen when you introduce a new variant into an ecosystem, because what was true in South Africa may not necessarily be true in Canada, if for no other reason than the fact that it’s summer versus winter. I mean, that probably makes a huge difference. So I’m always a little bit reluctant to draw too many firm comparisons between other countries just because there are so many variables at play.
One of the things I think a lot of people are concerned about, or at the very least, wondering about right now is, we know it’s bad, we know the healthcare system is really stressed, perhaps on the brink. And as you mentioned, testing is kind of unreliable as data right now because we seem to have maxed it out. And I understand from talking to folks like you over the past couple of years, that hospitalizations and ICU’s kind of lag well behind cases. So what I’m trying to get a sense of here for our listeners and also for me, as my daughter hopefully goes back to school next week, if case counts are unreliable and hospitalizations and ICU’s lag, how will we know when this wave is peaking or beginning to come down? And where can we find that data?
So here’s the thing. Even though testing capacity is limited, that doesn’t mean the information that we glean from it is useless. So there are things that you can look at that give you a sense. You can look at the positivity rate, so the number of positive cases that you’re actually catching, that gives you an idea of how things are going. There are other things that can be done that we haven’t used that much in Canada for reasons that I honestly don’t know. But like looking at wastewater to look at the amount of COVID, to give you a sense of how COVID is surging in communities.
But when you know that cases are underreported, you can still draw inferences from the numbers and think of the flu as an example. Not everybody who gets the flu every year gets a diagnosis, right? Most people get the flu, stay home, they don’t go to the hospital and get a nasal swab to get a lab confirmed diagnosis of the flu. And so if you just look at lab confirmed cases of the flu, that number seems very low compared to how much flu there is actually out there in the world. Now, we have dealt with the flu for long enough that there are ways to statistically extract what the actual number of flu cases is from the minority of cases that are actually diagnosed via lab tests. So there are things that you can do. And so when you look at the positivity rates, if you look at the demographics of who’s being tested, if you look at the cases in the test that you are able to do, you can draw certain inferences. So I think we’ll start to get a sense.
And there has been some inkling to suggest that we might be at the peak of the Omicron variant now. It’s a little speculative and it’s a little premature, but it’s not entirely inconceivable, and it would certainly make sense that with the public health interventions that were put in place at the end of December, beginning of January, that we would start to see the impact of those now and with a levelling off of cases and hopefully a stabilization of the system and hopefully the number of cases starting to go down.
The other thing that I think is going to be informative is that as the demand for tests starts to ease off, that will also be an early sign that maybe things are getting better. And of course, if we can start using rapid tests more, they have faced their own challenges in terms of rollout and supply, but if we can start using them more effectively and if we can find some way to report those positive cases, that will give us a better idea, too. So we may have an imperfect understanding of what the scope of COVID is in this country, but that doesn’t mean we can’t draw some inferences from the data that we do have.
One of the things that I try to do on this show is rather than get you to make predictions or get you to give us the data as of this moment is kind of try to educate myself and our listeners in terms of how to interpret some of the data that’s available. Which brings me to hospitalizations being either from COVID or with COVID. This is a stat the Ontario government has just started releasing. I know it’s been made available in places in the US. Not sure about Quebec right now. How effective is that data? And how much can it inform what we know personally about the virus and our community as well? Does it matter to the impact on the medical system at all?
So I’ll take your last question first. Does it matter to the impact on the healthcare system at all? And the answer to that is sort of no, because if you’re there in hospital, you’re there in hospital, regardless of what brought you into the hospital. If you are a COVID positive patient, meaning you have COVID and you’re infectious, that’s going to number one, make your stay in hospital more difficult. Number two, it is probably going to impact the care you receive because I would hope for obvious reasons.
If you’re actively infectious, you wouldn’t go for surgery or a heart procedure or to have a device implanted or get chemotherapy. Being actively sick delays your treatment because you need to recover from the first thing so that we can treat the second thing. So regardless of what brought you to hospital, if you have COVID, that is going to make your stay worse, it puts more stress on the healthcare system because now in order to treat you, all the healthcare professionals have to don all their personal protective equipment, they have to put you in isolation, they have to gown up. They have to put you in a special ward. You take up space and resources that makes things more cumbersome.
So whether you got hospitalized because of COVID or you are hospitalized with COVID, the end result for you and your experience is the same. You are going to get most likely suboptimal care. This whole debate about because of COVID or with COVID, it is being used by certain individuals to minimize the impact that COVID is having on the province and on the country because they’ll be like, well, all these hospitalizations, they aren’t really that sick. They were there in the hospital for other reasons. And if they didn’t have appendicitis, if they didn’t have a heart attack, we wouldn’t be counting them as COVID hospitalizations. Ergo, Covid is not that dangerous. Ergo, we don’t need to be worried. Ergo, we don’t need to vaccinate, et cetera. The logical sequence of events sort of follows from that initial argument. So it is being used as a talking point to sort of minimize the severity of COVID and the importance of the public health measures like vaccination.
But in reality, though, it actually makes the contrary point because if you assume that you have a bunch of vaccinated people who are in hospital for other things that happen to test COVID, if those people would otherwise stay home if they weren’t in hospital for other reasons, then the discrepancy between vaccinated and unvaccinated needing hospitalization would actually be more pronounced. And it would make the case even more forcibly for the benefit of vaccination, which is sort of, I think, a statistical irony that most people haven’t caught onto yet.
