This commentary is adapted from a version that was originally posted by Policy Wonks. It summarizes a full strategy document that can be found here.
This document outlines a strategy for emerging from the COVID-19 lockdown in a way that permits most social and economic activities to resume without sacrificing health and safety. The proposed strategy is described here in conceptual terms but our full report is complemented with an extensive set of annotated references that provide supporting evidence and contain links to detailed accounts that can inform implementation. The proposal is presented in a Nova Scotia context but would be equally applicable in any jurisdiction.
Balancing safety and openness through better information
The COVID-19 lockdown has been achieving its purpose. The curve has more than flattened. New infections and deaths have trended down, although to varying degrees across provinces. But the emotional and economic toll is trending in the opposite direction. Now that summer is upon us and various jurisdictions relax their restrictions, growing numbers will refuse to remain cooped up. The dilemma is that neither will the virus remain cooped up. Public health experts know that the threat of a second wave is inevitable without an effective containment strategy. So the question everyone is grappling with is how to continue to safely restart social and economic life in a way that ensures we don’t find ourselves right back where we’ve just been.
Complicating the decision is a polarization of attitudes between, 1) those who believe that advocates of extensive reopening value dollars more than lives, and 2) those who believe that the economic costs of continued restrictions have not been given enough consideration in reopening plans. Certainly, health must not be sacrificed in hopes of quicker economic recovery because unless most Nova Scotians are confident that it is safe to venture out, economic life will remain stunted. That is why good health is also good economics. The polarization of attitudes nevertheless persists due to an implicit assumption that there is an inescapable trade-off between safety on the one hand, and closer-to-normal activity on the other, making it impossible to devise an approach to COVID-19 that would allow more of both. The purpose of this document is to show that there is such an approach.
The key to having both more safety and more activity is to have more information. During the first wave of the pandemic, when information and understanding were limited, it was prudent to impose blanket restrictions on non-essential activity on the assumption that it was equally likely that the virus could be anywhere. By now we have learned a great deal from experience in Canada and around the world. With much more timely and comprehensive information about the modes of transmission of the virus, who is infectious, who are their recent contacts and who is likely to be immune, we can become far more targeted in combatting COVID-19. By combining better information with substantially increased public health resources, we can avoid trading off safety against more normal activity. We can end up with both better health and better economics.
A five-point information-based strategy to cope with COVID-19
Think of a forest fire as a metaphor for the pandemic. The strategy is to first bring the blaze under control, reduce it to a smolder, then focus on spotting and snuffing out the sparks the moment they appear. The objective is to suppress the virus and prevent a second wave while permitting the greatest feasible return to normal life. This approach has been described in different terms as “Hammer and Dance” and “Whac-a-Mole,” the latter by analogy with the arcade game. (For ease of reference we will refer to the strategy as “WaM.”) There are five core elements:
- Drive the Incidence of New Infections to Zero: The first requirement is to maintain tight restrictions until the daily number of new cases has been reduced to zero, or close to it, for at least two weeks — as Manitoba, Nova Scotia, Newfoundland and Labrador, New Brunswick and P.E.I. have already achieved. This is an essential precondition for everything else. Although the virus may still be present, the potential number of new cases would then be small enough to make identification and contact-tracing manageable, thus minimizing the risk of a second wave and lockdown.
- Mobilize and Enhance Public Health Resources: The strategy required for a safe reopening is very different from the blunt instrument of lockdown that was needed to suppress the initial epidemic. Public health resources — human, material and technological — urgently need to be beefed up so as to keep the virus bottled up in the face of resumed social and economic activity. The more effective the public health measures, the more complete can be the return to normal life. Public health capacity is therefore the linchpin of the reopening strategy. Whatever additional investment is needed is justified by the payoff (see Point 5 below).
- Sustain the Good Practices We Have Already Learned: Experience has shown that certain situations greatly increase the risk of transmission of the virus — for example, indoor gatherings of large numbers of people in close proximity with poor ventilation, talking loudly or singing. These and similar situations need to be prohibited unless there is assurance that the risk is negligible. The limited number of prohibitions need to be complemented with more general risk-reduction practices — such as physical distancing where practical, mask-wearing in many public situations and rigorous hygiene.
