Front Burner - When will this end?

Episode Date: April 24, 2020

Life began returning to German streets this week as the country took small steps to slowly re-open the economy. New Zealand is set to follow suit by bringing back businesses and school for young children next week. Here in Canada, Saskatchewan Premier Scott Moe has announced plans to reopen his province in five stages starting in May, and many other political leaders are starting to talk about how and when strict COVID-19 restrictions might be phased out. Today we’re asking about what benchmarks need to be hit for Canada to re-open, with help from Jeremy Konyndyk, Senior Policy Fellow at the Centre for Global Development, and Dr. Michael Gardam, an infectious disease specialist and chief of staff at Humber River Hospital.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hello, I'm Jamie Poisson. A sight not seen for many weeks in the North German city of Hanover. The streets beginning to fill, some shops smaller than 800 square metres gradually reopening. So life began returning to the streets of Europe's largest economy this week, as Germany took some tentative first steps towards easing strict COVID-19 restrictions,

allowing smaller shops to open and some students to sit for exams. And it's not the only place. New Zealand is moving to reopen its economy next week, bringing back businesses and school for young children. We have done what very few countries have been able to do. We have stopped a wave of devastation. Here in Canada, Saskatchewan Premier Scott Moe has announced plans to reopen his province in five stages starting in May. And after weeks of social isolation, many of the provinces are starting to have real

public conversations about the way out here. So today, we're starting with how exactly the lockdowns could end and ending with how prepared we are in Canada to do this. Jeremy Kanondyke is a Senior Policy Fellow at the Center for Global Development and the former Director of the USAID's Office of Foreign Disaster Assistance. He joins me now from just outside Washington, D.C. This is FrontBurner. Hi, Jeremy. It's so nice to have you on the podcast.

My pleasure. Thank you. So look, a lot of Canadians here are pretty desperate to get back to a more normal way of life. For many, many people, they want to get back to work, to their businesses. I know this isn't like ripping off a Band-Aid. We have to just ease into it at the right time. So I want to ask you today, where do we begin? What's step one when it comes to opening society back up again? Well, I think step one is to begin getting case counts back down to a manageable level so that we have a starting point that is relatively safer.

The higher the volume of cases when you begin reopening, the higher the volume of potential spread if things start going wrong. So I think it's both that question of trajectory. Trajectory is important, but also absolute level is important. And what does that level look like to you? The level will vary depending on the size and the capacity of the community that you're talking about. But with test positivity, I think you probably want to see that level of positive tests be not much more than low single digits, ideally not more than 1% or 2%. I think one of the things to watch is just when do you pass, again, below the levels of cases that triggered the lockdowns in the first place. cases that triggered the lockdowns in the first place. So I think what that tells you is that,

you know, until the level of cases gets to a low absolute level, then the risk of a flare-up once those measures are relaxed is quite high. And then once you have that sustained decline and things are at a low level, then it is safe to begin relaxing some of the measures and seeing what happens. And I think it needs to be an incremental process of relax a little bit, see what happens, adjust, relax a little bit more, see what happens and adjust. So let's assume a city, a province, a state sort of gets to that level where they're comfortable with the reduction in cases, what kind of measures would need to be put in place to manage that, essentially? I know you mentioned testing and contact tracing, but let's do testing first.

Sure. You know, what you need basically is an ability to fight the virus with something beyond a shelter-in-place order. So what that looks like is probably a combination of a more robust disease surveillance system so that you can recognize much earlier if cases are beginning to tick upwards again. That was a big vulnerability in the U.S. and I think really in much of the world. You know, you want a surveillance system a bit like we have, say, with hurricanes. You know, we don't begin reacting and preparing for a hurricane once it is lapping, you know, the waves are lapping at the shore. No, we see it coming out when there's still time to prepare and get some measures in place. And so we can do the same by building sophisticated disease surveillance systems. And that is an important early measure. Testing is a part of that. And testing needs to be scaled up to a level that anyone who needs to test can get it.

And testing needs to be scaled up to a level that anyone who needs to test can get it. That is going to be difficult. And so part of that is continuing to scale testing. But part of that, too, is getting the case counts down to a low enough level where within the volume of testing that you have available that you can realistically test all or almost everyone who needs it. And I would want to see areas that are able to have widespread on-demand testing and that with widespread on-demand testing, the positive rate for the people who are being tested is probably somewhere around one or two percent. Because that gives you a pretty good idea that you're testing widely, so you're getting a good picture of what the virus is doing,

