Several former public health leaders wrote a joint letter to Canada's first ministers urging the country to take a "balanced approach" to managing COVID-19, stressing that governments need to consider both the risks of the disease and the risks created by the measures put in place to control it.
"The current approach to dealing with COVID-19 carries significant risks to overall population health and threatens to increase inequities across the country," the letter, sent to the prime minister and Canada's premiers on Monday, states. "Aiming to prevent or contain every case of COVID-19 is simply no longer sustainable at this stage in the pandemic. We need to accept that COVID-19 will be with us for some time and to find ways to deal with it."
The letter writers include former Ontario deputy minister of health Dr. Bob Bell, former president of Public Health Ontario Dr. Vivek Goel, former Ontario chief medical officer of health Dr. Richard Schabas, former chief public health officer Dr. David Butler-Jones, former chief public health officer of Canada Dr. Gregory Taylor and other current and former health and public health leaders.
The letter includes a dozen recommendations for how the country should proceed in managing COVID-19, but urged nothing that Canada's federal and provincial governments aren't already doing, or working toward. For example, the letter urges the careful reopening of schools, businesses and health care and improving infection control practices in long-term care.
Bell told QP Briefing it's a "very Canadian letter" in that it doesn't propose radically different approaches, but does urge that the measures be proportionate to the risk of COVID-19 — and here the letter writers urge a change in thinking.
The letter focuses on the risks to health from the public health measures, over the risk of COVID-19 itself, and says that Canadians have "become fearful of COVID-19 and are worried about the impact of working, seeking routine and preventive medical care, participating in religious and cultural events, interacting with their family and friends, using public transportation, shopping and other normal activities."
"We need to look at all features of risk, including non-COVID risks. Risks to the development of children, risks to social disharmony, we need to be looking at everything we're doing," said Bell, speaking to what spurred the group to write the letter.
He said, as the letter does, that most of the deaths from COVID-19 have been in older people, and said someone who dies at the age of 90 has less of an impact on overall premature mortality than a younger person.
"There have been many deaths due to COVID-19 and every single one represents a tragic outcome," the letter says. "However, in overall population health terms COVID-19’s direct impact on premature mortality is small. While those under the age of 60 account for 65 per cent of cases, they represent just 3 per cent of deaths. With ready access to health services, severe outcomes can be averted in those who do not have pre-existing risk factors."
Bell said that wasn't meant to minimize the deaths of older COVID-19 victims and that the letter calls for interventions to be targeted to those at highest risk, including older people in long-term care homes, while allowing as many people as possible to have smaller disruption of their lives.
That comment was echoed by professor of health law and policy Trudo Lemmens, whose research focuses on ethical norms and values in the context of health care. He said the letter proceeds to recommend measures to protect specific populations and emphasizes the inequitable impact on people in specific groups, including the elderly.
"I don't read this document as indicating we should just live with the fact that the elderly will die," he said. "They say we have to look at what has been happening, we have to look at the risk factors in general, and realize ... that the risks are more significant for some populations and maybe not as significant for the general population as we might have thought."
Meanwhile, one prominent epidemiologist was highly critical of the letter and its assertion concerning premature mortality, calling it "damaging and unfortunate."
Dr. David Fisman, an epidemiology professor at the Dalla Lana School of Public Health, told QP Briefing the letter writers "are out of the loop and don't have the standing to speak about mortality," as the only reason deaths under age 50 have been relatively rare is because public health interventions have been successful.
"I think you can look south of the border and see where the approach they advocate leads," he wrote in an email. "In the U.S., which has had a less aggressive control response, they're at 2.5 Vietnam wars worth of casualties (130,000 deaths) since March," he wrote. "Those deaths occur in all age groups, though mortality takes off sharply after age 50."
In contrast, Canada is doing relatively well in a difficult global context, with economic and social life reopening as COVID-19 becomes more under control, Fisman said.