COVID 19: What's working, what's not, and why.

 COVID 19: What's working, what's not, and why.

--by Stewart Vriesinga                                                                              

 

Over the past year my understanding of COVID-causing novel corona virus SARS-CoV2 has evolved considerably. So have policies, mitigation measures,  and Public Health orders, not to mention the virus itself. Some of what we thought we knew was wrong, or has been called into question. Other things we never knew, and are still learning. Consequently some policies have become incomprehensible, contradictory, political, ineffectual, or, at best, based on old debunked science. At worst policies are more concerned with an existential threat to the economy and the popularity of elected officials among their support base, and less concerned with the fate of their most vulnerable citizens and those charged with looking after them.. 

I've tried to keep up with the science and tease out the most current, credible, science-based bits of information from no small amount of baseless conjecture, wishful thinking, the biases introduced by competing economic priorities, and far-fetched conspiracy theories. I am no expert, but I have tried to suss out those who are, and modify my opinions accordingly. While most were not, some authors and studies were very compelling. That said, this is nonetheless an opinion piece. You've been forewarned. 

In my opinion some things are not getting the attention they deserve, while other things are getting far more attention than they deserve. Fomite transmission and outdoor transmission would fall into the latter category; while they may play a role in transmission they are not the primary sources of transmission.  In the former category we have aerosol transmission, super-carriers, and super-spreader events, all of which do play a major role in transmission. The opportunity costs of putting too much emphasis on less effective containment measures comes at the expense of fully pursuing the most effective, all be they less popular, measures. I fear that the most effectual measures are taking a back seat to more popular, more convenient, but less economically and politically costly, and less effectual measures.    

Here is what I think we now know:

We know that the primary mode of transmission is through very fine aerosol droplets that can remain suspended in the air for hours. While time and greater distance from the source results in increasing dilution, even to the point of effectively neutralizing it, there is no magical cut-off distance past which this virus cannot travel --not six feet, not thirty-six feet, not one hundred and thirty-six feet. (See First10EM: COVID-19 is spread by aerosols: an evidence review )

We also know that transmission depends on the amount of aerosol in the air, and how long someone spends in a space where there is significant airborne virus in the air. Spending a very short period of time --say ten minutes or less--in a space where there is airborne virus is not likely to result in transmission.  On the other hand, entering and spending time in a poorly ventilated crowded space, even shortly after all the people have left, can and does cause transmission. Inversely, outdoor, sparsely populated and well ventilated spaces are highly unlikely sources/causes of transmission. 

Furthermore, there is compelling evidence suggesting that we are not all equal opportunity spreaders. A very small number of people have a very high viral load, and can easily infect numerous other people, even if they themselves are asymptomatic or presymptomatic.(1.)  Such people are sometimes referred to as "super-spreaders". There are no known markers --no way of knowing who the super-spreaders are--without testing and measuring the viral load of each particular carrier. Most people infected with the virus do not go on to infect anyone, or infect very few people. Only 2% of carriers carry 90% of the virus, and ostensibly do 90% of the spreading. (See Medical Press: 2% of people carry 90% of COVID-19 virus, and roommates are safer than you think, also see The Colorado SUN:  How CU scientists identified coronavirus “super-carriers” by collecting gallons of students’ spit.)

Only broad-based asymptomatic screening and testing can identify presymptomatic and asymptomatic cases of COVID infections. Only measuring the viral load of each known carrier will determine whether or not positive cases are highly-contagious super-spreaders, or whether, like most positive cases, they have a very low viral load and therefore are unlikely to infect anyone.  Therefore contact tracing, usually considered to be the most effective way of learning who each positive case may have infected while contagious, should be used primarily to determine where and by whom a positive case became infected in the first place. The latter requires tracing positive cases back to the initial infection, some five days before they had incubated the virus long enough to test positive, and up to fourteen days or more before they began to show symptoms. (If they ever go on to show symptoms. Some 40% of carriers do not, especially if they are young, although that may no longer be the case with some of the new variants of concern (VOCS.)).(See BBC Covid test-and-trace: Is backwards contact tracing the way forward? )

