Better Late than Never? Or is it Already too Late?

 

Triage

Better Late than Never? Or is it Already Too Late? 

The time for decisiveness was last May, but it's better late than never. Or maybe it's too late already. In the early stages it would have been possible to limit the spread by identifying and isolating the sources –people who were bringing the virus in from abroad and all those they may have infected. They only way do that would have been through isolating and testing everyone coming in from abroad, and anyone an infected traveller may have infected. But since testing was only done on those displaying symptoms, it is likely that community spread –a euphemism for we don't know where the hell they caught it-- occurred because of asymptomatic carriers who went undetected.

A decision to test only symptomatic individuals meant that contact tracing was only being done on symptomatic carriers who tested positive –a measure that, while it identified ever-growing numbers of symptomatic carriers, failed to stop community spread. Instead of putting more resources into universal testing, and into contact tracing of all positive cases, citizens were told not to clog up the system by getting tested if they were asymptomatic. Wastewater testing would also have helped stop the spread by identifying where community spread was occurring and testing and isolating all symptomatic, pre-symptomatic and asymptomatic carriers. That wasn't done either. Instead “community spread” was added to travel, close- contact, and outbreaks as an additional possible source of infection.

Our governments were very slow to acknowledge what is probably the primary source of infection –airborne transmission. Indoor airborne transmission can infect hundreds of people who spend fifteen minutes or more within a poorly ventilated space, even after the source spreader has left the premises. Unlike larger droplets presumed to travel only six feet or less before they drop to the ground, microscopic droplets can and do float in the air for a considerable period of time, and can be spread around the room by fans or air currents. Inhaling enough of them will infect people who spend a prolonged period of time in such a space. Plexiglas barriers or the use of sanitizers on surfaces do nothing to prevent this form of transmission. This form of transmission is often referred to as a “super-spreader event" –the kind of event that occurred on the Diamond Princess, in meat-packing plants, in prisons, and the over-crowded living-quarters on produce farms where migrant workers were generally housed. Despite the late acknowledgement of this form of transmission, to date it hasn't spawned many new protocols or restrictions regarding workplace gatherings.

By September the impact the virus was having on the economy eclipsed concerns about public health. Schools and most businesses were reopened, albeit with some COVID safety protocols in place. Daily self-assessment guidelines, masks, work-from-home-when-possible recommendations, the formation of bubbles and cohorts to limit the opportunities for spread, plexiglass barriers, sanitizing protocols, outdoor-only dining at restaurants, curbside pickup at stores, closed land borders, limits on the size of public gatherings and on social interactions were deemed to be adequate, not to stop the spread, but to at least limit it to levels considered to be within the capacity of our healthcare system to handle. Whenever the rate of spread seemed to be low enough to be manageable for the healthcare system, restrictions were eased; when it didn't, restrictions were tightened. The strategy was/is to manage these dual objectives of not exceeding the speed limit, but not driving under the speed limit either, the former to protect public health, the latter to protect economic interests.

Yet the government seems to exaggerate  the dangers of some forms of transmission while downplaying the dangers of others. This has undermined public confidence in government recommendations,  and consequently resulted in resistance and non-compliance with such restrictions.. For instance there is very little evidence to support that fomite transmission (transmission through contaminated surfaces), or outdoor transmission through close contact  play a major role in transmission, and a great deal of evidence suggesting much of the transmission takes place in enclosed work-spaces. Yet there are vigorous protocols about sanitizing surfaces and, more recently, prohibitions against outdoor gatherings of more than five people, while work places, and until recently, schools remained open. It would be easier to attribute and accept the exaggerations of some dangers to an overabundance of caution if the government wasn't simultaneously downplaying the very real and much greater dangers of airborne and workplace transmissions. It seems more than coincidental that the former restricts the freedom of individual's social activities, while the downplaying of airborne transmission favours economic interests. Are these distinctions really being made solely on the basis of protecting public health? Or are they based primarily economic and  political considerations? 

In practice it soon became apparent that the interests of public freedom and economic interests were two very different things. There was and is much greater reluctance on the part of government to place restrictions on businesses than on family and social interactions. Protocols around family bubbles, visits with LTC residents, attending church and other social gatherings, etc. are subject to far more restrictions work-places --factories, stores, schools, etc.  While family bubbles were reduced, first to  to eight and now to five, 'essential workers' are routinely exposed to hundreds of people --coworkers, customers and contractors--on a daily basis. While the level of risk of exposure in family and social gatherings is no greater than in a work-place gatherings of similar numbers, the former are being restricted to far lower numbers than the latter. Granted, some businesses are indeed essential because they provide essential goods and services, but restaurants, hair salons, manicurists, many big box stores, gymnasiums, and the like clearly are not. 

