Last week, Ontario set a grim new benchmark: the province reported 1,855 cases of COVID-19 on Friday, a record single-day total.
With the second wave of the pandemic having shown no signs of abating since then, TVO.org spoke with Raywat Deonandan, an epidemiologist at the University of Ottawa, about vaccines, hate mail — and why this pandemic serves as proof that society must pull together.
TVO.org: I wanted to start with some good news. In the last couple weeks, we’ve learned there will be a vaccine. There doesn’t seem to be a lot known about when we will get it or how it will be distributed to people, but there has been a lot of speculation about it. How do you see a vaccine rollout playing out?
Raywat Deonandan: Yeah, everyone’s got that same question. And there are a lot of issues to be explored here.
So the way it will probably work is the federal government will distribute vaccine allotments to the provinces and territories on a per capita basis and then advise the provinces on what they should do. And each province probably has to strike its own ethics committees to figure out how to distribute them. I anticipate it will be a hierarchy of who gets it first, probably beginning with health-care workers — because you don’t want to take your best players off the game board; you want to make sure that they’re healthy and able to contribute.
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Next will be the really vulnerable, probably the extremely elderly. Then there will be the first responders — the police and the firefighters and the ambulance drivers and the paramedics. Then maybe looking at people who have a lot of contacts daily, like teachers and mass-transit operators and maybe priests: you know, the people who are exposed to lots of people every day. Then after that, we have everybody else.
So it’s good to have to follow some rules of equity but also some rules of getting the biggest bang for your buck up front. We make sure that the rollout isn’t random, isn’t based on first come, first serve — or the most powerful get it first, as I think it’s going to happen in some parts of the world. It’s going to be where we can best apply this particular tool.
That brings me to the question: Is that the best way? I’m not sure. One metaphor to consider is if you have a raging forest fire, and you’ve got water, do you put the water where the fire is hottest and burning most brightly? Or do you distribute the water equitably across the entire forest? And that’s going to depend upon how much water you have and when you expect to get more water. Or maybe you want to distribute the water depending on the density of the forest, regardless if there’s a fire there or not. Obviously, the analogy I’m making here is COVID-19 is raging in this country in some parts more fiercely than others. And maybe it makes sense, for example, to give the Atlantic provinces’ allocation to Manitoba and Alberta and Quebec. But that would be a politically disastrous tactic.
Other complicating factors include the fact that the federal government is responsible, from a health perspective, for certain populations, like the military, incarcerated prisoners, and Indigenous groups. Now that brings up all kinds of new issues, complicating factors — like, how do we keep track of who gets it.
And this is critical. This is not like a flu vaccine, where we ship it off to the drugstore and say, hey, it’s there: make an appointment, and go get it. We need to know who got it, what formulation they got, and how many doses they got. Because, as far as we know, almost all the formulations require at least two shots: they can be three weeks apart, and you cannot get your second shot from the competitor formulation. So if you get your first shot from Moderna, you can’t get your second shot from Pfizer. So how do we keep track of that for a homeless population, for example, or for a nomadic population or people without family doctors?
TVO.org: So I’m in the vulnerable group. Probably not extremely vulnerable, because I’m not elderly. But closer to the front of the line than the back. How will I know when it’s my turn to get the vaccine?
Deonandan: So that’s another layer across all this: the communications. We have to deploy communications to inform people about the nature of the vaccines, the risks and benefits, to help assuage vaccine hesitancy. And there are all kinds of philosophies underlying the underpinning ethic of communication. Is it to compel human behaviour, or is it to actually empower people to make our choices? Part of that communication is informing people about what needs to be done, and that’s probably the core aspect of it, this stage of the game. So I suspect this will be something that would be handed down to local public health to communicate to people in the community about: this is where you need to go. And it’s now your time to go.
Now that brings up your question: How do you prove that you’re vulnerable? How do you prove that it’s your time? When I say health-care workers go first, does that mean part-time nurses and retired nurses? Does it mean midwives? So these things have to be defined and figured out.
So to get back to the idea of how we manage who gets two doses. If you’re dealing with a homeless population, that’s really hard. Even people without a family doctor, how do you keep track of what injections they got? Most people don’t know. And they forget that it’s time to get a second dose. So how are we going to do that? The way the Americans are planning to do it — and we might follow suit — is everyone gets a card that says when it’s your time to go to the vaccination centre. However it is you’re informed of that, your local public health will communicate to the entire city, hey, if you fall into this category, you’ve got these days to go to the local vaccination center. You show up, and the card is given to you telling you you got a Pfizer vaccine with this dosage on this date. And you’re scheduled to come back on this date.
TVO.org: Because if I get the Pfizer vaccine, they don’t want to give me the second dose of the Moderna vaccine. Is that right?
