Alberta Needs To Chase After Zero.
Foreword.
I am not an expert in public health, epidemiology, or pandemics. I am simply a person sitting in his improvised home office who desperately wants the pandemic to end. These opinions are my own.
My goal is to put together a cogent argument for why Alberta should adopt a strategy of elimination of the COVID-19 disease within our communities. To my frustration, there has been little serious treatment of the idea in this province beyond a select few shouting into the void on twitter. Elimination is still considered a radical idea by many, but there is increasing consensus that it is actually the optimal approach.
If you agree with some or all of what I write then I ask that you please share this piece on social media, and call or write your MLA and city councilor.
Alberta Has No Plan.
On February 27, 2020 the provincial budget was introduced. This document laid out the government’s priorities for the upcoming year. The word “pandemic” is nowhere to be found. The word “COVID-19” appears three times, twice in the context of oil prices, and once in the context of trade from emerging economies. Nowhere is the eventuality of community spread of the novel coronavirus in this province reckoned with.
This is instructive of how the pandemic has been managed here, which is to say begrudgingly and barely at all. Never has there been anything close to a comprehensive plan for how we will respond and what the goals of the response will be. The province has steadfastly refused to make the recommendations of the CMOH public, and do not explain the reasons for accepting or rejecting her suggestions. Until the latest round of harsher restrictions, public health measures were a confusing mess that left Albertans in the paradoxical state of being told that by law we cannot have a friend over for a drink, but we can gamble in a casino with hundreds of strangers.
In so far as the province has any ultimate goal, it is to keep cases manageable so as to keep the healthcare system from being overwhelmed, but what defines “manageable?” Is it a per-capita rate of active cases in the community? Is it test positivity below a certain threshold? Is it some percentage of hospital beds available to treat patients? We are not told.
Without any clear guidance and goals we have been left with a void that is filled with misinformation and echoes of the toxic partisanship and cultural wars that have erupted south of the border. This has allowed the virus to take charge and lead to exponential growth in active cases, hospitalizations, ICU occupancy, and death.
It doesn’t have to be this way.
What Is Zero Covid?
Zero Covid is the explicit goal of having no active cases caused by community transmission of COVID-19. It has also been termed an elimination strategy. Community transmission means the source of an infection in a community is not known. A case detected in quarantine at the border from a traveler is not community transmission. A person unknowingly exposed and infected in their workplace is community transmission. 80% of the currently active cases in Alberta are from community transmission.
A Zero Covid mentality takes the view that there is no acceptable level of spread within a community. It recognizes that “living with the virus” and accepting even a small level of community transmission leaves open the door to super-spreader events which can kick-start rapid exponential growth. Regions that have achieved Zero Covid don’t bother trying to keep spread “manageable,” because they have no spread to manage.
Zero Covid is a proactive and goal oriented approach instead of a reactive and ad-hoc approach. It means having processes in place to end outbreaks before they happen instead of scrambling to mitigate outbreaks after they happen. So far in Alberta, the virus has been calling the shots. We have had to respond to it. Adopting a Zero Covid mentality will allow us to reclaim our agency.
Zero Covid is a simple measure by which a pandemic response can be guided. It is a clear policy goal with an easy metric by which to judge success. It can be communicated to the public in plain language and provides a unifying goal that communities can rally around. Jurisdictions that have adopted a Zero Covid strategy have been wildly successful at ending community transmission and have shown themselves to be far more resilient to future outbreaks than places like Alberta and Canada that instead try to “live with the virus.”
Contrary to what many assert, Zero Covid is not impossible. It has been achieved in authoritarian countries (China, Vietnam), democracies (Taiwan, Australia, New Zealand), and those in between (Singapore, Thailand). As Robert Greenhill writes, the evidence suggests that Zero Covid is a credible, sustainable policy alternative.
Benefits and Feasibility.
Zero Covid solves the twin healthcare and economic crises wrought by the pandemic. It does so by rejecting the false idea that a choice has to be made between saving lives and saving jobs. Solving the healthcare crisis solves the economic crisis because the healthcare crisis is the economic crisis.