From the diagram above we see the initial transmission has occurred days before a person tested positive, and even longer than that before they become infectious and/or display symptoms. The contact-tracing challenges and resources required to trace an infection back to its source --backwards contact-tracing--are far greater than the challenges of determining who an infected individual may have gone on to infect if/while they were contagious. The former requires identifying all contacts in the eleven or so days before the positive case was identified; the latter is only concerned with the four or five days that a positive case may have been at large spreading the virus. Yet, if the objective is to eliminate rather than merely manage community spread, backwards contact-tracing is the only way this can be done. Forward contact tracing is only likely to identify one or two positive cases, most of whom will not transmit the virus to others. The source of transmission must be traced to either a super-spreader event (as described above), or a super-carrier (also described above), or worse, some combination of both. Identifying those exposed in a super-spreader event, or to those exposed to a super-carrier, or both, will enable contact-tracers to locate and isolate large numbers of COVID carriers, some of which may also be/become super-spreaders. Despite its challenges backwards contact-tracing is by far the most effective tool we have to eliminate rather than merely manage community spread. Measuring the viral load of all carriers could identify super-carriers.

Below is a diagram of the most prevalent forms of transmission:

 

Super-carrier "A" is spreading the virus (bottom left). Many of those he/she encounters become infected. Most of those infected do not go on to infect others, although they may go on to infect members of their own household bubbles and perhaps one or two others. This pattern is repeated in every cluster that super-spreader "A" comes into contact with. Unless super-spreader "A" comes into contact with a very large group of people in a crowded, usually indoor, poorly ventilated space, where they could end up infecting almost everyone in that space --a super-spreader event triggered by a super-carrier. Even though 98% of those infected at a super-spreader event will not become super-carriers themselves, about 2% of them will. In a group of one hundred, two people are likely to become super-carriers in their own right, infecting clusters (bubbles) and triggering super-spreader events of their own. (Super-spreaders "B" and "C" above.) For these reasons eliminating rather than managing community spread must focus on using backwards contact-tracing to identify large numbers of carriers resulting from super-spreader events, and by avoiding all gatherings that could potentially become super-spreader events. Such gatherings include church services, sports events, weddings, funerals, other large social gatherings, etc., but most transmission we now know occurs in workplaces. Gatherings of so-called "essential" workers should wherever possible be eliminated altogether, unless they are indeed essential, and all "essential" and service-sector workers should be routinely tested and vaccinated, and offered the supports necessary for them to stay at home if they feel at all sick or have potentially been exposed to someone else who is infectious.

Out of an abundance of caution we may continue to sanitize surfaces to reduce fomite spread, put up plexiglass barriers in our workplaces and businesses, maintain a distance of six feet or more from others, perhaps even outdoors, all to mitigate the likelihood of droplet spread. But none of these measures prevent aerosol spread, and should never substitute for eliminating aerosol spread. Aerosol spread is the primary way in which COVID spreads. It usually occurs during a prolonged period of time --ten minutes or more--in a workplace or other indoor, crowded or recently crowded, poorly ventilated space. Masking reduces the wearer's chances of both becoming infected, and of transmitting the infection to others, both in the case of aerosol as well as close-proximity larger droplet forms of transmission.

The effectiveness of vaccines of preventing the spread is often over-stated. The efficacy rating of vaccines is a measurement of how seriously ill a vaccinated person is likely to get. It is not a measurement of how likely they are to become infected or transmit the virus to others. Two doses of Pfizer or Moderna means that recipients are 90% likely to be protected from serious illness resulting in hospitalization or death. They are likely to remain asymptomatic, regardless of whether they are infected or not. Even one dose of Pfizer or Moderna yields 80% protection. AstraZeneca is rated at 76 % for one dose, and 81.3 % for two doses. Johnston and Johnston only requires one dose, with an 85% efficacy in preventing severe COVID-19,and 100% efficacy in preventing hospitalization or death caused by the disease. As to the efficacy of any of these vaccines in preventing infection or transmission altogether:

“While COVID-19 vaccines authorized in Canada have demonstrated efficacy against symptomatic illness, hospitalization and death, there were only limited data on their ability to prevent asymptomatic infection or to prevent transmission to others,” said André Gagnon, spokesperson for Health Canada, in an email. “While the Department is aware of this study, until there is more evidence, continuing adherence to public health measures to protect those around you remains necessary.”

