Canada enters critical phase of Covid-19 outbreak (opening up)...how risky is it to go outside?

AboutAnything  | Greg McComb

   It's finally happening. After a two-month pandemic-induced lockdown, Canada is starting to open-up. In time for spring -- parks, garden centres and golf courses are swinging their

United Nations COVID-19 Response

doors (or gates) open, the latter with a long list-of-rules to follow. Golfers don't care; just get me on the course or I'll slit-my-wrists, most say.  My God, even patios are opening in Manitoba, albeit at half-capacity. Can you imagine that?...sipping a beer with a friend in the sunshine.
     
     As discussed in previous blogs, pandemic curves have a reasonably predictable pattern (see graphic): there is an upward surge of cases, a flattening and then a slow come down. During the first two phases, people are quarantined to a prevent surge of coronavirus infections.

United Nations COVID-19 Response

  We did this for two months in Canada, and now we're in the last phase when medical experts think it's safe enough to go outside. In effect, we are testing the waters: we are guinea pigs sticking our heads outside, hoping that infections don't spike. It's critical times...
                               
    In this blog, I will give an update on where we are at with the Covid pandemic in Canada. Next, I will cover best practice to wind-down a pandemic; while the last section will explore the idea of risk, and apply it to our current situation.

                     Canada's Covid-19 pandemic: a tale of two worlds

    One of trends that has solidified in the past month is the fact the coronavirus outbreak in Canada was a tale two worlds. On the one side was all the provinces and territories outside central Canada (see bar graph below): all locked down quickly, and contained the virus or had

Data sources: Public Health Agency of Canada, Ontario and Quebec government reports and databases * Four Toronto-area Public Health Units

minor outbreaks. The Maritimes, Territories and Prairie provinces each had a small number of COVID-19 cases and only a few deaths, 69 combined. Canada's geography helped. We are a big country with isolated cities. Unlike major international centres like London or

Photo by Tonik on Unsplash

Rome -- Winnipeg, Regina, and St. John's, Nfld., are miles from anywhere and have only a sprinkling of viral-laden tourists traveling through. By comparison, British Columbia (146 deaths) and Alberta (128 deaths) had small outbreaks but they were quickly contained. Alberta had dozens of cases at a meat-packing plant in Calgary, and closed it down -- while British Columbia saw an early spike in cases at senior residences, and acted quickly to manage those. That's why these provinces were the first to 'open-up.' British Columbia's golf courses have been open for weeks while Manitoba was the first to open outdoor patios. This makes sense...

    The other world is central Canada: Ontario and Quebec. These provinces didn't do as well. Quebec's story has appeared over-and-over again in the press but it's worth repeating. Early on, numerous outbreaks occurred in

seniors' residences in Montreal, and they quickly got out-of-control. Low-paid part-time nursing aides often abandoned

Photo by Vlad Sargu on Unsplash

residences where there was little or no protective equipment. They in turn became infected and spread the virus throughout the community, as they rotated between homes in order to make a living, often at or below poverty. As aides quit, invalid seniors were often left unattended and so they perished at an alarming rate. Medical officers with the Canadian armed forces were called in. This tragedy was repeated to a lesser extent in Ontario with major outbreaks and subsequent deaths in seniors' homes, the first in early April at a nursing home in Bobcaygeon, Ontario.

   As discussed in an earlier blog,  the reason the coronavirus is so lethal at
 seniors' home is that it specifically targets the elderly. With weaker

Photo by Fusion Medical Animation on Unsplash

 immune systems and other sicknesses, seniors are easy prey for a multi-pronged virus (see graphic) that can easily attach to their cells. Research on this phenomena is in its infancy, but early results show older people have a higher mortality, (see graph to left, 91.4% of  Quebec deaths are people over 70) while

Data source: Quebec government

the younger survive, most with minor symptoms. A small percent of this younger cohort (under 40) contract either Kawasaki disease, a severe inflammatory disease in children under five -- while others experience similar severe symptoms as the elderly, some surviving with lasting issues such as breathing difficulties.

      
   Overall, Quebec and Ontario have been at the heart of Canada's COVID-19 outbreak. Combined the two provinces account for 94% of all the deaths in Canada, 5,909. As of May 20, Quebec had 3,647 COVID-19 deaths while Ontario had 1,919. In an earlier blog, (click here) I suggested Canada was

Data sources: worldometer and Public Health Agency of Canada

a world leader in containing the coronavirus outbreak. This is no longer the case, especially for  Quebec. If Quebec was a country, its Covid-19 deaths per million (427) would be similar to many of the countries with the most severe outbreaks: United States (283); United Kingdom (521) and Italy (532).  Around the world, Quebec's 427 death/million would be ranked as the 7th most severe, behind France (429) while Ontario at 130 deaths/million would be ranked 20th. 

