Issue 20: We need a Plan B (Part 1)

If test, trace, and isolate is the best plan we have for getting us out of lockdown and back to something approaching normal life, then we need another plan

This is the first of a two part examination of the emerging consensus pick for the best plan to get us out of lockdown — test, trace, and isolate. Today’s briefing is a critical look at the workability of that plan; tomorrow’s newsletter will explore alternative options and push the idea that our planning probably needs to get way outside the box that the public health officials have put us in. — Andrew Potter (AP)

“Two is one and one is none” -- a popular military planning maxim

1) The view from inside the box 

Even as  a handful of European countries, including Austria and Denmark, are starting to loosen their COVID-19 restrictions on social and economic life, Canada remains very much in lockdown mode.  A couple of provinces (notably BC and Saskatchewan) have started to mutter about taking baby steps, but Quebec premier Francois Legault had to apologise for musing last week about possibly re-opening schools in early May. 

Meanwhile federal officials have been extremely reluctant to even broach the topic, insisting that the current measures must remain in place indefinitely. On April 15, Canada’s Chief Public Health Officer, Theresa Tam, went so far as to say that physical distancing (to what extent isn’t clear) must remain in place until “all chains of COVID-19  transmission have been stamped out.” 

Still, the first inklings of what looks like a plan to lift the lockdown is starting to emerge. This past weekend’s Globe and Mail had two big pieces on the strategy  -- a long Folio by Adam Radwanski and Ivan Semeniuk, and a companion piece of analysis by Andrew Coyne. At the core of it is the recognition that we’re caught between two very unpleasant alternatives: open society and face the prospect of mass death, or remain on indefinite lockdown and face economic ruin and widespread social malaise. 

If you’ve been following the debate over how to end the lockdown taking place here and in other countries, the basics of the plan will be familiar. 

First, you lockdown society as much as possible to “flatten the curve” of transmission and get the cases under control, especially hospitalizations.  You keep pressing down until R0 gets to the point where recovery rates outpace hospitalizations, so we do not overwhelm hospitals and other health services. 

Once this is done, we can slowly start to reopen society -- not all at once, mind you, but a staged return. Coyne suggests this would probably be in the reverse order in which things were closed down, which means playgrounds and restaurants might open sooner, while the last things to return will be any sort of unnecessary mass gathering -- live sporting events, movies and concerts, and so on.  But one tricky part of this is that in order to reopen the economy we pretty much have to reopen the schools and daycares first -- and these are precisely the sorts of places where social distancing is basically impossible. 

Of course, any loosening of the lockdown risks just re-starting the outbreak. To avoid a sort of “pumping the brakes” scenario, where you ping pong between loosening and full-lockdown, the heart of the plan is to do what is being called “test, trace, and isolate”: Significantly increase the rate of testing of the population; trace back to the recent contacts of anyone who tests positive, and isolate them to snuff out any chains of transmission before they become uncontrollable. And we keep this up until we get a vaccine, hopefully sometime in 2021. 

2) Capacity capacity capacity

“Test, trace, and isolate until we get a vaccine” is not just the epitome of inside-the-box “pandexit” planning -- it sits in the exact mathematical centre of the box. It is so orthodox that it’s the only plan given any attention by either Coyne or  Radwanski and Semeniuk. It’s also the basis of virtually every plan being seriously considered at the moment for both the United Kingdom and the United States. The only other option that’s been in the table is the “herd immunity” theory that the UK started but quickly abandoned. It has not been widely attempted outside of Sweden, which is having decidedly mixed results. 

But like any complex plan, Test/Trace/Isolate (TTI)  needs to succeed at every stage for it to work at all, and doing so will challenge our governments and health authorities in ways they haven't since the Second World War.  More to the point, each stage of the plan will involve our governments going far beyond what they have so far shown themselves capable of doing, and will require Canadians to accept things they have so far shown very little inclination to accept. 

The first major bottleneck is testing. One TTI plan for the UK, published on Friday by the Lancet, proposes universal weekly testing with a 90 per cent compliance rate. So to test an entire small city of 300 000 people, you would need to test 26 000 people a day. To get there, the authors suggest the government might need to inculcate a “Dunkirk” mentality in the population.

To put these numbers in perspective, Ontario (pop. 14.5 million) currently has a total testing capacity of 13 000, and has struggled to perform half that many tests despite the premier reading his officials the riot act two weeks ago (it reported yesterday that 9600 tests were performed on Saturday, though the backlog is almost 6000). But on a per capita basis, the province with the biggest population is last in the country on testing. 