--source Global News

 

Vaccines, often touted as the solution to the epidemic, have in fact not been proven to prevent infection or transmission. Without a doubt they can, do, and have saved a lot of lives, and it is incumbent on everyone offered a vaccine to get one. But, with or without vaccines, COVID will continue to spread as long as there are those capable of becoming infected and spreading the virus, including those who have been previously  vaccinated and/or recovered.  Furthermore, the efficacy of vaccines in preventing disease is diminished over time. Its efficacy after six months is largely unknown. Finally, the efficacy of vaccines against some of these new VOCs also remains largely unknown, and in all likelihood even vaccinated/recovered people will require booster shots from time to time for continued protection from severe illness caused by VOCs and/or a decline in the  immunity vaccines conferred on previously vaccinated individuals. Some preliminary anecdotal evidence suggests that vaccines may indeed somewhat reduce the likelihood of infection and transmission, but their efficacy in this respect remains largely unknown, so masking, physical distancing, etc. remain in place.

All this to say that the proliferation of COVID will continue well into the foreseeable future, and our best course of action is to focus on the elimination of aerosol spread. Measures should include efforts to minimize large congregate indoor gatherings, efforts to ensure that everyone attending such a gathering is wearing a mask, has been screened including using asymptomatic testing, and all in attendance have been fully vaccinated.  We must also use backwards contact-tracing to identify and isolate each and every carrier and potential super-spreader.  We must not fall into the temptation of merely managing the spread based on available ICU beds, human resources, and economic and political considerations. Only the complete elimination of the spread will ensure our collective physical, mental, economic and political well-being, and allow things to turn back to 'normal'. Preferably not the 'normal' of the past that has left, and continues to unnecessarily leave large sectors of the population extremely vulnerable; a vulnerability further exacerbated by containment measures that further increase inequities, often punishing the most vulnerable without achieving any real and lasting reduction in transmission.

My concern is that too often we are putting our desire for economic recovery ahead of public health. The desire for economic survival and recovery must not be allowed to eclipse the need to end the proliferation of this virus. Public health measures that are deemed to adversely effect economic activity are too often eschewed in favour of half-measures that do little to end this pandemic. For many governmental  financial supports aren't enough; economic recovery requires a return to a pre-pandemic steady supply of cheap low-wage labour. For many the existential threat is not COVID; it is losing the source of cheap labour on which their businesses rely. This has been a major consideration for governments from the beginning. Businesses are continuously being bailed out, both directly and by ensuring them access to a continued supply of cheap labour. A guaranteed supply of cheap labour is achieved by; denying low-income workers sick leave; by failure to shut down non-essential unsafe workplaces; by keeping schools open so as to ensure that "essential workers" children's  needs are looked after as their parents continue to work; by allowing employers, not employees, to determine whether or not their work is essential; by providing the Emergency Wage Subsidy to employers rather than directly to employees; by providing rent subsidies to landlords rather than tenants; by refusal to vaccinate and test essential workers, etc. 

 

Even so, some people are still concerned about access to cheap labour.  They have names: New Brunswick's Premier Higgs,  Alberta's Premier Jason Kenney, Manitoba's  Premier Brian Pallisterare, Conservative finance critic Pierre Poilievre, and The C.D. Howe Institute, to name but a few (2)--all calling for an end to emergency benefits, not for large and small businesses, but  for the working poor. They want to end the benefits because such benefits --namely a paltry $2,000/month CERB payment--are "a disincentive to work", and are making it difficult for businesses to recruit workers. Businesses accustomed to paying their workers sub-subsistence wages are exercising an inordinate amount of power and influence, not to protect us from this pandemic, but to protect themselves from having to pay fair wages to their workers. This is not about protecting people from COVID; this is not about getting us through an 'we're all in this together' pandemic; it's about protecting employers from social justice --from having to pay their workers a living wage. They want economic recovery, complete with all its social and economic injustices. It is absolutely abhorrent! Yet it seems to be the driving force for much of government policy in the midst of this horrific pandemic; a pandemic that continues to present an existential threat to the lives of millions of society's most vulnerable members while it runs our front-line healthcare workers into the ground.