      This tale of two worlds is why Ontario and Quebec 'opened up' later than other provinces. Only last week, Ontario announced it was opening up cottage country, parks, golf courses and garden centres in time for the May long weekend. While Quebec has had an on-and-off-again approach to re-opening.  A few weeks ago, Premier Francois Legault announced the opening of primary schools, however, this stalled when only a handful of students showed up. A few days ago, the Premier toured Montreal admitting the city was a 'hotspot' for Covid-19 outbreak in the province, advising people to wear masks in public.

   Although I have presented a Covid-19 curve for all-of-Canada in previous blogs, the only way to understand outbreak progress now is to present the curves for Quebec and Ontario separately, (see graphs below). In the first one, we can

Data source: Public Health Agency of Canada, author constructed graph

see why Ontario delayed opening up:  its pandemic curve was 'stuck' at the top - the flattening period - for several weeks (horizontal line) due to outbreaks in seniors' homes that spread to the community. I penciled in a downward trend in Ontario's curve that seems to have taken hold in the last ten days. Similarly, Quebec

Data source: Public Health Agency of Canada, author constructed graph

was stuck in the flattening period for several weeks, with deaths ranging between 80 to 120. Only in the last week has there been a reasonably clear sign of a come-down.

    Putting these Covid curves next to each other, you can roughly see how much more severe the outbreak was in Quebec compared to Ontario. Throughout the pandemic, Quebec's 'raw' deaths per day were about double those in Ontario, (left axis) despite the fact Quebec has a much lower population: 8.7 million compared to 14.7 million in Ontario.  

                     What's the best way to wind-down a pandemic?

   I now live in the woodsy 'Outaouais' region of Quebec - nestled in the Gatineau Hills - the north half of Canada's national capital of Ottawa. Hard to describe, you need a map. My house is the black dot. (see map below). We have been lucky to have only a few

Canada's national capital region

Covid deaths, 10 so far.  Much unlike the 'hot spot' of Montreal, only an hour and a half away by car.  As part of our lockdown, Gatineau Mayor Maxime Pedneaud-Jobin closed the border with our sister city of Ottawa, setting up police stops at the five bridges across the Ottawa river.  This infuriated Ottawans, especially those with cottages in the Gatineau Hills they could not get to.   I didn't mind.  Although Ottawa is not a 'hot spot,' (~200 deaths) it's a populous region, and I didn't want these sweaty cottagers touring our streets during the pandemic.  

     So, you're probably wondering where I am going with this.... This anecdote actually demonstrates best risk-practice for a pandemic. An insightful note by world-leading consulting firm McKinsey and Company (click link for report) suggests the best way to  successfully wind-down a pandemic is not just country-by-country, but region-by-region starting with areas with low case numbers and hospitalizations (see page 8).  Then, closely monitor cases as people come-in-closer contact while, for example, getting their haircut or eating at a restaurant. That seems to

Ontario Covid-19 map: Ontario government

be what we're doing in Canada. Provinces with low Covid deaths and cases  (Prairies, Maritimes, B.C., Alberta)  opened first, while Ontario and Quebec - with greater surge risk - are lagging behind. Alberta is taking this approach, (See link) opening up the province in phases, delaying some high-risk openings (bars, barbers, restaurants etc.) in Calgary and Brooks, with localized outbreaks at meat-packing plants. On the other hand, despite the fact Toronto is the centre of the Covid outbreak, Ontario has not signaled a regional phase-in of openings similar to Alberta. The Northwest region (NWR, see map above) with canoe-country in Lake of the Woods has fewer than 50 cases, similar to Manitoba. It

Kwang Mathurosemontri

should probably go first and open up faster. Same thing for regions west of Toronto, all have fewer than 100 cases.  
    
      As for my case, Gatineau's mayor finally lifted the police-checks across the Ottawa river on Monday. Thought the timing was good: our regional lockdown probably prevented some spread of the coronavirus into our clean 'Outaouais' region. I did miss Ottawa though. On the first day, we crossed the bridge on bike to visit our national tulip festival. Every year, the Netherlands sends thousands of tulip bulbs to Canada, a lasting gift for sheltering the Royal family during the Second World War. Didn't want to miss that... I can only imagine what the war-imposed lockdown was like for the Dutch: thousands starved; others executed. We've had it pretty easy...

               A rational discussion about risk: is this possible? 