So I think it’s valid to report this data. I mean, more data is always a good thing for the most part. I think it’s going to be important to see what the reality is as long as we can interpret it properly. Numbers are never wrong. It’s the way we interpret them that can be flawed. And when it comes to statistics, it is unfortunately, very easy to draw the wrong conclusions. I have a 1 hour PowerPoint talk that I sometimes give to medical students and also to journalism students about how we misinterpret data and how the statistics can lead us down the wrong road. And one of the best examples is one of the arguments that’s being made now about vaccinations.
People are saying, look, vaccinated people are ending up in hospital, ergo, the vaccines don’t work. Half of all people in the ICU are vaccinated. So that clearly means the vaccines don’t work. And you’re like, no, because your risk of ending up in the ICU if you’re unvaccinated is orders of magnitude higher than somebody who isn’t. Once you adjust for population size, once you adjust for age, there is a clear benefit to vaccination. We’re seeing more vaccinated people end up in hospitals simply by virtue of the fact that there are more vaccinated people out there. There’s a discrepancy between the vaccinated and unvaccinated because the unvaccinated are over represented in our hospital population. The unvaccinated make up about 10% of the population, but represent about half of all hospitalizations and ICU cases, so they are clearly disproportionately affected there. But if you can’t explain that nuance to people just reporting the raw numbers can lead to a mistaken conclusion.
And so that’s where we have to be really careful when we start talking about hospitalized with COVID or because of COVID, it’s perfectly valid to do so. We just have to frame it in the right context so people understand what the data actually shows.
The last thing I want to get to is what happens next. And you mentioned a few minutes ago that when this variant showed up, there was a lot of discussion of maybe it’s really mild and we can just let everybody get it and then it will be fine and we’ll move on. Obviously, that’s not happening. Obviously, we have to be really concerned about the medical system. But what are the chances, I guess, based on what we’re learning and what we know by now that Omicron will get us back on the path to normalcy simply by exposing everyone for better or for worse? I guess I’m less concerned with should we do it or should we not do it, because I’m pretty sure I know the answer to that. But if it happens, what can the end result be? And is it true that this might be the last major wave?
Whether this is going to be the last wave or not really depends on a number of factors, and I think the biggest one is going to be do new variants emerge from this virus or not? If new variants that are significantly different from the previous variants continue to emerge, then we’re going to have to face the reality that people can get reinfected. And we’ve already seen that that is the case. People have and can get reinfected with Omicron, even if they had previous infections. If new variants continue to emerge, the vaccines will very possibly be less efficacious in preventing illness while probably still providing good protection against severe disease, which is what we’re seeing now.
So a lot of this discussion is going to depend on what happens in the summer. The situation is going to get better, cases will start to come down, the hospitalizations will start to get discharged, and as the weather warms up as people spend more time outdoors, transmissibility will fall, things will improve. And then the question is going to become what’s going to happen in the summer? Are we going to learn from the mistakes of the past and put certain measures in place to plan for future eventualities, or are we going to fall into I think the mistake that a lot of us made in the previous summer, which is to wash our hands of the situation and say, I don’t want to talk about COVID anymore. Let’s almost pretend like it didn’t happen. And let’s quote unquote, get back to normal.
We have to continue the vaccine roll out. Remember, there is a segment of the population ie young children that have not been vaccinated yet. And if we want to have next fall’s school season start on time without any incident, we should probably make sure that that vaccination effort continues. We need to plan for the not unrealistic possibility that as we get into the fall of 2022 and the winter of 2022, that cases might go up again. Because viruses spread more easily in the winter. We can’t be perpetually surprised by this problem and then scramble to find solutions.
We have to create some sort of long term solution to how are we going to handle a surge of cases if we need extra health care staff, not just for COVID, but for all public health emergencies, for all illnesses. When there is strain on the system, we need to have a plan in place. There needs to be some sort of metaphorical glass box somewhere that says break glass in case of emergency, where we can pull out an emergency plan and have steps in place to try to mitigate problems when we have a staffing shortage when there is a spike in an infectious illness, be it COVID, flu or something new down the road. And the other thing is that we have to maintain our effort for sending vaccines to parts of the world where vaccines are not available, because the more we can vaccinate the rest of the world, the less likely it is that new variants will emerge.
So that was a very long winded answer to your question. But the answer is, is this going to be the last wave? Well, it depends what we do. And so when we’re having this conversation six months from now in June, when COVID is very likely going to be better, do we have the discipline to still talk about COVID and resist the temptation to say, I don’t want to talk about COVID anymore. I don’t want to deal with this. I want to get back to my social life. And not neglect all the other stuff that we need to keep doing, even though we’re past the crisis phase of the pandemic.
Dr. Labos, thank you so much for this. I guess we can talk in six months. That’s kind of a goal of mine to not speak to any more epidemiologists in the summertime. But thank you again for helping us see what’s going on so clearly.
My pleasure. Happy to do it.
Dr. Christopher Labos and you can find his podcast, The Body of Evidence wherever you got this one, we’re all in the same place.
That was The Big Story. For more from us, head to the thebigstorypodcast.ca. Find us on Twitter at @TheBigStoryFPN. You can talk to us anytime via email, email@example.com [click here!].
Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.
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