and simultaneously, that the virus is transmitting only at a pretty low level. And that's, you know, that's what South Korea has been able to achieve. That testing then needs to feed into a contact tracing and quarantine and isolation process. Right. So talk to me about that. Yeah. And that's really bread and butter public health. The basic idea is you find a positive case, you identify all of their close contacts. And we do know this disease mostly tends to target close contact. It targets people who have had a sustained proximity to an infected person. And that's predominantly people in the household. It can also be people in the workplace or if you're at a large public event. And so you identify who those high-risk contacts are. You contact those people. You get in touch with them. Advise them

that they need to quarantine for a period of two weeks. Now, if they have indeed been exposed, it is too late to prevent them from getting it. But what you can do through the quarantine is you prevent that cluster, kind of that circle of contacts around the infected person from creating a second generation of transmission onward. So if you can get to all of those people within about two days of identifying the case, then most of them will have been reached before they are out of their incubation period and before they have had much of an opportunity to transmit it to others. And so through that, you repeat that cycle enough times and you can begin really crushing the chains of transmission. But that takes a lot of manpower and womanpower. I mean, that's a big workforce burden. That's exactly what I was just going to say, right? This sounds like it takes a lot.

It does. And I think we just need to accept that that's going to take a lot of effort and a lot of investment. In the city of Wuhan, it's been reported that they had about 9,000 people doing this during their outbreak. So it begins to give you a sense of scale. In the city of Wuhan, it's been reported that they had about 9,000 people doing this during their outbreak. So, you know, it gives you, it begins to give you a sense of scale. There's been another estimate out of, I think it was out of Johns Hopkins in the United States, that about 100, we would need about 100,000 people doing this across the United States. I think that's the order of magnitude we need to be thinking on. Right. I know some countries are talking about volunteers, and then there's obviously another conversation going on about using technology to try and help beef up this contact tracing, including cell phone data, right?

Yeah, and that can be a help. I think there is some suspicion about what powers are you giving to the federal government if they're allowed to begin collecting that kind of data. And I think there's some concerns about that that will need to be addressed. But the important thing is that is an assist to the people, but you still need the people. Okay, so we have a reduction in transmission, you know, widespread testing so that you're only getting about 1% positive, really aggressive contact tracing, and then isolation. You know, another hurdle that a lot of countries have come up against is a lack of protective equipment. And so what do we need to make sure that we put in place for our hospitals to make sure that they're protected, our health care system? That's right. Yeah, I would say two big areas need further protections.

One is the hospital system, and the other is high-risk facilities and high-risk populations. Obviously, we've seen how this overwhelms hospitals, but we've also seen both in the U.S. and in Canada that this disease can absolutely ravage through elder care facilities, prisons, detention centers, and other places like that. There will be a lot of emphasis needed on improving protections, improving sanitation, and reducing the risk of infection in those kinds of facilities because those are going to be at risk of being hot spots for the next two to three years until there is a vaccine widely available. And so we need a lot more protection focus there. And we need to expand surge capability in the health care system too. So if we're looking at a two to three year period of playing whack-a-mole with this virus,

there will be times when we miss. And so there will be flare-ups. And the hospital system needs to be ready to contend with those kind of flare-ups if an outbreak, a kind of a localized hotspot does begin to get out of control. Okay. Jeremy, can I thank you so much? My pleasure. Thank you. In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections.

So just to recap here, when we're thinking about whether parts of Canada should open back up again, here are the benchmarks. This is what experts say we need to hit. You need to have the infection under control with a sustained reduction of cases. You need widespread testing, aggressive contact tracing, and measures to quarantine or isolate new cases. Next, you need preparedness at hospitals and systems of protection for vulnerable populations like long-term care homes. And finally, you want to be able to roll it out with targeted openings in phases. So let's use those markers to see how prepared we are here in Canada with help from Dr. Michael Gardam.

He's an infectious disease specialist and chief of staff at Humber River Hospital in Toronto. Hi, Michael. Thank you so much for making the time to speak with me today. Thanks for having me. I'm hoping you can help us understand today how close Canada is to meeting these benchmarks I spoke about with Jeremy. So, let's start first with a sustained reduction in cases. And I know this differs from province to province, but generally, how are we doing here? Well, yeah, and I think that's actually the real key is that it has to be staged because

different provinces are definitely in different places right now. And so, you know, if you look at the provinces which have actually seen reductions in cases, you know, several have. New Brunswick has, Saskatchewan has, Manitoba has, BC is pretty flat, like they haven't changed all that much, and Ontario and Quebec are still going up. So you can see, you know, as of today, some provinces should be thinking about opening long before other provinces do. Because of the tremendous effort of Saskatchewan people and the success that we have had in reducing the spread, I think we can begin to provide a bit of optimism and a roadmap for businesses and services to gradually reopen. And so if we look at a province like Saskatchewan, for example, Premier Scott Moe

is announcing a plan essentially to reopen the economy in five phases. And when we look at the cases that they have 90% below the national average, 70% fewer cases total in the province and per capita Canadian average, do you feel good about where Saskatchewan is when we're talking about levels of transmission? Yeah, I really do. I think Saskatchewan is when we're talking about levels of transmission? Yeah, I really do. I think Saskatchewan has done very well. And they've also done a lot of testing per capita, which I think is excellent. The other advantage that Saskatchewan has over, say, Ontario is that its cities are much, much smaller. And they have much less population density. And so all of that makes it easier to control.