   As we enter the next phase - the 'opening' - most people are nervous while others are outright scared: "It's too risky to go outside. I might get the virus," they say. It's like walking a tight rope for some. Yet Canadians deal with a base-level risk of death every day when we

Photo by Loic Leray on Unsplash

cross a busy street, drive a car or breath polluted air. In general, people have trouble equating any of these 'probable' deaths to the tragic deaths we've seen or heard about in the emergency rooms or seniors' homes during the pandemic. It's human nature.  During the height of the outbreak, many politicians declared we cannot re-open if there is a risk of "just one more death."  If that was the case, people would be confined to their houses forever....and the economy would crash into a severe long-term depression. Thousands would eventually starve while millions would become impoverished.

  But what is a reasonable amount of risk? I already touched on this issue, citing the McKinsey note that recommends waiting until Covid cases and hospitalizations in a region fall to a manageable level before reopening. Yet, even in this happens, there is still some risk - albeit very small - that people will get infected with the coronavirus. Are they greater or smaller than any of our everyday risks? 
    
  Let's start with the regular flu. As we pass the second month of the Covid outbreak in Canada, we are approaching 6,000 deaths, and we will probably end up with a few thousand more. Early on, we heard from naysayers

Photo by CDC on Unsplash

that fatalities associated with the regular flu (type A and B) were just as bad. This turned out to be very wrong. Health Canada publishes a fact sheet (click here) that says Canada has an average of 3,500 deaths related to the flu every year. This is quite a bit less than the Covid deaths, although the two really can't be compared. Regular flu deaths occur with no quarantines or social distancing. With these measures, flu fatalities would be much lower.  We don't need a lockdown with seasonal flu, though -- we have effective flu vaccines and everyone is taking them. Right? The odd thing is that more than half of Canadians don't get a flu vaccine, (See Health Canada report).  In the 2018-19 flu season, only 42% of Canadian got a vaccine, although 70% of seniors - a higher risk group - got their shot. Even though provinces have offered vaccines free at neighborhood pharmacies, vaccination rates still haven't climbed over 50%. Haven't really figured that one out...surely, that many people can't believe anti-vaxxers. If so, this ill-informed lobby might be throwing off the people's perception of risk associated with vaccines, and hurting the health of Canadian.

  So, let's move on. Going outside means walking around or driving your car. No risk there, eh? Think again.  Although Canada has trended in the right direction, there were still 1,922 deaths caused by car collisions in 2018, according to Transport Canada (click link). This is better than 25 years ago when 3,313

Photo by Michael Jin on Unsplash

people died in car crashes. Major improvements in car safety such as curtain airbags and hard crumple-free car frames have pushed this trend lower. The same can't be said for walking around, pedestrians. As an example, the United States had a 35-year high for pedestrian fatalities in 2019: 6,227, a 41% increase from 2008 (click link). The reasons: people are crossing streets while staring at their smartphones, and getting hit by an ever-increasing number of larger high-impact SUVs. Tip to millennials: look-up when crossing streets!
    
   We have heard numerous news report that air pollution has declined across the world during the pandemic. In India, the skies have cleared as air pollution from

Photo by Patrick Hendry on Unsplash

industry, cars and planes has declined by 60% due a country-wide lockdown. Other reports suggest overall death rates may decline in several countries during the pandemic due, in part, to fewer deaths from air pollution. One of the reasons is that premature deaths from breathing air with pollutants (PM2.5, NO2, O3) from industry, transportation and home heating are estimated to be quite large; likely greater than the lives loss from the Covid outbreak. A rigorous study by Health Canada (2019) (click here for report) estimates those premature deaths from heart disease, stroke and lung cancer at 14,600, well above the current 6,000 pandemic deaths in Canada. Yet we tolerate the former fatalities in Canada because we know it's the price of running a modern economy. We need to drive our cars, heat our homes -- while industry needs fuel to make things we consume and farmers need gas to grow food.  Although we heavily regulate air pollution, we make an implicit risk calculation that the many benefits to society of burning fuel outweigh the costs of those premature deaths.

    To cap off this section, people generally know about and accept the many risks we experience when we go outside. Subconsciously or not, we know there is a chance of premature death, but we do it anyway. To most, the 'bad risk' is outweighed by the benefits of getting somewhere quicker in a car, walking downtown with friends or heating your home with energy from a polluted source: oil, gas or coal. Not sure we can say the same about the risk associated with the coronavirus. It's my read that 'pandemic hysteria' clouds people's risk in a similar way the anti-vaxxers have warned us off vaccines.  In regions with low Covid numbers, some people think they are walking a tight-rope when they are actually walking across a pretty safe, ordinary bridge. Hopefully, saner minds will prevail in the months to come, and the damage to the economy from the lockdown will be reduced. That will be the topic of my next blog...

 
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