Part II: The only thing certain about COVID-19 is uncertainty

Read part one of Michele and Chandra’s piece here.

What does this mean for protecting public health?
In order to have a hope of containing the virus, we need to know as quickly as possible who actually has the virus and who they in turn might have exposed. But as long as testing is limited or individuals are being told to self-isolate only if they meet a very narrow set of criteria, we will continue to miss out on identifying a large number of cases.

We need to have widespread testing that is available and accessible as early as possible when someone is experiencing symptoms. A single negative test should not be taken as evidence of being virus-free—either tests should be repeated targeting different locations in the body or a presumptive diagnosis should be adopted for patients who meet a broadly-defined case profile. This testing should be expanded to include antibody testing once an individual is more than fifteen days beyond symptom onset.

Simply asking people about a temperature and a cough provides a false sense of security, for workers and for customers. It is possible to be ill with the virus and have neither a cough nor a fever. Individuals should not be presumed to be “safe” simply because their temperature is normal.

There also needs to be better follow-up of cases and suspected cases to develop a clearer picture of symptom progression and recovery. In order to ensure that we are capturing all possible cases, this follow-up should include both patients who had positive tests and those who merely had symptoms that align with COVID-19. Research should also be conducted into patients with COVID symptoms in February and March when the connection to the virus might not have been made.

When developing guidelines for care, recovery, reintegration, and reopening the economy, public health officials should put the precautionary principle front and centre.¹ We should not wait for overwhelming evidence to take measures to protect people—measures should be taken immediately and only relaxed once it’s clear that the measures are not necessary.

We also urgently need to provide medical care to people with mild or moderate cases of COVID. In Ottawa and other urban centres, COVID Care clinics have been set up to treat respiratory ailments, but as we now know, the disease does not only affect the respiratory system. Patients need access to hands-on, diagnostic medical care and treatment for a variety of issues and secondary infections without tying up emergency rooms. This could take a variety of forms, including expanding the existing care clinics or home visits by doctors in PPE. In France and Germany, patients who are dealing with COVID at home receive daily calls from doctors, in addition to tracking symptoms via online apps. 

Doctors and other health care professionals also need to abide by the precautionary principle in providing care, acknowledging how much we still do not know about this illness. This means listening to patients’ stories carefully and taking their symptoms seriously. When an illness has only been around for six months, it is far too early to tell someone that their symptoms can’t possibly be related to COVID or that they should have recovered by now. Medical professionals may not like to operate on the basis of anecdote, but patients can’t afford to wait six months or a year for clinical studies to emerge. They need support now.

What does this mean for governments?
In order to curb this pandemic, governments need to prioritize the health and safety of workers, who are the most likely to get sick and the most likely to spread the virus to others. This may require a different way of thinking than prioritizing public safety. After all, a two-minute interaction in a store for the customer is very different from eight hours of interactions for a worker. 

Governments need to regulate penalties for employers who require or put pressure on workers who may be infectious to show up at work. This includes employer use of bonuses or rewards for attendance or any other policy designed to minimize use of sick leave. Use of sick leave should be determined by illness, not by calendar or company policy.

Governments also need to expand access to sick leave beyond two weeks. The news that the federal government is in talks with the provinces to ensure that all Canadian workers have access to 10 paid sick days is very welcome. However, for many COVID patients, two weeks of sick leave is quite simply not going to be enough to fully recover. Workers shouldn’t be penalized for not recovering faster or forced to return to work before they are well, possibly risking infection to others and creating risks for their own long-term well-being. Forcing workers to take unpaid leave or use up their vacation time will lead to workers returning before they have fully recovered.

The government also needs to ensure that income security programs are available to protect precarious workers who are self-employed, consultants, freelancers, or “gig” workers. Without a standard employment relationship, these workers have no employer to provide sick leave. This may leave them with no choice but to work despite their ill health or to go without income. 

