Canada is emerging from months of lockdown, but key questions remain unanswered about where Canadians are getting infected with COVID-19 and why case levels remain high in our hardest-hit provinces.
Ontario and Quebec have seen their rate of new cases plateau in recent weeks, still in the hundreds each day, and have little information on the source of infection or what effect reopening will have.
"It's scary. There's a large sense of unknown there," said Dr. Michael Gardam, an infectious disease specialist and chief of staff at Humber River Hospital in Toronto, who is a veteran of SARS and H1N1.
"And there's no way around the fact that this is uncomfortable."
In Ontario, where the number of new daily cases is actually trending upward, testing is falling far below targets and the source of infection for new cases still remains a mystery.
Even local health officials have concerns about lifting lockdown measures.
Dr. Lawrence Loh, the Medical Officer of Health for Peel Region, west of Toronto, said this week the province's move to reopen was "out of step" with the "continuing risk" of the coronavirus pandemic, and recommended delaying easing restrictions.
"We have seen our new cases starting to plateau, but we have just not seen a decline in line with the province's own framework for reopening at this point," he said, adding the region had 20 per cent of all new COVID-19 cases in Ontario last week.
He notes the recent new case levels in the province — between 300 and 500 each day — mirror the levels in the early days of lockdown.
That concern was echoed by Dr. Chris Mackie, the Medical Officer of Health and CEO for the Middlesex London Health Unit in London, Ont., who said the region may need to "reconsider" reopening after case counts rose this week.
"We should not be seeing these sorts of numbers at this stage," he said, adding the local increase, as well as the provincial one, is higher than it should be.
"If this continues on for the next few days, we might have to reconsider some of the loosening of public health measures."
The Ontario Ministry of Health could not provide CBC News with a clear picture of where exactly people are getting infected in the province.
"This is ongoing work," a spokesperson said in a statement, and said the issue was being examined by Ontario's Chief Medical Officer of Health Dr. David Williams.
"Dr. Williams has asked the local public health units to collect more specific information from new cases about the possible sources of transmission."
Experts say lifting lockdown measures without a clear picture of where new cases are coming from, and while testing is not at capacity, is cause for concern.
"We're only ever measuring the tip of the iceberg, and so there's a bunch of cases out there that we don't know about, and presumably those cases are transmitting," Gardam said.
"Because you're not testing everybody, you are going to get cases where you don't know where they came from."
Dr. Irfan Dhalla, a physician and University of Toronto medical professor who is also a vice-president at Unity Health Toronto, said Ontario needs to proceed with caution.
"I would be nervous about some elements of the reopening strategy in some areas of the province," he said.
"We need to redouble our efforts to continually improve our understanding of where ongoing transmission is occurring so that we can reopen safely."
Quebec forges ahead with reopening
In Quebec, the number of new cases remains the highest in the country, with 720 new cases and 82 deaths reported Thursday.
Quebec's Director of Public Health Dr. Horacio Arruda said he's still not satisfied with the number of people getting tested in the province, falling well below the capacity to test 20,000 per day.
And the province's latest public health data provides no clear information on why infection continues to occur even after months of lockdown.
Despite this, Quebec is moving ahead with reopening soon.
As of Friday, people from up to three different households in the province will be allowed to gather outside in groups of 10 as long as they maintain physical distancing.
And starting June 1, the province will allow a number of personal care services such as dental clinics and massage therapy to reopen.
Hairdressers, manicurists and other beauty care services will be allowed to open on the same date — but not in the greater Montreal and Joliette areas, where there are still significant COVID-19 outbreaks.
"This has to be done while ensuring everyone's protection — the protection of workers and clients as well," Health Minister Danielle McCann said Wednesday. "So there will be rigorous prevention measures set up."
Quebec's public health strategic adviser, Dr. Richard Massé, said visits to these types of service providers can be carried out safely if both the providers and the clients respect the rules.
"If it's done properly, there is a very good level of protection," he said.
No clarity on source of COVID-19 infections
But the level of uncertainty over where infections are happening in Ontario and Quebec as lockdown measures lift is compounded by the fact that a large number of cases in Canada have no known source of infection.
The federal government can only provide basic information on where infection is occurring for less than half of our more than 80,000 COVID-19 cases — and even that data is incomplete.
The latest available update from the Public Health Agency of Canada found 3,787 COVID-19 cases had travelled outside of Canada; 24,848 are from "domestic acquisition"; while a further 10,433 have "information pending."
But not all parts of the country have the same problem.
Alberta has expanded testing to asymptomatic close contacts of positive COVID-19 cases in an effort to find and isolate new cases before they turn into outbreaks.
While British Columbia, which looked like it could be among Canada's hardest-hit provinces early on in the pandemic, now appears to be one of the best positioned to reopen.
B.C. has greatly reduced its rate of new cases, expanded testing and contact tracing and mapped out the likely source of infection for the vast majority of its cases.
So should parts of the country be moving toward reopening even if they can't answer those key questions?
"Everybody would like them answered, but I think it's just not possible in the current circumstances to be able to think that we can," said Dr. Allison McGeer, an infectious disease expert and a professor at the University of Toronto's Dalla Lana School of Public Health.
"So if we can't do that, then the question becomes: Do we sit forever? Or do we move with everybody else in reducing precautions and watch to see what will happen?"
Ontario says its first phase of reopening is focused on "low-risk workplaces," and that public health officials will "carefully monitor each stage."
If the first stage of the gradual reopening of Ontario is successful, it will move toward second and third stages. If not, public health measures will need to be "adjusted and/or tightened."
There's really no way of knowing what the future holds for any part of the country as lockdown measures lift, McGeer says.
"The only way you can answer that question is by trying it out. There's not a rulebook. You can't know what's going to happen when you do this," she said.
"I hope that we all know, as Ontarians, as Canadians, that this step forward might be reversed, but we're going to try it out and we're going to see what happens."
1 step forward, 2 steps back?
But Canada should consider whether reopening then backtracking could ultimately set us back further.
South Korea was forced to take a step back from its reopening strategy last week after a cluster of cases at a nightclub district in Seoul called into question whether the country lifted certain restrictions too soon.
The incident led to an outbreak of more than 100 new cases and ultimately forced the country to shut down thousands of nightclubs indefinitely to prevent a spike in new cases.
"If you don't have to backtrack at all, then it probably suggests that we waited too long to reopen," said Dhalla.
"What we don't want to have happen are large outbreaks that result in lots of people needing to be cared for in hospital and people dying, but I think it's inevitable that we will learn as we go."
McGeer said although it may not be palatable for Canadians to think about lockdown measures being reimposed if things don't go well, it may be part of our new reality as we test the waters of reopening.
"Honestly, I think it's the best we can hope for. We don't want to stay in lockdown unless it's essential that we stay in lockdown," she said.
"But if we can allow more activity and not get into trouble, then that's what we should be doing."
She said Canadians should brace themselves for the possibility of lockdown measures being lifted then reimposed for the foreseeable future until an effective treatment or vaccine against COVID-19 is developed.
"As long as we know that's where we're going and what's going to happen, I think people will be happier with being allowed to do some things for a while rather than staying in lockdown for the whole time," she said.
"But it's really important that people know that this might happen — that we might have to go back."