Deonandan: That’s exactly right. If you did, probably nothing bad will happen; it just means that you won’t get proper full protection. And that’s critical for the other half of the reason you have to keep track of all this: because that’ll tell us how close we are to herd immunity, which is the goal here. We need to know pretty well who got it, when, how many doses, and where they’re distributed, so we know which parts of the country are closer to herd immunity so that we can start to remove mitigation tools from society — like physical distancing and limits on gatherings.
TVO.org: You’ve mentioned vaccine hesitancy a couple of times. Is that going to play a role?
Deonandan: Honestly, I don’t think it’s going to be a big deal at first. I think our first challenge in the first few months is going to be meeting demand. Demand is going to be through the roof. This will be the most in-demand public-health product in the history of our country.
And, right now, you see people screaming at the government, “Why don’t we have more deals in place to get more doses?” But to get to herd immunity — which is, like, 70 per cent of the population being immune — we’re going to have to run up against vaccine hesitancy, because it sounds as if 50 to 60 per cent of people are willing to take the vaccine right now, not knowing what the risks are, but we probably need 70 per cent to get herd immunity.
So how do we get that last 10 to 20 per cent of holdouts? Well, this is where public-health communication and public-science education have to play a role.
There are going to be strong disincentives for this group to want this vaccine. For example, it is a new product. And I understand that — I would be afraid of a new product being injected into my arms. Number two: we don’t know what the full safety profile is, because we haven’t had more than a few months of people being exposed to it. But the way we incentivize it is to say, “Well, if you do this, society gets to go back to normal faster.” What I don’t want to see is people feeling as if there’s an authoritarian foot on their neck, compelling them to accept the thing they don’t want.
What I would like to see is accommodation made for these people in the short term, so they can spend some time thinking about it. For example, if you’re a health-care worker who doesn’t want to receive a vaccine, we can say, “Okay. Instead, you must submit to regular frequent testing every couple of days.” So as the months roll out, and people become more comfortable with the vaccine, then that option’s taken off the table.
A lot of people aren’t familiar with the expected adverse reactions to a vaccine like this. So once word gets around that, “Oh, I got the COVID shot, and I got sick for a day,” that’s going to spook a lot of people. We’ve got to get ahead of that narrative and explain that you should expect the pain, expect a headache, expect some fatigue for one or two days — 10 per cent of people seem to have that reaction.
Two years ago, I got the shingles vaccine. And I had such a brutal adverse reaction: two days in bed. Probably the worst I’ve felt in decades. And I’m a scientist — I understood exactly what was happening to my body. I wasn’t afraid; I knew that this would last for two days. Now I’m immune to shingles. But it was terrifying. And when I had to get my booster shot, I was very hesitant to do this again. So imagine someone goes through a similar experience for their first shot. And now it’s three months later, three weeks later — rather than go and get their second COVID-19 booster shot, they have a strong disincentive to take it. And so we have to get ahead of that and prevent that from being a disincentive. I don’t know how it’s going to work. But these are the challenges.
TVO.org: I’d like to talk about where you see the epidemic going, especially into December and January.
Deonandan: We’re all focused on the vaccine, as we should be. Anthony Fauci [director of the National Institute of Allergy and Infectious Diseases] has a great analogy for this. He says, you’re fighting a battle on the front line, and it’s bloody and painful, and you really worried you’re going to lose, and you hear the cavalry is coming. The vaccine is the cavalry. Fantastic. But all is not done: the cavalry is not here yet. You can hear the hoofbeats in the distance, but you’ve still got to keep on fighting.
So that means we can’t take our foot off of the pedal right now, because now is the darkest part of the night. And the dawn will be upon us sometime in the spring, when the vaccine finds better penetration.
It’s going to get really bad, I think, for a number of reasons. One is, the trend lines in North America aren’t good to begin with. And second is, we’re coming up to the Christmas holidays, and I do not expect people to behave themselves.
Canadian Thanksgiving showed us that people were not able to, in large part, restrain themselves from large socialization. And we saw a significant bump in cases that we’re still feeling throughout Ontario. When we start travelling and socializing and gathering in groups over the Christmas holidays, we’re going to feel that into January. So I’m feeling pretty pessimistic about our COVID-19 load the next two months. I often wonder, you know, at the end of both World War One and World War Two, imagine being the last person killed in those wars. We don’t want that to be anybody here. The war is almost over. And when I say “almost,” I mean sometime next year, so you don’t want to be that last soldier who gets killed just before the end of the war.
TVO.org: That’s the exact argument that I made to my parents when they wanted to get on a plane.