What happens next will be determined by the most influential. Alas! It doesn't look like those most adversely impacted --the  most vulnerable, the working poor, the  essential workers--will be the decision-makers here. 

COVID 19: Whose bubble will be the first to burst?

"We are all in this together" we are repeatedly told. It is true that the COVID 19 virus doesn't discriminate on the basis of nationality, race, gender, or class. In the early stages it seemed that relatively wealthy business travellers, international tourists, and cruise ship passengers were more likely to be infected than those who lacked the means to travel. Snow Birds, returning from their southern winter homes, tourists and business travellers were the primary carriers responsible for the rapid global spread of the virus. A slow and sometimes reluctant response, further exacerbated  by a lack of PPE, undermined efforts by countries to trace, isolate and quarantine all likely carriers in order to prevent community spread of the virus. Healthcare systems were quickly overwhelmed, unable to cope with the large numbers of critically ill COVID 19 patients. Most governments responded with lock-downs, shutting down all but the most essential businesses and confining people to their homes in an effort to curtail the rapid spread of the virus --in an effort to flatten the curve. Economies ground to a halt. Countries with enough credit to do so, Canada included, introduced multi-billion dollar quantitative easing programs to sustain industries, businesses, and newly unemployed individuals during lock-downs.

But, although the virus itself didn't discriminate on the basis of class, the measures to control the spread certainly did! Most countries unable to finance quantitative easing, implemented and enforced lock-downs nonetheless, resulting in a dual crisis --the novel corona virus and a food security crisis for the majority of their citizens no longer able to buy food because they were prevented from going to work during the lock-downs.

Even in wealthier countries it quickly became apparent that the virus was spreading far more quickly among the most vulnerable sectors of the population --the aged, the homeless, those in long-term care facilities, those living in overcrowded substandard housing, foreign workers on farms or in the meat-packing plants. Low-income front-line workers in grocery stores, public transit, healthcare professionals and support staff, personal support workers (often forced to work at two or three part-time jobs in different long-term care facilities and/or private homes to earn a living wage) were all far more exposed and vulnerable than those able to social distance and safely work from home. While the virus itself didn't discriminate on the basis of class, wealthier individuals were certainly far more able to socially distance themselves from the high risks of exposure to which much of the workforce  employed in the essential service sector were subjected. Consequently the latter was far more frequently infected. 

But while more privileged citizens are better able to limit their exposure to the virus, they are nevertheless not immune to the economic impact of the virus. Much of the economic impact is due to a sharp decrease in global demand for the goods and services produced by formerly lucrative sectors of the economy in the pre-COVID 19 world; sectors like tourism, fossil fuel production, hospitality, air-travel, food services, etc. Even extractive industries, livestock producers, etc. have suddenly found themselves without buyers, while fabricating industries suffered interruptions in overseas supply lines. Governments portray this decline in demand as something temporary, attributing it to the lock-downs. They insist that once lock-downs are lifted, and people are free to resume their  former activities, they will once again flock to restaurants, travel to tourist destinations, book flights, burn fossil fuels, etc., and the economy will rebound. Our leaders seem inclined to see their task as building a bridge, an overpass of sorts, that will allow us to transcend this pandemic until it passes and things return to the way they were before, ostensibly complete with all its gross inequities, disregard for vulnerable populations, and climate crisis.

Here in Canada, as elsewhere, governments are now easing lock-downs. Despite low levels of testing, and the relatively recent discovery that screening people based on symptoms may miss 50% or more of contagious asymptomatic carriers, governments are confident that they can shut things down quickly enough to avoid a second wave that would once again overwhelms the healthcare system and further decimate the economy. While many business owners, alarmed by the prospect of losing their investments are eager to reopen, many of their workers are far less confident that the safety measures in place will adequately protect them. They don't want to be the expendable canaries in the coal mine, and may need a lot of persuading. Here in Canada PM Trudeau recently unveiled his plan for such persuasion.

