Tara Kiran is a family physician at the St. Michael’s Hospital Academic Family Health Team and the Fidani Chair of Improvement and Innovation at the University of Toronto.
Irfan Dhalla is a general internist and Vice-President of  Physician Quality, and Director of the Care Experience Institute at Unity Health Toronto.


 

The two of us – married with 3 children, one a family physician and the other a general internist – left for a family vacation to Panama on March 7th. It is not an exaggeration to say that health care in Canada changed more during the 2 weeks we were away than it did during the 2 decades since we were medical students.

The COVID-19 pandemic will go on for many months, and we hope to share our thoughts here each week. In this initial blog, we will share our thoughts about travel, based largely on our recent experience in Panama, Miami and Toronto.

In Panama, the government decided to shut down all international travel just 10 days after its first COVID-19 case. When we heard the news, we hustled to get an earlier flight home. On our drive back into Panama City, health care workers checked our temperatures through the windows of our rental car at a highway checkpoint. (Our temperatures had also been checked several days earlier at the airport, before boarding a domestic flight.) Our best guess is that if any of us had been febrile, we would have not been allowed back into Panama’s capital. Only afebrile passengers with a confirmed flight were allowed into the international airport, and every restaurant in the airport but one was closed.

The contrast with Miami, where we had a stop-over, was stark. The airport in Miami was crowded, virtually every restaurant was open, hand hygiene was abysmal, and signage was minimal and woefully out of date. A sticker on the cubicle of the customs and border patrol officer informed us to watch out for symptoms if we had recently been to China. This was several days after the World Health Organization had declared a pandemic, and long after it had become clear that COVID-19 was hitting the US hard. If any of the five of us ends up developing COVID-19 over the next two weeks, by far the most likely source of transmission will have been Miami International Airport.

Toronto was between these two extremes. There was plenty of signage and hand sanitizer in the airport, and border security agents gave us a handout on COVID-19 a few minutes after we landed. But, there was no social distancing at passport control or the baggage claims area. When we cleared customs, we were asked but not required to self-isolate. The Tim Horton’s was open, and it was still possible to get a double double.

In all three countries, our journey depended on airport staff, food handlers, taxi drivers and others. How much education did our Toronto taxi driver receive about protecting himself from COVID-19, and from whom? If he were to develop COVID-19, how many people will have been in contact with him during the time he is infectious? Has he been assured that if he can’t drive because he’s sick, he will receive some other source of income? Has he been asked or required to keep a log of passengers? We doubt it.

Limiting international and domestic travel, suddenly and totally, affects people in obviously important ways. Families cannot be reunited. Students cannot get back to school. People cannot get back to their jobs. We met several Europeans who will likely be stranded in Panama for at least a month, possibly longer. Other countries have taken similarly stringent approaches.

At the same time, there is no doubt that travel accelerates the rate at which new infectious diseases spread around the globe. Social distancing at airports, travel stations and bus depots is exceedingly difficult if not impossible. Travellers are not only vulnerable to the strength of containment efforts in the region they are visiting, they also put others at risk. It is easy to understand why many countries have taken a very strict approach.

But domestic and even international travel cannot be shut down forever.

Perhaps there is a middle ground that we can follow over the coming months, as we deal with both the “hammer” and the ensuing “dance.”

Until we have “flattened the curve” severe travel restrictions make sense. Even after the curve has started to flatten, all of us should probably limit discretionary travel, both across international borders and even within countries. That way, people living in cities and towns without ongoing community spread of COVID-19 can more easily be protected. Smaller numbers of travellers will also allow for easier implementation of strategies that improve safety for both travellers and those who work in the travel industry.

Transportation hubs – bus depots, train stations and airports – should employ more staff to minimize crowding and to screen travellers. More education and support should be provided to taxi drivers, baggage handlers and others. Essential workers need to know how to protect themselves from COVID-19, and they need to feel confident that they won’t go broke if they get sick. And maybe all inter-city travellers should be registered, to facilitate contact tracing when needed.

Travel practices need to change radically for us to minimize the number of people harmed by COVID-19.