It’s Time For A Different Approach to COVID: PART ONE

January 25, 2021 by David Nitkin | Categories: Public Administration | Tags: health policy, lockdown No Comments ↓

The Issue

There is an aphorism attributed to Albert Einstein that the definition of insanity is to try the same thing again and again and expect a different result. That’s my growing feeling about current public policy involving COVID. We’ve not inoculated ourselves in any meaningful way with either an effective leadership strategy, or coherent behavioural messages, or a vaccine to either cope or recover. If anything, wave two is proving to be more devastating than wave one, and we’ve not learned from or changed our attempts at “pandemic proofing” nursing homes, businesses, or shops much from wave one.

After writing some 75 blogs on the pandemic since March, and editing and publishing another 15 by other authors, I am taking a moment in this two part blog series to reflect on what I’ve learned and think I want to share.

This blog addresses three questions:

Why is the public policy framework for identifying decision-making choices between controlled shutdown and personal liberty not only wrong but also likely to yield an unsatisfactory dead (no pun intended) end?
What could a totally different, more efficacious, strategy toward social distancing and lockdowns do to enhance our economy and health outcomes?
What can we learn from South Korea about making better personal and public choices?

Distancing and Shut-Down Versus Responsible Testing, Tracking and Tracing

In generations past, our communities isolated those stricken with leprosy, cholera, plague or other infectious diseases. The emphasis was on quarantining the sick—protecting the rest from contagion. In this pandemic, however, Canadian provinces have universally “punished” the healthy as well as the sick—including job holders, business owners, and health-care workers as well as the civic-minded, stay-at-home majority. That is economically ruinous and morally indefensible.

In addressing COVID, by way of contrast, the South Korean government has avoided lockdowns. Restaurants, cafes and even nightclubs and gyms have stayed mostly open, but capacity is often limited. Patrons must scan a QR Code linked to a national contact tracing system before entering. Authorities put their emphasis on an assiduous, rigorously-maintained, widespread program of personal testing, tracking and contact tracing backed up by quarantine and isolation programs to identify and follow up those at risk. Throughout society, anyone who tested positive had their contacts screened, then those people had their own contacts screened, and so on until the chain stopped.

South Korean officials use testing and tracking data to monitor and publicize specific hazardous businesses and congregate settings, like evangelical churches. They don’t issue punitive stay at home orders on entire industries or sectors of civil society. Social-distancing measures of varying intensity are in place throughout the country, and masks are required in nearly every public place.

By way of contrast, Canadian officials have not invested seriously in timely testing or comprehensive tracking as cornerstone strategy. They have asked people to stay at home but (contradictorily) kept open over-crowded big box stores that sell non-essentials, liquor stores, and crowded food processing and warehouse enterprises. They have put so many changeable operational restrictions on “essential” and “non-essential” small and medium size businesses (SMEs) that tens of thousands of responsible enterprises have closed. We have ignored or underutilized best practice testing, tracking and tracing recommended by infectious disease professionals while combining that with inconsistent, incoherent, routinely-changing, one size fits all, stay-at-home “crisis management” messages. We have neither collected nor given citizens existing helpful responsible behaviour information on which specific institutions are spreading COVID.

As noted in EthicScan Blogs, The-future: The Ethics of Tracking (May 21) and Recovery Choice Planning: Part One: Testing and Tracing (July 8), public policy decisions have been made by emergency edict with little or no public debate or consensus. Politicians and epidemiologists have framed the choice as distance-inspired shut-down and stay in place versus personal liberty. Which is unfortunate and wrong-headed. Our safer and saner choice isn’t compulsory distance—rather, it’s seeking alternatives to closure that don’t cripple morale and business and community.

Here is a simplified summary of two conflicting approaches to minimize or live with virus risk. Canada’s current approach – distancing—is presenting in contrast to another – testing—as practiced in locations like South Korea and Japan.