So if you're in a more rural province, this is going to be easier for you. Sort of built-in social distancing. So you mentioned Saskatchewan and testing that they've done fairly well there. Let's move on to testing, which is another benchmark here. I know that we collaborate across Canada with provincial territorial laboratories, and that the capacity right now can increase to triple that amount, essentially, to close to 60,000. And we need the whole system to be working and people being tested. But there are... And so how are we doing when it comes to our testing capacity? there are. And so how are we doing when it comes to our testing capacity? Not great. And again,

different provinces are different. So Alberta leads the pack. Well, actually, the Northwest Territories leads the pack, but they have a very small population. But in terms of testing per population, Alberta is number one, followed by Nova Scotia and Saskatchewan. Ontario is right at the bottom of the list, last only to Nunavut. So there are clearly big differences in testing. And so again, for example, if Ontario or Quebec want to open up, not only do they have to see their rates dropping substantially, which is probably a few weeks away, largely due, I think, to the outbreaks in long-term care facilities, but they also need to see dramatically increased testing. Now, Quebec has done considerably more testing than Ontario, but both of them will need to ramp

that up because, as your previous guest mentioned, you need to have a system whereby it's easy for someone to get tested, and then you do the follow-up if they're positive. And so, several provinces are not there yet. What's your sense of whether Ontario and Quebec can get there in a reasonable amount of time? Are they making progress here? You know, it's actually not that hard to increase the testing capacity. All it requires is to buy whatever platform you're using and then getting the test kits. There has been some difficulty with supply for some of these platforms, but not all of them. So even at my hospital, I mean, we're looking at dramatically increasing our testing capacity over the next

week or so. And it seems to be fairly easy for us to do that. It just requires money. The harder part is the contact tracing. And that's one, as your previous guest mentioned, you've got to have a gazillion people on the ground who can follow up every one of these positives and then hunt down their contacts and then isolate their contacts. That's incredibly labor intensive. And that's the part that I think we're going to fall down on more so than the actual testing itself. Okay, what's your sense of what kind of preparations have been underway to get a system for contact tracing in place?

I know 36,000 people have applied to volunteer to do this, but it's not clear how many are doing it yet, where they're doing it. Yeah, I mean, I know for the City of Toronto, I mean, Toronto Public Health are working around the clock trying to do contact tracing, and they're overwhelmed. I mean, we don't normally do this level of contact tracing, right? So, this is something far beyond what most health units are able to do, and we're not talking about sustaining something for three weeks. We're talking about sustaining it for well over a year. And so, you know, this is why the call has gone out for, you know, new hires and that sort of

thing. And also the call has gone out for, do we look at technological ways of doing initial contact tracing, such as cell phone proximity and things like that, which other countries have done. You know, I haven't heard Canada picking up on that, but I wonder if it could be something we should at least be trying out. Do you worry that, you know, we could get infection levels down considerably because of all these social distancing measures, and then we could ramp up our testing because that is something that we've been working on and then just completely fall down on the benchmark of contact tracing. Yeah, I mean, we could. I mean, I think we could be heavily reliant upon people doing the right thing, right? So, we could say, hey, you know, Michael, you're positive. Anybody you've been in close contact with, you might give them a call and tell them to stay home for 14 days, like something like that.

You wonder, you know, whether we're going to be asking people to do a little bit of their own contact tracing. Typically, public health needs to do it themselves because they need to prove that, you know, things are actually happening. But I do worry that we won't have the capacity to do that. And we may have to come up with some sort of hybrid model. We have managed to avoid a big surge of cases in the hospitals. But the big tragedy playing out here is in our long-term care facilities, particularly in Ontario and Quebec. The next benchmark that we talked about with Jeremy was protecting vulnerable populations. And so I would be interested to hear your perspective here on how we're measuring up. I mean, the military has now been called in.

Right now, it's a mess, obviously. And I mean, sadly, it's been a mess for a long time, right? This is just, we've now kind of been caught. Now, what I've been witnessing here, and I've been involved in some of these outbreaks here in Toronto, is that when you do bring the right control measures in, you can definitely control it. I mean, we have outbreaks every winter of flu and metapneumovirus and RSV and all sorts of other viruses, which spread the same way that this virus does. And we are able to control them once we put the control measures in place, but we kind of wait for the badness to happen and then we try to deal with it rather than prevent the badness.