Given the limitations on access to testing, the federal government has quite rightly insisted on access to sick leave without a medical note. However, that access is only extended once—if someone returns to work and then needs to take sick leave again, they have to provide a medical note, at least in order to access the Canada Emergency Response Benefit (CERB). But this is problematic for workers who experience relapsing symptoms. Whether or not they had a positive COVID test at the onset of their symptoms, they are unlikely to keep testing positive as the weeks go by. But some doctors—unaware of the pattern of prolonged recoveries and the possibility of relapsing symptoms or development of new symptoms— may be reluctant to provide workers with the required medical note. This will put workers at risk of relapsing even harder or developing new complications. But given the lack of certainty around infectiousness, it may also be putting co-workers at risk.

We need to adopt a presumptive approach to sick leave that does not require a positive COVID test and allows for people to relapse without penalty. We also need to recognize that many workers may need a gradual return to work, a modified work schedule, or accommodations in their first few weeks or months returning to work. Employers should not be able to force workers who are still having symptoms or dealing with the long-term health consequences of COVID to maintain a normal workload.

Some workers will also need to be provided with non-punitive accommodations in the name of public safety. It would be untenable, for example, for a trucking or rail industry worker to be expected to return to work while still experiencing intermittent, unpredictable periods of fatigue, dizziness or brain fog. This would put both co-workers and the public at risk. 

The federal government also needs to re-think access to the CERB and to Employment Insurance. Currently, workers who are deemed to have “voluntarily” quit their jobs are not eligible for these programs. But unfortunately, this policy gives employers all the power in deciding whether or not someone has voluntarily quit, rather than recognizing that an individual may not have been healthy enough to return to work, may not have felt safe working, or may not have been able to keep people around them safe if they kept working. If an employer refuses to recognize these concerns as valid reasons for job separation or leave, the employer can prevent someone from accessing income support. This is unacceptable. Workers need to be able to prioritize their health and the health of their loved ones. 

What does this mean for employment?
What does all of this mean for workers and the labour unions who represent them? Until a vaccine is created and all social controls can be relaxed, the most likely places for Canadians to contract COVID-19 are in the workplace or the home. Workplaces need to be structured, to the greatest extent possible, in ways that keep workers safe, keeping physical distance between them, avoiding exposure to circulating air, offering personal protective equipment when distance is not possible, and keeping surfaces as clean as possible. Workers need to be allowed to refuse to work in conditions that will not keep them safe.  While in theory, workers already have this right, in reality the legal construct of the right to refuse unsafe work has not been set up to deal with a situation such as a highly infectious virus that does not affect everyone in the same way.

Instead, what constitutes an acceptable level of risk in this situation varies according to individual circumstances. Someone who is at higher risk if they contract the illness due to age or pre-existing condition should have a lower bar to claiming unsafe working conditions. This right should extend beyond the rights of the individual worker to recognize the social circle that a worker is part of. A worker who lives with an aging parent or an ill child should have the same right to refuse unsafe work as a worker who has a pre-existing condition themselves.

While even perfectly healthy individuals are getting very sick and even dying from COVID-19, we know that some pre-existing conditions put people at considerably greater risk. For instance, hypertension seems to greatly increase the chance of both developing Acute Respiratory Distress Syndrome and of dying from COVID-19. Early studies from Wuhan suggest that approximately one-third of patients dying of COVID-19 had hypertension.² The risk threshold for exposure for someone with hypertension should thus be much lower than for an individual with healthy blood pressure levels. 

In addition to paid sick leave and access to disability supports, workplaces need to develop a culture of “If you’re sick, stay home.” Employers and workers both need to be a part of developing this culture. We ourselves certainly have been guilty of coming to work sick in the past, committed to getting the work done no matter how we felt. Moving forward, we need to retrain ourselves away from this mentality. Staying home when you’re sick protects other workers. Employers need to abandon the idea that using sick days is about laziness, scamming the system, or lowering productivity. Sick leave is about keeping workers safe. In the context of a pandemic, it can actually make all the difference to productivity by allowing a workplace to remain open. Any system that pressures a worker to come to work sick or rewards them from doing so should be banned. In cases where such a system contributed to an outbreak of COVID-19, criminal charges should be considered. 