This double standard is especially apparent in the reopening of schools. In addition to other things, the reopening of the schools was essential for the resumption of a great deal of economic activity. Even the relatively privileged work-from-home minority found it difficult to work from home while overseeing their children's online education. But perhaps more significantly, decision-makers realized that in the absence of universal daycare the largest segment of the workforce --low-income service sector 'essential workers'--could only return to work if their children were being looked after --i.e. if the schools reopened. The resumption of a supply of cheap labour for 'essential services' in the service sector industries was therefore contingent on the reopening of the schools. Denying workers in these industries paid sick leave or CERB benefits by themselves were  not enough for workers to go back to work if they didn't have anyone to look after their school-aged children. Only some form of government-paid daycare --i.e. schools-- would enable them to go back to work. In other words, by ensuring that low income parents didn't have the financial where-with-all to refuse work in in workplaces that both their employers and the government deemed to be safe, because they would be relieved of their childcare duties by the reopened schools which were also deemed to be safe, regardless of whether or not the parents/workers, school teachers and staff felt they were safe. Like the option of working from home, the option of keeping their children safely at home through online-learning was not available for less privileged service sector workers. .

 

We've seen that when compliance with protocols regarding the reopening of schools were deemed to be unpractical –too expensive to implement—they were usually either relaxed or waived completely. For instance, it was soon decided that children displaying only one symptom presented no threat and could safely continue to attend classes (and their parents continue to work); reducing class-sizes too was impractical, so, far from allowing for social distancing by increasing the number of classrooms and employing more teachers, classes were instead combined. (Online learning by children of work-from-home parents reduced the number of students physically attending classes, so combining classes would free up teachers for online instruction); similarly, social distancing and cohorting on school buses was deemed unpractical (it would have required many more buses and many more drivers, neither of which were in the budget), so school buses were allowed to continue to operate at full capacity (72 children/bus), intermingling students from dozens of family bubbles with classroom cohorts of at least fourteen grades (junior kindergarten to grade twelve), in many cases attending six or more different schools. This effectively undid all the efforts schools were making at cohorting within the schools, because in practice even the children of parents who diligently drove their children to and from school were intermingling with classmates who rode the bus, and were therefor indirectly exposed to every other cohort and family bubble travelling by bus. 

When these watered-down measures proved to be  inadequate in the face of continued exponential spread, and students, teachers and other 'essential workers' were once again ordered to stay at home, rather than providing workers/parents with paid sick leave or CERB benefits, governments usually opted to pay employers to keep their laid-off employees on the payroll. This ensured that employees would remain dependent on and return to their low-paying jobs once restrictions were lifted, thus  preserving the pecking order and leaving the decision-making power in the hands of their employers. Albeit the recovery of an economy that favoured employers over workers; an economy thathad left PSWs, LTC residents, homeless people, low-paid 'essential workers', indigenous peoples, people of colour, prisoners, people living in shelters, etc. extremely vulnerable, economic recovery was based on restoring the pre-COVID socioeconomic order, complete with all its injustices, deficiencies and inequities. 

 

But by year's end vaccines had already become available. Salvation was at hand! Immunity would soon allow things to go back to the pre-COVID normal. The pressure to act was off! 

Well, not quite yet. It was obvious that existing measures had proven to be inadequate to prevent thousands of more deaths and the overwhelming of the healthcare system. Infection rates and COVID deaths were quickly spiralling completely out of control. Clearly more had to be done. But the economy could probably still recover from one more short stop-gap measure if restrictions were lifted after a few months once herd immunity had been achieved. More economic aid would be made available to help businesses weather new additional restrictions; restrictions that were necessary to mitigate the ever rising death toll. The authorities tell us that the dual objectives of economic recovery and protecting public health can both be accomplished without forfeiting the one for the sake of the other.

But now here we are in mid-January. Despite the new restrictions the healthcare system the healthcare system, as predicted by healthcare professionals, is completely overwhelmed.  Refrigerator trucks are parked outside city morgues, tents are being erected to accommodate ICU beds, and critically ill patients are being shipped to other cities where they can be attended. And after much of the country has decided to administer only the first dose of the Pfizer vaccine to as many people as possible, and wait until beyond the prescribed three weeks recommended by Pfizer to administer the second dose once the second Pfizer shipment arrives in January, Pfizer tells us that there will be delays in the arrival of the second shipment  because they are expanding their plant in Belgium, which is of greater importance to Pfizer than fulfilling their contractual obligations to Canada. In any case, they are probably not liable for the outcome, given that much of Canada, contrary to Pfizer recommendations, had itself unilaterally decided to delay the administration of the second dose.