Right. It's not that this is hard to understand or hard to implement. It's just that typically it requires money and people to actually ensure that you have the right things in place. Right. And it feels like we're just moving on that now, right? And throwing the military at this. Prime Minister Justin Trudeau said today is not a long-term solution here. It's not acceptable. The military should not be going into these homes. In Canada, we shouldn't have soldiers taking care of seniors. Going forward, in the weeks and months to come, we will all have to ask tough questions about how it came to this.

We will all have to do more to get through this terrible situation. Does this worry you about our ability to sort of open back up? In terms of opening up today, absolutely. In terms of opening up a month from now, we'll be in much better shape a month from now. Right. You hear Francois Lecoq kind of walking back now on some of what he was saying earlier about opening back up. Now he's saying, wait a second, wait a second. We have to get this under control. Of course, we still need some time to be sure that the pandemic is under control before reopening the economy and the schools. We have to do that gradually with the okay of Dr. Arruda. And as soon as... The last benchmark that I talked about, Jeremy, was around equipment, PPE at the hospitals and at these

more vulnerable facilities. I do note that two planes came back from China this week empty. They were supposed to pick up medical supplies. How do you think we're doing when it comes to stockpiling? Yeah, this is a topic that really, to be blunt, really annoys me. You know, I've been involved preparing for things like this since SARS when I first started my career. And at the end of SARS, one of the recommendations was to have stockpiles. The U.S. started hanging on to their medical supplies because they were worried. You fast forward to 2009, U.S. did the same thing. During the Ebola crisis, it was hard to get some forms of PPE because the Americans were hanging on to it again. Like, do you sense a trend here?

Like, honestly, this is now the fourth time in my career where there's been an emergency and concerns about PPE come up. And the solution was always to create a large stockpile. And it turns out that that never really existed. What we had were supposedly good supply chains. But that's irrelevant if you're in a worldwide emergency. People just don't follow the agreements. And so, you know, if there was one thing I would say that absolutely has to come out of this is a, you know, not only a stockpile, but actual domestic suppliers. domestic suppliers. Taking your point that this has been a disaster, do you think that we're getting to where we need to be to have the equipment that we need to start opening back up and to make sure that the people that work in these facilities and the people treated in these facilities are protected? It's better than it was a month ago. I am by no means comfortable to think that if we opened up too much, let's say in June,

cases started to get away on us and we ended up having a second surge, I could see us right back in the situation we were in a month ago where we were telling people they had one mask for the day. Okay. You just mentioned June. I mean, Scott Moe, Premier of Saskatchewan, is talking about the beginning of May. A bunch of other premiers are talking about sort of mid-end of May, sometime in May. Ontario, BC, Manitoba. Given all that we've talked about, how realistic do you think that is? I'd be willing to say end of May-ish. You know, whether it's the end of May or whether it's June, I do see, you know, the beginning of the summer at a time when we start to open up. But I mean, it is going to be very staged because you need to follow it for a while to see if you're getting any increase in cases with all of the increased testing that you're doing. And as I keep reminding people here at my own hospital, like we're not there yet. We all need the world to open up. We just have to do it safely. Okay, Dr. Gardam, thank you so much for this conversation. Thank you. All right, so before we go today, I want to tell you a little bit more about Saskatchewan's plan

to open back up again. What comes first, for example? This is according to Scott Moe's five phase plan. So May 4th, they're looking at optometry, dentistry clinics, physio, golf, as long as you socially distance, and parks. Gatherings will still be limited to 10 people. Two weeks later, May 19, clothing stores, electronic stores, we may see things like hairdressers opening up, but physical distancing will still be required. And so maybe your hairdresser is going to have to be wearing a mask. Again, gatherings will be limited to 10 people. Then you move to phase three, and there's no timing on this yet. We're looking at bars and restaurants at 50% capacity,

childcare and gyms could open up around this time too. Phase four, no timeline on this either, but things like casinos and playgrounds. And then phase five, we're looking at restrictions on travel being lifted and mandatory quarantine, stuff like that. So we're going to keep on travel being lifted and mandatory quarantine, stuff like that. So we're going to keep a really close eye on this story and we'll keep you posted as things develop. That is all for this week, though. Frontburner comes to you from CBC News and CBC Podcasts. The show is produced this week by Mark Apollonio, Imogen Burchard, Elaine Chow, Shannon Higgins, Ali Janes, Nahayat Tzush, and Ebian Abdigir. Derek VanderWijk does

our sound design with help this week from Matt Cameron. Our music is by Joseph Shabison of Boombox Sound. The executive producer of Frontburner is Nick McCabe-Locos, and I'm Jamie Poisson. Thanks so much for listening. We'll be back on Monday, and we'll talk to you then.