As part of this new culture, workers need to be safe to identify that they are sick, that they are relapsing, or that they need greater protection. There should be no retaliation or stigma for disclosing. At the same time, there should be a minimal threshold for disclosing. Workers should not have to share their entire medical history with an employer to explain why they have a higher risk or a greater vulnerability to the virus, nor their full history of relapsing symptoms. 

Should workers be required to disclose their COVID status? It is too early for any kind of blanket policy. Certainly anyone in a situation where they could infect others should be required to disclose and remain at home, whether that is on sick leave or working from home (although they shouldn’t be forced to disclose what their illness is – only that they have an infectious illness). But workers who are no longer infectious should be able to choose whether or not to disclose their illness, particularly given concerns about stigma and discrimination. 

Given the difficulty in accessing testing and diagnoses for COVID-19, employers should use a presumptive policy, rather than requiring a confirmed test to access any sick leave or supports. Workers who have any symptoms related to COVID-19 should be presumed to have the disease unless proven otherwise by diagnostic tests. Labour unions need to be prepared to pursue grievances in cases where workers are denied access to sick leave or reasonable accommodations on the grounds that they did not have a positive test. 

Regardless of diagnosis, many people returning to work after being ill with COVID symptoms will need graduated return-to-work plans or accommodations that can address lingering symptoms, relapses, fatigue, and brain fog. In some cases, these accommodations may need to be long term. In other cases, the need for accommodations may only be identified over time as workers discover they are not fully recovering from fatigue or as new symptoms develop. Flexibility will be critical, as will an understanding that this illness is so new that new information is coming out literally every day.

Workers may also need flexibility, accommodation, and other support as they support ill family members. The protracted recovery period and pattern of relapse and recovery may mean that workers’ needs change from week to week as their family member(s) require more or less care. 

Where do we go from here?
Three months after becoming ill, we are still not completely symptom-free. There are more good days than bad, but in some ways, that makes the symptoms harder to deal with. Michele and her husband have resumed normal activities, but occasionally, and without warning, have a resurgence of symptoms and are down for a day or so. We are both still facing questions about how long this illness will linger, if we will ever fully recover, or if we need to find a new “normal.” As many as one million Canadians may be asking themselves similar questions right now—and that number will only increase as we wait for a vaccine or a treatment to be developed.

As new information comes out daily about this virus and its impact, it could be a long time before these questions have answers. But if we are going to put people first, then it’s clear that how we answer them needs to centre two things—caution and flexibility. When it’s not clear how to respond, we need to pick the response that protects the most people with the greatest certainty. We can always course correct later but our mistakes won’t have cost lives. And as we learn new information, as symptoms change and recoveries progress and relapse, we need to provide support to people where they are, and not expect this new disease to conform to our expectations of what illness and recovery should look like.


Footnotes

¹  Marco Martuzzi and Joel A. Tickner, eds., The Precautionary Principle: Protecting Public Health, The Environment and The Future of Our Children, World Health Organization, 2004, http://www.euro.who.int/__data/assets/pdf_file/0003/91173/E83079.pdf?ua=1.

² Wu C, Chen X, Cai Y, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Internal Medicine. Published online March 13, 2020. doi:10.1001/jamainternmed.2020.0994


Chandra Pasma is a labour researcher and policy analyst specializing in issues of work and income security. She and her family live in Ottawa. You can find her on twitter at @ChandraPasma.

Michele Girash is an activist, organizer and labour campaign officer. She has education and experience in basic science research, health promotion and women’s wellness. Her current focus is on precarious work. Michele works in Ottawa but calls Northern Ontario home. Connect with her on twitter at @MGirash.

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