By disqualifying people who prefer getting EI benefits or $2,000/month CERB benefits to returning to their high-risk service-sector minimum-wage jobs, they will be left with no choice but to return to work. People who somehow miraculously manage to pay their rent and buy groceries with a mere $2,000/month may be unwillingly to return to work and unnecessarily expose themselves and their families to  higher risks of COVID 19 infections. Especially if their pay-cheques wouldn't amount to much more, or in come cases even less, than what they are receiving under EI or CERB benefits. Such workers must, therefore, be subjected to the same harsh options as poor people living in poor countries --the option of staying at home and watching their families slowly starve to death; or assume the risk of going out to work in the hopes that they won't take home and pass on the virus to family members and loved ones. In most cases it is highly unlikely that any Canadian who can both buy groceries and pay rent with a mere $2,000/month can afford accommodations that allow for much social distancing anyway. It may seem unjust, but in most cases their risk of exposure in the workplace can't be that much worse than futile attempts at social distancing in cramped, often substandard and overcrowded housing --the only standard of housing that a total income of $2,000/month will afford them.

Sure, it may be a misnomer to refer to most service sector jobs as essential.  Imported goods and clothes from far away places, hair styling, manicures, restaurant  meals and coffees are things most fellow Canadians. even those from the relatively privileged work-from-home crowd, can live without. But those unaccustomed to their newly acquired work-from-home duties, what with doing their own childcare, home-schooling and all, really miss the contributions of the service sector. They don't have time to prepare their own food, and despite everything must still appear competent, presentable and in control during their work-related Zoom calls. In addition to ordering skip-the-dishes take-out food, some may even want to venture out once in a while! After all the slight risk of being exposed to one vetted waitress/waiter/hair-stylist/store clerk or whatever in a well PPE equipped facility is almost negligible when compared to the risks assumed by the service providers themselves who are exposed to dozens of customers every day! A little relaxation of social distancing rules is okay if one is careful not to unnecessarily mingle socially with the service-sector class. A visit to the hair stylist should be a brief sortie, not unlike a fleeting encounter with the native chambermaid who changes your bed sheets in a tropical island resort.

In any case, even those services provided by service sector workers that are more appropriately described as desirable rather than essential, in a country were 70% of the workforce is employed in the service sector, even non-essential service sector jobs are essential to restarting of the economy! Flattening the curve was never about eliminating the risk; it was about reducing the spread to a numbers that our healthcare system can cope with. It just so happens that it is easier to reduce the risk for the work-from-home crowd than for service sector workers. But we are all in this together! The economic futures of both service sector workers and the work-from-home crowd are at stake!

So, since we cannot reduce the level of risk for service sector workers to that of the work-from-home crowd, we must at least put in safety measures to mitigate that risk. Service sector workers reticent to return to work need to be convinced that with new safety measures in place continuing to provide them with EI and CERB benefits can no longer be justified. However, there is one remaining impediment preventing may service sector workers from going back to work: the lack of childcare. For that reason, regardless of risk, daycare services and schools must also be reopened.

It is totally unrealistic to expect children –especially very young children-- to adhere to the rules of social distancing. Children want and need to touch each other or the physical reassurance and/or help from their care-givers and teachers. While the majority of children infected with COVID 19 will not get very sick --some will remain completely asymptomatic, they can and some will nevertheless become carriers and spread the virus to more vulnerable people they come in contact with --their teachers and childcare providers, siblings, parents, grandparents and whoever else is part of their household bubble. And some children will become sick with inflammatory syndrome, usually some time after previously having contracted and developed antibodies to the COVID 19 virus. Screening for and reducing the risk of spread where children are involved is going to be far riskier than other workplaces where only mature adults who fully understand the need for and rules of social distancing are present. Nevertheless too many of our service sector workers cannot return to work if there is no one is looking after their children. Therefore restarting the economy leaves us with no choice but to put both service sector workers and childcare providers in double jeopardy. If the service sector workers themselves don't unknowingly bring the virus into their home, there is still a good chance that their children will have caught the virus from an asymptomatic classmates and bring the virus into the house! 

