Opinion

An open letter to Minister of Health Cameron Friesen and Premier Brian Pallister: 

Given the current trajectory of COVID19 community spread in Manitoba, we physicians have an obligation to indicate our concerns and offer our best advice. We know everyone is working their way through this pandemic as best they can. We’ve not seen anything like it in 100 years. 

We agree with you that all Manitobans need to take the COVID19 situation seriously and avoid engaging in activities that can only propagate spread of the virus. However, we’re well past the stage where even a robust community response will significantly slow the epidemic. Fortunately, your government has already shown us what needs to be done. 

In the spring of this year, the province and the rest of the world was stricken by the most serious pandemic in living memory. Under your leadership, we crushed the progress of infection within weeks. This past summer, we had several weeks where we suffered no more than two or three cases in total. This hard-fought victory required the support of our communities for a province-wide lockdown for weeks.

Our fellow citizens bore tremendous hardship, but they did so willingly to protect their vulnerable friends, neighbors and family members. 

Unfortunately, with the lifting of restrictions, the virus causing COVID19 disease has surged again. The current trajectory of the provincial epidemic suggests that we are early in the exponential phase of growth. To understand what is coming, the experience of El Paso, Texas (like Winnipeg, a city of about 750,000), is instructive.

According to that city's website, in the week around Oct 1, El Paso had daily case counts of 150 to 200 (similar to what we are experiencing now). Two weeks later, around Oct. 14, case counts had risen to 350 to 550 per day. On Oct. 28, they had about 1,100 cases. This is exponential growth. They currently have 111 patients being mechanically ventilated, with more than 220 in ICU and in excess of 900 admitted to local hospitals. 

We simply don’t have that kind of capacity, even with emergency measures. We cannot allow this epidemic to progress unchecked. Despite the commendable efforts of WRHA administration to develop additional bed and ventilator capacity, overall surge capacity will be limited by the availability of front-line health care workers, including nurses, to provide hands-on care and respiratory technicians to operate the ventilators.

Once we reach 200-250 cases per day, we will overwhelm existing resources within a week or two. 

At that point, we will be staring at the need for triage; not just for COVID-19 patients, but for all patients who require ICU care. When our citizens need an ICU bed for a stroke or heart attack, it will likely not be available. Patients with acute surgical emergencies or trauma will have to be triaged according to criteria  the health authority has certainly already developed.

For those unlucky enough to not meet the triage threshold of likely survival, palliation will likely be the only option. This is not a theoretical consideration; this will happen in less than a month if we do not intervene now. 

We anticipate that further impacts will include major delays in emergency-room care, cancellation of elective surgery, delays of urgent surgery and cancer detection and treatment, as well as a high level of illness and death among health-care workers. 

Our public-health authority is clearly using an incremental targeted approach (an escalation strategy) to local outbreaks in order to minimize economic disruption. That is a worthy goal, and was worth trying. That’s what a lot of regions around the world have attempted, but their experiences show that this approach is consistently failing. 

The reason for this failure is clear: responsible officials have to make decisions before clear evidence emerges that the epidemic is out of control. Absent such evidence, the easy route is an incremental public-health response. But this incremental approach not suited for epidemics involving a rapidly progressive and dangerous infection such as the COVID-19 virus. And it will fail. 

By the time definitive evidence of failure of the incremental targeted approach to stop epidemic progression is apparent, it’s too late. You are two or three weeks behind. A targeted intervention we start today might work if that intervention had an immediate impact. It does not. The number of infections we are seeing now was determined by our interventions (or lack of them) several weeks ago.

Similarly, what we do now will determine the level of disease activity and case counts in two to four weeks. When an incremental targeted approach is applied to epidemic management, you’re going to be late every time. 

In catastrophic epidemic situations in which a large loss of life is likely, a better approach is what your government mandated in the spring: a maximally aggressive public-health response, including mandated mask use and a province-wide lockdown to damp down the infection level to the greatest extent possible. Then slowly remove restrictions every two or three weeks, while closely monitoring recurrence of infections. 

This has the advantage of making the normal delay in the epidemic’s response to your actions work in your favour. You can back off on your intervention (province-wide shutdown) and surveil for increasing test positivity. Once significant increases are seen, you can aggressively contact-trace and quarantine or, if necessary, even tighten up public-activity restrictions again for briefer periods. 

If you do this, your daily case counts will increase slowly from a much lower baseline. With good surveillance, the province will be able to maintain very low disease activity levels, similar to this summer, allowing for a sustained resumption of normal economic activity.   

We are confident that another aggressive province wide shutdown is coming. We see no real way to avoid that if we continue the current course. We can implement it now and, if we are fortunate, limit deaths to less than double what we have now. Or we can shut down in three weeks and have a death count in the multiple hundreds. 

The catastrophic situation we’ve seen in other cities is not inevitable. We are confident that aggressive mitigation efforts, combined with a subsequent ramping up of virus testing, contact tracing and targeted public messaging can avert disaster if implemented immediately.

We urge you to go to a full shutdown immediately. This is the time. A couple of weeks from now will be too late. The result will be an appalling and pointless loss of life and a sustained disastrous impact on the economy. 

The signatories of this letter have no political agenda in writing this message. Although the signatories include former medical-school deans, department chairs of medicine, surgery and anesthesia, infectious-diseases and critical-medicine attending staff and city-wide eirectors, director of the public health branch of Manitoba Health and senior physicians/professors of medicine, we are each writing in our individual capacity, many of us as physicians on the front edge of the pandemic response.

Our only concern is the well-being of our fellow Manitobans and health-care workers across the province. 

Anand Kumar, MD

Dan Roberts, MD

R. Bruce Light, MD

Eric Jacobsohn, MD

Steven Kowalski, MD

Allan Ronald, MD

Greg Hammond, MD

Fred Aoki, MD

Philippe Lagace-Wiens, MD

Terry Wuerz, MD

Faisal Siddiqui, MD

Kelly McDonald, MD

Sukarno Chaudhry, MD

Joel Enock Nkosi, MD

David Hochmann, MD

Dave Easton, MD

Paddy Griffin, MD

Eric Bow, MD