As the global COVID-19 pandemic worsens, talk of increased lockdowns are in the news daily. Dr. Matt Strauss, a professor at Queen’s University’s medical school, writes “the cold, hard fact is that lockdowns do not seem to achieve what one might hope” and he therefore calls for a more focused protection plan.
Dr. Lawrence Loh, Peel Region’s medical officer of health says restrictions, when properly done, are a useful tool. “At the appropriate moment, imposing broad closures immediately decreases interactions and interrupts transmission, which saves lives and protects the health care system in the short run.”
Every medical treatment plan comes with potential side effects. Every physician needs to consider whether the treatments they propose could cause more harm than good. In clinical medicine, a treatment generally only becomes widely accepted when high quality clinical trials are published in trustworthy journals to prove that its benefits outweigh its potential harms.
The benefits of lockdowns to prevent deaths from COVID-19 are far from proven. The very best paper evaluating whether lockdowns save lives was performed by researchers at the University of Toronto, Drs. Chaudry and Riazi, and published by the Lancet. They took data from 50 countries reporting COVID-19 mortality and performed statistical analyses to see whether those that enacted strict lockdowns had fewer COVID-19 deaths. They did not.
A similar analysis, by a Dr. Leffler and colleagues, used data from 200 countries and was published in the American Journal of Tropical Medicine and Hygiene. It likewise found no effect of lockdowns on COVID-19 mortality.
These papers can be criticized, and perhaps better data will one day supersede them. But for now, the cold, hard fact is that lockdowns do not seem to achieve what one might hope.
This might seem counterintuitive. Surely, if we all stay home, we cannot transmit the virus to each other, and if the virus doesn’t transmit, it cannot kill, right? Well, no, it’s more complicated than that.
For one thing, we will never have a perfect lockdown in which absolutely everyone stays home for all the time. More importantly, COVID-19 is not an equal opportunity killer. While the overall mortality is low (a recent World Health Organization bulletin estimated a less than 0.3 per cent mortality rate), it is up to 1,000 times more likely to kill someone over 70 than someone under 30. Therefore, the total number of deaths in a COVID-19 pandemic will not depend so much on how many cases there are but rather in whom those cases occur.
It’s easy to imagine situations in which a general lockdown could inadvertently expose vulnerable people to COVID-19: if universities shut down and students are sent home to their older parents, if working people can no longer afford their rent and enter multi-family living arrangements, if daycares are closed so health care workers have to involve grandparents for child care etc.
This is why I favour a focused protection plan in which we pour resources into protecting society’s most vulnerable, rather than subsidizing less vulnerable people to make unnecessary sacrifices.
And such resources we had to pour! The federal government has gone $350 billion in debt this year to pursue misguided lockdowns. For reference, $350 billion, adjusted for inflation, is more than we spent fighting the Second World War over six years.
That $350 billion could have built two new hospitals in every city and town in Canada! If we purport to care about our elders, we must stop and imagine what $350 billion could have done to ameliorate the chronic understaffing and sometimes squalid physical conditions of our long-term care homes.
How many lives could that strategy have saved? We need to ask such questions before we shoot ourselves in the other foot with a second lockdown.
So much for the supposed benefits, what about the harms? Evidence thereof is mounting. Three times as many Canadians were contemplating suicide this summer compared to last. In British Columbia, overdose deaths nearly tripled. I do not expect such trends to improve during a cold, dark winter of lockdowns with no Christmas.
The Globe and Mail reported a spike in violence against women back in May and a slew of missed cancer diagnoses up to October. In my own medical practice, I met only seven patients with COVID-19 over nine months, but I was admitting folks to hospital with lockdown-related illness almost every day.
One woman in her 80s, living in a retirement home, relied on family members to come feed her meals. When they were disallowed from the premises, she stopped eating. She was eventually sent to hospital for symptoms of confusion and weakness where she was found to have biochemical evidence of starvation. In Canada. In 2020. The sheer inhumanity of that scene will stick with me for a long time. I could describe many others.
