‘It’s shifting responsibility’: Epidemiologist Ashleigh Tuite on Ontario’s COVID-19 strategy

TVO.org speaks with the epidemiologist, math modeller, and U of T prof about what the province’s priorities are — and where they should be
By Sarah Trick - Published on Nov 10, 2020
The province unveiled a new colour-coded COVID-19 control system on November 3. (iStock.com/BlackJack3D)

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Last week, as coronavirus cases continued to rise, the province released a new colour-coded COVID-19 control system, which came in for criticism from a number of doctors and other experts. TVO.org spoke with Ashleigh Tuite, an epidemiologist, mathematical modeller, and assistant professor at the University of Toronto, about public-health measures, herd immunity, and what Ontario’s priorities should be.

TVO.org: Do you have any thoughts on the government’s new colour-coded system?

Ashleigh Tuite: I do. On a positive note, I think it’s a great idea to have something that’s a clear plan, a framework that people can look at and understand. And I like the colour-coding. I think the idea of having different stages and particular metrics associated with them may be useful, and it will help provide more clarity to what’s going on and will help people anticipate where things are going. In terms of the details of the framework, I think it’s highly problematic. I think the biggest issue is that it’s not proactive. The thresholds for moving toward restrictions that would reduce transmission are really, really high. So these high thresholds for closure mean that we’re going to be reactive; we’re not going to be in a situation where we’re able to nip this in the bud.

What’s going to happen is, in the short term, people may be happy with this because we can open up our businesses, and we don’t have to worry about the economy or businesses that are currently being shut down. But I think a month from now, we’re going to be in a situation where, if we wait to react until we have positivity that’s greater than 10 per cent and increasing numbers of cases and really high levels of transmission, we’re going to be in trouble. We’re going to be overwhelmed before we respond. It’s going to be a problem. The metrics that are presented are fine, but I don’t think that those thresholds make a lot of sense.

TVO.org: As a layperson reading the plan, I find it very confusing. A couple of weeks back, we had a spike in cases. We moved back to modified Stage 2 in the hot spots. Cases went down. It seems as if it was a success. And, from what I’m reading in the plan, it seems as if the thresholds to move back to these modified Stage 2 measures — which were successful — are so high that we wouldn’t have the same success if we needed to close again. I guess I just don’t understand the thinking, and the messaging doesn’t seem consistent to me.

Tuite: If you think about where we were a month ago, when we moved into modified Stage 2, we weren’t at a level that was as high as what’s currently required to enter into that stage. And the communication is not clear, and it’s not consistent. A month ago, the level of transmission that we were seeing was alarming enough that we implemented these restrictions. And they were effective. But I think we still need to have them in place. And, from the perspective of the general public, if we’re saying this works, we’re opening things up again — how are you supposed to interpret that, aside from the fact that we should go back to life and start going out to bars and restaurants because they’re open now?

And so there’s a disconnect between what’s being said by the government and what we’re seeing in terms of what businesses are open and what we’re being asked to do individually — because there’s still messaging that says that, although bars and restaurants are open, you should still only leave your house for essential purposes. And so I don’t really understand how that helps anyone. It’s inconsistent; it’s shifting responsibility to individuals.

TVO.org: Health Minister Christine Elliott was asked in question period about this new plan. Some of these concerns were brought up, and her response was, basically, we have to learn to live with the virus, because it’s not going away. Is this giving up?

Tuite: I think it’s giving up, and I don’t think that it’s a useful approach. I mean, we can look around the world, and we can see places that have figured this out. You get transmission down to low enough levels. And you do that by sometimes having restrictions in place, but, ultimately, by having good testing, having good tracing, having these various policies in place.

And when transmission is low, then you can reopen businesses, and you can continue to go about life in a way that allows everybody to participate in it. The challenge with what’s being proposed right now is that it’s really enabling some people to continue to go about their lives, but people who are vulnerable can’t. And so as much as there’s talk about protecting the vulnerable, it doesn’t really allow a large swath of our society to get back to life as normal.

I don’t think it’s wrong to say that we need to learn to live with this virus, because that’s correct. It is going to be here for a while. But there are ways that we can do it more equitably. Basically, we need to control transmission. If we have widespread transmission, it’s not reasonable to expect that we’re going to be able to keep businesses open and continue to protect our most vulnerable and keep schools and child care open.

One of the things that really struck me from the presentation of that framework is there was a slide that showed the list of priorities. And there were five or six different priorities listed there: limiting the spread of COVID, avoiding closures, keeping schools and child care open, maintaining our health-care capacity, protecting vulnerable populations. They can’t all be priorities. We need to prioritize within that. We have to decide, because we can’t do all of that right now. And so we have to identify what our true priorities are and recognize that not everybody is going to be happy.

