(Editor's note: This story was published before Ontario declared a state of emergency, which has a significant impact the views and conclusions expressed in this story. See here for an update.)
The provincial government has moved too slowly to implement social distancing measures to protect the public from COVID-19 and it may already be too late to prevent the province's intensive care units from becoming completely overwhelmed in the coming days, epidemiologists and frontline doctors warned Monday.
"The important thing is to act to prevent the very predictable catastrophe that is coming," Dr. David Fisman, an epidemiologist with the Dalla Lana School of Public Health, told QP Briefing on Monday morning.
He said he's concerned because he has modelled the possible outcomes for the spread of COVID-19 in Ontario and compared it to the number of Intensive Care Unit (ICU) beds in the province.
"If this hits us in a wave all at once, we can't keep up with it, we will drown," he said. "That is a positive feedback loop in terms of deaths, because not only do you have the epidemic killing people slowly in the ICUs, you have the epidemic killing people fast, because they can't even get into ICUs."
He, and others, called on the province to implement much stronger social distancing measures.
And by the end of the day, Ontario's Chief Medical Officer of Health Dr. David Williams had announced some new steps. He is recommending against gatherings of over 50 people, recommending all daycares close, asking bars and restaurants to close with the exception of takeout and delivery services, and recommending people work at home if they can.
He did not have any direction concerning non-essential businesses such as clothing stores, or for transit systems — saying only that those things should be further discussed.
Following Williams' announcement, Fisman said the measures are an improvement, but would be better if they came as an order under the Health Protection and Promotion Act, rather than a request to the public.
Meanwhile, the federal government ramped up its border measures, announcing that only Canadians, permanent residents, and Americans will be allowed in the country, and said no symptomatic people will be allowed in the country. Prime Minister Justin Trudeau also urged Canadians to avoid non-essential travel, for Canadians abroad to return home while they still can, and for all Canadians to stay home as much as possible.
But according to Fisman and others, the measures taken so far may not be enough to prevent the intensive care units at Ontario hospitals from becoming overwhelmed.
Fisman's modelling was based on the number of ICU beds in the province — there are about 2,000, 1,311 of which have the ventilators COVID-19 patients require, according to government data. Fisman said 90 per cent of them are currently occupied.
"That means we have an ICU capacity in Ontario of a bed per every 100,000 adults, facing a fairly large, likely imminent epidemic that has the signature feature of sending people into respiratory failure," Fisman said. "So, that's a problem and there's no ready way, in the face of a global pandemic, to quickly scale up capacity, because everybody else wants ventilators too right now."
Part of the reason political leaders may be slow to act, according to Fisman, is the progression of COVID-19 involves time lags — about 16 days from the time a person is infected to when they may need to be put on a ventilator in the ICU.
"Things can look very quiet, but the transmission events — the disease transmission that is going to fill and then collapse your ICUs — may have already happened," he said. "So the difficulty is we have a public health community, a public health leadership that seems to be reacting to what you can see right now, rather than what's around the corner, when what's around the corner is very predictable if you understand how communicable diseases work...which they are supposed to."
Waiting to respond to the crisis will ensure a crisis, he said. Toughening up social distancing measures to ensure that people don't go out to socialize and work, and keeping schools closed over the longer term, slows down the speed of the spread and pushes it back to later in the summer, buying the health-care system time to deal with it, preventing some avoidable deaths, he said.
Meanwhile, Dr. Michael Warner said his concern is the number of critical care physicians in the province — there are only about 400, and each typically only cares for 12 to 16 patients a day, and they would be overwhelmed if COVID-19 peaks in Ontario as it has in Italy.
"They're practicing what we call catastrophic medicine in the richest part of Italy, in Milan," he said. "People are dying in the hallways. If you're over 65 and your heart stops, nobody comes. If you have a non-COVID illness, say you overdose on fentanyl and you're 20 years old, there's no ambulance to pick you up."
He said avoiding those deaths from COVID-19, and collateral deaths from an overwhelmed health-care system, requires a complete shutdown of public activities including private business and public transit.
"We need strong language, we need definitive language from the government and policy makers," said Warner. "If we don't do it in a timely manner the window of opportunity to reduce the spread of this will be closed, and once's its closed, it's gone."
Until Monday afternoon, Ontarians had generally been told use their own judgement to decide what what kinds of social-distancing measures to employ.
For example, asked Monday morning if people should go out to crowded bars to celebrate St. Patrick's Day, Health Minister Christine Elliott replied, "We're recommending people be very cautious about that — make your own judgement," Elliott replied, and urged people planning events to contact their local public health unit. "Certainly we would discourage people from going into large gatherings tomorrow as on any other day."
But as a result of Williams' Monday afternoon announcement, it's now more likely those bars will be closed.
Both doctors were highly critical of the Ontario government's communication through the crisis.
"I see the advice they are giving as completely non-sensical, irresponsible, and completely ridiculous. People need clear, definitive advice from people they trust," Warner said, adding that he's speaking out to the media is to lend as much of his credibility as a physician to warning people before it's too late.
For his part, Fisman decried the "utter failure to communicate... what's going on."
"I'm an epidemiologist working about a block up from Public Health Ontario and I'm in the dark as anyone else is," Fisman said. "There is a culture of non-transparency, high-handedness, and there's no communication with the media. The media are regarded as antagonists rather than allies. It's a major problem. It's not how you deal with normal epidemics, much less a pandemic of this magnitude."
"If things play out as one expects them to play out we're going to have some changes in terms of public health in Ontario, the problem is that's going to be in reaction predictable disasters and I'd rather not have the predictable disasters," Fisman said.