This past week — for the first time — encouraging signs began to emerge that Canada may be flattening the curve of coronavirus infections. But how quickly will things return to normal? It’s a high stakes decision that pits lives against dollars.

Lifting restrictions too soon could lead to another wave of infections and hundreds of additional deaths; keeping them in place too long could cause more job losses and business closures while impairing long-term recovery efforts.

“It’s not new that we factor human life against the economy,” said Larry Smith, economics professor at the University of Waterloo. “We do this implicitly all the time. The difference now is that it has to be done explicitly.”

Given COVID-19’s brutal economic toll, pressure is mounting on public health officials to end the business shutdown, even if it means some lives will be sacrificed.

More than a million Canadians lost their jobs last month — by far the largest single-month job loss ever recorded — and April’s unemployment figures could be even worse.

The Bank of Canada said the economic restrictions required to fight the spread of COVID-19 could cause permanent damage to the Canadian economy if they aren’t lifted by the summer.

Politicians, sensing the public’s growing impatience, have tried to temper expectations. Prime Minister Justin Trudeau said it would be “weeks more” before the federal government considered loosening restrictions, warning of the potential for a second wave of infections. “We cannot be in a rush to get things going again,” he said on Wednesday.

When Premier Doug Ford extended the state of emergency until May 12 he indicated the economy will not be ramping up anytime soon. “This is a health crisis and I’m not going to jeopardize people’s health to open up the floodgates,” he said.

Toronto Mayor John Tory said the city is working on an approach to reopening city services guided by public health advice to ensure it doesn’t cause further health risks. He promised details in the coming days on what he called a “very complicated plan.”

Meanwhile, other jurisdictions are starting to take small steps toward easing restrictions. Quebec, the country’s hardest-hit province, allowed mining and home construction to resume. Leaders in British Columbia and Saskatchewan discussed tentative reopening plans. Some European countries began lifting restrictions this week, while parts of the U.S. are laying out the conditions under which they will reopen parts of their economies.

Earlier this week the World Health Organization identified six criteria that should be in place before countries consider relaxing physical distancing measures: that transmission of the virus is controlled; the health system has the capacity to detect, test, isolate and treat every new case and trace every contact; outbreak risks are minimized in vulnerable settings, such as hospitals and nursing homes; preventive measures are put in place in schools and workplaces; importation risks can be managed; and that communities are “fully educated, engaged and empowered” to adjust to the new norm.

There is no magic formula for making this decision, Smith said. Ultimately it’s a judgment call based on scientific evidence and guided by public health. But we can’t wait until there’s no risk of virus death before reopening the economy. “We don’t use that standard for anything,” he said. “Otherwise we’d prohibit all vehicle traffic.”

While there’s an inherent tension between the economic costs and health benefits of physical distancing, the economy also benefits from sound public health decisions, said Robyn Gibbard, senior economist at the Conference Board of Canada. “There is a point where we will reopen things even though that will increase the risk of additional people getting sick,” he said. “I think it’s a matter of just doing the best we can to protect people and protect their health, and recognizing that if we do open up too soon we increase the risk of things like a second wave of infections that will then force a second wave of lockdowns, which will then have a second wave of economic consequences.”

When and how restrictions are lifted could have major ramifications on public health and the economy for years to come. We asked epidemiologists and economists to identify the conditions that should be in place to ensure the best outcome.

“Let’s try to do it as soon as we can,” said University of Toronto epidemiologist David Fisman. “But let’s get our ducks in a row before we do it.”

Sustained decline in new infections

“Flattening the curve isn’t enough,” said Isaac Bogoch, a doctor and infectious disease specialist at the University of Toronto and Toronto General Hospital.

There should be a steady, continuous decline in new infections, not simply a plateau, he said. “We want to see this plunge and continue to plunge.” For how long? “The short answer is I don’t know. The longer, more nuanced answer is probably a few weeks, at least a couple of weeks. It’s not just a matter of saying, ‘Look, we have a reduction in the number of new cases, Hallelujah!’ We want to see this come down to a very low number of new cases per day and sustain that.”

Widespread testing and contact tracing

Trudeau said this week that wide-scale testing will be an essential part of reopening the economy once the first wave of the epidemic is over. This is what made the containment efforts in South Korea, Singapore, Hong Kong and Taiwan so effective.

“From what we’ve seen so far it appears to be the most effective way of keeping people safe while also allowing the economy to continue to function,” said Gibbard, the Conference Board of Canada economist.

The only way to keep track of how the virus is doing once more businesses are allowed to open is to have “good surveillance and good situational awareness,” said Fisman, the epidemiologist. “You have to watch like a hawk.”

Developing the test-and-trace infrastructure and ensuring there is enough capacity to handle widespread testing is the challenge. “When you start to lift up these public health restrictions we have to be able to rapidly identify new cases so we don’t go back to square one,” Bogoch said.

A gradual reopening

When California Gov. Gavin Newsom outlined how his state would start lifting restrictions earlier this week he emphasized that everything won’t come back at once. “There is no light switch here,” he said. “It’s more like a dimmer.”

Experts agree this is the best approach.

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“What’s going to happen when we start to loosen restrictions is very, very difficult to predict,” said Erin Strumpf, an associate professor in both the economics and epidemiology departments at McGill University. Easing restrictions incrementally allows for greater control, she said.

“So that if we start seeing an uptick in the number of new cases, you’re able to put some restrictions back in place in a way that’s incremental and not necessarily really intense.”

Strumpf said that public health officials and governments will be trying to keep the infection rate at a level the health care system can handle “without resorting to crisis-level care.”

“We’re going to tolerate some new infections,” she said. “But it should be at a low enough rate that the health care system can manage it well.”

Regional coordination

Trudeau has said the easing of restrictions is likely to happen at different rates across the country because the epidemic is in different phases in different regions. British Columbia, for example, peaked first, while the Prairies and Maritimes have seen relatively few cases.

But Bogoch said it’s important for there to be sustained reduction in the number of new cases in all provinces because there is still some interprovincial travel. “So if one province has a terrible outbreak and other provinces are under control, we still have to be cautious there. Although not all provinces are in sync, we likely have to see all provinces headed in the right direction and all provinces demonstrating some success managing their epidemics.”

Public support

While governments make the decision on whether businesses can open and what kind of economic activity is allowed to resume, people also need to feel safe and confident in those decisions, Gibbard said.

“Just opening things up on paper doesn’t mean things will return to normal. You really have to do this in a way that makes people feel safe.”

Gibbard cited data from OpenTable, the restaurant reservation platform, that showed even before governments ordered dining rooms to close reservations had declined significantly in many countries.

Similarly, Sweden, which resisted a broad lockdown, is suffering a higher death toll than neighbouring countries and still projecting an economic downturn that’s comparable to countries that imposed much stricter measures.

“So it’s not just up to checking a box and saying, ‘Things are open now,’” Gibbard said. “You actually have to make people feel safe if you want them to resume their normal economic activity.”

He said federal and provincial governments should follow the example of South Korea by publicizing a set of specific criteria before a broader reopening of the economy.

“You set really clear, easy to understand criteria based on the science around a low level of infectiousness, a low level of untracked spread, and once you get down to that level you say, ‘We’re at a point now where we feel we have this under control,’ and people expect things will open up from there.”

This way people have confidence that the decision is evidence-based and not politicized.

“Nobody has to doubt that the population’s health is kept in mind.”