COVID-19: The week in review with epidemiologist David Fisman (May 17-22)

TVO.org speaks with the University of Toronto professor about the testing, the numbers, and the outlook for Ontario
By Nathaniel Basen - Published on May 23, 2020
David Fisman spoke at the House of Commons health committee on May 20. (iStock.com/BlackJack3D)

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David Fisman, a professor of epidemiology at the University of Toronto’s Dalla Lana School of Public Health, has been carefully tracking Ontario’s response to COVID-19. He’s also involved with the province’s coronavirus-modelling group.

TVO.org is checking in with Fisman on an ongoing basis to get his insights into the province’s fight against the coronavirus. We caught up with him on Friday evening.

TVO.org: You testified before the House of Commons standing committee on health this week. Tell me about the experience

David Fisman: That was a first for me. I’ve not testified before a House of Commons committee before. It was an interesting thing to go through, and it felt good to be able to say my piece. Clearly, there’s both a policy aspect, and there’s also a little bit of political theatre that goes on, so it was interesting to watch that play out.

TVO.org: It must have been odd to watch that play out on a screen, too. How did it work, practically?

Fisman: It’s funny. On the one hand, you have the formality of parliamentary procedure, with rules of order and so forth. On the other hand, you have all the normal stuff, where people are muted when they’re trying to speak or someone’s screen freezes up. It feels like something that a comedic director, a Christopher Guest, could do something with. I wish I had those kinds of powers.

My emphasis was mostly on testing, testing aggressively, and trying not to give in to this idea that it’s either economic prosperity or disease control — you need both. To reopen the economy, we need to be doing better on surveillance and on testing. I suppose I’m a bit of a Johnny One-Note at this point, because I said to the committee what I’ve been saying over and over on Twitter and in the media and to anyone who will listen.

I’m also a little bit saddened that one of the other witnesses started up with what I see as a nonsensical approach to epidemic control — lauding the Swedish line of attack, wanting to let things just burn on until you have herd immunity. If folks don’t understand that this isn’t influenza and that we’ve had a ton of deaths even with lockdown and that we probably, at most, have had 5 per cent of the population infected and immune — the idea of letting this thing rip just seems to me unbelievably irresponsible. So I was sorry to hear one of the other witnesses harp on about that. I think he discredited himself, and, to be honest, he sort of embarrassed himself.

TVO.org: Who was it?

Fisman: Dr. Richard Schabas, a former chief medical officer of health, who has taken unfortunate positions on a lot of recent issues. I have respect for a lot of what Dr. Schabas did early in his career, but he’s well out of the mainstream at this point. I think, because of his prior accomplishments in Ontario public health, his voice carries a fair bit of weight, and it saddens me to see him end his career with this unhelpful rhetoric that really undermines and holds back a public-health response that’s challenging enough.

TVO.org: It’s one thing for someone to talk and another for people to listen. Did you feel the committee gave his ideas serious consideration?

Fisman: That was actually pretty encouraging. There was one MP who seemed to treat him seriously. But he didn’t get a lot of questions, and he spent most of the hearing looking like someone standing next to the wall at the prom waiting to get asked to dance. I got the sense that most of the MPs on that committee really did get it and understand this well enough to know that we’ve moved past that.

TVO.org: If you’ve been a Johnny One-Note in the past, that note has been all anyone’s spoken about this week. Premier Doug Ford has been publicly critical of testing levels; David Williams, the chief medical officer of health, has wondered aloud whether his messaging has been unclear. I know you’re an outsider, but can you help me understand how we still seem to be behind on this, when it feels as if we’ve been having these discussions for months? 

Fisman: I am completely baffled. I’ve expressed some frustration over the past couple of days with some of the contacts I do have with the province, saying I’m not playing this game anymore. Various people reach out and ask for your opinion or ask for your work, and it disappears down a black hole.

Sometimes it bubbles up a few weeks later in the language the province puts out, but I’m not interested in helping to prop up this completely dysfunctional outbreak response anymore. It doesn’t seem like a good use of our time or skills. At this point, my colleagues and I have very productive working relationships with Toronto Public Health, Ottawa Public Health, Peel public health, with federal colleagues, with colleagues at the state level in the United States, with colleagues in South Korea and in other countries. There, people reach out to you, and it’s a very respectful give and take, and we exchange ideas.

I find the interactions here in Ontario at the provincial level to be really opaque and, frankly, disrespectful. I am tired of folks reaching out to me and saying, “Hey, can I borrow your PowerPoint slides” or “Can you tell me how to explain this at the whatever table?” If you want to have a functioning discussion about how to end this in Ontario, we’re here to help. But there seems to be all of this byzantine intrigue, and I have no idea how stuff funnels through.

Maybe that’s why Williams seems so befuddled — maybe good information doesn’t get through to him, because there are these layers of courtiers who act as filters. Maybe that’s his problem. I’m an outsider. I don’t know what the issue is. But I know it’s pretty clear where the problems are in Ontario. I know folks in the city have very clear ideas about why you can’t put out the last few flames here in Toronto. A lot of it relates to disenfranchisement and socioeconomic status, and it’s not helped by what I’ll refer to as privileged idiots hanging out in Trinity Bellwoods Park sharing bottles.

But there doesn’t seem to be any clear strategic planning at the provincial level. We have lots of resources, good labs, and lots of smart people across the province. We have a province larger than France, but we have this dysfunctional messaging that’s treating Algoma the same way it’s treating Toronto the same way it’s treating Kingston. You have places that are hundreds of kilometres and sometimes thousands of kilometres apart, and the provincial hotspot is here in Toronto, and you’d never know it from the messaging coming out of the province, which treats the rest of the province as if it’s the GTA.