But if we focus on remedying the spread of COVID, keeping our schools and child care open, and protecting vulnerable populations, then the other priorities follow. We can figure out how to reopen our businesses, and we can figure out how to restart the economy, but we can’t do it all at once. The problem right now is we’re trying to do everything and please everyone, and we just don’t have the capacity or the infrastructure in place right now to do that.

TVO.org: There are jurisdictions that have seen widespread openings. Some have advocated for that sort of approach in Canada, and what they always say is, “Oh, we can go about our lives; we can shield the vulnerable.” And I’ve never actually heard a clear articulation of what that might mean. Do you know what it means?

Tuite: You’ve never heard an articulation of what it means because it’s not possible. In theory, there’s this idea that we shield and protect the vulnerable. But we have to acknowledge the fact that, first of all, we don’t have this ability to magically identify everybody who’s vulnerable. We know what some of the risk factors are, including being older, including having some underlying medical conditions. But if you were to just say the vulnerable are people who are age 60 and over, that’s about 20 per cent of the population of Ontario. So that’s 20 per cent of the population who can’t participate in life while we have this epidemic circulating.

And then there are also all the people who, for example, live with people who are vulnerable or who care for people who are vulnerable. And so when you start doing the math, you’re talking about a large segment of the population you would have to have shielded or protected from COVID. And then you would require the rest of the population to go about their life as usual.

Not only that, but the idea with this herd-immunity approach is that people have to get infected and develop immunity, so people would have to go and actively try to become infected: no more physical distancing, and no more wearing masks. I don’t think most people would be okay with that, because even if they’re not identified as being in the vulnerable group, some segment of the population will still have an adverse outcome, whether it be the long-term effects of a COVID infection, hospitalization, or death.

The reality of this is that this idea of protecting the vulnerable is not feasible or practical [without other measures], and it’s also highly unethical. I mean, there’s no way that you can operationalize this. It’s an appealing idea, because it sounds nice and simple. But if you dig down into it and think about how it would actually work, it doesn’t — which is why there are some countries that started thinking about this as an approach but then abandoned it, because they realized that it just doesn’t work.

TVO.org: Does the strategy represent a departure from the one we’ve followed up to this point?

Tuite: I think so. I think the biggest shift is that we’re really moving toward personal responsibility. And I saw that, in Peel, [Medical Officer of Health] Lawrence Loh is asking people to not have any sort of household or private gathering, as they move toward opening up bars and restaurants. So, basically, what that’s saying is, we acknowledge that to, keep transmission of COVID low, we need to reduce the number of contacts that people have — the way that we had been managing this in Peel was by having bars and restaurants shut down. And the government has decided that we’re going to open up bars and restaurants. So to compensate for that, we’re going to ask individuals to no longer have private gatherings. So the idea is the same: we need to reduce the number of contacts that we’re having, but we’re shifting the responsibility.

TVO.org: To individuals.

Tuite: Yeah. I think that’s going to cause issues, because if that’s the message that we want to convey, which is that we need to reduce the number of contacts that we’re having with people, particularly the people outside of our household, that messaging needs to be consistent. We need to do that in terms of what businesses are allowed to operate. And that’s not what’s happening right now; there is this shift, where we have different rules for what we can do in public versus what we can do in private.

TVO.org: Was there anything else that you wanted to add?

Tuite: Yeah. I think one of the frustrations that I’ve had with the release of this framework is that I know that there are so many people in Ontario who are working so hard to try to develop science-based and evidence-based policies to try to respond to this pandemic in a way that protects the health of everyone. It’s been a fascinating week, because there is this sense of politics trumping science. They know that science is not removed from politics. But, at this point, we know enough about the virus and what we can do to control it. We shouldn’t be at a point where we throw up our hands and say, well, we just have to live with this, and it’s going to be transmitted, and we’ll muddle our way through. I think that was appropriate for the first wave of the pandemic, when we didn’t have time to prepare, and we had to make do with what we had.

But we’ve had time to prepare. We’ve had time to build up our testing. We’ve had time to think about how we improve our contacts. And so the fact that we’ve entered the second wave with what feels like a lack of preparation is incredibly frustrating.

We need to be far more proactive in terms of our response and really push toward getting case numbers low, because it’s a lot easier to win with COVID-19 if we’re dealing with dozens of cases a day versus thousands of cases a day — which is where we’re heading.

TVO.org: So, as a scientist, what would you like to see?

Tuite: I would like to see continued restrictions in places that have high levels of cases until we reach a point where we have a number of cases per day that is manageable. The best-case scenario right now is, if we have a reproduction number around one, it means that we don’t have growth in cases. But we also don’t have a decline in cases. So that would mean that, for the foreseeable future, we’re dealing with 1,000 new cases a day. And that’s unsustainable. Ultimately, it comes down to getting community transmission to a low level, because then you have a bit more room to breathe. We can’t sustain this indefinitely. We need to get those numbers down. And we’re not going to get those numbers down right now, with the tools that we have at hand, without keeping some businesses closed right now.

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

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