- Test and Trace and Keep Doing It: Implement repeated testing of those who work in high-risk environments — particularly long-term care and other health facilities, homeless shelters, prisons and other situations where people are forced to work in close contact. These regular testing procedures need to be complemented with proactive testing of the general population but targeted more intensively in areas and situations determined to be of greater risk. Such determinations would be based on continuous up-to-the-moment information on infection within the province as well as in areas from which visitors originate. Testing must be followed up immediately by tracing the contacts of anyone who tests positive and then ensuring that those who are infected remain isolated for at least two weeks. Provision for alternative residence will need to be made in situations where isolation is not possible in the individual’s normal location, such as in shelters for homeless persons.
- Create a “WaM Unit” to Organize and Direct the Strategy: The foregoing activities need to be conducted on the equivalent of a war footing in light of what is at stake in terms of lives saved, overall health, and social and economic wellbeing. To take just one example: if safe reopening were to reduce the otherwise anticipated economic loss by even three percentage points of GDP, COVID’s toll on the Nova Scotia economy would be reduced by $1.4 billion over the next 12 months. The achievement of such savings — including the social and psychological wellbeing that would result — requires a full-time group to manage execution of the strategy. A diversity of skills will be needed, including epidemiology, testing, contact tracing, infection control, data management and analysis, procurement and logistics, business economics, public communications, and an “intelligence group” to keep fully abreast of the latest research and practice worldwide. Many of the skills would be seconded from within government (provincial and possibly federal and municipal) but others will likely require secondment from the private sector, universities and retirees (e.g. nurses and doctors).
Better health and better economics
It may appear that the strategy outlined here could not create a path to reopening that is safer than more cautious and gradual approaches. But the fact is that public frustration with a more limited pace and extent of reopening could lead to growing non-compliance, degenerating into a disorderly departure from the intended course, thus increasing the risk of transmission. There are already signs that this is what is happening in some parts of the U.S. There is also compelling evidence of adverse health impacts associated with tighter restrictions. The more that restrictions can be relaxed without increasing the risk of an uncontrolled new outbreak, the greater the net health benefit.
Implementing WaM would furthermore be failsafe in the sense that the option of re-imposing more general restrictions always remains if that were necessary — for example, if a second wave in the fall became uncontrollable. The WaM strategy does not foreclose other options but makes it much less likely they will be needed.
Implementing WaM requires both discipline and a resolve to stay the course when new cases inevitably arise — for example, as New Brunswick recently experienced despite an appearance that the virus had been thoroughly suppressed. The purpose of WaM is to deal with such circumstances without having to resort to widespread lockdown. That is why WaM emphasizes extensive testing to identify cases quickly, and contact tracing to immediately ring-fence the spread. The measure of success is that sparks do not become fires.
Still, no strategy can be without risk and the public must be led to understand and accept that uncomfortable reality. Here is where effective public communications can deliver enormous dividends because, without widespread public confidence, economic recovery will be crippled.
The WaM approach needs to be evaluated against the alternatives. More restrictive approaches are unsustainable socially and economically and would eventually be undermined by noncompliant behaviour. Less restrictive approaches, on the other hand, will not inspire the widespread public confidence needed for economic recovery and will lead eventually to a major new outbreak. WaM strikes the best balance.
The pandemic has taught the world the essential importance of an excellent public health infrastructure. Post-pandemic, it will confer a new competitive advantage in attracting investment and new residents. With a total commitment to testing and tracing, Nova Scotia can implement a reopening strategy that would earn the province a reputation as one of the leaders in the global effort to defeat COVID-19, and therefore make Nova Scotia even better positioned for the future than before the virus struck.
Peter Nicholson has served in numerous posts in government, business, science and higher education, including as head of policy in the Office of the Prime Minister of Canada, a member of the Nova Scotia Legislature, the Clifford Clark Visiting Economist in Finance Canada, and Special Advisor to the Secretary-General at the Organization for Economic Cooperation and Development (OECD) in Paris. Jeff Larsen is the Executive Director of Innovation and Entrepreneurship at Dalhousie University in Halifax, and the Site Lead for the Creative Destruction Lab – Atlantic.