There’s something very, very wrong with how the folks running the provincial response to this epidemic are reacting to it and how they’re processing information. I think you see that in how long it takes them to catch up with the science. I’ve vented about this repeatedly — not that this is all about asymptomatic and pre-symptomatic spread — but the importance of that has been case closed for a number of weeks, and it seems like, only now, we are very gradually coming to the realization that people without symptoms might be transmitting this, and that might actually be important to epidemiology.

We’ve wasted weeks. You see that over and over again: with masks, with community spread. You see that now with testing. There are folks in individual health units who came up with mobile testing way back in February. You’re worried your test numbers have dropped? Well, you’ve just spent the last few months discouraging people from coming to test centres. If you want to get some situational awareness and to know how much infection there is out there, maybe you leverage some of these good ideas.

The Koreans have piloted parking-lot testing; folks here in Ontario have come up with good ideas around mobile testing. There are lots of good ideas. Get out of your damn Queen’s Park bubble and use it. I know I sound frustrated, and I realize you’re a journalist, and this is probably going to torch a few more friendships for me, but I learned at this hearing that the burn rate for Canada is $12 billion a week. We need to get this job done and start getting the economy open, but, instead, we’re stuck in second gear. I honestly think the premier has some really hard decisions to make. I get the whole “don’t change horses in midstream” thing, but if you’re surrounded by folks who are in the most important public-health fight of their careers, and they are proving again and again that they just cannot get the job done, then I think he has to find people who can get the job done. They’re out there.

I think the premier is walking a fine line. He’s under a lot of pressure from folks who see the economy as the standalone and just want to get back to work. But the economy is only going to come back when people feel safe and secure, and you need to be able to walk and chew gum at the same time.

TVO.org: New infections are up this week despite low testing numbers, but some of the messaging has said that the virus is subsiding or plateauing. Is that what you see?

Fisman: No, we don’t see that. We’ve clearly had a spike in transmissions related to the Mother’s Day weekend, and our reproduction number is above one, which means we have a growing epidemic. It’s about a 12-day lag between transmission and cases showing up as cases. So, if today is the 22nd, 22 subtract 12 is May 10, which is Mother’s Day.

And you hear that anecdotally: we have colleagues who are trying to create contact matrices, and they’re hearing this from the people they interview, as well. This comes back to communication and muddled messaging: people don’t understand if this is over. The premier himself had a family gathering for Mother’s Day, so that starts to look like social distancing for thee but not for me. You’re going to lose people if the people in charge aren’t doing it while they’re telling everyone else to. You’re not going to get public buy-in. That’s very problematic, and it’s the second time the premier has done something like that. We all want to see our families.

It comes back to messaging, communication, and transparency. It’s having people buy in, having them understand that we’re on the same team and understand the stakes. I’d like to think the idiots in Trinity Bellwoods don’t want people to die as the result of their actions, but that’s what it is. If you spur disease transmission, you have a higher force of infection — you have more cases. Some fraction of those cases are going to find their target. They’re going to find that vulnerable person who goes into respiratory failure and dies or who gets a pulmonary embolism and dies. I’d like to think that most of those irresponsible people out there on the grass enjoying the sun aren’t bad or malicious people — they might be thoughtless — but there’s responsibility on the part of leaders to show people how to behave and to potentially sanction them if they’re messing things up for other people. You have to leave that up to the city and the province, but I think they should be. You’re hurting other people. It’s not fair.

TVO.org: Looking forward, what are you working on next week?

Fisman: What I’ve been working on right now is called a clinical prediction rule, so it’s just a simple little risk score that you can use to predict who with COVID-19 is going to die. It turns out, it works really well.

It’s helpful in terms of prioritizing who you want in the hospital, who you might want to intervene on early, and who might benefit the most from therapies that get developed. In the Ontario data, it’s really easy to predict who’s going to die. A lot of it is a function of age. Male gender has shown up in lots of studies, and that shows up, but it falls away when we adjust for other factors. Something that seems to be a really interesting predictor of death — and is going to be awfully hard to message from a public-health point of view — is that non-smokers seem more likely to die. We’re not the first ones to see that, and it’s caused a lot of consternation in terms of how you message that, but, yes, being a smoker does seem to have a fairly strong protective affect.

TVO.org: Wait — why would that be?

Fisman: I don’t know. It may be confounded by other medical illnesses. For example, heart and lung disease are big predictors, and it may be that you’re less likely to smoke if you have heart and lung problems. It’s a marker of risk; it’s not causal. It doesn’t mean that, by smoking, you’ll stave off the likelihood of death.

One of the targets for the virus is pulmonary macrophages, which are immune cells that are deep in the lungs and express a protein called ACE that the virus binds to. Folks have suggested that smokers may have less ACE. But smokers are also over-represented in asymptomatic cases, which is interesting. So, yeah. The more predictable ones are: if you live in a long-term-care facility, you’re more likely to die; if you have heart or lung disease; if you have a history of being immunocompromised; if you’re diabetic — there’s math you can do where you can assign points for each of these characteristics. A higher score correlates to a higher risk of death. You can come up with risk groupings where, if your point score is beyond some threshold, you’re considered to be really high risk. It inflects quite sharply at some point, and risk gets quite high.

TVO.org: I know you’re trying to cook dinner now. I’ll let you get back to it. Thanks so much for talking to me.

Fisman: Thanks a lot.

This interview has been condensed and edited for length and clarity. 


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