Even Alberta, which has one of the highest per-capita testing rates in the country, has only been doing about 2000 tests per day, despite a daily testing capacity of 7 400. It wants to get its capacity up to 20 000 tests per day by the end of May.  So to reach Lancet-sized numbers, Canada’s testing capacity and execution will need to expand by at least an order of magnitude. 

Why are we having such trouble scaling? There are blockages at every possible chokepoint. There is a worldwide shortage of the nasopharyngeal swabs that collect the samples from the back of the patient’s nasal passage. There is a widespread shortage  of the PCR reagents for the machines that do the testing. And there is a shortage of trained professionals to do the actual tests. Various proposals to cut corners on regulations and press other lab workers into service doing the tests has been strongly resisted by the Canadian Society for Medical Laboratory Science (CSMLS).

Perhaps some of these blockages will be overcome, but it’s also possible that the shortages might only get worse as other countries, especially the United States, start to scale their own testing regimes. The biggest hope is that there will soon be a non-PCR test that will get around the biggest testing obstacles.  But it still seems like the people pushing the TTI plan are massively discounting the mind boggling amount of command and control that would have to be in place. 

But let’s assume we can ramp up the testing. Can we do the contact tracing most of these plans require? Everyone agrees that contact tracing will require rather high levels of surveillance -- certainly far higher than Canadians are used to and will be inclined to accept without being forced. Countries that have successfully implemented contact tracing, such as South Korea and Singapore, have made extensive use of digital tracking technologies, invading citizens’ privacy in a manner that most Canadians would find shocking

The government obviously knows this a problem: they have been extremely reluctant to acknowledge that they are even considering making use of tracking software. And while Apple and Google are working on a joint contact tracing project that would supposedly protect privacy, there are already stirrings of resistance in Canada:

So this leaves us with very serious concerns about whether TTI is even feasible in Canada. First, there is every reason to be skeptical about the government’s capability to do the testing and the tracing that is required. And second, even if they did, there is good reason to believe they would encounter strong resistance by the population. At which point, compliance would require either a very nice carrot or a very strong stick — what either of those might look like, and how they might work, are an exercise for the readers’ imaginations.  

But what choice do we have? As Andrew Coyne puts it, the only alternatives are mass death or permanent lockdown until a vaccine is found. And since neither of those options are acceptable, this plan must work.  There actually is another possibility, namely failure. We might actually try but not succeed at implementing TTI, which would just impale us on horn or the other of this very unpleasant dilemma. 

But grant for the sake of argument that our government will find the capacity, and our citizens will discover a“Dunkirk mentality” for compliance, to execute test, trace, and isolate until a vaccine arrives.  There’s one further question: 

3) What if a vaccine doesn’t arrive?

In many ways it’s an unthinkable notion. There is a massive, global vaccine effort underway right now. According the WHO there are at least 70 vaccines under development, and at least three have started clinical trials. Ontario premier Doug Ford just pledged $20 million for a vaccine development effort in the province. Bill Gates has made a huge investment, promising billions to fund factories for seven different vaccines, even though he thinks a successful one is at least 18 months away. 

But there’s an uncomfortable fact about coronavirus vaccines: there aren’t any. There are a number of reasons why that’s the case, but the bottom line is that there is no guarantee we’ll ever get one, even with the 18-month time frame most experts give as the most optimistic scenario. If you really want to scare yourself, read the latest report from a group of Harvard epidemiologists who have run simulations showing that without a vaccine, the virus could persist until 2025. 

So to recap: We are currently under widespread economic and social lockdown because of the COVID-19 pandemic. The alternative to the lockdown is mass death. The best plan for getting us out of the lockdown, Test, Trace and Isolate, will require  far more from our government and our citizens than we have been given any reason to expect. And even if we succeed at that, the light at the end of the tunnel -- a workable vaccine -- may actually be an illusion. 

So if test, trace and isolate is our only plan, then as they say in the army, we don’t have a plan. We need to start thinking way outside of the box. We need a plan B, and probably a plan C, D, and E. 

Tomorrow’s newsletter will lay out some of the possibilities. (AP)

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Policy for Pandemics is produced and edited by Andrew Potter and co-edited by Charlotte Reboul and Paisley Sim (bios here) If you have any feedback or would like to contribute to this newsletter, please send an email to andrew2.potter@mcgill.ca