Deonandan: Yeah, I understand people’s desires, but they have to understand that this is not interminable. The situation that we’re in will end — and sooner than any of us thought it would end, which is the miracle of bioscience.
So if you can just put it off for a few months, we can celebrate Christmas in March. I liken this to a society-wide marshmallow test. It’s when you give a kid a marshmallow, and you tell them, “Hey, you can have this marshmallow now. But if you wait an hour, you can have two marshmallows.” Does that child have the strength of will to have delayed gratification such that he gets double the reward? And that is the test posed to us right now. Do we have the willpower, the strength of character, to delay our gratification so that we get all the marshmallows in March, and all the marshmallows means everyone’s alive?
TVO.org: I have been talking to so many people. And it seems to me that, even in my social circles, which are very careful, everybody seems to be making the holidays the one exception. And they all seem to think that they’re the only ones making the one exception, and that scares me. Have you seen similar trends?
Deonandan: Yes, I have. The pandemic has revealed the individualist bias, exception bias, that we are each the exception to the rule, which is just fascinating to me. And even I suffer from it. You know, I’ll wear my mask clumsily today, when I walk into a store, knowing full well what I should be doing.
There’s also a civics lesson here. Whatever I do affects you eventually. So if I choose to go to that house party, I’ll probably be fine. But maybe I catch COVID-19 and pass it on to my mailman. And he doesn’t even know he has it, and he gives it to an old couple down the street, never knowing that he did something. And they’re dead.
So because of a poor decision that I made — completely disconnected from that poor old couple down the street — they’re now dead. The interconnectedness of all things is playing out before us in this tragicomedy of 2020 life, accentuated by a pandemic. It’s fascinating and horrifying to watch.
TVO.org: I’ve noticed that a lot of people are watching the daily case counts in their region and using those as a metric for whether they should go out. Beyond policy circles, there’s not as much attention paid to hospitalizations and ICU usage. ICU admissions have been climbing up a lot. And it seems as if that trend is going to continue. Do you have any idea how that might play out over the holidays?
Deonandan: Well, again, there’s no way to be precisely sure. In Ontario, we seem to be levelling off because people have voluntarily restricted their exposures, and the economic restrictions seem to have been working. But with the anticipated greater socialization over the holidays, the spread will increase.
Now, there is a bright side to this: it’s entirely possible that the spread, the socialization, will only take place within small, intimate family groupings. It’s very possible. I doubt it, though. I think it’s likely that people will be going to multiple gatherings and socializing that way. And the holidays are also when you’re more likely to see your older relatives. And you should see them, by the way, but in a safe capacity. I’m more concerned about the ones who are not seeing them safely. There’s a greater-than-average chance that we will see spread of infection into that population. So I’m pessimistic. I would like to be wrong.
TVO.org: Do you think there might be a scenario in which care has to be rationed in some way?
Deonandan: I don’t see it happening in Ontario, because I think we’ve all been watching it so carefully. We have a government that, although it is reticent to act swiftly, seems eventually to act appropriately when the data strongly suggests it’s time.
I phrased that in a very specific way, because I want to avoid pointing fingers at decision makers. I don’t think that’s overly helpful right now. Look at the United States: Utah, for examplem has begun unofficially rationing care because it’s overwhelmed. We don’t have the same culture as Utah. We have a mostly responsible population that wants to get through this safely. It’s only a minority of people who seem to be ignoring public-health guidance, and that minority is driving a fair amount of transmission. But I don’t see that minority really becoming a majority. So, while it will get bad, I don’t anticipate rationing care. I do anticipate that we will probably be curtailing services — like cancelling some surgeries.
TVO.org: That’s good to hear, especially as you’ve admitted to being pessimistic.
Deonandan: Well, I think we’re going to see suffering, but we won’t see system collapse. Most people won’t even notice anything’s different. That’s the strange thing here. Most people do not come into contact with the health-care system except to see their doctor. So that’s why there’s this impression people have that the crisis is overblown. We don’t see bodies strewn across the street, as you would in the bubonic plague. We haven’t got people coming to your door every day saying, “Bring out your dead.”
If that were the case, public health’s job in some ways would be easier, because people would very quickly comply. What we have instead is, in many ways, a conceptual health-systems pandemic that has downstream negative effects on society. And a lot of people have a hard time digesting what that means and why they should care about the tragedy, because it tells us we’ve done a poor job in terms of civics, and alerting people to the ways in which their health-care system is one of the foundations of a functioning society. So it’s my failing as an educator.
Deonandan: It’s hard, right? And I don’t want to sound like I’m whining about it, because there are people in this province who are genuinely suffering. They’ve lost their job. They’ve lost loved ones. They’re really, really struggling. And I’m not in that category— not at all.