	Distancing Approach	Testing Approach
Societal Stress	See proximity to any other person as threat	See only ill health of others as risk or danger
Motivating Ideology	Command and control to decrease transmission of an invisible virus	Empower citizens; encourage shopping locally as well as community collaboration and enterprise
Logic model for schools	Aim to maximally limit movement and in-classroom close contact. In case of infection, shift to remote learning (1)	Aim to ensure children are healthy and well. Temperature and saliva testing before school, at school and after school, with isolation where necessary
Logic Model for Retail businesses	Shut down or control circulation within all face-to-face-contact indoor businesses	Temperature checks, entry/exit registry, and symptom screening are necessary to identify symptomatic persons to exclude them from entering buildings and business establishments
Logic model for factories	Ignore congregate settings like abattoirs and food processing because they are essential industries	All factories and warehouses should have policies governing paid sick-time for suspect infections, symptom screening, entry/exit tracking, and what to do if a worker becomes sick with COVID-19 symptoms (2)
Logic model for nursing homes	Make little or no immediate changes in resident care requirements in a pandemic	Enhance networking between long-term care facilities and other institutions (hospitals, testing centres, clinics, home care)
Daily testing	Variable, non-standardized, testing on an as needed basis	Comprehensive, continuous, widespread testing

Source: Knowledgebase

_{(1) Encourage students to wear masks while on school premises, although this may hamper certain learning efforts, like assessment of phonicization.
(2) As space considerations are tight, a much more detailed set of tables and Strategies for Re-opening of Schools, Businesses and Factories is available in the Knowledgebase.}

A Change in Decision-Making Lens

On at least three occasions, South Korea has contained dangerously fast-moving pandemic outbreaks by deploying aggressive testing, high-tech contact tracing, and mandatory isolation. South Korea’s economy barely contracted through two waves of COVID and is poised for growth. Unemployment is about 4%, higher than before the virus but far below that in Canada and other major economies. It has established a template for one of the world’s most impressive efforts to contain COVID. Contain, not cure. Live with the virus, until widespread vaccination occurs, all without not having imposed a single day of collective lockdown.

By contrast, our see-saw applications of lockdowns during and between COVID waves one and two do not seem to have made much progress in saving lives. Infectious disease experts have issued preventable death-loss critiques of rules for nursing homes, shelters, under-regulated bars, schools, and migrant agricultural worker settings. The evidence I think demonstrates, using simple outcome criteria or measures, that we have not learned or accomplished much in terms of:

Getting more and better care for nursing home residents
Controlling non-essential international flights and travel
Regulating inside service at responsible businesses in ways that positively affect infection rates (without having adverse effects on the businesses and/or on the economy)
Addressing risks posed by elective inter-regional travel
Recognizing and rewarding front line workers; or
Protecting those who chose to work when sick in order to pay their bills (sick benefits, counseling, and isolation facilities).

It isn’t realistic in a democracy to lock down everything or reduce harm for everyone. We don’t have the resources, nor the political leadership, nor is everyone at equal risk. What arguably makes more sense is to focus on identifying, alerting through warning, and quarantining those of greatest risk of being a spreader or infecting others, as well as those with co-morbidities in specific locations that have been or are putting them at great health risk.

What may be a more valuable, prudent and effective public policy than keeping everyone distanced and staying at home is saving lives for those most at risk. Doing so requires investing in and sustaining as rigorous a testing, tracking and tracing program as possible. The emphasis is using accurate specific, privacy protected data to identify and act upon each and every source and location of virus spread.

Based on discussion panels that EthicScan has hosted, there appear to be different values and attitudes embedded in two different public-health policy choices open to us:

Criterion	Total Harm Minimization	Save Lives
Overall threat of virus	The pandemic must be treated as potentially deadly to everyone	The pandemic is potentially deadly for certain populations, not everyone
Metric of choice for determining restrictions	Actions determined by number of available regional ICU hospital beds and nursing home isolation units	Actions determined by number of positive tests and forecast implication for intensive isolation or hospital care
Approach to Flattening the Curve	This is central to protect everyone and avoid morally gut-wrenching triage	This comes at the cost of denied service (surgery, diagnosis, treatment) for those with other diseases
Application of lockdown	Inhibits development and spread of immunity among low risk majority	Acknowledges that not all lives can be protected or patients saved
Personal freedoms	Encourage group and individual risk assessments and quarantining decisions	Public-health risk and transparency is essential, especially when non-compliance is indicated (1)
Logic of Testing	Ultimately futile as most cases are mild and resolve themselves spontaneously	Should be applied widely using less time-consuming methods
Surveillance and mobility rights	Rules on wearing masks and travel need to be clearly adjusted as virus infection risk rates change	Suspected carriers should not be allowed to enter public buildings or use transit until it is known that they are not carriers
Enforcement and privacy rights	Enforcement needs to be clearly defined and regionally/locally appropriate	Identities of known high risk or suspected carriers would be protected