Underlying each of those statistics, and all of the clinical vignettes I could share, is an ocean of individual suffering and family grieving that is not captured in the rising COVID-19 case counts featured in daily media reports.
COVID-19 is a devil of a problem, but we must be mindful not to employ unproven strategies with the potential of making the problem worse. I am very hopeful that by focusing our attention and effort where it matters most, we could see our way through this in better shape overall.
Throughout history, the arrival of contagious pestilences saw broad community efforts keep people apart and reduce spread. This was reflected in our lexicon with phrases like “avoiding someone like the plague” and the concept of quarantine, which was derived from Venice’s 40-day at sea quarantena during the same era. Humanity has always understood that a disease that spreads from person to person cannot spread if people are not meeting.
Without intervention, novel illnesses (i.e. for which humans do not have innate immunity) threaten communities in various ways. Rapid spread drives up infections, which can threaten lives and hospital capacity. Immune systems might overreact to a new intruder.
Finally, uncertainty drives fear and a loss of consumer confidence. With widespread contagion, it’s impossible to know exactly who is ill, which in the end still impacts how people come together.
Thus, closures or restrictions can serve as useful and powerful tools in the right circumstances. At the appropriate moment, imposing broad closures immediately decreases interactions and interrupts transmission, which saves lives and protects the health care system in the short run.
If kept to the shortest time required, with supports provided, the intervention can also help mitigate the indirect impacts of the pandemic on the community. In the long run, preserving life and health for more people also means a more robust economic recovery.
It’s important to remember that not all closures are created equally. When instituting measures in a pandemic, communities are ultimately threading a needle through two extremes: mitigating the harms of uncontrolled viral spread against those of the mitigation measures adopted.
Closures that are particularly severe can disrupt communities, isolate people, and cause economic stress in a manner similar to widespread viral circulation.
That’s why most public health specialists favour an adaptive approach, with reopening along with testing and tracing where case counts are low, and a return to closures where growing cases and hospitalizations begin to threaten.
This also reinforces why it’s so important to provide broad financial and social assistance to help the community through any closure. It protects people and businesses disproportionately impacted by the closures, tilting the scales towards the benefits reaped by controlling the virus.
Opponents of closures point to the negative effects on the community, especially among our most vulnerable: the elderly, essential and front-line workers, small businesses, and those experiencing poverty, homelessness, or mental illness.
What they miss in this line of focus is that uncontrolled viral spread also negatively impacts those same populations, as people fall sick and fear for their lives — with the added spectre of deaths and long-term disability to boot.
Around the world, we have seen what happens if a closure doesn’t arrive in time: community after community ravaged, along with the devastating consequences imposed on patients and front-line workers.
Certainly, closures themselves can impact health care services too, but uncontrolled viral spread almost always sees hospitals overwhelmed, with patients turned away, surgeries and treatments cancelled, and health care workers traumatized. When the trajectory points toward this happening, one must act.
Closures are one tool in the pandemic tool box, intended to be deployed in specific circumstances, over a limited period, with appropriate supports. Done well, closures are a useful tool to addressing the immediate threat of viral propagation. The negative effects are understood but can be mitigated.
It’s also worth noting that such impacts are also ultimately short term and would equally be visited if the virus ran loose.
As cases and hospitalizations continue to rise in Peel Region, I welcome discussions around additional closures to bring COVID-19 under control in the immediate term. Reducing person-to-person interactions would bring short-term relief, buying us time to address the underlying disparities and inequities that drive transmission in our community.
Proponents of a balanced approach sometimes forget that when the balance tips towards controlling COVID-19, you must act decisively to turn down viral spread so the community can stay open with confidence.
Hence, as one of many tools in my tool kit, I would not hesitate to call for broader closures should it be warranted in the community that I serve; doubly so if appropriate supports are provided to help the most vulnerable members of our community through the difficult moments.
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