Despite what Premier Kenney has repeatedly asserted, there is no magical balance to be struck that allows both the virus to spread and the economy to remain open. Dead people can’t go shopping. Pandemic diseases grow exponentially. That is their defining property. Tolerating community transmission means that explosive growth is always right around the corner, and eventually it will kick in. Even the best case nations for the “live with the virus” strategy are finding this out.
Regardless of what the Alberta government may think, it is the virus that has shut down the economy, not public health measures. Restrictions on economic activity and public life are a necessary response to continued community spread. Even after restrictions were lifted in the spring, economic activity did not return to pre-pandemic levels. Continued community spread meant people restricted their movements and activities due to the perceived risk of the virus in our communities.
Within the next couple weeks Alberta, with a population of a little over 4 million, will have more COVID-19 deaths than Australia, New Zealand, Taiwan, and Vietnam combined. It appears that we managed to strike exactly the wrong type of balance. Enough spread to bring our healthcare system to the brink of collapse and send deaths skyrocketing while small businesses barely hold on.
Zero Covid does not mean a perpetual lockdown; it actually means the opposite. Jurisdictions that have adopted a Zero Covid approach have been able to return to a near-normal form of life, allowing their domestic economies to rebound. Places that try to “live with the virus” remain in recession.
Business owners and consumers in Zero Covid jurisdictions have the two pillars that functioning economies require — certainty and confidence. With a clear goal to get to zero cases of community transmission and stay there, business owners gain an understanding of how and when restrictions will be brought in and phased out without the fear of yo-yoing between lockdowns and opening up. Likewise, without the fear of community transmission, consumers can return to near-normal local economic activity and set the foundation for a lasting recovery. It is not an accident that Nova Scotia has the lowest unemployment rate in Canada.
Zero Covid jurisdictions have shown themselves to be much more resilient to future outbreaks. Since achieving elimination in June, New Zealand has 5 times managed to bring outbreaks seeded from abroad under control through targeted public health restrictions, testing, and contact tracing. They have avoided having to return to the hammer of lockdowns, unlike Alberta. At time of writing, Australia is using a combination of mass testing and contact tracing, targeted restrictions, and interstate travel restrictions to battle an outbreak in Sydney after successfully containing an earlier outbreak in Adelaide swiftly. In Canada, the Atlantic provinces achieved Zero Covid through successful early public health measures in March combined with forming an Atlantic bubble that required anyone — even interprovincial Canadian travellers — to quarantine for 14 days upon arrival in any Atlantic province. Their second wave outbreaks are being rapidly brought under control, and they have been comparatively tiny compared to the other provinces.
No jurisdiction that has aimed for Zero Covid has failed. All jurisdictions that try to “manage” spread and “live with the virus” are failing. Contrary to assertions about elimination being a fantasy and an impossibility, it appears that Zero Covid is easier than trying to find some mythical “balance.”
The lessons learned by Zero Covid jurisdictions may well be permanent. This will not be the last pandemic. Just as countries that successfully battled SARS in 2003 have done better with COVID-19, places that successfully battled COVID-19 can use what they learned to respond to the next pandemic.
In summary, Zero Covid has immense benefits and lesser costs. It trades short-term pain for long-term gain. Having zero community transmission leads to improved health outcomes, increased social freedoms, greater economic freedoms with a more sustainable recovery, reduced fears of future recurring lockdowns, and greater resilience to future viral outbreaks and pandemics.
Why Now?
Like much of Canada, Alberta is at an inflection point. We tried and failed to live with the virus, and now find ourselves back where we started in March — with governments being forced to reintroduce harsh restrictions on economic activity and public life in order to prevent catastrophic hospital collapse and loss of life. We now have a choice about what to do next.
In November, Premier Kenney stated that “Alberta is not involved in a chase after zero,” but if not then what is the plan? Dr. Hinshaw has mentioned the success of Israel in beating back a second wave, but Israel is currently entering a third lockdown barely two months after their second one ended. If we as a province choose not to go for elimination and instead try to keep cases manageable we risk a third wave as early as February or March, assuming our current second wave subsides. This cannot be our decision.
Vaccines offer hope, but even if they are as safe and effective as advertised we are still a long ways off from administering enough doses to stop this pandemic. Alberta is currently planning to have 30% of the population vaccinated by June 2021, with the rest of the public able to get a shot by the fall. That is still 6–9 months during which this pandemic can continue to wreak havoc. Aiming for zero now means that we can achieve herd immunity via vaccines while also experiencing a fraction of the illness, deaths, and economic devastation we have experienced so far. Continuing our current approach means vaccines will arrive too late for many.