And, as if all that weren't enough, the already exponential growth in the rate of transmission of the virus is likely to increase astronomically. Various new mutations of the virus, some of which are as much as seventy times more contagious than the original, are now on the loose in Canada. In some cases the sources can't be traced to international travel, indicating that there is already community spread of these new more virulent mutants. The extent of the spread of these new variants is unknown due to a lack of systematic testing, but given their incredibly high rate of spread they will soon replace the original as the dominant forms of the virus here in Canada as it has already done elsewhere. 

These mutant viruses are not something that were unexpected by the scientific community; on the contrary, many of these variants  were not only anticipated; many of them had already been sequenced by scientists  before they even appeared in the natural world. Nevertheless the political decision-makers here in Canada failed to make any plans for such a contingency. Relatively little testing of any sort is being done here in Canada, and most of the little that is being done isn't designed to distinguish between the different variants of the virus, of which there are several, including variants of variants –something scientists with the expertise and funding anticipated, and were on the lookout for even before they actually occurred. The UK, South African and Brazilian variants (the latter first detected in Japan), are all far more contagious than the original.

The good news is that: 1.) none of the new variants so far discovered are more deadly than the original, and 2.) none of the variants so far discovered are necessarily able to get around existing vaccines, although the jury is still out on this latter point. One study, yet to be peer reviewed, has resulted in this ominous warning:

Ravi Gupta, professor of microbiology at the University of Cambridge, said it is this mutation—and not the much-covered British variant—that is "the most worrying of all".

Although research into the new variant is limited, a Brazilian study this month looked at a patient who had recovered from COVID-19 only to become reinfected with the new, mutated strain.

The paper has yet to be peer-reviewed, but the authors found that the E484K mutation could be "associated with escape from neutralising antibodies"—meaning it could bypass the body's natural defence memory that bestows immunity.

As countries accelerate their vaccination programmes, there is concern that the new mutation may render certain vaccines less effective...

In particular, one mutation, known as E484K, detected initially in South Africa and on subsequent variants in Brazil and Japan, has raised alarm among researchers.

"The E484K mutation has been shown to reduce antibody recognition. "As such, it helps the virus SARS-CoV-2 to bypass immune protection provided by prior infection or vaccination," Balloux said.

--Medical Press, New virus mutation raises vaccine questions

A worst-case scenario would be that a new dominant  vaccine-resistant virus evolves  before we can even immunize everyone against the original. That would put us back in square one, necessitating the development of yet another vaccine. Let's hope that doesn't happen, but let's prudently plan for that contingency. 

All this to say that to assume that all this will be over in a few short months may be the greatest failure yet. Last May was the ideal time for decisive leadership, but perhaps it is still better late than never. Time is of the essence. Even those who prioritize the health of the economy over public health must now acknowledge that all political and economic concerns will not and cannot be addressed until this virus and all of its variants are under control. Therefore economic interests must back off for now, and let the scientific and medical experts take the lead and do all the decision-making. The economy will not recover until this pandemic is brought under control. Extreme measures, including much stricter lock-downs,  including lock-downs of most work-places, are required. Large scale universal testing of all citizens, asymptomatic, pre-symptomatic and symptomatic alike, must begin immediately. Laboratories must be beefed up to be able to process millions of tests in a timely manner. Contact tracing capability must be to be able to trace all contacts of every single positive test result within two or three days of testing. Wastewater testing, which can not only identify the rate of community spread, but also the different variants of the virus responsible for that spread, needs to be done in every single wastewater treatment plant in the country. The time for waffling is long past. Decisive action based on the recommendations of our most competent science-based decision-makers must be implemented without delay. Anything less is criminal negligence.

Or, if it is already too late, and I believe it is, those of us who will survive this pandemic –the majority of us—should begin planning a new, post pandemic, hopefully more just, equitable and more sustainable economy; an economy not concerned about perpetual economic growth, but rather one in which we all can thrive and flourish; a world in which human activity does not consume natural resources more quickly than the ecosystem can regenerate them for the sustenance of all life form and of future generations; a world in which the distribution of resources does not leave some people much more vulnerable than others in the event of the next global pandemic, climate change, or some other catastrophic event. A world in which we have learned from, and will not repeat the mistakes of the  past.