Source: Knowledgebase

_{(1) Has risk of labeling people who have COVID.
(2) It is important to prevent infection in anyone, to prevent infection of that person’s contacts and rapid spread & increase in the number of cases, ultimately leading to more hospitalizations and deaths}

Communicating Better Choices

Our political leaders who say they are informed by or follow public-health modelling forecasts are being advised by media and management consultants. From early on, the messaging we were given was that our choice in fighting COVID was between economy-shattering lockdown and appalling viral casualties. There is compelling information from insiders that our elected officials were repeatedly presented with contrary, testing-centred policy options to keep society functioning while sufficiently or comparatively suppressing the virus until vaccines were widely available. That’s not what most provinces or territories chose as their strategy.

South Korea isn’t small. Its total population of 52 million makes it a third larger than Canada’s, and Seoul is both larger and denser than Toronto. The Asian country has lost more than 500 people to COVID since its first test case on January 19, 2020: by comparison, Canada has lost 18,000 citizens– twenty times the Korean number—although our first tested positive case was January 25th.

Here in Canada, the difference between “essential” and “discretionary” business and travel is not readily translatable or equitable across our far-flung communities and populations. Appealing to everyone to stay at home while condoning dozens of exceptions is less useful than telling us to be careful when we leave home, if we can and feel we must.

I believe most residents in our “peaceable kingdom” try not to offend others. We are concerned about what others think of us and we know how to hunker down in long winters. We likely might continue to accept a public-health policy concocted by public relations professionals centred on collectively minimizing harm for all – that is, total harm minimization, but a case is possible that we’d be better served by one focused on saving lives, where possible.

Criterion	Total Harm Minimization	Save Lives
Shutting down schools and businesses	Err on side of caution and prudent individual judgement. Resist re-imposing province-wide lockdown	Be ruthless and apply restrictive targeted lockdowns where and when necessary
Testing	Prioritize testing toward at-risk populations	The more widespread the testing and tracking the better
Thinking about risk	Weigh health with social, economic and other criteria	Focus primarily on health issues when disaster risk is truly severe
Target population	Need to target everyone to save the few, thus saving everyone	Prohibit movement of people from high to low transmission risk areas
Strategic impact	Treat everyone as if they were equally likely to be a spreader	Focus on eliminating risk from known or suspect spreaders
Public messaging	Punish/impact/treat everyone equally – the sick and the able bodied	Leave home and go to work when it’s safe to do so
Application	Lockdown best so long as needed and warranted by data	Localized risk response is best – Toronto and Ottawa are special cases
Personal freedoms	Encourage individual risk assessments and quarantining decisions	Public health guidance is essential, especially when non-compliance is indicated

Source: Knowledgebase

Conclusion

If practiced assiduously, testing, tracking and contact tracing has been shown in other countries to be central to an effective strategy to maintain the economy and save lives. (While it is always easy to speak in retrospect) this should have been the cornerstone of our public COVID containment policy from the beginning. It still can and should be.

Part two—a companion follow-up blog– addresses three questions:

Are we capable of learning from Korea, or is the steadiness and discipline they bring to the table something we Canadians just can’t manage?
To what extent is the current lockdown strategy a blunt attempt on the government’s part to deal with years and years of inadequate and mis-allocated health spending and poor management policy?
Are we ready to change direction or must we must bite the bullet and lock the country down for however long it takes to get the job done, all the while having created a troublesome governance model based on quasi-democratic emergency edicts?

Need More Answers?

Subscribe to the EthicScan Knowledgebase for in-depth research and the opportunity to share information with industry experts, policy-makers and other health-care professionals.

The Issue

Distancing and Shut-Down Versus Responsible Testing, Tracking and Tracing

A Change in Decision-Making Lens

Communicating Better Choices

Conclusion

Need More Answers?

Further Reading – EthicScan Blog Articles: