Our main objective in Saskatchewan has been and continues to be to “flatten the curve”, but what does that mean, and are we really doing it? On March 19, 2020, World Health Organization spokesperson, Christian Lindmeier explained that on a global scale, healthcare systems cannot cope with a large surge of patients of the size and nature that we have seen already in Italy and Spain, at any one time. This does not just mean COVID-19, this means any type of pandemic, any disease or illness that can spread around the world and infect masses of people. Lindmeier then stated that collectively people need to “slow down the spread and try to spread it over time as good as possible so that the health system can cope and production of vital medical equipment can cope,” and that is what flattening the curve means. Health agencies around the world are not pinning hopes on being able to reduce the ultimate overall number of illnesses and deaths, but rather they are striving to reduced the numbers that healthcare systems will have to deal with at any given time, time is what they are striving for. There is no vaccine for this virus, we have all been told that, but what individuals may not realize is that developing a vaccine does not happen in a week or a month, it takes months, potentially a year or more. While researchers around the globe are sharing information and working together to try and find an effective vaccine, once a breakthrough has been made testing needs to be done, thorough testing to ensure the vaccine is safe and effective, and even with global collaboration it will not be quick. It is for this reason the World Health Organization has asked people around the world to practice the best personal hygiene possible: to wash their hands regularly, avoid touching their eyes, nose and mouth, and maintain social distancing. Taking care of your respiratory health is equally important and to seek medical care if you start to experience the symptoms of COVID-19. “One thing that is cutting transmission is testing, testing (and) testing every single patient and following up on them,” Lindmeier said, before adding that every single suspect case should also be tested.
Roberto Rocha, a data journalist with CBC/Radio-Canada wrote in an article about the “flurry” of daily data (cbc.ca/news/health/covid-19-pandemic-data-primer-stats) which states that for the most part tests in Canada have been reserved for those who have travelled abroad and are showing symptoms, and patients who are showing severe symptoms. In Saskatchewan we know that those who have attended mass events and are symptomatic have also been tested, but compared to places like Singapore and South Korea, Canada’s testing falls short. Public health officials in different parts of the country have cautioned that the numbers being reported don’t give a clear picture. Those numbers do not show the potential cases that have either not been identified or not tested, besides those whose tests are caught in a backlog somewhere. Saskatchewan is fortunate that tests administered here can be analyzed here, but Saskatchewan Public Health officer Dr. Shahab and the Premier, Scott Moe stand firm in their belief that not everyone who presents symptoms need to be tested. And while Dr Shahab reaffirms that the majority of people will experience mild symptoms, that “can include pneumonia, but when people think of mild, they think it's like having a cold," according to Greta Bauer, a professor of epidemiology and biostatistics at Western University in London, Ont. "But it just means they don't have to be hospitalized. It doesn't mean they can breathe normally." In the provincial update on April 3, Dr. Shahab reiterated his stand on testing, stating that of those who have COVID-19, 10% of people will have no symptoms, 20% will have very mild symptoms maybe only a cough, and 50% will have more symptoms and definitely feel ill but still will be able to recover at home. He stated that it is not practical to test the first 30%, but anecdotal reports from individuals show that not all in the 50% grouping are being tested either, so how accurate is the data being released?
Health Minister Patty Hajdu warns Canadians, “We have to all act as if we are carrying this virus.” Individual actions are “critically important” in slowing the spread allowing the healthcare system to continue functioning effectively. Our health systems weren’t designed for a surge of patients of the magnitude the pandemic could produce, Hajdu stated. “By and large, people want to know,” says Dr. Judy Illes, Canada Research Chair in neuroethics at the University of British Columbia. “Information engenders trust, and trust engenders resilience.” The opposite makes people feel as if they have no control whatsoever. Models describe a range of possibilities and are based on assumptions and the data that is available. If the data being used to formulate the models is inaccurate then the model itself is inaccurate. On Friday, April 3, 2020, Ontario’s Head of Public Health, Dr. Peter Donnelly released some “stark” numbers comparing projected number of deaths if no protective measures had been taken with the numbers projected with the current restrictions in place, and projected numbers if further restrictions are enacted. The projected difference between those end numbers for current restrictions and tighter ones is roughly 1400 lives in the month of April alone. That in itself, should be a wake-up call.
Saskatchewan needs to prepare for the worst. The Saskatchewan Health Authority has been working through the numbers and looking at different scenarios to identify what they need to do. By taking note of what is occurring around the world, the SHA plans to form triage committees which would be responsible for making the difficult decisions that would need to be made in the event of a surge of severely ill COVID-19 patients. Dr. Shaw, Chief Medical Officer for the SHA, said “it’s important for the SHA to be transparent about the ethical framework that will guide those decisions.” The committees would spare bedside physicians from having to make heartbreaking choices about their own patients. The goal is of course to save as many lives as possible, but sometimes difficult decisions may have to be made if or when the surge comes. The triage committee would have the responsibility of continually monitoring and assessing the condition of patients on ventilators to identify worsening conditions or any new problems, like organ failure. In a crisis situation where the number of patients outnumber that of ventilators, that could mean removing one person from life-support to give it to another. That is a tough truth to hear, but that is the reality doctors in countries such as Italy have been forced into. Dr. Shaw emphasized that while removing ventilation would in most cases lead to the death of the patient, care of the patient would never stop, it would change and become palliative care, but patients would not be abandoned.
The surge hasn’t come. In fact, the ICU at RUH isn’t even as busy as usual, according to Dr. Shaw, and she hopes it will stay that way. Models pretty much summarize what is known at any given point in time and while they may be imperfect, policy makers would basically be working blind without them. Models and plans go hand in hand, without a plan for how to get where one wants to go, one’s arrival is left to chance and in a pandemic such as COVID-19, leaving things to chance is not the way to go. “We know the situation is serious,” Prime Minister Trudeau said on Saturday April 4. “What actually happens, depends on the choices we make every single day. We can change the predictions.”
