The Emergency at Hand

We must stop acting like consumers and behave like citizens.

If we can be rigorous and determined about these things, we might blunt this pandemic and have the capacity to deal with the sick.

The exponential threat

Viral pneumonia is no trivial cold: it is deadly and frightful. So this is an emergency.

Our hospital system, as every Canadian knows, is already overburdened with the routine human failings: from heart attacks and kidney stones to broken bones and diabetes. It can barely handle a bad influenza season.

There isn’t much room in our intensive care units for a virus that causes a vicious pneumonia. It will likely have a fatality rate between one and eight per cent.Researchers revisiting Chinese data say the mortality rate of COVID-19 could be as high as 20 per cent in Wuhan.

The key to how high the death rate rises is tied to the ability of the health system to deal with serious cases of COVID-19.

We must do everything to lessen and spread out the coming shock to Canada’s health system because it would be wrong to assume it is robust. In fact, Canada has fewer ICU beds per capita than most nations — 10 to 12 beds per 100,000. We won’t have enough if the country experiences an Italian surge in cases and deaths.

So how we behave as a community over the next few months (and this could be a long emergency) will dramatically shape how many people die, and to what degree our hospitals will be overwhelmed.

Great mistakes have already been made because few people appreciate the devastating power of exponential growth.

A pandemic is like a wildfire. The more fuel it finds, the hotter it burns and before you know it is running out of control, and there are not enough resources to put it out.

COVID-19 is a fire burning through human communities. We can slow this fire and perhaps even manage its spread by purposely reducing the fuel load. That means breaking the chain of infection by closing public places, eliminating travel and avoiding crowds, and washing hands.

But inertia is the general response to things that cannot be seen, such as multiplying viruses in asymptomatic carriers. Canada did not restrict travel from infected areas fast enough. It did not test and contain enough. Now that community spread is well established in B.C., Alberta and Ontario, things will get ugly before they will get better.

But community action can still determine how bad things become and how fast we recover from this biological invasion.

We’re late, but do it anyway

COVID-19 is a stealth virus and an entirely new one. It can breeze through a community much like the flu, but is ten times deadlier.

It is highly contagious and could have an infection rate between 35 per cent and 70 per cent in Canada. That means if one infected person mingles in a crowd of 50 people and shakes hands and sneezes, between 15 and 35 people will become infected. 

By the time health officials reported three deaths from COVID-19, as many as 1,500 infections have already passed through the community, reports University of Toronto epidemiologist David Fisman. How can that be when the reported death rate in other countries is far higher than three out of 1,500? Because we are at a moment when the virus is being spread quickly and widely but quietly because so many aren’t yet showing symptoms. The curve is almost certainly sharply steepening; we just can’t see it yet.

Dr. Michael Warner, an intensive care doctor at Michael Garron Hospital, elucidates on the math: There are 14.5 million Canadians in Ontario. Thirty per cent could contract COVID-19. Of those infected, five per cent will require time in intensive care. That’s 217,500 patients. But there are only 400 ICU physicians in Ontario who normally care for 12 to 16 patients. 

“Soon everyone in Canada will know someone with #COVID-19. Do we have to wait for this to occur to acknowledge it is completely irresponsible for the government to deem safe gatherings of (less than) 50 people?” he recently asked on Twitter.

“If you wait until it's a crisis and then say we're going to respond to this crisis by implementing drastic public health measures, they will work, they will work predictably, but you've already missed the boat,” Fisman has warned repeatedly.

“The time to intervene,” he said on CBC, “was before it got bad because you knew it was going to get bad, you knew that when it was quiet was the time for you to intervene.”

But let’s not interpret such sound analysis for a statement that our actions no longer matter.

China also didn’t act early. It minimized this cold-like virus for a month for a variety of political and social reasons. It even attacked doctors who warned that this was no normal cold virus. And so Wuhan City, an industrial town of 11 million, got overwhelmed. As Iran and Italy are now overwhelmed.

Math guys at the University of Southampton in the U.K. recently parsed the data and reached these impressive conclusions: Without the introduction of rapid testing, isolation of the infected and severe travel restrictions, the Chinese outbreak would have been 67 times worse than it was at the end of February, with 145,325 cases.

Had the Chinese overcome inertia and imposed the interventions one week earlier, 66 per cent fewer people would have been infected. Had they introduced the measures three weeks earlier, they would have reduced infections by 95 per cent.

The math modelers offered this conclusion: “The non-pharmaceutical Interventions deployed in China appear to be effectively containing the COVID-19 outbreak, but the efficacy of the different interventions varied, with the early case detection and contact reduction being the most effective."

South Korea, Taiwan and Singapore intervened with early case detection, testing and isolation. They blunted their outbreaks.

Canadians must do the same knowing that blunting the pandemic is not the same thing as ending it.

The misery to minimize

Assume that most healthy people will not experience any symptoms, which helps the virus spread rapidly. Still, about as many as 20 per cent — one fifth of 37 million Canadians — could get sick enough to require hospitalization.

The question is how soon, in clumped numbers, these sick people make demands of the health system. You do not want to be one of them, nor do you want to contribute to sending someone else to the hospital with COVID-19. (We know that smokers, people with asthma, the elderly and anyone who is immunocompromised are high risk.)

While you wash your hands feeling bored and isolated, picture what a case of viral pneumonia looks like.

A 48-year-old man, a U.S. educator with asthma, goes to Italy as healthy as a horse. He returns and then experiences growing fatigue, a dry cough and something like bronchitis. There is no fever. Then the virus hit him like a hurricane. He can’t breathe.

In an ICU unit, a team of specialists insert a breathing tube down his throat and another to provide antibiotics. Every two hours the team sucks fluid off his lungs for more than a week. They all wear hazmat suits because lots of doctors have already died of COVID-19.

“The feeling of choking. That was the worst part,” the man told the Wall Street Journal. “You feel like you’re asphyxiating, and you’re panicking because you can’t breathe.”

The man told his wife not to put him on life support if his lungs collapsed. His lungs held up. But the man’s viral pneumonia occupied an ICU bed for 13 days, and required an extraordinary volume of resources to survive.

The bottom line is this:

Simple changes in social behaviour can save lives and keep our hospitals working.  

These are hard things to do consistently over long periods of time because we are social creatures.

Careful hand washing breaks the chain of infection.

Keeping a distance (two metres) from other members of the community slows down the viral fire.  

Acting as though “coughs and sneezes spread diseases,” protects the community.

Meanwhile you can help those who at most at risk by delivering medicines or groceries to their homes, but leaving them on their doorstep.

Last but not least, avoid hospitals at all costs and emotionally support nurses and doctors in your community in any way you can.

If you have cold or flu symptoms stay at home. It is most likely a cold or a flu. Do not burden the system with unwarranted or petty demands.

But if you have a high fever and can’t breathe, call an emergency line (811). They will tell you where to get tested and where to go for treatment.

For the last 100 years (see sidebar) all the public health evidence says one thing: the earlier you act, the fewer people will die and the less your health care system will be overwhelmed.

And it pays to be extra slow to lift such measures. This virus, like influenza, might reappear as soon as controls are taken away.

So change your behaviours, and act like a citizen. Protect our hospitals and the most vulnerable.