How To Do It.
The good news is that the work has already been done. There are multiple examples spanning different nations, subnational regions, and cultures that Alberta can draw from. Most relevant in my opinion is Australia because of the fact that Australia’s success has largely been achieved at the subnational level. Alberta has an opportunity to join the Atlantic provinces in becoming a global leader that other provinces can follow.
Like Canada, Australia is a commonwealth nation with a parliamentary democracy. Like Canada, Australia is a federation of semi-autonomous states (or provinces) that have wide jurisdiction over things like healthcare, with backing from a federal government. Australia’s pandemic response has primarily been lead by the states (or provinces), much like Canada.
Former AHS CEO Stephen Duckett co-authored a report for the Australian based Grattan institute entitled Go for zero: How Australia can get to zero COVID-19 cases. It lays out four key pillars of a successful elimination strategy. The state of Victoria, Australia largely followed this plan to successfully overcome their large second wave and have now gone over a month with no cases of community transmission. Let us examine these four pillars and place them in an Albertan context.
Governments should be explicit about their goal of zero active COVID-19 cases in the community and their plans to hit this target.
Alberta should urgently and immediately adopt the goal of zero community transmission of COVID-19 within our borders. This should be reaffirmed at every daily update by the CMOH, Premier Kenney, and whichever other cabinet members or government officials are present. The necessary steps that will be taken to achieve this ambitious goal should be laid out in plain language and in no uncertain terms. It will certainly require extending or even escalating our current level of restrictions, and the reasoning for doing so should be explained as part of our effort to get to zero.
Governments should be clear to the public about conditions under which restrictions will be phased out or brought back in.
There has never been clear guidance from the Alberta government about how decisions to lift or reinstate restrictions were made. Going forward, there must be clear instructions to the public and business owners about how and when restrictions will be phased out or back in on our road to zero. There should be specific thresholds and triggers that link incidences of community transmission to activities being allowed. Less risky activities should be prioritized first. The state of Victoria again provides a good example.
Governments should improve public health efforts.
Every effort to reduce the turnaround time for testing to within 24 hours must be made. This enables self-isolation periods to be shorter and allows contact tracing to begin faster. Massive investments in contact tracing must be made and best practices pioneered elsewhere, such as retrospective contact tracing, should be immediately adopted. Greater isolation support for those who live in crowded living conditions should be brought in. The recently announced program is a good start, but must be expanded in scope. Information on how to access federal aid programs for both businesses and individuals affected by shutdowns should be disseminated widely, and the province should provide additional funding where needed. Sewage testing as an early detection system for missed cases should begin. Masks should be mandatory in public. Vaccine rollout must be done as quickly and safely as possible.
Once Australia gets to zero cases, governments should use frequent testing and international quarantine to seek to stay at zero cases.
Getting to zero is easy, staying there is harder. Fortunately, the work needed to reach zero community transmission also allows us to stay there. Investments in test-trace-isolate-support processes allow us to be ready to respond to further outbreaks when and if they happen, as seen in New Zealand, Vietnam, and Australia.
Quarantine procedures should be enhanced through the use of managed isolation facilities which have been used to great success elsewhere. The hotel quarantine models in New Zealand, Australia, and Taiwan can be used as a guide. For Alberta, staying at zero requires quarantine not only for international arrivals, but interprovincial as well so long as other provinces have community spread. Luckily, both the Atlantic provinces and Australian states demonstrate both how interprovincial quarantine can be accomplished and that it is effective.
Conclusion.
Getting to zero will not be easy, but it is better than the alternative. Adopting a Zero Covid approach will allow us to avoid a potential third wave and lockdown. It will allow us to regain much of our pre-pandemic freedoms, greatly boost the economy, and prevent needless death and suffering. It is the obvious and only correct choice for Alberta.
Further Reading.
For more on a Zero Covid approach visit endcoronavirus.org, read the work of Robert Greenhill and Global Canada, read the Grattan Institute report, read the British Medical Journal, and follow people like Andrew Morris on twitter.
