André Picard is a health columnist for The Globe and Mail. His new book Neglected No More: The Urgent Need to Improve the Lives of Canada’s Elders in the Wake of a Pandemic will be published in March.
This is the way the pandemic ends: Not with a bang, but a whimper.
Apologies to T.S. Eliot aside, the most likely scenario in the coming months is not world-ending catastrophe, but something more banal: More and more people getting vaccinated, followed by a gradual easing of public health restrictions, a rising tide of indifference and a petering out of one of the worst threats to global health the world has seen in a century.
“There won’t be a V-day where everyone runs into the streets and hugs,” said Ashleigh Tuite, an infectious disease epidemiologist and assistant professor at the Dalla Lana School of Public Health of the University of Toronto. “Just a gradual return to normal, but not normal-normal.”
Casual hugs, public celebrations and other indiscriminate mingling are still a long ways off. Masks, physical distancing, limits on gatherings and travel restrictions will be with us for the foreseeable future.
History tells us that pandemics don’t have Hollywood endings. The denouement tends to be slow and messy and COVID-19 will certainly be no exception.
The two big unknowns are the willingness of the public to get their shots, and the durability of immunity.
A lot will depend on how quickly we can get vaccines into people’s arms – and Canada doesn’t appear to be acting with much urgency on that count. Some provinces, such as Ontario, stopped or slowed the vaccine rollout during the holiday period, and some also held back stock to save it for second doses. Both policies have been reversed.
“The vaccine has given people a lot of hope,” Dr. Tuite said. “But whether we will reach herd immunity is still an open question. And if there’s a hiccup with the vaccines, all bets are off.”
Initially, it was estimated that 60 per cent to 70 per cent of the population would need to be vaccinated to make it difficult for the coronavirus to continue spreading – that elusive target called herd immunity. Now, because of more infectious variants, scientists are saying the target needs to be in the 80 per cent to 90 per cent range – which would be unprecedented with an adult vaccine.
Despite their loud, social-media-amplified voices, few people are actually anti-vaccination, and those who have doubts tend to become less hesitant as they see their peers roll up their sleeves. But there are many structural hurdles.
“The systems we have are designed to vaccinate kids. Getting beyond 50 to 60 per cent of adults will be really, really hard,” said Noni MacDonald, a professor of pediatrics at Dalhousie University in Halifax and vaccinologist who has worked for decades in global health.
The numerous challenges, she said, include vaccine hesitancy, hard-to-reach populations, weak public health infrastructure and the fact that, so far, the vaccines approved in Canada require ultracold storage (the Pfizer vaccine is stored at minus 70 C and the Moderna one at minus 20 C, and both must be used quickly after being thawed). Each of the existing vaccines also requires two shots to be fully effective. The third coronavirus vaccine to hit the market could resolve some of the daunting logistics problems as it can be stored in refrigerators already used for vaccines and may even require only one shot. Canada has ordered 20 million doses from AstraZeneca, but the vaccine has not yet received regulatory approval in Canada.
“We’ve only just begun to vaccinate and it will just get harder,” Dr. MacDonald said. “And, of course, the last mile will be the hardest mile.”
That’s just distribution. The immunology part of the puzzle is just as rife with potential complications.
Among those who are inoculated, the big question is: Will they be protected from infection for life – or at least for a few years? Similarly, are those who were infected by coronavirus at risk of reinfection? No one knows, and the only way to really answer those questions is with time and surveillance. It doesn’t feel like we have a lot of the former, and we’ve not done particularly well at the latter.
We’re all anxious to put 2020, the annus horribilis suprema, behind us. But the reality is that we’ve reached, at best, the halfway point of the pandemic. Not to mention that the collateral damage – everything from lingering mental-health wounds to staggering public debt – will be felt for years to come.
“In my experience with regional epidemics, one of the most important lessons I’ve learned is they always last longer than we think,” said Joanne Liu, a Canadian pediatric emergency physician and former international president of Médecins sans frontières.
“Infectious diseases are humbling at the best of times but what really matters in epidemics, or a pandemic, is the human factor, and no one can predict how people will behave in the coming months,” Dr. Liu said.
We can model different scenarios – how infections, hospitalizations and deaths will evolve over time. But we can’t model human behaviour. It’s the wild card in every prediction and plan.
What we do know is that a good chunk of the public seems to be getting sick and tired of restrictions – eager to return to work in the office, to go to the movies and to resume Tinder dating, while others want stricter rules, at least in the short term. Perhaps “more divided about the necessity of lockdowns” is a better way to put it.
Yet, when it comes to COVID-19, the lessons delivered time and time again have been: Impatience can be deadly. So, too, can hesitating to act.
To date, there have been more than 82 million infections in the world, and roughly 1.8 million deaths.
Canada is closing in on 600,000 cases and COVID-19 has claimed more than 15,000 lives here, making it the third leading cause of death in 2020.
By all appearances, the carnage is going to continue through the winter, whether vaccines are effective or not.
In fact, based on the trend lines of infections, hospitalizations and deaths, there is every reason to believe that the coming months will be the darkest yet – especially if we see a spike in new cases related to holiday gatherings, as occurred after Thanksgiving.
“I hate to say it, but this is far from over,” Dr. MacDonald said. “Many people have fallen ill and died, and many more are going to fall ill and die.”
But if the vaccination rollout goes smoothly, and the vaccine works relatively well, we should be able to breathe a bit by summer – maybe even dream of barbecues and baseball again.
Still, vaccinating 37 million people in Canada will take time, never mind seven billion around the globe.
As vaccination numbers rise, the way coronavirus spreads will also be altered. We can expect fewer large waves of illness, but more sporadic ripples concentrated in unvaccinated populations. Infectious disease experts predict the coronavirus is likely to become endemic, lurking about for years, maybe even sparking seasonal spikes of illness, much like the flu.
Global disparities will become more glaring. Countries with 13 per cent of the world’s population have already gobbled up more than half of all the vaccines available. (Canada alone has purchased 429 million doses of seven vaccines, enough to vaccinate our population six times over, and it isn’t clear how it will distribute the excess.)
“It’s like being invited to a feast but the LMIC [low- and middle-income countries] are at the kids’ table, waiting to get the leftovers,” Dr. Liu said.
She also warned that this “me first” attitude is counterproductive – that until coronavirus spread is tamped down everywhere, the threat remains for everyone.
As much as anything, the pandemic has laid bare disparities in society, even in wealthy countries.
In Canada, the most glaring failure has been in eldercare. More than 10,000 of the 15,000 deaths across the country have been in retirement homes and long-term care facilities, and the way others have been locked away is a testament to the ageism ingrained in social policies.
The pandemic has also hit women – especially working moms – particularly hard, setting back progress against gender inequality by years, if not decades. Correcting this requires, among other things, making accessible, affordable child care a public-policy priority.
COVID-19 has also forced us to recognize the importance of low-paid workers to a functioning society. If we don’t hike wages for essential workers (and not just temporarily), make benefits such as paid sick days mandatory, find ways to extend employment insurance benefits to the gig workers and the self-employed, and improve the work environment more generally, we will have workplace issues that extend well beyond the pandemic.
The Canada Emergency Relief Benefit (CERB), one of the most important initiatives taken by government during this public health crisis, brought some financial relief to 4.7 million workers, making it probably the world’s biggest pilot project on basic income. If it doesn’t spark a serious conversation about reforming social welfare, we will have missed an important opportunity.
The postpandemic period will also seriously test the resiliency of the health system. Surgeries are backed-up, patients with chronic illnesses are feeling ignored and front-line workers are burned out. No one knows what impact COVID-19 stress and trauma will have on the population’s mental health or how our medicare system, which has long neglected mental health, will cope.
“When there is a public health crisis, there is always a huge hangover, especially on health systems,” Dr. Liu said.
Going forward, the biggest political challenge will be addressing the many social and economic wounds that have been exposed.
There is much talk of silver linings, but those will only come to fruition if governments, businesses and individuals act on the lessons learned.
“Hopefully the vaccine will not be an excuse to not do all the things that need doing,” Dr. Tuite said.
Meanwhile, she said, the challenge of coronavirus will remain, maybe for many years. Eradication is unlikely, even with the best vaccines. Let’s not forget that only one human disease, smallpox, has been eradicated, and that happened more than 200 years after a vaccine. (Edward Jenner administered the first smallpox inoculation in 1796, and it was declared eradicated, thanks to vaccination, in 1980.)
The push to eradicate polio has not stalled for lack of vaccines, but because of complex geopolitics and socio-economic realities.
The best-case scenario is that SARS-CoV-2 becomes another seasonal coronavirus (there are seven known to infect humans) that causes only limited illness. A worst-case scenario is that it continues to mutate and returns every fall in different strains, similar to influenza, but more deadly. We’ve not been great in dealing with the coronavirus as an acute illness; would we do any better if it were a chronic problem?
At a certain point the world will also decide, through its actions, what level of death is “acceptable.” Tuberculosis still kills 1.5 million people a year, AIDS 700,000, malaria 400,000, and so on, and we barely bat an eye. When COVID-19 stops being a threat to wealthy countries, will it stop being a public health priority, as is the case with so many other infectious diseases?
As the immediate danger fades, we need to have a national plan beyond “reopen quickly.” It is not sufficient to have a schedule for vaccinating the population; we need to articulate a clear end game and how exactly we are going to “build back better,” as the political rhetoric goes.
When the epidemiological end of the pandemic occurs, likely not until 2022 at the earliest, we will only be starting to deal in earnest with the fallout.
A significant aspect of the recovery needs to include preparing for the next pandemic, which will no doubt pose new challenges. As the World Health Organization cautioned in its year-end briefing: This pandemic is “not necessarily the big one.”
Dr. MacDonald said we’ve learned a lot from COVID-19, but we have to be ready and willing to apply those lessons. “There will be other pandemic threats so we can’t afford to forget too quickly, as we have done in the past.”
The biggest challenge will be our short memories.
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