Be that as it may, given that 70% of Canada's workforce is employed in the service sector, they must go back to work. Lending billions of dollars to failing airline and oil industries that in all probability will go into bankruptcy long before they can repay these loans may be an extremely foolhardy investment on economic grounds, but  it is nevertheless a wise investment in the political futures of elected representatives. But that does not extend to giving free money to service sector workers minions so they can stay safely at home and sit on their duffs! An economy cannot be restored if people forget their proper place in it! Fortunately the problem of childcare too can similarly be solved by ensuring that daycare providers, school teachers, school bus drivers, etc. will also find themselves without any source of  income should they fail to take up their yoke and choose to continue safely social distancing with their own children in their own homes.

Decision-making power was never the purview of the lowly underpaid service sector workers. Much care has been taken to maintain the pecking order --to ensure in the post-COVID 19 economy it continues to be the employers, not the employees, who retain decision-making power. That's why whenever possible, instead of directly providing an income to unemployed workers, governments choose to subsidize employers in exchange for them keeping unemployed workers on the payroll. Similarly, rather than providing individuals and businesses unable to pay their rent with money, governments instead encouraged landlords to apply for subsidies with the expectation that they would pass on their savings to tenants. (Many landlords who had long wanted to get rid of their tenants so they could increase rents turned down the subsidies.) Thus it is the employers, not employees, who will determine whether or not the benefits of reopening up for business outweigh the risks. Once employers feel that they have put enough safeguards in place to keep their employees “reasonably safe" as stipulated by government guidelines, they will be allowed to re-open. Former employees who refuse to return will suddenly find themselves ineligible for EI or CERB benefits, and therefore obliged to return regardless of whether they feel it is safe to do so or not. Workers who think their working environment is unsafe can appeal. If they live long enough for their appeal to be heard, and if they and their legal team manage to convince the province that they were indeed exposed to an unreasonable amount of risk, and if after all that they are still being exposed to unacceptable level of risk, their benefits will be reinstated. Until then they and all those who share their household bubble must accept whatever level of risk their employers deem to be acceptable under the circumstances and in accordance with their interpretation of government guidelines.

"We will get through this" is refrain we often hear from our leadership. And undoubtedly most of us will. But there will be a few bubbles burst before this pandemic is over. Bubbles based on false assumptions that former levels of demand for tourism, air travel, fossil fuels, restaurant food, hotels, office space etc. will be restored; Bubbles based on the assumption that the economy will recover in time to fend off a recession and an unprecedented increase in declarations of bankruptcy; Bubbles based on assumptions that governments and society have learned their lesson and will henceforth place a higher value on the welfare of its most vulnerable citizens, and acknowledge and properly remunerate the contributions and sacrifices of their most essential workers will also deflate, succumbing  to pressure from the usual more influential decision-makers in the economy. But these won't be the only bubbles to burst. Nor will they be the first.

The first bubbles to burst will we the protective household social-distancing bubbles that for a short while protected the working poor, primarily employed in the service sector, from disproportionate risk and exposure. Their protective bubbles are about to be deliberately burst by the state in an effort to force them back to work. This group includes racial minorities, foreign workers, personal care providers, and indigenous peoples. They and their children and households, much like Greta Thunberg and her generation, will be sacrificed on the alter built to that old but omnipotent and increasingly demanding God --the God of economic growth.

It will be thus. We are all in this storm together, but we're not all in the same boat. Some of us are treading water, clutching to a plank like a refugee in the Mediterranean. Others are social-distancing in their mansions complete with swimming pools and gymnasiums.

Unless we seize this opportunity to build a new, just, sustainable and inclusive economy on the rubble left by this global pandemic; an economy that values the lives, safety, health and rights of workers no matter what their nationality or where they live on this planet; an economy rooted in the abundance provided by a healthy, appreciated, respected and well cared for planet; an economy that prioritizes our collective and universal well-being and seeks to promote our collective opportunity to thrive. An economy that rejects and has completely abandoned the unsustainable annihilating environmentally destructive perpetual pursuit of economic growth .