But, because you asked me, I’ll tell you. People have to understand that experts don’t get paid for this. I mean, I’m on parental leave; I can take my salary, stay home, and play with my kid. I don’t have to do any of this.
I feel, though, that the taxpayers have invested in me and therefore want some kind of return on their investment in a time of crisis — like now. So I feel it’s my moral responsibility to offer whatever passes for expertise to the public. And it’s hard when I get regular insults, occasionally threats. And it’s disappointing, because you do understand that those few who reach out in anger, they’re hurting, and they don’t know how to deal with their pain. And they see the talking head on TV and say, “Oh, it must be his fault.” Even though I didn’t invent this disease. I didn’t make public-health policy. I didn’t cause you to lose your business.
On the one hand, you understand the stresses that most people are under, which maybe scientists are not under — because we’re better paid and have better job security than most people. But on the other hand, that doesn’t make you immune to the endless torrents of abuse that many of us receive.
It is gratifying to know that your skills are relevant in a global emergency. But it is also disappointing knowing that they may not be welcome in a global emergency. And it causes you to question the nature of expertise in today’s democracy. There’s a current crisis of expertise in the sense that many people do not trust experts, and seek alternative viewpoints. And there’s also a crisis in trust. I think that is the crux of the matter.
TVO.org: Do you think that part of the reason people get so angry at you is that they think you’re being paid or have an agenda?
Deonandan: Epidemiologists, for years and decades, have been thinking about pandemic planning. We’ve thought about vaccine platforms, a responsive communication system, strong leadership and transparency, good surveillance systems. We did not anticipate that we would need to have to convince people that a real thing was real.
And that’s being driven by misinformation and disinformation. Misinformation is the result of a long-term lack of investment in science education; people just cannot parse the information themselves. And the disinformation is an intentional attempt to divide people on political lines, right? People claiming that, yes, scientists are incentivized financially to push a narrative. Somehow, I’m getting money from Bill Gates to push the vaccines. Or we’re being paid by grant money to push these agendas. We don’t get paid grants.
Having said that, there’s also a psychological nature of the human animal to focus on the negative. I get a ratio of 50 to one of supportive messages versus abusive ones. And we kind of forget about the supportive ones, because there are so many of them. I have elderly parents, and there’s a real chance that they could die. As an epidemiologist, if there’s anything I can do to just marginally increase their chances of survival, of course I have to do it.
One small thing is talking to the media to help them interpret some data, to advocate for certain policies and directions that may, down the road, increase the chances of my loved ones not dying. Of course I have to do it.
I think, from a civics perspective, everyone has a responsibility to one other. It’s kind of like, if you see an assault happening down across the street, you have a responsibility to intervene, because this is your community. Well, I have a certain skill set. It’s not a complete skill set. There are others who offer disease modelling and better statistics and laboratory skills. But, to the extent that I have a skill that is relevant, I have to offer it. To do less is cowardly and amoral. It doesn’t mean people have to accept it. I just have to make it available.
TVO.org: I was thinking back to what you said earlier about how, if you travel for the holidays, you may end up infecting somebody and not even know it. It might not be your family; it might be your neighbour down the street. Conversely, it follows that you may never actually know whom you’ve helped. If you do attend interviews and one person decides not to travel for the holidays, that might be somebody else’s parents that you’ve saved.
Deonandan: I’ve never thought about that. And when you say it, it almost brings tears to my eyes.
It’s hard to realize how much this ordeal has taken from you until someone points that out and there is a rush of emotion. I guess I have done some good. But that shouldn’t be a motivating factor here.
I think the motivating factor for anyone who has anything to offer during a crisis should be that that’s your job. And, again, this pandemic crisis has been an opportunity to re-examine so much of our society, including the nature of responsibility, the roles of various professionals and experts in responding to crises. We’re going to be dissecting this for decades, at so many levels. We’ll be talking about what we learned about for the next pandemic; we’ll learn about disease surveillance and vaccine development. But, at a deeper level, this is an opportunity to question the existential nature of democratic society. And it’s been eye-opening.
I’m thinking that the community mindset is going to win out — because people are also realizing things like, hey, when that crisis does come down, we need the government to step in and keep businesses afloat. We need all kinds of people pulling together to get out of a genuine crisis; we need the miracle of science to bring us vaccines at a remarkable pace.
And if we just resist this thing individually, we’re doomed. History has shown us that, in bad pandemics, if you rely just on yourself, hide in your house until it goes away, you have no society to come back to.
Whereas when society pulls together, then we can eradicate smallpox. We can almost eradicate polio. We can prevent a civilization from collapsing because of a pathogen. So this is a reminder that civilization works.
This interview has been condensed and edited for length and clarity.